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3550 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > Other Subscriber Information Loop > Other Payer Service Facility Location Loop > REF Other Payer Service Facility Location Secondary Identification To specify identifying information Example REFLUXXX~ Max use 3 Required REF-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification 0B State License Number G2 Provider Commercial Number This code designates a proprietary provider number for the non-destination payer identified in the Other Payer Name Loop ID-2330B for this iteration of Loop ID-2320. This is true regardless of whether that payer is Medicare, Medicaid, a Blue Cross Blue Shield plan, a commercial plan, or any other health plan. LU Location Number REF-02 127 Other Payer Service Facility Location Secondary Identifier String (AN) Required Min 1 Max 50 Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier 1/30/25, 11:52 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 236/665 2330F Other Payer Supervising Provider Loop Max 1 Optional Variants (all may be used) Other Subscriber Name Loop Other Payer Name Loop Other Payer Referring Provider Loop Other Payer Rendering Provider Loop Other Payer Service Facility Location Loop Other Payer Billing Provider Loop NM1 3250 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > Other Subscriber Information Loop > Other Payer Supervising Provider Loop > NM1 Other Payer Supervising Provider To supply the full name of an individual or organizational entity Usage notes See Crosswalking COB Data Elements section for more information on handling COB in the 837. Required prior to the mandated implementation of the HIPAA National Provider Identifier (NPI) rule when the provider in the corresponding Loop ID-2310 is sent and one or more additional payer-specific provider identification numbers are required by this non-destination payer (Loop ID-2330B) to identify the provider. OR Required after the mandated implementation of the NPI rule for providers who are not Health Care Providers when the provider is sent in the corresponding Loop ID-2310 and one or more additional payer-specific provider identification numbers are required by this non-destination payer (Loop ID-2330B) to identify the provider. If not required by this implementation guide, do not send. Example NM1DQ1~ Max use 1 Required NM1-01 98 Entity Identifier Code Identifier (ID) Required Code identifying an organizational entity, a physical location, property or an individual DQ Supervising Physician NM1-02 1065 Entity Type Qualifier Identifier (ID) Required Code qualifying the type of entity NM102 qualifies NM103. 1 Person 1/30/25, 11:52 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 237/665 2330F Other Payer Supervising Provider Loop end REF 3550 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > Other Subscriber Information Loop > Other Payer Supervising Provider Loop > REF Other Payer Supervising Provider Secondary Identification To specify identifying information Example REF0BX~ Max use 3 Required REF-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification 0B State License Number 1G Provider UPIN Number UPINs must be formatted as either X99999 or XXX999. G2 Provider Commercial Number This code designates a proprietary provider number for the non-destination payer identified in the Other Payer Name Loop ID-2330B for this iteration of Loop ID-2320. This is true regardless of whether that payer is Medicare, Medicaid, a Blue Cross Blue Shield plan, a commercial plan, or any other health plan. LU Location Number REF-02 127 Other Payer Supervising Provider Identifier Min 1 Max 50 String (AN) Required Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier 1/30/25, 11:52 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 238/665 2330G Other Payer Billing Provider Loop Max 1 Optional Variants (all may be used) Other Subscriber Name Loop Other Payer Name Loop Other Payer Referring Provider Loop Other Payer Rendering Provider Loop Other Payer Service Facility Location Loop Other Payer Supervising Provider Loop NM1 3250 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > Other Subscriber Information Loop > Other Payer Billing Provider Loop > NM1 Other Payer Billing Provider To supply the full name of an individual or organizational entity Usage notes Required prior to the mandated implementation of the HIPAA National Provider Identifier (NPI) rule when the provider in the corresponding Loop ID-2310 is sent and one or more additional payer-specific provider identification numbers are required by this non-destination payer (Loop ID-2330B) to identify the provider. OR Required after the mandated implementation of the NPI rule for providers who are not Health Care Providers when the provider is sent in the corresponding Loop ID-2310 and one or more additional payer-specific provider identification numbers are required by this non-destination payer (Loop ID-2330B) to identify the provider. If not required by this implementation guide, do not send. See Crosswalking COB Data Elements section for more information on handling COB in the 837. Example NM1851~ Max use 1 Required NM1-01 98 Entity Identifier Code Identifier (ID) Required Code identifying an organizational entity, a physical location, property or an individual 85 Billing Provider NM1-02 1065 Entity Type Qualifier Identifier (ID) Required Code qualifying the type of entity NM102 qualifies NM103. 1 Person 2 Non-Person Entity 1/30/25, 11:52 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 239/665 2330G Other Payer Billing Provider Loop end 2320 Other Subscriber Information Loop end REF 3550 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > Other Subscriber Information Loop > Other Payer Billing Provider Loop > REF Other Payer Billing Provider Secondary Identification To specify identifying information Usage notes See Crosswalking COB Data Elements section for more information on handling COB in the 837. Example REFLUXX~ Max use 2 Required REF-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification G2 Provider Commercial Number This code designates a proprietary provider number for the non-destination payer identified in the Other Payer Name Loop ID-2330B for this iteration of Loop ID-2320. This is true regardless of whether that payer is Medicare, Medicaid, a Blue Cross Blue Shield plan, a commercial plan, or any other health plan. LU Location Number REF-02 127 Other Payer Billing Provider Identifier Min 1 Max 50 String (AN) Required Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier 1/30/25, 11:52 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 240/665 2400 Service Line Number Loop Max 50 Required LX 3650 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > Service Line Number Loop > LX Service Line Number To reference a line number in a transaction set Usage notes The LX functions as a line counter. The Service Line LX segment must begin with one and is incremented by one for each additional service line of a claim. LX01 is used to indicate bundling in SVD06 in the Line Item Adjudication loop. See Section 1.4.1.2 for more information on bundling and unbundling. Example LX00000~ Max use 1 Required LX-01 554 Assigned Number Min 1 Max 6 Numeric (N0) Required Number assigned for differentiation within a transaction set 1/30/25, 11:52 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 241/665 SV1 3700 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > Service Line Number Loop > SV1 Professional Service To specify the service line item detail for a health care professional Example SV1ER>XXXX>XX>XX>XX>XX>XXXX000000MJ0000000000 00XX0>00>0>0Y*YY***0~ Max use 1 Required SV1-01 C003 Composite Medical Procedure Identifier To identify a medical procedure by its standardized codes and applicable modifiers Max use 1 Required C003-01 235 Product or Service ID Qualifier Identifier (ID) Required Code identifying the type/source of the descriptive number used in Product/Service ID (234) C003-01 qualifies C003-02 and C003-08. Usage notes The NDC number is used for reporting prescribed drugs and biologics when required by government regulation, or as deemed by the provider to enhance claim reporting or adjudication processes. The NDC number is reported in the LIN segment of Loop ID- 2410 only. ER Jurisdiction Specific Procedure and Supply Codes This code set is not allowed for use under HIPAA at the time of this writing. The qualifier can only be used: If a new rule names the Jurisdiction Specific Procedure and Supply Codes as an allowable code set under HIPAA, OR The Secretary grants an exception to use the code set as a pilot project as allowed under the law, OR For claims which are not covered under HIPAA. HC Health Care Financing Administration Common Procedural Coding System (HCPCS) Codes Because the AMA's CPT codes are also level 1 HCPCS codes, they are reported under HC. IV Home Infusion EDI Coalition (HIEC) Product/Service Code This code set is not allowed for use under HIPAA at the time of this writing. The qualifier can only be used: If a new rule names the Home Infusion EDI Coalition (HIEC) Product/Service Codes as an allowable code set under HIPAA, OR The Secretary grants an exception to use the code set as a pilot project as allowed under the law, OR For claims which are not covered under HIPAA.; WK Advanced Billing Concepts (ABC) Codes At the time of this writing, this code set has been approved by the Secretary of HHS as a pilot project allowed under HIPAA law. The qualifier may only be used in transactions covered under HIPAA; 1/30/25, 11:52 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 242/665 By parties registered in the pilot project and their trading partners, OR If a new rule names the Complementary, Alternative, or Holistic Procedure Codes as an allowable code set under HIPAA, OR For claims which are not covered under HIPAA. C003-02 234 Procedure Code Min 1 Max 48 String (AN) Required Identifying number for a product or service If C003-08 is used, then C003-02 represents the beginning value in the range in which the code occurs. C003-03 1339 Procedure Modifier Min 2 Max 2 String (AN) Optional This identifies special circumstances related to the performance of the service, as defined by trading partners C003-03 modifies the value in C003-02 and C003-08. C003-04 1339 Procedure Modifier Min 2 Max 2 String (AN) Optional This identifies special circumstances related to the performance of the service, as defined by trading partners C003-04 modifies the value in C003-02 and C003-08. C003-05 1339 Procedure Modifier Min 2 Max 2 String (AN) Optional This identifies special circumstances related to the performance of the service, as defined by trading partners C003-05 modifies the value in C003-02 and C003-08. C003-06 1339 Procedure Modifier Min 2 Max 2 String (AN) Optional This identifies special circumstances related to the performance of the service, as defined by trading partners C003-06 modifies the value in C003-02 and C003-08. C003-07 352 Description Min 1 Max 80 String (AN) Optional A free-form description to clarify the related data elements and their content C003-07 is the description of the procedure identified in C003-02. SV1-02 782 Line Item Charge Amount Min 1 Max 15 Decimal number (R) Required 1/30/25, 11:52 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 243/665 Monetary amount SV102 is the submitted service line item amount. Usage notes This is the total charge amount for this service line. The amount is inclusive of the provider's base charge and any applicable tax and/or postage claimed amounts reported within this line's AMT segments. Zero "0" is an acceptable value for this element. SV1-03 355 Unit or Basis for Measurement Code Identifier (ID) Required Code specifying the units in which a value is being expressed, or manner in which a measurement has been taken MJ Minutes Required for Anesthesia claims. Anesthesia time is counted from the moment that the practitioner, having completed the preoperative evaluation, starts an intravenous line, places monitors, administers pre- anesthesia sedation, or otherwise physically begins to prepare the patient for anesthesia. Time	Home State Health 837 Health Care Claim_ Professional.pdf
names the Home Infusion EDI Coalition (HIEC) Product/Service Codes as an allowable code set under HIPAA, OR The Secretary grants an exception to use the code set as a pilot project as allowed under the law, OR For claims which are not covered under HIPAA.; WK Advanced Billing Concepts (ABC) Codes At the time of this writing, this code set has been approved by the Secretary of HHS as a pilot project allowed under HIPAA law. The qualifier may only be used in transactions covered under HIPAA; 1/30/25, 11:52 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 242/665 By parties registered in the pilot project and their trading partners, OR If a new rule names the Complementary, Alternative, or Holistic Procedure Codes as an allowable code set under HIPAA, OR For claims which are not covered under HIPAA. C003-02 234 Procedure Code Min 1 Max 48 String (AN) Required Identifying number for a product or service If C003-08 is used, then C003-02 represents the beginning value in the range in which the code occurs. C003-03 1339 Procedure Modifier Min 2 Max 2 String (AN) Optional This identifies special circumstances related to the performance of the service, as defined by trading partners C003-03 modifies the value in C003-02 and C003-08. C003-04 1339 Procedure Modifier Min 2 Max 2 String (AN) Optional This identifies special circumstances related to the performance of the service, as defined by trading partners C003-04 modifies the value in C003-02 and C003-08. C003-05 1339 Procedure Modifier Min 2 Max 2 String (AN) Optional This identifies special circumstances related to the performance of the service, as defined by trading partners C003-05 modifies the value in C003-02 and C003-08. C003-06 1339 Procedure Modifier Min 2 Max 2 String (AN) Optional This identifies special circumstances related to the performance of the service, as defined by trading partners C003-06 modifies the value in C003-02 and C003-08. C003-07 352 Description Min 1 Max 80 String (AN) Optional A free-form description to clarify the related data elements and their content C003-07 is the description of the procedure identified in C003-02. SV1-02 782 Line Item Charge Amount Min 1 Max 15 Decimal number (R) Required 1/30/25, 11:52 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 243/665 Monetary amount SV102 is the submitted service line item amount. Usage notes This is the total charge amount for this service line. The amount is inclusive of the provider's base charge and any applicable tax and/or postage claimed amounts reported within this line's AMT segments. Zero "0" is an acceptable value for this element. SV1-03 355 Unit or Basis for Measurement Code Identifier (ID) Required Code specifying the units in which a value is being expressed, or manner in which a measurement has been taken MJ Minutes Required for Anesthesia claims. Anesthesia time is counted from the moment that the practitioner, having completed the preoperative evaluation, starts an intravenous line, places monitors, administers pre- anesthesia sedation, or otherwise physically begins to prepare the patient for anesthesia. Time continues throughout the case and while the practitioner accompanies the patient to the post-anesthesia recovery unit (PACU). Time stops when the practitioner releases the patient to the care of PACU personnel. UN Unit SV1-04 380 Service Unit Count Min 1 Max 15 Decimal number (R) Required Numeric value of quantity Usage notes Note: When a decimal is needed to report units, include it in this element, for example, "15.6". The maximum length for this field is 8 digits excluding the decimal. When a decimal is used, the maximum number of digits allowed to the right of the decimal is three. SV1-05 1331 Place of Service Code Min 1 Max 2 String (AN) Optional Code identifying where services were, or may be, performed; the first and second positions of the Uniform Bill Type Code for Institutional Services or the Place of Service Codes for Professional or Dental Services. SV105 is the place of service. Usage notes See CODE SOURCE 237: Place of Service Codes for Professional Claims SV1-07 C004 Composite Diagnosis Code Pointer To identify one or more diagnosis code pointers Max use 1 Required C004-01 1328 Diagnosis Code Pointer Min 1 Max 2 Numeric (N0) Required 1/30/25, 11:52 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 244/665 A pointer to the diagnosis code in the order of importance to this service C004-01 identifies the primary diagnosis code for this service line. Usage notes This first pointer designates the primary diagnosis for this service line. Remaining diagnosis pointers indicate declining level of importance to service line. Acceptable values are 1 through 12, and correspond to Composite Data Elements 01 through 12 in the Health Care Diagnosis Code HI segment in the Claim Loop ID-2300. C004-02 1328 Diagnosis Code Pointer Min 1 Max 2 Numeric (N0) Optional A pointer to the diagnosis code in the order of importance to this service C004-02 identifies the second diagnosis code for this service line. C004-03 1328 Diagnosis Code Pointer Min 1 Max 2 Numeric (N0) Optional A pointer to the diagnosis code in the order of importance to this service C004-03 identifies the third diagnosis code for this service line. C004-04 1328 Diagnosis Code Pointer Min 1 Max 2 Numeric (N0) Optional A pointer to the diagnosis code in the order of importance to this service C004-04 identifies the fourth diagnosis code for this service line. SV1-09 1073 Emergency Indicator Identifier (ID) Optional Code indicating a Yes or No condition or response SV109 is the emergency-related indicator; a "Y" value indicates service provided was emergency related; an "N" value indicates service provided was not emergency related. Usage notes For this implementation, the listed value takes precedence over the semantic note. Emergency definition: The patient requires immediate medical intervention as a result of severe, life threatening, or potentially disabling conditions. Y Yes SV1-11 1073 EPSDT Indicator Identifier (ID) Optional Code indicating a Yes or No condition or response SV111 is early and periodic screen for diagnosis and treatment of children (EPSDT) involvement; a "Y" value indicates EPSDT involvement; an "N" value indicates no EPSDT involvement. Usage notes For this implementation, the listed value takes precedence over the semantic note. 1/30/25, 11:52 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 245/665 When this element is used, this service is not the screening service. Y Yes SV1-12 1073 Family Planning Indicator Identifier (ID) Optional Code indicating a Yes or No condition or response SV112 is the family planning involvement indicator. A "Y" value indicates family planning services involvement; an "N" value indicates no family planning services involvement. Usage notes For this implementation, the listed value takes precedence over the semantic note. Y Yes SV1-15 1327 Co-Pay Status Code Identifier (ID) Optional Code indicating whether or not co-payment requirements were met on a line by line basis 0 Copay exempt 1/30/25, 11:52 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 246/665 SV5 4000 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > Service Line Number Loop > SV5 Durable Medical Equipment Service To specify the claim service detail for durable medical equipment Usage notes Required when necessary to report both the rental and purchase price information for durable medical equipment. This is not used for claims where the provider is reporting only the rental price or only the purchase price. If not required by this implementation guide, do not send. Example SV5HC>XXXXXXDA0000000000000000000000000006~ Max use 1 Optional SV5-01 C003 Composite Medical Procedure Identifier To identify a medical procedure by its standardized codes and applicable modifiers Max use 1 Required C003-01 235 Procedure Identifier Identifier (ID) Required Code identifying the type/source of the descriptive number used in Product/Service ID (234) C003-01 qualifies C003-02 and C003-08. HC Health Care Financing Administration Common Procedural Coding System (HCPCS) Codes Because the AMA's CPT codes are also level 1 HCPCS codes, they are reported under HC. C003-02 234 Procedure Code Min 1 Max 48 String (AN) Required Identifying number for a product or service If C003-08 is used, then C003-02 represents the beginning value in the range in which the code occurs. Usage notes This value must be the same as that reported in SV101-2. SV5-02 355 Unit or Basis for Measurement Code Identifier (ID) Required Code specifying the units in which a value is being expressed, or manner in which a measurement has been taken DA Days SV5-03 380 Length of Medical Necessity Min 1 Max 15 Decimal number (R) Required Numeric value of quantity 1/30/25, 11:52 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 247/665 SV503 is the length of medical treatment required. SV5-04 782 DME Rental Price Min 1 Max 15 Decimal number (R) Required Monetary amount SV504 is the rental price. SV5-05 782 DME Purchase Price Min 1 Max 15 Decimal number (R) Required Monetary amount SV505 is the purchase price. SV5-06 594 Rental Unit Price Indicator Identifier (ID) Required Code indicating frequency or type of activities or actions being reported SV506 is the frequency at which the rental equipment is billed. 1 Weekly 4 Monthly 6 Daily 1/30/25, 11:52 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 248/665 PWK 4200 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > Service Line Number Loop > PWK Durable Medical Equipment Certificate of Medical Necessity Indicator To identify the type or transmission or both of paperwork or supporting information Usage notes Required on claims that include a Durable Medical Equipment Regional Carrier (DMERC) Certificate of Medical Necessity (CMN). If not required by this implementation guide, do not send.; Example PWKCTAG~ Variants (all may be used) PWK Line Supplemental Information Max use 1 Optional PWK-01 755 Attachment Report Type Code Identifier (ID) Required Code indicating the title or contents of a document, report or supporting item CT Certification PWK-02 756 Attachment Transmission Code Identifier (ID) Required Code defining timing, transmission method or format by which reports are to be sent Usage notes Required when the actual attachment is maintained by an attachment warehouse or similar vendor. AB Previously Submitted to Payer AD Certification Included in this Claim AF Narrative Segment Included in this Claim AG No Documentation is Required NS Not Specified NS = Paperwork is available on request at the provider's site. This means that the paperwork is not being sent with the claim at this time. Instead, it is available to the payer (or appropriate entity) at their request. 1/30/25, 11:52 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 249/665 PWK 4200 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > Service Line Number Loop > PWK Line Supplemental Information To identify the type or transmission or both of paperwork or supporting information Usage notes Required when there is a paper attachment following this claim. OR Required when attachments are sent electronically (PWK02 = EL) but are transmitted in another functional group (for example, 275) rather than by paper. PWK06 is then used to identify the attached electronic documentation. The number in PWK06 is carried in the TRN of the electronic attachment. OR Required when the provider deems it necessary to identify additional information that is being held at the provider's office and is available upon request by the payer (or appropriate entity), but the information is not being submitted with the claim. Use the value of "AA" in PWK02 to convey this specific use of the PWK segment. If not required by this implementation guide, do not send. Example PWKASEL**ACXXXX~ Variants (all may be used) PWK Durable Medical Equipment Certificate of Medical Necessity Indicator If either Identification Code Qualifier (PWK-05) or Attachment Control Number (PWK-06) is present, then the other is required Max use 10 Optional PWK-01 755 Attachment Report Type Code Identifier (ID) Required Code indicating the title or contents of a document, report or supporting item 03 Report Justifying Treatment Beyond Utilization Guidelines 04 Drugs Administered 05 Treatment Diagnosis 06 Initial Assessment 07 Functional Goals 08 Plan of Treatment	Home State Health 837 Health Care Claim_ Professional.pdf
equipment is billed. 1 Weekly 4 Monthly 6 Daily 1/30/25, 11:52 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 248/665 PWK 4200 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > Service Line Number Loop > PWK Durable Medical Equipment Certificate of Medical Necessity Indicator To identify the type or transmission or both of paperwork or supporting information Usage notes Required on claims that include a Durable Medical Equipment Regional Carrier (DMERC) Certificate of Medical Necessity (CMN). If not required by this implementation guide, do not send.; Example PWKCTAG~ Variants (all may be used) PWK Line Supplemental Information Max use 1 Optional PWK-01 755 Attachment Report Type Code Identifier (ID) Required Code indicating the title or contents of a document, report or supporting item CT Certification PWK-02 756 Attachment Transmission Code Identifier (ID) Required Code defining timing, transmission method or format by which reports are to be sent Usage notes Required when the actual attachment is maintained by an attachment warehouse or similar vendor. AB Previously Submitted to Payer AD Certification Included in this Claim AF Narrative Segment Included in this Claim AG No Documentation is Required NS Not Specified NS = Paperwork is available on request at the provider's site. This means that the paperwork is not being sent with the claim at this time. Instead, it is available to the payer (or appropriate entity) at their request. 1/30/25, 11:52 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 249/665 PWK 4200 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > Service Line Number Loop > PWK Line Supplemental Information To identify the type or transmission or both of paperwork or supporting information Usage notes Required when there is a paper attachment following this claim. OR Required when attachments are sent electronically (PWK02 = EL) but are transmitted in another functional group (for example, 275) rather than by paper. PWK06 is then used to identify the attached electronic documentation. The number in PWK06 is carried in the TRN of the electronic attachment. OR Required when the provider deems it necessary to identify additional information that is being held at the provider's office and is available upon request by the payer (or appropriate entity), but the information is not being submitted with the claim. Use the value of "AA" in PWK02 to convey this specific use of the PWK segment. If not required by this implementation guide, do not send. Example PWKASEL**ACXXXX~ Variants (all may be used) PWK Durable Medical Equipment Certificate of Medical Necessity Indicator If either Identification Code Qualifier (PWK-05) or Attachment Control Number (PWK-06) is present, then the other is required Max use 10 Optional PWK-01 755 Attachment Report Type Code Identifier (ID) Required Code indicating the title or contents of a document, report or supporting item 03 Report Justifying Treatment Beyond Utilization Guidelines 04 Drugs Administered 05 Treatment Diagnosis 06 Initial Assessment 07 Functional Goals 08 Plan of Treatment 09 Progress Report 10 Continued Treatment 11 Chemical Analysis 13 Certified Test Report 15 Justification for Admission 21 Recovery Plan A3 Allergies/Sensitivities Document A4 Autopsy Report AM Ambulance Certification AS Admission Summary B2 Prescription B3 Physician Order B4 Referral Form BR Benchmark Testing Results 1/30/25, 11:52 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 250/665 BS Baseline BT Blanket Test Results CB Chiropractic Justification CK Consent Form(s) CT Certification D2 Drug Profile Document DA Dental Models DB Durable Medical Equipment Prescription DG Diagnostic Report DJ Discharge Monitoring Report DS Discharge Summary EB Explanation of Benefits (Coordination of Benefits or Medicare Secondary Payor) HC Health Certificate HR Health Clinic Records I5 Immunization Record IR State School Immunization Records LA Laboratory Results M1 Medical Record Attachment MT Models NN Nursing Notes OB Operative Note OC Oxygen Content Averaging Report OD Orders and Treatments Document OE Objective Physical Examination (including vital signs) Document OX Oxygen Therapy Certification OZ Support Data for Claim P4 Pathology Report P5 Patient Medical History Document PE Parenteral or Enteral Certification PN Physical Therapy Notes PO Prosthetics or Orthotic Certification PQ Paramedical Results PY Physician's Report PZ Physical Therapy Certification RB Radiology Films RR Radiology Reports RT Report of Tests and Analysis Report RX Renewable Oxygen Content Averaging Report SG Symptoms Document V5 Death Notification XP Photographs PWK-02 756 Attachment Transmission Code Identifier (ID) Required Code defining timing, transmission method or format by which reports are to be sent Usage notes Required when the actual attachment is maintained by an attachment warehouse or similar vendor. AA Available on Request at Provider Site 1/30/25, 11:52 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 251/665 This means that the additional information is not being sent with the claim at this time. Instead, it is available to the payer (or appropriate entity) at their request. BM By Mail EL Electronically Only Indicates that the attachment is being transmitted in a separate X12 functional group. EM E-Mail FT File Transfer FX By Fax PWK-05 66 Identification Code Qualifier Identifier (ID) Optional Code designating the system/method of code structure used for Identification Code (67) PWK05 and PWK06 may be used to identify the addressee by a code number. AC Attachment Control Number PWK-06 67 Attachment Control Number Min 2 Max 80 String (AN) Optional Code identifying a party or other code Usage notes PWK06 is used to identify the attached electronic documentation. The number in PWK06 is carried in the TRN of the electronic attachment. For the purpose of this implementation, the maximum field length is 50. 1/30/25, 11:52 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 252/665 CR1 4250 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > Service Line Number Loop > CR1 Ambulance Transport Information To supply information related to the ambulance service rendered to a patient Usage notes Required on ambulance transport services when the information applicable to any one of the segment's elements is different than the information reported in the CR1 at the claim level (Loop ID-2300). If not required by this implementation guide, do not send. Example CR1LB0000000*ADH00000*XXXXX~ If either Unit or Basis for Measurement Code (CR1-01) or Patient Weight (CR1-02) is present, then the other is required Max use 1 Optional CR1-01 355 Unit or Basis for Measurement Code Identifier (ID) Optional Code specifying the units in which a value is being expressed, or manner in which a measurement has been taken LB Pound CR1-02 81 Patient Weight Min 1 Max 10 Decimal number (R) Optional Numeric value of weight CR102 is the weight of the patient at time of transport. CR1-04 1317 Ambulance Transport Reason Code Identifier (ID) Required Code indicating the reason for ambulance transport A Patient was transported to nearest facility for care of symptoms, complaints, or both B Patient was transported for the benefit of a preferred physician C Patient was transported for the nearness of family members D Patient was transported for the care of a specialist or for availability of specialized equipment E Patient Transferred to Rehabilitation Facility CR1-05 355 Unit or Basis for Measurement Code Identifier (ID) Required Code specifying the units in which a value is being expressed, or manner in which a measurement has been taken DH Miles CR1-06 380 Transport Distance Min 1 Max 15 Decimal number (R) Required Numeric value of quantity CR106 is the distance traveled during transport. 1/30/25, 11:52 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 253/665 Usage notes 0 (zero) is a valid value when ambulance services do not include a charge for mileage. CR1-09 352 Round Trip Purpose Description Min 1 Max 80 String (AN) Optional A free-form description to clarify the related data elements and their content CR109 is the purpose for the round trip ambulance service. CR1-10 352 Stretcher Purpose Description Min 1 Max 80 String (AN) Optional A free-form description to clarify the related data elements and their content CR110 is the purpose for the usage of a stretcher during ambulance service. 1/30/25, 11:52 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 254/665 CR3 4350 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > Service Line Number Loop > CR3 Durable Medical Equipment Certification To supply information regarding a physician's certification for durable medical equipment Usage notes Required when a Durable Medical Equipment Regional Carrier Certificate of Medical Necessity (DMERC CMN) or a DMERC Information Form (DIF) or Oxygen Therapy Certification is included on this service line. If not required by this implementation guide, do not send. Example CR3RMO000000000000000~ Max use 1 Optional CR3-01 1322 Certification Type Code Identifier (ID) Required Code indicating the type of certification I Initial R Renewal S Revised CR3-02 355 Unit or Basis for Measurement Code Identifier (ID) Required Code specifying the units in which a value is being expressed, or manner in which a measurement has been taken CR302 and CR303 specify the time period covered by this certification. MO Months CR3-03 380 Durable Medical Equipment Duration Min 1 Max 15 Decimal number (R) Required Numeric value of quantity Usage notes Length of time DME equipment is needed. 1/30/25, 11:52 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 255/665 CRC 4500 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > Service Line Number Loop > CRC Ambulance Certification To supply information on conditions Usage notes The maximum number of CRC segments which can occur per Loop ID-2400 is 3. Submitters are free to mix and match the three types of service line level CRC segments shown in this implementation guide to meet their billing or reporting needs but no more than a total of 3 CRC segments per Loop ID-2400 are allowed. Required on ambulance transport services when the information applicable to any one of the segment's elements is different than the information reported in the Ambulance Certification CRC at the claim level (Loop ID-2300). If not required by this implementation guide, do not send. Example CRC07Y12XXXXXXXX~ Variants (all may be used) CRC Condition Indicator/Durable Medical Equipment CRC Hospice Employee Indicator Max use 3 Optional CRC-01 1136 Code Category Identifier (ID) Required Specifies the situation or category to which the code applies CRC01 qualifies CRC03 through CRC07. 07 Ambulance Certification CRC-02 1073 Certification Condition Indicator Identifier (ID) Required Code indicating a Yes or No condition or response CRC02 is a Certification Condition Code applies indicator. A "Y" value indicates the condition codes in CRC03 through CRC07 apply; an "N" value indicates the condition codes in CRC03 through CRC07 do not apply. N No Y Yes CRC-03 1321 Condition Code Identifier (ID) Required Code indicating a condition Usage notes The codes for CRC03 also can be used for CRC04 through CRC07. 01 Patient was admitted to a hospital 04 Patient was moved by stretcher 05 Patient was unconscious or in shock 06 Patient was transported in an emergency situation 1/30/25, 11:52 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 256/665 07 Patient had to be physically restrained 08 Patient had visible hemorrhaging 09 Ambulance service was medically necessary 12 Patient is confined to a bed or chair Use code 12 to indicate patient was bedridden during transport. CRC-04 1321 Condition Code Min 2 Max 3 Identifier (ID) Optional Code indicating a condition Usage notes Use the codes listed in CRC03. CRC-05 1321 Condition Code Min 2 Max 3 Identifier (ID) Optional Code indicating a condition Usage notes Use the codes listed in CRC03. CRC-06 1321 Condition Code Min 2 Max 3 Identifier (ID) Optional Code indicating a condition Usage notes Use the codes listed in CRC03. CRC-07 1321 Condition Code Min 2 Max 3 Identifier (ID) Optional Code indicating a condition Usage notes Use the codes listed in CRC03. 1/30/25, 11:52 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 257/665 CRC 4500 Detail > Billing Provider Hierarchical Level	Home State Health 837 Health Care Claim_ Professional.pdf
period covered by this certification. MO Months CR3-03 380 Durable Medical Equipment Duration Min 1 Max 15 Decimal number (R) Required Numeric value of quantity Usage notes Length of time DME equipment is needed. 1/30/25, 11:52 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 255/665 CRC 4500 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > Service Line Number Loop > CRC Ambulance Certification To supply information on conditions Usage notes The maximum number of CRC segments which can occur per Loop ID-2400 is 3. Submitters are free to mix and match the three types of service line level CRC segments shown in this implementation guide to meet their billing or reporting needs but no more than a total of 3 CRC segments per Loop ID-2400 are allowed. Required on ambulance transport services when the information applicable to any one of the segment's elements is different than the information reported in the Ambulance Certification CRC at the claim level (Loop ID-2300). If not required by this implementation guide, do not send. Example CRC07Y12XXXXXXXX~ Variants (all may be used) CRC Condition Indicator/Durable Medical Equipment CRC Hospice Employee Indicator Max use 3 Optional CRC-01 1136 Code Category Identifier (ID) Required Specifies the situation or category to which the code applies CRC01 qualifies CRC03 through CRC07. 07 Ambulance Certification CRC-02 1073 Certification Condition Indicator Identifier (ID) Required Code indicating a Yes or No condition or response CRC02 is a Certification Condition Code applies indicator. A "Y" value indicates the condition codes in CRC03 through CRC07 apply; an "N" value indicates the condition codes in CRC03 through CRC07 do not apply. N No Y Yes CRC-03 1321 Condition Code Identifier (ID) Required Code indicating a condition Usage notes The codes for CRC03 also can be used for CRC04 through CRC07. 01 Patient was admitted to a hospital 04 Patient was moved by stretcher 05 Patient was unconscious or in shock 06 Patient was transported in an emergency situation 1/30/25, 11:52 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 256/665 07 Patient had to be physically restrained 08 Patient had visible hemorrhaging 09 Ambulance service was medically necessary 12 Patient is confined to a bed or chair Use code 12 to indicate patient was bedridden during transport. CRC-04 1321 Condition Code Min 2 Max 3 Identifier (ID) Optional Code indicating a condition Usage notes Use the codes listed in CRC03. CRC-05 1321 Condition Code Min 2 Max 3 Identifier (ID) Optional Code indicating a condition Usage notes Use the codes listed in CRC03. CRC-06 1321 Condition Code Min 2 Max 3 Identifier (ID) Optional Code indicating a condition Usage notes Use the codes listed in CRC03. CRC-07 1321 Condition Code Min 2 Max 3 Identifier (ID) Optional Code indicating a condition Usage notes Use the codes listed in CRC03. 1/30/25, 11:52 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 257/665 CRC 4500 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > Service Line Number Loop > CRC Condition Indicator/Durable Medical Equipment To supply information on conditions Usage notes Required when a Durable Medical Equipment Regional Carrier Certificate of Medical Necessity (DMERC CMN) or a DMERC Information Form (DIF), or Oxygen Therapy Certification is included on this service line and the information is necessary for adjudication. If not required by this implementation guide, do not send. The maximum number of CRC segments which can occur per Loop ID-2400 is 3. Submitters are free to mix and match the three types of service line level CRC segments shown in this implementation guide to meet their billing or reporting needs but no more than a total of 3 CRC segments per Loop ID-2400 are allowed. The first example shows a case where an item billed was not a replacement item. Example CRC09NZVXX~ Variants (all may be used) CRC Ambulance Certification CRC Hospice Employee Indicator Max use 1 Optional CRC-01 1136 Code Category Identifier (ID) Required Specifies the situation or category to which the code applies CRC01 qualifies CRC03 through CRC07. 09 Durable Medical Equipment Certification CRC-02 1073 Certification Condition Indicator Identifier (ID) Required Code indicating a Yes or No condition or response CRC02 is a Certification Condition Code applies indicator. A "Y" value indicates the condition codes in CRC03 through CRC07 apply; an "N" value indicates the condition codes in CRC03 through CRC07 do not apply. N No Y Yes CRC-03 1321 Condition Indicator Identifier (ID) Required Code indicating a condition 38 Certification signed by the physician is on file at the supplier's office ZV Replacement Item CRC-04 1321 Condition Indicator Min 2 Max 3 Identifier (ID) Optional 1/30/25, 11:52 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 258/665 Code indicating a condition Usage notes Use the codes listed in CRC03. 1/30/25, 11:52 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 259/665 CRC 4500 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > Service Line Number Loop > CRC Hospice Employee Indicator To supply information on conditions Usage notes Required on all Medicare claims involving physician services to hospice patients. If not required by this implementation guide, do not send. The maximum number of CRC segments which can occur per Loop ID-2400 is 3. Submitters are free to mix and match the three types of service line level CRC segments shown in this implementation guide to meet their billing or reporting needs but no more than a total of 3 CRC segments per Loop ID-2400 are allowed. The example shows the method used to indicate whether the rendering provider is an employee of the hospice. Example CRC70Y65~ Variants (all may be used) CRC Ambulance Certification CRC Condition Indicator/Durable Medical Equipment Max use 1 Optional CRC-01 1136 Code Category Identifier (ID) Required Specifies the situation or category to which the code applies CRC01 qualifies CRC03 through CRC07. 70 Hospice CRC-02 1073 Hospice Employed Provider Indicator Identifier (ID) Required Code indicating a Yes or No condition or response CRC02 is a Certification Condition Code applies indicator. A "Y" value indicates the condition codes in CRC03 through CRC07 apply; an "N" value indicates the condition codes in CRC03 through CRC07 do not apply. Usage notes A "Y" value indicates the provider is employed by the hospice. A "N" value indicates the provider is not employed by the hospice. N No Y Yes CRC-03 1321 Condition Indicator Identifier (ID) Required Code indicating a condition 1/30/25, 11:52 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 260/665 65 Open This code value is a placeholder to satisfy the Mandatory Data Element syntax requirement. 1/30/25, 11:52 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 261/665 DTP 4550 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > Service Line Number Loop > DTP Date - Begin Therapy Date To specify any or all of a date, a time, or a time period Usage notes Required when a Durable Medical Equipment Regional Carrier Certificate of Medical Necessity (DMERC CMN) or DMERC Information Form (DIF), or Oxygen Therapy Certification is included on this service line. If not required by this implementation guide, do not send. Example DTP463D8XXXXX~ Variants (all may be used) DTP DATE - Certification Revision/Recertification Date DTP Date - Initial Treatment Date DTP Date - Last Certification Date DTP Date - Last Seen Date DTP Date - Last X-ray Date DTP Date - Prescription Date DTP Date - Service Date DTP Date - Shipped Date DTP Date - Test Date Max use 1 Optional DTP-01 374 Date Time Qualifier Identifier (ID) Required Code specifying type of date or time, or both date and time 463 Begin Therapy DTP-02 1250 Date Time Period Format Qualifier Identifier (ID) Required Code indicating the date format, time format, or date and time format DTP02 is the date or time or period format that will appear in DTP03. D8 Date Expressed in Format CCYYMMDD DTP-03 1251 Begin Therapy Date Min 1 Max 35 String (AN) Required Expression of a date, a time, or range of dates, times or dates and times 1/30/25, 11:52 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 262/665 DTP 4550 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > Service Line Number Loop > DTP DATE - Certification Revision/Recertification Date To specify any or all of a date, a time, or a time period Usage notes Required when CR301 (DMERC Certification) = "R" or "S". If not required by this implementation guide, do not send. Example DTP607D8XXXXXX~ Variants (all may be used) DTP Date - Begin Therapy Date DTP Date - Initial Treatment Date DTP Date - Last Certification Date DTP Date - Last Seen Date DTP Date - Last X-ray Date DTP Date - Prescription Date DTP Date - Service Date DTP Date - Shipped Date DTP Date - Test Date Max use 1 Optional DTP-01 374 Date Time Qualifier Identifier (ID) Required Code specifying type of date or time, or both date and time 607 Certification Revision DTP-02 1250 Date Time Period Format Qualifier Identifier (ID) Required Code indicating the date format, time format, or date and time format DTP02 is the date or time or period format that will appear in DTP03. D8 Date Expressed in Format CCYYMMDD DTP-03 1251 Certification Revision or Recertification Date String (AN) Required Min 1 Max 35 Expression of a date, a time, or range of dates, times or dates and times 1/30/25, 11:52 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 263/665 DTP 4550 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > Service Line Number Loop > DTP Date - Initial Treatment Date To specify any or all of a date, a time, or a time period Usage notes Required when the Initial Treatment Date is known to impact adjudication for claims involving spinal manipulation, physcial therapy, occupational therapy, or speech language pathology and when different from what is reported at the claim level. If not required by this implementation guide, do not send. Example DTP454D8X~ Variants (all may be used) DTP Date - Begin Therapy Date DTP DATE - Certification Revision/Recertification Date DTP Date - Last Certification Date DTP Date - Last Seen Date DTP Date - Last X-ray Date DTP Date - Prescription Date DTP Date - Service Date DTP Date - Shipped Date DTP Date - Test Date Max use 1 Optional DTP-01 374 Date Time Qualifier Identifier (ID) Required Code specifying type of date or time, or both date and time 454 Initial Treatment DTP-02 1250 Date Time Period Format Qualifier Identifier (ID) Required Code indicating the date format, time format, or date and time format DTP02 is the date or time or period format that will appear in DTP03. D8 Date Expressed in Format CCYYMMDD DTP-03 1251 Initial Treatment Date Min 1 Max 35 String (AN) Required Expression of a date, a time, or range of dates, times or dates and times 1/30/25, 11:52 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 264/665 DTP 4550 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > Service Line Number Loop > DTP Date - Last Certification Date To specify any or all of a date, a time, or a time period Usage notes Required when a Durable Medical Equipment Regional Carrier Certificate of Medical Necessity (DMERC CMN), DMERC Information Form (DIF), or Oxygen Therapy Certification is included on this service line. If not required by this implementation guide, do not send. This is the date the ordering physician signed the CMN or Oxygen Therapy Certification, or the date the supplier signed the DMERC Information Form (DIF). Example DTP461D8XXXX~ Variants (all may be used) DTP Date - Begin Therapy Date DTP DATE - Certification Revision/Recertification Date DTP	Home State Health 837 Health Care Claim_ Professional.pdf
DTP Date - Test Date Max use 1 Optional DTP-01 374 Date Time Qualifier Identifier (ID) Required Code specifying type of date or time, or both date and time 607 Certification Revision DTP-02 1250 Date Time Period Format Qualifier Identifier (ID) Required Code indicating the date format, time format, or date and time format DTP02 is the date or time or period format that will appear in DTP03. D8 Date Expressed in Format CCYYMMDD DTP-03 1251 Certification Revision or Recertification Date String (AN) Required Min 1 Max 35 Expression of a date, a time, or range of dates, times or dates and times 1/30/25, 11:52 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 263/665 DTP 4550 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > Service Line Number Loop > DTP Date - Initial Treatment Date To specify any or all of a date, a time, or a time period Usage notes Required when the Initial Treatment Date is known to impact adjudication for claims involving spinal manipulation, physcial therapy, occupational therapy, or speech language pathology and when different from what is reported at the claim level. If not required by this implementation guide, do not send. Example DTP454D8X~ Variants (all may be used) DTP Date - Begin Therapy Date DTP DATE - Certification Revision/Recertification Date DTP Date - Last Certification Date DTP Date - Last Seen Date DTP Date - Last X-ray Date DTP Date - Prescription Date DTP Date - Service Date DTP Date - Shipped Date DTP Date - Test Date Max use 1 Optional DTP-01 374 Date Time Qualifier Identifier (ID) Required Code specifying type of date or time, or both date and time 454 Initial Treatment DTP-02 1250 Date Time Period Format Qualifier Identifier (ID) Required Code indicating the date format, time format, or date and time format DTP02 is the date or time or period format that will appear in DTP03. D8 Date Expressed in Format CCYYMMDD DTP-03 1251 Initial Treatment Date Min 1 Max 35 String (AN) Required Expression of a date, a time, or range of dates, times or dates and times 1/30/25, 11:52 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 264/665 DTP 4550 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > Service Line Number Loop > DTP Date - Last Certification Date To specify any or all of a date, a time, or a time period Usage notes Required when a Durable Medical Equipment Regional Carrier Certificate of Medical Necessity (DMERC CMN), DMERC Information Form (DIF), or Oxygen Therapy Certification is included on this service line. If not required by this implementation guide, do not send. This is the date the ordering physician signed the CMN or Oxygen Therapy Certification, or the date the supplier signed the DMERC Information Form (DIF). Example DTP461D8XXXX~ Variants (all may be used) DTP Date - Begin Therapy Date DTP DATE - Certification Revision/Recertification Date DTP Date - Initial Treatment Date DTP Date - Last Seen Date DTP Date - Last X-ray Date DTP Date - Prescription Date DTP Date - Service Date DTP Date - Shipped Date DTP Date - Test Date Max use 1 Optional DTP-01 374 Date Time Qualifier Identifier (ID) Required Code specifying type of date or time, or both date and time 461 Last Certification DTP-02 1250 Date Time Period Format Qualifier Identifier (ID) Required Code indicating the date format, time format, or date and time format DTP02 is the date or time or period format that will appear in DTP03. D8 Date Expressed in Format CCYYMMDD DTP-03 1251 Last Certification Date Min 1 Max 35 String (AN) Required Expression of a date, a time, or range of dates, times or dates and times 1/30/25, 11:52 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 265/665 DTP 4550 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > Service Line Number Loop > DTP Date - Last Seen Date To specify any or all of a date, a time, or a time period Usage notes Required when a claim involves physician services for routine foot care; and is different than the date listed at the claim level and is known to impact the payer's adjudication process. If not required by this implementation guide, do not send.; Example DTP304D8XXX~ Variants (all may be used) DTP Date - Begin Therapy Date DTP DATE - Certification Revision/Recertification Date DTP Date - Initial Treatment Date DTP Date - Last Certification Date DTP Date - Last X-ray Date DTP Date - Prescription Date DTP Date - Service Date DTP Date - Shipped Date DTP Date - Test Date Max use 1 Optional DTP-01 374 Date Time Qualifier Identifier (ID) Required Code specifying type of date or time, or both date and time 304 Latest Visit or Consultation DTP-02 1250 Date Time Period Format Qualifier Identifier (ID) Required Code indicating the date format, time format, or date and time format DTP02 is the date or time or period format that will appear in DTP03. D8 Date Expressed in Format CCYYMMDD DTP-03 1251 Treatment or Therapy Date Min 1 Max 35 String (AN) Required Expression of a date, a time, or range of dates, times or dates and times 1/30/25, 11:52 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 266/665 DTP 4550 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > Service Line Number Loop > DTP Date - Last X-ray Date To specify any or all of a date, a time, or a time period Usage notes Required when claim involves spinal manipulation and an x-ray was taken and is different than information at the claim level (Loop ID-2300). If not required by this implementation guide, do not send. Example DTP455D8XX~ Variants (all may be used) DTP Date - Begin Therapy Date DTP DATE - Certification Revision/Recertification Date DTP Date - Initial Treatment Date DTP Date - Last Certification Date DTP Date - Last Seen Date DTP Date - Prescription Date DTP Date - Service Date DTP Date - Shipped Date DTP Date - Test Date Max use 1 Optional DTP-01 374 Date Time Qualifier Identifier (ID) Required Code specifying type of date or time, or both date and time 455 Last X-Ray DTP-02 1250 Date Time Period Format Qualifier Identifier (ID) Required Code indicating the date format, time format, or date and time format DTP02 is the date or time or period format that will appear in DTP03. D8 Date Expressed in Format CCYYMMDD DTP-03 1251 Last X-Ray Date Min 1 Max 35 String (AN) Required Expression of a date, a time, or range of dates, times or dates and times 1/30/25, 11:52 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 267/665 DTP 4550 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > Service Line Number Loop > DTP Date - Prescription Date To specify any or all of a date, a time, or a time period Usage notes Required when a drug is billed for this line and a prescription was written (or otherwise communicated by the prescriber if not written). If not required by this implementation guide, do not send. Example DTP471D8XXXXX~ Variants (all may be used) DTP Date - Begin Therapy Date DTP DATE - Certification Revision/Recertification Date DTP Date - Initial Treatment Date DTP Date - Last Certification Date DTP Date - Last Seen Date DTP Date - Last X-ray Date DTP Date - Service Date DTP Date - Shipped Date DTP Date - Test Date Max use 1 Optional DTP-01 374 Date Time Qualifier Identifier (ID) Required Code specifying type of date or time, or both date and time 471 Prescription DTP-02 1250 Date Time Period Format Qualifier Identifier (ID) Required Code indicating the date format, time format, or date and time format DTP02 is the date or time or period format that will appear in DTP03. D8 Date Expressed in Format CCYYMMDD DTP-03 1251 Prescription Date Min 1 Max 35 String (AN) Required Expression of a date, a time, or range of dates, times or dates and times 1/30/25, 11:52 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 268/665 DTP 4550 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > Service Line Number Loop > DTP Date - Service Date To specify any or all of a date, a time, or a time period Usage notes In cases where a drug is being billed on a service line, date range may be used to indicate drug duration for which the drug supply will be used by the patient. The difference in dates, including both the begin and end dates, are the days supply of the drug. Example: 20000101 - 20000107 (1/1/00 to 1/7/00) is used for a 7 day supply where the first day of the drug used by the patient is 1/1/00. In the event a drug is administered on less than a daily basis (for example, every other day) the date range would include the entire period during which the drug was supplied, including the last day the drug was used. Example: 20000101 - 20000108 (1/1/00 to 1/8/00) is used for an 8 days supply where the prescription is written for Q48 (every 48 hours), four doses of the drug are dispensed and the first dose is used on 1/1/00. Example DTP472RD8XXXX~ Variants (all may be used) DTP Date - Begin Therapy Date DTP DATE - Certification Revision/Recertification Date DTP Date - Initial Treatment Date DTP Date - Last Certification Date DTP Date - Last Seen Date DTP Date - Last X-ray Date DTP Date - Prescription Date DTP Date - Shipped Date DTP Date - Test Date Max use 1 Required DTP-01 374 Date Time Qualifier Identifier (ID) Required Code specifying type of date or time, or both date and time 472 Service DTP-02 1250 Date Time Period Format Qualifier Identifier (ID) Required Code indicating the date format, time format, or date and time format DTP02 is the date or time or period format that will appear in DTP03. Usage notes RD8 is required only when the "To and From" dates are different. However, at the discretion of the submitter, RD8 can also be used when the "To and From" dates are the same. 1/30/25, 11:52 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 269/665 D8 Date Expressed in Format CCYYMMDD RD8 Range of Dates Expressed in Format CCYYMMDD-CCYYMMDD DTP-03 1251 Service Date Min 1 Max 35 String (AN) Required Expression of a date, a time, or range of dates, times or dates and times 1/30/25, 11:52 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 270/665 DTP 4550 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > Service Line Number Loop > DTP Date - Shipped Date To specify any or all of a date, a time, or a time period Usage notes Required when billing or reporting shipped products. If not required by this implementation guide, do not send. Example DTP011D8*X~ Variants (all may be used) DTP Date - Begin Therapy Date DTP DATE - Certification Revision/Recertification Date DTP Date - Initial Treatment Date DTP Date - Last Certification Date DTP Date - Last Seen Date DTP Date - Last X-ray Date DTP Date - Prescription Date DTP Date - Service Date DTP Date - Test Date Max use 1 Optional DTP-01 374 Date Time Qualifier Identifier (ID) Required Code specifying type of date or time, or both date and time 011 Shipped DTP-02 1250 Date Time Period Format Qualifier Identifier (ID) Required Code indicating the date format, time format, or date and time format DTP02 is the date or time or period format that will appear in DTP03. D8 Date Expressed in Format CCYYMMDD DTP-03 1251 Shipped Date Min 1 Max	Home State Health 837 Health Care Claim_ Professional.pdf
drug used by the patient is 1/1/00. In the event a drug is administered on less than a daily basis (for example, every other day) the date range would include the entire period during which the drug was supplied, including the last day the drug was used. Example: 20000101 - 20000108 (1/1/00 to 1/8/00) is used for an 8 days supply where the prescription is written for Q48 (every 48 hours), four doses of the drug are dispensed and the first dose is used on 1/1/00. Example DTP472RD8XXXX~ Variants (all may be used) DTP Date - Begin Therapy Date DTP DATE - Certification Revision/Recertification Date DTP Date - Initial Treatment Date DTP Date - Last Certification Date DTP Date - Last Seen Date DTP Date - Last X-ray Date DTP Date - Prescription Date DTP Date - Shipped Date DTP Date - Test Date Max use 1 Required DTP-01 374 Date Time Qualifier Identifier (ID) Required Code specifying type of date or time, or both date and time 472 Service DTP-02 1250 Date Time Period Format Qualifier Identifier (ID) Required Code indicating the date format, time format, or date and time format DTP02 is the date or time or period format that will appear in DTP03. Usage notes RD8 is required only when the "To and From" dates are different. However, at the discretion of the submitter, RD8 can also be used when the "To and From" dates are the same. 1/30/25, 11:52 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 269/665 D8 Date Expressed in Format CCYYMMDD RD8 Range of Dates Expressed in Format CCYYMMDD-CCYYMMDD DTP-03 1251 Service Date Min 1 Max 35 String (AN) Required Expression of a date, a time, or range of dates, times or dates and times 1/30/25, 11:52 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 270/665 DTP 4550 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > Service Line Number Loop > DTP Date - Shipped Date To specify any or all of a date, a time, or a time period Usage notes Required when billing or reporting shipped products. If not required by this implementation guide, do not send. Example DTP011D8X~ Variants (all may be used) DTP Date - Begin Therapy Date DTP DATE - Certification Revision/Recertification Date DTP Date - Initial Treatment Date DTP Date - Last Certification Date DTP Date - Last Seen Date DTP Date - Last X-ray Date DTP Date - Prescription Date DTP Date - Service Date DTP Date - Test Date Max use 1 Optional DTP-01 374 Date Time Qualifier Identifier (ID) Required Code specifying type of date or time, or both date and time 011 Shipped DTP-02 1250 Date Time Period Format Qualifier Identifier (ID) Required Code indicating the date format, time format, or date and time format DTP02 is the date or time or period format that will appear in DTP03. D8 Date Expressed in Format CCYYMMDD DTP-03 1251 Shipped Date Min 1 Max 35 String (AN) Required Expression of a date, a time, or range of dates, times or dates and times 1/30/25, 11:52 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 271/665 DTP 4550 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > Service Line Number Loop > DTP Date - Test Date To specify any or all of a date, a time, or a time period Usage notes Required on initial EPO claims service lines for dialysis patients when test results are being billed or reported. If not required by this implementation guide, do not send. Example DTP738D8XXX~ Variants (all may be used) DTP Date - Begin Therapy Date DTP DATE - Certification Revision/Recertification Date DTP Date - Initial Treatment Date DTP Date - Last Certification Date DTP Date - Last Seen Date DTP Date - Last X-ray Date DTP Date - Prescription Date DTP Date - Service Date DTP Date - Shipped Date Max use 2 Optional DTP-01 374 Date Time Qualifier Identifier (ID) Required Code specifying type of date or time, or both date and time 738 Most Recent Hemoglobin or Hematocrit or Both 739 Most Recent Serum Creatine DTP-02 1250 Date Time Period Format Qualifier Identifier (ID) Required Code indicating the date format, time format, or date and time format DTP02 is the date or time or period format that will appear in DTP03. D8 Date Expressed in Format CCYYMMDD DTP-03 1251 Test Performed Date Min 1 Max 35 String (AN) Required Expression of a date, a time, or range of dates, times or dates and times 1/30/25, 11:52 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 272/665 QTY 4600 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > Service Line Number Loop > QTY Ambulance Patient Count To specify quantity information Usage notes Required when more than one patient is transported in the same vehicle for Ambulance or non-emergency transportation services. If not required by this implementation guide, do not send. The QTY02 is the only place to report the number of patients when there are multiple patients transported. Example QTYPT000000000000~ Variants (all may be used) QTY Obstetric Anesthesia Additional Units Max use 1 Optional QTY-01 673 Quantity Qualifier Identifier (ID) Required Code specifying the type of quantity PT Patients QTY-02 380 Ambulance Patient Count Min 1 Max 15 Decimal number (R) Required Numeric value of quantity 1/30/25, 11:52 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 273/665 QTY 4600 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > Service Line Number Loop > QTY Obstetric Anesthesia Additional Units To specify quantity information Usage notes Required in conjunction with anesthesia for obstetric services when the anesthesia provider chooses to report additional complexity beyond the normal services reflected by the procedure base units and anesthesia time. If not required by this implementation guide, do not send. Example QTYFL000000~ Variants (all may be used) QTY Ambulance Patient Count Max use 1 Optional QTY-01 673 Quantity Qualifier Identifier (ID) Required Code specifying the type of quantity FL Units QTY-02 380 Obstetric Additional Units Min 1 Max 15 Decimal number (R) Required Numeric value of quantity Usage notes The number of additional units reported by an anesthesia provider to reflect additional complexity of services. 1/30/25, 11:52 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 274/665 MEA 4620 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > Service Line Number Loop > MEA Test Result To specify physical measurements or counts, including dimensions, tolerances, variances, and weights (See Figures Appendix for example of use of C001) Usage notes Required on Dialysis related service lines for ESRD. Use R1, R2, R3, or R4 to qualify the Hemoglobin, Hematocrit, Epoetin Starting Dosage, and Creatinine test results. OR Required on DMERC service lines to report the Patient's Height from the Certificate of Medical Necessity (CMN). Use HT qualifier. If not required by this implementation guide, do not send. Example MEATRR30000~ Max use 5 Optional MEA-01 737 Measurement Reference Identification Code Identifier (ID) Required Code identifying the broad category to which a measurement applies OG Original Use OG to report Starting Dosage. TR Test Results MEA-02 738 Measurement Qualifier Identifier (ID) Required Code identifying a specific product or process characteristic to which a measurement applies HT Height R1 Hemoglobin R2 Hematocrit R3 Epoetin Starting Dosage R4 Creatinine MEA-03 739 Test Results Min 1 Max 15 Decimal number (R) Required The value of the measurement 1/30/25, 11:52 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 275/665 CN1 4650 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > Service Line Number Loop > CN1 Contract Information To specify basic data about the contract or contract line item Usage notes The developers of this implementation guide note that the CN1 segment is for use only for post-adjudicated claims, which do not meet the definition of a health care claim under HIPAA. Consequently, at the time of this writing, the CN1 segment is for non- HIPAA use only. Required when the submitter is contractually obligated to supply this information on post-adjudicated claims. If not required by this implementation guide, do not send. Example CN102000000000000XX000000XXXXX~ Max use 1 Optional CN1-01 1166 Contract Type Code Identifier (ID) Required Code identifying a contract type 01 Diagnosis Related Group (DRG) 02 Per Diem 03 Variable Per Diem 04 Flat 05 Capitated 06 Percent 09 Other CN1-02 782 Contract Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount CN102 is the contract amount. CN1-03 332 Contract Percentage Min 1 Max 6 Decimal number (R) Optional Percent given in decimal format (e.g., 0.0 through 100.0 represents 0% through 100%) CN103 is the allowance or charge percent. CN1-04 127 Contract Code Min 1 Max 50 String (AN) Optional Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier CN104 is the contract code. CN1-05 338 Terms Discount Percentage Min 1 Max 6 Decimal number (R) Optional 1/30/25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 276/665 Terms discount percentage, expressed as a percent, available to the purchaser if an invoice is paid on or before the Terms Discount Due Date CN1-06 799 Contract Version Identifier Min 1 Max 30 String (AN) Optional Revision level of a particular format, program, technique or algorithm CN106 is an additional identifying number for the contract. 1/30/25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 277/665 REF 4700 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > Service Line Number Loop > REF Adjusted Repriced Line Item Reference Number To specify identifying information Usage notes Required when a repricing (pricing) organization needs to have an identifying number on an adjusted service line in their submission to their payer organization. This segment is not completed by providers. If not required by this implementation guide, do not send. Example REF9DX~ Variants (all may be used) REF Clinical Laboratory Improvement Amendment (CLIA) Number REF Immunization Batch Number REF Line Item Control Number REF Mammography Certification Number REF Prior Authorization REF Referral Number REF Referring Clinical Laboratory Improvement Amendment (CLIA) Facility Identification REF Repriced Line Item Reference Number Max use 1 Optional REF-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification 9D Adjusted Repriced Line Item Reference Number REF-02 127 Adjusted Repriced Line Item Reference Number String (AN) Required Min 1 Max 50 Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier 1/30/25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 278/665 REF 4700 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > Service Line Number Loop > REF Clinical Laboratory Improvement Amendment (CLIA) Number To specify identifying information Usage notes Required for all CLIA certified facilities performing CLIA covered laboratory services and the number is different than the CLIA number reported at the claim level (Loop ID- 2300). If not required by this implementation guide, do not send.; Example REFX4XXXXXX~ Variants (all may be used) REF Adjusted Repriced Line Item Reference Number REF Immunization Batch Number REF Line Item Control Number REF Mammography Certification Number REF Prior Authorization REF Referral Number REF Referring Clinical Laboratory Improvement Amendment (CLIA) Facility Identification REF Repriced Line Item Reference Number Max use 1 Optional REF-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification X4 Clinical Laboratory Improvement Amendment Number REF-02 127 Clinical Laboratory Improvement Amendment Number String (AN) Required Min 1 Max 50 Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier 1/30/25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI	Home State Health 837 Health Care Claim_ Professional.pdf
particular Transaction Set or as specified by the Reference Identification Qualifier CN104 is the contract code. CN1-05 338 Terms Discount Percentage Min 1 Max 6 Decimal number (R) Optional 1/30/25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 276/665 Terms discount percentage, expressed as a percent, available to the purchaser if an invoice is paid on or before the Terms Discount Due Date CN1-06 799 Contract Version Identifier Min 1 Max 30 String (AN) Optional Revision level of a particular format, program, technique or algorithm CN106 is an additional identifying number for the contract. 1/30/25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 277/665 REF 4700 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > Service Line Number Loop > REF Adjusted Repriced Line Item Reference Number To specify identifying information Usage notes Required when a repricing (pricing) organization needs to have an identifying number on an adjusted service line in their submission to their payer organization. This segment is not completed by providers. If not required by this implementation guide, do not send. Example REF9DX~ Variants (all may be used) REF Clinical Laboratory Improvement Amendment (CLIA) Number REF Immunization Batch Number REF Line Item Control Number REF Mammography Certification Number REF Prior Authorization REF Referral Number REF Referring Clinical Laboratory Improvement Amendment (CLIA) Facility Identification REF Repriced Line Item Reference Number Max use 1 Optional REF-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification 9D Adjusted Repriced Line Item Reference Number REF-02 127 Adjusted Repriced Line Item Reference Number String (AN) Required Min 1 Max 50 Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier 1/30/25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 278/665 REF 4700 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > Service Line Number Loop > REF Clinical Laboratory Improvement Amendment (CLIA) Number To specify identifying information Usage notes Required for all CLIA certified facilities performing CLIA covered laboratory services and the number is different than the CLIA number reported at the claim level (Loop ID- 2300). If not required by this implementation guide, do not send.; Example REFX4XXXXXX~ Variants (all may be used) REF Adjusted Repriced Line Item Reference Number REF Immunization Batch Number REF Line Item Control Number REF Mammography Certification Number REF Prior Authorization REF Referral Number REF Referring Clinical Laboratory Improvement Amendment (CLIA) Facility Identification REF Repriced Line Item Reference Number Max use 1 Optional REF-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification X4 Clinical Laboratory Improvement Amendment Number REF-02 127 Clinical Laboratory Improvement Amendment Number String (AN) Required Min 1 Max 50 Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier 1/30/25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 279/665 REF 4700 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > Service Line Number Loop > REF Immunization Batch Number To specify identifying information Usage notes Required when mandated by state or federal law or regulations to report an Immunization Batch Number. If not required by this implementation guide, do not send. Example REFBTXXX~ Variants (all may be used) REF Adjusted Repriced Line Item Reference Number REF Clinical Laboratory Improvement Amendment (CLIA) Number REF Line Item Control Number REF Mammography Certification Number REF Prior Authorization REF Referral Number REF Referring Clinical Laboratory Improvement Amendment (CLIA) Facility Identification REF Repriced Line Item Reference Number Max use 1 Optional REF-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification BT Batch Number REF-02 127 Immunization Batch Number Min 1 Max 50 String (AN) Required Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier 1/30/25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 280/665 REF 4700 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > Service Line Number Loop > REF Line Item Control Number To specify identifying information Usage notes Required when the submitter needs a line item control number for subsequent communications to or from the payer. If not required by this implementation guide, do not send. The line item control number must be unique within a patient control number (CLM01). Payers are required to return this number in the remittance advice transaction (835) if the provider sends it to them in the 837 and adjudication is based upon line item detail regardless of whether bundling or unbundling has occurred. Submitters are STRONGLY encouraged to routinely send a unique line item control number on all service lines, particularly if the submitter automatically posts their remittance advice. Submitting a unique line item control number allows the capability to automatically post by service line. Example REF6RXXX~ Variants (all may be used) REF Adjusted Repriced Line Item Reference Number REF Clinical Laboratory Improvement Amendment (CLIA) Number REF Immunization Batch Number REF Mammography Certification Number REF Prior Authorization REF Referral Number REF Referring Clinical Laboratory Improvement Amendment (CLIA) Facility Identification REF Repriced Line Item Reference Number Max use 1 Optional REF-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification 6R Provider Control Number REF-02 127 Line Item Control Number Min 1 Max 50 String (AN) Required Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier Usage notes The maximum number of characters to be supported for this field is 30'. A submitter may submit fewer characters depending upon their needs. However, the HIPAA maximum requirement to be supported by any 1/30/25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 281/665 receiving system is 30'. Characters beyond 30 are not required to be stored nor returned by any 837-receiving system. 1/30/25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 282/665 REF 4700 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > Service Line Number Loop > REF Mammography Certification Number To specify identifying information Usage notes Required when mammography services are rendered by a certified mammography provider and the mammography certification number is different than that sent in Loop ID-2300. If not required by this implementation guide, do not send. Example REFEWXXXXXX~ Variants (all may be used) REF Adjusted Repriced Line Item Reference Number REF Clinical Laboratory Improvement Amendment (CLIA) Number REF Immunization Batch Number REF Line Item Control Number REF Prior Authorization REF Referral Number REF Referring Clinical Laboratory Improvement Amendment (CLIA) Facility Identification REF Repriced Line Item Reference Number Max use 1 Optional REF-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification EW Mammography Certification Number REF-02 127 Mammography Certification Number Min 1 Max 50 String (AN) Required Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier 1/30/25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 283/665 REF 4700 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > Service Line Number Loop > REF Prior Authorization To specify identifying information Usage notes Required when service line involved a prior authorization number that is different than the number reported at the claim level (Loop ID-2300). If not required by this implementation guide, do not send. When it is necessary to report one or more non-destination payer Prior Authorization Numbers, the composite data element in REF04 is used to identify the payer which assigned this number. Example REFG1XXXX*2U>X~ Variants (all may be used) REF Adjusted Repriced Line Item Reference Number REF Clinical Laboratory Improvement Amendment (CLIA) Number REF Immunization Batch Number REF Line Item Control Number REF Mammography Certification Number REF Referral Number REF Referring Clinical Laboratory Improvement Amendment (CLIA) Facility Identification REF Repriced Line Item Reference Number Max use 5 Optional REF-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification G1 Prior Authorization Number REF-02 127 Prior Authorization or Referral Number Min 1 Max 50 String (AN) Required Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier REF-04 C040 Reference Identifier To identify one or more reference numbers or identification numbers as specified by the Reference Qualifier - REF04 contains data relating to the value cited in REF02. Usage notes Required when the Prior Authorization Number reported in REF02 of this segment is for a non-destination payer. Max use 1 Optional 1/30/25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 284/665 C040-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification 2U Payer Identification Number C040-02 127 Other Payer Primary Identifier Min 1 Max 50 String (AN) Required Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier Usage notes The payer identifier reported in this field must match the cooresponding payer identifier reported in Loop ID-2330B NM109. 1/30/25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 285/665 REF 4700 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > Service Line Number Loop > REF Referral Number To specify identifying information Usage notes Required when this service line involved a referral number that is different than the number reported at the claim level (Loop-ID 2300). If not required by this implementation guide, do not send. When it is necessary to report one or more non-destination payer Referral Numbers, the composite data element in REF04 is used to identify the payer which assigned this referral number. Example REF9FX2U>XXXXXX~ Variants (all may be used) REF Adjusted Repriced Line Item Reference Number REF Clinical Laboratory Improvement Amendment (CLIA) Number REF Immunization Batch Number REF Line Item Control Number REF Mammography Certification Number REF Prior Authorization REF Referring Clinical Laboratory Improvement Amendment (CLIA) Facility Identification REF Repriced Line Item Reference Number Max use 5 Optional REF-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification 9F Referral Number REF-02 127 Referral Number Min 1 Max 50 String (AN) Required Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier REF-04 C040 Reference Identifier To identify one or more reference numbers or identification numbers as specified by the Reference Qualifier - REF04 contains data relating to the value cited in REF02. Usage notes Required when the Referral Number reported in REF02 of this segment is for a non- destination payer. Max use 1 Optional 1/30/25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 286/665 C040-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification 2U Payer Identification Number C040-02 127 Other Payer Primary Identifier Min 1 Max 50 String (AN) Required Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier Usage notes The payer identifier reported in this field must match the cooresponding payer identifier reported in Loop ID-2330B NM109. 1/30/25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 287/665 REF 4700 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > Service Line Number Loop > REF Referring Clinical Laboratory Improvement Amendment (CLIA) Facility Identification To specify identifying information Usage notes Required for claims for any laboratory that referred tests to another laboratory covered by the CLIA Act that is billed on this line. If not required by this implementation guide, do not send. Example REFF4*XXXX~ Variants (all may be used) REF Adjusted Repriced Line Item Reference Number REF Clinical Laboratory Improvement Amendment (CLIA) Number REF Immunization Batch Number REF Line Item Control Number REF Mammography Certification Number REF Prior Authorization REF Referral	Home State Health 837 Health Care Claim_ Professional.pdf
particular Transaction Set or as specified by the Reference Identification Qualifier Usage notes The payer identifier reported in this field must match the cooresponding payer identifier reported in Loop ID-2330B NM109. 1/30/25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 285/665 REF 4700 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > Service Line Number Loop > REF Referral Number To specify identifying information Usage notes Required when this service line involved a referral number that is different than the number reported at the claim level (Loop-ID 2300). If not required by this implementation guide, do not send. When it is necessary to report one or more non-destination payer Referral Numbers, the composite data element in REF04 is used to identify the payer which assigned this referral number. Example REF9FX*2U>XXXXXX~ Variants (all may be used) REF Adjusted Repriced Line Item Reference Number REF Clinical Laboratory Improvement Amendment (CLIA) Number REF Immunization Batch Number REF Line Item Control Number REF Mammography Certification Number REF Prior Authorization REF Referring Clinical Laboratory Improvement Amendment (CLIA) Facility Identification REF Repriced Line Item Reference Number Max use 5 Optional REF-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification 9F Referral Number REF-02 127 Referral Number Min 1 Max 50 String (AN) Required Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier REF-04 C040 Reference Identifier To identify one or more reference numbers or identification numbers as specified by the Reference Qualifier - REF04 contains data relating to the value cited in REF02. Usage notes Required when the Referral Number reported in REF02 of this segment is for a non- destination payer. Max use 1 Optional 1/30/25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 286/665 C040-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification 2U Payer Identification Number C040-02 127 Other Payer Primary Identifier Min 1 Max 50 String (AN) Required Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier Usage notes The payer identifier reported in this field must match the cooresponding payer identifier reported in Loop ID-2330B NM109. 1/30/25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 287/665 REF 4700 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > Service Line Number Loop > REF Referring Clinical Laboratory Improvement Amendment (CLIA) Facility Identification To specify identifying information Usage notes Required for claims for any laboratory that referred tests to another laboratory covered by the CLIA Act that is billed on this line. If not required by this implementation guide, do not send. Example REFF4XXXX~ Variants (all may be used) REF Adjusted Repriced Line Item Reference Number REF Clinical Laboratory Improvement Amendment (CLIA) Number REF Immunization Batch Number REF Line Item Control Number REF Mammography Certification Number REF Prior Authorization REF Referral Number REF Repriced Line Item Reference Number Max use 1 Optional REF-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification F4 Facility Certification Number REF-02 127 Referring CLIA Number Min 1 Max 50 String (AN) Required Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier 1/30/25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 288/665 REF 4700 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > Service Line Number Loop > REF Repriced Line Item Reference Number To specify identifying information Usage notes Required when a repricing (pricing) organization needs to have an identifying number on the service line in their submission to their payer organization. This segment is not completed by providers. If not required by this implementation guide, do not send. Example REF9BXXX~ Variants (all may be used) REF Adjusted Repriced Line Item Reference Number REF Clinical Laboratory Improvement Amendment (CLIA) Number REF Immunization Batch Number REF Line Item Control Number REF Mammography Certification Number REF Prior Authorization REF Referral Number REF Referring Clinical Laboratory Improvement Amendment (CLIA) Facility Identification Max use 1 Optional REF-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification 9B Repriced Line Item Reference Number REF-02 127 Repriced Line Item Reference Number Min 1 Max 50 String (AN) Required Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier 1/30/25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 289/665 AMT 4750 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > Service Line Number Loop > AMT Postage Claimed Amount To indicate the total monetary amount Usage notes Required when service line charge (SV102) includes postage amount claimed in this service line. If not required by this implementation guide, do not send. When reporting the Postage Claimed Amount (AMT02), the amount reported in the Line Item Charge Amount (SV102) for this service line must include the amount reported in the Postage Claimed Amount. Example AMTF4000000000000000~ Variants (all may be used) AMT Sales Tax Amount Max use 1 Optional AMT-01 522 Amount Qualifier Code Identifier (ID) Required Code to qualify amount F4 Postage Claimed AMT-02 782 Postage Claimed Amount Min 1 Max 15 Decimal number (R) Required Monetary amount 1/30/25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 290/665 AMT 4750 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > Service Line Number Loop > AMT Sales Tax Amount To indicate the total monetary amount Usage notes Required when sales tax applies to the service line and the submitter is required to report that information to the receiver. If not required by this implementation guide, do not send. When reporting the Sales Tax Amount (AMT02), the amount reported in the Line Item Charge Amount (SV102) for this service line must include the amount reported in the Sales Tax Amount. Example AMTT00000000~ Variants (all may be used) AMT Postage Claimed Amount Max use 1 Optional AMT-01 522 Amount Qualifier Code Identifier (ID) Required Code to qualify amount T Tax AMT-02 782 Sales Tax Amount Min 1 Max 15 Decimal number (R) Required Monetary amount 1/30/25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 291/665 K3 4800 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > Service Line Number Loop > K3 File Information To transmit a fixed-format record or matrix contents Usage notes Required when ALL of the following conditions are met: A regulatory agency concludes it must use the K3 to meet an emergency legislative requirement; The administering regulatory agency or other state organization has completed each one of the following steps: contacted the X12N workgroup, requested a review of the K3 data requirement to ensure there is not an existing method within the implementation guide to meet this requirement X12N determines that there is no method to meet the requirement. If not required by this implementation guide, do not send. At the time of publication of this implementation, K3 segments have no specific use. The K3 segment is expected to be used only when necessary to meet the unexpected data requirement of a legislative authority. Before this segment can be used : The X12N Health Care Claim workgroup must conclude there is no other available option in the implementation guide to meet the emergency legislative requirement. The requestor must submit a proposal for approval accompanied by the relevant business documentation to the X12N Health Care Claim workgroup chairs and receive approval for the request. Upon review of the request, X12N will issue an approval or denial decision to the requesting entity. Approved usage(s) of the K3 segment will be reviewed by the X12N Health Care Claim workgroup to develop a permanent change to include the business case in future transaction implementations. Only when all of the requirements above have been met, may the regulatory agency require the temporary use of the K3 segment. X12N will submit the necessary data maintenance and refer the request to the appropriate data content committee(s). Example K3XXXX~ Max use 10 Optional K3-01 449 Fixed Format Information Min 1 Max 80 String (AN) Required Data in fixed format agreed upon by sender and receiver 1/30/25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 292/665 NTE 4850 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > Service Line Number Loop > NTE Line Note To transmit information in a free-form format, if necessary, for comment or special instruction Usage notes Required when in the judgment of the provider, the information is needed to substantiate the medical treatment and is not supported elsewhere within the claim data set. If not required by this implementation guide, do not send. Use SV101-7 to describe non-specific procedure codes. Do not use this NTE Segment to describe a non-specific procedure code. If an NDC code is reported in Loop 2410, do not use this segment for a description of the procedure code. The NDC in loop 2410 will provide the description. Example NTEADDXX~ Variants (all may be used) NTE Third Party Organization Notes Max use 1 Optional NTE-01 363 Note Reference Code Identifier (ID) Required Code identifying the functional area or purpose for which the note applies ADD Additional Information DCP Goals, Rehabilitation Potential, or Discharge Plans NTE-02 352 Line Note Text Min 1 Max 80 String (AN) Required A free-form description to clarify the related data elements and their content 1/30/25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 293/665 NTE 4850 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > Service Line Number Loop > NTE Third Party Organization Notes To transmit information in a free-form format, if necessary, for comment or special instruction Usage notes Required when the TPO/repricer needs to forward additional information to the payer. This segment is not completed by providers. If not required by this implementation guide, do not send. Example NTETPOX~ Variants (all may be used) NTE Line Note Max use 1 Optional NTE-01 363 Note Reference Code Identifier (ID) Required Code identifying the functional area or purpose for which the note applies TPO Third Party Organization Notes NTE-02 352 Line Note Text Min 1 Max 80 String (AN) Required A free-form description to clarify the related data elements and their content 1/30/25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 294/665 PS1 4880 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > Service Line Number Loop > PS1 Purchased Service Information To specify the information about services that are purchased Usage notes Required on non-vision service lines when adjudication is known to be impacted by the charge amount for services purchased from another source. OR Required on vision service lines when adjudication is known to be impacted by the acquisition cost of lenses. If not required by this implementation guide, do not send. Example PS1XX0000~ Max use 1 Optional PS1-01 127 Purchased Service Provider Identifier Min 1 Max 50 String (AN) Required Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier PS101 is provider identification number. Usage notes This must be the identifier from the Purchased Service Provider Loop (Loop ID-2420B). When the Secondary Identifier REF is used, that is the identifier to be reported. If not present, use the identifier in NM109. PS1-02 782 Purchased Service Charge Amount Min 1 Max 15 Decimal number (R) Required Monetary amount PS102 is cost of the purchased service. 1/30/25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 295/665 HCP 4920 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information	Home State Health 837 Health Care Claim_ Professional.pdf
codes. Do not use this NTE Segment to describe a non-specific procedure code. If an NDC code is reported in Loop 2410, do not use this segment for a description of the procedure code. The NDC in loop 2410 will provide the description. Example NTEADDXX~ Variants (all may be used) NTE Third Party Organization Notes Max use 1 Optional NTE-01 363 Note Reference Code Identifier (ID) Required Code identifying the functional area or purpose for which the note applies ADD Additional Information DCP Goals, Rehabilitation Potential, or Discharge Plans NTE-02 352 Line Note Text Min 1 Max 80 String (AN) Required A free-form description to clarify the related data elements and their content 1/30/25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 293/665 NTE 4850 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > Service Line Number Loop > NTE Third Party Organization Notes To transmit information in a free-form format, if necessary, for comment or special instruction Usage notes Required when the TPO/repricer needs to forward additional information to the payer. This segment is not completed by providers. If not required by this implementation guide, do not send. Example NTETPOX~ Variants (all may be used) NTE Line Note Max use 1 Optional NTE-01 363 Note Reference Code Identifier (ID) Required Code identifying the functional area or purpose for which the note applies TPO Third Party Organization Notes NTE-02 352 Line Note Text Min 1 Max 80 String (AN) Required A free-form description to clarify the related data elements and their content 1/30/25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 294/665 PS1 4880 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > Service Line Number Loop > PS1 Purchased Service Information To specify the information about services that are purchased Usage notes Required on non-vision service lines when adjudication is known to be impacted by the charge amount for services purchased from another source. OR Required on vision service lines when adjudication is known to be impacted by the acquisition cost of lenses. If not required by this implementation guide, do not send. Example PS1XX0000~ Max use 1 Optional PS1-01 127 Purchased Service Provider Identifier Min 1 Max 50 String (AN) Required Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier PS101 is provider identification number. Usage notes This must be the identifier from the Purchased Service Provider Loop (Loop ID-2420B). When the Secondary Identifier REF is used, that is the identifier to be reported. If not present, use the identifier in NM109. PS1-02 782 Purchased Service Charge Amount Min 1 Max 15 Decimal number (R) Required Monetary amount PS102 is cost of the purchased service. 1/30/25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 295/665 HCP 4920 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > Service Line Number Loop > HCP Line Pricing/Repricing Information To specify pricing or repricing information about a health care claim or line item Usage notes This information is specific to the destination payer reported in Loop ID-2010BB. For capitated encounters, pricing or repricing information usually is not applicable and is provided to qualify other information within the claim. Required when this information is deemed necessary by the repricer. The segment is not completed by providers. The information is completed by repricers only. If not required by this implementation guide, do not send. Example HCP02000000000000000XXXXXX000000000XXX0W KXXXMJ0000000T646~ If either Product or Service ID Qualifier (HCP-09) or Repriced Approved HCPCS Code (HCP-10) is present, then the other is required If either Unit or Basis for Measurement Code (HCP-11) or Repriced Approved Service Unit Count (HCP-12) is present, then the other is required Max use 1 Optional HCP-01 1473 Pricing Methodology Identifier (ID) Required Code specifying pricing methodology at which the claim or line item has been priced or repriced Usage notes Specific code use is determined by Trading Partner Agreement due to the variances in contracting policies in the industry. 00 Zero Pricing (Not Covered Under Contract) 01 Priced as Billed at 100% 02 Priced at the Standard Fee Schedule 03 Priced at a Contractual Percentage 04 Bundled Pricing 05 Peer Review Pricing 06 Per Diem Pricing 07 Flat Rate Pricing 08 Combination Pricing 09 Maternity Pricing 10 Other Pricing 11 Lower of Cost 12 Ratio of Cost 13 Cost Reimbursed 14 Adjustment Pricing HCP-02 782 Repriced Allowed Amount Min 1 Max 15 Decimal number (R) Required Monetary amount 1/30/25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 296/665 HCP02 is the allowed amount. HCP-03 782 Repriced Saving Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount HCP03 is the savings amount. HCP-04 127 Repricing Organization Identifier Min 1 Max 50 String (AN) Optional Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier HCP04 is the repricing organization identification number. HCP-05 118 Repricing Per Diem or Flat Rate Amount Decimal number (R) Optional Min 1 Max 9 Rate expressed in the standard monetary denomination for the currency specified HCP05 is the pricing rate associated with per diem or flat rate repricing. HCP-06 127 Repriced Approved Ambulatory Patient Group Code String (AN) Optional Min 1 Max 50 Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier HCP06 is the approved DRG code. HCP06, HCP07, HCP08, HCP10, and HCP12 are fields that will contain different values from the original submitted values. HCP-07 782 Repriced Approved Ambulatory Patient Group Amount Decimal number (R) Optional Min 1 Max 15 Monetary amount HCP07 is the approved DRG amount. HCP-09 235 Product or Service ID Qualifier Identifier (ID) Optional Code identifying the type/source of the descriptive number used in Product/Service ID (234) ER Jurisdiction Specific Procedure and Supply Codes This code set is not allowed for use under HIPAA at the time of this writing. The qualifier can only be used: If a new rule names the Jurisdiction Specific Procedure and Supply Codes as an allowable code set under HIPAA, 1/30/25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 297/665 OR The Secretary grants an exception to use the code set as a pilot project as allowed under the law, OR For claims which are not covered under HIPAA. HC Health Care Financing Administration Common Procedural Coding System (HCPCS) Codes Because the AMA's CPT codes are also level 1 HCPCS codes, they are reported under HC. IV Home Infusion EDI Coalition (HIEC) Product/Service Code This code set is not allowed for use under HIPAA at the time of this writing. The qualifier can only be used: If a new rule names the Home Infusion EDI Coalition (HIEC) Product/Service Codes as an allowable code set under HIPAA, OR The Secretary grants an exception to use the code set as a pilot project as allowed under the law, OR For claims which are not covered under HIPAA.; WK Advanced Billing Concepts (ABC) Codes At the time of this writing, this code set has been approved by the Secretary of HHS as a pilot project allowed under HIPAA law. The qualifier may only be used in transactions covered under HIPAA; By parties registered in the pilot project and their trading partners, OR If a new rule names the Complementary, Alternative, or Holistic Procedure Codes as an allowable code set under HIPAA, OR For claims which are not covered under HIPAA. HCP-10 234 Repriced Approved HCPCS Code Min 1 Max 48 String (AN) Optional Identifying number for a product or service HCP10 is the approved procedure code. HCP-11 355 Unit or Basis for Measurement Code Identifier (ID) Optional Code specifying the units in which a value is being expressed, or manner in which a measurement has been taken MJ Minutes UN Unit HCP-12 380 Repriced Approved Service Unit Count Decimal number (R) Optional Min 1 Max 15 Numeric value of quantity HCP12 is the approved service units or inpatient days. Usage notes Note: When a decimal is needed to report units, include it in this element, for example, "15.6". 1/30/25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 298/665 The maximum length for this field is 8 digits excluding the decimal. When a decimal is used, the maximum number of digits allowed to the right of the decimal is three. HCP-13 901 Reject Reason Code Identifier (ID) Optional Code assigned by issuer to identify reason for rejection HCP13 is the rejection message returned from the third party organization. T1 Cannot Identify Provider as TPO (Third Party Organization) Participant T2 Cannot Identify Payer as TPO (Third Party Organization) Participant T3 Cannot Identify Insured as TPO (Third Party Organization) Participant T4 Payer Name or Identifier Missing T5 Certification Information Missing T6 Claim does not contain enough information for re-pricing HCP-14 1526 Policy Compliance Code Identifier (ID) Optional Code specifying policy compliance 1 Procedure Followed (Compliance) 2 Not Followed - Call Not Made (Non-Compliance Call Not Made) 3 Not Medically Necessary (Non-Compliance Non-Medically Necessary) 4 Not Followed Other (Non-Compliance Other) 5 Emergency Admit to Non-Network Hospital HCP-15 1527 Exception Code Identifier (ID) Optional Code specifying the exception reason for consideration of out-of-network health care services HCP15 is the exception reason generated by a third party organization. 1 Non-Network Professional Provider in Network Hospital 2 Emergency Care 3 Services or Specialist not in Network 4 Out-of-Service Area 5 State Mandates 6 Other 1/30/25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 299/665 2410 Drug Identification Loop Max 1 Optional LIN 4930 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > Service Line Number Loop > Drug Identification Loop > LIN Drug Identification To specify basic item identification data Usage notes Required when government regulation mandates that prescribed drugs and biologics are reported with NDC numbers. OR Required when the provider or submitter chooses to report NDC numbers to enhance the claim reporting or adjudication processes. OR Required when an HHS approved pilot project specifies reporting of Universal Product Number (UPN) by parties registered in the pilot and their trading partners. OR Required when government regulation mandates that medical and surgical supplies are reported with UPN's. If not required by this implementation guide, do not send. Drugs and biologics reported in this segment are a further specification of service(s) described in the SV1 segment of this Service Line Loop ID-2400. Example LINUKXXX~ Max use 1 Required LIN-02 235 Product or Service ID Qualifier Identifier (ID) Required Code identifying the type/source of the descriptive number used in Product/Service ID (234) LIN02 through LIN31 provide for fifteen different product/service IDs for each item. For example: Case, Color, Drawing No., U.P.C. No., ISBN No., Model No., or SKU. Usage notes At the time of this writing, UPN code sets designated by values EN, EO, HI, ON, UK, and UP have been approved by the Secretary of HHS as a pilot project allowed under HIPAA law. During the pilot, these code values may only be used by parties registered in the pilot project and their trading partners. Beyond the pilot, these codes may only be used if mandated by government regulation. EN EAN/UCC - 13 EO EAN/UCC - 8 HI HIBC (Health Care Industry Bar Code) Supplier Labeling Standard Primary Data Message N4 National Drug Code in 5-4-2 Format ON Customer Order Number UK GTIN 14-digit Data Structure UP UCC - 12 1/30/25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 300/665 LIN-03 234 National Drug Code or Universal Product Number String (AN) Required Min 1 Max 48 Identifying number for a product or service 1/30/25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 301/665 CTP 4940 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > Service Line Number Loop > Drug Identification Loop	Home State Health 837 Health Care Claim_ Professional.pdf
2 Not Followed - Call Not Made (Non-Compliance Call Not Made) 3 Not Medically Necessary (Non-Compliance Non-Medically Necessary) 4 Not Followed Other (Non-Compliance Other) 5 Emergency Admit to Non-Network Hospital HCP-15 1527 Exception Code Identifier (ID) Optional Code specifying the exception reason for consideration of out-of-network health care services HCP15 is the exception reason generated by a third party organization. 1 Non-Network Professional Provider in Network Hospital 2 Emergency Care 3 Services or Specialist not in Network 4 Out-of-Service Area 5 State Mandates 6 Other 1/30/25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 299/665 2410 Drug Identification Loop Max 1 Optional LIN 4930 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > Service Line Number Loop > Drug Identification Loop > LIN Drug Identification To specify basic item identification data Usage notes Required when government regulation mandates that prescribed drugs and biologics are reported with NDC numbers. OR Required when the provider or submitter chooses to report NDC numbers to enhance the claim reporting or adjudication processes. OR Required when an HHS approved pilot project specifies reporting of Universal Product Number (UPN) by parties registered in the pilot and their trading partners. OR Required when government regulation mandates that medical and surgical supplies are reported with UPN's. If not required by this implementation guide, do not send. Drugs and biologics reported in this segment are a further specification of service(s) described in the SV1 segment of this Service Line Loop ID-2400. Example LIN*UKXXX~ Max use 1 Required LIN-02 235 Product or Service ID Qualifier Identifier (ID) Required Code identifying the type/source of the descriptive number used in Product/Service ID (234) LIN02 through LIN31 provide for fifteen different product/service IDs for each item. For example: Case, Color, Drawing No., U.P.C. No., ISBN No., Model No., or SKU. Usage notes At the time of this writing, UPN code sets designated by values EN, EO, HI, ON, UK, and UP have been approved by the Secretary of HHS as a pilot project allowed under HIPAA law. During the pilot, these code values may only be used by parties registered in the pilot project and their trading partners. Beyond the pilot, these codes may only be used if mandated by government regulation. EN EAN/UCC - 13 EO EAN/UCC - 8 HI HIBC (Health Care Industry Bar Code) Supplier Labeling Standard Primary Data Message N4 National Drug Code in 5-4-2 Format ON Customer Order Number UK GTIN 14-digit Data Structure UP UCC - 12 1/30/25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 300/665 LIN-03 234 National Drug Code or Universal Product Number String (AN) Required Min 1 Max 48 Identifying number for a product or service 1/30/25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 301/665 CTP 4940 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > Service Line Number Loop > Drug Identification Loop > CTP Drug Quantity To specify pricing information Example CTP***0000000000000UN~ Max use 1 Required CTP-04 380 National Drug Unit Count Min 1 Max 15 Decimal number (R) Required Numeric value of quantity CTP-05 C001 Composite Unit of Measure To identify a composite unit of measure (See Figures Appendix for examples of use) Max use 1 Required C001-01 355 Code Qualifier Identifier (ID) Required Code specifying the units in which a value is being expressed, or manner in which a measurement has been taken F2 International Unit GR Gram ME Milligram ML Milliliter UN Unit 1/30/25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 302/665 2410 Drug Identification Loop end REF 4950 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > Service Line Number Loop > Drug Identification Loop > REF Prescription or Compound Drug Association Number To specify identifying information Usage notes Required when dispensing of the drug has been done with an assigned prescription number. OR Required when the provided medication involves the compounding of two or more drugs being reported and there is no prescription number. If not required by this implementation guide, do not send. In cases where a compound drug is being billed, the components of the compound will all have the same prescription number. Payers receiving the claim can relate all the components by matching the prescription number. For cases where the drug is provided without a prescription (for example, from a physician's office), the value provided in this segment is a "link sequence number". The link sequence number is a provider assigned number that is unique to this claim. Its purpose is to enable the receiver to piece together the components of the compound. Example REFVYXXXXXX~ Max use 1 Optional REF-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification VY Link Sequence Number XZ Pharmacy Prescription Number REF-02 127 Prescription Number Min 1 Max 50 String (AN) Required Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier 1/30/25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 303/665 2420A Rendering Provider Name Loop Max 1 Optional Usage notes You should only use 2420A when it is different than Loop 2310B/NM182. Variants (all may be used) Purchased Service Provider Name Loop Service Facility Location Name Loop Supervising Provider Name Loop Ordering Provider Name Loop Referring Provider Name Loop Ambulance Pick-up Location Loop Ambulance Drop-off Location Loop NM1 5000 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > Service Line Number Loop > Rendering Provider Name Loop > NM1 Rendering Provider Name To supply the full name of an individual or organizational entity Usage notes Used for all types of rendering providers including laboratories. The Rendering Provider is the person or company (laboratory or other facility) who rendered the care. In the case where a substitute provider (locum tenens) was used, enter that provider's information here. Required when the Rendering Provider NM1 information is different than that carried in the Loop ID-2310B Rendering Provider. OR Required when Loop ID-2310B Rendering Provider is not used AND this particular line item has different Rendering Provider information than that which is carried in Loop ID- 2010AA Billing Provider. If not required by this implementation guide, do not send.; Example NM1821XXXXXXXXXX*XXXXXXXXX~ If either Identification Code Qualifier (NM1-08) or Rendering Provider Identifier (NM1-09) is present, then the other is required Max use 1 Required NM1-01 98 Entity Identifier Code Identifier (ID) Required Code identifying an organizational entity, a physical location, property or an individual 82 Rendering Provider NM1-02 1065 Entity Type Qualifier Identifier (ID) Required Code qualifying the type of entity NM102 qualifies NM103. 1/30/25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 304/665 1 Person 2 Non-Person Entity NM1-03 1035 Rendering Provider Last or Organization Name String (AN) Required Min 1 Max 60 Individual last name or organizational name NM1-04 1036 Rendering Provider First Name Min 1 Max 35 String (AN) Optional Individual first name NM1-05 1037 Rendering Provider Middle Name or Initial Min 1 Max 25 String (AN) Optional Individual middle name or initial NM1-07 1039 Rendering Provider Name Suffix Min 1 Max 10 String (AN) Optional Suffix to individual name NM1-08 66 Identification Code Qualifier Identifier (ID) Optional Code designating the system/method of code structure used for Identification Code (67) XX Centers for Medicare and Medicaid Services National Provider Identifier NM1-09 67 Rendering Provider Identifier Min 2 Max 80 String (AN) Optional Code identifying a party or other code 1/30/25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 305/665 PRV 5050 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > Service Line Number Loop > Rendering Provider Name Loop > PRV Rendering Provider Specialty Information To specify the identifying characteristics of a provider Usage notes Required when adjudication is known to be impacted by the provider taxonomy code. If not required by this implementation guide, do not send. Example PRVPEPXCXX~ Max use 1 Optional PRV-01 1221 Provider Code Identifier (ID) Required Code identifying the type of provider PE Performing PRV-02 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification PXC Health Care Provider Taxonomy Code PRV-03 127 Provider Taxonomy Code Min 1 Max 50 String (AN) Required Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier 1/30/25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 306/665 REF 5250 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > Service Line Number Loop > Rendering Provider Name Loop > REF Rendering Provider Secondary Identification To specify identifying information Usage notes Required prior to the mandated HIPAA National Provider Identifier (NPI) implementation date when an identification number other than the NPI is necessary for the receiver to identify the provider. OR Required on or after the mandated NPI Implementation Date when NM109 in this loop is not used and an identification number other than the NPI is necessary for the receiver to identify the provider. If not required by this implementation guide, do not send. When it is necessary to report one or more non-destination payer Secondary Identifiers, the composite data element in REF04 is used to identify the payer who assigned this identifier. Example REF1GXXXX*2U>XXXXX~ Max use 20 Optional REF-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification 0B State License Number 1G Provider UPIN Number UPINs must be formatted as either X99999 or XXX999. G2 Provider Commercial Number This code designates a proprietary provider number for the destination payer identified in the Payer Name loop, Loop ID-2010BB, associated with this claim. This is to be used by all payers including: Medicare, Medicaid, Blue Cross, etc. LU Location Number REF-02 127 Rendering Provider Secondary Identifier Min 1 Max 50 String (AN) Required Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier REF-04 C040 Reference Identifier To identify one or more reference numbers or identification numbers as specified by the Reference Qualifier - REF04 contains data relating to the value cited in REF02. Usage notes Required when the identifier reported in REF02 of this segment is for a non-destination payer. Max use 1 Optional 1/30/25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 307/665 2420A Rendering Provider Name Loop end C040-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification 2U Payer Identification Number C040-02 127 Other Payer Primary Identifier Min 1 Max 50 String (AN) Required Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier Usage notes The payer identifier reported in this field must match the cooresponding payer identifier reported in Loop ID-2330B NM109. 1/30/25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 308/665 2420B Purchased Service Provider Name Loop Max 1 Optional Variants (all may be used) Rendering Provider Name Loop Service Facility Location Name Loop Supervising Provider Name Loop Ordering Provider Name Loop Referring Provider Name Loop Ambulance Pick-up Location Loop Ambulance Drop-off Location Loop NM1 5000 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > Service Line Number Loop > Purchased Service Provider Name Loop > NM1 Purchased Service Provider Name To supply the full name of an individual or organizational entity Usage notes Required when the service reported in this line item is a purchased service. If not required by this implementation guide, do not send. Purchased services are situations where, for example, a physician purchases a diagnostic exam from an outside entity. Purchased services do not include substitute (locum tenens) provider situations. Example NM1QB1****XXXXXXXX~ If either Identification Code Qualifier (NM1-08) or Purchased Service Provider Identifier (NM1-09) is present, then the other is required Max use 1 Required NM1-01 98	Home State Health 837 Health Care Claim_ Professional.pdf
Required on or after the mandated NPI Implementation Date when NM109 in this loop is not used and an identification number other than the NPI is necessary for the receiver to identify the provider. If not required by this implementation guide, do not send. When it is necessary to report one or more non-destination payer Secondary Identifiers, the composite data element in REF04 is used to identify the payer who assigned this identifier. Example REF1GXXXX*2U>XXXXX~ Max use 20 Optional REF-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification 0B State License Number 1G Provider UPIN Number UPINs must be formatted as either X99999 or XXX999. G2 Provider Commercial Number This code designates a proprietary provider number for the destination payer identified in the Payer Name loop, Loop ID-2010BB, associated with this claim. This is to be used by all payers including: Medicare, Medicaid, Blue Cross, etc. LU Location Number REF-02 127 Rendering Provider Secondary Identifier Min 1 Max 50 String (AN) Required Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier REF-04 C040 Reference Identifier To identify one or more reference numbers or identification numbers as specified by the Reference Qualifier - REF04 contains data relating to the value cited in REF02. Usage notes Required when the identifier reported in REF02 of this segment is for a non-destination payer. Max use 1 Optional 1/30/25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 307/665 2420A Rendering Provider Name Loop end C040-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification 2U Payer Identification Number C040-02 127 Other Payer Primary Identifier Min 1 Max 50 String (AN) Required Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier Usage notes The payer identifier reported in this field must match the cooresponding payer identifier reported in Loop ID-2330B NM109. 1/30/25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 308/665 2420B Purchased Service Provider Name Loop Max 1 Optional Variants (all may be used) Rendering Provider Name Loop Service Facility Location Name Loop Supervising Provider Name Loop Ordering Provider Name Loop Referring Provider Name Loop Ambulance Pick-up Location Loop Ambulance Drop-off Location Loop NM1 5000 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > Service Line Number Loop > Purchased Service Provider Name Loop > NM1 Purchased Service Provider Name To supply the full name of an individual or organizational entity Usage notes Required when the service reported in this line item is a purchased service. If not required by this implementation guide, do not send. Purchased services are situations where, for example, a physician purchases a diagnostic exam from an outside entity. Purchased services do not include substitute (locum tenens) provider situations. Example NM1QB1****XXXXXXXX~ If either Identification Code Qualifier (NM1-08) or Purchased Service Provider Identifier (NM1-09) is present, then the other is required Max use 1 Required NM1-01 98 Entity Identifier Code Identifier (ID) Required Code identifying an organizational entity, a physical location, property or an individual Usage notes The entity identifier in NM101 applies to all segments in this iteration of Loop ID-2420. QB Purchase Service Provider NM1-02 1065 Entity Type Qualifier Identifier (ID) Required Code qualifying the type of entity NM102 qualifies NM103. 1 Person 2 Non-Person Entity NM1-08 66 Identification Code Qualifier Identifier (ID) Optional 1/30/25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 309/665 Code designating the system/method of code structure used for Identification Code (67) XX Centers for Medicare and Medicaid Services National Provider Identifier NM1-09 67 Purchased Service Provider Identifier Min 2 Max 80 String (AN) Optional Code identifying a party or other code 1/30/25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 310/665 REF 5250 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > Service Line Number Loop > Purchased Service Provider Name Loop > REF Purchased Service Provider Secondary Identification To specify identifying information Usage notes Required prior to the mandated HIPAA National Provider Identifier (NPI) implementation date when an identification number other than the NPI is necessary for the receiver to identify the provider. OR Required on or after the mandated NPI Implementation Date when NM109 in this loop is not used and an identification number other than the NPI is necessary for the receiver to identify the provider. If not required by this implementation guide, do not send. When it is necessary to report one or more non-destination payer Secondary Identifiers, the composite data element in REF04 is used to identify the payer who assigned this identifier. Example REF0BXXXXXX*2U>XXXXXX~ Max use 20 Optional REF-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification 0B State License Number 1G Provider UPIN Number UPINs must be formatted as either X99999 or XXX999. G2 Provider Commercial Number This code designates a proprietary provider number for the destination payer identified in the Payer Name loop, Loop ID-2010BB, associated with this claim. This is to be used by all payers including: Medicare, Medicaid, Blue Cross, etc. REF-02 127 Purchased Service Provider Secondary Identifier String (AN) Required Min 1 Max 50 Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier REF-04 C040 Reference Identifier Max use 1 Optional 1/30/25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 311/665 2420B Purchased Service Provider Name Loop end To identify one or more reference numbers or identification numbers as specified by the Reference Qualifier - REF04 contains data relating to the value cited in REF02. Usage notes Required when the identifier reported in REF02 of this segment is for a non-destination payer. C040-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification 2U Payer Identification Number C040-02 127 Other Payer Primary Identifier Min 1 Max 50 String (AN) Required Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier Usage notes The payer identifier reported in this field must match the cooresponding payer identifier reported in Loop ID-2330B NM109. 1/30/25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 312/665 2420C Service Facility Location Name Loop Max 1 Optional Variants (all may be used) Rendering Provider Name Loop Purchased Service Provider Name Loop Supervising Provider Name Loop Ordering Provider Name Loop Referring Provider Name Loop Ambulance Pick-up Location Loop Ambulance Drop-off Location Loop NM1 5000 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > Service Line Number Loop > Service Facility Location Name Loop > NM1 Service Facility Location Name To supply the full name of an individual or organizational entity Usage notes When an organization health care provider's NPI is provided to identify the Service Location, the organization health care provider must be external to the entity identified as the Billing Provider (for example, reference lab). It is not permissible to report an organization health care provider NPI as the Service Location if the entity being identified is a component (for example, subpart) of the Billing Provider. In that case, the subpart must be the Billing Provider. Required when the location of health care service for this service line is different than that carried in Loop ID-2010AA Billing Provider or Loop ID-2310C Service Facility Location. If not required by this implementation guide, do not send. The purpose of this loop is to identify specifically where the service was rendered. When reporting ambulance services, do not use this loop. Use the pick-up (2420G) and drop-off location (2420H) loops elsewhere in this transaction.; Example NM1772XXXX****XXXXXX~ If either Identification Code Qualifier (NM1-08) or Laboratory or Facility Primary Identifier (NM1-09) is present, then the other is required Max use 1 Required NM1-01 98 Entity Identifier Code Identifier (ID) Required Code identifying an organizational entity, a physical location, property or an individual 77 Service Location NM1-02 1065 Entity Type Qualifier Identifier (ID) Required Code qualifying the type of entity NM102 qualifies NM103. 1/30/25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 313/665 2 Non-Person Entity NM1-03 1035 Laboratory or Facility Name Min 1 Max 60 String (AN) Required Individual last name or organizational name NM1-08 66 Identification Code Qualifier Identifier (ID) Optional Code designating the system/method of code structure used for Identification Code (67) XX Centers for Medicare and Medicaid Services National Provider Identifier NM1-09 67 Laboratory or Facility Primary Identifier Min 2 Max 80 String (AN) Optional Code identifying a party or other code 1/30/25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 314/665 N3 5140 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > Service Line Number Loop > Service Facility Location Name Loop > N3 Service Facility Location Address To specify the location of the named party Usage notes If service facility location is in an area where there are no street addresses, enter a description of where the service was rendered (for example, "crossroad of State Road 34 and 45" or "Exit near Mile marker 265 on Interstate 80".) Example N3XXXXXXXX~ Max use 1 Required N3-01 166 Laboratory or Facility Address Line Min 1 Max 55 String (AN) Required Address information N3-02 166 Laboratory or Facility Address Line Min 1 Max 55 String (AN) Optional Address information 1/30/25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 315/665 N4 5200 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > Service Line Number Loop > Service Facility Location Name Loop > N4 Service Facility Location City, State, ZIP Code To specify the geographic place of the named party Example N4XXXXXXXXXXXX~ Only one of Laboratory or Facility State or Province Code (N4-02) or Country Subdivision Code (N4-07) may be present If Country Subdivision Code (N4-07) is present, then Country Code (N4-04) is required Max use 1 Required N4-01 19 Laboratory or Facility City Name Min 2 Max 30 String (AN) Required Free-form text for city name A combination of either N401 through N404, or N405 and N406 may be adequate to specify a location. N4-02 156 Laboratory or Facility State or Province Code Identifier (ID) Optional Min 2 Max 2 Code (Standard State/Province) as defined by appropriate government agency N402 is required only if city name (N401) is in the U.S. or Canada. N4-03 116 Laboratory or Facility Postal Zone or ZIP Code Identifier (ID) Optional Min 3 Max 15 Code defining international postal zone code excluding punctuation and blanks (zip code for United States) Usage notes When reporting the ZIP code for U.S. addresses, the full nine digit ZIP code must be provided. N4-04 26 Country Code Min 2 Max 3 Identifier (ID) Optional Code identifying the country Usage notes Use the alpha-2 country codes from Part 1 of ISO 3166. N4-07 1715 Country Subdivision Code Min 1 Max 3 Identifier (ID) Optional Code identifying the country subdivision Usage notes 1/30/25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 316/665 Use the country subdivision codes from Part 2 of ISO 3166. 1/30/25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 317/665 REF 5250 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > Service Line Number Loop > Service Facility Location Name Loop > REF Service Facility Location Secondary Identification To specify identifying information Usage notes When it is necessary to report one or more non-destination payer Secondary Identifiers, the composite data element in REF04 is used to identify the payer who assigned this identifier. Required prior to the mandated HIPAA National Provider Identifier (NPI) implementation date when an identification number other than the NPI is necessary for the receiver to identify the provider. OR Required on or after the mandated NPI implementation date when	Home State Health 837 Health Care Claim_ Professional.pdf
facility location is in an area where there are no street addresses, enter a description of where the service was rendered (for example, "crossroad of State Road 34 and 45" or "Exit near Mile marker 265 on Interstate 80".) Example N3XXXXXXXX~ Max use 1 Required N3-01 166 Laboratory or Facility Address Line Min 1 Max 55 String (AN) Required Address information N3-02 166 Laboratory or Facility Address Line Min 1 Max 55 String (AN) Optional Address information 1/30/25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 315/665 N4 5200 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > Service Line Number Loop > Service Facility Location Name Loop > N4 Service Facility Location City, State, ZIP Code To specify the geographic place of the named party Example N4XXXXXXXXXXXX~ Only one of Laboratory or Facility State or Province Code (N4-02) or Country Subdivision Code (N4-07) may be present If Country Subdivision Code (N4-07) is present, then Country Code (N4-04) is required Max use 1 Required N4-01 19 Laboratory or Facility City Name Min 2 Max 30 String (AN) Required Free-form text for city name A combination of either N401 through N404, or N405 and N406 may be adequate to specify a location. N4-02 156 Laboratory or Facility State or Province Code Identifier (ID) Optional Min 2 Max 2 Code (Standard State/Province) as defined by appropriate government agency N402 is required only if city name (N401) is in the U.S. or Canada. N4-03 116 Laboratory or Facility Postal Zone or ZIP Code Identifier (ID) Optional Min 3 Max 15 Code defining international postal zone code excluding punctuation and blanks (zip code for United States) Usage notes When reporting the ZIP code for U.S. addresses, the full nine digit ZIP code must be provided. N4-04 26 Country Code Min 2 Max 3 Identifier (ID) Optional Code identifying the country Usage notes Use the alpha-2 country codes from Part 1 of ISO 3166. N4-07 1715 Country Subdivision Code Min 1 Max 3 Identifier (ID) Optional Code identifying the country subdivision Usage notes 1/30/25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 316/665 Use the country subdivision codes from Part 2 of ISO 3166. 1/30/25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 317/665 REF 5250 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > Service Line Number Loop > Service Facility Location Name Loop > REF Service Facility Location Secondary Identification To specify identifying information Usage notes When it is necessary to report one or more non-destination payer Secondary Identifiers, the composite data element in REF04 is used to identify the payer who assigned this identifier. Required prior to the mandated HIPAA National Provider Identifier (NPI) implementation date when an identification number other than the NPI is necessary for the receiver to identify the provider. OR Required on or after the mandated NPI implementation date when the entity is not a Health Care provider (a.k.a. an atypical provider), and an identifier is necessary for the claims processor to identify the entity. If not required by this implementation guide, do not send. Example REFG2XXX*2U>XXXXXX~ Max use 3 Optional REF-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification G2 Provider Commercial Number This code designates a proprietary provider number for the destination payer identified in the Payer Name loop, Loop ID-2010BB, associated with this claim. This is to be used by all payers including: Medicare, Medicaid, Blue Cross, etc. LU Location Number REF-02 127 Service Facility Location Secondary Identifier String (AN) Required Min 1 Max 50 Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier REF-04 C040 Reference Identifier To identify one or more reference numbers or identification numbers as specified by the Reference Qualifier - REF04 contains data relating to the value cited in REF02. Usage notes Required when the identifier reported in REF02 of this segment is for a non-destination payer. Max use 1 Optional C040-01 128 Reference Identification Qualifier Identifier (ID) Required 1/30/25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 318/665 2420C Service Facility Location Name Loop end Code qualifying the Reference Identification 2U Payer Identification Number C040-02 127 Other Payer Primary Identifier Min 1 Max 50 String (AN) Required Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier Usage notes The payer identifier reported in this field must match the cooresponding payer identifier reported in Loop ID-2330B NM109. 1/30/25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 319/665 2420D Supervising Provider Name Loop Max 1 Optional Variants (all may be used) Rendering Provider Name Loop Purchased Service Provider Name Loop Service Facility Location Name Loop Ordering Provider Name Loop Referring Provider Name Loop Ambulance Pick-up Location Loop Ambulance Drop-off Location Loop NM1 5000 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > Service Line Number Loop > Supervising Provider Name Loop > NM1 Supervising Provider Name To supply the full name of an individual or organizational entity Usage notes Required when the rendering provider is supervised by a physician and the supervising physician is different than that listed at the claim level for this service line. If not required by this implementation guide, do not send. Example NM1DQ1XXXXXXXX*XXXXXXXX~ If either Identification Code Qualifier (NM1-08) or Supervising Provider Identifier (NM1-09) is present, then the other is required Max use 1 Required NM1-01 98 Entity Identifier Code Identifier (ID) Required Code identifying an organizational entity, a physical location, property or an individual DQ Supervising Physician NM1-02 1065 Entity Type Qualifier Identifier (ID) Required Code qualifying the type of entity NM102 qualifies NM103. 1 Person NM1-03 1035 Supervising Provider Last Name Min 1 Max 60 String (AN) Required Individual last name or organizational name NM1-04 1036 Supervising Provider First Name Min 1 Max 35 String (AN) Optional 1/30/25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 320/665 Individual first name NM1-05 1037 Supervising Provider Middle Name or Initial String (AN) Optional Min 1 Max 25 Individual middle name or initial NM1-07 1039 Supervising Provider Name Suffix Min 1 Max 10 String (AN) Optional Suffix to individual name NM1-08 66 Identification Code Qualifier Identifier (ID) Optional Code designating the system/method of code structure used for Identification Code (67) XX Centers for Medicare and Medicaid Services National Provider Identifier NM1-09 67 Supervising Provider Identifier Min 2 Max 80 String (AN) Optional Code identifying a party or other code 1/30/25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 321/665 REF 5250 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > Service Line Number Loop > Supervising Provider Name Loop > REF Supervising Provider Secondary Identification To specify identifying information Usage notes Required prior to the mandated HIPAA National Provider Identifier (NPI) implementation date when an identification number other than the NPI is necessary for the receiver to identify the provider. OR Required on or after the mandated NPI Implementation Date when NM109 in this loop is not used and an identification number other than the NPI is necessary for the receiver to identify the provider. If not required by this implementation guide, do not send. When it is necessary to report one or more non-destination payer Secondary Identifiers, the composite data element in REF04 is used to identify the payer who assigned this identifier. Example REF0BXX2U>X~ Max use 20 Optional REF-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification 0B State License Number 1G Provider UPIN Number UPINs must be formatted as either X99999 or XXX999. G2 Provider Commercial Number This code designates a proprietary provider number for the destination payer identified in the Payer Name loop, Loop ID-2010BB, associated with this claim. This is to be used by all payers including: Medicare, Medicaid, Blue Cross, etc. LU Location Number REF-02 127 Supervising Provider Secondary Identifier Min 1 Max 50 String (AN) Required Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier REF-04 C040 Reference Identifier To identify one or more reference numbers or identification numbers as specified by the Reference Qualifier - REF04 contains data relating to the value cited in REF02. Usage notes Required when the identifier reported in REF02 of this segment is for a non-destination payer. Max use 1 Optional 1/30/25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 322/665 2420D Supervising Provider Name Loop end C040-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification 2U Payer Identification Number C040-02 127 Other Payer Primary Identifier Min 1 Max 50 String (AN) Required Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier Usage notes The payer identifier reported in this field must match the cooresponding payer identifier reported in Loop ID-2330B NM109. 1/30/25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 323/665 2420E Ordering Provider Name Loop Max 1 Optional Variants (all may be used) Rendering Provider Name Loop Purchased Service Provider Name Loop Service Facility Location Name Loop Supervising Provider Name Loop Referring Provider Name Loop Ambulance Pick-up Location Loop Ambulance Drop-off Location Loop NM1 5000 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > Service Line Number Loop > Ordering Provider Name Loop > NM1 Ordering Provider Name To supply the full name of an individual or organizational entity Usage notes Required when the service or supply was ordered by a provider who is different than the rendering provider for this service line. If not required by this implementation guide, do not send. Example NM1DK1XXXXX*XXXXXXXXXXXX~ If either Identification Code Qualifier (NM1-08) or Ordering Provider Identifier (NM1-09) is present, then the other is required Max use 1 Required NM1-01 98 Entity Identifier Code Identifier (ID) Required Code identifying an organizational entity, a physical location, property or an individual Usage notes The entity identifier in NM101 applies to all segments in this iteration of Loop ID-2420. DK Ordering Physician NM1-02 1065 Entity Type Qualifier Identifier (ID) Required Code qualifying the type of entity NM102 qualifies NM103. 1 Person NM1-03 1035 Ordering Provider Last Name Min 1 Max 60 String (AN) Required 1/30/25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 324/665 Individual last name or organizational name NM1-04 1036 Ordering Provider First Name Min 1 Max 35 String (AN) Optional Individual first name NM1-05 1037 Ordering Provider Middle Name or Initial Min 1 Max 25 String (AN) Optional Individual middle name or initial NM1-07 1039 Ordering Provider Name Suffix Min 1 Max 10 String (AN) Optional Suffix to individual name NM1-08 66 Identification Code Qualifier Identifier (ID) Optional Code designating the system/method of code structure used for Identification Code (67) XX Centers for Medicare and Medicaid Services National Provider Identifier NM1-09 67 Ordering Provider Identifier Min 2 Max 80 String (AN) Optional Code identifying a party or other code 1/30/25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 325/665 N3 5140 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > Service Line Number Loop > Ordering Provider Name Loop > N3 Ordering Provider Address To specify the location of the named party Usage notes Required when a Durable Medical Equipment Regional Carrier Certificate of Medical Necessity (DMERC CMN) or DMERC Information Form (DIF), or Oxygen Therapy Certification is included on this service line. If not required by this implementation guide, do not send. Example N3XXXX*XX~ Max use 1 Optional N3-01 166 Ordering Provider Address Line Min 1 Max 55 String (AN) Required Address information N3-02 166 Ordering Provider Address Line Min 1 Max 55 String (AN) Optional Address information 1/30/25, 11:53 AM	Home State Health 837 Health Care Claim_ Professional.pdf
field must match the cooresponding payer identifier reported in Loop ID-2330B NM109. 1/30/25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 323/665 2420E Ordering Provider Name Loop Max 1 Optional Variants (all may be used) Rendering Provider Name Loop Purchased Service Provider Name Loop Service Facility Location Name Loop Supervising Provider Name Loop Referring Provider Name Loop Ambulance Pick-up Location Loop Ambulance Drop-off Location Loop NM1 5000 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > Service Line Number Loop > Ordering Provider Name Loop > NM1 Ordering Provider Name To supply the full name of an individual or organizational entity Usage notes Required when the service or supply was ordered by a provider who is different than the rendering provider for this service line. If not required by this implementation guide, do not send. Example NM1DK1XXXXXXXXXXXXXXXXX~ If either Identification Code Qualifier (NM1-08) or Ordering Provider Identifier (NM1-09) is present, then the other is required Max use 1 Required NM1-01 98 Entity Identifier Code Identifier (ID) Required Code identifying an organizational entity, a physical location, property or an individual Usage notes The entity identifier in NM101 applies to all segments in this iteration of Loop ID-2420. DK Ordering Physician NM1-02 1065 Entity Type Qualifier Identifier (ID) Required Code qualifying the type of entity NM102 qualifies NM103. 1 Person NM1-03 1035 Ordering Provider Last Name Min 1 Max 60 String (AN) Required 1/30/25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 324/665 Individual last name or organizational name NM1-04 1036 Ordering Provider First Name Min 1 Max 35 String (AN) Optional Individual first name NM1-05 1037 Ordering Provider Middle Name or Initial Min 1 Max 25 String (AN) Optional Individual middle name or initial NM1-07 1039 Ordering Provider Name Suffix Min 1 Max 10 String (AN) Optional Suffix to individual name NM1-08 66 Identification Code Qualifier Identifier (ID) Optional Code designating the system/method of code structure used for Identification Code (67) XX Centers for Medicare and Medicaid Services National Provider Identifier NM1-09 67 Ordering Provider Identifier Min 2 Max 80 String (AN) Optional Code identifying a party or other code 1/30/25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 325/665 N3 5140 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > Service Line Number Loop > Ordering Provider Name Loop > N3 Ordering Provider Address To specify the location of the named party Usage notes Required when a Durable Medical Equipment Regional Carrier Certificate of Medical Necessity (DMERC CMN) or DMERC Information Form (DIF), or Oxygen Therapy Certification is included on this service line. If not required by this implementation guide, do not send. Example N3XXXXXX~ Max use 1 Optional N3-01 166 Ordering Provider Address Line Min 1 Max 55 String (AN) Required Address information N3-02 166 Ordering Provider Address Line Min 1 Max 55 String (AN) Optional Address information 1/30/25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 326/665 N4 5200 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > Service Line Number Loop > Ordering Provider Name Loop > N4 Ordering Provider City, State, ZIP Code To specify the geographic place of the named party Usage notes Required when a Durable Medical Equipment Regional Carrier Certificate of Medical Necessity (DMERC CMN) or DMERC Information Form (DIF), or Oxygen Therapy Certification is included on this service line. If not required by this implementation guide, do not send. Example N4XXXXXXXXX~ Only one of Ordering Provider State or Province Code (N4-02) or Country Subdivision Code (N4-07) may be present If Country Subdivision Code (N4-07) is present, then Country Code (N4-04) is required Max use 1 Optional N4-01 19 Ordering Provider City Name Min 2 Max 30 String (AN) Required Free-form text for city name A combination of either N401 through N404, or N405 and N406 may be adequate to specify a location. N4-02 156 Ordering Provider State or Province Code Min 2 Max 2 Identifier (ID) Optional Code (Standard State/Province) as defined by appropriate government agency N402 is required only if city name (N401) is in the U.S. or Canada. N4-03 116 Ordering Provider Postal Zone or ZIP Code Identifier (ID) Optional Min 3 Max 15 Code defining international postal zone code excluding punctuation and blanks (zip code for United States) N4-04 26 Country Code Min 2 Max 3 Identifier (ID) Optional Code identifying the country Usage notes Use the alpha-2 country codes from Part 1 of ISO 3166. N4-07 1715 Country Subdivision Code Min 1 Max 3 Identifier (ID) Optional Code identifying the country subdivision 1/30/25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 327/665 Usage notes Use the country subdivision codes from Part 2 of ISO 3166. 1/30/25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 328/665 REF 5250 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > Service Line Number Loop > Ordering Provider Name Loop > REF Ordering Provider Secondary Identification To specify identifying information Usage notes Required prior to the mandated HIPAA National Provider Identifier (NPI) implementation date when an identification number other than the NPI is necessary for the receiver to identify the provider. OR Required on or after the mandated NPI Implementation Date when NM109 in this loop is not used and an identification number other than the NPI is necessary for the receiver to identify the provider. If not required by this implementation guide, do not send. When it is necessary to report one or more non-destination payer Secondary Identifiers, the composite data element in REF04 is used to identify the payer who assigned this identifier. Example REFG2XXXXXX2U>XXXX~ Max use 20 Optional REF-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification 0B State License Number 1G Provider UPIN Number UPINs must be formatted as either X99999 or XXX999. G2 Provider Commercial Number This code designates a proprietary provider number for the destination payer identified in the Payer Name loop, Loop ID-2010BB, associated with this claim. This is to be used by all payers including: Medicare, Medicaid, Blue Cross, etc. REF-02 127 Ordering Provider Secondary Identifier Min 1 Max 50 String (AN) Required Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier REF-04 C040 Reference Identifier To identify one or more reference numbers or identification numbers as specified by the Reference Qualifier - REF04 contains data relating to the value cited in REF02. Usage notes Required when the identifier reported in REF02 of this segment is for a non-destination payer. Max use 1 Optional 1/30/25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 329/665 C040-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification 2U Payer Identification Number C040-02 127 Other Payer Primary Identifier Min 1 Max 50 String (AN) Required Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier Usage notes The payer identifier reported in this field must match the cooresponding payer identifier reported in Loop ID-2330B NM109. 1/30/25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 330/665 PER 5300 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > Service Line Number Loop > Ordering Provider Name Loop > PER Ordering Provider Contact Information To identify a person or office to whom administrative communications should be directed Usage notes Required when a Durable Medical Equipment Regional Carrier Certificate of Medical Necessity (DMERC CMN) or DMERC Information Form (DIF), or Oxygen Therapy Certification is included on this service line. If not required by this implementation guide, do not send. When the communication number represents a telephone number in the United States and other countries using the North American Dialing Plan (for voice, data, fax, etc.), the communication number must always include the area code and phone number using the format AAABBBCCCC where AAA is the area code, BBB is the telephone number prefix, and CCCC is the telephone number. Therefore, the following telephone number (555) 555-1234 would be represented as 5555551234. Do not submit long distance access numbers, such as "1", in the telephone number. Telephone extensions, when applicable, must be submitted in the next element immediately following the telephone number. When submitting telephone extensions, only submit the numeric extension. Do not include data that indicates an extension, such as "ext" or "x-". Example PERICXXXXXEMXXXXXXEMXXXEMXX~ If either Communication Number Qualifier (PER-05) or Communication Number (PER-06) is present, then the other is required If either Communication Number Qualifier (PER-07) or Communication Number (PER-08) is present, then the other is required Max use 1 Optional PER-01 366 Contact Function Code Identifier (ID) Required Code identifying the major duty or responsibility of the person or group named IC Information Contact PER-02 93 Ordering Provider Contact Name Min 1 Max 60 String (AN) Optional Free-form name PER-03 365 Communication Number Qualifier Identifier (ID) Required Code identifying the type of communication number EM Electronic Mail FX Facsimile TE Telephone PER-04 364 Communication Number Min 1 Max 256 String (AN) Required 1/30/25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 331/665 2420E Ordering Provider Name Loop end Complete communications number including country or area code when applicable PER-05 365 Communication Number Qualifier Identifier (ID) Optional Code identifying the type of communication number EM Electronic Mail EX Telephone Extension FX Facsimile TE Telephone PER-06 364 Communication Number Min 1 Max 256 String (AN) Optional Complete communications number including country or area code when applicable PER-07 365 Communication Number Qualifier Identifier (ID) Optional Code identifying the type of communication number EM Electronic Mail EX Telephone Extension FX Facsimile TE Telephone PER-08 364 Communication Number Min 1 Max 256 String (AN) Optional Complete communications number including country or area code when applicable 1/30/25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 332/665 2420F Referring Provider Name Loop Max 2 Optional Variants (all may be used) Rendering Provider Name Loop Purchased Service Provider Name Loop Service Facility Location Name Loop Supervising Provider Name Loop Ordering Provider Name Loop Ambulance Pick-up Location Loop Ambulance Drop-off Location Loop NM1 5000 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > Service Line Number Loop > Referring Provider Name Loop > NM1 Referring Provider Name To supply the full name of an individual or organizational entity Usage notes When reporting the provider who ordered services such as diagnostic and lab, use Loop ID-2310A at the claim level. For ordered services such as Durable Medical Equipment, use Loop ID-2420E at the line level. When there is only one referral on the claim, use code "DN - Referring Provider". When more than one referral exists and there is a requirement to report the additional referral, use code DN in the first iteration of this loop to indicate the referral received by the rendering provider on this claim. Use code "P3 - Primary Care Provider" in the second iteration of the loop to indicate the initial referral from the primary care provider or whatever provider wrote the initial referral for this patient's episode of care being billed/reported in this transaction. Required when this service line involves a referral and the referring provider differs from that reported at the claim level (loop 2310A). If not required by this implementation guide, may be provided at the sender's discretion, but cannot be required by the receiver. Example NM1P31XXXXXXXXXXX*XXXXXXX*XXXXXX~ If either Identification Code Qualifier (NM1-08) or Referring Provider Identifier (NM1-09) is present, then the other is required Max use 1 Required NM1-01 98 Entity Identifier Code Identifier (ID) Required Code identifying an organizational entity, a physical location, property or an individual DN Referring Provider Use on the first iteration of this loop. Use if loop is used only once. P3 Primary Care	Home State Health 837 Health Care Claim_ Professional.pdf
Min 1 Max 60 String (AN) Optional Free-form name PER-03 365 Communication Number Qualifier Identifier (ID) Required Code identifying the type of communication number EM Electronic Mail FX Facsimile TE Telephone PER-04 364 Communication Number Min 1 Max 256 String (AN) Required 1/30/25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 331/665 2420E Ordering Provider Name Loop end Complete communications number including country or area code when applicable PER-05 365 Communication Number Qualifier Identifier (ID) Optional Code identifying the type of communication number EM Electronic Mail EX Telephone Extension FX Facsimile TE Telephone PER-06 364 Communication Number Min 1 Max 256 String (AN) Optional Complete communications number including country or area code when applicable PER-07 365 Communication Number Qualifier Identifier (ID) Optional Code identifying the type of communication number EM Electronic Mail EX Telephone Extension FX Facsimile TE Telephone PER-08 364 Communication Number Min 1 Max 256 String (AN) Optional Complete communications number including country or area code when applicable 1/30/25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 332/665 2420F Referring Provider Name Loop Max 2 Optional Variants (all may be used) Rendering Provider Name Loop Purchased Service Provider Name Loop Service Facility Location Name Loop Supervising Provider Name Loop Ordering Provider Name Loop Ambulance Pick-up Location Loop Ambulance Drop-off Location Loop NM1 5000 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > Service Line Number Loop > Referring Provider Name Loop > NM1 Referring Provider Name To supply the full name of an individual or organizational entity Usage notes When reporting the provider who ordered services such as diagnostic and lab, use Loop ID-2310A at the claim level. For ordered services such as Durable Medical Equipment, use Loop ID-2420E at the line level. When there is only one referral on the claim, use code "DN - Referring Provider". When more than one referral exists and there is a requirement to report the additional referral, use code DN in the first iteration of this loop to indicate the referral received by the rendering provider on this claim. Use code "P3 - Primary Care Provider" in the second iteration of the loop to indicate the initial referral from the primary care provider or whatever provider wrote the initial referral for this patient's episode of care being billed/reported in this transaction. Required when this service line involves a referral and the referring provider differs from that reported at the claim level (loop 2310A). If not required by this implementation guide, may be provided at the sender's discretion, but cannot be required by the receiver. Example NM1P31XXXXXXXXXXXXXXXXXXXXXXXX~ If either Identification Code Qualifier (NM1-08) or Referring Provider Identifier (NM1-09) is present, then the other is required Max use 1 Required NM1-01 98 Entity Identifier Code Identifier (ID) Required Code identifying an organizational entity, a physical location, property or an individual DN Referring Provider Use on the first iteration of this loop. Use if loop is used only once. P3 Primary Care Provider Use only if loop is used twice. Use only on second iteration of this loop. NM1-02 1065 Entity Type Qualifier Identifier (ID) Required 1/30/25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 333/665 Code qualifying the type of entity NM102 qualifies NM103. 1 Person NM1-03 1035 Referring Provider Last Name Min 1 Max 60 String (AN) Required Individual last name or organizational name NM1-04 1036 Referring Provider First Name Min 1 Max 35 String (AN) Optional Individual first name NM1-05 1037 Referring Provider Middle Name or Initial Min 1 Max 25 String (AN) Optional Individual middle name or initial NM1-07 1039 Referring Provider Name Suffix Min 1 Max 10 String (AN) Optional Suffix to individual name NM1-08 66 Identification Code Qualifier Identifier (ID) Optional Code designating the system/method of code structure used for Identification Code (67) XX Centers for Medicare and Medicaid Services National Provider Identifier NM1-09 67 Referring Provider Identifier Min 2 Max 80 String (AN) Optional Code identifying a party or other code 1/30/25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 334/665 REF 5250 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > Service Line Number Loop > Referring Provider Name Loop > REF Referring Provider Secondary Identification To specify identifying information Usage notes Required prior to the mandated HIPAA National Provider Identifier (NPI) implementation date when an identification number other than the NPI is necessary for the receiver to identify the provider. OR Required on or after the mandated NPI Implementation Date when NM109 in this loop is not used and an identification number other than the NPI is necessary for the receiver to identify the provider. If not required by this implementation guide, do not send. When it is necessary to report one or more non-destination payer Secondary Identifiers, the composite data element in REF04 is used to identify the payer who assigned this identifier. Example REF1GXX2U>XX~ Max use 20 Optional REF-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification 0B State License Number 1G Provider UPIN Number UPINs must be formatted as either X99999 or XXX999. G2 Provider Commercial Number This code designates a proprietary provider number for the destination payer identified in the Payer Name loop, Loop ID-2010BB, associated with this claim. This is to be used by all payers including: Medicare, Medicaid, Blue Cross, etc. REF-02 127 Referring Provider Secondary Identifier Min 1 Max 50 String (AN) Required Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier REF-04 C040 Reference Identifier To identify one or more reference numbers or identification numbers as specified by the Reference Qualifier - REF04 contains data relating to the value cited in REF02. Usage notes Required when the identifier reported in REF02 of this segment is for a non-destination payer. Max use 1 Optional 1/30/25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 335/665 2420F Referring Provider Name Loop end C040-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification 2U Payer Identification Number C040-02 127 Other Payer Primary Identifier Min 1 Max 50 String (AN) Required Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier Usage notes The payer identifier reported in this field must match the cooresponding payer identifier reported in Loop ID-2330B NM109. 1/30/25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 336/665 2420G Ambulance Pick-up Location Loop Max 1 Optional Variants (all may be used) Rendering Provider Name Loop Purchased Service Provider Name Loop Service Facility Location Name Loop Supervising Provider Name Loop Ordering Provider Name Loop Referring Provider Name Loop Ambulance Drop-off Location Loop NM1 5000 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > Service Line Number Loop > Ambulance Pick-up Location Loop > NM1 Ambulance Pick-up Location To supply the full name of an individual or organizational entity Usage notes Required when the ambulance pick-up location for this service line is different than the ambulance pick-up location provided in Loop ID-2310E. If not required by this implementation guide, do not send.; Example NM1PW2~ Max use 1 Required NM1-01 98 Entity Identifier Code Identifier (ID) Required Code identifying an organizational entity, a physical location, property or an individual PW Pickup Address NM1-02 1065 Entity Type Qualifier Identifier (ID) Required Code qualifying the type of entity NM102 qualifies NM103. 2 Non-Person Entity 1/30/25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 337/665 N3 5140 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > Service Line Number Loop > Ambulance Pick-up Location Loop > N3 Ambulance Pick-up Location Address To specify the location of the named party Usage notes If the ambulance pickup location is in an area where there are no street addresses, enter a description of where the service was rendered (for example, "crossroad of State Road 34 and 45" or "Exit near Mile marker 265 on Interstate 80".) Example N3XXXXXXXXX~ Max use 1 Required N3-01 166 Ambulance Pick-up Address Line Min 1 Max 55 String (AN) Required Address information N3-02 166 Ambulance Pick-up Address Line Min 1 Max 55 String (AN) Optional Address information 1/30/25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 338/665 N4 5200 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > Service Line Number Loop > Ambulance Pick-up Location Loop > N4 Ambulance Pick-up Location City, State, ZIP Code To specify the geographic place of the named party Example N4XXXXXXXXXXXX~ Only one of Ambulance Pick-up State or Province Code (N4-02) or Country Subdivision Code (N4-07) may be present If Country Subdivision Code (N4-07) is present, then Country Code (N4-04) is required Max use 1 Required N4-01 19 Ambulance Pick-up City Name Min 2 Max 30 String (AN) Required Free-form text for city name A combination of either N401 through N404, or N405 and N406 may be adequate to specify a location. N4-02 156 Ambulance Pick-up State or Province Code Identifier (ID) Optional Min 2 Max 2 Code (Standard State/Province) as defined by appropriate government agency N402 is required only if city name (N401) is in the U.S. or Canada. N4-03 116 Ambulance Pick-up Postal Zone or ZIP Code Identifier (ID) Optional Min 3 Max 15 Code defining international postal zone code excluding punctuation and blanks (zip code for United States) N4-04 26 Country Code Min 2 Max 3 Identifier (ID) Optional Code identifying the country Usage notes Use the alpha-2 country codes from Part 1 of ISO 3166. N4-07 1715 Country Subdivision Code Min 1 Max 3 Identifier (ID) Optional Code identifying the country subdivision Usage notes 1/30/25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 339/665 2420G Ambulance Pick-up Location Loop end Use the country subdivision codes from Part 2 of ISO 3166. 1/30/25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 340/665 2420H Ambulance Drop-off Location Loop Max 1 Optional Variants (all may be used) Rendering Provider Name Loop Purchased Service Provider Name Loop Service Facility Location Name Loop Supervising Provider Name Loop Ordering Provider Name Loop Referring Provider Name Loop Ambulance Pick-up Location Loop NM1 5000 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > Service Line Number Loop > Ambulance Drop-off Location Loop > NM1 Ambulance Drop-off Location To supply the full name of an individual or organizational entity Usage notes Required when the ambulance drop-off location for this service line is different than the ambulance drop-off location provided in Loop ID-2310F. If not required by this implementation guide, do not send. Example NM1452XXXXX~ Max use 1 Required NM1-01 98 Entity Identifier Code Identifier (ID) Required Code identifying an organizational entity, a physical location, property or an individual 45 Drop-off Location NM1-02 1065 Entity Type Qualifier Identifier (ID) Required Code qualifying the type of entity NM102 qualifies NM103. 2 Non-Person Entity NM1-03 1035 Ambulance Drop-off Location Min 1 Max 60 String (AN) Optional Individual last name or organizational name 1/30/25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 341/665 N3 5140 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > Service Line Number Loop > Ambulance Drop-off Location Loop > N3 Ambulance Drop-off Location Address To specify the location of the named party Usage notes If the ambulance drop-off location is in an area where there are no street addresses, enter a description of where the service was rendered (for example, "crossroad of State Road 34 and 45" or "Exit near Mile marker 265 on Interstate 80".) Example N3XXX~ Max use 1 Required N3-01 166 Ambulance Drop-off Address Line Min 1 Max 55 String (AN) Required Address information N3-02 166 Ambulance Drop-off Address Line	Home State Health 837 Health Care Claim_ Professional.pdf
(AN) Required Free-form text for city name A combination of either N401 through N404, or N405 and N406 may be adequate to specify a location. N4-02 156 Ambulance Pick-up State or Province Code Identifier (ID) Optional Min 2 Max 2 Code (Standard State/Province) as defined by appropriate government agency N402 is required only if city name (N401) is in the U.S. or Canada. N4-03 116 Ambulance Pick-up Postal Zone or ZIP Code Identifier (ID) Optional Min 3 Max 15 Code defining international postal zone code excluding punctuation and blanks (zip code for United States) N4-04 26 Country Code Min 2 Max 3 Identifier (ID) Optional Code identifying the country Usage notes Use the alpha-2 country codes from Part 1 of ISO 3166. N4-07 1715 Country Subdivision Code Min 1 Max 3 Identifier (ID) Optional Code identifying the country subdivision Usage notes 1/30/25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 339/665 2420G Ambulance Pick-up Location Loop end Use the country subdivision codes from Part 2 of ISO 3166. 1/30/25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 340/665 2420H Ambulance Drop-off Location Loop Max 1 Optional Variants (all may be used) Rendering Provider Name Loop Purchased Service Provider Name Loop Service Facility Location Name Loop Supervising Provider Name Loop Ordering Provider Name Loop Referring Provider Name Loop Ambulance Pick-up Location Loop NM1 5000 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > Service Line Number Loop > Ambulance Drop-off Location Loop > NM1 Ambulance Drop-off Location To supply the full name of an individual or organizational entity Usage notes Required when the ambulance drop-off location for this service line is different than the ambulance drop-off location provided in Loop ID-2310F. If not required by this implementation guide, do not send. Example NM1452XXXXX~ Max use 1 Required NM1-01 98 Entity Identifier Code Identifier (ID) Required Code identifying an organizational entity, a physical location, property or an individual 45 Drop-off Location NM1-02 1065 Entity Type Qualifier Identifier (ID) Required Code qualifying the type of entity NM102 qualifies NM103. 2 Non-Person Entity NM1-03 1035 Ambulance Drop-off Location Min 1 Max 60 String (AN) Optional Individual last name or organizational name 1/30/25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 341/665 N3 5140 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > Service Line Number Loop > Ambulance Drop-off Location Loop > N3 Ambulance Drop-off Location Address To specify the location of the named party Usage notes If the ambulance drop-off location is in an area where there are no street addresses, enter a description of where the service was rendered (for example, "crossroad of State Road 34 and 45" or "Exit near Mile marker 265 on Interstate 80".) Example N3XXX~ Max use 1 Required N3-01 166 Ambulance Drop-off Address Line Min 1 Max 55 String (AN) Required Address information N3-02 166 Ambulance Drop-off Address Line Min 1 Max 55 String (AN) Optional Address information 1/30/25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 342/665 N4 5200 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > Service Line Number Loop > Ambulance Drop-off Location Loop > N4 Ambulance Drop-off Location City, State, ZIP Code To specify the geographic place of the named party Example N4XXXXXXXXXXXXXXXXXXX~ Only one of Ambulance Drop-off State or Province Code (N4-02) or Country Subdivision Code (N4-07) may be present If Country Subdivision Code (N4-07) is present, then Country Code (N4-04) is required Max use 1 Required N4-01 19 Ambulance Drop-off City Name Min 2 Max 30 String (AN) Required Free-form text for city name A combination of either N401 through N404, or N405 and N406 may be adequate to specify a location. N4-02 156 Ambulance Drop-off State or Province Code Identifier (ID) Optional Min 2 Max 2 Code (Standard State/Province) as defined by appropriate government agency N402 is required only if city name (N401) is in the U.S. or Canada. N4-03 116 Ambulance Drop-off Postal Zone or ZIP Code Identifier (ID) Optional Min 3 Max 15 Code defining international postal zone code excluding punctuation and blanks (zip code for United States) N4-04 26 Country Code Min 2 Max 3 Identifier (ID) Optional Code identifying the country Usage notes Use the alpha-2 country codes from Part 1 of ISO 3166. N4-07 1715 Country Subdivision Code Min 1 Max 3 Identifier (ID) Optional Code identifying the country subdivision Usage notes 1/30/25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 343/665 2420H Ambulance Drop-off Location Loop end Use the country subdivision codes from Part 2 of ISO 3166. 1/30/25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 344/665 2430 Line Adjudication Information Loop Max 15 Optional SVD 5400 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > Service Line Number Loop > Line Adjudication Information Loop > SVD Line Adjudication Information To convey service line adjudication information for coordination of benefits between the initial payers of a health care claim and all subsequent payers Usage notes Required when the claim has been previously adjudicated by payer identified in Loop ID-2330B and this service line has payments and/or adjustments applied to it. If not required by this implementation guide, do not send. To show unbundled lines: If, in the original claim, line 3 is unbundled into (for example) 2 additional lines, then the SVD for line 3 is used 3 times: once for the original adjustment to line 3 and then two more times for the additional unbundled lines. Example SVDXXXXXXX0000000000ER>XXXX>XX>XX>XX>XX>XXXX* 000000000000000000~ Max use 1 Required SVD-01 67 Other Payer Primary Identifier Min 2 Max 80 String (AN) Required Code identifying a party or other code SVD01 is the payer identification code. Usage notes This identifier indicates the payer responsible for the reimbursement described in this iteration of the 2430 loop. The identifier indicates the Other Payer by matching the appropriate Other Payer Primary Identifier (Loop ID-2330B, element NM109). SVD-02 782 Service Line Paid Amount Min 1 Max 15 Decimal number (R) Required Monetary amount SVD02 is the amount paid for this service line. Usage notes Zero "0" is an acceptable value for this element. SVD-03 C003 Composite Medical Procedure Identifier To identify a medical procedure by its standardized codes and applicable modifiers - SVD03 represents the medical procedure code upon which adjudication of this service line was based. This may be different than the submitted medical procedure code. Max use 1 Required C003-01 235 Product or Service ID Qualifier Identifier (ID) Required 1/30/25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 345/665 Code identifying the type/source of the descriptive number used in Product/Service ID (234) C003-01 qualifies C003-02 and C003-08. ER Jurisdiction Specific Procedure and Supply Codes This code set is not allowed for use under HIPAA at the time of this writing. The qualifier can only be used: If a new rule names the Jurisdiction Specific Procedure and Supply Codes as an allowable code set under HIPAA, OR The Secretary grants an exception to use the code set as a pilot project as allowed under the law, OR For claims which are not covered under HIPAA. HC Health Care Financing Administration Common Procedural Coding System (HCPCS) Codes Because the AMA's CPT codes are also level 1 HCPCS codes, they are reported under HC. IV Home Infusion EDI Coalition (HIEC) Product/Service Code This code set is not allowed for use under HIPAA at the time of this writing. The qualifier can only be used: If a new rule names the Home Infusion EDI Coalition (HIEC) Product/Service Codes as an allowable code set under HIPAA, OR The Secretary grants an exception to use the code set as a pilot project as allowed under the law, OR For claims which are not covered under HIPAA.; WK Advanced Billing Concepts (ABC) Codes At the time of this writing, this code set has been approved by the Secretary of HHS as a pilot project allowed under HIPAA law. The qualifier may only be used in transactions covered under HIPAA; By parties registered in the pilot project and their trading partners, OR If a new rule names the Complementary, Alternative, or Holistic Procedure Codes as an allowable code set under HIPAA, OR For claims which are not covered under HIPAA. C003-02 234 Procedure Code Min 1 Max 48 String (AN) Required Identifying number for a product or service If C003-08 is used, then C003-02 represents the beginning value in the range in which the code occurs. C003-03 1339 Procedure Modifier Min 2 Max 2 String (AN) Optional This identifies special circumstances related to the performance of the service, as defined by trading partners C003-03 modifies the value in C003-02 and C003-08. 1/30/25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 346/665 C003-04 1339 Procedure Modifier Min 2 Max 2 String (AN) Optional This identifies special circumstances related to the performance of the service, as defined by trading partners C003-04 modifies the value in C003-02 and C003-08. C003-05 1339 Procedure Modifier Min 2 Max 2 String (AN) Optional This identifies special circumstances related to the performance of the service, as defined by trading partners C003-05 modifies the value in C003-02 and C003-08. C003-06 1339 Procedure Modifier Min 2 Max 2 String (AN) Optional This identifies special circumstances related to the performance of the service, as defined by trading partners C003-06 modifies the value in C003-02 and C003-08. C003-07 352 Procedure Code Description Min 1 Max 80 String (AN) Optional A free-form description to clarify the related data elements and their content C003-07 is the description of the procedure identified in C003-02. SVD-05 380 Paid Service Unit Count Min 1 Max 15 Decimal number (R) Required Numeric value of quantity SVD05 is the paid units of service. Usage notes This is the number of paid units from the remittance advice. When paid units are not present on the remittance advice, use the original billed units. The maximum length for this field is 8 digits excluding the decimal. When a decimal is used, the maximum number of digits allowed to the right of the decimal is three. SVD-06 554 Bundled or Unbundled Line Number Min 1 Max 6 Numeric (N0) Optional Number assigned for differentiation within a transaction set SVD06 is only used for bundling of service lines. It references the LX Assigned Number of the service line into which this service line was bundled. 1/30/25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 347/665 CAS 5450 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > Service Line Number Loop > Line Adjudication Information Loop > CAS Line Adjustment To supply adjustment reason codes and amounts as needed for an entire claim or for a particular service within the claim being paid Usage notes Required when the payer identified in Loop 2330B made line level adjustments which caused the amount paid to differ from the amount originally charged. If not required by this implementation guide, do not send. A single CAS segment contains six repetitions of the "adjustment trio" composed of adjustment reason code, adjustment amount, and adjustment quantity. These six adjustment trios are used to report up to six adjustments related to a particular Claim Adjustment Group Code (CAS01). The first non-zero adjustment is reported in the first adjustment trio (CAS02-CAS04). If there is a second non-zero adjustment, it is reported in the second adjustment trio (CAS05-CAS07), and so on through the sixth adjustment trio (CAS17-CAS19). Example CASCOXXXXX00000000000000000000XXXXX00000000 00000000000XXXXX0000000000XXXX000000000000 00X0000000000X00000000*0~ If Adjustment Reason Code (CAS-05) is present, then at least one of Adjustment Amount (CAS-06) or Adjustment Quantity (CAS-07) is required If Adjustment Amount (CAS-06) is present, then Adjustment Reason Code (CAS-05) is required If Adjustment Quantity (CAS-07) is present, then Adjustment Reason Code (CAS-05) is required If Adjustment Reason Code (CAS-08) is present, then at	Home State Health 837 Health Care Claim_ Professional.pdf
2 String (AN) Optional This identifies special circumstances related to the performance of the service, as defined by trading partners C003-04 modifies the value in C003-02 and C003-08. C003-05 1339 Procedure Modifier Min 2 Max 2 String (AN) Optional This identifies special circumstances related to the performance of the service, as defined by trading partners C003-05 modifies the value in C003-02 and C003-08. C003-06 1339 Procedure Modifier Min 2 Max 2 String (AN) Optional This identifies special circumstances related to the performance of the service, as defined by trading partners C003-06 modifies the value in C003-02 and C003-08. C003-07 352 Procedure Code Description Min 1 Max 80 String (AN) Optional A free-form description to clarify the related data elements and their content C003-07 is the description of the procedure identified in C003-02. SVD-05 380 Paid Service Unit Count Min 1 Max 15 Decimal number (R) Required Numeric value of quantity SVD05 is the paid units of service. Usage notes This is the number of paid units from the remittance advice. When paid units are not present on the remittance advice, use the original billed units. The maximum length for this field is 8 digits excluding the decimal. When a decimal is used, the maximum number of digits allowed to the right of the decimal is three. SVD-06 554 Bundled or Unbundled Line Number Min 1 Max 6 Numeric (N0) Optional Number assigned for differentiation within a transaction set SVD06 is only used for bundling of service lines. It references the LX Assigned Number of the service line into which this service line was bundled. 1/30/25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 347/665 CAS 5450 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > Service Line Number Loop > Line Adjudication Information Loop > CAS Line Adjustment To supply adjustment reason codes and amounts as needed for an entire claim or for a particular service within the claim being paid Usage notes Required when the payer identified in Loop 2330B made line level adjustments which caused the amount paid to differ from the amount originally charged. If not required by this implementation guide, do not send. A single CAS segment contains six repetitions of the "adjustment trio" composed of adjustment reason code, adjustment amount, and adjustment quantity. These six adjustment trios are used to report up to six adjustments related to a particular Claim Adjustment Group Code (CAS01). The first non-zero adjustment is reported in the first adjustment trio (CAS02-CAS04). If there is a second non-zero adjustment, it is reported in the second adjustment trio (CAS05-CAS07), and so on through the sixth adjustment trio (CAS17-CAS19). Example CASCOXXXXX00000000000000000000XXXXX00000000 00000000000XXXXX0000000000XXXX000000000000 00X0000000000X000000000~ If Adjustment Reason Code (CAS-05) is present, then at least one of Adjustment Amount (CAS-06) or Adjustment Quantity (CAS-07) is required If Adjustment Amount (CAS-06) is present, then Adjustment Reason Code (CAS-05) is required If Adjustment Quantity (CAS-07) is present, then Adjustment Reason Code (CAS-05) is required If Adjustment Reason Code (CAS-08) is present, then at least one of Adjustment Amount (CAS-09) or Adjustment Quantity (CAS-10) is required If Adjustment Amount (CAS-09) is present, then Adjustment Reason Code (CAS-08) is required If Adjustment Quantity (CAS-10) is present, then Adjustment Reason Code (CAS-08) is required If Adjustment Reason Code (CAS-11) is present, then at least one of Adjustment Amount (CAS-12) or Adjustment Quantity (CAS-13) is required If Adjustment Amount (CAS-12) is present, then Adjustment Reason Code (CAS-11) is required If Adjustment Quantity (CAS-13) is present, then Adjustment Reason Code (CAS-11) is required If Adjustment Reason Code (CAS-14) is present, then at least one of Adjustment Amount (CAS-15) or Adjustment Quantity (CAS-16) is required If Adjustment Amount (CAS-15) is present, then Adjustment Reason Code (CAS-14) is required If Adjustment Quantity (CAS-16) is present, then Adjustment Reason Code (CAS-14) is required If Adjustment Reason Code (CAS-17) is present, then at least one of Adjustment Amount (CAS-18) or Adjustment Quantity (CAS-19) is required If Adjustment Amount (CAS-18) is present, then Adjustment Reason Code (CAS-17) is required If Adjustment Quantity (CAS-19) is present, then Adjustment Reason Code (CAS-17) is required Max use 5 Optional 1/30/25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 348/665 CAS-01 1033 Claim Adjustment Group Code Identifier (ID) Required Code identifying the general category of payment adjustment CO Contractual Obligations CR Correction and Reversals OA Other adjustments PI Payor Initiated Reductions PR Patient Responsibility CAS-02 1034 Adjustment Reason Code Min 1 Max 5 Identifier (ID) Required Code identifying the detailed reason the adjustment was made CAS-03 782 Adjustment Amount Min 1 Max 15 Decimal number (R) Required Monetary amount CAS03 is the amount of adjustment. CAS-04 380 Adjustment Quantity Min 1 Max 15 Decimal number (R) Optional Numeric value of quantity CAS04 is the units of service being adjusted. CAS-05 1034 Adjustment Reason Code Min 1 Max 5 Identifier (ID) Optional Code identifying the detailed reason the adjustment was made Usage notes See CODE SOURCE 139: Claim Adjustment Reason Code CAS-06 782 Adjustment Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount CAS06 is the amount of the adjustment. CAS-07 380 Adjustment Quantity Min 1 Max 15 Decimal number (R) Optional Numeric value of quantity CAS07 is the units of service being adjusted. 1/30/25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 349/665 CAS-08 1034 Adjustment Reason Code Min 1 Max 5 Identifier (ID) Optional Code identifying the detailed reason the adjustment was made Usage notes See CODE SOURCE 139: Claim Adjustment Reason Code CAS-09 782 Adjustment Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount CAS09 is the amount of the adjustment. CAS-10 380 Adjustment Quantity Min 1 Max 15 Decimal number (R) Optional Numeric value of quantity CAS10 is the units of service being adjusted. CAS-11 1034 Adjustment Reason Code Min 1 Max 5 Identifier (ID) Optional Code identifying the detailed reason the adjustment was made Usage notes See CODE SOURCE 139: Claim Adjustment Reason Code CAS-12 782 Adjustment Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount CAS12 is the amount of the adjustment. CAS-13 380 Adjustment Quantity Min 1 Max 15 Decimal number (R) Optional Numeric value of quantity CAS13 is the units of service being adjusted. CAS-14 1034 Adjustment Reason Code Min 1 Max 5 Identifier (ID) Optional Code identifying the detailed reason the adjustment was made Usage notes See CODE SOURCE 139: Claim Adjustment Reason Code CAS-15 782 Adjustment Amount Min 1 Max 15 Decimal number (R) Optional 1/30/25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 350/665 Monetary amount CAS15 is the amount of the adjustment. CAS-16 380 Adjustment Quantity Min 1 Max 15 Decimal number (R) Optional Numeric value of quantity CAS16 is the units of service being adjusted. CAS-17 1034 Adjustment Reason Code Min 1 Max 5 Identifier (ID) Optional Code identifying the detailed reason the adjustment was made Usage notes See CODE SOURCE 139: Claim Adjustment Reason Code CAS-18 782 Adjustment Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount CAS18 is the amount of the adjustment. CAS-19 380 Adjustment Quantity Min 1 Max 15 Decimal number (R) Optional Numeric value of quantity CAS19 is the units of service being adjusted. 1/30/25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 351/665 DTP 5500 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > Service Line Number Loop > Line Adjudication Information Loop > DTP Line Check or Remittance Date To specify any or all of a date, a time, or a time period Example DTP573D8XXXX~ Max use 1 Required DTP-01 374 Date Time Qualifier Identifier (ID) Required Code specifying type of date or time, or both date and time 573 Date Claim Paid DTP-02 1250 Date Time Period Format Qualifier Identifier (ID) Required Code indicating the date format, time format, or date and time format DTP02 is the date or time or period format that will appear in DTP03. D8 Date Expressed in Format CCYYMMDD DTP-03 1251 Adjudication or Payment Date Min 1 Max 35 String (AN) Required Expression of a date, a time, or range of dates, times or dates and times 1/30/25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 352/665 2430 Line Adjudication Information Loop end AMT 5505 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > Service Line Number Loop > Line Adjudication Information Loop > AMT Remaining Patient Liability To indicate the total monetary amount Usage notes In the judgment of the provider, this is the remaining amount to be paid after adjudication by the Other Payer referenced in SVD01 of this iteration of Loop ID-2430. This segment is only used in provider submitted claims. It is not used in Payer-to-Payer Coordination of Benefits (COB). Required when the Other Payer referenced in SVD01 of this iteration of Loop ID-2430 has adjudicated this claim, provided line level information, and the provider has the ability to report line item information. If not required by this implementation guide, do not send. This segment is not used if the claim level (Loop ID-2320) Remaining Patient Liability AMT segment is used for this Other Payer. Example AMTEAF00000000000~ Max use 1 Optional AMT-01 522 Amount Qualifier Code Identifier (ID) Required Code to qualify amount EAF Amount Owed AMT-02 782 Remaining Patient Liability Min 1 Max 15 Decimal number (R) Required Monetary amount 1/30/25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 353/665 2440 Form Identification Code Loop Max >1 Optional LQ 5510 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > Service Line Number Loop > Form Identification Code Loop > LQ Form Identification Code To identify standard industry codes Usage notes Required when adjudication is known to be impacted by one of the types of supporting documentation (standardized paper forms) listed in LQ01. If not required by this implementation guide, do not send. Loop ID-2440 is designed to allow providers to attach standardized supplemental information to the claim when required to do so by the payer. The LQ segment contains information to identify the form (LQ01) and the specific form number (LQ02). In the example given below, LQ01=UT which identifies the form as a Medicare DMERC CMN form. LQ02=01.02 identifies which DMERC CMN form is being used. An example application of this Form Identification Code Loop is for Medicare DMERC claims for which the DME provider is required to obtain a Certificate of Medical Necessity (DMERC CMN) or DMERC Information Form (DIF), or Oxygen Therapy Certification from the referring physician. Another example is payer documentation requirements for Home Health services. Example LQUTXXXXXX~ Max use 1 Required LQ-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list AS Form Type Code Code value AS indicates that a Home Health form from External Code Source 656 is being identified in LQ02. UT Centers for Medicare and Medicaid Services (CMS) Durable Medical Equipment Regional Carrier (DMERC) Certificate of Medical Necessity (CMN) Forms LQ-02 1271 Form Identifier Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list 1/30/25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 354/665 FRM 5520 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > Service Line Number Loop > Form Identification Code Loop > FRM Supporting Documentation To specify information in response to a codified questionnaire document Usage notes The LQ segment is used to identify the general (LQ01) and specific type (LQ02) for the form being reported in Loop ID-2440. The FRM segment is used to answer specific questions on the form identified in the LQ segment. FRM01 is used to indicate the question being answered. Answers can take one of 4 forms: FRM02 for Yes/No questions, FRM03 for text/uncodified answers, FRM04 for answers which use dates, and FRM05 for answers which are percents.	Home State Health 837 Health Care Claim_ Professional.pdf
to report line item information. If not required by this implementation guide, do not send. This segment is not used if the claim level (Loop ID-2320) Remaining Patient Liability AMT segment is used for this Other Payer. Example AMTEAF00000000000~ Max use 1 Optional AMT-01 522 Amount Qualifier Code Identifier (ID) Required Code to qualify amount EAF Amount Owed AMT-02 782 Remaining Patient Liability Min 1 Max 15 Decimal number (R) Required Monetary amount 1/30/25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 353/665 2440 Form Identification Code Loop Max >1 Optional LQ 5510 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > Service Line Number Loop > Form Identification Code Loop > LQ Form Identification Code To identify standard industry codes Usage notes Required when adjudication is known to be impacted by one of the types of supporting documentation (standardized paper forms) listed in LQ01. If not required by this implementation guide, do not send. Loop ID-2440 is designed to allow providers to attach standardized supplemental information to the claim when required to do so by the payer. The LQ segment contains information to identify the form (LQ01) and the specific form number (LQ02). In the example given below, LQ01=UT which identifies the form as a Medicare DMERC CMN form. LQ02=01.02 identifies which DMERC CMN form is being used. An example application of this Form Identification Code Loop is for Medicare DMERC claims for which the DME provider is required to obtain a Certificate of Medical Necessity (DMERC CMN) or DMERC Information Form (DIF), or Oxygen Therapy Certification from the referring physician. Another example is payer documentation requirements for Home Health services. Example LQUTXXXXXX~ Max use 1 Required LQ-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list AS Form Type Code Code value AS indicates that a Home Health form from External Code Source 656 is being identified in LQ02. UT Centers for Medicare and Medicaid Services (CMS) Durable Medical Equipment Regional Carrier (DMERC) Certificate of Medical Necessity (CMN) Forms LQ-02 1271 Form Identifier Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list 1/30/25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 354/665 FRM 5520 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > Service Line Number Loop > Form Identification Code Loop > FRM Supporting Documentation To specify information in response to a codified questionnaire document Usage notes The LQ segment is used to identify the general (LQ01) and specific type (LQ02) for the form being reported in Loop ID-2440. The FRM segment is used to answer specific questions on the form identified in the LQ segment. FRM01 is used to indicate the question being answered. Answers can take one of 4 forms: FRM02 for Yes/No questions, FRM03 for text/uncodified answers, FRM04 for answers which use dates, and FRM05 for answers which are percents. For each FRM01 (question) use a remaining FRM element, choosing the element which has the most appropriate format. One FRM segment is used for each question/answer pair. The example below shows how the FRM can be used to answer all the pertinent questions on DMERC form 0802 (LQUT08.02~). Example FRMXXXXNXXX20250130000~ At least one of Question Response (FRM-02), Question Response (FRM-03), Question Response (FRM-04) or Question Response (FRM-05) is required Max use 99 Required FRM-01 350 Question Number/Letter Min 1 Max 20 String (AN) Required Alphanumeric characters assigned for differentiation within a transaction set FRM01 is the question number on a questionnaire or codified form. FRM-02 1073 Question Response Identifier (ID) Optional Code indicating a Yes or No condition or response FRM02, FRM03, FRM04 and FRM05 are responses which only have meaning in reference to the question identified in FRM01. N No W Not Applicable Y Yes FRM-03 127 Question Response Min 1 Max 50 String (AN) Optional Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier FRM-04 373 Question Response CCYYMMDD format Date (DT) Optional 1/30/25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 355/665 2440 Form Identification Code Loop end 2400 Service Line Number Loop end 2300 Claim Information Loop end Date expressed as CCYYMMDD where CC represents the first two digits of the calendar year FRM-05 332 Question Response Min 1 Max 6 Decimal number (R) Optional Percent given in decimal format (e.g., 0.0 through 100.0 represents 0% through 100%) 1/30/25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 356/665 2000C Patient Hierarchical Level Loop Max >1 Optional HL 0010 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > HL Hierarchical Level To identify dependencies among and the content of hierarchically related groups of data segments Example HL32230~ Max use 1 Required HL-01 628 Hierarchical ID Number Min 1 Max 12 String (AN) Required A unique number assigned by the sender to identify a particular data segment in a hierarchical structure HL01 shall contain a unique alphanumeric number for each occurrence of the HL segment in the transaction set. For example, HL01 could be used to indicate the number of occurrences of the HL segment, in which case the value of HL01 would be "1" for the initial HL segment and would be incremented by one in each subsequent HL segment within the transaction. HL-02 734 Hierarchical Parent ID Number Min 1 Max 12 String (AN) Required Identification number of the next higher hierarchical data segment that the data segment being described is subordinate to HL02 identifies the hierarchical ID number of the HL segment to which the current HL segment is subordinate. HL-03 735 Hierarchical Level Code Identifier (ID) Required Code defining the characteristic of a level in a hierarchical structure HL03 indicates the context of the series of segments following the current HL segment up to the next occurrence of an HL segment in the transaction. For example, HL03 is used to indicate that subsequent segments in the HL loop form a logical grouping of data referring to shipment, order, or item-level information. 23 Dependent HL-04 736 Hierarchical Child Code Identifier (ID) Optional Code indicating if there are hierarchical child data segments subordinate to the level being described HL04 indicates whether or not there are subordinate (or child) HL segments related to the current HL segment. 1/30/25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 357/665 0 No Subordinate HL Segment in This Hierarchical Structure. 1/30/25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 358/665 PAT 0070 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > PAT Patient Information To supply patient information Example PAT53***D8XXXX01000000Y~ If either Date Time Period Format Qualifier (PAT-05) or Patient Death Date (PAT-06) is present, then the other is required If either Unit or Basis for Measurement Code (PAT-07) or Patient Weight (PAT-08) is present, then the other is required Max use 1 Required PAT-01 1069 Individual Relationship Code Identifier (ID) Required Code indicating the relationship between two individuals or entities Usage notes Specifies the patient's relationship to the person insured. 01 Spouse 19 Child 20 Employee 21 Unknown 39 Organ Donor 40 Cadaver Donor 53 Life Partner G8 Other Relationship PAT-05 1250 Date Time Period Format Qualifier Identifier (ID) Optional Code indicating the date format, time format, or date and time format D8 Date Expressed in Format CCYYMMDD PAT-06 1251 Patient Death Date Min 1 Max 35 String (AN) Optional Expression of a date, a time, or range of dates, times or dates and times PAT06 is the date of death. PAT-07 355 Unit or Basis for Measurement Code Identifier (ID) Optional Code specifying the units in which a value is being expressed, or manner in which a measurement has been taken 01 Actual Pounds PAT-08 81 Patient Weight Min 1 Max 10 Decimal number (R) Optional 1/30/25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 359/665 Numeric value of weight PAT08 is the patient's weight. PAT-09 1073 Pregnancy Indicator Identifier (ID) Optional Code indicating a Yes or No condition or response PAT09 indicates whether the patient is pregnant or not pregnant. Code "Y" indicates the patient is pregnant; code "N" indicates the patient is not pregnant. Usage notes For this implementation, the listed value takes precedence over the semantic note. Y Yes 1/30/25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 360/665 2010CA Patient Name Loop Max 1 Required NM1 0150 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Patient Name Loop > NM1 Patient Name To supply the full name of an individual or organizational entity Example NM1QC1XXXXX*XXXXXX~ Max use 1 Required NM1-01 98 Entity Identifier Code Identifier (ID) Required Code identifying an organizational entity, a physical location, property or an individual QC Patient NM1-02 1065 Entity Type Qualifier Identifier (ID) Required Code qualifying the type of entity NM102 qualifies NM103. 1 Person NM1-03 1035 Patient Last Name Min 1 Max 60 String (AN) Required Individual last name or organizational name NM1-04 1036 Patient First Name Min 1 Max 35 String (AN) Optional Individual first name NM1-05 1037 Patient Middle Name or Initial Min 1 Max 25 String (AN) Optional Individual middle name or initial NM1-07 1039 Patient Name Suffix Min 1 Max 10 String (AN) Optional Suffix to individual name 1/30/25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 361/665 N3 0250 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Patient Name Loop > N3 Patient Address To specify the location of the named party Example N3XXXXXXXX~ Max use 1 Required N3-01 166 Patient Address Line Min 1 Max 55 String (AN) Required Address information N3-02 166 Patient Address Line Min 1 Max 55 String (AN) Optional Address information 1/30/25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 362/665 N4 0300 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Patient Name Loop > N4 Patient City, State, ZIP Code To specify the geographic place of the named party Example N4XXXXXXXXXXXXXX~ Only one of Patient State Code (N4-02) or Country Subdivision Code (N4-07) may be present If Country Subdivision Code (N4-07) is present, then Country Code (N4-04) is required Max use 1 Required N4-01 19 Patient City Name Min 2 Max 30 String (AN) Required Free-form text for city name A combination of either N401 through N404, or N405 and N406 may be adequate to specify a location. N4-02 156 Patient State Code Min 2 Max 2 Identifier (ID) Optional Code (Standard State/Province) as defined by appropriate government agency N402 is required only if city name (N401) is in the U.S. or Canada. N4-03 116 Patient Postal Zone or ZIP Code Min 3 Max 15 Identifier (ID) Optional Code defining international postal zone code excluding punctuation and blanks (zip code for United States) N4-04 26 Country Code Min 2 Max 3 Identifier (ID) Optional Code identifying the country Usage notes Use the alpha-2 country codes from Part 1 of ISO 3166. N4-07 1715 Country Subdivision Code Min 1 Max 3 Identifier (ID) Optional Code identifying the country subdivision Usage notes Use the country subdivision codes from Part 2 of ISO 3166. 1/30/25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 363/665 DMG 0320 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Patient Name Loop > DMG Patient Demographic Information To supply demographic information Example DMGD8XXXXXXM~ Max use 1 Required DMG-01 1250 Date Time Period Format Qualifier Identifier (ID) Required Code indicating the date format, time format, or date and time format D8 Date Expressed in Format	Home State Health 837 Health Care Claim_ Professional.pdf
property or an individual QC Patient NM1-02 1065 Entity Type Qualifier Identifier (ID) Required Code qualifying the type of entity NM102 qualifies NM103. 1 Person NM1-03 1035 Patient Last Name Min 1 Max 60 String (AN) Required Individual last name or organizational name NM1-04 1036 Patient First Name Min 1 Max 35 String (AN) Optional Individual first name NM1-05 1037 Patient Middle Name or Initial Min 1 Max 25 String (AN) Optional Individual middle name or initial NM1-07 1039 Patient Name Suffix Min 1 Max 10 String (AN) Optional Suffix to individual name 1/30/25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 361/665 N3 0250 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Patient Name Loop > N3 Patient Address To specify the location of the named party Example N3XXXXXXXX~ Max use 1 Required N3-01 166 Patient Address Line Min 1 Max 55 String (AN) Required Address information N3-02 166 Patient Address Line Min 1 Max 55 String (AN) Optional Address information 1/30/25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 362/665 N4 0300 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Patient Name Loop > N4 Patient City, State, ZIP Code To specify the geographic place of the named party Example N4XXXXXXXXXXXXXX~ Only one of Patient State Code (N4-02) or Country Subdivision Code (N4-07) may be present If Country Subdivision Code (N4-07) is present, then Country Code (N4-04) is required Max use 1 Required N4-01 19 Patient City Name Min 2 Max 30 String (AN) Required Free-form text for city name A combination of either N401 through N404, or N405 and N406 may be adequate to specify a location. N4-02 156 Patient State Code Min 2 Max 2 Identifier (ID) Optional Code (Standard State/Province) as defined by appropriate government agency N402 is required only if city name (N401) is in the U.S. or Canada. N4-03 116 Patient Postal Zone or ZIP Code Min 3 Max 15 Identifier (ID) Optional Code defining international postal zone code excluding punctuation and blanks (zip code for United States) N4-04 26 Country Code Min 2 Max 3 Identifier (ID) Optional Code identifying the country Usage notes Use the alpha-2 country codes from Part 1 of ISO 3166. N4-07 1715 Country Subdivision Code Min 1 Max 3 Identifier (ID) Optional Code identifying the country subdivision Usage notes Use the country subdivision codes from Part 2 of ISO 3166. 1/30/25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 363/665 DMG 0320 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Patient Name Loop > DMG Patient Demographic Information To supply demographic information Example DMGD8XXXXXXM~ Max use 1 Required DMG-01 1250 Date Time Period Format Qualifier Identifier (ID) Required Code indicating the date format, time format, or date and time format D8 Date Expressed in Format CCYYMMDD DMG-02 1251 Patient Birth Date Min 1 Max 35 String (AN) Required Expression of a date, a time, or range of dates, times or dates and times DMG02 is the date of birth. DMG-03 1068 Patient Gender Code Identifier (ID) Required Code indicating the sex of the individual F Female M Male U Unknown 1/30/25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 364/665 REF 0350 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Patient Name Loop > REF Property and Casualty Claim Number To specify identifying information Usage notes Required when the services included in this claim are to be considered as part of a property and casualty claim. If not required by this implementation guide, do not send. This is a property and casualty payer-assigned claim number. Providers receive this number from the property and casualty payer during eligibility determinations or some other communication with that payer. See Section 1.4.2, Property and Casualty, for additional information about property and casualty claims.; This segment is not a HIPAA requirement as of this writing. Example REFY4XX~ Variants (all may be used) REF Property and Casualty Patient Identifier Max use 1 Optional REF-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification Y4 Agency Claim Number REF-02 127 Property Casualty Claim Number Min 1 Max 50 String (AN) Required Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier 1/30/25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 365/665 REF 0350 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Patient Name Loop > REF Property and Casualty Patient Identifier To specify identifying information Usage notes Required when an identification number is needed by the receiver to identify the patient for Property and Casualty claims. If not required by this implementation guide, do not send. Example REFSYXXXXX~ Variants (all may be used) REF Property and Casualty Claim Number Max use 1 Optional REF-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification 1W Member Identification Number This code designates a patient identification number used by the destination payer identified in the Payer Name loop, Loop ID 2010BB, associated with this claim. SY Social Security Number The Social Security Number must be a string of exactly nine numbers with no separators. For example, sending "111002222" would be valid, while sending "111-00-2222" would be invalid. REF-02 127 Property and Casualty Patient Identifier Min 1 Max 50 String (AN) Required Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier 1/30/25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 366/665 PER 0400 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Patient Name Loop > PER Property and Casualty Patient Contact Information To identify a person or office to whom administrative communications should be directed Usage notes Required for Property and Casualty claims when this information is different than the information provided in the Subscriber Contact Information PER segment in Loop ID- 2010BA and this information is deemed necessary by the submitter. If not required by this implementation guide, do not send. When the communication number represents a telephone number in the United States and other countries using the North American Dialing Plan (for voice, data, fax, etc.), the communication number must always include the area code and phone number using the format AAABBBCCCC where AAA is the area code, BBB is the telephone number prefix, and CCCC is the telephone number. Therefore, the following telephone number (555) 555-1234 would be represented as 5555551234. Do not submit long distance access numbers, such as "1", in the telephone number. Telephone extensions, when applicable, must be submitted in the next element immediately following the telephone number. When submitting telephone extensions, only submit the numeric extension. Do not include data that indicates an extension, such as "ext" or "x-". Example PERICXTEXXXXXXEXXXX~ If either Communication Number Qualifier (PER-05) or Communication Number (PER-06) is present, then the other is required Max use 1 Optional PER-01 366 Contact Function Code Identifier (ID) Required Code identifying the major duty or responsibility of the person or group named IC Information Contact PER-02 93 Name Min 1 Max 60 String (AN) Optional Free-form name PER-03 365 Communication Number Qualifier Identifier (ID) Required Code identifying the type of communication number TE Telephone PER-04 364 Communication Number Min 1 Max 256 String (AN) Required Complete communications number including country or area code when applicable PER-05 365 Communication Number Qualifier Identifier (ID) Optional 1/30/25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 367/665 2010CA Patient Name Loop end Code identifying the type of communication number EX Telephone Extension PER-06 364 Communication Number Min 1 Max 256 String (AN) Optional Complete communications number including country or area code when applicable 1/30/25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 368/665 2300 Claim Information Loop Max 100 Required CLM 1300 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > CLM Claim Information To specify basic data about the claim Usage notes The developers of this implementation guide recommend that trading partners limit the size of the transaction (ST-SE envelope) to a maximum of 5000 CLM segments. There is no recommended limit to the number of ST-SE transactions within a GS-GE or ISA- IEA. Willing trading partners can agree to set limits higher. For purposes of this documentation, the claim detail information is presented only in the dependent level. Specific claim detail information can be given in either the subscriber or the dependent hierarchical level. Because of this, the claim information is said to "float." Claim information is positioned in the same hierarchical level that describes its owner-participant, either the subscriber or the dependent. In other words, the claim information, Loop ID-2300, is placed following Loop ID-2010BB in the Subscriber Hierarchical Level (HL) when patient information is sent in Loop ID-2010BA of the Subscriber HL. Claim information is placed in the Patient HL when the patient information is sent in Loop ID-2010CA of the Patient HL. When the patient is the subscriber or is considered to be the subscriber, Loop ID-2000C and Loop ID-2010CA are not sent. See Subscriber/Patient HL Segment explanation in section 1.4.3.2.2.1 for details. Example CLMXX00*X>B>XYBNYPEM>XX>>XX>XXX02*** *3~ Max use 1 Required CLM-01 1028 Patient Control Number Min 1 Max 38 String (AN) Required Identifier used to track a claim from creation by the health care provider through payment Usage notes The number that the submitter transmits in this position is echoed back to the submitter in the 835 and other transactions. This permits the submitter to use the value in this field as a key in the submitter's system to match the claim to the payment information returned in the 835 transaction. The two recommended identifiers are either the Patient Account Number or the Claim Number in the billing submitter's patient management system. The developers of this implementation guide strongly recommend that submitters use unique numbers for this field for each individual claim. When Loop ID-2010AC is present, CLM01 represents the subrogated Medicaid agency's claim number (ICN/DCN) from their original 835 CLP07 - Payer Claim Control Number. See Section 1.4.1.4 of the front matter for a description of post payment recovery claims for subrogated Medicaid agencies. The maximum number of characters to be supported for this field is `20'. Characters beyond the maximum are not required to be stored nor returned by any 837-receiving system. 1/30/25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 369/665 CLM-02 782 Total Claim Charge Amount Min 1 Max 15 Decimal number (R) Required Monetary amount CLM02 is the total amount of all submitted charges of service segments for this claim. Usage notes The Total Claim Charge Amount must be greater than or equal to zero. The total claim charge amount must balance to the sum of all service line charge amounts reported in the Professional Service (SV1) segments for this claim. CLM-05 C023 Health Care Service Location Information To provide information that identifies the place of service or the type of bill related to the location at which a health care service was rendered Max use 1 Required C023-01 1331 Place of Service Code Min 1 Max 2 String (AN) Required Code identifying where services were, or may be, performed; the first and second positions of the Uniform Bill Type Code for Institutional Services or the Place of Service Codes for Professional or Dental Services. C023-02 1332 Facility Code Qualifier Identifier (ID) Required Code identifying the type of facility referenced C023-02 qualifies C023-01 and C023-03. B Place of Service Codes for Professional or Dental Services C023-03 1325 Claim Frequency Code Min 1 Max 1 Identifier (ID) Required Code specifying the frequency of the claim; this is	Home State Health 837 Health Care Claim_ Professional.pdf
or the dependent. In other words, the claim information, Loop ID-2300, is placed following Loop ID-2010BB in the Subscriber Hierarchical Level (HL) when patient information is sent in Loop ID-2010BA of the Subscriber HL. Claim information is placed in the Patient HL when the patient information is sent in Loop ID-2010CA of the Patient HL. When the patient is the subscriber or is considered to be the subscriber, Loop ID-2000C and Loop ID-2010CA are not sent. See Subscriber/Patient HL Segment explanation in section 1.4.3.2.2.1 for details. Example CLMXX00**X>B>XYBNYPEM>XX>>XX>XXX02*** 3~ Max use 1 Required CLM-01 1028 Patient Control Number Min 1 Max 38 String (AN) Required Identifier used to track a claim from creation by the health care provider through payment Usage notes The number that the submitter transmits in this position is echoed back to the submitter in the 835 and other transactions. This permits the submitter to use the value in this field as a key in the submitter's system to match the claim to the payment information returned in the 835 transaction. The two recommended identifiers are either the Patient Account Number or the Claim Number in the billing submitter's patient management system. The developers of this implementation guide strongly recommend that submitters use unique numbers for this field for each individual claim. When Loop ID-2010AC is present, CLM01 represents the subrogated Medicaid agency's claim number (ICN/DCN) from their original 835 CLP07 - Payer Claim Control Number. See Section 1.4.1.4 of the front matter for a description of post payment recovery claims for subrogated Medicaid agencies. The maximum number of characters to be supported for this field is `20'. Characters beyond the maximum are not required to be stored nor returned by any 837-receiving system. 1/30/25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 369/665 CLM-02 782 Total Claim Charge Amount Min 1 Max 15 Decimal number (R) Required Monetary amount CLM02 is the total amount of all submitted charges of service segments for this claim. Usage notes The Total Claim Charge Amount must be greater than or equal to zero. The total claim charge amount must balance to the sum of all service line charge amounts reported in the Professional Service (SV1) segments for this claim. CLM-05 C023 Health Care Service Location Information To provide information that identifies the place of service or the type of bill related to the location at which a health care service was rendered Max use 1 Required C023-01 1331 Place of Service Code Min 1 Max 2 String (AN) Required Code identifying where services were, or may be, performed; the first and second positions of the Uniform Bill Type Code for Institutional Services or the Place of Service Codes for Professional or Dental Services. C023-02 1332 Facility Code Qualifier Identifier (ID) Required Code identifying the type of facility referenced C023-02 qualifies C023-01 and C023-03. B Place of Service Codes for Professional or Dental Services C023-03 1325 Claim Frequency Code Min 1 Max 1 Identifier (ID) Required Code specifying the frequency of the claim; this is the third position of the Uniform Billing Claim Form Bill Type CLM-06 1073 Provider or Supplier Signature Indicator Identifier (ID) Required Code indicating a Yes or No condition or response CLM06 is provider signature on file indicator. A "Y" value indicates the provider signature is on file; an "N" value indicates the provider signature is not on file. N No Y Yes CLM-07 1359 Assignment or Plan Participation Code Identifier (ID) Required Code indicating whether the provider accepts assignment Usage notes 1/30/25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 370/665 Within this element the context of the word assignment is related to the relationship between the provider and the payer. This is NOT the field for reporting whether the patient has or has not assigned benefits to the provider. The benefit assignment indicator is in CLM08. A Assigned Required when the provider accepts assignment and/or has a participation agreement with the destination payer. OR Required when the provider does not accept assignment and/or have a participation agreement, but is advising the payer to adjudicate this specific claim under participating provider benefits as allowed under certain plans. B Assignment Accepted on Clinical Lab Services Only Required when the provider accepts assignment for Clinical Lab Services only. C Not Assigned Required when neither codes A' nor B' apply. CLM-08 1073 Benefits Assignment Certification Indicator Identifier (ID) Required Code indicating a Yes or No condition or response CLM08 is assignment of benefits indicator. A "Y" value indicates insured or authorized person authorizes benefits to be assigned to the provider; an "N" value indicates benefits have not been assigned to the provider. Usage notes This element answers the question whether or not the insured has authorized the plan to remit payment directly to the provider. N No W Not Applicable Use code `W' when the patient refuses to assign benefits. Y Yes CLM-09 1363 Release of Information Code Identifier (ID) Required Code indicating whether the provider has on file a signed statement by the patient authorizing the release of medical data to other organizations Usage notes The Release of Information response is limited to the information carried in this claim. I Informed Consent to Release Medical Information for Conditions or Diagnoses Regulated by Federal Statutes Required when the provider has not collected a signature AND state or federal laws do not require a signature be collected. Y Yes, Provider has a Signed Statement Permitting Release of Medical Billing Data Related to a Claim Required when the provider has collected a signature. OR Required when state or federal laws require a signature be collected. CLM-10 1351 Patient Signature Source Code Identifier (ID) Optional 1/30/25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 371/665 Code indicating how the patient or subscriber authorization signatures were obtained and how they are being retained by the provider P Signature generated by provider because the patient was not physically present for services Signature generated by an entity other than the patient according to State or Federal law. CLM-11 C024 Related Causes Information To identify one or more related causes and associated state or country information Usage notes Required when the services provided are employment related or the result of an accident. If not required by this implementation guide, do not send. Max use 1 Optional C024-01 1362 Related Causes Code Identifier (ID) Required Code identifying an accompanying cause of an illness, injury or an accident AA Auto Accident EM Employment OA Other Accident C024-02 1362 Related Causes Code Min 2 Max 3 Identifier (ID) Optional Code identifying an accompanying cause of an illness, injury or an accident C024-04 156 Auto Accident State or Province Code Identifier (ID) Optional Min 2 Max 2 Code (Standard State/Province) as defined by appropriate government agency C024-04 and C024-05 apply only to auto accidents when C024-01, C024-02, or C024-03 is equal to "AA". C024-05 26 Country Code Min 2 Max 3 Identifier (ID) Optional Code identifying the country CLM-12 1366 Special Program Indicator Identifier (ID) Optional Code indicating the Special Program under which the services rendered to the patient were performed 02 Physically Handicapped Children's Program This code is used for Medicaid claims only. 03 Special Federal Funding This code is used for Medicaid claims only. 05 Disability 1/30/25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 372/665 This code is used for Medicaid claims only. 09 Second Opinion or Surgery This code is used for Medicaid claims only. CLM-20 1514 Delay Reason Code Identifier (ID) Optional Code indicating the reason why a request was delayed 1 Proof of Eligibility Unknown or Unavailable 2 Litigation 3 Authorization Delays 4 Delay in Certifying Provider 5 Delay in Supplying Billing Forms 6 Delay in Delivery of Custom-made Appliances 7 Third Party Processing Delay 8 Delay in Eligibility Determination 9 Original Claim Rejected or Denied Due to a Reason Unrelated to the Billing Limitation Rules 10 Administration Delay in the Prior Approval Process 11 Other 15 Natural Disaster 1/30/25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 373/665 DTP 1350 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > DTP Date - Accident To specify any or all of a date, a time, or a time period Usage notes Required when CLM11-1 or CLM11-2 has a value of AA' or OA'. OR Required when CLM11-1 or CLM11-2 has a value of `EM' and this claim is the result of an accident. If not required by this implementation guide, do not send. Example DTP439D8XXXXX~ Variants (all may be used) DTP Date - Acute Manifestation DTP Date - Admission DTP Date - Assumed and Relinquished Care Dates DTP Date - Authorized Return to Work DTP Date - Disability Dates DTP Date - Discharge DTP Date - Hearing and Vision Prescription Date DTP Date - Initial Treatment Date DTP Date - Last Menstrual Period DTP Date - Last Seen Date DTP Date - Last Worked DTP Date - Last X-ray Date DTP Date - Onset of Current Illness or Symptom DTP Date - Property and Casualty Date of First Contact DTP Date - Repricer Received Date Max use 1 Optional DTP-01 374 Date Time Qualifier Identifier (ID) Required Code specifying type of date or time, or both date and time 439 Accident DTP-02 1250 Date Time Period Format Qualifier Identifier (ID) Required Code indicating the date format, time format, or date and time format DTP02 is the date or time or period format that will appear in DTP03. D8 Date Expressed in Format CCYYMMDD DTP-03 1251 Accident Date Min 1 Max 35 String (AN) Required 1/30/25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 374/665 Expression of a date, a time, or range of dates, times or dates and times 1/30/25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 375/665 DTP 1350 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > DTP Date - Acute Manifestation To specify any or all of a date, a time, or a time period Usage notes Required when Loop ID-2300 CR208 = "A" or "M", the claim involves spinal manipulation, and the payer is Medicare. If not required by this implementation guide, do not send. Example DTP453D8*X~ Variants (all may be used) DTP Date - Accident DTP Date - Admission DTP Date - Assumed and Relinquished Care Dates DTP Date - Authorized Return to Work DTP Date - Disability Dates DTP Date - Discharge DTP Date - Hearing and Vision Prescription Date DTP Date - Initial Treatment Date DTP Date - Last Menstrual Period DTP Date - Last Seen Date DTP Date - Last Worked DTP Date - Last X-ray Date DTP Date - Onset of Current Illness or Symptom DTP Date - Property and Casualty Date of First Contact DTP Date - Repricer Received Date Max use 1 Optional DTP-01 374 Date Time Qualifier Identifier (ID) Required Code specifying type of date or time, or both date and time 453 Acute Manifestation of a Chronic Condition DTP-02 1250 Date Time Period Format Qualifier Identifier (ID) Required Code indicating the date format, time format, or date and time format DTP02 is the date or time or period format that will appear in DTP03. D8 Date Expressed in Format CCYYMMDD DTP-03 1251 Acute Manifestation Date Min 1 Max 35 String (AN) Required 1/30/25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 376/665 Expression of a date, a time, or range of dates, times or dates and times 1/30/25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 377/665 DTP 1350 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > DTP Date - Admission To specify any or all of a date, a time, or a time period Usage notes	Home State Health 837 Health Care Claim_ Professional.pdf
X-ray Date DTP Date - Onset of Current Illness or Symptom DTP Date - Property and Casualty Date of First Contact DTP Date - Repricer Received Date Max use 1 Optional DTP-01 374 Date Time Qualifier Identifier (ID) Required Code specifying type of date or time, or both date and time 439 Accident DTP-02 1250 Date Time Period Format Qualifier Identifier (ID) Required Code indicating the date format, time format, or date and time format DTP02 is the date or time or period format that will appear in DTP03. D8 Date Expressed in Format CCYYMMDD DTP-03 1251 Accident Date Min 1 Max 35 String (AN) Required 1/30/25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 374/665 Expression of a date, a time, or range of dates, times or dates and times 1/30/25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 375/665 DTP 1350 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > DTP Date - Acute Manifestation To specify any or all of a date, a time, or a time period Usage notes Required when Loop ID-2300 CR208 = "A" or "M", the claim involves spinal manipulation, and the payer is Medicare. If not required by this implementation guide, do not send. Example DTP453D8X~ Variants (all may be used) DTP Date - Accident DTP Date - Admission DTP Date - Assumed and Relinquished Care Dates DTP Date - Authorized Return to Work DTP Date - Disability Dates DTP Date - Discharge DTP Date - Hearing and Vision Prescription Date DTP Date - Initial Treatment Date DTP Date - Last Menstrual Period DTP Date - Last Seen Date DTP Date - Last Worked DTP Date - Last X-ray Date DTP Date - Onset of Current Illness or Symptom DTP Date - Property and Casualty Date of First Contact DTP Date - Repricer Received Date Max use 1 Optional DTP-01 374 Date Time Qualifier Identifier (ID) Required Code specifying type of date or time, or both date and time 453 Acute Manifestation of a Chronic Condition DTP-02 1250 Date Time Period Format Qualifier Identifier (ID) Required Code indicating the date format, time format, or date and time format DTP02 is the date or time or period format that will appear in DTP03. D8 Date Expressed in Format CCYYMMDD DTP-03 1251 Acute Manifestation Date Min 1 Max 35 String (AN) Required 1/30/25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 376/665 Expression of a date, a time, or range of dates, times or dates and times 1/30/25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 377/665 DTP 1350 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > DTP Date - Admission To specify any or all of a date, a time, or a time period Usage notes Required on all ambulance claims when the patient was known to be admitted to the hospital. OR Required on all claims involving inpatient medical visits. If not required by this implementation guide, do not send. Example DTP435D8XXXX~ Variants (all may be used) DTP Date - Accident DTP Date - Acute Manifestation DTP Date - Assumed and Relinquished Care Dates DTP Date - Authorized Return to Work DTP Date - Disability Dates DTP Date - Discharge DTP Date - Hearing and Vision Prescription Date DTP Date - Initial Treatment Date DTP Date - Last Menstrual Period DTP Date - Last Seen Date DTP Date - Last Worked DTP Date - Last X-ray Date DTP Date - Onset of Current Illness or Symptom DTP Date - Property and Casualty Date of First Contact DTP Date - Repricer Received Date Max use 1 Optional DTP-01 374 Date Time Qualifier Identifier (ID) Required Code specifying type of date or time, or both date and time 435 Admission DTP-02 1250 Date Time Period Format Qualifier Identifier (ID) Required Code indicating the date format, time format, or date and time format DTP02 is the date or time or period format that will appear in DTP03. D8 Date Expressed in Format CCYYMMDD DTP-03 1251 Related Hospitalization Admission Date Min 1 Max 35 String (AN) Required 1/30/25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 378/665 Expression of a date, a time, or range of dates, times or dates and times 1/30/25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 379/665 DTP 1350 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > DTP Date - Assumed and Relinquished Care Dates To specify any or all of a date, a time, or a time period Usage notes Required to indicate "assumed care date" or "relinquished care date" when providers share post-operative care (global surgery claims). If not required by this implementation guide, do not send. Assumed Care Date is the date care was assumed by another provider during post- operative care. Relinquished Care Date is the date the provider filing this claim ceased post-operative care. See Medicare guidelines for further explanation of these dates. Example: Surgeon "A" relinquished post-operative care to Physician "B" five days after surgery. When Surgeon "A" submits a claim, "A" will use code "091 - Report End" to indicate the day the surgeon relinquished care of this patient to Physician "B". When Physician "B" submits a claim, "B" will use code "090 - Report Start" to indicate the date they assumed care of this patient from Surgeon "A". Example DTP091D8XXXXXX~ Variants (all may be used) DTP Date - Accident DTP Date - Acute Manifestation DTP Date - Admission DTP Date - Authorized Return to Work DTP Date - Disability Dates DTP Date - Discharge DTP Date - Hearing and Vision Prescription Date DTP Date - Initial Treatment Date DTP Date - Last Menstrual Period DTP Date - Last Seen Date DTP Date - Last Worked DTP Date - Last X-ray Date DTP Date - Onset of Current Illness or Symptom DTP Date - Property and Casualty Date of First Contact DTP Date - Repricer Received Date Max use 2 Optional DTP-01 374 Date Time Qualifier Identifier (ID) Required Code specifying type of date or time, or both date and time 090 Report Start Assumed Care Date - Use code "090" to indicate the date the provider filing this claim assumed care from another provider during post-operative care. 091 Report End Relinquished Care Date - Use code "091" to indicate the date the provider filing this claim relinquished post-operative care to another provider. 1/30/25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 380/665 DTP-02 1250 Date Time Period Format Qualifier Identifier (ID) Required Code indicating the date format, time format, or date and time format DTP02 is the date or time or period format that will appear in DTP03. D8 Date Expressed in Format CCYYMMDD DTP-03 1251 Assumed or Relinquished Care Date Min 1 Max 35 String (AN) Required Expression of a date, a time, or range of dates, times or dates and times 1/30/25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 381/665 DTP 1350 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > DTP Date - Authorized Return to Work To specify any or all of a date, a time, or a time period Usage notes Required on claims where this information is necessary for adjudication of the claim (for example, workers compensation claims involving absence from work). If not required by this implementation guide, do not send. Example DTP296D8XX~ Variants (all may be used) DTP Date - Accident DTP Date - Acute Manifestation DTP Date - Admission DTP Date - Assumed and Relinquished Care Dates DTP Date - Disability Dates DTP Date - Discharge DTP Date - Hearing and Vision Prescription Date DTP Date - Initial Treatment Date DTP Date - Last Menstrual Period DTP Date - Last Seen Date DTP Date - Last Worked DTP Date - Last X-ray Date DTP Date - Onset of Current Illness or Symptom DTP Date - Property and Casualty Date of First Contact DTP Date - Repricer Received Date Max use 1 Optional DTP-01 374 Date Time Qualifier Identifier (ID) Required Code specifying type of date or time, or both date and time 296 Initial Disability Period Return To Work This is the date the provider has authorized the patient to return to work. DTP-02 1250 Date Time Period Format Qualifier Identifier (ID) Required Code indicating the date format, time format, or date and time format DTP02 is the date or time or period format that will appear in DTP03. D8 Date Expressed in Format CCYYMMDD DTP-03 1251 Work Return Date Min 1 Max 35 String (AN) Required 1/30/25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 382/665 Expression of a date, a time, or range of dates, times or dates and times 1/30/25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 383/665 DTP 1350 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > DTP Date - Disability Dates To specify any or all of a date, a time, or a time period Usage notes Required on claims involving disability where, in the judgment of the provider, the patient was or will be unable to perform the duties normally associated with his/her work. OR Required on non-HIPAA claims (for example workers compensation or property and casualty) when required by the claims processor. If not required by this implementation guide, do not send. Example DTP360RD8*XXXXXX~ Variants (all may be used) DTP Date - Accident DTP Date - Acute Manifestation DTP Date - Admission DTP Date - Assumed and Relinquished Care Dates DTP Date - Authorized Return to Work DTP Date - Discharge DTP Date - Hearing and Vision Prescription Date DTP Date - Initial Treatment Date DTP Date - Last Menstrual Period DTP Date - Last Seen Date DTP Date - Last Worked DTP Date - Last X-ray Date DTP Date - Onset of Current Illness or Symptom DTP Date - Property and Casualty Date of First Contact DTP Date - Repricer Received Date Max use 1 Optional DTP-01 374 Date Time Qualifier Identifier (ID) Required Code specifying type of date or time, or both date and time 314 Disability Use code 314 when both disability start and end date are being reported. 360 Initial Disability Period Start Use code 360 if patient is currently disabled and disability end date is unknown. 361 Initial Disability Period End Use code 361 if patient is no longer disabled and the start date is unknown. DTP-02 1250 Date Time Period Format Qualifier Identifier (ID) Required 1/30/25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 384/665 Code indicating the date format, time format, or date and time format DTP02 is the date or time or period format that will appear in DTP03. D8 Date Expressed in Format CCYYMMDD Use code D8 when DTP01 is 360 or 361. RD8 Range of Dates Expressed in Format CCYYMMDD-CCYYMMDD Use code RD8 when DTP01 is 314. DTP-03 1251 Disability From Date Min 1 Max 35 String (AN) Required Expression of a date, a time, or range of dates, times or dates and times 1/30/25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 385/665 DTP 1350 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > DTP Date - Discharge To specify any or all of a date, a time, or a time period Usage notes Required for inpatient claims when the patient was discharged from the facility and the discharge date is known. If not required	Home State Health 837 Health Care Claim_ Professional.pdf
EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 382/665 Expression of a date, a time, or range of dates, times or dates and times 1/30/25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 383/665 DTP 1350 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > DTP Date - Disability Dates To specify any or all of a date, a time, or a time period Usage notes Required on claims involving disability where, in the judgment of the provider, the patient was or will be unable to perform the duties normally associated with his/her work. OR Required on non-HIPAA claims (for example workers compensation or property and casualty) when required by the claims processor. If not required by this implementation guide, do not send. Example DTP360RD8XXXXXX~ Variants (all may be used) DTP Date - Accident DTP Date - Acute Manifestation DTP Date - Admission DTP Date - Assumed and Relinquished Care Dates DTP Date - Authorized Return to Work DTP Date - Discharge DTP Date - Hearing and Vision Prescription Date DTP Date - Initial Treatment Date DTP Date - Last Menstrual Period DTP Date - Last Seen Date DTP Date - Last Worked DTP Date - Last X-ray Date DTP Date - Onset of Current Illness or Symptom DTP Date - Property and Casualty Date of First Contact DTP Date - Repricer Received Date Max use 1 Optional DTP-01 374 Date Time Qualifier Identifier (ID) Required Code specifying type of date or time, or both date and time 314 Disability Use code 314 when both disability start and end date are being reported. 360 Initial Disability Period Start Use code 360 if patient is currently disabled and disability end date is unknown. 361 Initial Disability Period End Use code 361 if patient is no longer disabled and the start date is unknown. DTP-02 1250 Date Time Period Format Qualifier Identifier (ID) Required 1/30/25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 384/665 Code indicating the date format, time format, or date and time format DTP02 is the date or time or period format that will appear in DTP03. D8 Date Expressed in Format CCYYMMDD Use code D8 when DTP01 is 360 or 361. RD8 Range of Dates Expressed in Format CCYYMMDD-CCYYMMDD Use code RD8 when DTP01 is 314. DTP-03 1251 Disability From Date Min 1 Max 35 String (AN) Required Expression of a date, a time, or range of dates, times or dates and times 1/30/25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 385/665 DTP 1350 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > DTP Date - Discharge To specify any or all of a date, a time, or a time period Usage notes Required for inpatient claims when the patient was discharged from the facility and the discharge date is known. If not required by this implementation guide, do not send. Example DTP096D8XXXXXX~ Variants (all may be used) DTP Date - Accident DTP Date - Acute Manifestation DTP Date - Admission DTP Date - Assumed and Relinquished Care Dates DTP Date - Authorized Return to Work DTP Date - Disability Dates DTP Date - Hearing and Vision Prescription Date DTP Date - Initial Treatment Date DTP Date - Last Menstrual Period DTP Date - Last Seen Date DTP Date - Last Worked DTP Date - Last X-ray Date DTP Date - Onset of Current Illness or Symptom DTP Date - Property and Casualty Date of First Contact DTP Date - Repricer Received Date Max use 1 Optional DTP-01 374 Date Time Qualifier Identifier (ID) Required Code specifying type of date or time, or both date and time 096 Discharge DTP-02 1250 Date Time Period Format Qualifier Identifier (ID) Required Code indicating the date format, time format, or date and time format DTP02 is the date or time or period format that will appear in DTP03. D8 Date Expressed in Format CCYYMMDD DTP-03 1251 Related Hospitalization Discharge Date Min 1 Max 35 String (AN) Required 1/30/25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 386/665 Expression of a date, a time, or range of dates, times or dates and times 1/30/25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 387/665 DTP 1350 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > DTP Date - Hearing and Vision Prescription Date To specify any or all of a date, a time, or a time period Usage notes Required on claims where a prescription has been written for hearing devices or vision frames and lenses and it is being billed on this claim. If not required by this implementation guide, do not send. Example DTP471D8XXXXXX~ Variants (all may be used) DTP Date - Accident DTP Date - Acute Manifestation DTP Date - Admission DTP Date - Assumed and Relinquished Care Dates DTP Date - Authorized Return to Work DTP Date - Disability Dates DTP Date - Discharge DTP Date - Initial Treatment Date DTP Date - Last Menstrual Period DTP Date - Last Seen Date DTP Date - Last Worked DTP Date - Last X-ray Date DTP Date - Onset of Current Illness or Symptom DTP Date - Property and Casualty Date of First Contact DTP Date - Repricer Received Date Max use 1 Optional DTP-01 374 Date Time Qualifier Identifier (ID) Required Code specifying type of date or time, or both date and time 471 Prescription DTP-02 1250 Date Time Period Format Qualifier Identifier (ID) Required Code indicating the date format, time format, or date and time format DTP02 is the date or time or period format that will appear in DTP03. D8 Date Expressed in Format CCYYMMDD DTP-03 1251 Prescription Date Min 1 Max 35 String (AN) Required 1/30/25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 388/665 Expression of a date, a time, or range of dates, times or dates and times 1/30/25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 389/665 DTP 1350 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > DTP Date - Initial Treatment Date To specify any or all of a date, a time, or a time period Usage notes Required when the Initial Treatment Date is known to impact adjudication for claims involving spinal manipulation, physical therapy, occupational therapy, speech language pathology, dialysis, optical refractions, or pregnancy. If not required by this implementation guide, do not send. Dates in Loop ID-2300 apply to all service lines within Loop ID-2400 unless a DTP segment occurs in Loop ID-2400 with the same value in DTP01. In that case, the DTP in Loop ID-2400 overrides the DTP in Loop ID-2300 for that service line only. Example DTP454D8XX~ Variants (all may be used) DTP Date - Accident DTP Date - Acute Manifestation DTP Date - Admission DTP Date - Assumed and Relinquished Care Dates DTP Date - Authorized Return to Work DTP Date - Disability Dates DTP Date - Discharge DTP Date - Hearing and Vision Prescription Date DTP Date - Last Menstrual Period DTP Date - Last Seen Date DTP Date - Last Worked DTP Date - Last X-ray Date DTP Date - Onset of Current Illness or Symptom DTP Date - Property and Casualty Date of First Contact DTP Date - Repricer Received Date Max use 1 Optional DTP-01 374 Date Time Qualifier Identifier (ID) Required Code specifying type of date or time, or both date and time 454 Initial Treatment DTP-02 1250 Date Time Period Format Qualifier Identifier (ID) Required Code indicating the date format, time format, or date and time format DTP02 is the date or time or period format that will appear in DTP03. D8 Date Expressed in Format CCYYMMDD 1/30/25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 390/665 DTP-03 1251 Initial Treatment Date Min 1 Max 35 String (AN) Required Expression of a date, a time, or range of dates, times or dates and times 1/30/25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 391/665 DTP 1350 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > DTP Date - Last Menstrual Period To specify any or all of a date, a time, or a time period Usage notes Required when, in the judgment of the provider, the services on this claim are related to the patient's pregnancy. If not required by this implementation guide, do not send. Example DTP484D8XXXXXX~ Variants (all may be used) DTP Date - Accident DTP Date - Acute Manifestation DTP Date - Admission DTP Date - Assumed and Relinquished Care Dates DTP Date - Authorized Return to Work DTP Date - Disability Dates DTP Date - Discharge DTP Date - Hearing and Vision Prescription Date DTP Date - Initial Treatment Date DTP Date - Last Seen Date DTP Date - Last Worked DTP Date - Last X-ray Date DTP Date - Onset of Current Illness or Symptom DTP Date - Property and Casualty Date of First Contact DTP Date - Repricer Received Date Max use 1 Optional DTP-01 374 Date Time Qualifier Identifier (ID) Required Code specifying type of date or time, or both date and time 484 Last Menstrual Period DTP-02 1250 Date Time Period Format Qualifier Identifier (ID) Required Code indicating the date format, time format, or date and time format DTP02 is the date or time or period format that will appear in DTP03. D8 Date Expressed in Format CCYYMMDD DTP-03 1251 Last Menstrual Period Date Min 1 Max 35 String (AN) Required 1/30/25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 392/665 Expression of a date, a time, or range of dates, times or dates and times 1/30/25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 393/665 DTP 1350 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > DTP Date - Last Seen Date To specify any or all of a date, a time, or a time period Usage notes Required when claims involve services for routine foot care and it is known to impact the payer's adjudication process. If not required by this implementation guide, do not send. This is the date that the patient was seen by the attending or supervising physician for the qualifying medical condition related to the services performed. Dates in Loop ID-2300 apply to all service lines within Loop ID-2400 unless a DTP segment occurs in Loop ID-2400 with the same value in DTP01. In that case, the DTP in Loop ID-2400 overrides the DTP in Loop ID-2300 for that service line only. Example DTP304D8XX~ Variants (all may be used) DTP Date - Accident DTP Date - Acute Manifestation DTP Date - Admission DTP Date - Assumed and Relinquished Care Dates DTP Date - Authorized Return to Work DTP Date - Disability Dates DTP Date - Discharge DTP Date - Hearing and Vision Prescription Date DTP Date - Initial Treatment Date DTP Date - Last Menstrual Period DTP Date - Last Worked DTP Date - Last X-ray Date DTP Date - Onset of Current Illness or Symptom DTP Date - Property and Casualty Date of First Contact DTP Date - Repricer Received Date Max use 1 Optional DTP-01 374 Date Time Qualifier Identifier (ID) Required Code specifying type of date or time, or both date and time 304 Latest Visit or Consultation DTP-02 1250 Date Time Period Format Qualifier Identifier (ID) Required Code indicating the date format, time format, or date and time format DTP02 is the date or time or period format that will appear in DTP03. 1/30/25, 11:53 AM Home	Home State Health 837 Health Care Claim_ Professional.pdf
Date - Disability Dates DTP Date - Discharge DTP Date - Hearing and Vision Prescription Date DTP Date - Initial Treatment Date DTP Date - Last Seen Date DTP Date - Last Worked DTP Date - Last X-ray Date DTP Date - Onset of Current Illness or Symptom DTP Date - Property and Casualty Date of First Contact DTP Date - Repricer Received Date Max use 1 Optional DTP-01 374 Date Time Qualifier Identifier (ID) Required Code specifying type of date or time, or both date and time 484 Last Menstrual Period DTP-02 1250 Date Time Period Format Qualifier Identifier (ID) Required Code indicating the date format, time format, or date and time format DTP02 is the date or time or period format that will appear in DTP03. D8 Date Expressed in Format CCYYMMDD DTP-03 1251 Last Menstrual Period Date Min 1 Max 35 String (AN) Required 1/30/25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 392/665 Expression of a date, a time, or range of dates, times or dates and times 1/30/25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 393/665 DTP 1350 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > DTP Date - Last Seen Date To specify any or all of a date, a time, or a time period Usage notes Required when claims involve services for routine foot care and it is known to impact the payer's adjudication process. If not required by this implementation guide, do not send. This is the date that the patient was seen by the attending or supervising physician for the qualifying medical condition related to the services performed. Dates in Loop ID-2300 apply to all service lines within Loop ID-2400 unless a DTP segment occurs in Loop ID-2400 with the same value in DTP01. In that case, the DTP in Loop ID-2400 overrides the DTP in Loop ID-2300 for that service line only. Example DTP304D8XX~ Variants (all may be used) DTP Date - Accident DTP Date - Acute Manifestation DTP Date - Admission DTP Date - Assumed and Relinquished Care Dates DTP Date - Authorized Return to Work DTP Date - Disability Dates DTP Date - Discharge DTP Date - Hearing and Vision Prescription Date DTP Date - Initial Treatment Date DTP Date - Last Menstrual Period DTP Date - Last Worked DTP Date - Last X-ray Date DTP Date - Onset of Current Illness or Symptom DTP Date - Property and Casualty Date of First Contact DTP Date - Repricer Received Date Max use 1 Optional DTP-01 374 Date Time Qualifier Identifier (ID) Required Code specifying type of date or time, or both date and time 304 Latest Visit or Consultation DTP-02 1250 Date Time Period Format Qualifier Identifier (ID) Required Code indicating the date format, time format, or date and time format DTP02 is the date or time or period format that will appear in DTP03. 1/30/25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 394/665 D8 Date Expressed in Format CCYYMMDD DTP-03 1251 Last Seen Date Min 1 Max 35 String (AN) Required Expression of a date, a time, or range of dates, times or dates and times 1/30/25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 395/665 DTP 1350 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > DTP Date - Last Worked To specify any or all of a date, a time, or a time period Usage notes Required on claims where this information is necessary for adjudication of the claim (for example, workers compensation claims involving absence from work). If not required by this implementation guide, do not send. Example DTP297D8XXXXX~ Variants (all may be used) DTP Date - Accident DTP Date - Acute Manifestation DTP Date - Admission DTP Date - Assumed and Relinquished Care Dates DTP Date - Authorized Return to Work DTP Date - Disability Dates DTP Date - Discharge DTP Date - Hearing and Vision Prescription Date DTP Date - Initial Treatment Date DTP Date - Last Menstrual Period DTP Date - Last Seen Date DTP Date - Last X-ray Date DTP Date - Onset of Current Illness or Symptom DTP Date - Property and Casualty Date of First Contact DTP Date - Repricer Received Date Max use 1 Optional DTP-01 374 Date Time Qualifier Identifier (ID) Required Code specifying type of date or time, or both date and time 297 Initial Disability Period Last Day Worked DTP-02 1250 Date Time Period Format Qualifier Identifier (ID) Required Code indicating the date format, time format, or date and time format DTP02 is the date or time or period format that will appear in DTP03. D8 Date Expressed in Format CCYYMMDD DTP-03 1251 Last Worked Date Min 1 Max 35 String (AN) Required 1/30/25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 396/665 Expression of a date, a time, or range of dates, times or dates and times 1/30/25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 397/665 DTP 1350 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > DTP Date - Last X-ray Date To specify any or all of a date, a time, or a time period Usage notes Required when claim involves spinal manipulation and an x-ray was taken. If not required by this implementation guide, do not send. Dates in Loop ID-2300 apply to all service lines within Loop ID-2400 unless a DTP segment occurs in Loop ID-2400 with the same value in DTP01. In that case, the DTP in Loop ID-2400 overrides the DTP in Loop ID-2300 for that service line only. Example DTP455D8X~ Variants (all may be used) DTP Date - Accident DTP Date - Acute Manifestation DTP Date - Admission DTP Date - Assumed and Relinquished Care Dates DTP Date - Authorized Return to Work DTP Date - Disability Dates DTP Date - Discharge DTP Date - Hearing and Vision Prescription Date DTP Date - Initial Treatment Date DTP Date - Last Menstrual Period DTP Date - Last Seen Date DTP Date - Last Worked DTP Date - Onset of Current Illness or Symptom DTP Date - Property and Casualty Date of First Contact DTP Date - Repricer Received Date Max use 1 Optional DTP-01 374 Date Time Qualifier Identifier (ID) Required Code specifying type of date or time, or both date and time 455 Last X-Ray DTP-02 1250 Date Time Period Format Qualifier Identifier (ID) Required Code indicating the date format, time format, or date and time format DTP02 is the date or time or period format that will appear in DTP03. D8 Date Expressed in Format CCYYMMDD DTP-03 1251 Last X-Ray Date Min 1 Max 35 String (AN) Required 1/30/25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 398/665 Expression of a date, a time, or range of dates, times or dates and times 1/30/25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 399/665 DTP 1350 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > DTP Date - Onset of Current Illness or Symptom To specify any or all of a date, a time, or a time period Usage notes Required for the initial medical service or visit performed in response to a medical emergency when the date is available and is different than the date of service. If not required by this implementation guide, do not send. This date is the onset of acute symptoms for the current illness or condition. Example DTP431D8X~ Variants (all may be used) DTP Date - Accident DTP Date - Acute Manifestation DTP Date - Admission DTP Date - Assumed and Relinquished Care Dates DTP Date - Authorized Return to Work DTP Date - Disability Dates DTP Date - Discharge DTP Date - Hearing and Vision Prescription Date DTP Date - Initial Treatment Date DTP Date - Last Menstrual Period DTP Date - Last Seen Date DTP Date - Last Worked DTP Date - Last X-ray Date DTP Date - Property and Casualty Date of First Contact DTP Date - Repricer Received Date Max use 1 Optional DTP-01 374 Date Time Qualifier Identifier (ID) Required Code specifying type of date or time, or both date and time 431 Onset of Current Symptoms or Illness DTP-02 1250 Date Time Period Format Qualifier Identifier (ID) Required Code indicating the date format, time format, or date and time format DTP02 is the date or time or period format that will appear in DTP03. D8 Date Expressed in Format CCYYMMDD DTP-03 1251 Onset of Current Illness or Injury Date Min 1 Max 35 String (AN) Required Expression of a date, a time, or range of dates, times or dates and times 1/30/25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 400/665 1/30/25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 401/665 DTP 1350 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > DTP Date - Property and Casualty Date of First Contact To specify any or all of a date, a time, or a time period Usage notes Required for Property and Casualty claims when state mandated. If not required by this implementation guide, do not send. This is the date the patient first consulted the service provider for this condition. The date of first contact is the date the patient first consulted the provider by any means. It is not necessarily the Initial Treatment Date. Example DTP444D8XXX~ Variants (all may be used) DTP Date - Accident DTP Date - Acute Manifestation DTP Date - Admission DTP Date - Assumed and Relinquished Care Dates DTP Date - Authorized Return to Work DTP Date - Disability Dates DTP Date - Discharge DTP Date - Hearing and Vision Prescription Date DTP Date - Initial Treatment Date DTP Date - Last Menstrual Period DTP Date - Last Seen Date DTP Date - Last Worked DTP Date - Last X-ray Date DTP Date - Onset of Current Illness or Symptom DTP Date - Repricer Received Date Max use 1 Optional DTP-01 374 Date Time Qualifier Identifier (ID) Required Code specifying type of date or time, or both date and time 444 First Visit or Consultation DTP-02 1250 Date Time Period Format Qualifier Identifier (ID) Required Code indicating the date format, time format, or date and time format DTP02 is the date or time or period format that will appear in DTP03. D8 Date Expressed in Format CCYYMMDD DTP-03 1251 Date Time Period Min 1 Max 35 String (AN) Required 1/30/25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 402/665 Expression of a date, a time, or range of dates, times or dates and times 1/30/25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 403/665 DTP 1350 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > DTP Date - Repricer Received Date To specify any or all of a date, a time, or a time period Usage notes Required when a repricer is passing the claim onto the payer. If not required by this implementation guide, do not send. Example DTP050D8XXXX~ Variants (all may be used) DTP Date - Accident DTP Date - Acute Manifestation DTP Date - Admission DTP Date - Assumed and Relinquished Care Dates DTP Date - Authorized Return to Work DTP Date - Disability Dates DTP Date - Discharge DTP Date - Hearing and Vision Prescription Date DTP Date - Initial Treatment Date DTP Date - Last Menstrual Period DTP Date - Last Seen Date	Home State Health 837 Health Care Claim_ Professional.pdf
times 1/30/25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 400/665 1/30/25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 401/665 DTP 1350 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > DTP Date - Property and Casualty Date of First Contact To specify any or all of a date, a time, or a time period Usage notes Required for Property and Casualty claims when state mandated. If not required by this implementation guide, do not send. This is the date the patient first consulted the service provider for this condition. The date of first contact is the date the patient first consulted the provider by any means. It is not necessarily the Initial Treatment Date. Example DTP444D8XXX~ Variants (all may be used) DTP Date - Accident DTP Date - Acute Manifestation DTP Date - Admission DTP Date - Assumed and Relinquished Care Dates DTP Date - Authorized Return to Work DTP Date - Disability Dates DTP Date - Discharge DTP Date - Hearing and Vision Prescription Date DTP Date - Initial Treatment Date DTP Date - Last Menstrual Period DTP Date - Last Seen Date DTP Date - Last Worked DTP Date - Last X-ray Date DTP Date - Onset of Current Illness or Symptom DTP Date - Repricer Received Date Max use 1 Optional DTP-01 374 Date Time Qualifier Identifier (ID) Required Code specifying type of date or time, or both date and time 444 First Visit or Consultation DTP-02 1250 Date Time Period Format Qualifier Identifier (ID) Required Code indicating the date format, time format, or date and time format DTP02 is the date or time or period format that will appear in DTP03. D8 Date Expressed in Format CCYYMMDD DTP-03 1251 Date Time Period Min 1 Max 35 String (AN) Required 1/30/25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 402/665 Expression of a date, a time, or range of dates, times or dates and times 1/30/25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 403/665 DTP 1350 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > DTP Date - Repricer Received Date To specify any or all of a date, a time, or a time period Usage notes Required when a repricer is passing the claim onto the payer. If not required by this implementation guide, do not send. Example DTP050D8XXXX~ Variants (all may be used) DTP Date - Accident DTP Date - Acute Manifestation DTP Date - Admission DTP Date - Assumed and Relinquished Care Dates DTP Date - Authorized Return to Work DTP Date - Disability Dates DTP Date - Discharge DTP Date - Hearing and Vision Prescription Date DTP Date - Initial Treatment Date DTP Date - Last Menstrual Period DTP Date - Last Seen Date DTP Date - Last Worked DTP Date - Last X-ray Date DTP Date - Onset of Current Illness or Symptom DTP Date - Property and Casualty Date of First Contact Max use 1 Optional DTP-01 374 Date Time Qualifier Identifier (ID) Required Code specifying type of date or time, or both date and time 050 Received DTP-02 1250 Date Time Period Format Qualifier Identifier (ID) Required Code indicating the date format, time format, or date and time format DTP02 is the date or time or period format that will appear in DTP03. D8 Date Expressed in Format CCYYMMDD DTP-03 1251 Repricer Received Date Min 1 Max 35 String (AN) Required 1/30/25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 404/665 Expression of a date, a time, or range of dates, times or dates and times 1/30/25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 405/665 PWK 1550 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > PWK Claim Supplemental Information To identify the type or transmission or both of paperwork or supporting information Usage notes Required when there is a paper attachment following this claim. OR Required when attachments are sent electronically (PWK02 = EL) but are transmitted in another functional group (for example, 275) rather than by paper. PWK06 is then used to identify the attached electronic documentation. The number in PWK06 is carried in the TRN of the electronic attachment. OR Required when the provider deems it necessary to identify additional information that is being held at the provider's office and is available upon request by the payer (or appropriate entity), but the information is not being submitted with the claim. Use the value of "AA" in PWK02 to convey this specific use of the PWK segment. If not required by this implementation guide, do not send. Example PWKDJEM**ACXX~ If either Identification Code Qualifier (PWK-05) or Attachment Control Number (PWK-06) is present, then the other is required Max use 10 Optional PWK-01 755 Attachment Report Type Code Identifier (ID) Required Code indicating the title or contents of a document, report or supporting item 03 Report Justifying Treatment Beyond Utilization Guidelines 04 Drugs Administered 05 Treatment Diagnosis 06 Initial Assessment 07 Functional Goals 08 Plan of Treatment 09 Progress Report 10 Continued Treatment 11 Chemical Analysis 13 Certified Test Report 15 Justification for Admission 21 Recovery Plan A3 Allergies/Sensitivities Document A4 Autopsy Report AM Ambulance Certification AS Admission Summary B2 Prescription B3 Physician Order B4 Referral Form BR Benchmark Testing Results BS Baseline BT Blanket Test Results CB Chiropractic Justification 1/30/25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 406/665 CK Consent Form(s) CT Certification D2 Drug Profile Document DA Dental Models DB Durable Medical Equipment Prescription DG Diagnostic Report DJ Discharge Monitoring Report DS Discharge Summary EB Explanation of Benefits (Coordination of Benefits or Medicare Secondary Payor) HC Health Certificate HR Health Clinic Records I5 Immunization Record IR State School Immunization Records LA Laboratory Results M1 Medical Record Attachment MT Models NN Nursing Notes OB Operative Note OC Oxygen Content Averaging Report OD Orders and Treatments Document OE Objective Physical Examination (including vital signs) Document OX Oxygen Therapy Certification OZ Support Data for Claim P4 Pathology Report P5 Patient Medical History Document PE Parenteral or Enteral Certification PN Physical Therapy Notes PO Prosthetics or Orthotic Certification PQ Paramedical Results PY Physician's Report PZ Physical Therapy Certification RB Radiology Films RR Radiology Reports RT Report of Tests and Analysis Report RX Renewable Oxygen Content Averaging Report SG Symptoms Document V5 Death Notification XP Photographs PWK-02 756 Attachment Transmission Code Identifier (ID) Required Code defining timing, transmission method or format by which reports are to be sent AA Available on Request at Provider Site This means that the additional information is not being sent with the claim at this time. Instead, it is available to the payer (or appropriate entity) at their request. BM By Mail EL Electronically Only Indicates that the attachment is being transmitted in a separate X12 functional group. EM E-Mail FT File Transfer 1/30/25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 407/665 Required when the actual attachment is maintained by an attachment warehouse or similar vendor. FX By Fax PWK-05 66 Identification Code Qualifier Identifier (ID) Optional Code designating the system/method of code structure used for Identification Code (67) PWK05 and PWK06 may be used to identify the addressee by a code number. AC Attachment Control Number PWK-06 67 Attachment Control Number Min 2 Max 80 String (AN) Optional Code identifying a party or other code Usage notes PWK06 is used to identify the attached electronic documentation. The number in PWK06 is carried in the TRN of the electronic attachment. For the purpose of this implementation, the maximum field length is 50. 1/30/25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 408/665 CN1 1600 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > CN1 Contract Information To specify basic data about the contract or contract line item Usage notes The developers of this implementation guide note that the CN1 segment is for use only for post-adjudicated claims, which do not meet the definition of a health care claim under HIPAA. Consequently, at the time of this writing, the CN1 segment is for non- HIPAA use only. Required when the submitter is contractually obligated to supply this information on post-adjudicated claims. If not required by this implementation guide, do not send. Example CN10200000000XXX000XXX~ Max use 1 Optional CN1-01 1166 Contract Type Code Identifier (ID) Required Code identifying a contract type 01 Diagnosis Related Group (DRG) 02 Per Diem 03 Variable Per Diem 04 Flat 05 Capitated 06 Percent 09 Other CN1-02 782 Contract Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount CN102 is the contract amount. CN1-03 332 Contract Percentage Min 1 Max 6 Decimal number (R) Optional Percent given in decimal format (e.g., 0.0 through 100.0 represents 0% through 100%) CN103 is the allowance or charge percent. CN1-04 127 Contract Code Min 1 Max 50 String (AN) Optional Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier CN104 is the contract code. CN1-05 338 Terms Discount Percentage Min 1 Max 6 Decimal number (R) Optional 1/30/25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 409/665 Terms discount percentage, expressed as a percent, available to the purchaser if an invoice is paid on or before the Terms Discount Due Date CN1-06 799 Contract Version Identifier Min 1 Max 30 String (AN) Optional Revision level of a particular format, program, technique or algorithm CN106 is an additional identifying number for the contract. 1/30/25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 410/665 AMT 1750 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > AMT Patient Amount Paid To indicate the total monetary amount Usage notes Required when patient has made payment specifically toward this claim. If not required by this implementation guide, do not send. Patient Amount Paid refers to the sum of all amounts paid on the claim by the patient or his or her representative(s). Example AMTF50~ Max use 1 Optional AMT-01 522 Amount Qualifier Code Identifier (ID) Required Code to qualify amount F5 Patient Amount Paid AMT-02 782 Patient Amount Paid Min 1 Max 15 Decimal number (R) Required Monetary amount 1/30/25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 411/665 REF 1800 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > REF Adjusted Repriced Claim Number To specify identifying information Usage notes Required when this information is deemed necessary by the repricer. The segment is not completed by providers. The information is completed by repricers only. If not required by this implementation guide, do not send. This information is specific to the destination payer reported in Loop ID-2010BB. Example REF9CXXXXX~ Variants (all may be used) REF Care Plan Oversight REF Claim Identifier For Transmission Intermediaries REF Clinical Laboratory Improvement Amendment (CLIA) Number REF Demonstration Project Identifier REF Investigational Device Exemption Number REF Mammography Certification Number REF Mandatory Medicare (Section 4081) Crossover Indicator REF Medical Record Number REF Payer Claim Control Number REF Prior Authorization REF Referral Number REF Repriced Claim Number REF Service Authorization Exception Code Max use 1 Optional REF-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification 9C Adjusted Repriced Claim Reference Number REF-02 127 Adjusted Repriced Claim Reference Number String (AN) Required Min 1 Max 50 Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier 1/30/25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2)	Home State Health 837 Health Care Claim_ Professional.pdf
1 Max 6 Decimal number (R) Optional Percent given in decimal format (e.g., 0.0 through 100.0 represents 0% through 100%) CN103 is the allowance or charge percent. CN1-04 127 Contract Code Min 1 Max 50 String (AN) Optional Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier CN104 is the contract code. CN1-05 338 Terms Discount Percentage Min 1 Max 6 Decimal number (R) Optional 1/30/25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 409/665 Terms discount percentage, expressed as a percent, available to the purchaser if an invoice is paid on or before the Terms Discount Due Date CN1-06 799 Contract Version Identifier Min 1 Max 30 String (AN) Optional Revision level of a particular format, program, technique or algorithm CN106 is an additional identifying number for the contract. 1/30/25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 410/665 AMT 1750 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > AMT Patient Amount Paid To indicate the total monetary amount Usage notes Required when patient has made payment specifically toward this claim. If not required by this implementation guide, do not send. Patient Amount Paid refers to the sum of all amounts paid on the claim by the patient or his or her representative(s). Example AMTF50~ Max use 1 Optional AMT-01 522 Amount Qualifier Code Identifier (ID) Required Code to qualify amount F5 Patient Amount Paid AMT-02 782 Patient Amount Paid Min 1 Max 15 Decimal number (R) Required Monetary amount 1/30/25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 411/665 REF 1800 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > REF Adjusted Repriced Claim Number To specify identifying information Usage notes Required when this information is deemed necessary by the repricer. The segment is not completed by providers. The information is completed by repricers only. If not required by this implementation guide, do not send. This information is specific to the destination payer reported in Loop ID-2010BB. Example REF9CXXXXX~ Variants (all may be used) REF Care Plan Oversight REF Claim Identifier For Transmission Intermediaries REF Clinical Laboratory Improvement Amendment (CLIA) Number REF Demonstration Project Identifier REF Investigational Device Exemption Number REF Mammography Certification Number REF Mandatory Medicare (Section 4081) Crossover Indicator REF Medical Record Number REF Payer Claim Control Number REF Prior Authorization REF Referral Number REF Repriced Claim Number REF Service Authorization Exception Code Max use 1 Optional REF-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification 9C Adjusted Repriced Claim Reference Number REF-02 127 Adjusted Repriced Claim Reference Number String (AN) Required Min 1 Max 50 Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier 1/30/25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 412/665 REF 1800 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > REF Care Plan Oversight To specify identifying information Usage notes Required when the physician is billing Medicare for Care Plan Oversight (CPO). If not required by this implementation guide, do not send. This is the number of the home health agency or hospice providing Medicare covered services to the patient for the period during which CPO services were furnished. Prior to the mandated HIPAA National Provider Identifier (NPI) implementation date this number is the Medicare Number. On or after the mandated HIPAA National Provider Identifier (NPI) implementation date this is the NPI. Example REF1JXXX~ Variants (all may be used) REF Adjusted Repriced Claim Number REF Claim Identifier For Transmission Intermediaries REF Clinical Laboratory Improvement Amendment (CLIA) Number REF Demonstration Project Identifier REF Investigational Device Exemption Number REF Mammography Certification Number REF Mandatory Medicare (Section 4081) Crossover Indicator REF Medical Record Number REF Payer Claim Control Number REF Prior Authorization REF Referral Number REF Repriced Claim Number REF Service Authorization Exception Code Max use 1 Optional REF-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification 1J Facility ID Number REF-02 127 Care Plan Oversight Number Min 1 Max 50 String (AN) Required Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier 1/30/25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 413/665 REF 1800 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > REF Claim Identifier For Transmission Intermediaries To specify identifying information Usage notes Required when this information is deemed necessary by transmission intermediaries (Automated Clearinghouses, and others) who need to attach their own unique claim number. If not required by this implementation guide, do not send. Although this REF is supplied for transmission intermediaries to attach their own unique claim number to a claim, 837-recipients are not required under HIPAA to return this number in any HIPAA transaction. Trading partners may voluntarily agree to this interaction if they wish. Example REFD9XXXXXX~ Variants (all may be used) REF Adjusted Repriced Claim Number REF Care Plan Oversight REF Clinical Laboratory Improvement Amendment (CLIA) Number REF Demonstration Project Identifier REF Investigational Device Exemption Number REF Mammography Certification Number REF Mandatory Medicare (Section 4081) Crossover Indicator REF Medical Record Number REF Payer Claim Control Number REF Prior Authorization REF Referral Number REF Repriced Claim Number REF Service Authorization Exception Code Max use 1 Optional REF-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification Usage notes Number assigned by clearinghouse, van, etc. D9 Claim Number REF-02 127 Value Added Network Trace Number Min 1 Max 50 String (AN) Required Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier Usage notes 1/30/25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 414/665 The value carried in this element is limited to a maximum of 20 positions. 1/30/25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 415/665 REF 1800 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > REF Clinical Laboratory Improvement Amendment (CLIA) Number To specify identifying information Usage notes Required for all CLIA certified facilities performing CLIA covered laboratory services. If not required by this implementation guide, do not send. If a CLIA number is indicated at the line level (Loop ID-2400) in addition to the claim level (Loop ID-2300), that would indicate an exception to the CLIA number at the claim level for that individual line. In cases where this claim contains both in-house and outsourced laboratory services, the CLIA Number for laboratory services performed by the Billing or Rendering Provider is reported in this loop. The CLIA number for laboratory services which were outsourced is reported in Loop ID-2400. Example REFX4XXXXXX~ Variants (all may be used) REF Adjusted Repriced Claim Number REF Care Plan Oversight REF Claim Identifier For Transmission Intermediaries REF Demonstration Project Identifier REF Investigational Device Exemption Number REF Mammography Certification Number REF Mandatory Medicare (Section 4081) Crossover Indicator REF Medical Record Number REF Payer Claim Control Number REF Prior Authorization REF Referral Number REF Repriced Claim Number REF Service Authorization Exception Code Max use 1 Optional REF-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification X4 Clinical Laboratory Improvement Amendment Number REF-02 127 Clinical Laboratory Improvement Amendment Number String (AN) Required Min 1 Max 50 1/30/25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 416/665 Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier 1/30/25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 417/665 REF 1800 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > REF Demonstration Project Identifier To specify identifying information Usage notes Required when it is necessary to identify claims which are atypical in ways such as content, purpose, and/or payment, as could be the case for a demonstration or other special project, or a clinical trial. If not required by this implementation guide, do not send. Example REFP4XXX~ Variants (all may be used) REF Adjusted Repriced Claim Number REF Care Plan Oversight REF Claim Identifier For Transmission Intermediaries REF Clinical Laboratory Improvement Amendment (CLIA) Number REF Investigational Device Exemption Number REF Mammography Certification Number REF Mandatory Medicare (Section 4081) Crossover Indicator REF Medical Record Number REF Payer Claim Control Number REF Prior Authorization REF Referral Number REF Repriced Claim Number REF Service Authorization Exception Code Max use 1 Optional REF-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification P4 Project Code REF-02 127 Demonstration Project Identifier Min 1 Max 50 String (AN) Required Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier 1/30/25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 418/665 REF 1800 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > REF Investigational Device Exemption Number To specify identifying information Usage notes Required when claim involves a Food and Drug Administration (FDA) assigned investigational device exemption (IDE) number. When more than one IDE applies, they must be split into separate claims. If not required by this implementation guide, do not send. Example REFLXXXXXXX~ Variants (all may be used) REF Adjusted Repriced Claim Number REF Care Plan Oversight REF Claim Identifier For Transmission Intermediaries REF Clinical Laboratory Improvement Amendment (CLIA) Number REF Demonstration Project Identifier REF Mammography Certification Number REF Mandatory Medicare (Section 4081) Crossover Indicator REF Medical Record Number REF Payer Claim Control Number REF Prior Authorization REF Referral Number REF Repriced Claim Number REF Service Authorization Exception Code Max use 1 Optional REF-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification LX Qualified Products List REF-02 127 Investigational Device Exemption Identifier String (AN) Required Min 1 Max 50 Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier 1/30/25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 419/665 REF 1800 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > REF Mammography Certification Number To specify identifying information Usage notes Required when mammography services are rendered by a certified mammography provider. If not required by this implementation guide, do not send. Example REFEWXX~ Variants (all may be used) REF Adjusted Repriced Claim Number REF Care Plan Oversight REF Claim Identifier For Transmission Intermediaries REF Clinical Laboratory Improvement Amendment (CLIA) Number REF Demonstration Project Identifier REF Investigational Device Exemption Number REF Mandatory Medicare (Section 4081) Crossover Indicator REF Medical Record Number REF Payer Claim Control Number REF Prior Authorization REF Referral Number REF Repriced Claim Number REF Service Authorization Exception Code Max use 1 Optional REF-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification EW Mammography Certification Number REF-02 127 Mammography Certification Number Min 1 Max 50 String (AN) Required Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier 1/30/25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 420/665 REF 1800 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > REF Mandatory Medicare (Section 4081) Crossover Indicator To specify identifying information Usage notes Required when the submitter is Medicare and the claim is a Medigap or COB crossover claim. If not required by this implementation guide, do not send. Example REFF5XXXXXX~ Variants (all may be used) REF Adjusted Repriced	Home State Health 837 Health Care Claim_ Professional.pdf
Required Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier 1/30/25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 418/665 REF 1800 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > REF Investigational Device Exemption Number To specify identifying information Usage notes Required when claim involves a Food and Drug Administration (FDA) assigned investigational device exemption (IDE) number. When more than one IDE applies, they must be split into separate claims. If not required by this implementation guide, do not send. Example REFLXXXXXXX~ Variants (all may be used) REF Adjusted Repriced Claim Number REF Care Plan Oversight REF Claim Identifier For Transmission Intermediaries REF Clinical Laboratory Improvement Amendment (CLIA) Number REF Demonstration Project Identifier REF Mammography Certification Number REF Mandatory Medicare (Section 4081) Crossover Indicator REF Medical Record Number REF Payer Claim Control Number REF Prior Authorization REF Referral Number REF Repriced Claim Number REF Service Authorization Exception Code Max use 1 Optional REF-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification LX Qualified Products List REF-02 127 Investigational Device Exemption Identifier String (AN) Required Min 1 Max 50 Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier 1/30/25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 419/665 REF 1800 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > REF Mammography Certification Number To specify identifying information Usage notes Required when mammography services are rendered by a certified mammography provider. If not required by this implementation guide, do not send. Example REFEWXX~ Variants (all may be used) REF Adjusted Repriced Claim Number REF Care Plan Oversight REF Claim Identifier For Transmission Intermediaries REF Clinical Laboratory Improvement Amendment (CLIA) Number REF Demonstration Project Identifier REF Investigational Device Exemption Number REF Mandatory Medicare (Section 4081) Crossover Indicator REF Medical Record Number REF Payer Claim Control Number REF Prior Authorization REF Referral Number REF Repriced Claim Number REF Service Authorization Exception Code Max use 1 Optional REF-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification EW Mammography Certification Number REF-02 127 Mammography Certification Number Min 1 Max 50 String (AN) Required Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier 1/30/25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 420/665 REF 1800 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > REF Mandatory Medicare (Section 4081) Crossover Indicator To specify identifying information Usage notes Required when the submitter is Medicare and the claim is a Medigap or COB crossover claim. If not required by this implementation guide, do not send. Example REFF5XXXXXX~ Variants (all may be used) REF Adjusted Repriced Claim Number REF Care Plan Oversight REF Claim Identifier For Transmission Intermediaries REF Clinical Laboratory Improvement Amendment (CLIA) Number REF Demonstration Project Identifier REF Investigational Device Exemption Number REF Mammography Certification Number REF Medical Record Number REF Payer Claim Control Number REF Prior Authorization REF Referral Number REF Repriced Claim Number REF Service Authorization Exception Code Max use 1 Optional REF-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification F5 Medicare Version Code REF-02 127 Medicare Section 4081 Indicator Min 1 Max 50 String (AN) Required Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier Usage notes The allowed values for this element are: Y 4081 N Regular crossover 1/30/25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 421/665 REF 1800 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > REF Medical Record Number To specify identifying information Usage notes Required when the provider needs to identify for future inquiries, the actual medical record of the patient identified in either Loop ID-2010BA or Loop ID-2010CA for this episode of care. If not required by this implementation guide, do not send. Example REFEAX~ Variants (all may be used) REF Adjusted Repriced Claim Number REF Care Plan Oversight REF Claim Identifier For Transmission Intermediaries REF Clinical Laboratory Improvement Amendment (CLIA) Number REF Demonstration Project Identifier REF Investigational Device Exemption Number REF Mammography Certification Number REF Mandatory Medicare (Section 4081) Crossover Indicator REF Payer Claim Control Number REF Prior Authorization REF Referral Number REF Repriced Claim Number REF Service Authorization Exception Code Max use 1 Optional REF-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification EA Medical Record Identification Number REF-02 127 Medical Record Number Min 1 Max 50 String (AN) Required Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier 1/30/25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 422/665 REF 1800 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > REF Payer Claim Control Number To specify identifying information Usage notes Required when CLM05-3 (Claim Frequency Code) indicates this claim is a replacement or void to a previously adjudicated claim. If not required by this implementation guide, do not send. This information is specific to the destination payer reported in Loop ID-2010BB. Example REFF8XX~ Variants (all may be used) REF Adjusted Repriced Claim Number REF Care Plan Oversight REF Claim Identifier For Transmission Intermediaries REF Clinical Laboratory Improvement Amendment (CLIA) Number REF Demonstration Project Identifier REF Investigational Device Exemption Number REF Mammography Certification Number REF Mandatory Medicare (Section 4081) Crossover Indicator REF Medical Record Number REF Prior Authorization REF Referral Number REF Repriced Claim Number REF Service Authorization Exception Code Max use 1 Optional REF-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification F8 Original Reference Number REF-02 127 Payer Claim Control Number Min 1 Max 50 String (AN) Required Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier 1/30/25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 423/665 REF 1800 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > REF Prior Authorization To specify identifying information Usage notes Generally, preauthorization numbers are assigned by the payer or UMO to authorize a service prior to its being performed. The UMO (Utilization Management Organization) is generally the entity empowered to make a decision regarding the outcome of a health services review or the owner of information. The prior authorization number carried in this REF is specific to the destination payer reported in the Loop ID-2010BB. If other payers have similar numbers for this claim, report that information in the Loop ID-2330 loop REF which holds that payer's information. Numbers at this position apply to the entire claim unless they are overridden in the REF segment in Loop ID-2400. A reference identification is considered to be overridden if the value in REF01 is the same in both the Loop ID-2300 REF segment and the Loop ID-2400 REF segment. In that case, the Loop ID-2400 REF applies only to that specific line. Required when an authorization number is assigned by the payer or UMO AND the services on this claim were preauthorized. If not required by this implementation guide, do not send. Example REFG1XX~ Variants (all may be used) REF Adjusted Repriced Claim Number REF Care Plan Oversight REF Claim Identifier For Transmission Intermediaries REF Clinical Laboratory Improvement Amendment (CLIA) Number REF Demonstration Project Identifier REF Investigational Device Exemption Number REF Mammography Certification Number REF Mandatory Medicare (Section 4081) Crossover Indicator REF Medical Record Number REF Payer Claim Control Number REF Referral Number REF Repriced Claim Number REF Service Authorization Exception Code Max use 1 Optional REF-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification G1 Prior Authorization Number REF-02 127 Prior Authorization Number Min 1 Max 50 String (AN) Required 1/30/25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 424/665 Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier 1/30/25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 425/665 REF 1800 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > REF Referral Number To specify identifying information Usage notes Required when a referral number is assigned by the payer or Utilization Management Organization (UMO) AND a referral is involved. If not required by this implementation guide, do not send. Numbers at this position apply to the entire claim unless they are overridden in the REF segment in Loop ID-2400. A reference identification is considered to be overridden if the value in REF01 is the same in both the Loop ID-2300 REF segment and the Loop ID-2400 REF segment. In that case, the Loop ID-2400 REF applies only to that specific line. Example REF9FX~ Variants (all may be used) REF Adjusted Repriced Claim Number REF Care Plan Oversight REF Claim Identifier For Transmission Intermediaries REF Clinical Laboratory Improvement Amendment (CLIA) Number REF Demonstration Project Identifier REF Investigational Device Exemption Number REF Mammography Certification Number REF Mandatory Medicare (Section 4081) Crossover Indicator REF Medical Record Number REF Payer Claim Control Number REF Prior Authorization REF Repriced Claim Number REF Service Authorization Exception Code Max use 1 Optional REF-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification 9F Referral Number REF-02 127 Referral Number Min 1 Max 50 String (AN) Required 1/30/25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 426/665 Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier 1/30/25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 427/665 REF 1800 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > REF Repriced Claim Number To specify identifying information Usage notes Required when this information is deemed necessary by the repricer. The segment is not completed by providers. The information is completed by repricers only. If not required by this implementation guide, do not send. This information is specific to the destination payer reported in Loop ID-2010BB. Example REF9AX~ Variants (all may be used) REF Adjusted Repriced Claim Number REF Care Plan Oversight REF Claim Identifier For Transmission Intermediaries REF Clinical Laboratory Improvement Amendment (CLIA) Number REF Demonstration Project Identifier REF Investigational Device Exemption Number REF Mammography Certification Number REF Mandatory Medicare (Section 4081) Crossover Indicator REF Medical Record Number REF Payer Claim Control Number REF Prior Authorization REF Referral Number REF Service Authorization Exception Code Max use 1 Optional REF-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification 9A Repriced Claim Reference Number REF-02 127 Repriced Claim Reference Number Min 1 Max 50 String (AN) Required Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier 1/30/25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 428/665 REF 1800 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > REF Service Authorization Exception Code To specify identifying information Usage notes Required when mandated by government law or regulation to obtain authorization for specific service(s) but, for the reasons listed in REF02, the service was performed without obtaining the authorization. If not required by this implementation guide, do not send. Example REF4NXX~ Variants (all may be used) REF Adjusted Repriced Claim Number REF Care Plan Oversight REF Claim Identifier For Transmission Intermediaries REF Clinical Laboratory Improvement Amendment (CLIA) Number REF Demonstration	Home State Health 837 Health Care Claim_ Professional.pdf
if the value in REF01 is the same in both the Loop ID-2300 REF segment and the Loop ID-2400 REF segment. In that case, the Loop ID-2400 REF applies only to that specific line. Example REF9FX~ Variants (all may be used) REF Adjusted Repriced Claim Number REF Care Plan Oversight REF Claim Identifier For Transmission Intermediaries REF Clinical Laboratory Improvement Amendment (CLIA) Number REF Demonstration Project Identifier REF Investigational Device Exemption Number REF Mammography Certification Number REF Mandatory Medicare (Section 4081) Crossover Indicator REF Medical Record Number REF Payer Claim Control Number REF Prior Authorization REF Repriced Claim Number REF Service Authorization Exception Code Max use 1 Optional REF-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification 9F Referral Number REF-02 127 Referral Number Min 1 Max 50 String (AN) Required 1/30/25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 426/665 Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier 1/30/25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 427/665 REF 1800 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > REF Repriced Claim Number To specify identifying information Usage notes Required when this information is deemed necessary by the repricer. The segment is not completed by providers. The information is completed by repricers only. If not required by this implementation guide, do not send. This information is specific to the destination payer reported in Loop ID-2010BB. Example REF9AX~ Variants (all may be used) REF Adjusted Repriced Claim Number REF Care Plan Oversight REF Claim Identifier For Transmission Intermediaries REF Clinical Laboratory Improvement Amendment (CLIA) Number REF Demonstration Project Identifier REF Investigational Device Exemption Number REF Mammography Certification Number REF Mandatory Medicare (Section 4081) Crossover Indicator REF Medical Record Number REF Payer Claim Control Number REF Prior Authorization REF Referral Number REF Service Authorization Exception Code Max use 1 Optional REF-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification 9A Repriced Claim Reference Number REF-02 127 Repriced Claim Reference Number Min 1 Max 50 String (AN) Required Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier 1/30/25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 428/665 REF 1800 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > REF Service Authorization Exception Code To specify identifying information Usage notes Required when mandated by government law or regulation to obtain authorization for specific service(s) but, for the reasons listed in REF02, the service was performed without obtaining the authorization. If not required by this implementation guide, do not send. Example REF4NXX~ Variants (all may be used) REF Adjusted Repriced Claim Number REF Care Plan Oversight REF Claim Identifier For Transmission Intermediaries REF Clinical Laboratory Improvement Amendment (CLIA) Number REF Demonstration Project Identifier REF Investigational Device Exemption Number REF Mammography Certification Number REF Mandatory Medicare (Section 4081) Crossover Indicator REF Medical Record Number REF Payer Claim Control Number REF Prior Authorization REF Referral Number REF Repriced Claim Number Max use 1 Optional REF-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification 4N Special Payment Reference Number REF-02 127 Service Authorization Exception Code Min 1 Max 50 String (AN) Required Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier Usage notes Allowable values for this element are: 1 Immediate/Urgent Care 2 Services Rendered in a Retroactive Period 3 Emergency Care 4 Client has Temporary Medicaid 5 Request from County for Second Opinion to Determine if Recipient Can Work 1/30/25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 429/665 6 Request for Override Pending 7 Special Handling 1/30/25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 430/665 K3 1850 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > K3 File Information To transmit a fixed-format record or matrix contents Usage notes Required when ALL of the following conditions are met: A regulatory agency concludes it must use the K3 to meet an emergency legislative requirement; The administering regulatory agency or other state organization has completed each one of the following steps: contacted the X12N workgroup, requested a review of the K3 data requirement to ensure there is not an existing method within the implementation guide to meet this requirement X12N determines that there is no method to meet the requirement. If not required by this implementation guide, do not send. At the time of publication of this implementation, K3 segments have no specific use. The K3 segment is expected to be used only when necessary to meet the unexpected data requirement of a legislative authority. Before this segment can be used : The X12N Health Care Claim workgroup must conclude there is no other available option in the implementation guide to meet the emergency legislative requirement. The requestor must submit a proposal for approval accompanied by the relevant business documentation to the X12N Health Care Claim workgroup chairs and receive approval for the request. Upon review of the request, X12N will issue an approval or denial decision to the requesting entity. Approved usage(s) of the K3 segment will be reviewed by the X12N Health Care Claim workgroup to develop a permanent change to include the business case in future transaction implementations. Only when all of the requirements above have been met, may the regulatory agency require the temporary use of the K3 segment. X12N will submit the necessary data maintenance and refer the request to the appropriate data content committee(s). Example K3XXX~ Max use 10 Optional K3-01 449 Fixed Format Information Min 1 Max 80 String (AN) Required Data in fixed format agreed upon by sender and receiver 1/30/25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 431/665 NTE 1900 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > NTE Claim Note To transmit information in a free-form format, if necessary, for comment or special instruction Usage notes Required when in the judgment of the provider, the information is needed to substantiate the medical treatment and is not supported elsewhere within the claim data set. If not required by this implementation guide, do not send. Information in the NTE segment in Loop ID-2300 applies to the entire claim unless overridden by information in the NTE segment in Loop ID-2400. Information is considered to be overridden when the value in NTE01 in Loop ID-2400 is the same as the value in NTE01 in Loop ID-2300. The developers of this implementation guide discourage using narrative information within the 837. Trading partners who use narrative information with claims are strongly encouraged to codify that information within the X12 environment.; Example NTETPOXXXXX~ Max use 1 Optional NTE-01 363 Note Reference Code Identifier (ID) Required Code identifying the functional area or purpose for which the note applies ADD Additional Information CER Certification Narrative DCP Goals, Rehabilitation Potential, or Discharge Plans DGN Diagnosis Description TPO Third Party Organization Notes NTE-02 352 Claim Note Text Min 1 Max 80 String (AN) Required A free-form description to clarify the related data elements and their content 1/30/25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 432/665 CR1 1950 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > CR1 Ambulance Transport Information To supply information related to the ambulance service rendered to a patient Usage notes Required on all claims involving ambulance transport services. If not required by this implementation guide, do not send. The CR1 segment in Loop ID-2300 applies to the entire claim unless overridden by a CR1 segment at the service line level in Loop ID-2400 with the same value in CR101. Example CR1LB000000ADH0*XXXXX~ If either Unit or Basis for Measurement Code (CR1-01) or Patient Weight (CR1-02) is present, then the other is required Max use 1 Optional CR1-01 355 Unit or Basis for Measurement Code Identifier (ID) Optional Code specifying the units in which a value is being expressed, or manner in which a measurement has been taken LB Pound CR1-02 81 Patient Weight Min 1 Max 10 Decimal number (R) Optional Numeric value of weight CR102 is the weight of the patient at time of transport. CR1-04 1317 Ambulance Transport Reason Code Identifier (ID) Required Code indicating the reason for ambulance transport A Patient was transported to nearest facility for care of symptoms, complaints, or both Can be used to indicate that the patient was transferred to a residential facility. B Patient was transported for the benefit of a preferred physician C Patient was transported for the nearness of family members D Patient was transported for the care of a specialist or for availability of specialized equipment E Patient Transferred to Rehabilitation Facility CR1-05 355 Unit or Basis for Measurement Code Identifier (ID) Required Code specifying the units in which a value is being expressed, or manner in which a measurement has been taken DH Miles CR1-06 380 Transport Distance Min 1 Max 15 Decimal number (R) Required 1/30/25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 433/665 Numeric value of quantity CR106 is the distance traveled during transport. Usage notes 0 (zero) is a valid value when ambulance services do not include a charge for mileage. CR1-09 352 Round Trip Purpose Description Min 1 Max 80 String (AN) Optional A free-form description to clarify the related data elements and their content CR109 is the purpose for the round trip ambulance service. CR1-10 352 Stretcher Purpose Description Min 1 Max 80 String (AN) Optional A free-form description to clarify the related data elements and their content CR110 is the purpose for the usage of a stretcher during ambulance service. 1/30/25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 434/665 CR2 2000 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > CR2 Spinal Manipulation Service Information To supply information related to the chiropractic service rendered to a patient Usage notes Required on chiropractic claims involving spinal manipulation when the information is known to impact the payer's adjudication process. If not required by this implementation guide, do not send. Example CR2******FXXXXXX~ Max use 1 Optional CR2-08 1342 Patient Condition Code Identifier (ID) Required Code indicating the nature of a patient's condition A Acute Condition C Chronic Condition D Non-acute E Non-Life Threatening F Routine G Symptomatic M Acute Manifestation of a Chronic Condition CR2-10 352 Patient Condition Description Min 1 Max 80 String (AN) Optional A free-form description to clarify the related data elements and their content CR210 is a description of the patient's condition. CR2-11 352 Patient Condition Description Min 1 Max 80 String (AN) Optional A free-form description to clarify the related data elements and their content CR211 is an additional description of the patient's condition. 1/30/25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 435/665 CRC 2200 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > CRC Ambulance Certification To supply information on conditions Usage notes Required when the claim involves ambulance transport services AND when reporting condition codes in any of CRC03 through CRC07. If not required by this implementation guide, do not send. The CRC segment in Loop ID-2300 applies to the entire claim unless overridden by a CRC segment at the service line level in Loop ID-2400 with the same value in CRC01. Repeat this segment only when it is necessary to report additional unique values to those reported in CRC03 thru CRC07. Example CRC07N05XXXXXXXXXX~ Variants (all	Home State Health 837 Health Care Claim_ Professional.pdf
a specialist or for availability of specialized equipment E Patient Transferred to Rehabilitation Facility CR1-05 355 Unit or Basis for Measurement Code Identifier (ID) Required Code specifying the units in which a value is being expressed, or manner in which a measurement has been taken DH Miles CR1-06 380 Transport Distance Min 1 Max 15 Decimal number (R) Required 1/30/25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 433/665 Numeric value of quantity CR106 is the distance traveled during transport. Usage notes 0 (zero) is a valid value when ambulance services do not include a charge for mileage. CR1-09 352 Round Trip Purpose Description Min 1 Max 80 String (AN) Optional A free-form description to clarify the related data elements and their content CR109 is the purpose for the round trip ambulance service. CR1-10 352 Stretcher Purpose Description Min 1 Max 80 String (AN) Optional A free-form description to clarify the related data elements and their content CR110 is the purpose for the usage of a stretcher during ambulance service. 1/30/25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 434/665 CR2 2000 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > CR2 Spinal Manipulation Service Information To supply information related to the chiropractic service rendered to a patient Usage notes Required on chiropractic claims involving spinal manipulation when the information is known to impact the payer's adjudication process. If not required by this implementation guide, do not send. Example CR2******FXXXXXX~ Max use 1 Optional CR2-08 1342 Patient Condition Code Identifier (ID) Required Code indicating the nature of a patient's condition A Acute Condition C Chronic Condition D Non-acute E Non-Life Threatening F Routine G Symptomatic M Acute Manifestation of a Chronic Condition CR2-10 352 Patient Condition Description Min 1 Max 80 String (AN) Optional A free-form description to clarify the related data elements and their content CR210 is a description of the patient's condition. CR2-11 352 Patient Condition Description Min 1 Max 80 String (AN) Optional A free-form description to clarify the related data elements and their content CR211 is an additional description of the patient's condition. 1/30/25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 435/665 CRC 2200 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > CRC Ambulance Certification To supply information on conditions Usage notes Required when the claim involves ambulance transport services AND when reporting condition codes in any of CRC03 through CRC07. If not required by this implementation guide, do not send. The CRC segment in Loop ID-2300 applies to the entire claim unless overridden by a CRC segment at the service line level in Loop ID-2400 with the same value in CRC01. Repeat this segment only when it is necessary to report additional unique values to those reported in CRC03 thru CRC07. Example CRC07N05XXXXXXXXXX~ Variants (all may be used) CRC EPSDT Referral CRC Homebound Indicator CRC Patient Condition Information: Vision Max use 3 Optional CRC-01 1136 Code Category Identifier (ID) Required Specifies the situation or category to which the code applies CRC01 qualifies CRC03 through CRC07. 07 Ambulance Certification CRC-02 1073 Certification Condition Indicator Identifier (ID) Required Code indicating a Yes or No condition or response CRC02 is a Certification Condition Code applies indicator. A "Y" value indicates the condition codes in CRC03 through CRC07 apply; an "N" value indicates the condition codes in CRC03 through CRC07 do not apply. N No Y Yes CRC-03 1321 Condition Code Identifier (ID) Required Code indicating a condition Usage notes The codes for CRC03 also can be used for CRC04 through CRC07. 01 Patient was admitted to a hospital 04 Patient was moved by stretcher 05 Patient was unconscious or in shock 1/30/25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 436/665 06 Patient was transported in an emergency situation 07 Patient had to be physically restrained 08 Patient had visible hemorrhaging 09 Ambulance service was medically necessary 12 Patient is confined to a bed or chair Use code 12 to indicate patient was bedridden during transport. CRC-04 1321 Condition Code Min 2 Max 3 Identifier (ID) Optional Code indicating a condition Usage notes Use the codes listed in CRC03. CRC-05 1321 Condition Code Min 2 Max 3 Identifier (ID) Optional Code indicating a condition Usage notes Use the codes listed in CRC03. CRC-06 1321 Condition Code Min 2 Max 3 Identifier (ID) Optional Code indicating a condition Usage notes Use the codes listed in CRC03. CRC-07 1321 Condition Code Min 2 Max 3 Identifier (ID) Optional Code indicating a condition Usage notes Use the codes listed in CRC03. 1/30/25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 437/665 CRC 2200 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > CRC EPSDT Referral To supply information on conditions Usage notes Required on Early & Periodic Screening, Diagnosis, and Treatment (EPSDT) claims when the screening service is being billed in this claim. If not required by this implementation guide, do not send. Example CRCZZYAVXXXXXX~ Variants (all may be used) CRC Ambulance Certification CRC Homebound Indicator CRC Patient Condition Information: Vision Max use 1 Optional CRC-01 1136 Code Qualifier Identifier (ID) Required Specifies the situation or category to which the code applies CRC01 qualifies CRC03 through CRC07. ZZ Mutually Defined EPSDT Screening referral information. CRC-02 1073 Certification Condition Code Applies Indicator Identifier (ID) Required Code indicating a Yes or No condition or response CRC02 is a Certification Condition Code applies indicator. A "Y" value indicates the condition codes in CRC03 through CRC07 apply; an "N" value indicates the condition codes in CRC03 through CRC07 do not apply. Usage notes The response answers the question: Was an EPSDT referral given to the patient? N No If no, then choose "NU" in CRC03 indicating no referral given. Y Yes CRC-03 1321 Condition Indicator Identifier (ID) Required Code indicating a condition Usage notes The codes for CRC03 also can be used for CRC04 through CRC05. AV Available - Not Used Patient refused referral. 1/30/25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 438/665 NU Not Used This conditioner indicator must be used when the submitter answers "N" in CRC02. S2 Under Treatment Patient is currently under treatment for referred diagnostic or corrective health problem. ST New Services Requested Patient is referred to another provider for diagnostic or corrective treatment for at least one health problem identified during an initial or periodic screening service (not including dental referrals). OR Patient is scheduled for another appointment with screening provider for diagnostic or corrective treatment for at least one health problem identified during an initial or periodic screening service (not including dental referrals).; CRC-04 1321 Condition Indicator Min 2 Max 3 Identifier (ID) Optional Code indicating a condition Usage notes Use the codes listed in CRC03. CRC-05 1321 Condition Indicator Min 2 Max 3 Identifier (ID) Optional Code indicating a condition Usage notes Use the codes listed in CRC03. 1/30/25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 439/665 CRC 2200 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > CRC Homebound Indicator To supply information on conditions Usage notes Required for Medicare claims when an independent laboratory renders an EKG tracing or obtains a specimen from a homebound or institutionalized patient. If not required by this implementation guide, do not send. Example CRC75YIH~ Variants (all may be used) CRC Ambulance Certification CRC EPSDT Referral CRC Patient Condition Information: Vision Max use 1 Optional CRC-01 1136 Code Category Identifier (ID) Required Specifies the situation or category to which the code applies CRC01 qualifies CRC03 through CRC07. 75 Functional Limitations CRC-02 1073 Certification Condition Indicator Identifier (ID) Required Code indicating a Yes or No condition or response CRC02 is a Certification Condition Code applies indicator. A "Y" value indicates the condition codes in CRC03 through CRC07 apply; an "N" value indicates the condition codes in CRC03 through CRC07 do not apply. Y Yes CRC-03 1321 Homebound Indicator Identifier (ID) Required Code indicating a condition IH Independent at Home 1/30/25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 440/665 CRC 2200 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > CRC Patient Condition Information: Vision To supply information on conditions Usage notes Required on vision claims involving replacement lenses or frames when this information is known to impact reimbursement. If not required by this implementation guide, do not send. Example CRCE2NL2XXXXXXXXX~ Variants (all may be used) CRC Ambulance Certification CRC EPSDT Referral CRC Homebound Indicator Max use 3 Optional CRC-01 1136 Code Category Identifier (ID) Required Specifies the situation or category to which the code applies CRC01 qualifies CRC03 through CRC07. E1 Spectacle Lenses E2 Contact Lenses E3 Spectacle Frames CRC-02 1073 Certification Condition Indicator Identifier (ID) Required Code indicating a Yes or No condition or response CRC02 is a Certification Condition Code applies indicator. A "Y" value indicates the condition codes in CRC03 through CRC07 apply; an "N" value indicates the condition codes in CRC03 through CRC07 do not apply. N No Y Yes CRC-03 1321 Condition Code Identifier (ID) Required Code indicating a condition L1 General Standard of 20 Degree or .5 Diopter Sphere or Cylinder Change Met L2 Replacement Due to Loss or Theft L3 Replacement Due to Breakage or Damage L4 Replacement Due to Patient Preference L5 Replacement Due to Medical Reason CRC-04 1321 Condition Code Min 2 Max 3 Identifier (ID) Optional 1/30/25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 441/665 Code indicating a condition Usage notes Use the codes listed in CRC03. CRC-05 1321 Condition Code Min 2 Max 3 Identifier (ID) Optional Code indicating a condition Usage notes Use the codes listed in CRC03. CRC-06 1321 Condition Code Min 2 Max 3 Identifier (ID) Optional Code indicating a condition Usage notes Use the codes listed in CRC03. CRC-07 1321 Condition Code Min 2 Max 3 Identifier (ID) Optional Code indicating a condition Usage notes Use the codes listed in CRC03. 1/30/25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 442/665 HI 2310 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > HI Anesthesia Related Procedure To supply information related to the delivery of health care Usage notes Required on claims where anesthesiology services are being billed or reported when the provider knows the surgical code and knows the adjudication of the claim will depend on provision of the surgical code. If not required by this implementation guide, do not send. Example HIBP>XXXXX*BO>XXXXX~ Variants (all may be used) HI Condition Information HI Health Care Diagnosis Code Max use 1 Optional HI-01 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Max use 1 Required C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. BP Health Care Financing Administration Common Procedural Coding System Principal Procedure C022-02 1271 Anesthesia Related Surgical Procedure String (AN) Required Min 1 Max 30 Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. HI-02 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Required when it is necessary to report an additional procedure and the preceding HI data elements have been used to report other procedures. If not required by this implementation guide, do not send. Max use 1 Optional C022-01 1270 Code List Qualifier Code Identifier (ID)	Home State Health 837 Health Care Claim_ Professional.pdf
code applies CRC01 qualifies CRC03 through CRC07. E1 Spectacle Lenses E2 Contact Lenses E3 Spectacle Frames CRC-02 1073 Certification Condition Indicator Identifier (ID) Required Code indicating a Yes or No condition or response CRC02 is a Certification Condition Code applies indicator. A "Y" value indicates the condition codes in CRC03 through CRC07 apply; an "N" value indicates the condition codes in CRC03 through CRC07 do not apply. N No Y Yes CRC-03 1321 Condition Code Identifier (ID) Required Code indicating a condition L1 General Standard of 20 Degree or .5 Diopter Sphere or Cylinder Change Met L2 Replacement Due to Loss or Theft L3 Replacement Due to Breakage or Damage L4 Replacement Due to Patient Preference L5 Replacement Due to Medical Reason CRC-04 1321 Condition Code Min 2 Max 3 Identifier (ID) Optional 1/30/25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 441/665 Code indicating a condition Usage notes Use the codes listed in CRC03. CRC-05 1321 Condition Code Min 2 Max 3 Identifier (ID) Optional Code indicating a condition Usage notes Use the codes listed in CRC03. CRC-06 1321 Condition Code Min 2 Max 3 Identifier (ID) Optional Code indicating a condition Usage notes Use the codes listed in CRC03. CRC-07 1321 Condition Code Min 2 Max 3 Identifier (ID) Optional Code indicating a condition Usage notes Use the codes listed in CRC03. 1/30/25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 442/665 HI 2310 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > HI Anesthesia Related Procedure To supply information related to the delivery of health care Usage notes Required on claims where anesthesiology services are being billed or reported when the provider knows the surgical code and knows the adjudication of the claim will depend on provision of the surgical code. If not required by this implementation guide, do not send. Example HIBP>XXXXXBO>XXXXX~ Variants (all may be used) HI Condition Information HI Health Care Diagnosis Code Max use 1 Optional HI-01 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Max use 1 Required C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. BP Health Care Financing Administration Common Procedural Coding System Principal Procedure C022-02 1271 Anesthesia Related Surgical Procedure String (AN) Required Min 1 Max 30 Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. HI-02 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Required when it is necessary to report an additional procedure and the preceding HI data elements have been used to report other procedures. If not required by this implementation guide, do not send. Max use 1 Optional C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. 1/30/25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 443/665 BO Health Care Financing Administration Common Procedural Coding System C022-02 1271 Industry Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. 1/30/25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 444/665 HI 2310 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > HI Condition Information To supply information related to the delivery of health care Usage notes Required when condition information applies to the claim. If not required by this implementation guide, do not send. Example HIBG>XXXXXBG>XXBG>XBG>XXXXXBG>XXXXXBG>XXXXX XBG>XXXXXBG>XXXXXXBG>XXXXXXBG>XXBG>XXXBG>XX XXXX~ Variants (all may be used) HI Anesthesia Related Procedure HI Health Care Diagnosis Code Max use 2 Optional HI-01 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Max use 1 Required C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. BG Condition C022-02 1271 Condition Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. HI-02 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Required when it is necessary to report an additional condition code and the preceding HI data elements have been used to report other condition codes. If not required by this implementation guide, do not send. Max use 1 Optional C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. 1/30/25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 445/665 BG Condition C022-02 1271 Condition Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. HI-03 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Required when it is necessary to report an additional condition code and the preceding HI data elements have been used to report other condition codes. If not required by this implementation guide, do not send. Max use 1 Optional C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. BG Condition C022-02 1271 Condition Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. HI-04 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Required when it is necessary to report an additional condition code and the preceding HI data elements have been used to report other condition codes. If not required by this implementation guide, do not send. Max use 1 Optional C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. BG Condition C022-02 1271 Condition Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list 1/30/25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 446/665 If C022-08 is used, then C022-02 represents the beginning value in a range of codes. HI-05 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Required when it is necessary to report an additional condition code and the preceding HI data elements have been used to report other condition codes. If not required by this implementation guide, do not send. Max use 1 Optional C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. BG Condition C022-02 1271 Condition Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. HI-06 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Required when it is necessary to report an additional condition code and the preceding HI data elements have been used to report other condition codes. If not required by this implementation guide, do not send. Max use 1 Optional C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. BG Condition C022-02 1271 Condition Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. HI-07 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Max use 1 Optional 1/30/25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 447/665 Required when it is necessary to report an additional condition code and the preceding HI data elements have been used to report other condition codes. If not required by this implementation guide, do not send. C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. BG Condition C022-02 1271 Condition Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. HI-08 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Required when it is necessary to report an additional condition code and the preceding HI data elements have been used to report other condition codes. If not required by this implementation guide, do not send. Max use 1 Optional C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. BG Condition C022-02 1271 Condition Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. HI-09 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Required when it is necessary to report an additional condition code and the preceding HI data elements have been used to report other condition codes. If not required by this implementation guide, do not send. Max use 1 Optional C022-01 1270 Code List Qualifier Code Identifier (ID) Required 1/30/25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 448/665 Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. BG Condition C022-02 1271 Condition Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. HI-10 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Required when it is necessary to report an additional condition code and the preceding HI data elements have been used to report other condition codes. If not required by this implementation guide, do not send. Max use 1 Optional C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. BG Condition C022-02 1271 Condition Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. HI-11 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Required when it is necessary to report an additional condition code and the preceding HI data elements have been used to report other condition codes. If not required by this implementation guide, do not send. Max use 1 Optional C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. BG Condition C022-02 1271 Condition Code Min 1 Max 30 String (AN) Required 1/30/25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 449/665 Code	Home State Health 837 Health Care Claim_ Professional.pdf
list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. HI-08 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Required when it is necessary to report an additional condition code and the preceding HI data elements have been used to report other condition codes. If not required by this implementation guide, do not send. Max use 1 Optional C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. BG Condition C022-02 1271 Condition Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. HI-09 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Required when it is necessary to report an additional condition code and the preceding HI data elements have been used to report other condition codes. If not required by this implementation guide, do not send. Max use 1 Optional C022-01 1270 Code List Qualifier Code Identifier (ID) Required 1/30/25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 448/665 Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. BG Condition C022-02 1271 Condition Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. HI-10 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Required when it is necessary to report an additional condition code and the preceding HI data elements have been used to report other condition codes. If not required by this implementation guide, do not send. Max use 1 Optional C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. BG Condition C022-02 1271 Condition Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. HI-11 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Required when it is necessary to report an additional condition code and the preceding HI data elements have been used to report other condition codes. If not required by this implementation guide, do not send. Max use 1 Optional C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. BG Condition C022-02 1271 Condition Code Min 1 Max 30 String (AN) Required 1/30/25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 449/665 Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. HI-12 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Required when it is necessary to report an additional condition code and the preceding HI data elements have been used to report other condition codes. If not required by this implementation guide, do not send. Max use 1 Optional C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. BG Condition C022-02 1271 Condition Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. 1/30/25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 450/665 HI 2310 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > HI Health Care Diagnosis Code To supply information related to the delivery of health care Usage notes Do not transmit the decimal point for ICD codes. The decimal point is implied. Example HIBK>XXXXXXABF>XXXABF>XXXBF>XXBF>XBF>XXXXX XABF>XXXXBF>XXABF>XABF>XXXXBF>XXBF>XXXXX~ Variants (all may be used) HI Anesthesia Related Procedure HI Condition Information Max use 1 Required HI-01 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Max use 1 Required C022-01 1270 Diagnosis Type Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. ABK International Classification of Diseases Clinical Modification (ICD-10-CM) Principal Diagnosis This code set is not allowed for use under HIPAA at the time of this writing. The qualifier can only be used: If a new rule names the ICD-10-CM as an allowable code set under HIPAA, OR The Secretary grants an exception to use the code set as a pilot project as allowed under the law, OR For claims which are not covered under HIPAA. BK International Classification of Diseases Clinical Modification (ICD-9-CM) Principal Diagnosis C022-02 1271 Diagnosis Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. HI-02 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Required when it is necessary to report an additional diagnosis and the preceding HI data elements have been used to report other diagnoses. If not required by this implementation guide, do not send. Max use 1 Optional 1/30/25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 451/665 C022-01 1270 Diagnosis Type Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. ABF International Classification of Diseases Clinical Modification (ICD-10-CM) Diagnosis This code set is not allowed for use under HIPAA at the time of this writing. The qualifier can only be used: If a new rule names the ICD-10-CM as an allowable code set under HIPAA, OR The Secretary grants an exception to use the code set as a pilot project as allowed under the law, OR For claims which are not covered under HIPAA. BF International Classification of Diseases Clinical Modification (ICD-9-CM) Diagnosis C022-02 1271 Diagnosis Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. HI-03 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Required when it is necessary to report an additional diagnosis and the preceding HI data elements have been used to report other diagnoses. If not required by this implementation guide, do not send. Max use 1 Optional C022-01 1270 Diagnosis Type Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. ABF International Classification of Diseases Clinical Modification (ICD-10-CM) Diagnosis This code set is not allowed for use under HIPAA at the time of this writing. The qualifier can only be used: If a new rule names the ICD-10-CM as an allowable code set under HIPAA, OR The Secretary grants an exception to use the code set as a pilot project as allowed under the law, OR For claims which are not covered under HIPAA. BF International Classification of Diseases Clinical Modification (ICD-9-CM) Diagnosis C022-02 1271 Diagnosis Code Min 1 Max 30 String (AN) Required 1/30/25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 452/665 Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. HI-04 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Required when it is necessary to report an additional diagnosis and the preceding HI data elements have been used to report other diagnoses. If not required by this implementation guide, do not send. Max use 1 Optional C022-01 1270 Diagnosis Type Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. ABF International Classification of Diseases Clinical Modification (ICD-10-CM) Diagnosis This code set is not allowed for use under HIPAA at the time of this writing. The qualifier can only be used: If a new rule names the ICD-10-CM as an allowable code set under HIPAA, OR The Secretary grants an exception to use the code set as a pilot project as allowed under the law, OR For claims which are not covered under HIPAA. BF International Classification of Diseases Clinical Modification (ICD-9-CM) Diagnosis C022-02 1271 Diagnosis Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. HI-05 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Required when it is necessary to report an additional diagnosis and the preceding HI data elements have been used to report other diagnoses. If not required by this implementation guide, do not send. Max use 1 Optional C022-01 1270 Diagnosis Type Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. ABF International Classification of Diseases Clinical Modification (ICD-10-CM) Diagnosis This code set is not allowed for use under HIPAA at the time of this writing. The qualifier can only be used: 1/30/25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 453/665 If a new rule names the ICD-10-CM as an allowable code set under HIPAA, OR The Secretary grants an exception to use the code set as a pilot project as allowed under the law, OR For claims which are not covered under HIPAA. BF International Classification of Diseases Clinical Modification (ICD-9-CM) Diagnosis C022-02 1271 Diagnosis Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. HI-06 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Required when it is necessary to report an additional diagnosis and the preceding HI data elements have been used to report other diagnoses. If not required by this implementation guide, do not send. Max use 1 Optional C022-01 1270 Diagnosis Type Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. ABF International Classification of Diseases Clinical Modification (ICD-10-CM) Diagnosis This code set is not allowed for use under HIPAA at the time of this writing. The qualifier can only be used: If a new rule names the ICD-10-CM as an allowable code set under HIPAA, OR The Secretary grants an exception to use the code set as a pilot project as allowed under the law, OR For claims which are not covered under HIPAA. BF International Classification of Diseases Clinical Modification (ICD-9-CM) Diagnosis C022-02 1271 Diagnosis Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. HI-07 C022 Health Care Code Information Max use 1 Optional 1/30/25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 454/665 To send health care codes and their associated dates, amounts and quantities Usage notes Required when it is necessary to report an additional diagnosis and the preceding HI data elements have been used to report other diagnoses. If not required by this implementation guide, do not send. C022-01 1270 Diagnosis Type Code Identifier (ID) Required Code	Home State Health 837 Health Care Claim_ Professional.pdf
used, then C022-02 represents the beginning value in a range of codes. HI-05 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Required when it is necessary to report an additional diagnosis and the preceding HI data elements have been used to report other diagnoses. If not required by this implementation guide, do not send. Max use 1 Optional C022-01 1270 Diagnosis Type Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. ABF International Classification of Diseases Clinical Modification (ICD-10-CM) Diagnosis This code set is not allowed for use under HIPAA at the time of this writing. The qualifier can only be used: 1/30/25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 453/665 If a new rule names the ICD-10-CM as an allowable code set under HIPAA, OR The Secretary grants an exception to use the code set as a pilot project as allowed under the law, OR For claims which are not covered under HIPAA. BF International Classification of Diseases Clinical Modification (ICD-9-CM) Diagnosis C022-02 1271 Diagnosis Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. HI-06 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Required when it is necessary to report an additional diagnosis and the preceding HI data elements have been used to report other diagnoses. If not required by this implementation guide, do not send. Max use 1 Optional C022-01 1270 Diagnosis Type Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. ABF International Classification of Diseases Clinical Modification (ICD-10-CM) Diagnosis This code set is not allowed for use under HIPAA at the time of this writing. The qualifier can only be used: If a new rule names the ICD-10-CM as an allowable code set under HIPAA, OR The Secretary grants an exception to use the code set as a pilot project as allowed under the law, OR For claims which are not covered under HIPAA. BF International Classification of Diseases Clinical Modification (ICD-9-CM) Diagnosis C022-02 1271 Diagnosis Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. HI-07 C022 Health Care Code Information Max use 1 Optional 1/30/25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 454/665 To send health care codes and their associated dates, amounts and quantities Usage notes Required when it is necessary to report an additional diagnosis and the preceding HI data elements have been used to report other diagnoses. If not required by this implementation guide, do not send. C022-01 1270 Diagnosis Type Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. ABF International Classification of Diseases Clinical Modification (ICD-10-CM) Diagnosis This code set is not allowed for use under HIPAA at the time of this writing. The qualifier can only be used: If a new rule names the ICD-10-CM as an allowable code set under HIPAA, OR The Secretary grants an exception to use the code set as a pilot project as allowed under the law, OR For claims which are not covered under HIPAA. BF International Classification of Diseases Clinical Modification (ICD-9-CM) Diagnosis ICD-9 Codes C022-02 1271 Diagnosis Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. HI-08 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Required when it is necessary to report an additional diagnosis and the preceding HI data elements have been used to report other diagnoses. If not required by this implementation guide, do not send. Max use 1 Optional C022-01 1270 Diagnosis Type Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. ABF International Classification of Diseases Clinical Modification (ICD-10-CM) Diagnosis This code set is not allowed for use under HIPAA at the time of this writing. The qualifier can only be used: If a new rule names the ICD-10-CM as an allowable code set under HIPAA, OR The Secretary grants an exception to use the code set as a pilot project as allowed under the law, 1/30/25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 455/665 OR For claims which are not covered under HIPAA. BF International Classification of Diseases Clinical Modification (ICD-9-CM) Diagnosis C022-02 1271 Diagnosis Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. HI-09 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Required when it is necessary to report an additional diagnosis and the preceding HI data elements have been used to report other diagnoses. If not required by this implementation guide, do not send. Max use 1 Optional C022-01 1270 Diagnosis Type Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. ABF International Classification of Diseases Clinical Modification (ICD-10-CM) Diagnosis This code set is not allowed for use under HIPAA at the time of this writing. The qualifier can only be used: If a new rule names the ICD-10-CM as an allowable code set under HIPAA, OR The Secretary grants an exception to use the code set as a pilot project as allowed under the law, OR For claims which are not covered under HIPAA. BF International Classification of Diseases Clinical Modification (ICD-9-CM) Diagnosis C022-02 1271 Diagnosis Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. HI-10 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Required when it is necessary to report an additional diagnosis and the preceding HI data elements have been used to report other diagnoses. If not required by this implementation guide, do not send. Max use 1 Optional C022-01 1270 Diagnosis Type Code Identifier (ID) Required 1/30/25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 456/665 Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. ABF International Classification of Diseases Clinical Modification (ICD-10-CM) Diagnosis This code set is not allowed for use under HIPAA at the time of this writing. The qualifier can only be used: If a new rule names the ICD-10-CM as an allowable code set under HIPAA, OR The Secretary grants an exception to use the code set as a pilot project as allowed under the law, OR For claims which are not covered under HIPAA. BF International Classification of Diseases Clinical Modification (ICD-9-CM) Diagnosis C022-02 1271 Diagnosis Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. HI-11 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Required when it is necessary to report an additional diagnosis and the preceding HI data elements have been used to report other diagnoses. If not required by this implementation guide, do not send. Max use 1 Optional C022-01 1270 Diagnosis Type Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. ABF International Classification of Diseases Clinical Modification (ICD-10-CM) Diagnosis This code set is not allowed for use under HIPAA at the time of this writing. The qualifier can only be used: If a new rule names the ICD-10-CM as an allowable code set under HIPAA, OR The Secretary grants an exception to use the code set as a pilot project as allowed under the law, OR For claims which are not covered under HIPAA. BF International Classification of Diseases Clinical Modification (ICD-9-CM) Diagnosis C022-02 1271 Diagnosis Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. 1/30/25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 457/665 HI-12 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Required when it is necessary to report an additional diagnosis and the preceding HI data elements have been used to report other diagnoses. If not required by this implementation guide, do not send. Max use 1 Optional C022-01 1270 Diagnosis Type Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. ABF International Classification of Diseases Clinical Modification (ICD-10-CM) Diagnosis This code set is not allowed for use under HIPAA at the time of this writing. The qualifier can only be used: If a new rule names the ICD-10-CM as an allowable code set under HIPAA, OR The Secretary grants an exception to use the code set as a pilot project as allowed under the law, OR For claims which are not covered under HIPAA. BF International Classification of Diseases Clinical Modification (ICD-9-CM) Diagnosis C022-02 1271 Diagnosis Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. 1/30/25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 458/665 HCP 2410 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > HCP Claim Pricing/Repricing Information To specify pricing or repricing information about a health care claim or line item Usage notes Required when this information is deemed necessary by the repricer. The segment is not completed by providers. The information is completed by repricers only. If not required by this implementation guide, do not send. This information is specific to the destination payer reported in Loop ID-2010BB. For capitated encounters, pricing or repricing information usually is not applicable and is provided to qualify other information within the claim. Example HCP140000000000000000000000000XXXXXX00X000 00000000****T31*6~ Max use 1 Optional HCP-01 1473 Pricing Methodology Identifier (ID) Required Code specifying pricing methodology at which the claim or line item has been priced or repriced Usage notes Specific code use is determined by Trading Partner Agreement due to the variances in contracting policies in the industry. 00 Zero Pricing (Not Covered Under Contract) 01 Priced as Billed at 100% 02 Priced at the Standard Fee Schedule 03 Priced at a Contractual Percentage 04 Bundled Pricing 05 Peer Review Pricing 07 Flat Rate Pricing 08 Combination Pricing 09 Maternity Pricing 10 Other Pricing 11 Lower of Cost 12 Ratio of Cost 13 Cost Reimbursed 14 Adjustment Pricing HCP-02 782 Repriced Allowed Amount Min 1 Max 15 Decimal number (R) Required Monetary amount HCP02 is the allowed amount. HCP-03 782 Repriced Saving Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount 1/30/25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 459/665 HCP03 is the savings amount. Usage notes This information is specific to the destination payer reported in Loop ID-2010BB. HCP-04 127 Repricing Organization Identifier Min 1 Max 50 String (AN) Optional Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier HCP04 is the repricing organization identification number. Usage notes This information	Home State Health 837 Health Care Claim_ Professional.pdf
to report other diagnoses. If not required by this implementation guide, do not send. Max use 1 Optional C022-01 1270 Diagnosis Type Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. ABF International Classification of Diseases Clinical Modification (ICD-10-CM) Diagnosis This code set is not allowed for use under HIPAA at the time of this writing. The qualifier can only be used: If a new rule names the ICD-10-CM as an allowable code set under HIPAA, OR The Secretary grants an exception to use the code set as a pilot project as allowed under the law, OR For claims which are not covered under HIPAA. BF International Classification of Diseases Clinical Modification (ICD-9-CM) Diagnosis C022-02 1271 Diagnosis Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. 1/30/25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 458/665 HCP 2410 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > HCP Claim Pricing/Repricing Information To specify pricing or repricing information about a health care claim or line item Usage notes Required when this information is deemed necessary by the repricer. The segment is not completed by providers. The information is completed by repricers only. If not required by this implementation guide, do not send. This information is specific to the destination payer reported in Loop ID-2010BB. For capitated encounters, pricing or repricing information usually is not applicable and is provided to qualify other information within the claim. Example HCP140000000000000000000000000XXXXXX00X000 00000000****T316~ Max use 1 Optional HCP-01 1473 Pricing Methodology Identifier (ID) Required Code specifying pricing methodology at which the claim or line item has been priced or repriced Usage notes Specific code use is determined by Trading Partner Agreement due to the variances in contracting policies in the industry. 00 Zero Pricing (Not Covered Under Contract) 01 Priced as Billed at 100% 02 Priced at the Standard Fee Schedule 03 Priced at a Contractual Percentage 04 Bundled Pricing 05 Peer Review Pricing 07 Flat Rate Pricing 08 Combination Pricing 09 Maternity Pricing 10 Other Pricing 11 Lower of Cost 12 Ratio of Cost 13 Cost Reimbursed 14 Adjustment Pricing HCP-02 782 Repriced Allowed Amount Min 1 Max 15 Decimal number (R) Required Monetary amount HCP02 is the allowed amount. HCP-03 782 Repriced Saving Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount 1/30/25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 459/665 HCP03 is the savings amount. Usage notes This information is specific to the destination payer reported in Loop ID-2010BB. HCP-04 127 Repricing Organization Identifier Min 1 Max 50 String (AN) Optional Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier HCP04 is the repricing organization identification number. Usage notes This information is specific to the destination payer reported in Loop ID-2010BB. HCP-05 118 Repricing Per Diem or Flat Rate Amount Decimal number (R) Optional Min 1 Max 9 Rate expressed in the standard monetary denomination for the currency specified HCP05 is the pricing rate associated with per diem or flat rate repricing. Usage notes This information is specific to the destination payer reported in Loop ID-2010BB. HCP-06 127 Repriced Approved Ambulatory Patient Group Code String (AN) Optional Min 1 Max 50 Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier HCP06 is the approved DRG code. HCP06, HCP07, HCP08, HCP10, and HCP12 are fields that will contain different values from the original submitted values. Usage notes This information is specific to the destination payer reported in Loop ID-2010BB. HCP-07 782 Repriced Approved Ambulatory Patient Group Amount Decimal number (R) Optional Min 1 Max 15 Monetary amount HCP07 is the approved DRG amount. Usage notes This information is specific to the destination payer reported in Loop ID-2010BB. HCP-13 901 Reject Reason Code Identifier (ID) Optional 1/30/25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 460/665 Code assigned by issuer to identify reason for rejection HCP13 is the rejection message returned from the third party organization. Usage notes This information is specific to the destination payer reported in Loop ID-2010BB. T1 Cannot Identify Provider as TPO (Third Party Organization) Participant T2 Cannot Identify Payer as TPO (Third Party Organization) Participant T3 Cannot Identify Insured as TPO (Third Party Organization) Participant T4 Payer Name or Identifier Missing T5 Certification Information Missing T6 Claim does not contain enough information for re-pricing HCP-14 1526 Policy Compliance Code Identifier (ID) Optional Code specifying policy compliance Usage notes This information is specific to the destination payer reported in Loop ID-2010BB. 1 Procedure Followed (Compliance) 2 Not Followed - Call Not Made (Non-Compliance Call Not Made) 3 Not Medically Necessary (Non-Compliance Non-Medically Necessary) 4 Not Followed Other (Non-Compliance Other) 5 Emergency Admit to Non-Network Hospital HCP-15 1527 Exception Code Identifier (ID) Optional Code specifying the exception reason for consideration of out-of-network health care services HCP15 is the exception reason generated by a third party organization. Usage notes This information is specific to the destination payer reported in Loop ID-2010BB. 1 Non-Network Professional Provider in Network Hospital 2 Emergency Care 3 Services or Specialist not in Network 4 Out-of-Service Area 5 State Mandates 6 Other 1/30/25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 461/665 2310A Referring Provider Name Loop Max 2 Optional Variants (all may be used) Rendering Provider Name Loop Service Facility Location Name Loop Supervising Provider Name Loop Ambulance Pick-up Location Loop Ambulance Drop-off Location Loop NM1 2500 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > Referring Provider Name Loop > NM1 Referring Provider Name To supply the full name of an individual or organizational entity Usage notes Required when this claim involves a referral. If not required by this implementation guide, do not send. When reporting the provider who ordered services such as diagnostic and lab, use Loop ID-2310A at the claim level. For ordered services such as Durable Medical Equipment, use Loop ID-2420E at the line level. When there is only one referral on the claim, use code "DN - Referring Provider". When more than one referral exists and there is a requirement to report the additional referral, use code DN in the first iteration of this loop to indicate the referral received by the rendering provider on this claim. Use code "P3 - Primary Care Provider" in the second iteration of the loop to indicate the initial referral from the primary care provider or whatever provider wrote the initial referral for this patient's episode of care being billed/reported in this transaction. Information in Loop ID-2310 applies to the entire claim unless overridden on a service line by the presence of Loop ID-2420 with the same value in NM101. Example NM1DN1XXXXXXXXXXXXXX*XXXXXXXXXXX~ If either Identification Code Qualifier (NM1-08) or Referring Provider Identifier (NM1-09) is present, then the other is required Max use 1 Required NM1-01 98 Entity Identifier Code Identifier (ID) Required Code identifying an organizational entity, a physical location, property or an individual DN Referring Provider Use on the first iteration of this loop. Use if loop is used only once. P3 Primary Care Provider Use only if loop is used twice. Use only on second iteration of this loop. NM1-02 1065 Entity Type Qualifier Identifier (ID) Required Code qualifying the type of entity 1/30/25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 462/665 NM102 qualifies NM103. 1 Person NM1-03 1035 Referring Provider Last Name Min 1 Max 60 String (AN) Required Individual last name or organizational name NM1-04 1036 Referring Provider First Name Min 1 Max 35 String (AN) Optional Individual first name NM1-05 1037 Referring Provider Middle Name or Initial Min 1 Max 25 String (AN) Optional Individual middle name or initial NM1-07 1039 Referring Provider Name Suffix Min 1 Max 10 String (AN) Optional Suffix to individual name NM1-08 66 Identification Code Qualifier Identifier (ID) Optional Code designating the system/method of code structure used for Identification Code (67) XX Centers for Medicare and Medicaid Services National Provider Identifier NM1-09 67 Referring Provider Identifier Min 2 Max 80 String (AN) Optional Code identifying a party or other code 1/30/25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 463/665 2310A Referring Provider Name Loop end REF 2710 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > Referring Provider Name Loop > REF Referring Provider Secondary Identification To specify identifying information Usage notes The REF segment in Loop ID-2310 applies to the entire claim unless overridden on the service line level by the presence of a REF segment with the same value in REF01. Required prior to the mandated HIPAA National Provider Identifier (NPI) implementation date when an identification number other than the NPI is necessary for the receiver to identify the provider. OR Required on or after the mandated NPI Implementation Date when NM109 in this loop is not used and an identification number other than the NPI is necessary for the receiver to identify the provider. If not required by this implementation guide, do not send. Example REFG2XX~ Max use 3 Optional REF-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification 0B State License Number 1G Provider UPIN Number UPINs must be formatted as either X99999 or XXX999. G2 Provider Commercial Number This code designates a proprietary provider number for the destination payer identified in the Payer Name loop, Loop ID-2010BB, associated with this claim. This is to be used by all payers including: Medicare, Medicaid, Blue Cross, etc. REF-02 127 Referring Provider Secondary Identifier Min 1 Max 50 String (AN) Required Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier 1/30/25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 464/665 2310B Rendering Provider Name Loop Max 1 Optional Variants (all may be used) Referring Provider Name Loop Service Facility Location Name Loop Supervising Provider Name Loop Ambulance Pick-up Location Loop Ambulance Drop-off Location Loop NM1 2500 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > Rendering Provider Name Loop > NM1 Rendering Provider Name To supply the full name of an individual or organizational entity Usage notes Required when the Rendering Provider information is different than that carried in Loop ID-2010AA - Billing Provider. If not required by this implementation guide, do not send. Used for all types of rendering providers including laboratories. The Rendering Provider is the person or company (laboratory or other facility) who rendered the care. In the case where a substitute provider (locum tenens) was used, enter that provider's information here. Information in Loop ID-2310 applies to the entire claim unless overridden on a service line by the presence of Loop ID-2420 with the same value in NM101. Example NM1822XXXXXXXXXXXXX*XXXXXXX*XX~ If either Identification Code Qualifier (NM1-08) or Rendering Provider Identifier (NM1-09) is present, then the other is required Max use 1 Required NM1-01 98 Entity Identifier Code Identifier (ID) Required Code identifying an organizational entity, a physical location, property or an individual 82 Rendering Provider NM1-02 1065 Entity Type Qualifier Identifier (ID) Required Code qualifying the type of entity NM102 qualifies NM103. 1 Person 2 Non-Person Entity NM1-03 1035 Rendering Provider Last or Organization Name String (AN) Required Min 1 Max 60 1/30/25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 465/665 Individual last name or organizational name NM1-04 1036 Rendering Provider First Name Min 1 Max 35 String (AN) Optional Individual first name NM1-05 1037 Rendering Provider Middle Name or Initial Min 1 Max 25 String (AN) Optional Individual middle name or initial NM1-07 1039	Home State Health 837 Health Care Claim_ Professional.pdf
Identifier (NPI) implementation date when an identification number other than the NPI is necessary for the receiver to identify the provider. OR Required on or after the mandated NPI Implementation Date when NM109 in this loop is not used and an identification number other than the NPI is necessary for the receiver to identify the provider. If not required by this implementation guide, do not send. Example REFG2XX~ Max use 3 Optional REF-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification 0B State License Number 1G Provider UPIN Number UPINs must be formatted as either X99999 or XXX999. G2 Provider Commercial Number This code designates a proprietary provider number for the destination payer identified in the Payer Name loop, Loop ID-2010BB, associated with this claim. This is to be used by all payers including: Medicare, Medicaid, Blue Cross, etc. REF-02 127 Referring Provider Secondary Identifier Min 1 Max 50 String (AN) Required Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier 1/30/25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 464/665 2310B Rendering Provider Name Loop Max 1 Optional Variants (all may be used) Referring Provider Name Loop Service Facility Location Name Loop Supervising Provider Name Loop Ambulance Pick-up Location Loop Ambulance Drop-off Location Loop NM1 2500 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > Rendering Provider Name Loop > NM1 Rendering Provider Name To supply the full name of an individual or organizational entity Usage notes Required when the Rendering Provider information is different than that carried in Loop ID-2010AA - Billing Provider. If not required by this implementation guide, do not send. Used for all types of rendering providers including laboratories. The Rendering Provider is the person or company (laboratory or other facility) who rendered the care. In the case where a substitute provider (locum tenens) was used, enter that provider's information here. Information in Loop ID-2310 applies to the entire claim unless overridden on a service line by the presence of Loop ID-2420 with the same value in NM101. Example NM1822XXXXXXXXXXXXXXXXXXXXXX~ If either Identification Code Qualifier (NM1-08) or Rendering Provider Identifier (NM1-09) is present, then the other is required Max use 1 Required NM1-01 98 Entity Identifier Code Identifier (ID) Required Code identifying an organizational entity, a physical location, property or an individual 82 Rendering Provider NM1-02 1065 Entity Type Qualifier Identifier (ID) Required Code qualifying the type of entity NM102 qualifies NM103. 1 Person 2 Non-Person Entity NM1-03 1035 Rendering Provider Last or Organization Name String (AN) Required Min 1 Max 60 1/30/25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 465/665 Individual last name or organizational name NM1-04 1036 Rendering Provider First Name Min 1 Max 35 String (AN) Optional Individual first name NM1-05 1037 Rendering Provider Middle Name or Initial Min 1 Max 25 String (AN) Optional Individual middle name or initial NM1-07 1039 Rendering Provider Name Suffix Min 1 Max 10 String (AN) Optional Suffix to individual name NM1-08 66 Identification Code Qualifier Identifier (ID) Optional Code designating the system/method of code structure used for Identification Code (67) XX Centers for Medicare and Medicaid Services National Provider Identifier NM1-09 67 Rendering Provider Identifier Min 2 Max 80 String (AN) Optional Code identifying a party or other code 1/30/25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 466/665 PRV 2550 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > Rendering Provider Name Loop > PRV Rendering Provider Specialty Information To specify the identifying characteristics of a provider Usage notes Required when adjudication is known to be impacted by the provider taxonomy code. If not required by this implementation guide, do not send. The PRV segment in Loop ID-2310 applies to the entire claim unless overridden on the service line level by the presence of a PRV segment with the same value in PRV01. Example PRVPEPXCXXX~ Max use 1 Optional PRV-01 1221 Provider Code Identifier (ID) Required Code identifying the type of provider PE Performing PRV-02 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification PXC Health Care Provider Taxonomy Code PRV-03 127 Provider Taxonomy Code Min 1 Max 50 String (AN) Required Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier 1/30/25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 467/665 2310B Rendering Provider Name Loop end REF 2710 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > Rendering Provider Name Loop > REF Rendering Provider Secondary Identification To specify identifying information Usage notes The REF segment in Loop ID-2310 applies to the entire claim unless overridden on the service line level by the presence of a REF segment with the same value in REF01. Required prior to the mandated HIPAA National Provider Identifier (NPI) implementation date when an identification number other than the NPI is necessary for the receiver to identify the provider. OR Required on or after the mandated NPI Implementation Date when NM109 in this loop is not used and an identification number other than the NPI is necessary for the receiver to identify the provider. If not required by this implementation guide, do not send. Example REF1GXXX~ Max use 4 Optional REF-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification 0B State License Number 1G Provider UPIN Number UPINs must be formatted as either X99999 or XXX999. G2 Provider Commercial Number This code designates a proprietary provider number for the destination payer identified in the Payer Name loop, Loop ID-2010BB, associated with this claim. This is to be used by all payers including: Medicare, Medicaid, Blue Cross, etc. LU Location Number REF-02 127 Rendering Provider Secondary Identifier Min 1 Max 50 String (AN) Required Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier 1/30/25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 468/665 2310C Service Facility Location Name Loop Max 1 Optional Variants (all may be used) Referring Provider Name Loop Rendering Provider Name Loop Supervising Provider Name Loop Ambulance Pick-up Location Loop Ambulance Drop-off Location Loop NM1 2500 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > Service Facility Location Name Loop > NM1 Service Facility Location Name To supply the full name of an individual or organizational entity Usage notes Required when the location of health care service is different than that carried in Loop ID-2010AA (Billing Provider). If not required by this implementation guide, do not send. When an organization health care provider's NPI is provided to identify the Service Location, the organization health care provider must be external to the entity identified as the Billing Provider (for example, reference lab). It is not permissible to report an organization health care provider NPI as the Service Location if the entity being identified is a component (for example, subpart) of the Billing Provider. In that case, the subpart must be the Billing Provider. The purpose of this loop is to identify specifically where the service was rendered. When reporting ambulance services, do not use this loop. Use Loop ID-2310E - Ambulance Pick-up Location and Loop ID-2310F - Ambulance Drop-off Location. Information in Loop ID-2310 applies to the entire claim unless overridden on a service line by the presence of Loop ID-2420 with the same value in NM101. Example NM1772XXXX***XXXXXXX~ If either Identification Code Qualifier (NM1-08) or Laboratory or Facility Primary Identifier (NM1-09) is present, then the other is required Max use 1 Required NM1-01 98 Entity Identifier Code Identifier (ID) Required Code identifying an organizational entity, a physical location, property or an individual 77 Service Location NM1-02 1065 Entity Type Qualifier Identifier (ID) Required Code qualifying the type of entity NM102 qualifies NM103. 2 Non-Person Entity 1/30/25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 469/665 NM1-03 1035 Laboratory or Facility Name Min 1 Max 60 String (AN) Required Individual last name or organizational name NM1-08 66 Identification Code Qualifier Identifier (ID) Optional Code designating the system/method of code structure used for Identification Code (67) XX Centers for Medicare and Medicaid Services National Provider Identifier NM1-09 67 Laboratory or Facility Primary Identifier Min 2 Max 80 String (AN) Optional Code identifying a party or other code 1/30/25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 470/665 N3 2650 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > Service Facility Location Name Loop > N3 Service Facility Location Address To specify the location of the named party Usage notes If service facility location is in an area where there are no street addresses, enter a description of where the service was rendered (for example, "crossroad of State Road 34 and 45" or "Exit near Mile marker 265 on Interstate 80".) Example N3XXXXXXXXXXXX~ Max use 1 Required N3-01 166 Laboratory or Facility Address Line Min 1 Max 55 String (AN) Required Address information N3-02 166 Laboratory or Facility Address Line Min 1 Max 55 String (AN) Optional Address information 1/30/25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 471/665 N4 2700 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > Service Facility Location Name Loop > N4 Service Facility Location City, State, ZIP Code To specify the geographic place of the named party Example N4XXXXXXXXXXXXXXX~ Only one of Laboratory or Facility State or Province Code (N4-02) or Country Subdivision Code (N4-07) may be present If Country Subdivision Code (N4-07) is present, then Country Code (N4-04) is required Max use 1 Required N4-01 19 Laboratory or Facility City Name Min 2 Max 30 String (AN) Required Free-form text for city name A combination of either N401 through N404, or N405 and N406 may be adequate to specify a location. N4-02 156 Laboratory or Facility State or Province Code Identifier (ID) Optional Min 2 Max 2 Code (Standard State/Province) as defined by appropriate government agency N402 is required only if city name (N401) is in the U.S. or Canada. N4-03 116 Laboratory or Facility Postal Zone or ZIP Code Identifier (ID) Optional Min 3 Max 15 Code defining international postal zone code excluding punctuation and blanks (zip code for United States) Usage notes When reporting the ZIP code for U.S. addresses, the full nine digit ZIP code must be provided. N4-04 26 Country Code Min 2 Max 3 Identifier (ID) Optional Code identifying the country Usage notes Use the alpha-2 country codes from Part 1 of ISO 3166. N4-07 1715 Country Subdivision Code Min 1 Max 3 Identifier (ID) Optional Code identifying the country subdivision Usage notes 1/30/25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 472/665 Use the country subdivision codes from Part 2 of ISO 3166. 1/30/25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 473/665 REF 2710 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > Service Facility Location Name Loop > REF Service Facility Location Secondary Identification To specify identifying information Usage notes Required prior to the mandated HIPAA National Provider Identifier (NPI) implementation date when an identification number other than the NPI is necessary for the receiver to identify the provider. OR Required on or after the mandated NPI Implementation Date when NM109 in this loop is not used and an identification number other than the NPI is necessary for the receiver to identify the provider. If not required by this implementation guide, do not send. Example REF0BX~	Home State Health 837 Health Care Claim_ Professional.pdf
there are no street addresses, enter a description of where the service was rendered (for example, "crossroad of State Road 34 and 45" or "Exit near Mile marker 265 on Interstate 80".) Example N3XXXXXXXXXXXX~ Max use 1 Required N3-01 166 Laboratory or Facility Address Line Min 1 Max 55 String (AN) Required Address information N3-02 166 Laboratory or Facility Address Line Min 1 Max 55 String (AN) Optional Address information 1/30/25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 471/665 N4 2700 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > Service Facility Location Name Loop > N4 Service Facility Location City, State, ZIP Code To specify the geographic place of the named party Example N4XXXXXXXXXXXXXXX~ Only one of Laboratory or Facility State or Province Code (N4-02) or Country Subdivision Code (N4-07) may be present If Country Subdivision Code (N4-07) is present, then Country Code (N4-04) is required Max use 1 Required N4-01 19 Laboratory or Facility City Name Min 2 Max 30 String (AN) Required Free-form text for city name A combination of either N401 through N404, or N405 and N406 may be adequate to specify a location. N4-02 156 Laboratory or Facility State or Province Code Identifier (ID) Optional Min 2 Max 2 Code (Standard State/Province) as defined by appropriate government agency N402 is required only if city name (N401) is in the U.S. or Canada. N4-03 116 Laboratory or Facility Postal Zone or ZIP Code Identifier (ID) Optional Min 3 Max 15 Code defining international postal zone code excluding punctuation and blanks (zip code for United States) Usage notes When reporting the ZIP code for U.S. addresses, the full nine digit ZIP code must be provided. N4-04 26 Country Code Min 2 Max 3 Identifier (ID) Optional Code identifying the country Usage notes Use the alpha-2 country codes from Part 1 of ISO 3166. N4-07 1715 Country Subdivision Code Min 1 Max 3 Identifier (ID) Optional Code identifying the country subdivision Usage notes 1/30/25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 472/665 Use the country subdivision codes from Part 2 of ISO 3166. 1/30/25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 473/665 REF 2710 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > Service Facility Location Name Loop > REF Service Facility Location Secondary Identification To specify identifying information Usage notes Required prior to the mandated HIPAA National Provider Identifier (NPI) implementation date when an identification number other than the NPI is necessary for the receiver to identify the provider. OR Required on or after the mandated NPI Implementation Date when NM109 in this loop is not used and an identification number other than the NPI is necessary for the receiver to identify the provider. If not required by this implementation guide, do not send. Example REF0BX~ Max use 3 Optional REF-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification 0B State License Number G2 Provider Commercial Number This code designates a proprietary provider number for the destination payer identified in the Payer Name loop, Loop ID-2010BB, associated with this claim. This is to be used by all payers including: Medicare, Medicaid, Blue Cross, etc. LU Location Number REF-02 127 Laboratory or Facility Secondary Identifier Min 1 Max 50 String (AN) Required Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier 1/30/25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 474/665 PER 2750 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > Service Facility Location Name Loop > PER Service Facility Contact Information To identify a person or office to whom administrative communications should be directed Usage notes Required for Property and Casualty claims when this information is different than the information provided in Loop ID-1000A Submitter EDI Contact Information PER Segment, and Loop ID-2010AA Billing Provider Contact Information PER segment and when deemed necessary by the submitter. If not required by this implementation guide, do not send. When the communication number represents a telephone number in the United States and other countries using the North American Dialing Plan (for voice, data, fax, etc.), the communication number must always include the area code and phone number using the format AAABBBCCCC where AAA is the area code, BBB is the telephone number prefix, and CCCC is the telephone number. Therefore, the following telephone number (555) 555-1234 would be represented as 5555551234. Do not submit long distance access numbers, such as "1", in the telephone number. Telephone extensions, when applicable, must be submitted in the next element immediately following the telephone number. When submitting telephone extensions, only submit the numeric extension. Do not include data that indicates an extension, such as "ext" or "x-". Example PERICXXTEXXEXXXXXXX~ If either Communication Number Qualifier (PER-05) or Communication Number (PER-06) is present, then the other is required Max use 1 Optional PER-01 366 Contact Function Code Identifier (ID) Required Code identifying the major duty or responsibility of the person or group named IC Information Contact PER-02 93 Name Min 1 Max 60 String (AN) Optional Free-form name PER-03 365 Communication Number Qualifier Identifier (ID) Required Code identifying the type of communication number TE Telephone PER-04 364 Communication Number Min 1 Max 256 String (AN) Required Complete communications number including country or area code when applicable 1/30/25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 475/665 2310C Service Facility Location Name Loop end PER-05 365 Communication Number Qualifier Identifier (ID) Optional Code identifying the type of communication number EX Telephone Extension PER-06 364 Communication Number Min 1 Max 256 String (AN) Optional Complete communications number including country or area code when applicable 1/30/25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 476/665 2310D Supervising Provider Name Loop Max 1 Optional Variants (all may be used) Referring Provider Name Loop Rendering Provider Name Loop Service Facility Location Name Loop Ambulance Pick-up Location Loop Ambulance Drop-off Location Loop NM1 2500 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > Supervising Provider Name Loop > NM1 Supervising Provider Name To supply the full name of an individual or organizational entity Usage notes Required when the rendering provider is supervised by a physician. If not required by this implementation guide, do not send. Information in Loop ID-2310 applies to the entire claim unless overridden on a service line by the presence of Loop ID-2420 with the same value in NM101. Example NM1DQ1XXXXXXXXXXXXXXXXXXXXXXXXXXX~ If either Identification Code Qualifier (NM1-08) or Supervising Provider Identifier (NM1-09) is present, then the other is required Max use 1 Required NM1-01 98 Entity Identifier Code Identifier (ID) Required Code identifying an organizational entity, a physical location, property or an individual DQ Supervising Physician NM1-02 1065 Entity Type Qualifier Identifier (ID) Required Code qualifying the type of entity NM102 qualifies NM103. 1 Person NM1-03 1035 Supervising Provider Last Name Min 1 Max 60 String (AN) Required Individual last name or organizational name NM1-04 1036 Supervising Provider First Name Min 1 Max 35 String (AN) Optional 1/30/25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 477/665 Individual first name NM1-05 1037 Supervising Provider Middle Name or Initial String (AN) Optional Min 1 Max 25 Individual middle name or initial NM1-07 1039 Supervising Provider Name Suffix Min 1 Max 10 String (AN) Optional Suffix to individual name NM1-08 66 Identification Code Qualifier Identifier (ID) Optional Code designating the system/method of code structure used for Identification Code (67) XX Centers for Medicare and Medicaid Services National Provider Identifier NM1-09 67 Supervising Provider Identifier Min 2 Max 80 String (AN) Optional Code identifying a party or other code 1/30/25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 478/665 2310D Supervising Provider Name Loop end REF 2710 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > Supervising Provider Name Loop > REF Supervising Provider Secondary Identification To specify identifying information Usage notes Required prior to the mandated HIPAA National Provider Identifier (NPI) implementation date when an identification number other than the NPI is necessary for the receiver to identify the provider. OR Required on or after the mandated NPI implementation date when the entity is not a Health Care provider (a.k.a. an atypical provider), and an identifier is necessary for the claims processor to identify the entity. If not required by this implementation guide, do not send. Example REF1GXXXXXX~ Max use 4 Optional REF-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification 0B State License Number 1G Provider UPIN Number UPINs must be formatted as either X99999 or XXX999. G2 Provider Commercial Number This code designates a proprietary provider number for the destination payer identified in the Payer Name loop, Loop ID-2010BB, associated with this claim. This is to be used by all payers including: Medicare, Medicaid, Blue Cross, etc. LU Location Number REF-02 127 Supervising Provider Secondary Identifier Min 1 Max 50 String (AN) Required Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier 1/30/25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 479/665 2310E Ambulance Pick-up Location Loop Max 1 Optional Variants (all may be used) Referring Provider Name Loop Rendering Provider Name Loop Service Facility Location Name Loop Supervising Provider Name Loop Ambulance Drop-off Location Loop NM1 2500 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > Ambulance Pick-up Location Loop > NM1 Ambulance Pick-up Location To supply the full name of an individual or organizational entity Usage notes Required when billing for ambulance or non-emergency transportation services. If not required by this implementation guide, do not send. Information in Loop ID-2310 applies to the entire claim unless overridden on a service line by the presence of Loop ID-2420 with the same value in NM101. Example NM1PW2~ Max use 1 Required NM1-01 98 Entity Identifier Code Identifier (ID) Required Code identifying an organizational entity, a physical location, property or an individual PW Pickup Address NM1-02 1065 Entity Type Qualifier Identifier (ID) Required Code qualifying the type of entity NM102 qualifies NM103. 2 Non-Person Entity 1/30/25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 480/665 N3 2650 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > Ambulance Pick-up Location Loop > N3 Ambulance Pick-up Location Address To specify the location of the named party Usage notes If the ambulance pickup location is in an area where there are no street addresses, enter a description of where the service was rendered (for example, "crossroad of State Road 34 and 45" or "Exit near Mile marker 265 on Interstate 80".) Example N3XXXXXXXXXX~ Max use 1 Required N3-01 166 Ambulance Pick-up Address Line Min 1 Max 55 String (AN) Required Address information N3-02 166 Ambulance Pick-up Address Line Min 1 Max 55 String (AN) Optional Address information 1/30/25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 481/665 N4 2700 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > Ambulance Pick-up Location Loop > N4 Ambulance Pick-up Location City, State, ZIP Code To specify the geographic place of the named party Example N4XXXXXXXXXX*XXX~ Only one of Ambulance Pick-up State or Province Code (N4-02) or Country Subdivision Code (N4-07) may be present If Country Subdivision Code (N4-07) is present, then Country Code (N4-04) is required Max use 1 Required N4-01 19 Ambulance Pick-up	Home State Health 837 Health Care Claim_ Professional.pdf
G2 Provider Commercial Number This code designates a proprietary provider number for the destination payer identified in the Payer Name loop, Loop ID-2010BB, associated with this claim. This is to be used by all payers including: Medicare, Medicaid, Blue Cross, etc. LU Location Number REF-02 127 Supervising Provider Secondary Identifier Min 1 Max 50 String (AN) Required Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier 1/30/25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 479/665 2310E Ambulance Pick-up Location Loop Max 1 Optional Variants (all may be used) Referring Provider Name Loop Rendering Provider Name Loop Service Facility Location Name Loop Supervising Provider Name Loop Ambulance Drop-off Location Loop NM1 2500 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > Ambulance Pick-up Location Loop > NM1 Ambulance Pick-up Location To supply the full name of an individual or organizational entity Usage notes Required when billing for ambulance or non-emergency transportation services. If not required by this implementation guide, do not send. Information in Loop ID-2310 applies to the entire claim unless overridden on a service line by the presence of Loop ID-2420 with the same value in NM101. Example NM1PW2~ Max use 1 Required NM1-01 98 Entity Identifier Code Identifier (ID) Required Code identifying an organizational entity, a physical location, property or an individual PW Pickup Address NM1-02 1065 Entity Type Qualifier Identifier (ID) Required Code qualifying the type of entity NM102 qualifies NM103. 2 Non-Person Entity 1/30/25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 480/665 N3 2650 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > Ambulance Pick-up Location Loop > N3 Ambulance Pick-up Location Address To specify the location of the named party Usage notes If the ambulance pickup location is in an area where there are no street addresses, enter a description of where the service was rendered (for example, "crossroad of State Road 34 and 45" or "Exit near Mile marker 265 on Interstate 80".) Example N3XXXXXXXXXX~ Max use 1 Required N3-01 166 Ambulance Pick-up Address Line Min 1 Max 55 String (AN) Required Address information N3-02 166 Ambulance Pick-up Address Line Min 1 Max 55 String (AN) Optional Address information 1/30/25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 481/665 N4 2700 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > Ambulance Pick-up Location Loop > N4 Ambulance Pick-up Location City, State, ZIP Code To specify the geographic place of the named party Example N4XXXXXXXXXXXXX~ Only one of Ambulance Pick-up State or Province Code (N4-02) or Country Subdivision Code (N4-07) may be present If Country Subdivision Code (N4-07) is present, then Country Code (N4-04) is required Max use 1 Required N4-01 19 Ambulance Pick-up City Name Min 2 Max 30 String (AN) Required Free-form text for city name A combination of either N401 through N404, or N405 and N406 may be adequate to specify a location. N4-02 156 Ambulance Pick-up State or Province Code Identifier (ID) Optional Min 2 Max 2 Code (Standard State/Province) as defined by appropriate government agency N402 is required only if city name (N401) is in the U.S. or Canada. N4-03 116 Ambulance Pick-up Postal Zone or ZIP Code Identifier (ID) Optional Min 3 Max 15 Code defining international postal zone code excluding punctuation and blanks (zip code for United States) N4-04 26 Country Code Min 2 Max 3 Identifier (ID) Optional Code identifying the country Usage notes Use the alpha-2 country codes from Part 1 of ISO 3166. N4-07 1715 Country Subdivision Code Min 1 Max 3 Identifier (ID) Optional Code identifying the country subdivision Usage notes 1/30/25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 482/665 2310E Ambulance Pick-up Location Loop end Use the country subdivision codes from Part 2 of ISO 3166. 1/30/25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 483/665 2310F Ambulance Drop-off Location Loop Max 1 Optional Variants (all may be used) Referring Provider Name Loop Rendering Provider Name Loop Service Facility Location Name Loop Supervising Provider Name Loop Ambulance Pick-up Location Loop NM1 2500 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > Ambulance Drop-off Location Loop > NM1 Ambulance Drop-off Location To supply the full name of an individual or organizational entity Usage notes Required when billing for ambulance or non-emergency transportation services. If not required by this implementation guide, do not send. Information in Loop ID-2310 applies to the entire claim unless overridden on a service line by the presence of Loop ID-2420 with the same value in NM101. Example NM1452X~ Max use 1 Required NM1-01 98 Entity Identifier Code Identifier (ID) Required Code identifying an organizational entity, a physical location, property or an individual 45 Drop-off Location NM1-02 1065 Entity Type Qualifier Identifier (ID) Required Code qualifying the type of entity NM102 qualifies NM103. 2 Non-Person Entity NM1-03 1035 Ambulance Drop-off Location Min 1 Max 60 String (AN) Optional Individual last name or organizational name 1/30/25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 484/665 N3 2650 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > Ambulance Drop-off Location Loop > N3 Ambulance Drop-off Location Address To specify the location of the named party Example N3XXXXXXXX~ Max use 1 Required N3-01 166 Ambulance Drop-off Address Line Min 1 Max 55 String (AN) Required Address information N3-02 166 Ambulance Drop-off Address Line Min 1 Max 55 String (AN) Optional Address information 1/30/25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 485/665 N4 2700 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > Ambulance Drop-off Location Loop > N4 Ambulance Drop-off Location City, State, ZIP Code To specify the geographic place of the named party Example N4XXXXXXXXXXXXXXXX~ Only one of Ambulance Drop-off State or Province Code (N4-02) or Country Subdivision Code (N4-07) may be present If Country Subdivision Code (N4-07) is present, then Country Code (N4-04) is required Max use 1 Required N4-01 19 Ambulance Drop-off City Name Min 2 Max 30 String (AN) Required Free-form text for city name A combination of either N401 through N404, or N405 and N406 may be adequate to specify a location. N4-02 156 Ambulance Drop-off State or Province Code Identifier (ID) Optional Min 2 Max 2 Code (Standard State/Province) as defined by appropriate government agency N402 is required only if city name (N401) is in the U.S. or Canada. N4-03 116 Ambulance Drop-off Postal Zone or ZIP Code Identifier (ID) Optional Min 3 Max 15 Code defining international postal zone code excluding punctuation and blanks (zip code for United States) N4-04 26 Country Code Min 2 Max 3 Identifier (ID) Optional Code identifying the country Usage notes Use the alpha-2 country codes from Part 1 of ISO 3166. N4-07 1715 Country Subdivision Code Min 1 Max 3 Identifier (ID) Optional Code identifying the country subdivision Usage notes 1/30/25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 486/665 2310F Ambulance Drop-off Location Loop end Use the country subdivision codes from Part 2 of ISO 3166. 1/30/25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 487/665 2320 Other Subscriber Information Loop Max 10 Optional SBR 2900 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > Other Subscriber Information Loop > SBR Other Subscriber Information To record information specific to the primary insured and the insurance carrier for that insured Usage notes Required when other payers are known to potentially be involved in paying on this claim. If not required by this implementation guide, do not send. All information contained in Loop ID-2320 applies only to the payer identified in Loop ID-2330B of this iteration of Loop ID-2320. It is specific only to that payer. If information for an additional payer is necessary, repeat Loop ID-2320 with its respective 2330 Loops.; See Crosswalking COB Data Elements section for more information on handling COB in the 837. Example SBRC01XXXXXXXX42****MC~ Max use 1 Required SBR-01 1138 Payer Responsibility Sequence Number Code Identifier (ID) Required Code identifying the insurance carrier's level of responsibility for a payment of a claim Usage notes Within a given claim, the various values for the Payer Responsibility Sequence Number Code (other than value "U") may occur no more than once. A Payer Responsibility Four B Payer Responsibility Five C Payer Responsibility Six D Payer Responsibility Seven E Payer Responsibility Eight F Payer Responsibility Nine G Payer Responsibility Ten H Payer Responsibility Eleven P Primary S Secondary T Tertiary U Unknown This code may only be used in payer to payer COB claims when the original payer determined the presence of this coverage from eligibility files received from this payer or when the original claim did not provide the responsibility sequence for this payer. SBR-02 1069 Individual Relationship Code Identifier (ID) Required Code indicating the relationship between two individuals or entities SBR02 specifies the relationship to the person insured. 1/30/25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 488/665 01 Spouse 18 Self 19 Child 20 Employee 21 Unknown 39 Organ Donor 40 Cadaver Donor 53 Life Partner G8 Other Relationship SBR-03 127 Insured Group or Policy Number Min 1 Max 50 String (AN) Optional Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier SBR03 is policy or group number. Usage notes This is not the number uniquely identifying the subscriber. The unique subscriber number is submitted in Loop 2330A-NM109 for this iteration of Loop ID-2320. SBR-04 93 Other Insured Group Name Min 1 Max 60 String (AN) Optional Free-form name SBR04 is plan name. SBR-05 1336 Insurance Type Code Identifier (ID) Optional Code identifying the type of insurance policy within a specific insurance program 12 Medicare Secondary Working Aged Beneficiary or Spouse with Employer Group Health Plan 13 Medicare Secondary End-Stage Renal Disease Beneficiary in the Mandated Coordination Period with an Employer's Group Health Plan 14 Medicare Secondary, No-fault Insurance including Auto is Primary 15 Medicare Secondary Worker's Compensation 16 Medicare Secondary Public Health Service (PHS)or Other Federal Agency 41 Medicare Secondary Black Lung 42 Medicare Secondary Veteran's Administration 43 Medicare Secondary Disabled Beneficiary Under Age 65 with Large Group Health Plan (LGHP) 47 Medicare Secondary, Other Liability Insurance is Primary SBR-09 1032 Claim Filing Indicator Code Identifier (ID) Required Code identifying type of claim 11 Other Non-Federal Programs 12 Preferred Provider Organization (PPO) 13 Point of Service (POS) 14 Exclusive Provider Organization (EPO) 15 Indemnity Insurance 1/30/25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 489/665 16 Health Maintenance Organization (HMO) Medicare Risk 17 Dental Maintenance Organization AM Automobile Medical BL Blue Cross/Blue Shield CH Champus CI Commercial Insurance Co. DS Disability FI Federal Employees Program HM Health Maintenance Organization LM Liability Medical MA Medicare Part A MB Medicare Part B MC Medicaid OF Other Federal Program Use code OF when submitting Medicare Part D claims. TV Title V VA Veterans Affairs Plan WC Workers' Compensation Health Claim ZZ Mutually Defined Use Code ZZ when Type of Insurance is not known. 1/30/25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 490/665 CAS 2950 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > Other Subscriber Information Loop > CAS Claim Level Adjustments To supply adjustment reason codes and amounts as needed for an entire claim or for	Home State Health 837 Health Care Claim_ Professional.pdf
Responsibility Eleven P Primary S Secondary T Tertiary U Unknown This code may only be used in payer to payer COB claims when the original payer determined the presence of this coverage from eligibility files received from this payer or when the original claim did not provide the responsibility sequence for this payer. SBR-02 1069 Individual Relationship Code Identifier (ID) Required Code indicating the relationship between two individuals or entities SBR02 specifies the relationship to the person insured. 1/30/25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 488/665 01 Spouse 18 Self 19 Child 20 Employee 21 Unknown 39 Organ Donor 40 Cadaver Donor 53 Life Partner G8 Other Relationship SBR-03 127 Insured Group or Policy Number Min 1 Max 50 String (AN) Optional Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier SBR03 is policy or group number. Usage notes This is not the number uniquely identifying the subscriber. The unique subscriber number is submitted in Loop 2330A-NM109 for this iteration of Loop ID-2320. SBR-04 93 Other Insured Group Name Min 1 Max 60 String (AN) Optional Free-form name SBR04 is plan name. SBR-05 1336 Insurance Type Code Identifier (ID) Optional Code identifying the type of insurance policy within a specific insurance program 12 Medicare Secondary Working Aged Beneficiary or Spouse with Employer Group Health Plan 13 Medicare Secondary End-Stage Renal Disease Beneficiary in the Mandated Coordination Period with an Employer's Group Health Plan 14 Medicare Secondary, No-fault Insurance including Auto is Primary 15 Medicare Secondary Worker's Compensation 16 Medicare Secondary Public Health Service (PHS)or Other Federal Agency 41 Medicare Secondary Black Lung 42 Medicare Secondary Veteran's Administration 43 Medicare Secondary Disabled Beneficiary Under Age 65 with Large Group Health Plan (LGHP) 47 Medicare Secondary, Other Liability Insurance is Primary SBR-09 1032 Claim Filing Indicator Code Identifier (ID) Required Code identifying type of claim 11 Other Non-Federal Programs 12 Preferred Provider Organization (PPO) 13 Point of Service (POS) 14 Exclusive Provider Organization (EPO) 15 Indemnity Insurance 1/30/25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 489/665 16 Health Maintenance Organization (HMO) Medicare Risk 17 Dental Maintenance Organization AM Automobile Medical BL Blue Cross/Blue Shield CH Champus CI Commercial Insurance Co. DS Disability FI Federal Employees Program HM Health Maintenance Organization LM Liability Medical MA Medicare Part A MB Medicare Part B MC Medicaid OF Other Federal Program Use code OF when submitting Medicare Part D claims. TV Title V VA Veterans Affairs Plan WC Workers' Compensation Health Claim ZZ Mutually Defined Use Code ZZ when Type of Insurance is not known. 1/30/25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 490/665 CAS 2950 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > Other Subscriber Information Loop > CAS Claim Level Adjustments To supply adjustment reason codes and amounts as needed for an entire claim or for a particular service within the claim being paid Usage notes Required when the claim has been adjudicated by the payer identified in this loop, and the claim has claim level adjustment information. If not required by this implementation guide, do not send. Submitters must use this CAS segment to report prior payers' claim level adjustments that cause the amount paid to differ from the amount originally charged. Only one Group Code is allowed per CAS. If it is necessary to send more than one Group Code at the claim level, repeat the CAS segment. Codes and associated amounts must come from either paper remittance advice or 835s (Electronic Remittance Advice) received on the claim. When the information originates from a paper remittance advice that does not use the standard Claim Adjustment Reason Codes, the paper values must be converted to standard Claim Adjustment Reason Codes.; A single CAS segment contains six repetitions of the "adjustment trio" composed of adjustment reason code, adjustment amount, and adjustment quantity. These six adjustment trios are used to report up to six adjustments related to a particular Claim Adjustment Group Code (CAS01). The first non-zero adjustment is reported in the first adjustment trio (CAS02-CAS04). If there is a second non-zero adjustment, it is reported in the second adjustment trio (CAS05-CAS07), and so on through the sixth adjustment trio (CAS17-CAS19). Example CASPIX00000000000000000XX00000000000000 00XXXX0000000000XXXXX0000000XXX000000000 000000000XXXXX0000000000000000000~ If Adjustment Reason Code (CAS-05) is present, then at least one of Adjustment Amount (CAS-06) or Adjustment Quantity (CAS-07) is required If Adjustment Amount (CAS-06) is present, then Adjustment Reason Code (CAS-05) is required If Adjustment Quantity (CAS-07) is present, then Adjustment Reason Code (CAS-05) is required If Adjustment Reason Code (CAS-08) is present, then at least one of Adjustment Amount (CAS-09) or Adjustment Quantity (CAS-10) is required If Adjustment Amount (CAS-09) is present, then Adjustment Reason Code (CAS-08) is required If Adjustment Quantity (CAS-10) is present, then Adjustment Reason Code (CAS-08) is required If Adjustment Reason Code (CAS-11) is present, then at least one of Adjustment Amount (CAS-12) or Adjustment Quantity (CAS-13) is required If Adjustment Amount (CAS-12) is present, then Adjustment Reason Code (CAS-11) is required If Adjustment Quantity (CAS-13) is present, then Adjustment Reason Code (CAS-11) is required If Adjustment Reason Code (CAS-14) is present, then at least one of Adjustment Amount (CAS-15) or Adjustment Quantity (CAS-16) is required Max use 5 Optional 1/30/25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 491/665 If Adjustment Amount (CAS-15) is present, then Adjustment Reason Code (CAS-14) is required If Adjustment Quantity (CAS-16) is present, then Adjustment Reason Code (CAS-14) is required If Adjustment Reason Code (CAS-17) is present, then at least one of Adjustment Amount (CAS-18) or Adjustment Quantity (CAS-19) is required If Adjustment Amount (CAS-18) is present, then Adjustment Reason Code (CAS-17) is required If Adjustment Quantity (CAS-19) is present, then Adjustment Reason Code (CAS-17) is required CAS-01 1033 Claim Adjustment Group Code Identifier (ID) Required Code identifying the general category of payment adjustment CO Contractual Obligations CR Correction and Reversals OA Other adjustments PI Payor Initiated Reductions PR Patient Responsibility CAS-02 1034 Adjustment Reason Code Min 1 Max 5 Identifier (ID) Required Code identifying the detailed reason the adjustment was made Usage notes See CODE SOURCE 139: Claim Adjustment Reason Code CAS-03 782 Adjustment Amount Min 1 Max 15 Decimal number (R) Required Monetary amount CAS03 is the amount of adjustment. CAS-04 380 Adjustment Quantity Min 1 Max 15 Decimal number (R) Optional Numeric value of quantity CAS04 is the units of service being adjusted. CAS-05 1034 Adjustment Reason Code Min 1 Max 5 Identifier (ID) Optional Code identifying the detailed reason the adjustment was made CAS-06 782 Adjustment Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount 1/30/25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 492/665 CAS06 is the amount of the adjustment. CAS-07 380 Adjustment Quantity Min 1 Max 15 Decimal number (R) Optional Numeric value of quantity CAS07 is the units of service being adjusted. CAS-08 1034 Adjustment Reason Code Min 1 Max 5 Identifier (ID) Optional Code identifying the detailed reason the adjustment was made CAS-09 782 Adjustment Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount CAS09 is the amount of the adjustment. CAS-10 380 Adjustment Quantity Min 1 Max 15 Decimal number (R) Optional Numeric value of quantity CAS10 is the units of service being adjusted. CAS-11 1034 Adjustment Reason Code Min 1 Max 5 Identifier (ID) Optional Code identifying the detailed reason the adjustment was made CAS-12 782 Adjustment Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount CAS12 is the amount of the adjustment. CAS-13 380 Adjustment Quantity Min 1 Max 15 Decimal number (R) Optional Numeric value of quantity CAS13 is the units of service being adjusted. CAS-14 1034 Adjustment Reason Code Min 1 Max 5 Identifier (ID) Optional Code identifying the detailed reason the adjustment was made 1/30/25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 493/665 CAS-15 782 Adjustment Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount CAS15 is the amount of the adjustment. CAS-16 380 Adjustment Quantity Min 1 Max 15 Decimal number (R) Optional Numeric value of quantity CAS16 is the units of service being adjusted. CAS-17 1034 Adjustment Reason Code Min 1 Max 5 Identifier (ID) Optional Code identifying the detailed reason the adjustment was made CAS-18 782 Adjustment Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount CAS18 is the amount of the adjustment. CAS-19 380 Adjustment Quantity Min 1 Max 15 Decimal number (R) Optional Numeric value of quantity CAS19 is the units of service being adjusted. 1/30/25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 494/665 AMT 3000 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > Other Subscriber Information Loop > AMT Coordination of Benefits (COB) Payer Paid Amount To indicate the total monetary amount Usage notes Required when the claim has been adjudicated by the payer identified in Loop ID- 2330B of this loop. OR Required when Loop ID-2010AC is present. In this case, the claim is a post payment recovery claim submitted by a subrogated Medicaid agency. If not required by this implementation guide, do not send.; Example AMTD000000000000~ Variants (all may be used) AMT Coordination of Benefits (COB) Total Non-Covered Amount AMT Remaining Patient Liability Max use 1 Optional AMT-01 522 Amount Qualifier Code Identifier (ID) Required Code to qualify amount D Payor Amount Paid AMT-02 782 Payer Paid Amount Min 1 Max 15 Decimal number (R) Required Monetary amount Usage notes It is acceptable to show "0" as the amount paid. When Loop ID-2010AC is present, this is the amount the Medicaid agency actually paid. 1/30/25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 495/665 AMT 3000 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > Other Subscriber Information Loop > AMT Coordination of Benefits (COB) Total Non-Covered Amount To indicate the total monetary amount Usage notes Required when the destination payer's cost avoidance policy allows providers to bypass claim submission to the otherwise prior payer identified in Loop ID-2330B. If not required by this implementation guide, do not send. When this segment is used, the amount reported in AMT02 must equal the total claim charge amount reported in CLM02. Neither the prior payer paid AMT, nor any CAS segments are used as this claim has not been adjudicated by this payer. Example AMTA8*000000000~ Variants (all may be used) AMT Coordination of Benefits (COB) Payer Paid Amount AMT Remaining Patient Liability Max use 1 Optional AMT-01 522 Amount Qualifier Code Identifier (ID) Required Code to qualify amount A8 Noncovered Charges - Actual AMT-02 782 Non-Covered Charge Amount Min 1 Max 15 Decimal number (R) Required Monetary amount 1/30/25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 496/665 AMT 3000 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > Other Subscriber Information Loop > AMT Remaining Patient Liability To indicate the total monetary amount Usage notes Required when the Other Payer identified in Loop ID-2330B (of this iteration of Loop ID-2320) has adjudicated this claim and provided claim level information only. OR Required when the Other Payer identified in Loop ID-2330B (of this iteration of Loop ID-2320) has adjudicated this claim and the provider received a paper remittance advice and the provider does not have the ability to report line item information. If not required by this implementation guide, do not send. In the judgment of the provider, this is the remaining amount to be paid after adjudication by the Other Payer identified in Loop ID-2330B of this iteration of Loop ID-2320. This segment is only used in provider submitted claims. It is not used in Payer-to-Payer Coordination of Benefits (COB). This segment is not	Home State Health 837 Health Care Claim_ Professional.pdf
when the claim has been adjudicated by the payer identified in Loop ID- 2330B of this loop. OR Required when Loop ID-2010AC is present. In this case, the claim is a post payment recovery claim submitted by a subrogated Medicaid agency. If not required by this implementation guide, do not send.; Example AMTD000000000000~ Variants (all may be used) AMT Coordination of Benefits (COB) Total Non-Covered Amount AMT Remaining Patient Liability Max use 1 Optional AMT-01 522 Amount Qualifier Code Identifier (ID) Required Code to qualify amount D Payor Amount Paid AMT-02 782 Payer Paid Amount Min 1 Max 15 Decimal number (R) Required Monetary amount Usage notes It is acceptable to show "0" as the amount paid. When Loop ID-2010AC is present, this is the amount the Medicaid agency actually paid. 1/30/25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 495/665 AMT 3000 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > Other Subscriber Information Loop > AMT Coordination of Benefits (COB) Total Non-Covered Amount To indicate the total monetary amount Usage notes Required when the destination payer's cost avoidance policy allows providers to bypass claim submission to the otherwise prior payer identified in Loop ID-2330B. If not required by this implementation guide, do not send. When this segment is used, the amount reported in AMT02 must equal the total claim charge amount reported in CLM02. Neither the prior payer paid AMT, nor any CAS segments are used as this claim has not been adjudicated by this payer. Example AMTA8000000000~ Variants (all may be used) AMT Coordination of Benefits (COB) Payer Paid Amount AMT Remaining Patient Liability Max use 1 Optional AMT-01 522 Amount Qualifier Code Identifier (ID) Required Code to qualify amount A8 Noncovered Charges - Actual AMT-02 782 Non-Covered Charge Amount Min 1 Max 15 Decimal number (R) Required Monetary amount 1/30/25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 496/665 AMT 3000 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > Other Subscriber Information Loop > AMT Remaining Patient Liability To indicate the total monetary amount Usage notes Required when the Other Payer identified in Loop ID-2330B (of this iteration of Loop ID-2320) has adjudicated this claim and provided claim level information only. OR Required when the Other Payer identified in Loop ID-2330B (of this iteration of Loop ID-2320) has adjudicated this claim and the provider received a paper remittance advice and the provider does not have the ability to report line item information. If not required by this implementation guide, do not send. In the judgment of the provider, this is the remaining amount to be paid after adjudication by the Other Payer identified in Loop ID-2330B of this iteration of Loop ID-2320. This segment is only used in provider submitted claims. It is not used in Payer-to-Payer Coordination of Benefits (COB). This segment is not used if the line level (Loop ID-2430) Remaining Patient Liability AMT segment is used for this Other Payer. Example AMTEAF000000000000000~ Variants (all may be used) AMT Coordination of Benefits (COB) Payer Paid Amount AMT Coordination of Benefits (COB) Total Non-Covered Amount Max use 1 Optional AMT-01 522 Amount Qualifier Code Identifier (ID) Required Code to qualify amount EAF Amount Owed AMT-02 782 Remaining Patient Liability Min 1 Max 15 Decimal number (R) Required Monetary amount 1/30/25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 497/665 OI 3100 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > Other Subscriber Information Loop > OI Other Insurance Coverage Information To specify information associated with other health insurance coverage Usage notes All information contained in the OI segment applies only to the payer identified in Loop ID-2330B in this iteration of Loop ID-2320. Example OI**WP*Y~ Max use 1 Required OI-03 1073 Benefits Assignment Certification Indicator Identifier (ID) Required Code indicating a Yes or No condition or response OI03 is the assignment of benefits indicator. A "Y" value indicates insured or authorized person authorizes benefits to be assigned to the provider; an "N" value indicates benefits have not been assigned to the provider. Usage notes This is a crosswalk from CLM08 when doing COB. This element answers the question whether or not the insured has authorized the plan to remit payment directly to the provider. N No W Not Applicable Use code `W' when the patient refuses to assign benefits. Y Yes OI-04 1351 Patient Signature Source Code Identifier (ID) Optional Code indicating how the patient or subscriber authorization signatures were obtained and how they are being retained by the provider Usage notes This is a crosswalk from CLM10 when doing COB. P Signature generated by provider because the patient was not physically present for services Signature generated by an entity other than the patient according to State or Federal law. OI-06 1363 Release of Information Code Identifier (ID) Required Code indicating whether the provider has on file a signed statement by the patient authorizing the release of medical data to other organizations Usage notes This is a crosswalk from CLM09 when doing COB. The Release of Information response is limited to the information carried in this claim. I Informed Consent to Release Medical Information for Conditions or Diagnoses Regulated by Federal Statutes 1/30/25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 498/665 Required when the provider has not collected a signature AND state or federal laws do not require a signature be collected. Y Yes, Provider has a Signed Statement Permitting Release of Medical Billing Data Related to a Claim Required when the provider has collected a signature. OR Required when state or federal laws require a signature be collected. 1/30/25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 499/665 MOA 3200 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > Other Subscriber Information Loop > MOA Outpatient Adjudication Information To convey claim-level data related to the adjudication of Medicare claims not related to an inpatient setting Usage notes Required when outpatient adjudication information is reported in the remittance advice OR Required when it is necessary to report remark codes. If not required by this implementation guide, do not send. Example MOA0000000000000000XXXXXXXXXXXXXXXXXX0000 0000000000000~ Max use 1 Optional MOA-01 954 Reimbursement Rate Min 1 Max 10 Decimal number (R) Optional Percentage expressed as a decimal (e.g., 0.0 through 1.0 represents 0% through 100%) MOA01 is the reimbursement rate. MOA-02 782 HCPCS Payable Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount MOA02 is the claim Health Care Financing Administration Common Procedural Coding System (HCPCS) payable amount. MOA-03 127 Claim Payment Remark Code Min 1 Max 50 String (AN) Optional Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier MOA03 is the Claim Payment Remark Code. See Code Source 411. MOA-04 127 Claim Payment Remark Code Min 1 Max 50 String (AN) Optional Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier MOA04 is the Claim Payment Remark Code. See Code Source 411. MOA-05 127 Claim Payment Remark Code Min 1 Max 50 String (AN) Optional Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier 1/30/25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 500/665 MOA05 is the Claim Payment Remark Code. See Code Source 411. MOA-06 127 Claim Payment Remark Code Min 1 Max 50 String (AN) Optional Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier MOA06 is the Claim Payment Remark Code. See Code Source 411. MOA-07 127 Claim Payment Remark Code Min 1 Max 50 String (AN) Optional Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier MOA07 is the Claim Payment Remark Code. See Code Source 411. MOA-08 782 End Stage Renal Disease Payment Amount Decimal number (R) Optional Min 1 Max 15 Monetary amount MOA08 is the End Stage Renal Disease (ESRD) payment amount. MOA-09 782 Non-Payable Professional Component Billed Amount Decimal number (R) Optional Min 1 Max 15 Monetary amount MOA09 is the professional component amount billed but not payable. 1/30/25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 501/665 2330A Other Subscriber Name Loop Max 1 Required Variants (all may be used) Other Payer Name Loop Other Payer Referring Provider Loop Other Payer Rendering Provider Loop Other Payer Service Facility Location Loop Other Payer Supervising Provider Loop Other Payer Billing Provider Loop NM1 3250 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > Other Subscriber Information Loop > Other Subscriber Name Loop > NM1 Other Subscriber Name To supply the full name of an individual or organizational entity Usage notes If the patient can be uniquely identified to the Other Payer indicated in this iteration of Loop ID-2320 by a unique Member Identification Number, then the patient is the subscriber or is considered to be the subscriber and is identified in this Other Subscriber's Name Loop ID-2330A.; If the patient is a dependent of the subscriber for this other coverage and cannot be uniquely identified to the Other Payer indicated in this iteration of Loop ID-2320 by a unique Member Identification Number, then the subscriber for this other coverage is identified in this Other Subscriber's Name Loop ID-2330A. See Crosswalking COB Data Elements section for more information on handling COB in the 837. Example NM1IL2XXXXXXXXXXXXXXXMI*XXXXXX~ Max use 1 Required NM1-01 98 Entity Identifier Code Identifier (ID) Required Code identifying an organizational entity, a physical location, property or an individual IL Insured or Subscriber NM1-02 1065 Entity Type Qualifier Identifier (ID) Required Code qualifying the type of entity NM102 qualifies NM103. 1 Person 2 Non-Person Entity NM1-03 1035 Other Insured Last Name Min 1 Max 60 String (AN) Required 1/30/25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 502/665 Individual last name or organizational name NM1-04 1036 Other Insured First Name Min 1 Max 35 String (AN) Optional Individual first name NM1-05 1037 Other Insured Middle Name Min 1 Max 25 String (AN) Optional Individual middle name or initial NM1-07 1039 Other Insured Name Suffix Min 1 Max 10 String (AN) Optional Suffix to individual name NM1-08 66 Identification Code Qualifier Identifier (ID) Required Code designating the system/method of code structure used for Identification Code (67) II Standard Unique Health Identifier for each Individual in the United States Required if the HIPAA Individual Patient Identifier is mandated use. If not required, use value `MI' instead. MI Member Identification Number The code MI is intended to be the subscriber's identification number as assigned by the payer. (For example, Insured's ID, Subscriber's ID, Health Insurance Claim Number (HIC), etc.) MI is also intended to be used in claims submitted to the Indian Health Service/Contract Health Services (IHS/CHS) Fiscal Intermediary for the purpose of reporting the Tribe Residency Code (Tribe County State). In the event that a Social Security Number (SSN) is also available on an IHS/CHS claim, put the SSN in REF02. When sending the Social Security Number as the Member ID, it must be a string of exactly nine numbers with no separators. For example, sending "111002222" would be valid, while sending "111-00-2222" would be invalid. NM1-09 67 Other Insured Identifier Min 2 Max 80 String (AN) Required Code identifying a party or other code 1/30/25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 503/665 N3 3320 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > Other Subscriber Information Loop > Other Subscriber Name Loop >	Home State Health 837 Health Care Claim_ Professional.pdf
Loop > NM1 Other Subscriber Name To supply the full name of an individual or organizational entity Usage notes If the patient can be uniquely identified to the Other Payer indicated in this iteration of Loop ID-2320 by a unique Member Identification Number, then the patient is the subscriber or is considered to be the subscriber and is identified in this Other Subscriber's Name Loop ID-2330A.; If the patient is a dependent of the subscriber for this other coverage and cannot be uniquely identified to the Other Payer indicated in this iteration of Loop ID-2320 by a unique Member Identification Number, then the subscriber for this other coverage is identified in this Other Subscriber's Name Loop ID-2330A. See Crosswalking COB Data Elements section for more information on handling COB in the 837. Example NM1IL2XXXXXXXXXXXXXXXMIXXXXXX~ Max use 1 Required NM1-01 98 Entity Identifier Code Identifier (ID) Required Code identifying an organizational entity, a physical location, property or an individual IL Insured or Subscriber NM1-02 1065 Entity Type Qualifier Identifier (ID) Required Code qualifying the type of entity NM102 qualifies NM103. 1 Person 2 Non-Person Entity NM1-03 1035 Other Insured Last Name Min 1 Max 60 String (AN) Required 1/30/25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 502/665 Individual last name or organizational name NM1-04 1036 Other Insured First Name Min 1 Max 35 String (AN) Optional Individual first name NM1-05 1037 Other Insured Middle Name Min 1 Max 25 String (AN) Optional Individual middle name or initial NM1-07 1039 Other Insured Name Suffix Min 1 Max 10 String (AN) Optional Suffix to individual name NM1-08 66 Identification Code Qualifier Identifier (ID) Required Code designating the system/method of code structure used for Identification Code (67) II Standard Unique Health Identifier for each Individual in the United States Required if the HIPAA Individual Patient Identifier is mandated use. If not required, use value `MI' instead. MI Member Identification Number The code MI is intended to be the subscriber's identification number as assigned by the payer. (For example, Insured's ID, Subscriber's ID, Health Insurance Claim Number (HIC), etc.) MI is also intended to be used in claims submitted to the Indian Health Service/Contract Health Services (IHS/CHS) Fiscal Intermediary for the purpose of reporting the Tribe Residency Code (Tribe County State). In the event that a Social Security Number (SSN) is also available on an IHS/CHS claim, put the SSN in REF02. When sending the Social Security Number as the Member ID, it must be a string of exactly nine numbers with no separators. For example, sending "111002222" would be valid, while sending "111-00-2222" would be invalid. NM1-09 67 Other Insured Identifier Min 2 Max 80 String (AN) Required Code identifying a party or other code 1/30/25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 503/665 N3 3320 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > Other Subscriber Information Loop > Other Subscriber Name Loop > N3 Other Subscriber Address To specify the location of the named party Usage notes Required when the information is available. If not required by this implementation guide, do not send. Example N3XXXXX~ Max use 1 Optional N3-01 166 Other Subscriber Address Line Min 1 Max 55 String (AN) Required Address information N3-02 166 Other Insured Address Line Min 1 Max 55 String (AN) Optional Address information 1/30/25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 504/665 N4 3400 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > Other Subscriber Information Loop > Other Subscriber Name Loop > N4 Other Subscriber City, State, ZIP Code To specify the geographic place of the named party Usage notes Required when the information is available. If not required by this implementation guide, do not send. Example N4XXXXXXXXXXXXXXXXX~ Only one of Other Subscriber State or Province Code (N4-02) or Country Subdivision Code (N4-07) may be present If Country Subdivision Code (N4-07) is present, then Country Code (N4-04) is required Max use 1 Optional N4-01 19 Other Subscriber City Name Min 2 Max 30 String (AN) Required Free-form text for city name A combination of either N401 through N404, or N405 and N406 may be adequate to specify a location. N4-02 156 Other Subscriber State or Province Code Min 2 Max 2 Identifier (ID) Optional Code (Standard State/Province) as defined by appropriate government agency N402 is required only if city name (N401) is in the U.S. or Canada. N4-03 116 Other Subscriber Postal Zone or ZIP Code Min 3 Max 15 Identifier (ID) Optional Code defining international postal zone code excluding punctuation and blanks (zip code for United States) N4-04 26 Country Code Min 2 Max 3 Identifier (ID) Optional Code identifying the country Usage notes Use the alpha-2 country codes from Part 1 of ISO 3166. N4-07 1715 Country Subdivision Code Min 1 Max 3 Identifier (ID) Optional Code identifying the country subdivision Usage notes Use the country subdivision codes from Part 2 of ISO 3166. 1/30/25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 505/665 1/30/25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 506/665 2330A Other Subscriber Name Loop end REF 3550 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > Other Subscriber Information Loop > Other Subscriber Name Loop > REF Other Subscriber Secondary Identification To specify identifying information Usage notes Required when an additional identification number to that provided in NM109 of this loop is necessary for the claim processor to identify the entity. If not required by this implementation guide, do not send. Example REFSYXX~ Max use 1 Optional REF-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification SY Social Security Number The Social Security Number must be a string of exactly nine numbers with no separators. For example, sending "111002222" would be valid, while sending "111-00-2222" would be invalid. REF-02 127 Other Insured Additional Identifier Min 1 Max 50 String (AN) Required Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier 1/30/25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 507/665 2330B Other Payer Name Loop Max 1 Required Variants (all may be used) Other Subscriber Name Loop Other Payer Referring Provider Loop Other Payer Rendering Provider Loop Other Payer Service Facility Location Loop Other Payer Supervising Provider Loop Other Payer Billing Provider Loop NM1 3250 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > Other Subscriber Information Loop > Other Payer Name Loop > NM1 Other Payer Name To supply the full name of an individual or organizational entity Usage notes See Crosswalking COB Data Elements section for more information on handling COB in the 837. Example NM1PR2X****XVXXXXXX~ Max use 1 Required NM1-01 98 Entity Identifier Code Identifier (ID) Required Code identifying an organizational entity, a physical location, property or an individual PR Payer NM1-02 1065 Entity Type Qualifier Identifier (ID) Required Code qualifying the type of entity NM102 qualifies NM103. 2 Non-Person Entity NM1-03 1035 Other Payer Organization Name Min 1 Max 60 String (AN) Required Individual last name or organizational name NM1-08 66 Identification Code Qualifier Identifier (ID) Required Code designating the system/method of code structure used for Identification Code (67) Usage notes Use code value "PI" when reporting Payor Identification. Use code value "XV" when reporting Health Plan ID (HPID) or Other Entity Identifier 1/30/25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 508/665 (OEID). Prior to the mandated implementation date for Health Plan Identifier, willing trading partners may agree to: Follow a dual use approach in which both the HPID or OEID and the Payor Identification are sent. Send XV qualifier in NM108 with HPID or OEID in NM109 and the Payor Identification, that would have been sent using qualifier PI, in the corresponding REF segment using qualifier 2U (Payer Identification Number). OR Follow an early implementation approach in which the HPID or OEID is sent in NM109. PI Payor Identification XV Centers for Medicare and Medicaid Services PlanID NM1-09 67 Other Payer Primary Identifier Min 2 Max 80 String (AN) Required Code identifying a party or other code Usage notes When sending Line Adjudication Information for this payer, the identifier sent in SVD01 (Payer Identifier) of Loop ID-2430 (Line Adjudication Information) must match this value.; 1/30/25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 509/665 N3 3320 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > Other Subscriber Information Loop > Other Payer Name Loop > N3 Other Payer Address To specify the location of the named party Usage notes Required when the payer address is available and the submitter intends for the claim to be printed on paper at the next EDI location (for example, a clearinghouse). If not required by this implementation guide, do not send. Example N3XXXXXXXX~ Max use 1 Optional N3-01 166 Other Payer Address Line Min 1 Max 55 String (AN) Required Address information N3-02 166 Other Payer Address Line Min 1 Max 55 String (AN) Optional Address information 1/30/25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 510/665 N4 3400 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > Other Subscriber Information Loop > Other Payer Name Loop > N4 Other Payer City, State, ZIP Code To specify the geographic place of the named party Usage notes Required when the payer address is available and the submitter intends for the claim to be printed on paper at the next EDI location (for example, a clearinghouse). If not required by this implementation guide, do not send. Example N4XXXXXXXXXXXXXXX~ Only one of Other Payer State or Province Code (N4-02) or Country Subdivision Code (N4-07) may be present If Country Subdivision Code (N4-07) is present, then Country Code (N4-04) is required Max use 1 Optional N4-01 19 Other Payer City Name Min 2 Max 30 String (AN) Required Free-form text for city name A combination of either N401 through N404, or N405 and N406 may be adequate to specify a location. N4-02 156 Other Payer State or Province Code Min 2 Max 2 Identifier (ID) Optional Code (Standard State/Province) as defined by appropriate government agency N402 is required only if city name (N401) is in the U.S. or Canada. N4-03 116 Other Payer Postal Zone or ZIP Code Min 3 Max 15 Identifier (ID) Optional Code defining international postal zone code excluding punctuation and blanks (zip code for United States) N4-04 26 Country Code Min 2 Max 3 Identifier (ID) Optional Code identifying the country Usage notes Use the alpha-2 country codes from Part 1 of ISO 3166. N4-07 1715 Country Subdivision Code Min 1 Max 3 Identifier (ID) Optional Code identifying the country subdivision Usage notes 1/30/25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 511/665 Use the country subdivision codes from Part 2 of ISO 3166. 1/30/25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 512/665 DTP 3450 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > Other Subscriber Information Loop > Other Payer Name Loop > DTP Claim Check or Remittance Date To specify any or all of a date, a time, or a time period Usage notes Required when the payer identified in this loop has previously adjudicated the claim and Loop ID-2430, Line Check or Remittance Date, is not used. If not required by this implementation guide, do not send.; Example DTP573D8*XXXX~ Max use 1 Optional DTP-01 374 Date	Home State Health 837 Health Care Claim_ Professional.pdf
is available and the submitter intends for the claim to be printed on paper at the next EDI location (for example, a clearinghouse). If not required by this implementation guide, do not send. Example N3XXXXXXXX~ Max use 1 Optional N3-01 166 Other Payer Address Line Min 1 Max 55 String (AN) Required Address information N3-02 166 Other Payer Address Line Min 1 Max 55 String (AN) Optional Address information 1/30/25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 510/665 N4 3400 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > Other Subscriber Information Loop > Other Payer Name Loop > N4 Other Payer City, State, ZIP Code To specify the geographic place of the named party Usage notes Required when the payer address is available and the submitter intends for the claim to be printed on paper at the next EDI location (for example, a clearinghouse). If not required by this implementation guide, do not send. Example N4XXXXXXXXXXXXXXX~ Only one of Other Payer State or Province Code (N4-02) or Country Subdivision Code (N4-07) may be present If Country Subdivision Code (N4-07) is present, then Country Code (N4-04) is required Max use 1 Optional N4-01 19 Other Payer City Name Min 2 Max 30 String (AN) Required Free-form text for city name A combination of either N401 through N404, or N405 and N406 may be adequate to specify a location. N4-02 156 Other Payer State or Province Code Min 2 Max 2 Identifier (ID) Optional Code (Standard State/Province) as defined by appropriate government agency N402 is required only if city name (N401) is in the U.S. or Canada. N4-03 116 Other Payer Postal Zone or ZIP Code Min 3 Max 15 Identifier (ID) Optional Code defining international postal zone code excluding punctuation and blanks (zip code for United States) N4-04 26 Country Code Min 2 Max 3 Identifier (ID) Optional Code identifying the country Usage notes Use the alpha-2 country codes from Part 1 of ISO 3166. N4-07 1715 Country Subdivision Code Min 1 Max 3 Identifier (ID) Optional Code identifying the country subdivision Usage notes 1/30/25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 511/665 Use the country subdivision codes from Part 2 of ISO 3166. 1/30/25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 512/665 DTP 3450 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > Other Subscriber Information Loop > Other Payer Name Loop > DTP Claim Check or Remittance Date To specify any or all of a date, a time, or a time period Usage notes Required when the payer identified in this loop has previously adjudicated the claim and Loop ID-2430, Line Check or Remittance Date, is not used. If not required by this implementation guide, do not send.; Example DTP573D8XXXX~ Max use 1 Optional DTP-01 374 Date Time Qualifier Identifier (ID) Required Code specifying type of date or time, or both date and time 573 Date Claim Paid DTP-02 1250 Date Time Period Format Qualifier Identifier (ID) Required Code indicating the date format, time format, or date and time format DTP02 is the date or time or period format that will appear in DTP03. D8 Date Expressed in Format CCYYMMDD DTP-03 1251 Adjudication or Payment Date Min 1 Max 35 String (AN) Required Expression of a date, a time, or range of dates, times or dates and times 1/30/25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 513/665 REF 3550 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > Other Subscriber Information Loop > Other Payer Name Loop > REF Other Payer Claim Adjustment Indicator To specify identifying information Usage notes Required when the claim is being sent in the payer-to-payer COB model, AND the destination payer is secondary to the payer identified in this Loop ID-2330B, AND the payer identified in this Loop ID-2330B has re-adjudicated the claim. If not required by this implementation guide, do not send. Example REFT4XXXXX~ Variants (all may be used) REF Other Payer Claim Control Number REF Other Payer Prior Authorization Number REF Other Payer Referral Number REF Other Payer Secondary Identifier Max use 1 Optional REF-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification T4 Signal Code REF-02 127 Other Payer Claim Adjustment Indicator Min 1 Max 50 String (AN) Required Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier Usage notes The only valid value for this element is `Y'. 1/30/25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 514/665 REF 3550 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > Other Subscriber Information Loop > Other Payer Name Loop > REF Other Payer Claim Control Number To specify identifying information Usage notes Required when it is necessary to identify the Other Payer's Claim Control Number in a payer-to-payer COB situation. OR Required when the Other Payer's Claim Control Number is available. If not required by this implementation guide, do not send. Example REFF8XXX~ Variants (all may be used) REF Other Payer Claim Adjustment Indicator REF Other Payer Prior Authorization Number REF Other Payer Referral Number REF Other Payer Secondary Identifier Max use 1 Optional REF-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification F8 Original Reference Number REF-02 127 Other Payer's Claim Control Number Min 1 Max 50 String (AN) Required Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier 1/30/25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 515/665 REF 3550 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > Other Subscriber Information Loop > Other Payer Name Loop > REF Other Payer Prior Authorization Number To specify identifying information Usage notes Required when the payer identified in this loop has assigned a prior authorization number to this claim. If not required by this implementation guide, do not send. Example REFG1XXXXX~ Variants (all may be used) REF Other Payer Claim Adjustment Indicator REF Other Payer Claim Control Number REF Other Payer Referral Number REF Other Payer Secondary Identifier Max use 1 Optional REF-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification G1 Prior Authorization Number REF-02 127 Other Payer Prior Authorization Number Min 1 Max 50 String (AN) Required Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier 1/30/25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 516/665 REF 3550 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > Other Subscriber Information Loop > Other Payer Name Loop > REF Other Payer Referral Number To specify identifying information Usage notes Required when the payer identified in this loop has assigned a referral number to this claim. If not required by this implementation guide, do not send. Example REF9FXXXXXX~ Variants (all may be used) REF Other Payer Claim Adjustment Indicator REF Other Payer Claim Control Number REF Other Payer Prior Authorization Number REF Other Payer Secondary Identifier Max use 1 Optional REF-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification 9F Referral Number REF-02 127 Other Payer Prior Authorization or Referral Number String (AN) Required Min 1 Max 50 Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier 1/30/25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 517/665 2330B Other Payer Name Loop end REF 3550 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > Other Subscriber Information Loop > Other Payer Name Loop > REF Other Payer Secondary Identifier To specify identifying information Usage notes Required when an additional identification number to that provided in the NM109 of this loop is necessary to identify the entity. If not required by this implementation guide, do not send. Example REFEIXXX~ Variants (all may be used) REF Other Payer Claim Adjustment Indicator REF Other Payer Claim Control Number REF Other Payer Prior Authorization Number REF Other Payer Referral Number Max use 2 Optional REF-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification 2U Payer Identification Number This code is only allowed when the qualifier XV is reported in NM108 of this loop. EI Employer's Identification Number The Employer's Identification Number must be a string of exactly nine numbers with no separators. For example, "001122333" would be valid, while sending "001-12-2333" or "00-1122333" would be invalid. FY Claim Office Number NF National Association of Insurance Commissioners (NAIC) Code REF-02 127 Other Payer Secondary Identifier Min 1 Max 50 String (AN) Required Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier 1/30/25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 518/665 2330C Other Payer Referring Provider Loop Max 2 Optional Variants (all may be used) Other Subscriber Name Loop Other Payer Name Loop Other Payer Rendering Provider Loop Other Payer Service Facility Location Loop Other Payer Supervising Provider Loop Other Payer Billing Provider Loop NM1 3250 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > Other Subscriber Information Loop > Other Payer Referring Provider Loop > NM1 Other Payer Referring Provider To supply the full name of an individual or organizational entity Usage notes See Crosswalking COB Data Elements section for more information on handling COB in the 837. Required prior to the mandated implementation of the HIPAA National Provider Identifier (NPI) rule when the provider in the corresponding Loop ID-2310 is sent and one or more additional payer-specific provider identification numbers are required by this non-destination payer (Loop ID-2330B) to identify the provider. OR Required after the mandated implementation of the NPI rule for providers who are not Health Care Providers when the provider is sent in the corresponding Loop ID-2310 and one or more additional payer-specific provider identification numbers are required by this non-destination payer (Loop ID-2330B) to identify the provider. If not required by this implementation guide, do not send. Example NM1DN1~ Max use 1 Required NM1-01 98 Entity Identifier Code Identifier (ID) Required Code identifying an organizational entity, a physical location, property or an individual DN Referring Provider Use on the first iteration of this loop. Use if loop is used only once. P3 Primary Care Provider Use only if loop is used twice. Use only on second iteration of this loop. NM1-02 1065 Entity Type Qualifier Identifier (ID) Required Code qualifying the type of entity NM102 qualifies NM103. 1/30/25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 519/665 1 Person 1/30/25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 520/665 2330C Other Payer Referring Provider Loop end REF 3550 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > Other Subscriber Information Loop > Other Payer Referring Provider Loop > REF Other Payer Referring Provider Secondary Identification To specify identifying information Usage notes Non-destination (COB) payer's provider identification number(s). See Crosswalking COB Data Elements section for more information on handling COB in the 837. Example REF0B*XXXXXX~ Max use 3 Required REF-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification 0B State License Number 1G Provider UPIN Number UPINs must be formatted as either X99999 or XXX999. G2 Provider Commercial Number This code designates a proprietary	Home State Health 837 Health Care Claim_ Professional.pdf
Office Number NF National Association of Insurance Commissioners (NAIC) Code REF-02 127 Other Payer Secondary Identifier Min 1 Max 50 String (AN) Required Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier 1/30/25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 518/665 2330C Other Payer Referring Provider Loop Max 2 Optional Variants (all may be used) Other Subscriber Name Loop Other Payer Name Loop Other Payer Rendering Provider Loop Other Payer Service Facility Location Loop Other Payer Supervising Provider Loop Other Payer Billing Provider Loop NM1 3250 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > Other Subscriber Information Loop > Other Payer Referring Provider Loop > NM1 Other Payer Referring Provider To supply the full name of an individual or organizational entity Usage notes See Crosswalking COB Data Elements section for more information on handling COB in the 837. Required prior to the mandated implementation of the HIPAA National Provider Identifier (NPI) rule when the provider in the corresponding Loop ID-2310 is sent and one or more additional payer-specific provider identification numbers are required by this non-destination payer (Loop ID-2330B) to identify the provider. OR Required after the mandated implementation of the NPI rule for providers who are not Health Care Providers when the provider is sent in the corresponding Loop ID-2310 and one or more additional payer-specific provider identification numbers are required by this non-destination payer (Loop ID-2330B) to identify the provider. If not required by this implementation guide, do not send. Example NM1DN1~ Max use 1 Required NM1-01 98 Entity Identifier Code Identifier (ID) Required Code identifying an organizational entity, a physical location, property or an individual DN Referring Provider Use on the first iteration of this loop. Use if loop is used only once. P3 Primary Care Provider Use only if loop is used twice. Use only on second iteration of this loop. NM1-02 1065 Entity Type Qualifier Identifier (ID) Required Code qualifying the type of entity NM102 qualifies NM103. 1/30/25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 519/665 1 Person 1/30/25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 520/665 2330C Other Payer Referring Provider Loop end REF 3550 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > Other Subscriber Information Loop > Other Payer Referring Provider Loop > REF Other Payer Referring Provider Secondary Identification To specify identifying information Usage notes Non-destination (COB) payer's provider identification number(s). See Crosswalking COB Data Elements section for more information on handling COB in the 837. Example REF0BXXXXXX~ Max use 3 Required REF-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification 0B State License Number 1G Provider UPIN Number UPINs must be formatted as either X99999 or XXX999. G2 Provider Commercial Number This code designates a proprietary provider number for the non-destination payer identified in the Other Payer Name Loop ID-2330B for this iteration of Loop ID-2320. This is true regardless of whether that payer is Medicare, Medicaid, a Blue Cross Blue Shield plan, a commercial plan, or any other health plan. REF-02 127 Other Payer Referring Provider Identifier Min 1 Max 50 String (AN) Required Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier 1/30/25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 521/665 2330D Other Payer Rendering Provider Loop Max 1 Optional Variants (all may be used) Other Subscriber Name Loop Other Payer Name Loop Other Payer Referring Provider Loop Other Payer Service Facility Location Loop Other Payer Supervising Provider Loop Other Payer Billing Provider Loop NM1 3250 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > Other Subscriber Information Loop > Other Payer Rendering Provider Loop > NM1 Other Payer Rendering Provider To supply the full name of an individual or organizational entity Usage notes See Crosswalking COB Data Elements section for more information on handling COB in the 837. Required prior to the mandated implementation of the HIPAA National Provider Identifier (NPI) rule when the provider in the corresponding Loop ID-2310 is sent and one or more additional payer-specific provider identification numbers are required by this non-destination payer (Loop ID-2330B) to identify the provider. OR Required after the mandated implementation of the NPI rule for providers who are not Health Care Providers when the provider is sent in the corresponding Loop ID-2310 and one or more additional payer-specific provider identification numbers are required by this non-destination payer (Loop ID-2330B) to identify the provider. If not required by this implementation guide, do not send. Example NM1821~ Max use 1 Required NM1-01 98 Entity Identifier Code Identifier (ID) Required Code identifying an organizational entity, a physical location, property or an individual 82 Rendering Provider NM1-02 1065 Entity Type Qualifier Identifier (ID) Required Code qualifying the type of entity NM102 qualifies NM103. 1/30/25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 522/665 1 Person 2 Non-Person Entity 1/30/25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 523/665 2330D Other Payer Rendering Provider Loop end REF 3550 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > Other Subscriber Information Loop > Other Payer Rendering Provider Loop > REF Other Payer Rendering Provider Secondary Identification To specify identifying information Usage notes Required when an additional identification number to that provided in NM109 of this loop is necessary for the claim processor to identify the entity. If not required by this implementation guide, do not send. See Crosswalking COB Data Elements section for more information on handling COB in the 837. Example REFLUXX~ Max use 3 Required REF-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification 0B State License Number 1G Provider UPIN Number UPINs must be formatted as either X99999 or XXX999. G2 Provider Commercial Number This code designates a proprietary provider number for the non-destination payer identified in the Other Payer Name Loop ID-2330B for this iteration of Loop ID-2320. This is true regardless of whether that payer is Medicare, Medicaid, a Blue Cross Blue Shield plan, a commercial plan, or any other health plan. LU Location Number REF-02 127 Other Payer Rendering Provider Secondary Identifier String (AN) Required Min 1 Max 50 Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier 1/30/25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 524/665 2330E Other Payer Service Facility Location Loop Max 1 Optional Variants (all may be used) Other Subscriber Name Loop Other Payer Name Loop Other Payer Referring Provider Loop Other Payer Rendering Provider Loop Other Payer Supervising Provider Loop Other Payer Billing Provider Loop NM1 3250 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > Other Subscriber Information Loop > Other Payer Service Facility Location Loop > NM1 Other Payer Service Facility Location To supply the full name of an individual or organizational entity Usage notes See Crosswalking COB Data Elements section for more information on handling COB in the 837. Required prior to the mandated implementation of the HIPAA National Provider Identifier (NPI) rule when the provider in the corresponding Loop ID-2310 is sent and one or more additional payer-specific provider identification numbers are required by this non-destination payer (Loop ID-2330B) to identify the provider. OR Required after the mandated implementation of the NPI rule for providers who are not Health Care Providers when the provider is sent in the corresponding Loop ID-2310 and one or more additional payer-specific provider identification numbers are required by this non-destination payer (Loop ID-2330B) to identify the provider. If not required by this implementation guide, do not send. Example NM1772~ Max use 1 Required NM1-01 98 Entity Identifier Code Identifier (ID) Required Code identifying an organizational entity, a physical location, property or an individual 77 Service Location NM1-02 1065 Entity Type Qualifier Identifier (ID) Required Code qualifying the type of entity NM102 qualifies NM103. 2 Non-Person Entity 1/30/25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 525/665 2330E Other Payer Service Facility Location Loop end REF 3550 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > Other Subscriber Information Loop > Other Payer Service Facility Location Loop > REF Other Payer Service Facility Location Secondary Identification To specify identifying information Example REF0BXXX~ Max use 3 Required REF-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification 0B State License Number G2 Provider Commercial Number This code designates a proprietary provider number for the non-destination payer identified in the Other Payer Name Loop ID-2330B for this iteration of Loop ID-2320. This is true regardless of whether that payer is Medicare, Medicaid, a Blue Cross Blue Shield plan, a commercial plan, or any other health plan. LU Location Number REF-02 127 Other Payer Service Facility Location Secondary Identifier String (AN) Required Min 1 Max 50 Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier 1/30/25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 526/665 2330F Other Payer Supervising Provider Loop Max 1 Optional Variants (all may be used) Other Subscriber Name Loop Other Payer Name Loop Other Payer Referring Provider Loop Other Payer Rendering Provider Loop Other Payer Service Facility Location Loop Other Payer Billing Provider Loop NM1 3250 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > Other Subscriber Information Loop > Other Payer Supervising Provider Loop > NM1 Other Payer Supervising Provider To supply the full name of an individual or organizational entity Usage notes See Crosswalking COB Data Elements section for more information on handling COB in the 837. Required prior to the mandated implementation of the HIPAA National Provider Identifier (NPI) rule when the provider in the corresponding Loop ID-2310 is sent and one or more additional payer-specific provider identification numbers are required by this non-destination payer (Loop ID-2330B) to identify the provider. OR Required after the mandated implementation of the NPI rule for providers who are not Health Care Providers when the provider is sent in the corresponding Loop ID-2310 and one or more additional payer-specific provider identification numbers are required by this non-destination payer (Loop ID-2330B) to identify the provider. If not required by this implementation guide, do not send. Example NM1DQ1~ Max use 1 Required NM1-01 98 Entity Identifier Code Identifier (ID) Required Code identifying an organizational entity, a physical location, property or an individual DQ Supervising Physician NM1-02 1065 Entity Type Qualifier Identifier (ID) Required Code qualifying the type of entity NM102 qualifies NM103. 1 Person 1/30/25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 527/665 2330F Other Payer Supervising Provider Loop end REF 3550 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > Other Subscriber Information Loop > Other Payer Supervising Provider Loop > REF Other Payer Supervising Provider Secondary Identification To specify identifying information Example REFLUXXXX~ Max use 3 Required REF-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification 0B State License Number 1G Provider UPIN Number UPINs must be formatted as either X99999 or XXX999. G2 Provider Commercial Number This code designates a proprietary provider number for the non-destination payer identified in the Other Payer Name Loop ID-2330B for this iteration of Loop ID-2320. This is true regardless of whether that payer is Medicare, Medicaid, a Blue Cross Blue Shield plan, a commercial plan, or any other	Home State Health 837 Health Care Claim_ Professional.pdf
Other Payer Name Loop ID-2330B for this iteration of Loop ID-2320. This is true regardless of whether that payer is Medicare, Medicaid, a Blue Cross Blue Shield plan, a commercial plan, or any other health plan. LU Location Number REF-02 127 Other Payer Service Facility Location Secondary Identifier String (AN) Required Min 1 Max 50 Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier 1/30/25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 526/665 2330F Other Payer Supervising Provider Loop Max 1 Optional Variants (all may be used) Other Subscriber Name Loop Other Payer Name Loop Other Payer Referring Provider Loop Other Payer Rendering Provider Loop Other Payer Service Facility Location Loop Other Payer Billing Provider Loop NM1 3250 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > Other Subscriber Information Loop > Other Payer Supervising Provider Loop > NM1 Other Payer Supervising Provider To supply the full name of an individual or organizational entity Usage notes See Crosswalking COB Data Elements section for more information on handling COB in the 837. Required prior to the mandated implementation of the HIPAA National Provider Identifier (NPI) rule when the provider in the corresponding Loop ID-2310 is sent and one or more additional payer-specific provider identification numbers are required by this non-destination payer (Loop ID-2330B) to identify the provider. OR Required after the mandated implementation of the NPI rule for providers who are not Health Care Providers when the provider is sent in the corresponding Loop ID-2310 and one or more additional payer-specific provider identification numbers are required by this non-destination payer (Loop ID-2330B) to identify the provider. If not required by this implementation guide, do not send. Example NM1DQ1~ Max use 1 Required NM1-01 98 Entity Identifier Code Identifier (ID) Required Code identifying an organizational entity, a physical location, property or an individual DQ Supervising Physician NM1-02 1065 Entity Type Qualifier Identifier (ID) Required Code qualifying the type of entity NM102 qualifies NM103. 1 Person 1/30/25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 527/665 2330F Other Payer Supervising Provider Loop end REF 3550 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > Other Subscriber Information Loop > Other Payer Supervising Provider Loop > REF Other Payer Supervising Provider Secondary Identification To specify identifying information Example REFLUXXXX~ Max use 3 Required REF-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification 0B State License Number 1G Provider UPIN Number UPINs must be formatted as either X99999 or XXX999. G2 Provider Commercial Number This code designates a proprietary provider number for the non-destination payer identified in the Other Payer Name Loop ID-2330B for this iteration of Loop ID-2320. This is true regardless of whether that payer is Medicare, Medicaid, a Blue Cross Blue Shield plan, a commercial plan, or any other health plan. LU Location Number REF-02 127 Other Payer Supervising Provider Identifier Min 1 Max 50 String (AN) Required Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier 1/30/25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 528/665 2330G Other Payer Billing Provider Loop Max 1 Optional Variants (all may be used) Other Subscriber Name Loop Other Payer Name Loop Other Payer Referring Provider Loop Other Payer Rendering Provider Loop Other Payer Service Facility Location Loop Other Payer Supervising Provider Loop NM1 3250 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > Other Subscriber Information Loop > Other Payer Billing Provider Loop > NM1 Other Payer Billing Provider To supply the full name of an individual or organizational entity Usage notes Required prior to the mandated implementation of the HIPAA National Provider Identifier (NPI) rule when the provider in the corresponding Loop ID-2310 is sent and one or more additional payer-specific provider identification numbers are required by this non-destination payer (Loop ID-2330B) to identify the provider. OR Required after the mandated implementation of the NPI rule for providers who are not Health Care Providers when the provider is sent in the corresponding Loop ID-2310 and one or more additional payer-specific provider identification numbers are required by this non-destination payer (Loop ID-2330B) to identify the provider. If not required by this implementation guide, do not send. See Crosswalking COB Data Elements section for more information on handling COB in the 837. Example NM1851~ Max use 1 Required NM1-01 98 Entity Identifier Code Identifier (ID) Required Code identifying an organizational entity, a physical location, property or an individual 85 Billing Provider NM1-02 1065 Entity Type Qualifier Identifier (ID) Required Code qualifying the type of entity NM102 qualifies NM103. 1/30/25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 529/665 1 Person 2 Non-Person Entity 1/30/25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 530/665 2330G Other Payer Billing Provider Loop end 2320 Other Subscriber Information Loop end REF 3550 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > Other Subscriber Information Loop > Other Payer Billing Provider Loop > REF Other Payer Billing Provider Secondary Identification To specify identifying information Usage notes See Crosswalking COB Data Elements section for more information on handling COB in the 837. Example REFG2XXXX~ Max use 2 Required REF-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification G2 Provider Commercial Number This code designates a proprietary provider number for the non-destination payer identified in the Other Payer Name Loop ID-2330B for this iteration of Loop ID-2320. This is true regardless of whether that payer is Medicare, Medicaid, a Blue Cross Blue Shield plan, a commercial plan, or any other health plan. LU Location Number REF-02 127 Other Payer Billing Provider Identifier Min 1 Max 50 String (AN) Required Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier 1/30/25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 531/665 2400 Service Line Number Loop Max 50 Required LX 3650 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > Service Line Number Loop > LX Service Line Number To reference a line number in a transaction set Usage notes The LX functions as a line counter. The Service Line LX segment must begin with one and is incremented by one for each additional service line of a claim. LX01 is used to indicate bundling in SVD06 in the Line Item Adjudication loop. See Section 1.4.1.2 for more information on bundling and unbundling. Example LX00~ Max use 1 Required LX-01 554 Assigned Number Min 1 Max 6 Numeric (N0) Required Number assigned for differentiation within a transaction set 1/30/25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 532/665 SV1 3700 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > Service Line Number Loop > SV1 Professional Service To specify the service line item detail for a health care professional Example SV1ER>XXXXX>XX>XX>XX>XX>XXXXX00000MJ000000X* 0>0>00>00YYY***0~ Max use 1 Required SV1-01 C003 Composite Medical Procedure Identifier To identify a medical procedure by its standardized codes and applicable modifiers Max use 1 Required C003-01 235 Product or Service ID Qualifier Identifier (ID) Required Code identifying the type/source of the descriptive number used in Product/Service ID (234) C003-01 qualifies C003-02 and C003-08. Usage notes The NDC number is used for reporting prescribed drugs and biologics when required by government regulation, or as deemed by the provider to enhance claim reporting or adjudication processes. The NDC number is reported in the LIN segment of Loop ID- 2410 only. ER Jurisdiction Specific Procedure and Supply Codes This code set is not allowed for use under HIPAA at the time of this writing. The qualifier can only be used: If a new rule names the Jurisdiction Specific Procedure and Supply Codes as an allowable code set under HIPAA, OR The Secretary grants an exception to use the code set as a pilot project as allowed under the law, OR For claims which are not covered under HIPAA. HC Health Care Financing Administration Common Procedural Coding System (HCPCS) Codes Because the AMA's CPT codes are also level 1 HCPCS codes, they are reported under HC. IV Home Infusion EDI Coalition (HIEC) Product/Service Code This code set is not allowed for use under HIPAA at the time of this writing. The qualifier can only be used: If a new rule names the Home Infusion EDI Coalition (HIEC) Product/Service Codes as an allowable code set under HIPAA, OR The Secretary grants an exception to use the code set as a pilot project as allowed under the law, OR For claims which are not covered under HIPAA.; WK Advanced Billing Concepts (ABC) Codes At the time of this writing, this code set has been approved by the Secretary of HHS as a pilot project allowed under HIPAA law. The qualifier may only be used in transactions covered under HIPAA; 1/30/25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 533/665 By parties registered in the pilot project and their trading partners, OR If a new rule names the Complementary, Alternative, or Holistic Procedure Codes as an allowable code set under HIPAA, OR For claims which are not covered under HIPAA. C003-02 234 Procedure Code Min 1 Max 48 String (AN) Required Identifying number for a product or service If C003-08 is used, then C003-02 represents the beginning value in the range in which the code occurs. C003-03 1339 Procedure Modifier Min 2 Max 2 String (AN) Optional This identifies special circumstances related to the performance of the service, as defined by trading partners C003-03 modifies the value in C003-02 and C003-08. C003-04 1339 Procedure Modifier Min 2 Max 2 String (AN) Optional This identifies special circumstances related to the performance of the service, as defined by trading partners C003-04 modifies the value in C003-02 and C003-08. C003-05 1339 Procedure Modifier Min 2 Max 2 String (AN) Optional This identifies special circumstances related to the performance of the service, as defined by trading partners C003-05 modifies the value in C003-02 and C003-08. C003-06 1339 Procedure Modifier Min 2 Max 2 String (AN) Optional This identifies special circumstances related to the performance of the service, as defined by trading partners C003-06 modifies the value in C003-02 and C003-08. C003-07 352 Description Min 1 Max 80 String (AN) Optional A free-form description to clarify the related data elements and their content C003-07 is the description of the procedure identified in C003-02. SV1-02 782 Line Item Charge Amount Min 1 Max 15 Decimal number (R) Required 1/30/25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 534/665 Monetary amount SV102 is the submitted service line item amount. Usage notes This is the total charge amount for this service line. The amount is inclusive of the provider's base charge and any applicable tax and/or postage claimed amounts reported within this line's AMT segments. Zero "0" is an acceptable value for this element. SV1-03 355 Unit or Basis for Measurement Code Identifier (ID) Required Code specifying the units in which a value is being expressed, or manner in which a measurement has been taken MJ Minutes Required for Anesthesia claims. Anesthesia time is counted from the moment that the practitioner, having completed the preoperative evaluation, starts an intravenous line, places monitors, administers pre- anesthesia sedation, or otherwise physically begins to prepare the patient for anesthesia. Time continues throughout the case and while the practitioner accompanies the patient to the post-anesthesia recovery unit (PACU). Time stops when the practitioner releases the patient to the care of PACU personnel. UN Unit SV1-04 380	Home State Health 837 Health Care Claim_ Professional.pdf
law, OR For claims which are not covered under HIPAA.; WK Advanced Billing Concepts (ABC) Codes At the time of this writing, this code set has been approved by the Secretary of HHS as a pilot project allowed under HIPAA law. The qualifier may only be used in transactions covered under HIPAA; 1/30/25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 533/665 By parties registered in the pilot project and their trading partners, OR If a new rule names the Complementary, Alternative, or Holistic Procedure Codes as an allowable code set under HIPAA, OR For claims which are not covered under HIPAA. C003-02 234 Procedure Code Min 1 Max 48 String (AN) Required Identifying number for a product or service If C003-08 is used, then C003-02 represents the beginning value in the range in which the code occurs. C003-03 1339 Procedure Modifier Min 2 Max 2 String (AN) Optional This identifies special circumstances related to the performance of the service, as defined by trading partners C003-03 modifies the value in C003-02 and C003-08. C003-04 1339 Procedure Modifier Min 2 Max 2 String (AN) Optional This identifies special circumstances related to the performance of the service, as defined by trading partners C003-04 modifies the value in C003-02 and C003-08. C003-05 1339 Procedure Modifier Min 2 Max 2 String (AN) Optional This identifies special circumstances related to the performance of the service, as defined by trading partners C003-05 modifies the value in C003-02 and C003-08. C003-06 1339 Procedure Modifier Min 2 Max 2 String (AN) Optional This identifies special circumstances related to the performance of the service, as defined by trading partners C003-06 modifies the value in C003-02 and C003-08. C003-07 352 Description Min 1 Max 80 String (AN) Optional A free-form description to clarify the related data elements and their content C003-07 is the description of the procedure identified in C003-02. SV1-02 782 Line Item Charge Amount Min 1 Max 15 Decimal number (R) Required 1/30/25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 534/665 Monetary amount SV102 is the submitted service line item amount. Usage notes This is the total charge amount for this service line. The amount is inclusive of the provider's base charge and any applicable tax and/or postage claimed amounts reported within this line's AMT segments. Zero "0" is an acceptable value for this element. SV1-03 355 Unit or Basis for Measurement Code Identifier (ID) Required Code specifying the units in which a value is being expressed, or manner in which a measurement has been taken MJ Minutes Required for Anesthesia claims. Anesthesia time is counted from the moment that the practitioner, having completed the preoperative evaluation, starts an intravenous line, places monitors, administers pre- anesthesia sedation, or otherwise physically begins to prepare the patient for anesthesia. Time continues throughout the case and while the practitioner accompanies the patient to the post-anesthesia recovery unit (PACU). Time stops when the practitioner releases the patient to the care of PACU personnel. UN Unit SV1-04 380 Service Unit Count Min 1 Max 15 Decimal number (R) Required Numeric value of quantity Usage notes Note: When a decimal is needed to report units, include it in this element, for example, "15.6". The maximum length for this field is 8 digits excluding the decimal. When a decimal is used, the maximum number of digits allowed to the right of the decimal is three. SV1-05 1331 Place of Service Code Min 1 Max 2 String (AN) Optional Code identifying where services were, or may be, performed; the first and second positions of the Uniform Bill Type Code for Institutional Services or the Place of Service Codes for Professional or Dental Services. SV105 is the place of service. Usage notes See CODE SOURCE 237: Place of Service Codes for Professional Claims SV1-07 C004 Composite Diagnosis Code Pointer To identify one or more diagnosis code pointers Max use 1 Required C004-01 1328 Diagnosis Code Pointer Min 1 Max 2 Numeric (N0) Required 1/30/25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 535/665 A pointer to the diagnosis code in the order of importance to this service C004-01 identifies the primary diagnosis code for this service line. Usage notes This first pointer designates the primary diagnosis for this service line. Remaining diagnosis pointers indicate declining level of importance to service line. Acceptable values are 1 through 12, and correspond to Composite Data Elements 01 through 12 in the Health Care Diagnosis Code HI segment in the Claim Loop ID-2300. C004-02 1328 Diagnosis Code Pointer Min 1 Max 2 Numeric (N0) Optional A pointer to the diagnosis code in the order of importance to this service C004-02 identifies the second diagnosis code for this service line. C004-03 1328 Diagnosis Code Pointer Min 1 Max 2 Numeric (N0) Optional A pointer to the diagnosis code in the order of importance to this service C004-03 identifies the third diagnosis code for this service line. C004-04 1328 Diagnosis Code Pointer Min 1 Max 2 Numeric (N0) Optional A pointer to the diagnosis code in the order of importance to this service C004-04 identifies the fourth diagnosis code for this service line. SV1-09 1073 Emergency Indicator Identifier (ID) Optional Code indicating a Yes or No condition or response SV109 is the emergency-related indicator; a "Y" value indicates service provided was emergency related; an "N" value indicates service provided was not emergency related. Usage notes For this implementation, the listed value takes precedence over the semantic note. Emergency definition: The patient requires immediate medical intervention as a result of severe, life threatening, or potentially disabling conditions. Y Yes SV1-11 1073 EPSDT Indicator Identifier (ID) Optional Code indicating a Yes or No condition or response SV111 is early and periodic screen for diagnosis and treatment of children (EPSDT) involvement; a "Y" value indicates EPSDT involvement; an "N" value indicates no EPSDT involvement. Usage notes For this implementation, the listed value takes precedence over the semantic note. 1/30/25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 536/665 When this element is used, this service is not the screening service. Y Yes SV1-12 1073 Family Planning Indicator Identifier (ID) Optional Code indicating a Yes or No condition or response SV112 is the family planning involvement indicator. A "Y" value indicates family planning services involvement; an "N" value indicates no family planning services involvement. Usage notes For this implementation, the listed value takes precedence over the semantic note. Y Yes SV1-15 1327 Co-Pay Status Code Identifier (ID) Optional Code indicating whether or not co-payment requirements were met on a line by line basis 0 Copay exempt 1/30/25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 537/665 SV5 4000 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > Service Line Number Loop > SV5 Durable Medical Equipment Service To specify the claim service detail for durable medical equipment Usage notes Required when necessary to report both the rental and purchase price information for durable medical equipment. This is not used for claims where the provider is reporting only the rental price or only the purchase price. If not required by this implementation guide, do not send. Example SV5HC>XXXXDA0000000000000000000000000006~ Max use 1 Optional SV5-01 C003 Composite Medical Procedure Identifier To identify a medical procedure by its standardized codes and applicable modifiers Max use 1 Required C003-01 235 Procedure Identifier Identifier (ID) Required Code identifying the type/source of the descriptive number used in Product/Service ID (234) C003-01 qualifies C003-02 and C003-08. HC Health Care Financing Administration Common Procedural Coding System (HCPCS) Codes Because the AMA's CPT codes are also level 1 HCPCS codes, they are reported under HC. C003-02 234 Procedure Code Min 1 Max 48 String (AN) Required Identifying number for a product or service If C003-08 is used, then C003-02 represents the beginning value in the range in which the code occurs. Usage notes This value must be the same as that reported in SV101-2. SV5-02 355 Unit or Basis for Measurement Code Identifier (ID) Required Code specifying the units in which a value is being expressed, or manner in which a measurement has been taken DA Days SV5-03 380 Length of Medical Necessity Min 1 Max 15 Decimal number (R) Required Numeric value of quantity 1/30/25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 538/665 SV503 is the length of medical treatment required. SV5-04 782 DME Rental Price Min 1 Max 15 Decimal number (R) Required Monetary amount SV504 is the rental price. SV5-05 782 DME Purchase Price Min 1 Max 15 Decimal number (R) Required Monetary amount SV505 is the purchase price. SV5-06 594 Rental Unit Price Indicator Identifier (ID) Required Code indicating frequency or type of activities or actions being reported SV506 is the frequency at which the rental equipment is billed. 1 Weekly 4 Monthly 6 Daily 1/30/25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 539/665 PWK 4200 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > Service Line Number Loop > PWK Durable Medical Equipment Certificate of Medical Necessity Indicator To identify the type or transmission or both of paperwork or supporting information Usage notes Required on claims that include a Durable Medical Equipment Regional Carrier (DMERC) Certificate of Medical Necessity (CMN). If not required by this implementation guide, do not send.; Example PWKCTAB~ Variants (all may be used) PWK Line Supplemental Information Max use 1 Optional PWK-01 755 Attachment Report Type Code Identifier (ID) Required Code indicating the title or contents of a document, report or supporting item CT Certification PWK-02 756 Attachment Transmission Code Identifier (ID) Required Code defining timing, transmission method or format by which reports are to be sent Usage notes Required when the actual attachment is maintained by an attachment warehouse or similar vendor. AB Previously Submitted to Payer AD Certification Included in this Claim AF Narrative Segment Included in this Claim AG No Documentation is Required NS Not Specified NS = Paperwork is available on request at the provider's site. This means that the paperwork is not being sent with the claim at this time. Instead, it is available to the payer (or appropriate entity) at their request. 1/30/25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 540/665 PWK 4200 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > Service Line Number Loop > PWK Line Supplemental Information To identify the type or transmission or both of paperwork or supporting information Usage notes Required when there is a paper attachment following this claim. OR Required when attachments are sent electronically (PWK02 = EL) but are transmitted in another functional group (for example, 275) rather than by paper. PWK06 is then used to identify the attached electronic documentation. The number in PWK06 is carried in the TRN of the electronic attachment. OR Required when the provider deems it necessary to identify additional information that is being held at the provider's office and is available upon request by the payer (or appropriate entity), but the information is not being submitted with the claim. Use the value of "AA" in PWK02 to convey this specific use of the PWK segment. If not required by this implementation guide, do not send. Example PWK15FT**ACXXXX~ Variants (all may be used) PWK Durable Medical Equipment Certificate of Medical Necessity Indicator If either Identification Code Qualifier (PWK-05) or Attachment Control Number (PWK-06) is present, then the other is required Max use 10 Optional PWK-01 755 Attachment Report Type Code Identifier (ID) Required Code indicating the title or contents of a document, report or supporting item 03 Report Justifying Treatment Beyond Utilization Guidelines 04 Drugs Administered 05 Treatment Diagnosis 06 Initial Assessment 07 Functional Goals 08 Plan of Treatment 09 Progress Report 10 Continued Treatment 11 Chemical Analysis 13 Certified Test Report 15 Justification for Admission 21 Recovery Plan	Home State Health 837 Health Care Claim_ Professional.pdf
> Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > Service Line Number Loop > PWK Durable Medical Equipment Certificate of Medical Necessity Indicator To identify the type or transmission or both of paperwork or supporting information Usage notes Required on claims that include a Durable Medical Equipment Regional Carrier (DMERC) Certificate of Medical Necessity (CMN). If not required by this implementation guide, do not send.; Example PWKCTAB~ Variants (all may be used) PWK Line Supplemental Information Max use 1 Optional PWK-01 755 Attachment Report Type Code Identifier (ID) Required Code indicating the title or contents of a document, report or supporting item CT Certification PWK-02 756 Attachment Transmission Code Identifier (ID) Required Code defining timing, transmission method or format by which reports are to be sent Usage notes Required when the actual attachment is maintained by an attachment warehouse or similar vendor. AB Previously Submitted to Payer AD Certification Included in this Claim AF Narrative Segment Included in this Claim AG No Documentation is Required NS Not Specified NS = Paperwork is available on request at the provider's site. This means that the paperwork is not being sent with the claim at this time. Instead, it is available to the payer (or appropriate entity) at their request. 1/30/25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 540/665 PWK 4200 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > Service Line Number Loop > PWK Line Supplemental Information To identify the type or transmission or both of paperwork or supporting information Usage notes Required when there is a paper attachment following this claim. OR Required when attachments are sent electronically (PWK02 = EL) but are transmitted in another functional group (for example, 275) rather than by paper. PWK06 is then used to identify the attached electronic documentation. The number in PWK06 is carried in the TRN of the electronic attachment. OR Required when the provider deems it necessary to identify additional information that is being held at the provider's office and is available upon request by the payer (or appropriate entity), but the information is not being submitted with the claim. Use the value of "AA" in PWK02 to convey this specific use of the PWK segment. If not required by this implementation guide, do not send. Example PWK15FT**ACXXXX~ Variants (all may be used) PWK Durable Medical Equipment Certificate of Medical Necessity Indicator If either Identification Code Qualifier (PWK-05) or Attachment Control Number (PWK-06) is present, then the other is required Max use 10 Optional PWK-01 755 Attachment Report Type Code Identifier (ID) Required Code indicating the title or contents of a document, report or supporting item 03 Report Justifying Treatment Beyond Utilization Guidelines 04 Drugs Administered 05 Treatment Diagnosis 06 Initial Assessment 07 Functional Goals 08 Plan of Treatment 09 Progress Report 10 Continued Treatment 11 Chemical Analysis 13 Certified Test Report 15 Justification for Admission 21 Recovery Plan A3 Allergies/Sensitivities Document A4 Autopsy Report AM Ambulance Certification AS Admission Summary B2 Prescription B3 Physician Order B4 Referral Form BR Benchmark Testing Results 1/30/25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 541/665 BS Baseline BT Blanket Test Results CB Chiropractic Justification CK Consent Form(s) CT Certification D2 Drug Profile Document DA Dental Models DB Durable Medical Equipment Prescription DG Diagnostic Report DJ Discharge Monitoring Report DS Discharge Summary EB Explanation of Benefits (Coordination of Benefits or Medicare Secondary Payor) HC Health Certificate HR Health Clinic Records I5 Immunization Record IR State School Immunization Records LA Laboratory Results M1 Medical Record Attachment MT Models NN Nursing Notes OB Operative Note OC Oxygen Content Averaging Report OD Orders and Treatments Document OE Objective Physical Examination (including vital signs) Document OX Oxygen Therapy Certification OZ Support Data for Claim P4 Pathology Report P5 Patient Medical History Document PE Parenteral or Enteral Certification PN Physical Therapy Notes PO Prosthetics or Orthotic Certification PQ Paramedical Results PY Physician's Report PZ Physical Therapy Certification RB Radiology Films RR Radiology Reports RT Report of Tests and Analysis Report RX Renewable Oxygen Content Averaging Report SG Symptoms Document V5 Death Notification XP Photographs PWK-02 756 Attachment Transmission Code Identifier (ID) Required Code defining timing, transmission method or format by which reports are to be sent Usage notes Required when the actual attachment is maintained by an attachment warehouse or similar vendor. AA Available on Request at Provider Site 1/30/25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 542/665 This means that the additional information is not being sent with the claim at this time. Instead, it is available to the payer (or appropriate entity) at their request. BM By Mail EL Electronically Only Indicates that the attachment is being transmitted in a separate X12 functional group. EM E-Mail FT File Transfer FX By Fax PWK-05 66 Identification Code Qualifier Identifier (ID) Optional Code designating the system/method of code structure used for Identification Code (67) PWK05 and PWK06 may be used to identify the addressee by a code number. AC Attachment Control Number PWK-06 67 Attachment Control Number Min 2 Max 80 String (AN) Optional Code identifying a party or other code Usage notes PWK06 is used to identify the attached electronic documentation. The number in PWK06 is carried in the TRN of the electronic attachment. For the purpose of this implementation, the maximum field length is 50. 1/30/25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 543/665 CR1 4250 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > Service Line Number Loop > CR1 Ambulance Transport Information To supply information related to the ambulance service rendered to a patient Usage notes Required on ambulance transport services when the information applicable to any one of the segment's elements is different than the information reported in the CR1 at the claim level (Loop ID-2300). If not required by this implementation guide, do not send. Example CR1LB00000000*EDH00000000*XXXXXX~ If either Unit or Basis for Measurement Code (CR1-01) or Patient Weight (CR1-02) is present, then the other is required Max use 1 Optional CR1-01 355 Unit or Basis for Measurement Code Identifier (ID) Optional Code specifying the units in which a value is being expressed, or manner in which a measurement has been taken LB Pound CR1-02 81 Patient Weight Min 1 Max 10 Decimal number (R) Optional Numeric value of weight CR102 is the weight of the patient at time of transport. CR1-04 1317 Ambulance Transport Reason Code Identifier (ID) Required Code indicating the reason for ambulance transport A Patient was transported to nearest facility for care of symptoms, complaints, or both B Patient was transported for the benefit of a preferred physician C Patient was transported for the nearness of family members D Patient was transported for the care of a specialist or for availability of specialized equipment E Patient Transferred to Rehabilitation Facility CR1-05 355 Unit or Basis for Measurement Code Identifier (ID) Required Code specifying the units in which a value is being expressed, or manner in which a measurement has been taken DH Miles CR1-06 380 Transport Distance Min 1 Max 15 Decimal number (R) Required Numeric value of quantity CR106 is the distance traveled during transport. 1/30/25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 544/665 Usage notes 0 (zero) is a valid value when ambulance services do not include a charge for mileage. CR1-09 352 Round Trip Purpose Description Min 1 Max 80 String (AN) Optional A free-form description to clarify the related data elements and their content CR109 is the purpose for the round trip ambulance service. CR1-10 352 Stretcher Purpose Description Min 1 Max 80 String (AN) Optional A free-form description to clarify the related data elements and their content CR110 is the purpose for the usage of a stretcher during ambulance service. 1/30/25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 545/665 CR3 4350 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > Service Line Number Loop > CR3 Durable Medical Equipment Certification To supply information regarding a physician's certification for durable medical equipment Usage notes Required when a Durable Medical Equipment Regional Carrier Certificate of Medical Necessity (DMERC CMN) or a DMERC Information Form (DIF) or Oxygen Therapy Certification is included on this service line. If not required by this implementation guide, do not send. Example CR3SMO00000000000000~ Max use 1 Optional CR3-01 1322 Certification Type Code Identifier (ID) Required Code indicating the type of certification I Initial R Renewal S Revised CR3-02 355 Unit or Basis for Measurement Code Identifier (ID) Required Code specifying the units in which a value is being expressed, or manner in which a measurement has been taken CR302 and CR303 specify the time period covered by this certification. MO Months CR3-03 380 Durable Medical Equipment Duration Min 1 Max 15 Decimal number (R) Required Numeric value of quantity Usage notes Length of time DME equipment is needed. 1/30/25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 546/665 CRC 4500 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > Service Line Number Loop > CRC Ambulance Certification To supply information on conditions Usage notes The maximum number of CRC segments which can occur per Loop ID-2400 is 3. Submitters are free to mix and match the three types of service line level CRC segments shown in this implementation guide to meet their billing or reporting needs but no more than a total of 3 CRC segments per Loop ID-2400 are allowed. Required on ambulance transport services when the information applicable to any one of the segment's elements is different than the information reported in the Ambulance Certification CRC at the claim level (Loop ID-2300). If not required by this implementation guide, do not send. Example CRC07N05XXXXXXXX~ Variants (all may be used) CRC Condition Indicator/Durable Medical Equipment CRC Hospice Employee Indicator Max use 3 Optional CRC-01 1136 Code Category Identifier (ID) Required Specifies the situation or category to which the code applies CRC01 qualifies CRC03 through CRC07. 07 Ambulance Certification CRC-02 1073 Certification Condition Indicator Identifier (ID) Required Code indicating a Yes or No condition or response CRC02 is a Certification Condition Code applies indicator. A "Y" value indicates the condition codes in CRC03 through CRC07 apply; an "N" value indicates the condition codes in CRC03 through CRC07 do not apply. N No Y Yes CRC-03 1321 Condition Code Identifier (ID) Required Code indicating a condition Usage notes The codes for CRC03 also can be used for CRC04 through CRC07. 01 Patient was admitted to a hospital 04 Patient was moved by stretcher 05 Patient was unconscious or in shock 06 Patient was transported in an emergency situation 1/30/25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 547/665 07 Patient had to be physically restrained 08 Patient had visible hemorrhaging 09 Ambulance service was medically necessary 12 Patient is confined to a bed or chair Use code 12 to indicate patient was bedridden during transport. CRC-04 1321 Condition Code Min 2 Max 3 Identifier (ID) Optional Code indicating a condition Usage notes Use the codes listed in CRC03. CRC-05 1321 Condition Code Min 2 Max 3 Identifier (ID) Optional Code indicating a condition Usage notes Use the codes listed in CRC03. CRC-06 1321 Condition Code Min 2 Max 3 Identifier (ID) Optional Code indicating a condition Usage notes Use the codes listed in CRC03. CRC-07 1321 Condition Code Min 2 Max 3 Identifier (ID) Optional Code indicating a condition Usage notes Use the codes listed in CRC03. 1/30/25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 548/665 CRC 4500 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level	Home State Health 837 Health Care Claim_ Professional.pdf
Medical Equipment Duration Min 1 Max 15 Decimal number (R) Required Numeric value of quantity Usage notes Length of time DME equipment is needed. 1/30/25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 546/665 CRC 4500 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > Service Line Number Loop > CRC Ambulance Certification To supply information on conditions Usage notes The maximum number of CRC segments which can occur per Loop ID-2400 is 3. Submitters are free to mix and match the three types of service line level CRC segments shown in this implementation guide to meet their billing or reporting needs but no more than a total of 3 CRC segments per Loop ID-2400 are allowed. Required on ambulance transport services when the information applicable to any one of the segment's elements is different than the information reported in the Ambulance Certification CRC at the claim level (Loop ID-2300). If not required by this implementation guide, do not send. Example CRC07N05XXXXXXXX~ Variants (all may be used) CRC Condition Indicator/Durable Medical Equipment CRC Hospice Employee Indicator Max use 3 Optional CRC-01 1136 Code Category Identifier (ID) Required Specifies the situation or category to which the code applies CRC01 qualifies CRC03 through CRC07. 07 Ambulance Certification CRC-02 1073 Certification Condition Indicator Identifier (ID) Required Code indicating a Yes or No condition or response CRC02 is a Certification Condition Code applies indicator. A "Y" value indicates the condition codes in CRC03 through CRC07 apply; an "N" value indicates the condition codes in CRC03 through CRC07 do not apply. N No Y Yes CRC-03 1321 Condition Code Identifier (ID) Required Code indicating a condition Usage notes The codes for CRC03 also can be used for CRC04 through CRC07. 01 Patient was admitted to a hospital 04 Patient was moved by stretcher 05 Patient was unconscious or in shock 06 Patient was transported in an emergency situation 1/30/25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 547/665 07 Patient had to be physically restrained 08 Patient had visible hemorrhaging 09 Ambulance service was medically necessary 12 Patient is confined to a bed or chair Use code 12 to indicate patient was bedridden during transport. CRC-04 1321 Condition Code Min 2 Max 3 Identifier (ID) Optional Code indicating a condition Usage notes Use the codes listed in CRC03. CRC-05 1321 Condition Code Min 2 Max 3 Identifier (ID) Optional Code indicating a condition Usage notes Use the codes listed in CRC03. CRC-06 1321 Condition Code Min 2 Max 3 Identifier (ID) Optional Code indicating a condition Usage notes Use the codes listed in CRC03. CRC-07 1321 Condition Code Min 2 Max 3 Identifier (ID) Optional Code indicating a condition Usage notes Use the codes listed in CRC03. 1/30/25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 548/665 CRC 4500 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > Service Line Number Loop > CRC Condition Indicator/Durable Medical Equipment To supply information on conditions Usage notes Required when a Durable Medical Equipment Regional Carrier Certificate of Medical Necessity (DMERC CMN) or a DMERC Information Form (DIF), or Oxygen Therapy Certification is included on this service line and the information is necessary for adjudication. If not required by this implementation guide, do not send. The maximum number of CRC segments which can occur per Loop ID-2400 is 3. Submitters are free to mix and match the three types of service line level CRC segments shown in this implementation guide to meet their billing or reporting needs but no more than a total of 3 CRC segments per Loop ID-2400 are allowed. The first example shows a case where an item billed was not a replacement item. Example CRC09NZVXX~ Variants (all may be used) CRC Ambulance Certification CRC Hospice Employee Indicator Max use 1 Optional CRC-01 1136 Code Category Identifier (ID) Required Specifies the situation or category to which the code applies CRC01 qualifies CRC03 through CRC07. 09 Durable Medical Equipment Certification CRC-02 1073 Certification Condition Indicator Identifier (ID) Required Code indicating a Yes or No condition or response CRC02 is a Certification Condition Code applies indicator. A "Y" value indicates the condition codes in CRC03 through CRC07 apply; an "N" value indicates the condition codes in CRC03 through CRC07 do not apply. N No Y Yes CRC-03 1321 Condition Indicator Identifier (ID) Required Code indicating a condition 38 Certification signed by the physician is on file at the supplier's office ZV Replacement Item CRC-04 1321 Condition Indicator Min 2 Max 3 Identifier (ID) Optional 1/30/25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 549/665 Code indicating a condition Usage notes Use the codes listed in CRC03. 1/30/25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 550/665 CRC 4500 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > Service Line Number Loop > CRC Hospice Employee Indicator To supply information on conditions Usage notes Required on all Medicare claims involving physician services to hospice patients. If not required by this implementation guide, do not send. The maximum number of CRC segments which can occur per Loop ID-2400 is 3. Submitters are free to mix and match the three types of service line level CRC segments shown in this implementation guide to meet their billing or reporting needs but no more than a total of 3 CRC segments per Loop ID-2400 are allowed. The example shows the method used to indicate whether the rendering provider is an employee of the hospice. Example CRC70N65~ Variants (all may be used) CRC Ambulance Certification CRC Condition Indicator/Durable Medical Equipment Max use 1 Optional CRC-01 1136 Code Category Identifier (ID) Required Specifies the situation or category to which the code applies CRC01 qualifies CRC03 through CRC07. 70 Hospice CRC-02 1073 Hospice Employed Provider Indicator Identifier (ID) Required Code indicating a Yes or No condition or response CRC02 is a Certification Condition Code applies indicator. A "Y" value indicates the condition codes in CRC03 through CRC07 apply; an "N" value indicates the condition codes in CRC03 through CRC07 do not apply. Usage notes A "Y" value indicates the provider is employed by the hospice. A "N" value indicates the provider is not employed by the hospice. N No Y Yes CRC-03 1321 Condition Indicator Identifier (ID) Required Code indicating a condition 1/30/25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 551/665 65 Open This code value is a placeholder to satisfy the Mandatory Data Element syntax requirement. 1/30/25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 552/665 DTP 4550 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > Service Line Number Loop > DTP Date - Begin Therapy Date To specify any or all of a date, a time, or a time period Usage notes Required when a Durable Medical Equipment Regional Carrier Certificate of Medical Necessity (DMERC CMN) or DMERC Information Form (DIF), or Oxygen Therapy Certification is included on this service line. If not required by this implementation guide, do not send. Example DTP463D8XXXX~ Variants (all may be used) DTP DATE - Certification Revision/Recertification Date DTP Date - Initial Treatment Date DTP Date - Last Certification Date DTP Date - Last Seen Date DTP Date - Last X-ray Date DTP Date - Prescription Date DTP Date - Service Date DTP Date - Shipped Date DTP Date - Test Date Max use 1 Optional DTP-01 374 Date Time Qualifier Identifier (ID) Required Code specifying type of date or time, or both date and time 463 Begin Therapy DTP-02 1250 Date Time Period Format Qualifier Identifier (ID) Required Code indicating the date format, time format, or date and time format DTP02 is the date or time or period format that will appear in DTP03. D8 Date Expressed in Format CCYYMMDD DTP-03 1251 Begin Therapy Date Min 1 Max 35 String (AN) Required Expression of a date, a time, or range of dates, times or dates and times 1/30/25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 553/665 DTP 4550 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > Service Line Number Loop > DTP DATE - Certification Revision/Recertification Date To specify any or all of a date, a time, or a time period Usage notes Required when CR301 (DMERC Certification) = "R" or "S". If not required by this implementation guide, do not send. Example DTP607D8X~ Variants (all may be used) DTP Date - Begin Therapy Date DTP Date - Initial Treatment Date DTP Date - Last Certification Date DTP Date - Last Seen Date DTP Date - Last X-ray Date DTP Date - Prescription Date DTP Date - Service Date DTP Date - Shipped Date DTP Date - Test Date Max use 1 Optional DTP-01 374 Date Time Qualifier Identifier (ID) Required Code specifying type of date or time, or both date and time 607 Certification Revision DTP-02 1250 Date Time Period Format Qualifier Identifier (ID) Required Code indicating the date format, time format, or date and time format DTP02 is the date or time or period format that will appear in DTP03. D8 Date Expressed in Format CCYYMMDD DTP-03 1251 Certification Revision or Recertification Date String (AN) Required Min 1 Max 35 Expression of a date, a time, or range of dates, times or dates and times 1/30/25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 554/665 DTP 4550 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > Service Line Number Loop > DTP Date - Initial Treatment Date To specify any or all of a date, a time, or a time period Usage notes Required when the Initial Treatment Date is known to impact adjudication for claims involving spinal manipulation, physcial therapy, occupational therapy, or speech language pathology and when different from what is reported at the claim level. If not required by this implementation guide, do not send. Example DTP454D8*XX~ Variants (all may be used) DTP Date - Begin Therapy Date DTP DATE - Certification Revision/Recertification Date DTP Date - Last Certification Date DTP Date - Last Seen Date DTP Date - Last X-ray Date DTP Date - Prescription Date DTP Date - Service Date DTP Date - Shipped Date DTP Date - Test Date Max use 1 Optional DTP-01 374 Date Time Qualifier Identifier (ID) Required Code specifying type of date or time, or both date and time 454 Initial Treatment DTP-02 1250 Date Time Period Format Qualifier Identifier (ID) Required Code indicating the date format, time format, or date and time format DTP02 is the date or time or period format that will appear in DTP03. D8 Date Expressed in Format CCYYMMDD DTP-03 1251 Initial Treatment Date Min 1 Max 35 String (AN) Required Expression of a date, a time, or range of dates, times or dates and times 1/30/25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 555/665 DTP 4550 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > Service Line Number Loop > DTP Date - Last Certification Date To specify any or all of a date, a time, or a time period Usage notes Required when a Durable Medical Equipment Regional Carrier Certificate of Medical Necessity (DMERC CMN), DMERC Information Form (DIF), or Oxygen Therapy Certification is included on this service line. If not required by this implementation guide, do not send. This is the date the ordering physician signed the CMN or Oxygen Therapy Certification, or the date the supplier signed	Home State Health 837 Health Care Claim_ Professional.pdf
DTP Date - Prescription Date DTP Date - Service Date DTP Date - Shipped Date DTP Date - Test Date Max use 1 Optional DTP-01 374 Date Time Qualifier Identifier (ID) Required Code specifying type of date or time, or both date and time 607 Certification Revision DTP-02 1250 Date Time Period Format Qualifier Identifier (ID) Required Code indicating the date format, time format, or date and time format DTP02 is the date or time or period format that will appear in DTP03. D8 Date Expressed in Format CCYYMMDD DTP-03 1251 Certification Revision or Recertification Date String (AN) Required Min 1 Max 35 Expression of a date, a time, or range of dates, times or dates and times 1/30/25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 554/665 DTP 4550 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > Service Line Number Loop > DTP Date - Initial Treatment Date To specify any or all of a date, a time, or a time period Usage notes Required when the Initial Treatment Date is known to impact adjudication for claims involving spinal manipulation, physcial therapy, occupational therapy, or speech language pathology and when different from what is reported at the claim level. If not required by this implementation guide, do not send. Example DTP454D8XX~ Variants (all may be used) DTP Date - Begin Therapy Date DTP DATE - Certification Revision/Recertification Date DTP Date - Last Certification Date DTP Date - Last Seen Date DTP Date - Last X-ray Date DTP Date - Prescription Date DTP Date - Service Date DTP Date - Shipped Date DTP Date - Test Date Max use 1 Optional DTP-01 374 Date Time Qualifier Identifier (ID) Required Code specifying type of date or time, or both date and time 454 Initial Treatment DTP-02 1250 Date Time Period Format Qualifier Identifier (ID) Required Code indicating the date format, time format, or date and time format DTP02 is the date or time or period format that will appear in DTP03. D8 Date Expressed in Format CCYYMMDD DTP-03 1251 Initial Treatment Date Min 1 Max 35 String (AN) Required Expression of a date, a time, or range of dates, times or dates and times 1/30/25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 555/665 DTP 4550 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > Service Line Number Loop > DTP Date - Last Certification Date To specify any or all of a date, a time, or a time period Usage notes Required when a Durable Medical Equipment Regional Carrier Certificate of Medical Necessity (DMERC CMN), DMERC Information Form (DIF), or Oxygen Therapy Certification is included on this service line. If not required by this implementation guide, do not send. This is the date the ordering physician signed the CMN or Oxygen Therapy Certification, or the date the supplier signed the DMERC Information Form (DIF). Example DTP461D8X~ Variants (all may be used) DTP Date - Begin Therapy Date DTP DATE - Certification Revision/Recertification Date DTP Date - Initial Treatment Date DTP Date - Last Seen Date DTP Date - Last X-ray Date DTP Date - Prescription Date DTP Date - Service Date DTP Date - Shipped Date DTP Date - Test Date Max use 1 Optional DTP-01 374 Date Time Qualifier Identifier (ID) Required Code specifying type of date or time, or both date and time 461 Last Certification DTP-02 1250 Date Time Period Format Qualifier Identifier (ID) Required Code indicating the date format, time format, or date and time format DTP02 is the date or time or period format that will appear in DTP03. D8 Date Expressed in Format CCYYMMDD DTP-03 1251 Last Certification Date Min 1 Max 35 String (AN) Required Expression of a date, a time, or range of dates, times or dates and times 1/30/25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 556/665 DTP 4550 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > Service Line Number Loop > DTP Date - Last Seen Date To specify any or all of a date, a time, or a time period Usage notes Required when a claim involves physician services for routine foot care; and is different than the date listed at the claim level and is known to impact the payer's adjudication process. If not required by this implementation guide, do not send.; Example DTP304D8XXX~ Variants (all may be used) DTP Date - Begin Therapy Date DTP DATE - Certification Revision/Recertification Date DTP Date - Initial Treatment Date DTP Date - Last Certification Date DTP Date - Last X-ray Date DTP Date - Prescription Date DTP Date - Service Date DTP Date - Shipped Date DTP Date - Test Date Max use 1 Optional DTP-01 374 Date Time Qualifier Identifier (ID) Required Code specifying type of date or time, or both date and time 304 Latest Visit or Consultation DTP-02 1250 Date Time Period Format Qualifier Identifier (ID) Required Code indicating the date format, time format, or date and time format DTP02 is the date or time or period format that will appear in DTP03. D8 Date Expressed in Format CCYYMMDD DTP-03 1251 Treatment or Therapy Date Min 1 Max 35 String (AN) Required Expression of a date, a time, or range of dates, times or dates and times 1/30/25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 557/665 DTP 4550 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > Service Line Number Loop > DTP Date - Last X-ray Date To specify any or all of a date, a time, or a time period Usage notes Required when claim involves spinal manipulation and an x-ray was taken and is different than information at the claim level (Loop ID-2300). If not required by this implementation guide, do not send. Example DTP455D8XXXXXX~ Variants (all may be used) DTP Date - Begin Therapy Date DTP DATE - Certification Revision/Recertification Date DTP Date - Initial Treatment Date DTP Date - Last Certification Date DTP Date - Last Seen Date DTP Date - Prescription Date DTP Date - Service Date DTP Date - Shipped Date DTP Date - Test Date Max use 1 Optional DTP-01 374 Date Time Qualifier Identifier (ID) Required Code specifying type of date or time, or both date and time 455 Last X-Ray DTP-02 1250 Date Time Period Format Qualifier Identifier (ID) Required Code indicating the date format, time format, or date and time format DTP02 is the date or time or period format that will appear in DTP03. D8 Date Expressed in Format CCYYMMDD DTP-03 1251 Last X-Ray Date Min 1 Max 35 String (AN) Required Expression of a date, a time, or range of dates, times or dates and times 1/30/25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 558/665 DTP 4550 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > Service Line Number Loop > DTP Date - Prescription Date To specify any or all of a date, a time, or a time period Usage notes Required when a drug is billed for this line and a prescription was written (or otherwise communicated by the prescriber if not written). If not required by this implementation guide, do not send. Example DTP471D8XXX~ Variants (all may be used) DTP Date - Begin Therapy Date DTP DATE - Certification Revision/Recertification Date DTP Date - Initial Treatment Date DTP Date - Last Certification Date DTP Date - Last Seen Date DTP Date - Last X-ray Date DTP Date - Service Date DTP Date - Shipped Date DTP Date - Test Date Max use 1 Optional DTP-01 374 Date Time Qualifier Identifier (ID) Required Code specifying type of date or time, or both date and time 471 Prescription DTP-02 1250 Date Time Period Format Qualifier Identifier (ID) Required Code indicating the date format, time format, or date and time format DTP02 is the date or time or period format that will appear in DTP03. D8 Date Expressed in Format CCYYMMDD DTP-03 1251 Prescription Date Min 1 Max 35 String (AN) Required Expression of a date, a time, or range of dates, times or dates and times 1/30/25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 559/665 DTP 4550 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > Service Line Number Loop > DTP Date - Service Date To specify any or all of a date, a time, or a time period Usage notes In cases where a drug is being billed on a service line, date range may be used to indicate drug duration for which the drug supply will be used by the patient. The difference in dates, including both the begin and end dates, are the days supply of the drug. Example: 20000101 - 20000107 (1/1/00 to 1/7/00) is used for a 7 day supply where the first day of the drug used by the patient is 1/1/00. In the event a drug is administered on less than a daily basis (for example, every other day) the date range would include the entire period during which the drug was supplied, including the last day the drug was used. Example: 20000101 - 20000108 (1/1/00 to 1/8/00) is used for an 8 days supply where the prescription is written for Q48 (every 48 hours), four doses of the drug are dispensed and the first dose is used on 1/1/00. Example DTP472RD8XXX~ Variants (all may be used) DTP Date - Begin Therapy Date DTP DATE - Certification Revision/Recertification Date DTP Date - Initial Treatment Date DTP Date - Last Certification Date DTP Date - Last Seen Date DTP Date - Last X-ray Date DTP Date - Prescription Date DTP Date - Shipped Date DTP Date - Test Date Max use 1 Required DTP-01 374 Date Time Qualifier Identifier (ID) Required Code specifying type of date or time, or both date and time 472 Service DTP-02 1250 Date Time Period Format Qualifier Identifier (ID) Required Code indicating the date format, time format, or date and time format DTP02 is the date or time or period format that will appear in DTP03. Usage notes RD8 is required only when the "To and From" dates are different. However, at the discretion of the submitter, RD8 can also be used when the "To and From" dates are the same. 1/30/25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 560/665 D8 Date Expressed in Format CCYYMMDD RD8 Range of Dates Expressed in Format CCYYMMDD-CCYYMMDD DTP-03 1251 Service Date Min 1 Max 35 String (AN) Required Expression of a date, a time, or range of dates, times or dates and times 1/30/25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 561/665 DTP 4550 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > Service Line Number Loop > DTP Date - Shipped Date To specify any or all of a date, a time, or a time period Usage notes Required when billing or reporting shipped products. If not required by this implementation guide, do not send. Example DTP011D8*XXXX~ Variants (all may be used) DTP Date - Begin Therapy Date DTP DATE - Certification Revision/Recertification Date DTP Date - Initial Treatment Date DTP Date - Last Certification Date DTP Date - Last Seen Date DTP Date - Last X-ray Date DTP Date - Prescription Date DTP Date - Service Date DTP Date - Test Date Max use 1 Optional DTP-01 374 Date Time Qualifier Identifier (ID) Required Code specifying type of date or time, or both date and time 011	Home State Health 837 Health Care Claim_ Professional.pdf
supply will be used by the patient. The difference in dates, including both the begin and end dates, are the days supply of the drug. Example: 20000101 - 20000107 (1/1/00 to 1/7/00) is used for a 7 day supply where the first day of the drug used by the patient is 1/1/00. In the event a drug is administered on less than a daily basis (for example, every other day) the date range would include the entire period during which the drug was supplied, including the last day the drug was used. Example: 20000101 - 20000108 (1/1/00 to 1/8/00) is used for an 8 days supply where the prescription is written for Q48 (every 48 hours), four doses of the drug are dispensed and the first dose is used on 1/1/00. Example DTP472RD8XXX~ Variants (all may be used) DTP Date - Begin Therapy Date DTP DATE - Certification Revision/Recertification Date DTP Date - Initial Treatment Date DTP Date - Last Certification Date DTP Date - Last Seen Date DTP Date - Last X-ray Date DTP Date - Prescription Date DTP Date - Shipped Date DTP Date - Test Date Max use 1 Required DTP-01 374 Date Time Qualifier Identifier (ID) Required Code specifying type of date or time, or both date and time 472 Service DTP-02 1250 Date Time Period Format Qualifier Identifier (ID) Required Code indicating the date format, time format, or date and time format DTP02 is the date or time or period format that will appear in DTP03. Usage notes RD8 is required only when the "To and From" dates are different. However, at the discretion of the submitter, RD8 can also be used when the "To and From" dates are the same. 1/30/25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 560/665 D8 Date Expressed in Format CCYYMMDD RD8 Range of Dates Expressed in Format CCYYMMDD-CCYYMMDD DTP-03 1251 Service Date Min 1 Max 35 String (AN) Required Expression of a date, a time, or range of dates, times or dates and times 1/30/25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 561/665 DTP 4550 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > Service Line Number Loop > DTP Date - Shipped Date To specify any or all of a date, a time, or a time period Usage notes Required when billing or reporting shipped products. If not required by this implementation guide, do not send. Example DTP011D8XXXX~ Variants (all may be used) DTP Date - Begin Therapy Date DTP DATE - Certification Revision/Recertification Date DTP Date - Initial Treatment Date DTP Date - Last Certification Date DTP Date - Last Seen Date DTP Date - Last X-ray Date DTP Date - Prescription Date DTP Date - Service Date DTP Date - Test Date Max use 1 Optional DTP-01 374 Date Time Qualifier Identifier (ID) Required Code specifying type of date or time, or both date and time 011 Shipped DTP-02 1250 Date Time Period Format Qualifier Identifier (ID) Required Code indicating the date format, time format, or date and time format DTP02 is the date or time or period format that will appear in DTP03. D8 Date Expressed in Format CCYYMMDD DTP-03 1251 Shipped Date Min 1 Max 35 String (AN) Required Expression of a date, a time, or range of dates, times or dates and times 1/30/25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 562/665 DTP 4550 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > Service Line Number Loop > DTP Date - Test Date To specify any or all of a date, a time, or a time period Usage notes Required on initial EPO claims service lines for dialysis patients when test results are being billed or reported. If not required by this implementation guide, do not send. Example DTP738D8XX~ Variants (all may be used) DTP Date - Begin Therapy Date DTP DATE - Certification Revision/Recertification Date DTP Date - Initial Treatment Date DTP Date - Last Certification Date DTP Date - Last Seen Date DTP Date - Last X-ray Date DTP Date - Prescription Date DTP Date - Service Date DTP Date - Shipped Date Max use 2 Optional DTP-01 374 Date Time Qualifier Identifier (ID) Required Code specifying type of date or time, or both date and time 738 Most Recent Hemoglobin or Hematocrit or Both 739 Most Recent Serum Creatine DTP-02 1250 Date Time Period Format Qualifier Identifier (ID) Required Code indicating the date format, time format, or date and time format DTP02 is the date or time or period format that will appear in DTP03. D8 Date Expressed in Format CCYYMMDD DTP-03 1251 Test Performed Date Min 1 Max 35 String (AN) Required Expression of a date, a time, or range of dates, times or dates and times 1/30/25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 563/665 QTY 4600 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > Service Line Number Loop > QTY Ambulance Patient Count To specify quantity information Usage notes Required when more than one patient is transported in the same vehicle for Ambulance or non-emergency transportation services. If not required by this implementation guide, do not send. The QTY02 is the only place to report the number of patients when there are multiple patients transported. Example QTYPT0000000000~ Variants (all may be used) QTY Obstetric Anesthesia Additional Units Max use 1 Optional QTY-01 673 Quantity Qualifier Identifier (ID) Required Code specifying the type of quantity PT Patients QTY-02 380 Ambulance Patient Count Min 1 Max 15 Decimal number (R) Required Numeric value of quantity 1/30/25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 564/665 QTY 4600 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > Service Line Number Loop > QTY Obstetric Anesthesia Additional Units To specify quantity information Usage notes Required in conjunction with anesthesia for obstetric services when the anesthesia provider chooses to report additional complexity beyond the normal services reflected by the procedure base units and anesthesia time. If not required by this implementation guide, do not send. Example QTYFL000000000000000~ Variants (all may be used) QTY Ambulance Patient Count Max use 1 Optional QTY-01 673 Quantity Qualifier Identifier (ID) Required Code specifying the type of quantity FL Units QTY-02 380 Obstetric Additional Units Min 1 Max 15 Decimal number (R) Required Numeric value of quantity Usage notes The number of additional units reported by an anesthesia provider to reflect additional complexity of services. 1/30/25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 565/665 MEA 4620 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > Service Line Number Loop > MEA Test Result To specify physical measurements or counts, including dimensions, tolerances, variances, and weights (See Figures Appendix for example of use of C001) Usage notes Required on Dialysis related service lines for ESRD. Use R1, R2, R3, or R4 to qualify the Hemoglobin, Hematocrit, Epoetin Starting Dosage, and Creatinine test results. OR Required on DMERC service lines to report the Patient's Height from the Certificate of Medical Necessity (CMN). Use HT qualifier. If not required by this implementation guide, do not send. Example MEAOGR100000000000~ Max use 5 Optional MEA-01 737 Measurement Reference Identification Code Identifier (ID) Required Code identifying the broad category to which a measurement applies OG Original Use OG to report Starting Dosage. TR Test Results MEA-02 738 Measurement Qualifier Identifier (ID) Required Code identifying a specific product or process characteristic to which a measurement applies HT Height R1 Hemoglobin R2 Hematocrit R3 Epoetin Starting Dosage R4 Creatinine MEA-03 739 Test Results Min 1 Max 15 Decimal number (R) Required The value of the measurement 1/30/25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 566/665 CN1 4650 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > Service Line Number Loop > CN1 Contract Information To specify basic data about the contract or contract line item Usage notes The developers of this implementation guide note that the CN1 segment is for use only for post-adjudicated claims, which do not meet the definition of a health care claim under HIPAA. Consequently, at the time of this writing, the CN1 segment is for non- HIPAA use only. Required when the submitter is contractually obligated to supply this information on post-adjudicated claims. If not required by this implementation guide, do not send. Example CN105000000000000000000XXX00000XXXX~ Max use 1 Optional CN1-01 1166 Contract Type Code Identifier (ID) Required Code identifying a contract type 01 Diagnosis Related Group (DRG) 02 Per Diem 03 Variable Per Diem 04 Flat 05 Capitated 06 Percent 09 Other CN1-02 782 Contract Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount CN102 is the contract amount. CN1-03 332 Contract Percentage Min 1 Max 6 Decimal number (R) Optional Percent given in decimal format (e.g., 0.0 through 100.0 represents 0% through 100%) CN103 is the allowance or charge percent. CN1-04 127 Contract Code Min 1 Max 50 String (AN) Optional Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier CN104 is the contract code. CN1-05 338 Terms Discount Percentage Min 1 Max 6 Decimal number (R) Optional 1/30/25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 567/665 Terms discount percentage, expressed as a percent, available to the purchaser if an invoice is paid on or before the Terms Discount Due Date CN1-06 799 Contract Version Identifier Min 1 Max 30 String (AN) Optional Revision level of a particular format, program, technique or algorithm CN106 is an additional identifying number for the contract. 1/30/25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 568/665 REF 4700 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > Service Line Number Loop > REF Adjusted Repriced Line Item Reference Number To specify identifying information Usage notes Required when a repricing (pricing) organization needs to have an identifying number on an adjusted service line in their submission to their payer organization. This segment is not completed by providers. If not required by this implementation guide, do not send. Example REF9DXXX~ Variants (all may be used) REF Clinical Laboratory Improvement Amendment (CLIA) Number REF Immunization Batch Number REF Line Item Control Number REF Mammography Certification Number REF Prior Authorization REF Referral Number REF Referring Clinical Laboratory Improvement Amendment (CLIA) Facility Identification REF Repriced Line Item Reference Number Max use 1 Optional REF-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification 9D Adjusted Repriced Line Item Reference Number REF-02 127 Adjusted Repriced Line Item Reference Number String (AN) Required Min 1 Max 50 Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier 1/30/25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 569/665 REF 4700 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > Service Line Number Loop > REF Clinical Laboratory Improvement Amendment (CLIA) Number To specify identifying information Usage notes Required for all CLIA certified facilities performing CLIA covered laboratory services and the number is different than the CLIA number reported at the claim level (Loop ID- 2300). If not required by this implementation guide, do not send.; Example REFX4XXXX~ Variants (all may be used) REF Adjusted Repriced Line Item Reference Number REF Immunization Batch Number REF Line Item Control Number REF Mammography Certification Number REF Prior Authorization REF Referral	Home State Health 837 Health Care Claim_ Professional.pdf
Flat 05 Capitated 06 Percent 09 Other CN1-02 782 Contract Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount CN102 is the contract amount. CN1-03 332 Contract Percentage Min 1 Max 6 Decimal number (R) Optional Percent given in decimal format (e.g., 0.0 through 100.0 represents 0% through 100%) CN103 is the allowance or charge percent. CN1-04 127 Contract Code Min 1 Max 50 String (AN) Optional Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier CN104 is the contract code. CN1-05 338 Terms Discount Percentage Min 1 Max 6 Decimal number (R) Optional 1/30/25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 567/665 Terms discount percentage, expressed as a percent, available to the purchaser if an invoice is paid on or before the Terms Discount Due Date CN1-06 799 Contract Version Identifier Min 1 Max 30 String (AN) Optional Revision level of a particular format, program, technique or algorithm CN106 is an additional identifying number for the contract. 1/30/25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 568/665 REF 4700 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > Service Line Number Loop > REF Adjusted Repriced Line Item Reference Number To specify identifying information Usage notes Required when a repricing (pricing) organization needs to have an identifying number on an adjusted service line in their submission to their payer organization. This segment is not completed by providers. If not required by this implementation guide, do not send. Example REF9DXXX~ Variants (all may be used) REF Clinical Laboratory Improvement Amendment (CLIA) Number REF Immunization Batch Number REF Line Item Control Number REF Mammography Certification Number REF Prior Authorization REF Referral Number REF Referring Clinical Laboratory Improvement Amendment (CLIA) Facility Identification REF Repriced Line Item Reference Number Max use 1 Optional REF-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification 9D Adjusted Repriced Line Item Reference Number REF-02 127 Adjusted Repriced Line Item Reference Number String (AN) Required Min 1 Max 50 Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier 1/30/25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 569/665 REF 4700 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > Service Line Number Loop > REF Clinical Laboratory Improvement Amendment (CLIA) Number To specify identifying information Usage notes Required for all CLIA certified facilities performing CLIA covered laboratory services and the number is different than the CLIA number reported at the claim level (Loop ID- 2300). If not required by this implementation guide, do not send.; Example REFX4XXXX~ Variants (all may be used) REF Adjusted Repriced Line Item Reference Number REF Immunization Batch Number REF Line Item Control Number REF Mammography Certification Number REF Prior Authorization REF Referral Number REF Referring Clinical Laboratory Improvement Amendment (CLIA) Facility Identification REF Repriced Line Item Reference Number Max use 1 Optional REF-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification X4 Clinical Laboratory Improvement Amendment Number REF-02 127 Clinical Laboratory Improvement Amendment Number String (AN) Required Min 1 Max 50 Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier 1/30/25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 570/665 REF 4700 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > Service Line Number Loop > REF Immunization Batch Number To specify identifying information Usage notes Required when mandated by state or federal law or regulations to report an Immunization Batch Number. If not required by this implementation guide, do not send. Example REFBTX~ Variants (all may be used) REF Adjusted Repriced Line Item Reference Number REF Clinical Laboratory Improvement Amendment (CLIA) Number REF Line Item Control Number REF Mammography Certification Number REF Prior Authorization REF Referral Number REF Referring Clinical Laboratory Improvement Amendment (CLIA) Facility Identification REF Repriced Line Item Reference Number Max use 1 Optional REF-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification BT Batch Number REF-02 127 Immunization Batch Number Min 1 Max 50 String (AN) Required Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier 1/30/25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 571/665 REF 4700 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > Service Line Number Loop > REF Line Item Control Number To specify identifying information Usage notes Required when the submitter needs a line item control number for subsequent communications to or from the payer. If not required by this implementation guide, do not send. The line item control number must be unique within a patient control number (CLM01). Payers are required to return this number in the remittance advice transaction (835) if the provider sends it to them in the 837 and adjudication is based upon line item detail regardless of whether bundling or unbundling has occurred. Submitters are STRONGLY encouraged to routinely send a unique line item control number on all service lines, particularly if the submitter automatically posts their remittance advice. Submitting a unique line item control number allows the capability to automatically post by service line. Example REF6RXXX~ Variants (all may be used) REF Adjusted Repriced Line Item Reference Number REF Clinical Laboratory Improvement Amendment (CLIA) Number REF Immunization Batch Number REF Mammography Certification Number REF Prior Authorization REF Referral Number REF Referring Clinical Laboratory Improvement Amendment (CLIA) Facility Identification REF Repriced Line Item Reference Number Max use 1 Optional REF-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification 6R Provider Control Number REF-02 127 Line Item Control Number Min 1 Max 50 String (AN) Required Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier Usage notes The maximum number of characters to be supported for this field is 30'. A submitter may submit fewer characters depending upon their needs. However, the HIPAA maximum requirement to be supported by any 1/30/25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 572/665 receiving system is 30'. Characters beyond 30 are not required to be stored nor returned by any 837-receiving system. 1/30/25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 573/665 REF 4700 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > Service Line Number Loop > REF Mammography Certification Number To specify identifying information Usage notes Required when mammography services are rendered by a certified mammography provider and the mammography certification number is different than that sent in Loop ID-2300. If not required by this implementation guide, do not send. Example REFEWXXX~ Variants (all may be used) REF Adjusted Repriced Line Item Reference Number REF Clinical Laboratory Improvement Amendment (CLIA) Number REF Immunization Batch Number REF Line Item Control Number REF Prior Authorization REF Referral Number REF Referring Clinical Laboratory Improvement Amendment (CLIA) Facility Identification REF Repriced Line Item Reference Number Max use 1 Optional REF-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification EW Mammography Certification Number REF-02 127 Mammography Certification Number Min 1 Max 50 String (AN) Required Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier 1/30/25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 574/665 REF 4700 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > Service Line Number Loop > REF Prior Authorization To specify identifying information Usage notes Required when service line involved a prior authorization number that is different than the number reported at the claim level (Loop ID-2300). If not required by this implementation guide, do not send. When it is necessary to report one or more non-destination payer Prior Authorization Numbers, the composite data element in REF04 is used to identify the payer which assigned this number. Example REFG1XXXXXX*2U>XXX~ Variants (all may be used) REF Adjusted Repriced Line Item Reference Number REF Clinical Laboratory Improvement Amendment (CLIA) Number REF Immunization Batch Number REF Line Item Control Number REF Mammography Certification Number REF Referral Number REF Referring Clinical Laboratory Improvement Amendment (CLIA) Facility Identification REF Repriced Line Item Reference Number Max use 5 Optional REF-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification G1 Prior Authorization Number REF-02 127 Prior Authorization or Referral Number Min 1 Max 50 String (AN) Required Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier REF-04 C040 Reference Identifier To identify one or more reference numbers or identification numbers as specified by the Reference Qualifier - REF04 contains data relating to the value cited in REF02. Usage notes Required when the Prior Authorization Number reported in REF02 of this segment is for a non-destination payer. Max use 1 Optional 1/30/25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 575/665 C040-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification 2U Payer Identification Number C040-02 127 Other Payer Primary Identifier Min 1 Max 50 String (AN) Required Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier Usage notes The payer identifier reported in this field must match the cooresponding payer identifier reported in Loop ID-2330B NM109. 1/30/25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 576/665 REF 4700 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > Service Line Number Loop > REF Referral Number To specify identifying information Usage notes Required when this service line involved a referral number that is different than the number reported at the claim level (Loop-ID 2300). If not required by this implementation guide, do not send. When it is necessary to report one or more non-destination payer Referral Numbers, the composite data element in REF04 is used to identify the payer which assigned this referral number. Example REF9FX*2U>XXXXXX~ Variants (all may be used) REF Adjusted Repriced Line Item Reference Number REF Clinical Laboratory Improvement Amendment (CLIA) Number REF Immunization Batch Number REF Line Item Control Number REF Mammography Certification Number REF Prior Authorization REF Referring Clinical Laboratory Improvement Amendment (CLIA) Facility Identification REF Repriced Line Item Reference Number Max use 5 Optional REF-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification 9F Referral Number REF-02 127 Referral Number Min 1 Max 50 String (AN) Required Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier REF-04 C040 Reference Identifier To identify one or more reference numbers or identification numbers as specified by the Reference Qualifier - REF04 contains data relating to the value cited in REF02. Usage notes Required when the Referral Number reported in REF02 of this segment is for a non- destination payer. Max use 1 Optional 1/30/25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 577/665 C040-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification 2U Payer Identification Number C040-02 127 Other Payer Primary Identifier Min 1 Max 50 String (AN) Required Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier Usage notes The payer identifier reported in this field must match the cooresponding payer identifier reported in Loop ID-2330B NM109. 1/30/25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 578/665 REF	Home State Health 837 Health Care Claim_ Professional.pdf
Identifier To identify one or more reference numbers or identification numbers as specified by the Reference Qualifier - REF04 contains data relating to the value cited in REF02. Usage notes Required when the Prior Authorization Number reported in REF02 of this segment is for a non-destination payer. Max use 1 Optional 1/30/25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 575/665 C040-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification 2U Payer Identification Number C040-02 127 Other Payer Primary Identifier Min 1 Max 50 String (AN) Required Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier Usage notes The payer identifier reported in this field must match the cooresponding payer identifier reported in Loop ID-2330B NM109. 1/30/25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 576/665 REF 4700 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > Service Line Number Loop > REF Referral Number To specify identifying information Usage notes Required when this service line involved a referral number that is different than the number reported at the claim level (Loop-ID 2300). If not required by this implementation guide, do not send. When it is necessary to report one or more non-destination payer Referral Numbers, the composite data element in REF04 is used to identify the payer which assigned this referral number. Example REF9FX*2U>XXXXXX~ Variants (all may be used) REF Adjusted Repriced Line Item Reference Number REF Clinical Laboratory Improvement Amendment (CLIA) Number REF Immunization Batch Number REF Line Item Control Number REF Mammography Certification Number REF Prior Authorization REF Referring Clinical Laboratory Improvement Amendment (CLIA) Facility Identification REF Repriced Line Item Reference Number Max use 5 Optional REF-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification 9F Referral Number REF-02 127 Referral Number Min 1 Max 50 String (AN) Required Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier REF-04 C040 Reference Identifier To identify one or more reference numbers or identification numbers as specified by the Reference Qualifier - REF04 contains data relating to the value cited in REF02. Usage notes Required when the Referral Number reported in REF02 of this segment is for a non- destination payer. Max use 1 Optional 1/30/25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 577/665 C040-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification 2U Payer Identification Number C040-02 127 Other Payer Primary Identifier Min 1 Max 50 String (AN) Required Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier Usage notes The payer identifier reported in this field must match the cooresponding payer identifier reported in Loop ID-2330B NM109. 1/30/25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 578/665 REF 4700 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > Service Line Number Loop > REF Referring Clinical Laboratory Improvement Amendment (CLIA) Facility Identification To specify identifying information Usage notes Required for claims for any laboratory that referred tests to another laboratory covered by the CLIA Act that is billed on this line. If not required by this implementation guide, do not send. Example REFF4XXXXXX~ Variants (all may be used) REF Adjusted Repriced Line Item Reference Number REF Clinical Laboratory Improvement Amendment (CLIA) Number REF Immunization Batch Number REF Line Item Control Number REF Mammography Certification Number REF Prior Authorization REF Referral Number REF Repriced Line Item Reference Number Max use 1 Optional REF-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification F4 Facility Certification Number REF-02 127 Referring CLIA Number Min 1 Max 50 String (AN) Required Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier 1/30/25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 579/665 REF 4700 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > Service Line Number Loop > REF Repriced Line Item Reference Number To specify identifying information Usage notes Required when a repricing (pricing) organization needs to have an identifying number on the service line in their submission to their payer organization. This segment is not completed by providers. If not required by this implementation guide, do not send. Example REF9BXXXXX~ Variants (all may be used) REF Adjusted Repriced Line Item Reference Number REF Clinical Laboratory Improvement Amendment (CLIA) Number REF Immunization Batch Number REF Line Item Control Number REF Mammography Certification Number REF Prior Authorization REF Referral Number REF Referring Clinical Laboratory Improvement Amendment (CLIA) Facility Identification Max use 1 Optional REF-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification 9B Repriced Line Item Reference Number REF-02 127 Repriced Line Item Reference Number Min 1 Max 50 String (AN) Required Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier 1/30/25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 580/665 AMT 4750 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > Service Line Number Loop > AMT Postage Claimed Amount To indicate the total monetary amount Usage notes Required when service line charge (SV102) includes postage amount claimed in this service line. If not required by this implementation guide, do not send. When reporting the Postage Claimed Amount (AMT02), the amount reported in the Line Item Charge Amount (SV102) for this service line must include the amount reported in the Postage Claimed Amount. Example AMTF4000000000000~ Variants (all may be used) AMT Sales Tax Amount Max use 1 Optional AMT-01 522 Amount Qualifier Code Identifier (ID) Required Code to qualify amount F4 Postage Claimed AMT-02 782 Postage Claimed Amount Min 1 Max 15 Decimal number (R) Required Monetary amount 1/30/25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 581/665 AMT 4750 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > Service Line Number Loop > AMT Sales Tax Amount To indicate the total monetary amount Usage notes Required when sales tax applies to the service line and the submitter is required to report that information to the receiver. If not required by this implementation guide, do not send. When reporting the Sales Tax Amount (AMT02), the amount reported in the Line Item Charge Amount (SV102) for this service line must include the amount reported in the Sales Tax Amount. Example AMTT0000000000~ Variants (all may be used) AMT Postage Claimed Amount Max use 1 Optional AMT-01 522 Amount Qualifier Code Identifier (ID) Required Code to qualify amount T Tax AMT-02 782 Sales Tax Amount Min 1 Max 15 Decimal number (R) Required Monetary amount 1/30/25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 582/665 K3 4800 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > Service Line Number Loop > K3 File Information To transmit a fixed-format record or matrix contents Usage notes Required when ALL of the following conditions are met: A regulatory agency concludes it must use the K3 to meet an emergency legislative requirement; The administering regulatory agency or other state organization has completed each one of the following steps: contacted the X12N workgroup, requested a review of the K3 data requirement to ensure there is not an existing method within the implementation guide to meet this requirement X12N determines that there is no method to meet the requirement. If not required by this implementation guide, do not send. At the time of publication of this implementation, K3 segments have no specific use. The K3 segment is expected to be used only when necessary to meet the unexpected data requirement of a legislative authority. Before this segment can be used : The X12N Health Care Claim workgroup must conclude there is no other available option in the implementation guide to meet the emergency legislative requirement. The requestor must submit a proposal for approval accompanied by the relevant business documentation to the X12N Health Care Claim workgroup chairs and receive approval for the request. Upon review of the request, X12N will issue an approval or denial decision to the requesting entity. Approved usage(s) of the K3 segment will be reviewed by the X12N Health Care Claim workgroup to develop a permanent change to include the business case in future transaction implementations. Only when all of the requirements above have been met, may the regulatory agency require the temporary use of the K3 segment. X12N will submit the necessary data maintenance and refer the request to the appropriate data content committee(s). Example K3XXX~ Max use 10 Optional K3-01 449 Fixed Format Information Min 1 Max 80 String (AN) Required Data in fixed format agreed upon by sender and receiver 1/30/25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 583/665 NTE 4850 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > Service Line Number Loop > NTE Line Note To transmit information in a free-form format, if necessary, for comment or special instruction Usage notes Required when in the judgment of the provider, the information is needed to substantiate the medical treatment and is not supported elsewhere within the claim data set. If not required by this implementation guide, do not send. Use SV101-7 to describe non-specific procedure codes. Do not use this NTE Segment to describe a non-specific procedure code. If an NDC code is reported in Loop 2410, do not use this segment for a description of the procedure code. The NDC in loop 2410 will provide the description. Example NTEADDXX~ Variants (all may be used) NTE Third Party Organization Notes Max use 1 Optional NTE-01 363 Note Reference Code Identifier (ID) Required Code identifying the functional area or purpose for which the note applies ADD Additional Information DCP Goals, Rehabilitation Potential, or Discharge Plans NTE-02 352 Line Note Text Min 1 Max 80 String (AN) Required A free-form description to clarify the related data elements and their content 1/30/25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 584/665 NTE 4850 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > Service Line Number Loop > NTE Third Party Organization Notes To transmit information in a free-form format, if necessary, for comment or special instruction Usage notes Required when the TPO/repricer needs to forward additional information to the payer. This segment is not completed by providers. If not required by this implementation guide, do not send. Example NTETPOXXX~ Variants (all may be used) NTE Line Note Max use 1 Optional NTE-01 363 Note Reference Code Identifier (ID) Required Code identifying the functional area or purpose for which the note applies TPO Third Party Organization Notes NTE-02 352 Line Note Text Min 1 Max 80 String (AN) Required A free-form description to clarify the related data elements and their content 1/30/25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 585/665 PS1 4880 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > Service Line Number Loop > PS1 Purchased Service Information To specify the information about services that are purchased Usage notes Required on non-vision service lines when adjudication is known to be impacted by the charge amount for services purchased from another source. OR Required on vision service lines when adjudication is known to be impacted by the	Home State Health 837 Health Care Claim_ Professional.pdf
data content committee(s). Example K3XXX~ Max use 10 Optional K3-01 449 Fixed Format Information Min 1 Max 80 String (AN) Required Data in fixed format agreed upon by sender and receiver 1/30/25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 583/665 NTE 4850 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > Service Line Number Loop > NTE Line Note To transmit information in a free-form format, if necessary, for comment or special instruction Usage notes Required when in the judgment of the provider, the information is needed to substantiate the medical treatment and is not supported elsewhere within the claim data set. If not required by this implementation guide, do not send. Use SV101-7 to describe non-specific procedure codes. Do not use this NTE Segment to describe a non-specific procedure code. If an NDC code is reported in Loop 2410, do not use this segment for a description of the procedure code. The NDC in loop 2410 will provide the description. Example NTEADDXX~ Variants (all may be used) NTE Third Party Organization Notes Max use 1 Optional NTE-01 363 Note Reference Code Identifier (ID) Required Code identifying the functional area or purpose for which the note applies ADD Additional Information DCP Goals, Rehabilitation Potential, or Discharge Plans NTE-02 352 Line Note Text Min 1 Max 80 String (AN) Required A free-form description to clarify the related data elements and their content 1/30/25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 584/665 NTE 4850 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > Service Line Number Loop > NTE Third Party Organization Notes To transmit information in a free-form format, if necessary, for comment or special instruction Usage notes Required when the TPO/repricer needs to forward additional information to the payer. This segment is not completed by providers. If not required by this implementation guide, do not send. Example NTETPOXXX~ Variants (all may be used) NTE Line Note Max use 1 Optional NTE-01 363 Note Reference Code Identifier (ID) Required Code identifying the functional area or purpose for which the note applies TPO Third Party Organization Notes NTE-02 352 Line Note Text Min 1 Max 80 String (AN) Required A free-form description to clarify the related data elements and their content 1/30/25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 585/665 PS1 4880 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > Service Line Number Loop > PS1 Purchased Service Information To specify the information about services that are purchased Usage notes Required on non-vision service lines when adjudication is known to be impacted by the charge amount for services purchased from another source. OR Required on vision service lines when adjudication is known to be impacted by the acquisition cost of lenses. If not required by this implementation guide, do not send. Example PS1XXXXXX00000000000000~ Max use 1 Optional PS1-01 127 Purchased Service Provider Identifier Min 1 Max 50 String (AN) Required Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier PS101 is provider identification number. Usage notes This must be the identifier from the Purchased Service Provider Loop (Loop ID-2420B). When the Secondary Identifier REF is used, that is the identifier to be reported. If not present, use the identifier in NM109. PS1-02 782 Purchased Service Charge Amount Min 1 Max 15 Decimal number (R) Required Monetary amount PS102 is cost of the purchased service. 1/30/25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 586/665 HCP 4920 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > Service Line Number Loop > HCP Line Pricing/Repricing Information To specify pricing or repricing information about a health care claim or line item Usage notes This information is specific to the destination payer reported in Loop ID-2010BB. For capitated encounters, pricing or repricing information usually is not applicable and is provided to qualify other information within the claim. Required when this information is deemed necessary by the repricer. The segment is not completed by providers. The information is completed by repricers only. If not required by this implementation guide, do not send. Example HCP010000000000XXX00000000X00000000000*W KXMJ000T526~ If either Product or Service ID Qualifier (HCP-09) or Repriced Approved HCPCS Code (HCP-10) is present, then the other is required If either Unit or Basis for Measurement Code (HCP-11) or Repriced Approved Service Unit Count (HCP-12) is present, then the other is required Max use 1 Optional HCP-01 1473 Pricing Methodology Identifier (ID) Required Code specifying pricing methodology at which the claim or line item has been priced or repriced Usage notes Specific code use is determined by Trading Partner Agreement due to the variances in contracting policies in the industry. 00 Zero Pricing (Not Covered Under Contract) 01 Priced as Billed at 100% 02 Priced at the Standard Fee Schedule 03 Priced at a Contractual Percentage 04 Bundled Pricing 05 Peer Review Pricing 06 Per Diem Pricing 07 Flat Rate Pricing 08 Combination Pricing 09 Maternity Pricing 10 Other Pricing 11 Lower of Cost 12 Ratio of Cost 13 Cost Reimbursed 14 Adjustment Pricing HCP-02 782 Repriced Allowed Amount Min 1 Max 15 Decimal number (R) Required Monetary amount 1/30/25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 587/665 HCP02 is the allowed amount. HCP-03 782 Repriced Saving Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount HCP03 is the savings amount. HCP-04 127 Repricing Organization Identifier Min 1 Max 50 String (AN) Optional Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier HCP04 is the repricing organization identification number. HCP-05 118 Repricing Per Diem or Flat Rate Amount Decimal number (R) Optional Min 1 Max 9 Rate expressed in the standard monetary denomination for the currency specified HCP05 is the pricing rate associated with per diem or flat rate repricing. HCP-06 127 Repriced Approved Ambulatory Patient Group Code String (AN) Optional Min 1 Max 50 Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier HCP06 is the approved DRG code. HCP06, HCP07, HCP08, HCP10, and HCP12 are fields that will contain different values from the original submitted values. HCP-07 782 Repriced Approved Ambulatory Patient Group Amount Decimal number (R) Optional Min 1 Max 15 Monetary amount HCP07 is the approved DRG amount. HCP-09 235 Product or Service ID Qualifier Identifier (ID) Optional Code identifying the type/source of the descriptive number used in Product/Service ID (234) ER Jurisdiction Specific Procedure and Supply Codes This code set is not allowed for use under HIPAA at the time of this writing. The qualifier can only be used: If a new rule names the Jurisdiction Specific Procedure and Supply Codes as an allowable code set under HIPAA, 1/30/25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 588/665 OR The Secretary grants an exception to use the code set as a pilot project as allowed under the law, OR For claims which are not covered under HIPAA. HC Health Care Financing Administration Common Procedural Coding System (HCPCS) Codes Because the AMA's CPT codes are also level 1 HCPCS codes, they are reported under HC. IV Home Infusion EDI Coalition (HIEC) Product/Service Code This code set is not allowed for use under HIPAA at the time of this writing. The qualifier can only be used: If a new rule names the Home Infusion EDI Coalition (HIEC) Product/Service Codes as an allowable code set under HIPAA, OR The Secretary grants an exception to use the code set as a pilot project as allowed under the law, OR For claims which are not covered under HIPAA.; WK Advanced Billing Concepts (ABC) Codes At the time of this writing, this code set has been approved by the Secretary of HHS as a pilot project allowed under HIPAA law. The qualifier may only be used in transactions covered under HIPAA; By parties registered in the pilot project and their trading partners, OR If a new rule names the Complementary, Alternative, or Holistic Procedure Codes as an allowable code set under HIPAA, OR For claims which are not covered under HIPAA. HCP-10 234 Repriced Approved HCPCS Code Min 1 Max 48 String (AN) Optional Identifying number for a product or service HCP10 is the approved procedure code. HCP-11 355 Unit or Basis for Measurement Code Identifier (ID) Optional Code specifying the units in which a value is being expressed, or manner in which a measurement has been taken MJ Minutes UN Unit HCP-12 380 Repriced Approved Service Unit Count Decimal number (R) Optional Min 1 Max 15 Numeric value of quantity HCP12 is the approved service units or inpatient days. Usage notes Note: When a decimal is needed to report units, include it in this element, for example, "15.6". 1/30/25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 589/665 The maximum length for this field is 8 digits excluding the decimal. When a decimal is used, the maximum number of digits allowed to the right of the decimal is three. HCP-13 901 Reject Reason Code Identifier (ID) Optional Code assigned by issuer to identify reason for rejection HCP13 is the rejection message returned from the third party organization. T1 Cannot Identify Provider as TPO (Third Party Organization) Participant T2 Cannot Identify Payer as TPO (Third Party Organization) Participant T3 Cannot Identify Insured as TPO (Third Party Organization) Participant T4 Payer Name or Identifier Missing T5 Certification Information Missing T6 Claim does not contain enough information for re-pricing HCP-14 1526 Policy Compliance Code Identifier (ID) Optional Code specifying policy compliance 1 Procedure Followed (Compliance) 2 Not Followed - Call Not Made (Non-Compliance Call Not Made) 3 Not Medically Necessary (Non-Compliance Non-Medically Necessary) 4 Not Followed Other (Non-Compliance Other) 5 Emergency Admit to Non-Network Hospital HCP-15 1527 Exception Code Identifier (ID) Optional Code specifying the exception reason for consideration of out-of-network health care services HCP15 is the exception reason generated by a third party organization. 1 Non-Network Professional Provider in Network Hospital 2 Emergency Care 3 Services or Specialist not in Network 4 Out-of-Service Area 5 State Mandates 6 Other 1/30/25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 590/665 2410 Drug Identification Loop Max 1 Optional LIN 4930 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > Service Line Number Loop > Drug Identification Loop > LIN Drug Identification To specify basic item identification data Usage notes Required when government regulation mandates that prescribed drugs and biologics are reported with NDC numbers. OR Required when the provider or submitter chooses to report NDC numbers to enhance the claim reporting or adjudication processes. OR Required when an HHS approved pilot project specifies reporting of Universal Product Number (UPN) by parties registered in the pilot and their trading partners. OR Required when government regulation mandates that medical and surgical supplies are reported with UPN's. If not required by this implementation guide, do not send. Drugs and biologics reported in this segment are a further specification of service(s) described in the SV1 segment of this Service Line Loop ID-2400. Example LINUKXXXXXX~ Max use 1 Required LIN-02 235 Product or Service ID Qualifier Identifier (ID) Required Code identifying the type/source of the descriptive number used in Product/Service ID (234) LIN02 through LIN31 provide for fifteen different product/service IDs for each item. For example: Case, Color, Drawing No., U.P.C. No., ISBN No., Model No., or SKU. Usage notes At the time of this writing, UPN code sets designated by values EN, EO, HI, ON, UK, and UP have been approved by the Secretary of HHS as a pilot project allowed under HIPAA law. During the	Home State Health 837 Health Care Claim_ Professional.pdf
is needed to report units, include it in this element, for example, "15.6". 1/30/25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 589/665 The maximum length for this field is 8 digits excluding the decimal. When a decimal is used, the maximum number of digits allowed to the right of the decimal is three. HCP-13 901 Reject Reason Code Identifier (ID) Optional Code assigned by issuer to identify reason for rejection HCP13 is the rejection message returned from the third party organization. T1 Cannot Identify Provider as TPO (Third Party Organization) Participant T2 Cannot Identify Payer as TPO (Third Party Organization) Participant T3 Cannot Identify Insured as TPO (Third Party Organization) Participant T4 Payer Name or Identifier Missing T5 Certification Information Missing T6 Claim does not contain enough information for re-pricing HCP-14 1526 Policy Compliance Code Identifier (ID) Optional Code specifying policy compliance 1 Procedure Followed (Compliance) 2 Not Followed - Call Not Made (Non-Compliance Call Not Made) 3 Not Medically Necessary (Non-Compliance Non-Medically Necessary) 4 Not Followed Other (Non-Compliance Other) 5 Emergency Admit to Non-Network Hospital HCP-15 1527 Exception Code Identifier (ID) Optional Code specifying the exception reason for consideration of out-of-network health care services HCP15 is the exception reason generated by a third party organization. 1 Non-Network Professional Provider in Network Hospital 2 Emergency Care 3 Services or Specialist not in Network 4 Out-of-Service Area 5 State Mandates 6 Other 1/30/25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 590/665 2410 Drug Identification Loop Max 1 Optional LIN 4930 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > Service Line Number Loop > Drug Identification Loop > LIN Drug Identification To specify basic item identification data Usage notes Required when government regulation mandates that prescribed drugs and biologics are reported with NDC numbers. OR Required when the provider or submitter chooses to report NDC numbers to enhance the claim reporting or adjudication processes. OR Required when an HHS approved pilot project specifies reporting of Universal Product Number (UPN) by parties registered in the pilot and their trading partners. OR Required when government regulation mandates that medical and surgical supplies are reported with UPN's. If not required by this implementation guide, do not send. Drugs and biologics reported in this segment are a further specification of service(s) described in the SV1 segment of this Service Line Loop ID-2400. Example LIN*UKXXXXXX~ Max use 1 Required LIN-02 235 Product or Service ID Qualifier Identifier (ID) Required Code identifying the type/source of the descriptive number used in Product/Service ID (234) LIN02 through LIN31 provide for fifteen different product/service IDs for each item. For example: Case, Color, Drawing No., U.P.C. No., ISBN No., Model No., or SKU. Usage notes At the time of this writing, UPN code sets designated by values EN, EO, HI, ON, UK, and UP have been approved by the Secretary of HHS as a pilot project allowed under HIPAA law. During the pilot, these code values may only be used by parties registered in the pilot project and their trading partners. Beyond the pilot, these codes may only be used if mandated by government regulation. EN EAN/UCC - 13 EO EAN/UCC - 8 HI HIBC (Health Care Industry Bar Code) Supplier Labeling Standard Primary Data Message N4 National Drug Code in 5-4-2 Format ON Customer Order Number UK GTIN 14-digit Data Structure UP UCC - 12 1/30/25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 591/665 LIN-03 234 National Drug Code or Universal Product Number String (AN) Required Min 1 Max 48 Identifying number for a product or service 1/30/25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 592/665 CTP 4940 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > Service Line Number Loop > Drug Identification Loop > CTP Drug Quantity To specify pricing information Example CTP***000000ML~ Max use 1 Required CTP-04 380 National Drug Unit Count Min 1 Max 15 Decimal number (R) Required Numeric value of quantity CTP-05 C001 Composite Unit of Measure To identify a composite unit of measure (See Figures Appendix for examples of use) Max use 1 Required C001-01 355 Code Qualifier Identifier (ID) Required Code specifying the units in which a value is being expressed, or manner in which a measurement has been taken F2 International Unit GR Gram ME Milligram ML Milliliter UN Unit 1/30/25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 593/665 2410 Drug Identification Loop end REF 4950 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > Service Line Number Loop > Drug Identification Loop > REF Prescription or Compound Drug Association Number To specify identifying information Usage notes Required when dispensing of the drug has been done with an assigned prescription number. OR Required when the provided medication involves the compounding of two or more drugs being reported and there is no prescription number. If not required by this implementation guide, do not send. In cases where a compound drug is being billed, the components of the compound will all have the same prescription number. Payers receiving the claim can relate all the components by matching the prescription number. For cases where the drug is provided without a prescription (for example, from a physician's office), the value provided in this segment is a "link sequence number". The link sequence number is a provider assigned number that is unique to this claim. Its purpose is to enable the receiver to piece together the components of the compound. Example REFVYX~ Max use 1 Optional REF-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification VY Link Sequence Number XZ Pharmacy Prescription Number REF-02 127 Prescription Number Min 1 Max 50 String (AN) Required Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier 1/30/25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 594/665 2420A Rendering Provider Name Loop Max 1 Optional Variants (all may be used) Purchased Service Provider Name Loop Service Facility Location Name Loop Supervising Provider Name Loop Ordering Provider Name Loop Referring Provider Name Loop Ambulance Pick-up Location Loop Ambulance Drop-off Location Loop NM1 5000 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > Service Line Number Loop > Rendering Provider Name Loop > NM1 Rendering Provider Name To supply the full name of an individual or organizational entity Usage notes Used for all types of rendering providers including laboratories. The Rendering Provider is the person or company (laboratory or other facility) who rendered the care. In the case where a substitute provider (locum tenens) was used, enter that provider's information here. Required when the Rendering Provider NM1 information is different than that carried in the Loop ID-2310B Rendering Provider. OR Required when Loop ID-2310B Rendering Provider is not used AND this particular line item has different Rendering Provider information than that which is carried in Loop ID- 2010AA Billing Provider. If not required by this implementation guide, do not send.; Example NM1822XXXXXXXXXXXXXXX~ If either Identification Code Qualifier (NM1-08) or Rendering Provider Identifier (NM1-09) is present, then the other is required Max use 1 Required NM1-01 98 Entity Identifier Code Identifier (ID) Required Code identifying an organizational entity, a physical location, property or an individual 82 Rendering Provider NM1-02 1065 Entity Type Qualifier Identifier (ID) Required Code qualifying the type of entity NM102 qualifies NM103. 1/30/25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 595/665 1 Person 2 Non-Person Entity NM1-03 1035 Rendering Provider Last or Organization Name String (AN) Required Min 1 Max 60 Individual last name or organizational name NM1-04 1036 Rendering Provider First Name Min 1 Max 35 String (AN) Optional Individual first name NM1-05 1037 Rendering Provider Middle Name or Initial Min 1 Max 25 String (AN) Optional Individual middle name or initial NM1-07 1039 Rendering Provider Name Suffix Min 1 Max 10 String (AN) Optional Suffix to individual name NM1-08 66 Identification Code Qualifier Identifier (ID) Optional Code designating the system/method of code structure used for Identification Code (67) XX Centers for Medicare and Medicaid Services National Provider Identifier NM1-09 67 Rendering Provider Identifier Min 2 Max 80 String (AN) Optional Code identifying a party or other code 1/30/25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 596/665 PRV 5050 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > Service Line Number Loop > Rendering Provider Name Loop > PRV Rendering Provider Specialty Information To specify the identifying characteristics of a provider Usage notes Required when adjudication is known to be impacted by the provider taxonomy code. If not required by this implementation guide, do not send. Example PRVPEPXCXXX~ Max use 1 Optional PRV-01 1221 Provider Code Identifier (ID) Required Code identifying the type of provider PE Performing PRV-02 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification PXC Health Care Provider Taxonomy Code PRV-03 127 Provider Taxonomy Code Min 1 Max 50 String (AN) Required Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier 1/30/25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 597/665 REF 5250 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > Service Line Number Loop > Rendering Provider Name Loop > REF Rendering Provider Secondary Identification To specify identifying information Usage notes Required prior to the mandated HIPAA National Provider Identifier (NPI) implementation date when an identification number other than the NPI is necessary for the receiver to identify the provider. OR Required on or after the mandated NPI Implementation Date when NM109 in this loop is not used and an identification number other than the NPI is necessary for the receiver to identify the provider. If not required by this implementation guide, do not send. When it is necessary to report one or more non-destination payer Secondary Identifiers, the composite data element in REF04 is used to identify the payer who assigned this identifier. Example REFG2XXXXXX**2U>XXXXXX~ Max use 20 Optional REF-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification 0B State License Number 1G Provider UPIN Number UPINs must be formatted as either X99999 or XXX999. G2 Provider Commercial Number This code designates a proprietary provider number for the destination payer identified in the Payer Name loop, Loop ID-2010BB, associated with this claim. This is to be used by all payers including: Medicare, Medicaid, Blue Cross, etc. LU Location Number REF-02 127 Rendering Provider Secondary Identifier Min 1 Max 50 String (AN) Required Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier REF-04 C040 Reference Identifier To identify one or more reference numbers or identification numbers as specified by the Reference Qualifier - REF04 contains data relating to the value cited in REF02. Usage notes Required when the identifier reported in REF02 of this segment is for a non-destination payer. Max use 1 Optional 1/30/25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 598/665 2420A Rendering Provider Name Loop end C040-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification 2U Payer Identification Number C040-02 127 Other Payer Primary Identifier Min 1 Max 50 String (AN) Required Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier Usage notes The payer identifier reported in this field must match the cooresponding payer identifier reported in Loop ID-2330B NM109. 1/30/25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI	Home State Health 837 Health Care Claim_ Professional.pdf
not required by this implementation guide, do not send. Example PRVPEPXCXXX~ Max use 1 Optional PRV-01 1221 Provider Code Identifier (ID) Required Code identifying the type of provider PE Performing PRV-02 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification PXC Health Care Provider Taxonomy Code PRV-03 127 Provider Taxonomy Code Min 1 Max 50 String (AN) Required Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier 1/30/25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 597/665 REF 5250 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > Service Line Number Loop > Rendering Provider Name Loop > REF Rendering Provider Secondary Identification To specify identifying information Usage notes Required prior to the mandated HIPAA National Provider Identifier (NPI) implementation date when an identification number other than the NPI is necessary for the receiver to identify the provider. OR Required on or after the mandated NPI Implementation Date when NM109 in this loop is not used and an identification number other than the NPI is necessary for the receiver to identify the provider. If not required by this implementation guide, do not send. When it is necessary to report one or more non-destination payer Secondary Identifiers, the composite data element in REF04 is used to identify the payer who assigned this identifier. Example REFG2XXXXXX2U>XXXXXX~ Max use 20 Optional REF-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification 0B State License Number 1G Provider UPIN Number UPINs must be formatted as either X99999 or XXX999. G2 Provider Commercial Number This code designates a proprietary provider number for the destination payer identified in the Payer Name loop, Loop ID-2010BB, associated with this claim. This is to be used by all payers including: Medicare, Medicaid, Blue Cross, etc. LU Location Number REF-02 127 Rendering Provider Secondary Identifier Min 1 Max 50 String (AN) Required Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier REF-04 C040 Reference Identifier To identify one or more reference numbers or identification numbers as specified by the Reference Qualifier - REF04 contains data relating to the value cited in REF02. Usage notes Required when the identifier reported in REF02 of this segment is for a non-destination payer. Max use 1 Optional 1/30/25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 598/665 2420A Rendering Provider Name Loop end C040-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification 2U Payer Identification Number C040-02 127 Other Payer Primary Identifier Min 1 Max 50 String (AN) Required Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier Usage notes The payer identifier reported in this field must match the cooresponding payer identifier reported in Loop ID-2330B NM109. 1/30/25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 599/665 2420B Purchased Service Provider Name Loop Max 1 Optional Variants (all may be used) Rendering Provider Name Loop Service Facility Location Name Loop Supervising Provider Name Loop Ordering Provider Name Loop Referring Provider Name Loop Ambulance Pick-up Location Loop Ambulance Drop-off Location Loop NM1 5000 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > Service Line Number Loop > Purchased Service Provider Name Loop > NM1 Purchased Service Provider Name To supply the full name of an individual or organizational entity Usage notes Required when the service reported in this line item is a purchased service. If not required by this implementation guide, do not send. Purchased services are situations where, for example, a physician purchases a diagnostic exam from an outside entity. Purchased services do not include substitute (locum tenens) provider situations. Example NM1QB1****XXXX~ If either Identification Code Qualifier (NM1-08) or Purchased Service Provider Identifier (NM1-09) is present, then the other is required Max use 1 Required NM1-01 98 Entity Identifier Code Identifier (ID) Required Code identifying an organizational entity, a physical location, property or an individual Usage notes The entity identifier in NM101 applies to all segments in this iteration of Loop ID-2420. QB Purchase Service Provider NM1-02 1065 Entity Type Qualifier Identifier (ID) Required Code qualifying the type of entity NM102 qualifies NM103. 1 Person 2 Non-Person Entity NM1-08 66 Identification Code Qualifier Identifier (ID) Optional 1/30/25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 600/665 Code designating the system/method of code structure used for Identification Code (67) XX Centers for Medicare and Medicaid Services National Provider Identifier NM1-09 67 Purchased Service Provider Identifier Min 2 Max 80 String (AN) Optional Code identifying a party or other code 1/30/25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 601/665 REF 5250 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > Service Line Number Loop > Purchased Service Provider Name Loop > REF Purchased Service Provider Secondary Identification To specify identifying information Usage notes Required prior to the mandated HIPAA National Provider Identifier (NPI) implementation date when an identification number other than the NPI is necessary for the receiver to identify the provider. OR Required on or after the mandated NPI Implementation Date when NM109 in this loop is not used and an identification number other than the NPI is necessary for the receiver to identify the provider. If not required by this implementation guide, do not send. When it is necessary to report one or more non-destination payer Secondary Identifiers, the composite data element in REF04 is used to identify the payer who assigned this identifier. Example REF1GXXX*2U>X~ Max use 20 Optional REF-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification 0B State License Number 1G Provider UPIN Number UPINs must be formatted as either X99999 or XXX999. G2 Provider Commercial Number This code designates a proprietary provider number for the destination payer identified in the Payer Name loop, Loop ID-2010BB, associated with this claim. This is to be used by all payers including: Medicare, Medicaid, Blue Cross, etc. REF-02 127 Purchased Service Provider Secondary Identifier String (AN) Required Min 1 Max 50 Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier REF-04 C040 Reference Identifier To identify one or more reference numbers or identification numbers as specified by the Reference Qualifier - REF04 contains data relating to the value cited in REF02. Usage notes Max use 1 Optional 1/30/25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 602/665 2420B Purchased Service Provider Name Loop end Required when the identifier reported in REF02 of this segment is for a non-destination payer. C040-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification 2U Payer Identification Number C040-02 127 Other Payer Primary Identifier Min 1 Max 50 String (AN) Required Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier Usage notes The payer identifier reported in this field must match the cooresponding payer identifier reported in Loop ID-2330B NM109. 1/30/25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 603/665 2420C Service Facility Location Name Loop Max 1 Optional Variants (all may be used) Rendering Provider Name Loop Purchased Service Provider Name Loop Supervising Provider Name Loop Ordering Provider Name Loop Referring Provider Name Loop Ambulance Pick-up Location Loop Ambulance Drop-off Location Loop NM1 5000 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > Service Line Number Loop > Service Facility Location Name Loop > NM1 Service Facility Location Name To supply the full name of an individual or organizational entity Usage notes When an organization health care provider's NPI is provided to identify the Service Location, the organization health care provider must be external to the entity identified as the Billing Provider (for example, reference lab). It is not permissible to report an organization health care provider NPI as the Service Location if the entity being identified is a component (for example, subpart) of the Billing Provider. In that case, the subpart must be the Billing Provider. Required when the location of health care service for this service line is different than that carried in Loop ID-2010AA Billing Provider or Loop ID-2310C Service Facility Location. If not required by this implementation guide, do not send. The purpose of this loop is to identify specifically where the service was rendered. When reporting ambulance services, do not use this loop. Use the pick-up (2420G) and drop-off location (2420H) loops elsewhere in this transaction.; Example NM1772X****XXXXXXX~ If either Identification Code Qualifier (NM1-08) or Laboratory or Facility Primary Identifier (NM1-09) is present, then the other is required Max use 1 Required NM1-01 98 Entity Identifier Code Identifier (ID) Required Code identifying an organizational entity, a physical location, property or an individual 77 Service Location NM1-02 1065 Entity Type Qualifier Identifier (ID) Required Code qualifying the type of entity NM102 qualifies NM103. 1/30/25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 604/665 2 Non-Person Entity NM1-03 1035 Laboratory or Facility Name Min 1 Max 60 String (AN) Required Individual last name or organizational name NM1-08 66 Identification Code Qualifier Identifier (ID) Optional Code designating the system/method of code structure used for Identification Code (67) XX Centers for Medicare and Medicaid Services National Provider Identifier NM1-09 67 Laboratory or Facility Primary Identifier Min 2 Max 80 String (AN) Optional Code identifying a party or other code 1/30/25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 605/665 N3 5140 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > Service Line Number Loop > Service Facility Location Name Loop > N3 Service Facility Location Address To specify the location of the named party Usage notes If service facility location is in an area where there are no street addresses, enter a description of where the service was rendered (for example, "crossroad of State Road 34 and 45" or "Exit near Mile marker 265 on Interstate 80".) Example N3XXXXXXXXX~ Max use 1 Required N3-01 166 Laboratory or Facility Address Line Min 1 Max 55 String (AN) Required Address information N3-02 166 Laboratory or Facility Address Line Min 1 Max 55 String (AN) Optional Address information 1/30/25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 606/665 N4 5200 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > Service Line Number Loop > Service Facility Location Name Loop > N4 Service Facility Location City, State, ZIP Code To specify the geographic place of the named party Example N4XXXXXXXXXXXXXXX~ Only one of Laboratory or Facility State or Province Code (N4-02) or Country Subdivision Code (N4-07) may be present If Country Subdivision Code (N4-07) is present, then Country Code (N4-04) is required Max use 1 Required N4-01 19 Laboratory or Facility City Name Min 2 Max 30 String (AN) Required Free-form text for city name A combination of either N401 through N404, or N405 and N406 may be adequate to specify a location. N4-02 156 Laboratory or Facility State or Province Code Identifier (ID) Optional Min 2 Max 2 Code (Standard State/Province) as defined by appropriate government agency N402 is required only if city name (N401) is in the U.S. or Canada. N4-03 116 Laboratory or Facility Postal Zone or ZIP Code Identifier (ID) Optional Min 3 Max 15 Code defining international postal zone code excluding punctuation and blanks (zip code for United States) Usage notes When reporting the ZIP code for U.S. addresses, the full nine digit ZIP code must be provided. N4-04 26 Country Code Min 2 Max 3 Identifier	Home State Health 837 Health Care Claim_ Professional.pdf
an organizational entity, a physical location, property or an individual 77 Service Location NM1-02 1065 Entity Type Qualifier Identifier (ID) Required Code qualifying the type of entity NM102 qualifies NM103. 1/30/25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 604/665 2 Non-Person Entity NM1-03 1035 Laboratory or Facility Name Min 1 Max 60 String (AN) Required Individual last name or organizational name NM1-08 66 Identification Code Qualifier Identifier (ID) Optional Code designating the system/method of code structure used for Identification Code (67) XX Centers for Medicare and Medicaid Services National Provider Identifier NM1-09 67 Laboratory or Facility Primary Identifier Min 2 Max 80 String (AN) Optional Code identifying a party or other code 1/30/25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 605/665 N3 5140 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > Service Line Number Loop > Service Facility Location Name Loop > N3 Service Facility Location Address To specify the location of the named party Usage notes If service facility location is in an area where there are no street addresses, enter a description of where the service was rendered (for example, "crossroad of State Road 34 and 45" or "Exit near Mile marker 265 on Interstate 80".) Example N3XXXXXXXXX~ Max use 1 Required N3-01 166 Laboratory or Facility Address Line Min 1 Max 55 String (AN) Required Address information N3-02 166 Laboratory or Facility Address Line Min 1 Max 55 String (AN) Optional Address information 1/30/25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 606/665 N4 5200 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > Service Line Number Loop > Service Facility Location Name Loop > N4 Service Facility Location City, State, ZIP Code To specify the geographic place of the named party Example N4XXXXXXXXXXXXXXX~ Only one of Laboratory or Facility State or Province Code (N4-02) or Country Subdivision Code (N4-07) may be present If Country Subdivision Code (N4-07) is present, then Country Code (N4-04) is required Max use 1 Required N4-01 19 Laboratory or Facility City Name Min 2 Max 30 String (AN) Required Free-form text for city name A combination of either N401 through N404, or N405 and N406 may be adequate to specify a location. N4-02 156 Laboratory or Facility State or Province Code Identifier (ID) Optional Min 2 Max 2 Code (Standard State/Province) as defined by appropriate government agency N402 is required only if city name (N401) is in the U.S. or Canada. N4-03 116 Laboratory or Facility Postal Zone or ZIP Code Identifier (ID) Optional Min 3 Max 15 Code defining international postal zone code excluding punctuation and blanks (zip code for United States) Usage notes When reporting the ZIP code for U.S. addresses, the full nine digit ZIP code must be provided. N4-04 26 Country Code Min 2 Max 3 Identifier (ID) Optional Code identifying the country Usage notes Use the alpha-2 country codes from Part 1 of ISO 3166. N4-07 1715 Country Subdivision Code Min 1 Max 3 Identifier (ID) Optional Code identifying the country subdivision 1/30/25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 607/665 Usage notes Use the country subdivision codes from Part 2 of ISO 3166. 1/30/25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 608/665 REF 5250 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > Service Line Number Loop > Service Facility Location Name Loop > REF Service Facility Location Secondary Identification To specify identifying information Usage notes When it is necessary to report one or more non-destination payer Secondary Identifiers, the composite data element in REF04 is used to identify the payer who assigned this identifier. Required prior to the mandated HIPAA National Provider Identifier (NPI) implementation date when an identification number other than the NPI is necessary for the receiver to identify the provider. OR Required on or after the mandated NPI implementation date when the entity is not a Health Care provider (a.k.a. an atypical provider), and an identifier is necessary for the claims processor to identify the entity. If not required by this implementation guide, do not send. Example REFLUX*2U>XXXXXX~ Max use 3 Optional REF-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification G2 Provider Commercial Number This code designates a proprietary provider number for the destination payer identified in the Payer Name loop, Loop ID-2010BB, associated with this claim. This is to be used by all payers including: Medicare, Medicaid, Blue Cross, etc. LU Location Number REF-02 127 Service Facility Location Secondary Identifier String (AN) Required Min 1 Max 50 Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier REF-04 C040 Reference Identifier To identify one or more reference numbers or identification numbers as specified by the Reference Qualifier - REF04 contains data relating to the value cited in REF02. Usage notes Required when the identifier reported in REF02 of this segment is for a non-destination payer. Max use 1 Optional C040-01 128 Reference Identification Qualifier Identifier (ID) Required 1/30/25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 609/665 2420C Service Facility Location Name Loop end Code qualifying the Reference Identification 2U Payer Identification Number C040-02 127 Other Payer Primary Identifier Min 1 Max 50 String (AN) Required Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier Usage notes The payer identifier reported in this field must match the cooresponding payer identifier reported in Loop ID-2330B NM109. 1/30/25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 610/665 2420D Supervising Provider Name Loop Max 1 Optional Variants (all may be used) Rendering Provider Name Loop Purchased Service Provider Name Loop Service Facility Location Name Loop Ordering Provider Name Loop Referring Provider Name Loop Ambulance Pick-up Location Loop Ambulance Drop-off Location Loop NM1 5000 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > Service Line Number Loop > Supervising Provider Name Loop > NM1 Supervising Provider Name To supply the full name of an individual or organizational entity Usage notes Required when the rendering provider is supervised by a physician and the supervising physician is different than that listed at the claim level for this service line. If not required by this implementation guide, do not send. Example NM1DQ1XXXXXXXXXXXXX*XXXXXXXXXXXXX~ If either Identification Code Qualifier (NM1-08) or Supervising Provider Identifier (NM1-09) is present, then the other is required Max use 1 Required NM1-01 98 Entity Identifier Code Identifier (ID) Required Code identifying an organizational entity, a physical location, property or an individual DQ Supervising Physician NM1-02 1065 Entity Type Qualifier Identifier (ID) Required Code qualifying the type of entity NM102 qualifies NM103. 1 Person NM1-03 1035 Supervising Provider Last Name Min 1 Max 60 String (AN) Required Individual last name or organizational name NM1-04 1036 Supervising Provider First Name Min 1 Max 35 String (AN) Optional 1/30/25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 611/665 Individual first name NM1-05 1037 Supervising Provider Middle Name or Initial String (AN) Optional Min 1 Max 25 Individual middle name or initial NM1-07 1039 Supervising Provider Name Suffix Min 1 Max 10 String (AN) Optional Suffix to individual name NM1-08 66 Identification Code Qualifier Identifier (ID) Optional Code designating the system/method of code structure used for Identification Code (67) XX Centers for Medicare and Medicaid Services National Provider Identifier NM1-09 67 Supervising Provider Identifier Min 2 Max 80 String (AN) Optional Code identifying a party or other code 1/30/25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 612/665 REF 5250 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > Service Line Number Loop > Supervising Provider Name Loop > REF Supervising Provider Secondary Identification To specify identifying information Usage notes Required prior to the mandated HIPAA National Provider Identifier (NPI) implementation date when an identification number other than the NPI is necessary for the receiver to identify the provider. OR Required on or after the mandated NPI Implementation Date when NM109 in this loop is not used and an identification number other than the NPI is necessary for the receiver to identify the provider. If not required by this implementation guide, do not send. When it is necessary to report one or more non-destination payer Secondary Identifiers, the composite data element in REF04 is used to identify the payer who assigned this identifier. Example REF0BXXX2U>X~ Max use 20 Optional REF-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification 0B State License Number 1G Provider UPIN Number UPINs must be formatted as either X99999 or XXX999. G2 Provider Commercial Number This code designates a proprietary provider number for the destination payer identified in the Payer Name loop, Loop ID-2010BB, associated with this claim. This is to be used by all payers including: Medicare, Medicaid, Blue Cross, etc. LU Location Number REF-02 127 Supervising Provider Secondary Identifier Min 1 Max 50 String (AN) Required Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier REF-04 C040 Reference Identifier To identify one or more reference numbers or identification numbers as specified by the Reference Qualifier - REF04 contains data relating to the value cited in REF02. Usage notes Required when the identifier reported in REF02 of this segment is for a non-destination payer. Max use 1 Optional 1/30/25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 613/665 2420D Supervising Provider Name Loop end C040-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification 2U Payer Identification Number C040-02 127 Other Payer Primary Identifier Min 1 Max 50 String (AN) Required Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier Usage notes The payer identifier reported in this field must match the cooresponding payer identifier reported in Loop ID-2330B NM109. 1/30/25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 614/665 2420E Ordering Provider Name Loop Max 1 Optional Variants (all may be used) Rendering Provider Name Loop Purchased Service Provider Name Loop Service Facility Location Name Loop Supervising Provider Name Loop Referring Provider Name Loop Ambulance Pick-up Location Loop Ambulance Drop-off Location Loop NM1 5000 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > Service Line Number Loop > Ordering Provider Name Loop > NM1 Ordering Provider Name To supply the full name of an individual or organizational entity Usage notes Required when the service or supply was ordered by a provider who is different than the rendering provider for this service line. If not required by this implementation guide, do not send. Example NM1DK1XXXXXXXX*XXXXX*XXXXXX~ If either Identification Code Qualifier (NM1-08) or Ordering Provider Identifier (NM1-09) is present, then the other is required Max use 1 Required NM1-01 98 Entity Identifier Code Identifier (ID) Required Code identifying an organizational entity, a physical location, property or an individual Usage notes The entity identifier in NM101 applies to all segments in this iteration of Loop ID-2420. DK Ordering Physician NM1-02 1065 Entity Type Qualifier Identifier (ID) Required Code qualifying the type of entity NM102 qualifies NM103. 1 Person NM1-03 1035 Ordering Provider Last Name Min 1 Max 60 String (AN) Required 1/30/25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 615/665 Individual last name or organizational name NM1-04 1036 Ordering Provider First Name Min 1 Max 35 String (AN) Optional Individual first name NM1-05 1037 Ordering Provider Middle Name or Initial Min	Home State Health 837 Health Care Claim_ Professional.pdf
formatted as either X99999 or XXX999. G2 Provider Commercial Number This code designates a proprietary provider number for the destination payer identified in the Payer Name loop, Loop ID-2010BB, associated with this claim. This is to be used by all payers including: Medicare, Medicaid, Blue Cross, etc. LU Location Number REF-02 127 Supervising Provider Secondary Identifier Min 1 Max 50 String (AN) Required Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier REF-04 C040 Reference Identifier To identify one or more reference numbers or identification numbers as specified by the Reference Qualifier - REF04 contains data relating to the value cited in REF02. Usage notes Required when the identifier reported in REF02 of this segment is for a non-destination payer. Max use 1 Optional 1/30/25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 613/665 2420D Supervising Provider Name Loop end C040-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification 2U Payer Identification Number C040-02 127 Other Payer Primary Identifier Min 1 Max 50 String (AN) Required Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier Usage notes The payer identifier reported in this field must match the cooresponding payer identifier reported in Loop ID-2330B NM109. 1/30/25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 614/665 2420E Ordering Provider Name Loop Max 1 Optional Variants (all may be used) Rendering Provider Name Loop Purchased Service Provider Name Loop Service Facility Location Name Loop Supervising Provider Name Loop Referring Provider Name Loop Ambulance Pick-up Location Loop Ambulance Drop-off Location Loop NM1 5000 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > Service Line Number Loop > Ordering Provider Name Loop > NM1 Ordering Provider Name To supply the full name of an individual or organizational entity Usage notes Required when the service or supply was ordered by a provider who is different than the rendering provider for this service line. If not required by this implementation guide, do not send. Example NM1DK1XXXXXXXXXXXXXXXXXXX~ If either Identification Code Qualifier (NM1-08) or Ordering Provider Identifier (NM1-09) is present, then the other is required Max use 1 Required NM1-01 98 Entity Identifier Code Identifier (ID) Required Code identifying an organizational entity, a physical location, property or an individual Usage notes The entity identifier in NM101 applies to all segments in this iteration of Loop ID-2420. DK Ordering Physician NM1-02 1065 Entity Type Qualifier Identifier (ID) Required Code qualifying the type of entity NM102 qualifies NM103. 1 Person NM1-03 1035 Ordering Provider Last Name Min 1 Max 60 String (AN) Required 1/30/25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 615/665 Individual last name or organizational name NM1-04 1036 Ordering Provider First Name Min 1 Max 35 String (AN) Optional Individual first name NM1-05 1037 Ordering Provider Middle Name or Initial Min 1 Max 25 String (AN) Optional Individual middle name or initial NM1-07 1039 Ordering Provider Name Suffix Min 1 Max 10 String (AN) Optional Suffix to individual name NM1-08 66 Identification Code Qualifier Identifier (ID) Optional Code designating the system/method of code structure used for Identification Code (67) XX Centers for Medicare and Medicaid Services National Provider Identifier NM1-09 67 Ordering Provider Identifier Min 2 Max 80 String (AN) Optional Code identifying a party or other code 1/30/25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 616/665 N3 5140 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > Service Line Number Loop > Ordering Provider Name Loop > N3 Ordering Provider Address To specify the location of the named party Usage notes Required when a Durable Medical Equipment Regional Carrier Certificate of Medical Necessity (DMERC CMN) or DMERC Information Form (DIF), or Oxygen Therapy Certification is included on this service line. If not required by this implementation guide, do not send. Example N3XXXXXXXX~ Max use 1 Optional N3-01 166 Ordering Provider Address Line Min 1 Max 55 String (AN) Required Address information N3-02 166 Ordering Provider Address Line Min 1 Max 55 String (AN) Optional Address information 1/30/25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 617/665 N4 5200 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > Service Line Number Loop > Ordering Provider Name Loop > N4 Ordering Provider City, State, ZIP Code To specify the geographic place of the named party Usage notes Required when a Durable Medical Equipment Regional Carrier Certificate of Medical Necessity (DMERC CMN) or DMERC Information Form (DIF), or Oxygen Therapy Certification is included on this service line. If not required by this implementation guide, do not send. Example N4XXXXXXXXXXXXXXXX~ Only one of Ordering Provider State or Province Code (N4-02) or Country Subdivision Code (N4-07) may be present If Country Subdivision Code (N4-07) is present, then Country Code (N4-04) is required Max use 1 Optional N4-01 19 Ordering Provider City Name Min 2 Max 30 String (AN) Required Free-form text for city name A combination of either N401 through N404, or N405 and N406 may be adequate to specify a location. N4-02 156 Ordering Provider State or Province Code Min 2 Max 2 Identifier (ID) Optional Code (Standard State/Province) as defined by appropriate government agency N402 is required only if city name (N401) is in the U.S. or Canada. N4-03 116 Ordering Provider Postal Zone or ZIP Code Identifier (ID) Optional Min 3 Max 15 Code defining international postal zone code excluding punctuation and blanks (zip code for United States) N4-04 26 Country Code Min 2 Max 3 Identifier (ID) Optional Code identifying the country Usage notes Use the alpha-2 country codes from Part 1 of ISO 3166. N4-07 1715 Country Subdivision Code Min 1 Max 3 Identifier (ID) Optional Code identifying the country subdivision 1/30/25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 618/665 Usage notes Use the country subdivision codes from Part 2 of ISO 3166. 1/30/25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 619/665 REF 5250 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > Service Line Number Loop > Ordering Provider Name Loop > REF Ordering Provider Secondary Identification To specify identifying information Usage notes Required prior to the mandated HIPAA National Provider Identifier (NPI) implementation date when an identification number other than the NPI is necessary for the receiver to identify the provider. OR Required on or after the mandated NPI Implementation Date when NM109 in this loop is not used and an identification number other than the NPI is necessary for the receiver to identify the provider. If not required by this implementation guide, do not send. When it is necessary to report one or more non-destination payer Secondary Identifiers, the composite data element in REF04 is used to identify the payer who assigned this identifier. Example REFG2XXXXXX2U>X~ Max use 20 Optional REF-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification 0B State License Number 1G Provider UPIN Number UPINs must be formatted as either X99999 or XXX999. G2 Provider Commercial Number This code designates a proprietary provider number for the destination payer identified in the Payer Name loop, Loop ID-2010BB, associated with this claim. This is to be used by all payers including: Medicare, Medicaid, Blue Cross, etc. REF-02 127 Ordering Provider Secondary Identifier Min 1 Max 50 String (AN) Required Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier REF-04 C040 Reference Identifier To identify one or more reference numbers or identification numbers as specified by the Reference Qualifier - REF04 contains data relating to the value cited in REF02. Usage notes Required when the identifier reported in REF02 of this segment is for a non-destination payer. Max use 1 Optional 1/30/25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 620/665 C040-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification 2U Payer Identification Number C040-02 127 Other Payer Primary Identifier Min 1 Max 50 String (AN) Required Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier Usage notes The payer identifier reported in this field must match the cooresponding payer identifier reported in Loop ID-2330B NM109. 1/30/25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 621/665 PER 5300 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > Service Line Number Loop > Ordering Provider Name Loop > PER Ordering Provider Contact Information To identify a person or office to whom administrative communications should be directed Usage notes Required when a Durable Medical Equipment Regional Carrier Certificate of Medical Necessity (DMERC CMN) or DMERC Information Form (DIF), or Oxygen Therapy Certification is included on this service line. If not required by this implementation guide, do not send. When the communication number represents a telephone number in the United States and other countries using the North American Dialing Plan (for voice, data, fax, etc.), the communication number must always include the area code and phone number using the format AAABBBCCCC where AAA is the area code, BBB is the telephone number prefix, and CCCC is the telephone number. Therefore, the following telephone number (555) 555-1234 would be represented as 5555551234. Do not submit long distance access numbers, such as "1", in the telephone number. Telephone extensions, when applicable, must be submitted in the next element immediately following the telephone number. When submitting telephone extensions, only submit the numeric extension. Do not include data that indicates an extension, such as "ext" or "x-". Example PERICXXXXFXXFXXXXFX*X~ If either Communication Number Qualifier (PER-05) or Communication Number (PER-06) is present, then the other is required If either Communication Number Qualifier (PER-07) or Communication Number (PER-08) is present, then the other is required Max use 1 Optional PER-01 366 Contact Function Code Identifier (ID) Required Code identifying the major duty or responsibility of the person or group named IC Information Contact PER-02 93 Ordering Provider Contact Name Min 1 Max 60 String (AN) Optional Free-form name PER-03 365 Communication Number Qualifier Identifier (ID) Required Code identifying the type of communication number EM Electronic Mail FX Facsimile TE Telephone PER-04 364 Communication Number Min 1 Max 256 String (AN) Required 1/30/25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 622/665 2420E Ordering Provider Name Loop end Complete communications number including country or area code when applicable PER-05 365 Communication Number Qualifier Identifier (ID) Optional Code identifying the type of communication number EM Electronic Mail EX Telephone Extension FX Facsimile TE Telephone PER-06 364 Communication Number Min 1 Max 256 String (AN) Optional Complete communications number including country or area code when applicable PER-07 365 Communication Number Qualifier Identifier (ID) Optional Code identifying the type of communication number EM Electronic Mail EX Telephone Extension FX Facsimile TE Telephone PER-08 364 Communication Number Min 1 Max 256 String (AN) Optional Complete communications number including country or area code when applicable 1/30/25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 623/665 2420F Referring Provider Name Loop Max 2 Optional Variants (all may be used) Rendering Provider Name Loop Purchased Service Provider Name Loop Service Facility Location Name Loop Supervising Provider Name Loop Ordering Provider Name Loop Ambulance Pick-up Location Loop Ambulance Drop-off Location Loop NM1 5000 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > Service Line Number Loop > Referring Provider Name Loop > NM1 Referring Provider Name To supply the full name of an individual or	Home State Health 837 Health Care Claim_ Professional.pdf
directed Usage notes Required when a Durable Medical Equipment Regional Carrier Certificate of Medical Necessity (DMERC CMN) or DMERC Information Form (DIF), or Oxygen Therapy Certification is included on this service line. If not required by this implementation guide, do not send. When the communication number represents a telephone number in the United States and other countries using the North American Dialing Plan (for voice, data, fax, etc.), the communication number must always include the area code and phone number using the format AAABBBCCCC where AAA is the area code, BBB is the telephone number prefix, and CCCC is the telephone number. Therefore, the following telephone number (555) 555-1234 would be represented as 5555551234. Do not submit long distance access numbers, such as "1", in the telephone number. Telephone extensions, when applicable, must be submitted in the next element immediately following the telephone number. When submitting telephone extensions, only submit the numeric extension. Do not include data that indicates an extension, such as "ext" or "x-". Example PERICXXXXFXXFXXXXFXX~ If either Communication Number Qualifier (PER-05) or Communication Number (PER-06) is present, then the other is required If either Communication Number Qualifier (PER-07) or Communication Number (PER-08) is present, then the other is required Max use 1 Optional PER-01 366 Contact Function Code Identifier (ID) Required Code identifying the major duty or responsibility of the person or group named IC Information Contact PER-02 93 Ordering Provider Contact Name Min 1 Max 60 String (AN) Optional Free-form name PER-03 365 Communication Number Qualifier Identifier (ID) Required Code identifying the type of communication number EM Electronic Mail FX Facsimile TE Telephone PER-04 364 Communication Number Min 1 Max 256 String (AN) Required 1/30/25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 622/665 2420E Ordering Provider Name Loop end Complete communications number including country or area code when applicable PER-05 365 Communication Number Qualifier Identifier (ID) Optional Code identifying the type of communication number EM Electronic Mail EX Telephone Extension FX Facsimile TE Telephone PER-06 364 Communication Number Min 1 Max 256 String (AN) Optional Complete communications number including country or area code when applicable PER-07 365 Communication Number Qualifier Identifier (ID) Optional Code identifying the type of communication number EM Electronic Mail EX Telephone Extension FX Facsimile TE Telephone PER-08 364 Communication Number Min 1 Max 256 String (AN) Optional Complete communications number including country or area code when applicable 1/30/25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 623/665 2420F Referring Provider Name Loop Max 2 Optional Variants (all may be used) Rendering Provider Name Loop Purchased Service Provider Name Loop Service Facility Location Name Loop Supervising Provider Name Loop Ordering Provider Name Loop Ambulance Pick-up Location Loop Ambulance Drop-off Location Loop NM1 5000 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > Service Line Number Loop > Referring Provider Name Loop > NM1 Referring Provider Name To supply the full name of an individual or organizational entity Usage notes When reporting the provider who ordered services such as diagnostic and lab, use Loop ID-2310A at the claim level. For ordered services such as Durable Medical Equipment, use Loop ID-2420E at the line level. When there is only one referral on the claim, use code "DN - Referring Provider". When more than one referral exists and there is a requirement to report the additional referral, use code DN in the first iteration of this loop to indicate the referral received by the rendering provider on this claim. Use code "P3 - Primary Care Provider" in the second iteration of the loop to indicate the initial referral from the primary care provider or whatever provider wrote the initial referral for this patient's episode of care being billed/reported in this transaction. Required when this service line involves a referral and the referring provider differs from that reported at the claim level (loop 2310A). If not required by this implementation guide, may be provided at the sender's discretion, but cannot be required by the receiver. Example NM1P31XXXXXXXXXXXXXXXXXXX~ If either Identification Code Qualifier (NM1-08) or Referring Provider Identifier (NM1-09) is present, then the other is required Max use 1 Required NM1-01 98 Entity Identifier Code Identifier (ID) Required Code identifying an organizational entity, a physical location, property or an individual DN Referring Provider Use on the first iteration of this loop. Use if loop is used only once. P3 Primary Care Provider Use only if loop is used twice. Use only on second iteration of this loop. 1/30/25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 624/665 NM1-02 1065 Entity Type Qualifier Identifier (ID) Required Code qualifying the type of entity NM102 qualifies NM103. 1 Person NM1-03 1035 Referring Provider Last Name Min 1 Max 60 String (AN) Required Individual last name or organizational name NM1-04 1036 Referring Provider First Name Min 1 Max 35 String (AN) Optional Individual first name NM1-05 1037 Referring Provider Middle Name or Initial Min 1 Max 25 String (AN) Optional Individual middle name or initial NM1-07 1039 Referring Provider Name Suffix Min 1 Max 10 String (AN) Optional Suffix to individual name NM1-08 66 Identification Code Qualifier Identifier (ID) Optional Code designating the system/method of code structure used for Identification Code (67) XX Centers for Medicare and Medicaid Services National Provider Identifier NM1-09 67 Referring Provider Identifier Min 2 Max 80 String (AN) Optional Code identifying a party or other code 1/30/25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 625/665 REF 5250 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > Service Line Number Loop > Referring Provider Name Loop > REF Referring Provider Secondary Identification To specify identifying information Usage notes Required prior to the mandated HIPAA National Provider Identifier (NPI) implementation date when an identification number other than the NPI is necessary for the receiver to identify the provider. OR Required on or after the mandated NPI Implementation Date when NM109 in this loop is not used and an identification number other than the NPI is necessary for the receiver to identify the provider. If not required by this implementation guide, do not send. When it is necessary to report one or more non-destination payer Secondary Identifiers, the composite data element in REF04 is used to identify the payer who assigned this identifier. Example REFG2X2U>XXXXX~ Max use 20 Optional REF-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification 0B State License Number 1G Provider UPIN Number UPINs must be formatted as either X99999 or XXX999. G2 Provider Commercial Number This code designates a proprietary provider number for the destination payer identified in the Payer Name loop, Loop ID-2010BB, associated with this claim. This is to be used by all payers including: Medicare, Medicaid, Blue Cross, etc. REF-02 127 Referring Provider Secondary Identifier Min 1 Max 50 String (AN) Required Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier REF-04 C040 Reference Identifier To identify one or more reference numbers or identification numbers as specified by the Reference Qualifier - REF04 contains data relating to the value cited in REF02. Usage notes Required when the identifier reported in REF02 of this segment is for a non-destination payer. Max use 1 Optional 1/30/25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 626/665 2420F Referring Provider Name Loop end C040-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification 2U Payer Identification Number C040-02 127 Other Payer Primary Identifier Min 1 Max 50 String (AN) Required Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier Usage notes The payer identifier reported in this field must match the cooresponding payer identifier reported in Loop ID-2330B NM109. 1/30/25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 627/665 2420G Ambulance Pick-up Location Loop Max 1 Optional Variants (all may be used) Rendering Provider Name Loop Purchased Service Provider Name Loop Service Facility Location Name Loop Supervising Provider Name Loop Ordering Provider Name Loop Referring Provider Name Loop Ambulance Drop-off Location Loop NM1 5000 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > Service Line Number Loop > Ambulance Pick-up Location Loop > NM1 Ambulance Pick-up Location To supply the full name of an individual or organizational entity Usage notes Required when the ambulance pick-up location for this service line is different than the ambulance pick-up location provided in Loop ID-2310E. If not required by this implementation guide, do not send.; Example NM1PW2~ Max use 1 Required NM1-01 98 Entity Identifier Code Identifier (ID) Required Code identifying an organizational entity, a physical location, property or an individual PW Pickup Address NM1-02 1065 Entity Type Qualifier Identifier (ID) Required Code qualifying the type of entity NM102 qualifies NM103. 2 Non-Person Entity 1/30/25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 628/665 N3 5140 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > Service Line Number Loop > Ambulance Pick-up Location Loop > N3 Ambulance Pick-up Location Address To specify the location of the named party Usage notes If the ambulance pickup location is in an area where there are no street addresses, enter a description of where the service was rendered (for example, "crossroad of State Road 34 and 45" or "Exit near Mile marker 265 on Interstate 80".) Example N3XXXXX~ Max use 1 Required N3-01 166 Ambulance Pick-up Address Line Min 1 Max 55 String (AN) Required Address information N3-02 166 Ambulance Pick-up Address Line Min 1 Max 55 String (AN) Optional Address information 1/30/25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 629/665 N4 5200 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > Service Line Number Loop > Ambulance Pick-up Location Loop > N4 Ambulance Pick-up Location City, State, ZIP Code To specify the geographic place of the named party Example N4XXXXXXXXXXXXXXXX*XXX~ Only one of Ambulance Pick-up State or Province Code (N4-02) or Country Subdivision Code (N4-07) may be present If Country Subdivision Code (N4-07) is present, then Country Code (N4-04) is required Max use 1 Required N4-01 19 Ambulance Pick-up City Name Min 2 Max 30 String (AN) Required Free-form text for city name A combination of either N401 through N404, or N405 and N406 may be adequate to specify a location. N4-02 156 Ambulance Pick-up State or Province Code Identifier (ID) Optional Min 2 Max 2 Code (Standard State/Province) as defined by appropriate government agency N402 is required only if city name (N401) is in the U.S. or Canada. N4-03 116 Ambulance Pick-up Postal Zone or ZIP Code Identifier (ID) Optional Min 3 Max 15 Code defining international postal zone code excluding punctuation and blanks (zip code for United States) N4-04 26 Country Code Min 2 Max 3 Identifier (ID) Optional Code identifying the country Usage notes Use the alpha-2 country codes from Part 1 of ISO 3166. N4-07 1715 Country Subdivision Code Min 1 Max 3 Identifier (ID) Optional Code identifying the country subdivision Usage notes 1/30/25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 630/665 2420G Ambulance Pick-up Location Loop end Use the country subdivision codes from Part 2 of ISO 3166. 1/30/25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 631/665 2420H Ambulance Drop-off Location Loop Max 1 Optional Variants (all may be used) Rendering Provider Name Loop Purchased Service Provider Name Loop Service Facility Location Name Loop Supervising Provider Name Loop Ordering Provider Name Loop Referring Provider Name Loop Ambulance Pick-up Location Loop NM1 5000 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop	Home State Health 837 Health Care Claim_ Professional.pdf
11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 628/665 N3 5140 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > Service Line Number Loop > Ambulance Pick-up Location Loop > N3 Ambulance Pick-up Location Address To specify the location of the named party Usage notes If the ambulance pickup location is in an area where there are no street addresses, enter a description of where the service was rendered (for example, "crossroad of State Road 34 and 45" or "Exit near Mile marker 265 on Interstate 80".) Example N3XXXXX~ Max use 1 Required N3-01 166 Ambulance Pick-up Address Line Min 1 Max 55 String (AN) Required Address information N3-02 166 Ambulance Pick-up Address Line Min 1 Max 55 String (AN) Optional Address information 1/30/25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 629/665 N4 5200 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > Service Line Number Loop > Ambulance Pick-up Location Loop > N4 Ambulance Pick-up Location City, State, ZIP Code To specify the geographic place of the named party Example N4XXXXXXXXXXXXXXXXXXX~ Only one of Ambulance Pick-up State or Province Code (N4-02) or Country Subdivision Code (N4-07) may be present If Country Subdivision Code (N4-07) is present, then Country Code (N4-04) is required Max use 1 Required N4-01 19 Ambulance Pick-up City Name Min 2 Max 30 String (AN) Required Free-form text for city name A combination of either N401 through N404, or N405 and N406 may be adequate to specify a location. N4-02 156 Ambulance Pick-up State or Province Code Identifier (ID) Optional Min 2 Max 2 Code (Standard State/Province) as defined by appropriate government agency N402 is required only if city name (N401) is in the U.S. or Canada. N4-03 116 Ambulance Pick-up Postal Zone or ZIP Code Identifier (ID) Optional Min 3 Max 15 Code defining international postal zone code excluding punctuation and blanks (zip code for United States) N4-04 26 Country Code Min 2 Max 3 Identifier (ID) Optional Code identifying the country Usage notes Use the alpha-2 country codes from Part 1 of ISO 3166. N4-07 1715 Country Subdivision Code Min 1 Max 3 Identifier (ID) Optional Code identifying the country subdivision Usage notes 1/30/25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 630/665 2420G Ambulance Pick-up Location Loop end Use the country subdivision codes from Part 2 of ISO 3166. 1/30/25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 631/665 2420H Ambulance Drop-off Location Loop Max 1 Optional Variants (all may be used) Rendering Provider Name Loop Purchased Service Provider Name Loop Service Facility Location Name Loop Supervising Provider Name Loop Ordering Provider Name Loop Referring Provider Name Loop Ambulance Pick-up Location Loop NM1 5000 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > Service Line Number Loop > Ambulance Drop-off Location Loop > NM1 Ambulance Drop-off Location To supply the full name of an individual or organizational entity Usage notes Required when the ambulance drop-off location for this service line is different than the ambulance drop-off location provided in Loop ID-2310F. If not required by this implementation guide, do not send. Example NM1452XXX~ Max use 1 Required NM1-01 98 Entity Identifier Code Identifier (ID) Required Code identifying an organizational entity, a physical location, property or an individual 45 Drop-off Location NM1-02 1065 Entity Type Qualifier Identifier (ID) Required Code qualifying the type of entity NM102 qualifies NM103. 2 Non-Person Entity NM1-03 1035 Ambulance Drop-off Location Min 1 Max 60 String (AN) Optional Individual last name or organizational name 1/30/25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 632/665 N3 5140 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > Service Line Number Loop > Ambulance Drop-off Location Loop > N3 Ambulance Drop-off Location Address To specify the location of the named party Usage notes If the ambulance drop-off location is in an area where there are no street addresses, enter a description of where the service was rendered (for example, "crossroad of State Road 34 and 45" or "Exit near Mile marker 265 on Interstate 80".) Example N3XXXXXXXX~ Max use 1 Required N3-01 166 Ambulance Drop-off Address Line Min 1 Max 55 String (AN) Required Address information N3-02 166 Ambulance Drop-off Address Line Min 1 Max 55 String (AN) Optional Address information 1/30/25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 633/665 N4 5200 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > Service Line Number Loop > Ambulance Drop-off Location Loop > N4 Ambulance Drop-off Location City, State, ZIP Code To specify the geographic place of the named party Example N4XXXXXXXXXXXX~ Only one of Ambulance Drop-off State or Province Code (N4-02) or Country Subdivision Code (N4-07) may be present If Country Subdivision Code (N4-07) is present, then Country Code (N4-04) is required Max use 1 Required N4-01 19 Ambulance Drop-off City Name Min 2 Max 30 String (AN) Required Free-form text for city name A combination of either N401 through N404, or N405 and N406 may be adequate to specify a location. N4-02 156 Ambulance Drop-off State or Province Code Identifier (ID) Optional Min 2 Max 2 Code (Standard State/Province) as defined by appropriate government agency N402 is required only if city name (N401) is in the U.S. or Canada. N4-03 116 Ambulance Drop-off Postal Zone or ZIP Code Identifier (ID) Optional Min 3 Max 15 Code defining international postal zone code excluding punctuation and blanks (zip code for United States) N4-04 26 Country Code Min 2 Max 3 Identifier (ID) Optional Code identifying the country Usage notes Use the alpha-2 country codes from Part 1 of ISO 3166. N4-07 1715 Country Subdivision Code Min 1 Max 3 Identifier (ID) Optional Code identifying the country subdivision Usage notes 1/30/25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 634/665 2420H Ambulance Drop-off Location Loop end Use the country subdivision codes from Part 2 of ISO 3166. 1/30/25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 635/665 2430 Line Adjudication Information Loop Max 15 Optional SVD 5400 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > Service Line Number Loop > Line Adjudication Information Loop > SVD Line Adjudication Information To convey service line adjudication information for coordination of benefits between the initial payers of a health care claim and all subsequent payers Usage notes Required when the claim has been previously adjudicated by payer identified in Loop ID-2330B and this service line has payments and/or adjustments applied to it. If not required by this implementation guide, do not send. To show unbundled lines: If, in the original claim, line 3 is unbundled into (for example) 2 additional lines, then the SVD for line 3 is used 3 times: once for the original adjustment to line 3 and then two more times for the additional unbundled lines. Example SVDXXXXXX00ER>X>XX>XX>XX>XX>XXX*0000000~ Max use 1 Required SVD-01 67 Other Payer Primary Identifier Min 2 Max 80 String (AN) Required Code identifying a party or other code SVD01 is the payer identification code. Usage notes This identifier indicates the payer responsible for the reimbursement described in this iteration of the 2430 loop. The identifier indicates the Other Payer by matching the appropriate Other Payer Primary Identifier (Loop ID-2330B, element NM109). SVD-02 782 Service Line Paid Amount Min 1 Max 15 Decimal number (R) Required Monetary amount SVD02 is the amount paid for this service line. Usage notes Zero "0" is an acceptable value for this element. SVD-03 C003 Composite Medical Procedure Identifier To identify a medical procedure by its standardized codes and applicable modifiers - SVD03 represents the medical procedure code upon which adjudication of this service line was based. This may be different than the submitted medical procedure code. Max use 1 Required C003-01 235 Product or Service ID Qualifier Identifier (ID) Required 1/30/25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 636/665 Code identifying the type/source of the descriptive number used in Product/Service ID (234) C003-01 qualifies C003-02 and C003-08. ER Jurisdiction Specific Procedure and Supply Codes This code set is not allowed for use under HIPAA at the time of this writing. The qualifier can only be used: If a new rule names the Jurisdiction Specific Procedure and Supply Codes as an allowable code set under HIPAA, OR The Secretary grants an exception to use the code set as a pilot project as allowed under the law, OR For claims which are not covered under HIPAA. HC Health Care Financing Administration Common Procedural Coding System (HCPCS) Codes Because the AMA's CPT codes are also level 1 HCPCS codes, they are reported under HC. IV Home Infusion EDI Coalition (HIEC) Product/Service Code This code set is not allowed for use under HIPAA at the time of this writing. The qualifier can only be used: If a new rule names the Home Infusion EDI Coalition (HIEC) Product/Service Codes as an allowable code set under HIPAA, OR The Secretary grants an exception to use the code set as a pilot project as allowed under the law, OR For claims which are not covered under HIPAA.; WK Advanced Billing Concepts (ABC) Codes At the time of this writing, this code set has been approved by the Secretary of HHS as a pilot project allowed under HIPAA law. The qualifier may only be used in transactions covered under HIPAA; By parties registered in the pilot project and their trading partners, OR If a new rule names the Complementary, Alternative, or Holistic Procedure Codes as an allowable code set under HIPAA, OR For claims which are not covered under HIPAA. C003-02 234 Procedure Code Min 1 Max 48 String (AN) Required Identifying number for a product or service If C003-08 is used, then C003-02 represents the beginning value in the range in which the code occurs. C003-03 1339 Procedure Modifier Min 2 Max 2 String (AN) Optional This identifies special circumstances related to the performance of the service, as defined by trading partners C003-03 modifies the value in C003-02 and C003-08. 1/30/25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 637/665 C003-04 1339 Procedure Modifier Min 2 Max 2 String (AN) Optional This identifies special circumstances related to the performance of the service, as defined by trading partners C003-04 modifies the value in C003-02 and C003-08. C003-05 1339 Procedure Modifier Min 2 Max 2 String (AN) Optional This identifies special circumstances related to the performance of the service, as defined by trading partners C003-05 modifies the value in C003-02 and C003-08. C003-06 1339 Procedure Modifier Min 2 Max 2 String (AN) Optional This identifies special circumstances related to the performance of the service, as defined by trading partners C003-06 modifies the value in C003-02 and C003-08. C003-07 352 Procedure Code Description Min 1 Max 80 String (AN) Optional A free-form description to clarify the related data elements and their content C003-07 is the description of the procedure identified in C003-02. SVD-05 380 Paid Service Unit Count Min 1 Max 15 Decimal number (R) Required Numeric value of quantity SVD05 is the paid units of service. Usage notes This is the number of paid units from the remittance advice. When paid units are not present on the remittance advice, use the original billed units. The maximum length for this field is 8 digits excluding the decimal. When a decimal is used, the maximum number of digits allowed to the right of the decimal is three. SVD-06 554 Bundled or Unbundled Line Number Min 1 Max 6 Numeric (N0) Optional Number assigned	Home State Health 837 Health Care Claim_ Professional.pdf
Administration Common Procedural Coding System (HCPCS) Codes Because the AMA's CPT codes are also level 1 HCPCS codes, they are reported under HC. IV Home Infusion EDI Coalition (HIEC) Product/Service Code This code set is not allowed for use under HIPAA at the time of this writing. The qualifier can only be used: If a new rule names the Home Infusion EDI Coalition (HIEC) Product/Service Codes as an allowable code set under HIPAA, OR The Secretary grants an exception to use the code set as a pilot project as allowed under the law, OR For claims which are not covered under HIPAA.; WK Advanced Billing Concepts (ABC) Codes At the time of this writing, this code set has been approved by the Secretary of HHS as a pilot project allowed under HIPAA law. The qualifier may only be used in transactions covered under HIPAA; By parties registered in the pilot project and their trading partners, OR If a new rule names the Complementary, Alternative, or Holistic Procedure Codes as an allowable code set under HIPAA, OR For claims which are not covered under HIPAA. C003-02 234 Procedure Code Min 1 Max 48 String (AN) Required Identifying number for a product or service If C003-08 is used, then C003-02 represents the beginning value in the range in which the code occurs. C003-03 1339 Procedure Modifier Min 2 Max 2 String (AN) Optional This identifies special circumstances related to the performance of the service, as defined by trading partners C003-03 modifies the value in C003-02 and C003-08. 1/30/25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 637/665 C003-04 1339 Procedure Modifier Min 2 Max 2 String (AN) Optional This identifies special circumstances related to the performance of the service, as defined by trading partners C003-04 modifies the value in C003-02 and C003-08. C003-05 1339 Procedure Modifier Min 2 Max 2 String (AN) Optional This identifies special circumstances related to the performance of the service, as defined by trading partners C003-05 modifies the value in C003-02 and C003-08. C003-06 1339 Procedure Modifier Min 2 Max 2 String (AN) Optional This identifies special circumstances related to the performance of the service, as defined by trading partners C003-06 modifies the value in C003-02 and C003-08. C003-07 352 Procedure Code Description Min 1 Max 80 String (AN) Optional A free-form description to clarify the related data elements and their content C003-07 is the description of the procedure identified in C003-02. SVD-05 380 Paid Service Unit Count Min 1 Max 15 Decimal number (R) Required Numeric value of quantity SVD05 is the paid units of service. Usage notes This is the number of paid units from the remittance advice. When paid units are not present on the remittance advice, use the original billed units. The maximum length for this field is 8 digits excluding the decimal. When a decimal is used, the maximum number of digits allowed to the right of the decimal is three. SVD-06 554 Bundled or Unbundled Line Number Min 1 Max 6 Numeric (N0) Optional Number assigned for differentiation within a transaction set SVD06 is only used for bundling of service lines. It references the LX Assigned Number of the service line into which this service line was bundled. 1/30/25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 638/665 CAS 5450 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > Service Line Number Loop > Line Adjudication Information Loop > CAS Line Adjustment To supply adjustment reason codes and amounts as needed for an entire claim or for a particular service within the claim being paid Usage notes Required when the payer identified in Loop 2330B made line level adjustments which caused the amount paid to differ from the amount originally charged. If not required by this implementation guide, do not send. A single CAS segment contains six repetitions of the "adjustment trio" composed of adjustment reason code, adjustment amount, and adjustment quantity. These six adjustment trios are used to report up to six adjustments related to a particular Claim Adjustment Group Code (CAS01). The first non-zero adjustment is reported in the first adjustment trio (CAS02-CAS04). If there is a second non-zero adjustment, it is reported in the second adjustment trio (CAS05-CAS07), and so on through the sixth adjustment trio (CAS17-CAS19). Example CASOAXXXX00000000000000000XX0000000000XXX X00000000000000000X000000000000000000000XX X00000000000XXX00000000000000000000~ If Adjustment Reason Code (CAS-05) is present, then at least one of Adjustment Amount (CAS-06) or Adjustment Quantity (CAS-07) is required If Adjustment Amount (CAS-06) is present, then Adjustment Reason Code (CAS-05) is required If Adjustment Quantity (CAS-07) is present, then Adjustment Reason Code (CAS-05) is required If Adjustment Reason Code (CAS-08) is present, then at least one of Adjustment Amount (CAS-09) or Adjustment Quantity (CAS-10) is required If Adjustment Amount (CAS-09) is present, then Adjustment Reason Code (CAS-08) is required If Adjustment Quantity (CAS-10) is present, then Adjustment Reason Code (CAS-08) is required If Adjustment Reason Code (CAS-11) is present, then at least one of Adjustment Amount (CAS-12) or Adjustment Quantity (CAS-13) is required If Adjustment Amount (CAS-12) is present, then Adjustment Reason Code (CAS-11) is required If Adjustment Quantity (CAS-13) is present, then Adjustment Reason Code (CAS-11) is required If Adjustment Reason Code (CAS-14) is present, then at least one of Adjustment Amount (CAS-15) or Adjustment Quantity (CAS-16) is required If Adjustment Amount (CAS-15) is present, then Adjustment Reason Code (CAS-14) is required If Adjustment Quantity (CAS-16) is present, then Adjustment Reason Code (CAS-14) is required If Adjustment Reason Code (CAS-17) is present, then at least one of Adjustment Amount (CAS-18) or Adjustment Quantity (CAS-19) is required If Adjustment Amount (CAS-18) is present, then Adjustment Reason Code (CAS-17) is required If Adjustment Quantity (CAS-19) is present, then Adjustment Reason Code (CAS-17) is required Max use 5 Optional 1/30/25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 639/665 CAS-01 1033 Claim Adjustment Group Code Identifier (ID) Required Code identifying the general category of payment adjustment CO Contractual Obligations CR Correction and Reversals OA Other adjustments PI Payor Initiated Reductions PR Patient Responsibility CAS-02 1034 Adjustment Reason Code Min 1 Max 5 Identifier (ID) Required Code identifying the detailed reason the adjustment was made CAS-03 782 Adjustment Amount Min 1 Max 15 Decimal number (R) Required Monetary amount CAS03 is the amount of adjustment. CAS-04 380 Adjustment Quantity Min 1 Max 15 Decimal number (R) Optional Numeric value of quantity CAS04 is the units of service being adjusted. CAS-05 1034 Adjustment Reason Code Min 1 Max 5 Identifier (ID) Optional Code identifying the detailed reason the adjustment was made Usage notes See CODE SOURCE 139: Claim Adjustment Reason Code CAS-06 782 Adjustment Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount CAS06 is the amount of the adjustment. CAS-07 380 Adjustment Quantity Min 1 Max 15 Decimal number (R) Optional Numeric value of quantity CAS07 is the units of service being adjusted. 1/30/25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 640/665 CAS-08 1034 Adjustment Reason Code Min 1 Max 5 Identifier (ID) Optional Code identifying the detailed reason the adjustment was made Usage notes See CODE SOURCE 139: Claim Adjustment Reason Code CAS-09 782 Adjustment Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount CAS09 is the amount of the adjustment. CAS-10 380 Adjustment Quantity Min 1 Max 15 Decimal number (R) Optional Numeric value of quantity CAS10 is the units of service being adjusted. CAS-11 1034 Adjustment Reason Code Min 1 Max 5 Identifier (ID) Optional Code identifying the detailed reason the adjustment was made Usage notes See CODE SOURCE 139: Claim Adjustment Reason Code CAS-12 782 Adjustment Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount CAS12 is the amount of the adjustment. CAS-13 380 Adjustment Quantity Min 1 Max 15 Decimal number (R) Optional Numeric value of quantity CAS13 is the units of service being adjusted. CAS-14 1034 Adjustment Reason Code Min 1 Max 5 Identifier (ID) Optional Code identifying the detailed reason the adjustment was made Usage notes See CODE SOURCE 139: Claim Adjustment Reason Code CAS-15 782 Adjustment Amount Min 1 Max 15 Decimal number (R) Optional 1/30/25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 641/665 Monetary amount CAS15 is the amount of the adjustment. CAS-16 380 Adjustment Quantity Min 1 Max 15 Decimal number (R) Optional Numeric value of quantity CAS16 is the units of service being adjusted. CAS-17 1034 Adjustment Reason Code Min 1 Max 5 Identifier (ID) Optional Code identifying the detailed reason the adjustment was made Usage notes See CODE SOURCE 139: Claim Adjustment Reason Code CAS-18 782 Adjustment Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount CAS18 is the amount of the adjustment. CAS-19 380 Adjustment Quantity Min 1 Max 15 Decimal number (R) Optional Numeric value of quantity CAS19 is the units of service being adjusted. 1/30/25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 642/665 DTP 5500 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > Service Line Number Loop > Line Adjudication Information Loop > DTP Line Check or Remittance Date To specify any or all of a date, a time, or a time period Example DTP573D8X~ Max use 1 Required DTP-01 374 Date Time Qualifier Identifier (ID) Required Code specifying type of date or time, or both date and time 573 Date Claim Paid DTP-02 1250 Date Time Period Format Qualifier Identifier (ID) Required Code indicating the date format, time format, or date and time format DTP02 is the date or time or period format that will appear in DTP03. D8 Date Expressed in Format CCYYMMDD DTP-03 1251 Adjudication or Payment Date Min 1 Max 35 String (AN) Required Expression of a date, a time, or range of dates, times or dates and times 1/30/25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 643/665 2430 Line Adjudication Information Loop end AMT 5505 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > Service Line Number Loop > Line Adjudication Information Loop > AMT Remaining Patient Liability To indicate the total monetary amount Usage notes In the judgment of the provider, this is the remaining amount to be paid after adjudication by the Other Payer referenced in SVD01 of this iteration of Loop ID-2430. This segment is only used in provider submitted claims. It is not used in Payer-to-Payer Coordination of Benefits (COB). Required when the Other Payer referenced in SVD01 of this iteration of Loop ID-2430 has adjudicated this claim, provided line level information, and the provider has the ability to report line item information. If not required by this implementation guide, do not send. This segment is not used if the claim level (Loop ID-2320) Remaining Patient Liability AMT segment is used for this Other Payer. Example AMTEAF00000000000~ Max use 1 Optional AMT-01 522 Amount Qualifier Code Identifier (ID) Required Code to qualify amount EAF Amount Owed AMT-02 782 Remaining Patient Liability Min 1 Max 15 Decimal number (R) Required Monetary amount 1/30/25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 644/665 2440 Form Identification Code Loop Max >1 Optional LQ 5510 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > Service Line Number Loop > Form Identification Code Loop > LQ Form Identification Code To identify standard industry codes Usage notes Required when adjudication is known to be impacted by one of the types of supporting documentation (standardized paper forms) listed in LQ01. If not required by this implementation guide, do not send. Loop ID-2440 is designed to allow providers to attach standardized supplemental information to the claim when required to do so by the payer. The LQ segment contains information to identify the form (LQ01) and the specific form number (LQ02). In the	Home State Health 837 Health Care Claim_ Professional.pdf
Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > Service Line Number Loop > Line Adjudication Information Loop > DTP Line Check or Remittance Date To specify any or all of a date, a time, or a time period Example DTP573D8X~ Max use 1 Required DTP-01 374 Date Time Qualifier Identifier (ID) Required Code specifying type of date or time, or both date and time 573 Date Claim Paid DTP-02 1250 Date Time Period Format Qualifier Identifier (ID) Required Code indicating the date format, time format, or date and time format DTP02 is the date or time or period format that will appear in DTP03. D8 Date Expressed in Format CCYYMMDD DTP-03 1251 Adjudication or Payment Date Min 1 Max 35 String (AN) Required Expression of a date, a time, or range of dates, times or dates and times 1/30/25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 643/665 2430 Line Adjudication Information Loop end AMT 5505 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > Service Line Number Loop > Line Adjudication Information Loop > AMT Remaining Patient Liability To indicate the total monetary amount Usage notes In the judgment of the provider, this is the remaining amount to be paid after adjudication by the Other Payer referenced in SVD01 of this iteration of Loop ID-2430. This segment is only used in provider submitted claims. It is not used in Payer-to-Payer Coordination of Benefits (COB). Required when the Other Payer referenced in SVD01 of this iteration of Loop ID-2430 has adjudicated this claim, provided line level information, and the provider has the ability to report line item information. If not required by this implementation guide, do not send. This segment is not used if the claim level (Loop ID-2320) Remaining Patient Liability AMT segment is used for this Other Payer. Example AMTEAF00000000000~ Max use 1 Optional AMT-01 522 Amount Qualifier Code Identifier (ID) Required Code to qualify amount EAF Amount Owed AMT-02 782 Remaining Patient Liability Min 1 Max 15 Decimal number (R) Required Monetary amount 1/30/25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 644/665 2440 Form Identification Code Loop Max >1 Optional LQ 5510 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > Service Line Number Loop > Form Identification Code Loop > LQ Form Identification Code To identify standard industry codes Usage notes Required when adjudication is known to be impacted by one of the types of supporting documentation (standardized paper forms) listed in LQ01. If not required by this implementation guide, do not send. Loop ID-2440 is designed to allow providers to attach standardized supplemental information to the claim when required to do so by the payer. The LQ segment contains information to identify the form (LQ01) and the specific form number (LQ02). In the example given below, LQ01=UT which identifies the form as a Medicare DMERC CMN form. LQ02=01.02 identifies which DMERC CMN form is being used. An example application of this Form Identification Code Loop is for Medicare DMERC claims for which the DME provider is required to obtain a Certificate of Medical Necessity (DMERC CMN) or DMERC Information Form (DIF), or Oxygen Therapy Certification from the referring physician. Another example is payer documentation requirements for Home Health services. Example LQASX~ Max use 1 Required LQ-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list AS Form Type Code Code value AS indicates that a Home Health form from External Code Source 656 is being identified in LQ02. UT Centers for Medicare and Medicaid Services (CMS) Durable Medical Equipment Regional Carrier (DMERC) Certificate of Medical Necessity (CMN) Forms LQ-02 1271 Form Identifier Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list 1/30/25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 645/665 FRM 5520 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > Service Line Number Loop > Form Identification Code Loop > FRM Supporting Documentation To specify information in response to a codified questionnaire document Usage notes The LQ segment is used to identify the general (LQ01) and specific type (LQ02) for the form being reported in Loop ID-2440. The FRM segment is used to answer specific questions on the form identified in the LQ segment. FRM01 is used to indicate the question being answered. Answers can take one of 4 forms: FRM02 for Yes/No questions, FRM03 for text/uncodified answers, FRM04 for answers which use dates, and FRM05 for answers which are percents. For each FRM01 (question) use a remaining FRM element, choosing the element which has the most appropriate format. One FRM segment is used for each question/answer pair. The example below shows how the FRM can be used to answer all the pertinent questions on DMERC form 0802 (LQUT08.02~). Example FRMXXXXWXXXXX2025013100~ At least one of Question Response (FRM-02), Question Response (FRM-03), Question Response (FRM-04) or Question Response (FRM-05) is required Max use 99 Required FRM-01 350 Question Number/Letter Min 1 Max 20 String (AN) Required Alphanumeric characters assigned for differentiation within a transaction set FRM01 is the question number on a questionnaire or codified form. FRM-02 1073 Question Response Identifier (ID) Optional Code indicating a Yes or No condition or response FRM02, FRM03, FRM04 and FRM05 are responses which only have meaning in reference to the question identified in FRM01. N No W Not Applicable Y Yes FRM-03 127 Question Response Min 1 Max 50 String (AN) Optional Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier FRM-04 373 Question Response CCYYMMDD format Date (DT) Optional 1/30/25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 646/665 2440 Form Identification Code Loop end 2400 Service Line Number Loop end 2300 Claim Information Loop end 2000C Patient Hierarchical Level Loop end 2000B Subscriber Hierarchical Level Loop end 2000A Billing Provider Hierarchical Level Loop end Date expressed as CCYYMMDD where CC represents the first two digits of the calendar year FRM-05 332 Question Response Min 1 Max 6 Decimal number (R) Optional Percent given in decimal format (e.g., 0.0 through 100.0 represents 0% through 100%) SE 5550 Detail > SE Transaction Set Trailer To indicate the end of the transaction set and provide the count of the transmitted segments (including the beginning (ST) and ending (SE) segments) Example SE00001~ Max use 1 Required SE-01 96 Transaction Segment Count Min 1 Max 10 Numeric (N0) Required Total number of segments included in a transaction set including ST and SE segments SE-02 329 Transaction Set Control Number Min 4 Max 9 Numeric (N) Required Identifying control number that must be unique within the transaction set functional group assigned by the originator for a transaction set Usage notes 1/30/25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 647/665 Detail end The Transaction Set Control Number in ST02 and SE02 must be identical. The number must be unique within a specific interchange (ISA-IEA), but can repeat in other interchanges. 1/30/25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 648/665 GE Functional Group Trailer To indicate the end of a functional group and to provide control information Example GE0000000000000~ Max use 1 Required GE-01 97 Number of Transaction Sets Included Min 1 Max 6 Numeric (N0) Required Total number of transaction sets included in the functional group or interchange (transmission) group terminated by the trailer containing this data element GE-02 28 Group Control Number Min 1 Max 9 Numeric (N0) Required Assigned number originated and maintained by the sender 1/30/25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 649/665 IEA Interchange Control Trailer To define the end of an interchange of zero or more functional groups and interchange- related control segments Example IEA00000000000000~ Max use 1 Required IEA-01 I16 Number of Included Functional Groups Min 1 Max 5 Numeric (N0) Required A count of the number of functional groups included in an interchange IEA-02 I12 Interchange Control Number Min 9 Max 9 Numeric (N0) Required A control number assigned by the interchange sender 1/30/25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 650/665 EDI Samples Example 1: Commercial Health Insurance ISA00 00 ZZSENDER ZZRECEIVER 2310300211^005010000000010T>~ GSHCSENDERGSRECEIVERGS20231030021108000000001X005010X222A2~ ST8370021005010X222A2~ BHT001900244579200610151023CH~ NM1412PREMIER BILLING SERVICE****46TGJ23~ PERICJERRYTE3055552222EX231~ NM1402KEY INSURANCE COMPANY***4666783JJT~ HL1201~ PRVBIPXC203BF0100Y~ NM1852BEN KILDARE SERVICE****XX9876543210~ N3234 SEAWAY ST~ N4MIAMIFL33111~ REFEI587654321~ NM1872~ N32345 OCEAN BLVD~ N4MIAMIFL33111~ HL21221~ SBRP2222-SJ****CI~ NM1IL1SMITHJANE**MIJS00111223333~ DMGD819430501F~ NM1PR2KEY INSURANCE COMPANY****PI999996666~ REFG2KA6663~ HL32230~ PAT19~ NM1QC1SMITHTED~ N3236 N MAIN ST~ N4MIAMIFL33413~ DMGD819730501M~ CLM26463774100**11>B>1YAYI~ REFD917312345600006351~ HIBK>0340BF>V7389~ LX1~ SV1HC>9921340UN1**1~ DTP472D820061003~ LX2~ SV1HC>8707015UN1*1~ DTP472D820061003~ LX3~ SV1HC>9921435UN1*2~ DTP472D820061010~ LX4~ SV1HC>8666310UN1*2~ DTP472D820061010~ SE420021~ GE1000000001~ IEA1000000001~ 1/30/25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 651/665 Example 10a: Drug administered in the Physician Office ISA00 00 ZZSENDER ZZRECEIVER 2310300211^005010000000010T>~ GSHCSENDERGSRECEIVERGS20231030021120000000001X005010X222A2~ ST8370711005010X222A2~ BHT0019000013200408011200CH~ NM1412Associates in Medicine****46587654321~ PERICBud HollyTE8017268899~ NM1402XYZ Receiver***46369852758~ HL1201~ NM1852Associates in Medicine***XX587654321~ N31313 Las Vegas Boulevard~ N4Las VegasNV89109~ REFEI587654321~ HL21220~ SBRP18GRP01020102****CI~ NM1IL1VaughnSteveR**MIMBRID12345~ N3236 Diamond ST~ N4Las VegasNV89109~ DMGD819430501M~ NM1PR2R&R Health Plan****XVPLANID12345~ CLMCLMNO12345103.37**11>B>1YAYY~ HIBK>03591~ NM1821HendrixJim***XX1122333341~ PRVPEPXC208D00000X~ LX1~ SV1HC>9078250UN1111~ DTP472D820040711~ LX2~ SV1HC>J155053.37UN111*1~ DTP472D820040711~ AMTT3.37~ LIN*N400026063512~ CTP***10ML~ SE310711~ GE1000000001~ IEA1000000001~ 1/30/25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 652/665 Example 11: PPO Repriced Claim ISA00 00 ZZSENDER ZZRECEIVER 2310300211^005010000000010T>~ GSHCSENDERGSRECEIVERGS20231030021132000000001X005010X222A2~ ST8371002005010X222A2~ BHT00190010022005062009460000CH~ NM1412REGIONAL PPO NETWORK****46123456789~ PERICSUBMITTER CONTACT INFOTE8001231234~ NM1402EXTRA HEALTHY INSURANCE***46112244~ HL1201~ NM1852HAPPY DOCTORS GROUP PRACTICE***XX1234567890~ N3P O BOX 123~ N4FORT WAYNEIN462540000~ REFEI555512345~ PERICSUE BILLINGSWORTHTE8881231234~ HL21220~ SBRP18123XYZ****CI~ NM1IL1RINGDIAMONDD**MI00124A089~ N3123 EXAMPLE DRIVE~ N4INDIANAPOLISIN462290000~ DMGD819401229F~ NM1PR2EXTRA HEALTHY INSURANCE****PI12345~ CLMABC123-RI28.75**11>B>1YAYYP~ REF9A0902352342~ REFD9061505501749388~ HIBK>496BF>25000~ HCP0326.752908231234~ NM1DN1DOEJOHN***XX9988776655~ NM1821ANTHONYSUSANB*XX1122334455~ NM1772HAPPY DOCTORS GROUP~ N3123 FEEL GOOD ROAD~ N4WASHINGTONIN475010000~ LX1~ SV1HC>E0570>RR25UN1**1>2~ DTP472D820050514~ HCP0323.751.25908231234~ LX2~ SV1HC>A7003>NU3.75UN1*1~ DTP472D820050514~ HCP033.75908231234~ SE371002~ GE1000000001~ IEA1000000001~ 1/30/25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 653/665 Example 12: Out of Network Repriced Claim ISA00 00 ZZSENDER ZZRECEIVER 2310300211^005010000000010T>~ GSHCSENDERGSRECEIVERGS20231030021145000000001X005010X222A2~ ST8371024005010X222A2~ BHT0019001024200507111335CH~ NM1412REGIONAL PPO NETWORK****46123456789~ PERICSUBMITTER CONTACT INFOTE8001231234~ NM1402CONSERVATIVE INSURANCE***46000110002~ HL1201~ NM1852EMERGENCY PHYSICIANS GROUP***XX1122334455~ N37423 SUPER STREET~ N4BILLINGSMO919910000~ REFEI111002222~ HL21221~ SBRP232AA****CI~ NM1IL1SMITHMATTHEWR**MI57976235C~ N35698 SOUTH STREET~ N4BILLINGSMO919910000~ DMGD819561015M~ NM1PR2CONSERVATIVE INSURANCE****PI00123~ HL32230~ PAT19~ NM1QC1SMITHTOME~ N35698 SOUTH STREET~ N4BILLINGSMO919910000~ DMGD819960807M~ CLMTS234H3252.71*23>B>1YAYYP~ REF9A0902345406~ REFD9687534234346~ HIBK>9951~ HCP000333001234*******T1~ NM1821BLUEJACKIED**XX1112223336~ SBRS1856567***CI~ OIY*Y~ NM1IL1SMITHTOME**MI23424570~ N35698 SOUTH STREET~ N4BILLINGSMO919910000~ NM1PR2SECONDARY INSURANCE COMPANY***PI95645~ LX1~ SV1HC>99284252.71UN1*1~ DTP472D820050506~ SE391024~ GE1000000001~ IEA1000000001~ 1/30/25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 654/665 Example 2: Encounter ISA00 00 ZZSENDER ZZRECEIVER 2310300212^005010000000010T>~ GSHCSENDERGSRECEIVERGS20231030021201000000001X005010X222A2~ ST8370021005010X222A2~ BHT0019000123200610151023RP~ NM1412PREMIER BILLING SERVICE****46TGJ23~ PERICJERRYTE3055552222EX231~ NM1402AHLIC***4666783JJT~ HL1201~ PRVBIPXC203BF0100Y~ NM1852BEN KILDARE SERVICE****XX9876543210~ N3234 SEAWAY ST~ N4MIAMIFL33111~ REFEI587654321~ NM1872~ N32345 OCEAN BLVD~ N4MIAMIFL33111~ HL21220~ SBRP1812312-A****HM~ NM1IL1SMITHTED**MI000221111~ N3236 N MAIN ST~ N4MIAMIFL33413~ DMGD819430501M~ NM1PR2ALLIANCE HEALTH AND LIFE INSURANCE****PI741234~ CLM26462967100**11>B>1YAYI~ DTP431D819981003~ REFD917312345600006351~ HIBK>0340BF>V7389~ NM1772KILDARE ASSOCIATES***XX5812345679~ N32345 OCEAN BLVD~ N4MIAMIFL33111~ LX1~ SV1HC>9921340UN1*1~ DTP472D820061003~ LX2~ SV1HC>8707215UN1*1~ DTP472D820061003~ LX3~ SV1HC>9921435UN1*2~ DTP472D820061010~ LX4~ SV1HC>8666310UN1*2~ DTP472D820061010~ SE410021~ GE1000000001~ IEA1000000001~ 1/30/25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 655/665 Example 3a: Claim from Billing Provider to Payer A ISA00 00 ZZSENDER ZZRECEIVER 2310300212^005010000000010T>~ GSHCSENDERGSRECEIVERGS20231030021212000000001X005010X222A2~ ST8370021005010X222A2~ BHT0019000123200510151023CH~ NM1412PREMIER BILLING SERVICE****46TGJ23~ PERICJERRYTE3055552222~ NM1402XYZ REPRICER***4666783JJT~ HL1201~ NM1851KILDAREBEN***XX1999996666~ N3234 SEAWAY ST~ N4MIAMIFL33111~ REFEI123456789~ PERICCONNIETE3055551234~ NM1872~ N32345 OCEAN BLVD~ N4MIAMIFL33111~ HL21221~ SBRP******CI~ NM1IL1SMITHJANE**MI111223333~ DMGD819430501F~ NM1PR2KEY INSURANCE COMPANY****PI999996666~ N33333 OCEAN ST~ N4SOUTH MIAMIFL33000~ REFG2PBS3334~ HL32230~ PAT19~ NM1QC1SMITHTED~ N3236 N MAIN ST~ N4MIAMIFL33413~ DMGD819730501M~ CLM2640778979.04**11>B>1YAYIP~ HIBK>4779BF>2724BF>2780BF>53081~ NM1821KILDAREBEN***XX1999996666~ PRVPEPXC204C00000X~ REFG2KA6663~ NM1772KILDARE ASSOCIATES****XX1581234567~ N32345 OCEAN BLVD~ N4MIAMIFL33111~ SBRS01*****CI~ OIYP*Y~ NM1IL1SMITHJACK**MIT55TY666~ N3236 N MAIN ST~ N4MIAMIFL33111~ NM1PR2KEY INSURANCE COMPANY***PI999996666~ LX1~ SV1HC>9921343UN1*1>2>3>4~ DTP472D820051003~ LX2~ SV1HC>9078215UN1*1>2~ DTP472D820051003~ LX3~ SV1HC>J330121.04UN1*1>2~ DTP472D820051003~ 1/30/25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 656/665 SE520021~ GE1000000001~ IEA1000000001~ 1/30/25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 657/665 Example 4: Medicare Secondary Payer (COB) ISA00 00 ZZSENDER ZZRECEIVER 2310300210^005010000000010T>~ GSHCSENDERGSRECEIVERGS20231030021055000000001X005010X222A2~ ST8370002005010X222A2~ BHT00190000000114220050214115101CH~ NM1412SPECIALISTS****461111111~ PERICSUETE8005558888~ NM1402MEDICARE PENNSYLVANIA***4610234~ HL1201~ NM1852SPECIALISTS***XX0100000090~ N35 MAP COURT~ N4MAYNEPA17111~ REFEI890123456~ REF1G110101~ HL21220~ SBRS18MEDICARE12****MB~ NM1IL1MEDYUMWAYNEM**MI102200221B1~ N3*1010 THOUSAND OAK	Home State Health 837 Health Care Claim_ Professional.pdf
Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 651/665 Example 10a: Drug administered in the Physician Office ISA00 00 ZZSENDER ZZRECEIVER 2310300211^005010000000010T>~ GSHCSENDERGSRECEIVERGS20231030021120000000001X005010X222A2~ ST8370711005010X222A2~ BHT0019000013200408011200CH~ NM1412Associates in Medicine****46587654321~ PERICBud HollyTE8017268899~ NM1402XYZ Receiver***46369852758~ HL1201~ NM1852Associates in Medicine***XX587654321~ N31313 Las Vegas Boulevard~ N4Las VegasNV89109~ REFEI587654321~ HL21220~ SBRP18GRP01020102****CI~ NM1IL1VaughnSteveR**MIMBRID12345~ N3236 Diamond ST~ N4Las VegasNV89109~ DMGD819430501M~ NM1PR2R&R Health Plan****XVPLANID12345~ CLMCLMNO12345103.37**11>B>1YAYY~ HIBK>03591~ NM1821HendrixJim***XX1122333341~ PRVPEPXC208D00000X~ LX1~ SV1HC>9078250UN1111~ DTP472D820040711~ LX2~ SV1HC>J155053.37UN111*1~ DTP472D820040711~ AMTT3.37~ LIN*N400026063512~ CTP***10ML~ SE310711~ GE1000000001~ IEA1000000001~ 1/30/25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 652/665 Example 11: PPO Repriced Claim ISA00 00 ZZSENDER ZZRECEIVER 2310300211^005010000000010T>~ GSHCSENDERGSRECEIVERGS20231030021132000000001X005010X222A2~ ST8371002005010X222A2~ BHT00190010022005062009460000CH~ NM1412REGIONAL PPO NETWORK****46123456789~ PERICSUBMITTER CONTACT INFOTE8001231234~ NM1402EXTRA HEALTHY INSURANCE***46112244~ HL1201~ NM1852HAPPY DOCTORS GROUP PRACTICE***XX1234567890~ N3P O BOX 123~ N4FORT WAYNEIN462540000~ REFEI555512345~ PERICSUE BILLINGSWORTHTE8881231234~ HL21220~ SBRP18123XYZ****CI~ NM1IL1RINGDIAMONDD**MI00124A089~ N3123 EXAMPLE DRIVE~ N4INDIANAPOLISIN462290000~ DMGD819401229F~ NM1PR2EXTRA HEALTHY INSURANCE****PI12345~ CLMABC123-RI28.75**11>B>1YAYYP~ REF9A0902352342~ REFD9061505501749388~ HIBK>496BF>25000~ HCP0326.752908231234~ NM1DN1DOEJOHN***XX9988776655~ NM1821ANTHONYSUSANB*XX1122334455~ NM1772HAPPY DOCTORS GROUP~ N3123 FEEL GOOD ROAD~ N4WASHINGTONIN475010000~ LX1~ SV1HC>E0570>RR25UN1**1>2~ DTP472D820050514~ HCP0323.751.25908231234~ LX2~ SV1HC>A7003>NU3.75UN1*1~ DTP472D820050514~ HCP033.75908231234~ SE371002~ GE1000000001~ IEA1000000001~ 1/30/25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 653/665 Example 12: Out of Network Repriced Claim ISA00 00 ZZSENDER ZZRECEIVER 2310300211^005010000000010T>~ GSHCSENDERGSRECEIVERGS20231030021145000000001X005010X222A2~ ST8371024005010X222A2~ BHT0019001024200507111335CH~ NM1412REGIONAL PPO NETWORK****46123456789~ PERICSUBMITTER CONTACT INFOTE8001231234~ NM1402CONSERVATIVE INSURANCE***46000110002~ HL1201~ NM1852EMERGENCY PHYSICIANS GROUP***XX1122334455~ N37423 SUPER STREET~ N4BILLINGSMO919910000~ REFEI111002222~ HL21221~ SBRP232AA****CI~ NM1IL1SMITHMATTHEWR**MI57976235C~ N35698 SOUTH STREET~ N4BILLINGSMO919910000~ DMGD819561015M~ NM1PR2CONSERVATIVE INSURANCE****PI00123~ HL32230~ PAT19~ NM1QC1SMITHTOME~ N35698 SOUTH STREET~ N4BILLINGSMO919910000~ DMGD819960807M~ CLMTS234H3252.71*23>B>1YAYYP~ REF9A0902345406~ REFD9687534234346~ HIBK>9951~ HCP000333001234*******T1~ NM1821BLUEJACKIED**XX1112223336~ SBRS1856567***CI~ OIY*Y~ NM1IL1SMITHTOME**MI23424570~ N35698 SOUTH STREET~ N4BILLINGSMO919910000~ NM1PR2SECONDARY INSURANCE COMPANY***PI95645~ LX1~ SV1HC>99284252.71UN1*1~ DTP472D820050506~ SE391024~ GE1000000001~ IEA1000000001~ 1/30/25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 654/665 Example 2: Encounter ISA00 00 ZZSENDER ZZRECEIVER 2310300212^005010000000010T>~ GSHCSENDERGSRECEIVERGS20231030021201000000001X005010X222A2~ ST8370021005010X222A2~ BHT0019000123200610151023RP~ NM1412PREMIER BILLING SERVICE****46TGJ23~ PERICJERRYTE3055552222EX231~ NM1402AHLIC***4666783JJT~ HL1201~ PRVBIPXC203BF0100Y~ NM1852BEN KILDARE SERVICE****XX9876543210~ N3234 SEAWAY ST~ N4MIAMIFL33111~ REFEI587654321~ NM1872~ N32345 OCEAN BLVD~ N4MIAMIFL33111~ HL21220~ SBRP1812312-A****HM~ NM1IL1SMITHTED**MI000221111~ N3236 N MAIN ST~ N4MIAMIFL33413~ DMGD819430501M~ NM1PR2ALLIANCE HEALTH AND LIFE INSURANCE****PI741234~ CLM26462967100**11>B>1YAYI~ DTP431D819981003~ REFD917312345600006351~ HIBK>0340BF>V7389~ NM1772KILDARE ASSOCIATES***XX5812345679~ N32345 OCEAN BLVD~ N4MIAMIFL33111~ LX1~ SV1HC>9921340UN1*1~ DTP472D820061003~ LX2~ SV1HC>8707215UN1*1~ DTP472D820061003~ LX3~ SV1HC>9921435UN1*2~ DTP472D820061010~ LX4~ SV1HC>8666310UN1*2~ DTP472D820061010~ SE410021~ GE1000000001~ IEA1000000001~ 1/30/25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 655/665 Example 3a: Claim from Billing Provider to Payer A ISA00 00 ZZSENDER ZZRECEIVER 2310300212^005010000000010T>~ GSHCSENDERGSRECEIVERGS20231030021212000000001X005010X222A2~ ST8370021005010X222A2~ BHT0019000123200510151023CH~ NM1412PREMIER BILLING SERVICE****46TGJ23~ PERICJERRYTE3055552222~ NM1402XYZ REPRICER***4666783JJT~ HL1201~ NM1851KILDAREBEN***XX1999996666~ N3234 SEAWAY ST~ N4MIAMIFL33111~ REFEI123456789~ PERICCONNIETE3055551234~ NM1872~ N32345 OCEAN BLVD~ N4MIAMIFL33111~ HL21221~ SBRP******CI~ NM1IL1SMITHJANE**MI111223333~ DMGD819430501F~ NM1PR2KEY INSURANCE COMPANY****PI999996666~ N33333 OCEAN ST~ N4SOUTH MIAMIFL33000~ REFG2PBS3334~ HL32230~ PAT19~ NM1QC1SMITHTED~ N3236 N MAIN ST~ N4MIAMIFL33413~ DMGD819730501M~ CLM2640778979.04**11>B>1YAYIP~ HIBK>4779BF>2724BF>2780BF>53081~ NM1821KILDAREBEN***XX1999996666~ PRVPEPXC204C00000X~ REFG2KA6663~ NM1772KILDARE ASSOCIATES****XX1581234567~ N32345 OCEAN BLVD~ N4MIAMIFL33111~ SBRS01*****CI~ OIYP*Y~ NM1IL1SMITHJACK**MIT55TY666~ N3236 N MAIN ST~ N4MIAMIFL33111~ NM1PR2KEY INSURANCE COMPANY***PI999996666~ LX1~ SV1HC>9921343UN1*1>2>3>4~ DTP472D820051003~ LX2~ SV1HC>9078215UN1*1>2~ DTP472D820051003~ LX3~ SV1HC>J330121.04UN1*1>2~ DTP472D820051003~ 1/30/25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 656/665 SE520021~ GE1000000001~ IEA1000000001~ 1/30/25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 657/665 Example 4: Medicare Secondary Payer (COB) ISA00 00 ZZSENDER ZZRECEIVER 2310300210^005010000000010T>~ GSHCSENDERGSRECEIVERGS20231030021055000000001X005010X222A2~ ST8370002005010X222A2~ BHT00190000000114220050214115101CH~ NM1412SPECIALISTS****461111111~ PERICSUETE8005558888~ NM1402MEDICARE PENNSYLVANIA***4610234~ HL1201~ NM1852SPECIALISTS***XX0100000090~ N35 MAP COURT~ N4MAYNEPA17111~ REFEI890123456~ REF1G110101~ HL21220~ SBRS18MEDICARE12****MB~ NM1IL1MEDYUMWAYNEM**MI102200221B1~ N31010 THOUSAND OAK LANE~ N4MAYNPA17089~ DMGD819560110M~ NM1PR2MEDICARE PENNSYLVANIA****PI10234~ N35232 MAYNE AVENUE~ N4LYGHTPA17009~ CLM101KEN6055120**11>B>1YAYYP~ HIBK>71516BF>71906~ NM1DN1BRYHTLEET~ REF1GB01010~ NM1821HENZESJACK**XX9090909090~ PRVPEPXC207X00000X~ REFG2110102CCC~ SBRP01COMMERCE***CI~ AMTD80~ AMTA815~ OI*YP*Y~ NM1IL1MEDYUMCAROL**MICOM188-404777~ N3PO BOX 45~ N4MAYNPA17089~ NM1PR2COMMERCE***PI59999~ LX1~ SV1HC>99203>25120UN1*1>2~ DTP472D820050119~ SVD5999980HC>99203>251~ CASCO4225~ CASPR215~ DTP573D820050128~ SE430002~ GE1000000001~ IEA1000000001~ 1/30/25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 658/665 Example 5: Ambulance ISA00 00 ZZSENDER ZZRECEIVER 2310300212^005010000000010T>~ GSHCSENDERGSRECEIVERGS20231030021237000000001X005010X222A2~ ST837000017712005010X222A2~ BHT001900000017712200502081112CH~ NM1412AAA AMBULANCE SERVICE****46376985369~ PERICLISA SMITHTE3037752536~ NM1402MEDICARE B***46123245~ HL1201~ PRVBIPXC3416L0300X~ NM1852AAA AMBULANCE SERVICE****XX2366554859~ N312202 AIRPORT WAY~ N4BROOMFIELDCO800210021~ REFEI376985369~ HL21220~ SBRP18******MB~ NM1IL1JONESSARAHA**MI012345678A~ N31129 REINDEER ROAD~ N4CARRCO80612~ DMGD819630729F~ NM1PR2MEDICARE PART B****PI123245~ N3PO BOX 3543~ N4BALTIMOREMD666013543~ CLM051068766.50**41>B>1YAYYPOA~ DTP439D820050208~ CR1LB275*ADH21**PATIENT IMOBILIZED~ CRC07Y040609~ CRC07N050708~ HIBK>8628BF>E8888BF>9592BF>8540~ NM1PW2~ N31129 REINDEER ROAD~ N4CARRCO80612~ NM1452~ N310005 BANNOCK ST~ N4CHEYENNEWY82009~ LX1~ SV1HC>A0427>RH700UN1*1>2>3>4Y~ DTP472D820050208~ QTYPT2~ REF6R1001~ NTEADDCARDIAC EMERGENCY~ LX2~ SV1HC>A0425>RH8.20UN21*1>2>3>4Y~ DTP472D820050208~ QTYPT2~ REF6R1002~ LX3~ SV1HC>A0422>RH46UN1*1>2>3>4Y~ DTP472D820050208~ REF6R1003~ LX4~ SV1HC>A0382>RH12.30UN1*1>2>3>4Y~ DTP472D820050208~ REF6R1004~ 1/30/25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 659/665 SE52000017712~ GE1000000001~ IEA1000000001~ 1/30/25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 660/665 Example 6: Chiropractic ISA00* 00 ZZSENDER ZZRECEIVER 2310300212^005010000000010T>~ GSHCSENDERGSRECEIVERGS20231030021257000000001X005010X222A2~ ST8373701005010X222A2~ BHT00190000722720050215075420CH~ NM1412DAVID GREEN****46S01057~ PERICKATHY SMITHTE4105558888~ NM1402MEDICARE PART B MARYLAND***4612345~ HL1201~ NM1851GREENEDAVIDM*XX1234567890~ N31264 OAKWOOD AVE~ N4BALTIMOREMD21236~ REFEI987654321~ PERICDRTE4105551212~ HL21220~ SBRP18******MB~ NM1IL1WILLIAMSONMATTHEWJ**MI123456789A~ N3128 BROADCREEK~ N4BALTIMOREMD21234~ DMGD819250110M~ NM1PR2MEDICARE PART B MARYLAND****PIC12345~ CLM125WILL145.5**11>B>1YAYY~ DTP454D820050115~ DTP453D820050110~ DTP455D820050113~ CR2******ACHRONIC PAIN AND DISCOMFORT~ HIBK>7215~ LX1~ SV1HC>98940145.5UN1**1~ DTP472D820050215~ REF6R01~ SE293701~ GE1000000001~ IEA1000000001~ 1/30/25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 661/665 Example 7: Oxygen ISA00 00 ZZSENDER ZZRECEIVER 2310300219^005010000000010T>~ GSHCSENDERGSRECEIVERGS20231030021945000000001X005010X222A2~ ST8370001005010X222A2~ BHT00190016200503261036CH~ NM1412OXYGEN SUPPLY COMPANY****46ABC11111~ PERICBONNIETE8125551111EM[email protected]~ NM1402DMERC CARRIER***4699999~ HL1201~ NM1852OXYGEN SUPPLY COMPANY***XX9992233334~ N31800 EAST RIDGE DRIVE~ N4RICHMONDIN46224~ REFEI389999999~ HL21220~ SBRP18******MB~ NM1IL1SMITHTERRY**MI111222333A~ N3121 SOUTH ST~ N4RICHMONDIN46236~ DMGD819380105F~ NM1PR2DMERC CARRIER****PI99999~ CLMR03996273 #01520.24**11>B>1YAYY~ HIBK>496BF>51881BF>2859~ LX1~ SV1HC>E1390>RR461.1UN1*1>2~ PWKCTAD~ CR3RMO99~ DTP472RD820050321-20050321~ DTP607D820050321~ DTP463D820040321~ DTP461D820050321~ NM1DK1WILSONLARRY***XX5555511111~ N31212 NORTH MERIDIAN~ N4RICHMONDIN46223~ REF1GX99999~ PERICLEETE5554446666~ LQUT04.03~ FRM1A056~ FRM1C*20050228~ FRM2*1~ FRM3*1~ FRM4Y~ FRM5*2~ FRM7Y~ FRM8N~ FRM9Y~ LX2~ SV1HC>E0431>RR59.14UN1**1>2~ PWKCTAD~ CR3RMO99~ DTP472RD820050321-20050321~ DTP607D820050321~ DTP463D820040321~ DTP461D820050321~ NM1DK1WILSONLARRY***XX5555511111~ 1/30/25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 662/665 N31212 NORTH MERIDIAN~ N4RICHMONDIN46223~ REF1GX99999~ PERICLEETE5554446666~ LQUT04.03~ FRM1A056~ FRM1C*20050228~ FRM2*1~ FRM3*1~ FRM4Y~ FRM5*2~ FRM7Y~ FRM8N~ FRM9Y~ SE660001~ GE1000000001~ IEA1000000001~ 1/30/25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 663/665 Example 8: Wheelchair ISA00* 00 ZZSENDER ZZRECEIVER 2310300214^005010000000010T>~ GSHCSENDERGSRECEIVERGS20231030021406000000001X005010X222A2~ ST837112233005010X222A2~ BHT00190016200503261036CH~ NM1412XYZ WHEELCHAIRS INC****46ABC55~ PERICJANETE2225551111~ NM1402DMERC CARRIER***4699999~ HL1201~ NM1852XYZ WHEELCHAIR INC***XX7778889999~ N31440 NORTH STREET~ N4LAFAYETTEIN47904~ REFEI123567989~ REF1G0426960001~ HL21220~ SBRP18*****MB~ PAT****01155~ NM1IL1SMITHJAMES***MI987654321A~ N312 MAIN ST~ N4FRANKFORTIN46209~ DMGD819201023M~ NM1PR2DMERC CARRIER****PI99999~ CLMSMI12375**12>B>1YAYY~ HIBK>436BF>3449~ LX1~ SV1HC>K0001>RR>KH>BR75UN1**1>2~ PWKCTAD~ CR3IMO99~ DTP472RD820050321-20050321~ DTP463D820040321~ DTP461D820050321~ MEATRHT70~ NM1DK1WILSONRANDALL***XX1111155555~ N31226 WEST RAILROAD STREET~ N4LAFAYETTEIN47905~ REF1GM12345~ PERICLEETE7659259999~ LQUT02.03B~ FRM1Y~ FRM2N~ FRM3N~ FRM4N~ FRM58~ FRM8N~ FRM9Y~ SE43112233~ GE1000000001~ IEA1000000001~ 1/30/25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 664/665 Stedi is a registered trademark of Stedi, Inc. All names, logos, and brands of third parties listed on this page are trademarks of their respective owners (including “X12”, which is a trademark of X12 Incorporated). Stedi, Inc. and its products and services are not endorsed by, sponsored by, or affiliated with these third parties. Use of these names, logos, and brands is for identification purposes only, and does not imply any such endorsement, sponsorship, or affiliation. Example 9: Anesthesia ISA00* 00 ZZSENDER ZZRECEIVER 2310300214^005010000000010T>~ GSHCSENDERGSRECEIVERGS20231030021427000000001X005010X222A2~ ST8370001005010X222A2~ BHT0019000123200501171023CH~ NM1412PROVIDER MEDICAL GROUP****46N305~ PERICNINATE6155551212EX911~ NM1402ABC PAYER***4605440~ HL1201~ NM1852PROVIDER MEDICAL GROUP***XX2366554859~ N31234 WEST END AVE~ N4NASHVILLETN37232~ REFEI756473826~ HL21220~ SBRP18******MB~ NM1IL1JONESMARGARET**MI123456789A~ N3123 RAINBOW ROAD~ N4NASHVILLETN37232~ DMGD819740303F~ NM1PR2ABC PAYER****PI05440~ CLM153829140827**22>B>1YAYY~ HIBK>36616~ NM1821TOWNSENDJACOBE*XX5678912345~ PRVPEPXC207L00000X~ REFG29741234~ NM1772PROVIDER OP HOSP****XX432198765~ N3345 MAIN DRIVE~ N4NASHVILLETN37232~ LX1~ SV1HC>00142>QK>QS>P1827MJ61*1~ DTP472D820050112~ SE290001~ GE1000000001~ IEA1000000001~ 1/30/25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 665/665	Home State Health 837 Health Care Claim_ Professional.pdf
835 Transaction Companion Guide ANSI x12 Version 005010X221A1 General Guidelines August 201 5 CDPHP® 835 TRANSACTION COMPANION GUIDE 2 Table of Contents Disclosure ..................................................................................................................................... 3 Preface .......................................................................................................................................... 3 1. Introduction ............................................................................................................................ 4 Scope ...................................................................................................................................... 5 Overview .................................................................................................................... ............ 5 2. Getting started ........................................................................................................................ 5 Electronic Data Interchange Enrollment ................................................................................ 5 Electronic Funds Transfer ...................................................................................................... 5 835 Electronic Remittance Advice (ERA) ............................................................................. 5 Questions and General Information ....................................................................................... 5 3. Certification and Testing Overview ....................................................................................... 6 Test Plan ................................................................................................................................. 6 Security .................................................................................................................................. 6 4. Connectivity ........................................................................................................................... 7 Prerequisites ........................................................................................................................... 7 Supported Web Browsers ....................................................................................................... 7 Supported Secure FTP/SSL Clients ....................................................................................... 7 Supported Secure FTP/SSH (and SCP2) Clients ................................................................... 8 Passwords ............................................................................................................................... 9 5. Contact Information ............................................................................................................... 9 CDPHP Hours of Operation ................................................................................................... 9 6. Control Segments/Envelopes ............................................................................................... 10 7. Trading Partner Agreements ................................................................................................ 1 0 8. Transaction Specific Information ......................................................................................... 10 General Statements............................................................................................................... 10 Health Reimbursement Arrangement (HRA) Information ................................................. 16 Coordination of Benefit Information in the 835 Transaction .............................................. 16 Appendix .................................................................................................................................... 17 CDPHP® 835 TRANSACTION COMPANION GUIDE 3 Disclosure This document is based on requirements of the Affordable Care Act (ACA). All rights are reserved. This document is provided “as is” without any express or implied warranty. The Washington Publishing Company documentation was prepared for use by all health insurance payers in the United States. The CDPHP 835 ANSI Companion Guide Document is a supplement but does not contradict any requirements in the ASC X12N 835 (005010X221A1) data standards, as mandated by Health and Human Services. Preface This Companion Guide to the v5010 ASC X12N Implementation Guides and associated errata adopted under HIPAA clarifies and specifies the data content when exchanging electronically with Capital District Physicians’ Health Plan, Inc. (CDPHP®). Transmissions based on this companion guide, used in conjunction with the v5010 ASC X12N Implementation Guides, are compliant with both ASC X12 syntax and those guides, all of which are available from the Washington Publishing Company website at: www.wpc-edi.com. The Companion Guide is not intended to convey information that in any way exceeds the requirements or usages of data expressed in the Implementation Guides. CDPHP® 835 TRANSACTION COMPANION GUIDE 4 1. Introduction This section describes how ASC X12N Implementation Guides (IGs) adopted under HIPAA will be detailed with the use of a table. The tables contain a row for each segment that CDPHP has something additional, over and above, the information in the IGs. That information can: 1. Limit the repeat of loops or segments 2. Limit the length of a simple data element 3. Specify a subset of the IG’s internal code listings 4. Clarify the use of loops, segments, composite, and simple data elements 5. Any other information tied directly to a loop, segment, composite, or simple data element pertinent to trading electronically with CDPHP. In addition to the row for each segment, one or more additional rows are used to describe CDPHP’s usage for composite and simple data elements and for any other information. Notes and comments should be placed at the deepest level of detail. The following table is an example: Shaded Rows represent “segments” in the X12N Implementation Guide. Non-Shaded rows represent “data elements” in the X12N Implementation Guide. Loop Element Identifier Description ID Min/ Max Usage Loop Repeat Values Requirement Description HDR ISA Interchange Control Header 1 R Loop Repeat Values Requirement Description HDR ISA01 Authorized Information Qualifier ID 2-2 R 00,03 HDR ISA02 Security Information Qualifier ID 2-2 R 00,01 HDR ISA05 Interchange ID Qualifier ID 2-2 R 01, 14, 20, 27, 28, 29, 30, 33, ZZ Use ‘ZZ’ Mutually Defined CDPHP® 835 TRANSACTION COMPANION GUIDE 5 • Scope This document is to be used in addition to the HIPAA 835 Implementation Guide. It is designed for implementation of the HIPAA Transaction for Health Care Claim Payment/Advice, also known as the Electronic Remittance Advice (ERA). • Overview This Companion Guide will replace any previous CDPHP Companion Guide for 835 Health Care Claim transactions. This Companion Guide will assist you in designing and implementing 835 Claim Payment/Advice transactions that meet CDPHP’s processing standards. The CDPHP Companion Guide identifies key data elements that we request be sent in the submitting transaction set. Adherence to these guidelines will enable you to more effectively process 835 claims from CDPHP. 2. Getting started • Electronic Data Interchange Enrollment Should you decide to receive your payments and /or claim payment remittance advice electronically, you must first complete and return the necessary enrollment forms applicable to the transaction(s) your organization is requesting. Please contact your financial institution to arrange for the delivery of the CORE (Committee on Operating Rules for Information Exchange)-required Minimum CCD+(Corporate Credit or Debit entry) data elements needed for reassociation of the payment and the Electronic Remittance Advice (ERA). • Electronic Funds Transfer To enroll for Electronic Funds Transfer (EFT), you’ll need to complete your enrollment request by registering at https://CDPHP.payeehub.org and establishing a user account that will give you access as an authorized agent to request set up of EFT payments. To modify an existing EFT enrollment, you will also need to be a registered user at https://CDPHP.payeehub.org • 835 Electronic Remittance Advice (ERA) Enrollment to receive an 835 Electronic Remittance Advice is a separate sign up process and requires a Group/Provider Access Information for 835 Transaction Set Form which can be found online at: http://www.cdphp.com/~/media/Files/providers/835-Access-Request-Form-FIELDS-FINAL.ashx Once CDPHP receives your enrollment request, a CDPHP employee will establish your organization as an eligible EDI Trading Partner with CDPHP and contact you to discuss next steps in getting set up to trade electronic data. • Questions and General Information For assistance with any questions and /or general information regarding the sign up process, please contact: CDPHP® 835 TRANSACTION COMPANION GUIDE 6 CDPHP Provider Relations Team [email protected] 3. Certification and Testing Overview Becoming HIPAA compliant will require providers and payers to make significant changes to their existing Electronic Data Interchange (EDI) process. Process change inevitably includes testing for results validation. This testing can be one of the most time-consuming efforts in the development process. CDPHP expects the following approach will optimize test time and expedite our trading partners’ transition from test to production status. The trading partner must complete testing for each of the transactions they will implement and shall not be allowed to exchange data with CDPHP in production mode until testing has passed as determined by CDPHP. Successful testing means the ability to successfully pass HIPAA compliance checks and to process protected health information (PHI) transmitted by the trading partner to CDPHP. Test Step Description Test Plan The CDPHP EDI Support Center and trading partner will agree to a predefined set of test data with expected results. This matrix will vary by trading partner. Security CDPHP will verify that trading partners have a valid user ID and password. Connectivity and Transmission Integrity CDPHP connectivity protocols are outlined in “4. Connectivity.” We suggest that the trading partner limit transactions to a small volume during the testing phase. Transaction Validation CDPHP will verify that the trading partner is submitting transactions allowed per their enrollment applications. Data Integrity Data integrity is determined by the X12 and HIPAA Implementation Guide. The trading partner should correct transactions reported as errors and resubmit them. Data integrity testing is successfully completed when the trading partner’s data has no compliance errors. Acknowledgment and Response Transactions Trading partners must demonstrate the ability to receive acknowledgment and response transactions. Result Analysis CDPHP and the trading partner will review the acknowledgment and response transaction for consistency with the predefined results. CDPHP® 835 TRANSACTION COMPANION GUIDE 7 4. Connectivity Prerequisites • An Internet connection. • Ability to connect to a HTTPS Web site. • Desktop Web browser. Browsers supported are: • Mozilla v.1.0 and higher Advantages • File transfers are not time consuming. • Can use existing desktop browsers and Internet connectivity to transfer files. • Browser-based solutions are well-suited for on-demand, manual transfers involving desktops and laptops because they are free, already installed, and end-users know how to use the existing software. • Files are protected in transit by SSL (Secure Socket Layer). There is no need to send encrypted files. Supported Web Browsers MOVEit DMZ has been tested against and fully supports the following major browsers: • Internet Explorer version 6.0 and higher o Internet Explorer 7.0 and higher preferred o when using MOVEit Upload/Download Wizard (ActiveX or Java) • FireFox (2.0 and 3.0) o when using MOVEit Upload/Download Wizard (Java Windows/nix/Mac OS X) • Safari (versions 2 and 3) under Macintosh OS X o o when using MOVEit Upload/Download Wizard (Java Only) = Indicates this client ensures the integrity of transferred files and proves who uploaded and who downloaded a specific file (non-repudiation). Use of the MOVEit Java Wizard on the Macintosh version of Firefox requires that you use the Java Preferences applet to select Java 1.5 (rather than 1.4.2). Supported Secure FTP/SSL Clients MOVEit DMZ has been tested against and fully supports a large number of secure FTP clients using FTP over SSL: CDPHP® 835 TRANSACTION COMPANION GUIDE 8 • MOVEit Freely (free command-line) • MOVEit Buddy (GUI) • MOVEit Central (w/Admin) • WS_FTP Professional and WS_FTP Home (GUI, version 7 and higher, Windows) ( version 12 and higher) • SmartFTP (GUI, version 1.6 and higher, Windows) • SmartFTP (free GUI, version 1.0 and higher, Windows) • Cute FTP Pro (GUI, version 1.0 and higher, Windows) • BitKinex (GUI, version 2.5 and higher, Windows) • Glub FTP (GUI, Java 2.0 and higher) • FlashFXP (GUI, version 3.0 and higher) • IPWorks SSL (API, Windows, version 5.0) • LFTP (free command-line, Linux, Unix, Solaris, AIX, etc.) • NetKit (command-line, Linux, Unix, Solaris, etc.) • SurgeFTP (command-line, FreeBSD, Linux, Macintosh, Windows, Solaris) • C-Kermit (command-line; v8.0+, AIX, VMS, Linux, Unix, Solaris) • AS/400 native FTPS client (OS/400 minicomputer) • z/OS Secure Sockets FTP client (z/OS mainframe) • TrailBlaxer ZMOD (OS/400 minicomputer) • NetFinder (GUI, Apple) • Sterling Commerce (batch, various) • Tumbleweed SecureTransport (4.2+ on Windows, batch, various) • Cleo Lexicom (batch, various) • bTrade TDAccess (batch, AIX, AS/400, HP-UX, Linux, MVS, Solaris, Windows) • cURL (command-line, AIX, HP-UX, Linux, QNX, Windows, AmigaOS, BeOS, Solaris, BSD and more) • South River Technologies "WebDrive" (Windows "drive letter" - requires "passive, implicit and 'PROT P'" options) • Stairways Software Pty Ltd. "Interarchy" (Mac "local drive" and GUI ) FTP Client Developers: Please consult the "FTP - Interoperability - Integrity Check How-To" documentation for information about how to support integrity checks with your FTP client too. Supported Secure FTP/SSH (and SCP2) Clients MOVEit DMZ has been tested against and fully supports the most popular secure FTP clients using FTP over SSH as well: • OpenSSH sftp for nix (free command-line, Unix - including Linux and BSD, password and client key modes) • OpenSSH for Windows (free command-line, Windows, password and client key modes) • OpenSSH sftp for Mac (preinstalled command-line, Mac, password and client key modes) • OpenSSH sftp for z/OS (part of "IBM Ported Tools for z/OS", z/OS 1.4+, password and client key modes) • Putty PSFTP, (command-line, Windows, password and client key modes) CDPHP® 835 TRANSACTION COMPANION GUIDE 9 • WS_FTP (GUI, Windows, version 7.0 and higher; version 7.62 has a compression-related bug which prevents it from uploading large, highly compressible files) • BitKinex (GUI, version 2.5 and higher, Windows) • F-Secure SSH (command-line, 3.2.0 Client for Unix, password and client key modes) • FileZilla (GUI, Windows) • SSH Communications SSH Secure Shell FTP (GUI, Windows, password and client key modes; requires setting # of transfers to 1) • SSH Tectia Connector (Windows) • SSH Tectia Client (Windows,AIX,HP-UX,Linux,Solaris) • J2SSH (free Java class - requires Java 1.3+) • Net::SFTP - Net::SSH::Perl (free Perl module for Unix) • MacSSH (GUI, Mac, password mode only) • Fugu (free GUI, Mac, password mode only) • Cyberduck (free GUI, Mac, password and client key modes) • Rbrowser (GUI, Mac, password mode only) • Transmit2 (GUI, Mac, password and client key modes) • gftp (GUI, Linux, password and client key modes) • Magnetk LLC sftpdrive (Windows "drive letter", password mode only) • South River Technologies "WebDrive" (Windows "drive letter", password mode only) • Cyclone Commerce Interchange (Solaris, client key mode only) • Stairways Software Pty Ltd. "Interarchy" (Mac "local drive" and GUI, password mode only) • Miklos Szeredi's "SSH FileSystem", a.k.a. "SSHFS" (nix "mount file system" utility, password and client	835_companion_guide.pdf
GUI, version 1.0 and higher, Windows) • Cute FTP Pro (GUI, version 1.0 and higher, Windows) • BitKinex (GUI, version 2.5 and higher, Windows) • Glub FTP (GUI, Java 2.0 and higher) • FlashFXP (GUI, version 3.0 and higher) • IPWorks SSL (API, Windows, version 5.0) • LFTP (free command-line, Linux, Unix, Solaris, AIX, etc.) • NetKit (command-line, Linux, Unix, Solaris, etc.) • SurgeFTP (command-line, FreeBSD, Linux, Macintosh, Windows, Solaris) • C-Kermit (command-line; v8.0+, AIX, VMS, Linux, Unix, Solaris) • AS/400 native FTPS client (OS/400 minicomputer) • z/OS Secure Sockets FTP client (z/OS mainframe) • TrailBlaxer ZMOD (OS/400 minicomputer) • NetFinder (GUI, Apple) • Sterling Commerce (batch, various) • Tumbleweed SecureTransport (4.2+ on Windows, batch, various) • Cleo Lexicom (batch, various) • bTrade TDAccess (batch, AIX, AS/400, HP-UX, Linux, MVS, Solaris, Windows) • cURL (command-line, AIX, HP-UX, Linux, QNX, Windows, AmigaOS, BeOS, Solaris, BSD and more) • South River Technologies "WebDrive" (Windows "drive letter" - requires "passive, implicit and 'PROT P'" options) • Stairways Software Pty Ltd. "Interarchy" (Mac "local drive" and GUI ) FTP Client Developers: Please consult the "FTP - Interoperability - Integrity Check How-To" documentation for information about how to support integrity checks with your FTP client too. Supported Secure FTP/SSH (and SCP2) Clients MOVEit DMZ has been tested against and fully supports the most popular secure FTP clients using FTP over SSH as well: • OpenSSH sftp for nix (free command-line, Unix - including Linux and BSD, password and client key modes) • OpenSSH for Windows (free command-line, Windows, password and client key modes) • OpenSSH sftp for Mac (preinstalled command-line, Mac, password and client key modes) • OpenSSH sftp for z/OS (part of "IBM Ported Tools for z/OS", z/OS 1.4+, password and client key modes) • Putty PSFTP, (command-line, Windows, password and client key modes) CDPHP® 835 TRANSACTION COMPANION GUIDE 9 • WS_FTP (GUI, Windows, version 7.0 and higher; version 7.62 has a compression-related bug which prevents it from uploading large, highly compressible files) • BitKinex (GUI, version 2.5 and higher, Windows) • F-Secure SSH (command-line, 3.2.0 Client for Unix, password and client key modes) • FileZilla (GUI, Windows) • SSH Communications SSH Secure Shell FTP (GUI, Windows, password and client key modes; requires setting # of transfers to 1) • SSH Tectia Connector (Windows) • SSH Tectia Client (Windows,AIX,HP-UX,Linux,Solaris) • J2SSH (free Java class - requires Java 1.3+) • Net::SFTP - Net::SSH::Perl (free Perl module for Unix) • MacSSH (GUI, Mac, password mode only) • Fugu (free GUI, Mac, password mode only) • Cyberduck (free GUI, Mac, password and client key modes) • Rbrowser (GUI, Mac, password mode only) • Transmit2 (GUI, Mac, password and client key modes) • gftp (GUI, Linux, password and client key modes) • Magnetk LLC sftpdrive (Windows "drive letter", password mode only) • South River Technologies "WebDrive" (Windows "drive letter", password mode only) • Cyclone Commerce Interchange (Solaris, client key mode only) • Stairways Software Pty Ltd. "Interarchy" (Mac "local drive" and GUI, password mode only) • Miklos Szeredi's "SSH FileSystem", a.k.a. "SSHFS" (nix "mount file system" utility, password and client key modes; requires OpenSSH and FUSE) • Tumbleweed SecureTransport (4.2+ on Windows, batch, various) = Indicates this client ensures the integrity of transferred files and proves who uploaded and who downloaded a specific file (non-repudiation). Passwords • Passwords must be changed upon first log-on. • Passwords and user names are case sensitive. • Passwords must be six characters. • Passwords must contain at least one alpha and one numeric character. • Passwords cannot resemble user names. • Passwords cannot contain dictionary words. Examples: Unacceptable passwords: Security, Security 9 Acceptable passwords: Sec9urity, sec9urity 5. Contact Information For assistance regarding 835 ERA enrollment, EDI technical assistance, or general provider services, please email our EDI Customer Service at [email protected] CDPHP® 835 TRANSACTION COMPANION GUIDE 10 By visiting https://CDPHP.payeehub.org you can access information about how to register and enroll to receive Electronic Funds Transfer (EFT) payments, and/or how to make modifications to your existing EFT enrollment. CDPHP Hours of Operation CDPHP business areas process non-inquiry files Monday through Friday. Files may be submitted 24 hours a day, 7 days a week, 365 days a year. Files received after 2 p.m. EST will be processed the next business day. CDPHP does NOT process claims on the following days: • Saturday • Sunday • New Year’s Day • President’s Day • Memorial Day • Independence Day • Labor Day • Thanksgiving • Friday following Thanksgiving • Christmas Eve Day • Christmas Day Under normal operating conditions, 835 files are available for pick up no later than noon, EST every Tuesday of each week. The above list is subject to change. Days may be added or removed from the list without notice. 6. Control Segments/Envelopes ASC X12 transaction envelopes (i.e., ISA, IEA, GS and GE segments) should be populated per instructions found in the section labeled “8. Transaction Specific Information.” Transactions returned by CDPHP to the trading partner will be enveloped consistent with the specifications described in Example 1B. ASC X12 transaction record formats are available as downloads from The Washington Publishing Company (WPC), website: http://Wpc-Edi.Com/ 7. Trading Partner Agreements An EDI Trading Partner is defined as any CDPHP customer (provider, billing service, software, software vendor, etc.) that transmits to, or receives electronic data from CDPHP. Payers have EDI Trading Partner Agreements that accompany the standard implementation guide to ensure the integrity of the electronic transaction process. The Trading Partner Agreement is related to the electronic exchange of information, whether the agreement is an entity or a part of a larger agreement, between each party agreement. 8. Transaction Specific Information CDPHP® 835 TRANSACTION COMPANION GUIDE 11 The following information is intended to serve as a guide to the HIPAA ANSI X12 835 Implementation Guide. Please refer to the complete HIPAA ANSI x12 835 Implementation Guide for a full listing of required and situational fields. The rules in the implementation guide take precedence over the CDPHP companion guide. • General Statements • The outbound 835 transactions utilize delimiters from the following list: ‘>’, ‘’, ‘~’, ‘^’, ‘\|’, and ‘:’. • CDPHP utilizes ‘:’. If you need this changed, please contact CDPHP, or else the ‘:’ is assumed. • Transaction File Naming Structure File Name: 835 files received from CDPHP will be named using a standard naming convention. File names contain four parts separated by underscore characters and end with an .edi extension. The parts of the file name are: Trading Partner No: Typically a Tax Identification number. Sequence number: Unlimited characters. The sequence number will be used by CDPHP to identify a file as unique for that trading partner on a given day. Transaction Type: 835 File Extension: edi Example of filename: 123456789_54126_916740_835.edi Version Loop Segment Field Description Suggestion HDR ISA Interchange Control Header 005010X221A1 - ISA 05 Interchange ID Qualifier Value of "30" - Federal Tax ID 005010X221A1 ISA 06 Interchange Sender ID 141641028 005010X221A1 ISA 07 Interchange ID Qualifier Value of "30" - Federal Tax ID 005010X221A1 ISA 08 Interchange Receiver ID Receiver's Tax ID Version Loop Segment Field Description Suggestion CDPHP® 835 TRANSACTION COMPANION GUIDE 12 HDR GS Functional Group Header 005010X221A1 - GS 02 Application Sender's Code 141641028 005010X221A1 - GS 03 Application Receiver's Code Same value as what was in ISA08 for consistency Version Loop Segment Field Description Suggestion HDR BPR Financial Information 005010X221A1 - BPR 04 Payment Method Code CDPHP will utilize all available Payment Method codes: • ACH – Automated Clearing House • CHK – Check • NON – Non-Payment Data BPR 05 Payment Format Code CCP – Cash Concentration/Disbursement plus Addenda BPR05 will only be valued when BPR04 is ACH. BPR 10 Originating Company Identifier 141641028 (Only when BPR04 is ACH.) Version Loop Segment Field Description Suggestion HDR TRN Re-Association Trace Number 005010X221A1 - TRN 02 Check or EFT Trace Number If BPR04 = ACH TRN02 = Re-association Trace Number on EFT Transaction 005010X221A1 - TRN 03 Originating Company Identifier Tax ID of Business Program/Group Administering Benefit CDPHP® 835 TRANSACTION COMPANION GUIDE 13 005010X221A1 - TRN 04 Originating Company Supplemental Code If • BPR04 = ACH, The same value as BPR10 ( originating Company Supplemental Code is used) • IF BPR04 = CHK or NON, The RA Advice Number is used. Version Loop Segment Field Description Suggestion HDR CUR Foreign Currency Information 005010X221A1 - CUR All Foreign Currency Segment CDPHP will not use this segment. All funds will be in US dollars Version Loop Segment Field Description Suggestion 1000 A Payer Identification 005010X221A1 1000 A N1 02 Payer Name Name of Business Program/Group Administering Benefit 005010X221A1 1000 A N1 04 Payer Identifier CDPHP as the entity to contact with questions 005010X221A1 1000 A REF 01 Reference Identification Qualifier 2U 005010X221A1 1000 A REF 02 Additional Payer Identifier SX065_12X03 (professional and institutional identifiers) Version Loop Segment Field Description Suggestion 1000 B Payee Identification 005010X221A1 1000 B N1 03 Identification Code Qualifier Value of "XX" - National Provider ID 005010X221A1 1000 B N1 04 Identification Code NPI Number CDPHP® 835 TRANSACTION COMPANION GUIDE 14 005010X221A1 1000 B REF 01 Reference Identification Qualifier Value of "TJ" - Payee Identification 005010X221A1 1000 B REF 02 Reference Identification The "pay to" Tax Identification number on file with CDPHP Version Loop Segment Field Description Suggestion 2100 NM1 Corrected Priority Payee Name 005010X221A1 2100 NM1 01 Entity Identifier Code QC 005010X221A1 2100 NM1 08 Identification Code Qualifier Value "MI" -Member Identification Number 005010X221A1 2100 NM1 09 Identification Code - Patient Identifier Member ID including suffix 005010X221A1 2100 NM1 01 Entity Identifier Code IL - This segment will only be used if the insured or subscriber is difference from the patient. 005010X221A1 2100 NM1 08 Identification Code Qualifier Value "MI" -Member Identification Number 005010X221A1 2100 NM1 09 Identification Code - Insured Identifier Member ID including suffix • Additional Information in the 835 Transaction The following is intended to highlight additional information that may be returned from CDPHP on an 835. This information is compliant with HIPAA ANSI X12 835 but may be new to you. • Claim Adjustment Group and Reason Codes CDPHP utilizes the Washington Publishing Company for 835 claim adjustment reason codes and remittance advice remark codes: Refer to www.wpc-edi.com for information. Version Loop Segment Field Value Description 2100 CAS Claim Adjustment 005010X221A1 2100 / 2110 CAS 01 PR CO PI OA CDPHP will utilize all available claim adjustment group codes: 6. PR – Patient Responsibility 7. CO – Contractual Obligations 8. PI - Payer Initiated Reductions 9. OA – Other Adjustments CDPHP® 835 TRANSACTION COMPANION GUIDE 15 005010X221A1 2110 CAS 01/ 02 PR/95 Patient Responsibility—In addition to a patient responsibility for co-pay, coinsurance, and deductible, patient responsibility can also be the result of a contractual provision between the patient and insurer. Claim Adjustment Reason Code 95 will be used to indicate a patient responsibility that is the result of a penalty being applied when member contract provisions are not followed. 005010X221A1 2110 CAS 01 PI/45 PI/94 Payer Initiated Reductions— Inpatient or Outpatient—Per Diem or an APC or APG or ASC reimbursement: The PI (45) segment represents the total of all other individual line items disallowed due to the per diem. DRG or Outpatient Flat Rate reimbursement—The PI (94) segment represents the difference between the flat rate and the submitted charge when the submitted charge is less than the negotiated rate. This will result in a negative dollar amount. 005010X221A1 2110 CAS 01/ 02 CO/104 Contractual Obligation—In addition to the normal contractual obligation disallows, CO will also be used for Managed Care Withholding. This disallow segment represents the amount of the CDPHP allowance withheld (aka risk) as part of the provider’s contractual agreement with CDPHP. Risk is applied on claims where CDPHP is processing as secondary, as well as primary. 005010X221A1 2100 CAS DRG Reimbursement—Reimbursement of DRG claims will be reflected at the claim level rather than the line level. There will be no 2110 loop. Version Loop Segment Field Value Description 2110 CAS Service Adjustment 005010X221A1 2110 CAS 01 PR CO PI OA CDPHP will utilize all available claim adjustment group codes: 10. PR – Patient Responsibility 11. CO – Contractual Obligations 12. PI - Payer Initiated Reductions 13. OA – Other Adjustments CDPHP® 835 TRANSACTION COMPANION GUIDE 16 Version Loop Segment Field Value Description PLB Service Adjustment 005010X221A1 PLB 03-02	835_companion_guide.pdf
Loop Segment Field Description Suggestion 2100 NM1 Corrected Priority Payee Name 005010X221A1 2100 NM1 01 Entity Identifier Code QC 005010X221A1 2100 NM1 08 Identification Code Qualifier Value "MI" -Member Identification Number 005010X221A1 2100 NM1 09 Identification Code - Patient Identifier Member ID including suffix 005010X221A1 2100 NM1 01 Entity Identifier Code IL - This segment will only be used if the insured or subscriber is difference from the patient. 005010X221A1 2100 NM1 08 Identification Code Qualifier Value "MI" -Member Identification Number 005010X221A1 2100 NM1 09 Identification Code - Insured Identifier Member ID including suffix • Additional Information in the 835 Transaction The following is intended to highlight additional information that may be returned from CDPHP on an 835. This information is compliant with HIPAA ANSI X12 835 but may be new to you. • Claim Adjustment Group and Reason Codes CDPHP utilizes the Washington Publishing Company for 835 claim adjustment reason codes and remittance advice remark codes: Refer to www.wpc-edi.com for information. Version Loop Segment Field Value Description 2100 CAS Claim Adjustment 005010X221A1 2100 / 2110 CAS 01 PR CO PI OA CDPHP will utilize all available claim adjustment group codes: 6. PR – Patient Responsibility 7. CO – Contractual Obligations 8. PI - Payer Initiated Reductions 9. OA – Other Adjustments CDPHP® 835 TRANSACTION COMPANION GUIDE 15 005010X221A1 2110 CAS 01/ 02 PR/95 Patient Responsibility—In addition to a patient responsibility for co-pay, coinsurance, and deductible, patient responsibility can also be the result of a contractual provision between the patient and insurer. Claim Adjustment Reason Code 95 will be used to indicate a patient responsibility that is the result of a penalty being applied when member contract provisions are not followed. 005010X221A1 2110 CAS 01 PI/45 PI/94 Payer Initiated Reductions— Inpatient or Outpatient—Per Diem or an APC or APG or ASC reimbursement: The PI (45) segment represents the total of all other individual line items disallowed due to the per diem. DRG or Outpatient Flat Rate reimbursement—The PI (94) segment represents the difference between the flat rate and the submitted charge when the submitted charge is less than the negotiated rate. This will result in a negative dollar amount. 005010X221A1 2110 CAS 01/ 02 CO/104 Contractual Obligation—In addition to the normal contractual obligation disallows, CO will also be used for Managed Care Withholding. This disallow segment represents the amount of the CDPHP allowance withheld (aka risk) as part of the provider’s contractual agreement with CDPHP. Risk is applied on claims where CDPHP is processing as secondary, as well as primary. 005010X221A1 2100 CAS DRG Reimbursement—Reimbursement of DRG claims will be reflected at the claim level rather than the line level. There will be no 2110 loop. Version Loop Segment Field Value Description 2110 CAS Service Adjustment 005010X221A1 2110 CAS 01 PR CO PI OA CDPHP will utilize all available claim adjustment group codes: 10. PR – Patient Responsibility 11. CO – Contractual Obligations 12. PI - Payer Initiated Reductions 13. OA – Other Adjustments CDPHP® 835 TRANSACTION COMPANION GUIDE 16 Version Loop Segment Field Value Description PLB Service Adjustment 005010X221A1 PLB 03-02 Provider Adjustment Identifier will contain both the CDPHP claim number and provider patient account number. ie: 1513300XXX00 123456XY22Z • Health Reimbursement Arrangement (HRA) Information on CDPHP 835 Outbound File In the event that a member has an HRA administered by CDPHP and it is a fully automated plan, patient liability, with the exception of penalty, will be considered for an additional payment according to the member’s employer group rules. In the event that an additional payment is created, the medical payment will appear on your 835 as a medical claim as reflected above and it will also appear on your 835 as an HRA considered claim. The HRA portion will be attached to the Payer “Capital District Physicians’ Healthcare Network CD”. See below: N1PRCapital District Physicians’ Healthcare Network CD~ • Coordination of Benefit Information in the 835 Transaction The following is intended to explain the COB information on the 835. Claim adjustment reason code 22 is used to indicate “Other Carrier Paid Amount.” This code may be associated with the following group codes: CO, OA and PR. This is because when mapping the COB amounts, it is necessary to offset the patient responsibility (PR) with the COB amount. When COB amount is in excess of the patient responsibility amount, the difference will be applied to the next CAS segment. Adjustment reason code 23 often reflects the difference between the CDPHP allowance and the primary carrier’s allowance. Finally, CDPHP supports COB savings in which denied or non covered services may be reimbursed out of a savings that has been established for the member and based on the savings CDPHP has received through coordination of benefits. The following is an example of what you could see returned on the 835 when there is credit banking involved: CLP2091830396PR25403215XXXXXXXXXXXX23~ CDPHP® 835 TRANSACTION COMPANION GUIDE 17 NM1QC1WONKAWILLY***MIABCD1234F00~ NM1741WonkaWillyC*FABCD1234F~ NM1821Brown MDMichaelE*XX321456ABCD~ REF1L10008559~ DTM05020090711~ SVCHC:9397126LT5401~ DTM47220090628~ CASPR20454*23-22~ CASOA22*22~ CDPHP® 835 TRANSACTION COMPANION GUIDE 18 Appendix Change Summary: Date Version Description Oct. 2015 2 Added N1, REF segments to loop 1000A to reference additional payers; PLB segment now contains CDPHP claim number and provider patient account number Dec. 2021 3 (Dan M.) Changed CAQH text and links to new EFT administrator Zelis Healthcare and their custom CDPHP portal https://CDPHP.payeehub.org July 2022 4 (Dan M.) Added the following text to Page 5: Please contact your financial institution to arrange for the delivery of the CORE (Committee on Operating Rules for Information Exchange)-required Minimum CCD+(Corporate Credit or Debit entry) data elements needed for reassociation of the payment and the Electronic Remittance Advice (ERA).	835_companion_guide.pdf
Page 1 of 18 Standard Companion Guide Refers to the Implementation Guide Based on X12 Version 005010X222A1 Health Care Claim – Professional (837P) Companion Guide Version Number 6.2 March 8, 2023 Page 2 of 18 CHANGE LOG Version Release Date Changes 1.0 12/10/2010 Initial draft release 2.0 03/24/2014 ICD-10 effective date change to 10/01/2014 3.0 09/17/2015 ICD-10 effective date change to 10/01/2015 4.0 01/05/2018 Updated UnitedHealthcare and Optum contact information, including hyperlinks to online resources 5.0 10/17/2019 Updated corrected claim information in section 6.1 Electronic Claim Submission Guidelines 6.0 05/04/2020 Section 6 updated to include Laboratory test code requirement 6.1 06/23/2020 Removed Section 6 on the Laboratory test code requirement 6.2 03/08/2023 Updated Version Date Page 3 of 18 PREFACE This companion guide (CG) to the v5010 ASC X12N Technical Report Type 3 (TR3) adopted under Health Insurance Portability and Accountability Act (HIPAA) clarifies and specifies the data content when exchanging transactions electronically with UnitedHealthcare. Transmissions based on this companion guide, used in tandem with the TR3, also called 837 Health Care Claim: Professional ASC X12N (005010X222A1), are compliant with both ASC X12 syntax and those guides. There are separate transactions for Health Care Claims - institutional (837I) and professional (837P). This companion guide is intended to convey information that is within the framework of the ASC X12N TR3 adopted for use under HIPAA. The companion guide is not intended to convey information that in any way exceeds the requirements or usages of data expressed in the TR3. The TR3, also known as X12N Implementation Guide (IG), adopted under HIPAA, here on in within this document will be known as IG or TR3. Page 4 of 18 Table of Contents CHANGE LOG ..............................................................................................................................................................2 PREFACE .....................................................................................................................................................................3 INTRODUCTION ............................................................................................................................................. 6 1.1 SCOPE .....................................................................................................................................................6 1.2 OVERVIEW ..............................................................................................................................................7 1.3 REFERENCE .............................................................................................................................................7 1.4 ADDITIONAL INFORMATION .................................................................................................................7 GETTING STARTED ........................................................................................................................................ 7 2.1 EXCHANGING TRANSACTIONS WITH UNITEDHEALTHCARE .................................................................7 2.2 CLEARINGHOUSE CONNECTION ............................................................................................................7 2.3 CERTIFICATION AND TESTING ................................................................................................................8 CONNECTIVITY AND COMMUNICATION PROTOCOLS ................................................................................. 8 3.1 PROCESS FLOW: BATCH 837 INSTITUTIONAL CLAIM ............................................................................8 3.2 TRANSMISSION ADMINISTRATIVE PROCEDURES .................................................................................8 3.3 RE-TRANSMISSION PROCEDURES ..........................................................................................................8 3.4 COMMUNICATION PROTOCOL SPECIFICATIONS ..................................................................................8 3.5 PASSWORDS ...........................................................................................................................................9 3.6 SYSTEM AVAILABILITY ...........................................................................................................................9 3.7 COSTS TO CONNECT ...............................................................................................................................9 CONTACT INFORMATION ............................................................................................................................. 9 4.1 EDI SUPPORT ..........................................................................................................................................9 4.2 EDI TECHNICAL SUPPORT .......................................................................................................................9 4.3 PROVIDER SERVICES............................................................................................................................ 10 4.4 APPLICABLE WEBSITES/EMAIL ........................................................................................................... 10 CONTROL SEGMENTS/ENVELOPES ............................................................................................................. 10 5.1 ISA-IEA ................................................................................................................................................. 10 5.2 GS-GE ................................................................................................................................................... 10 5.3 ST-SE .................................................................................................................................................... 11 5.4 CONTROL SEGMENT HIERARCHY ........................................................................................................ 11 5.5 CONTROL SEGMENT NOTES ................................................................................................................ 11 5.6 FILE DELIMITERS .................................................................................................................................. 12 PAYER SPECIFIC BUSINESS RULES AND LIMITATIONS................................................................................ 12 6.1 ELECTRONIC CLAIM SUBMISSION GUIDELINES .................................................................................. 12 6.2 VALIDATION OF CLAIMS ..................................................................................................................... 14 ACKNOWLEDGEMENTS AND REPORTS ...................................................................................................... 14 Page 5 of 18 7.1 ACKNOWLEDGEMENTS ....................................................................................................................... 14 7.2 REPORT INVENTORY ........................................................................................................................... 15 TRADING PARTNER AGREEMENTS ............................................................................................................. 15 8.1 TRADING PARTNERS ........................................................................................................................... 15 TRANSACTION SPECIFIC INFORMATION .................................................................................................... 15 APPENDECIES .............................................................................................................................................. 17 10.1 IMPLEMENTATION CHECKLIST ............................................................................................................ 17 10.2 FREQUENTLY ASKED QUESTIONS ....................................................................................................... 17 10.3 FILE NAMING CONVENTIONS ............................................................................................................. 18 Page 6 of 18 INTRODUCTION This section describes how Technical Report Type 3 (TR3), also called 837 Health Care Claim: Professional (837P) ASC X12N/005010X222A1, adopted under HIPAA, will be detailed with the use of a table. The tables contain a row for each segment that UnitedHealth Group has included, in addition to the information contained in the TR3s. That information can: 1. Limit the repeat of loops, or segments 2. Limit the length of a simple data element 3. Specify a sub-set of the TR3’s internal code listings 4. Clarify the use of loops, segments, composite and simple data elements 5. Any other information tied directly to a loop, segment, and composite or simple data element pertinent to trading electronically with UnitedHealthcare In addition to the row for each segment, one or more additional rows are used to describe UnitedHealthcare’s usage for composite and simple data elements and for any other information. Notes and comments should be placed at the deepest level of detail. For example, a note about a code value should be placed on a row specifically for that code value, not in a general note about the segment. The table below specifies the columns and suggested use of the rows for the detailed description of the transaction set companion guides. The table contains a row for each segment that UnitedHealthcare has included, in addition to the information contained in the TR3s. The following is an example (from Section 9 – Transaction Specific Information) of the type of information that may be included: Page # Loop ID Reference Name Codes Length Notes/Comments 71 1000A NM1 Submitter Name This type of row always exists to indicate that a new segment has begun. It is always shaded at 10% and notes or comment about the segment itself goes in this cell. 114 2100C NM109 Subscriber Primary Identifier This type of row exists to limit the length of the specified data element. 114 2100C NM108 Identification Code Qualifier MI This type of row exists when a note for a particular code value is required. For example, this note may say that value MI is the default. Not populating the first 3 columns makes it clear that the code value belongs to the row immediately above it. 184 2300 HI Principal Diagnosis Code 2300 HI01-2 Code List Qualifier Code BK This row illustrates how to indicate a component data element in the Reference column and also how to specify that only one code value is applicable. 1.1 SCOPE This document is to be used for the implementation of the TR3 HIPAA 5010 837 Health Care Claim: Professional (referred to as Professional Claim or 837P Claim in the rest of this document) for the purpose of submitting an institutional claim electronically. This companion guide is not intended to replace the TR3. Page 7 of 18 1.2 OVERVIEW This CG will replace, in total, the previous UnitedHealthcare CG versions for Health Care Institutional Claim and must be used in conjunction with the TR3 instructions. This CG is intended to assist you in implementing electronic Institutional Claim transactions that meet UnitedHealthcare processing standards, by identifying pertinent structural and data related requirements and recommendations. Updates to this companion guide occur periodically and are available online. CG documents are posted in the Electronic Data Interchange (EDI) section of our Resource Library on the Companion Guides page: https://www.uhcprovider.com/en/resource-library/edi/edi-companion-guides.html In addition, trading partners can sign up for the Network Bulletin and other online news: https://uhg.csharmony.epsilon.com/Account/Register. 1.3 REFERENCE For more information regarding the ASC X12 Standards for Electronic Data Interchange 837 Health Care Claim: Institutional (005010X223A2) and to purchase copies of the TR3 documents, consult the Washington Publishing Company website: http://www.wpc-edi.com 1.4 ADDITIONAL INFORMATION The American National Standards Institute (ANSI) is the coordinator for information on national and international standards. In 1979 ANSI chartered the Accredited Standards Committee (ASC) X12 to develop uniform standards for electronic interchange of business transactions and eliminate the problem of non-standard electronic data communication. The objective of the ASC X12 Committee is to develop standards to facilitate electronic interchange relating to all types of business transactions. The ANSI X12 standards is recognized by the United States as the standard for North America. EDI adoption has been proved to reduce the administrative burden on providers. Please note that this is UnitedHealthcare’s approach to 837 Professional claim transactions. After careful review of the existing IG for the Version 005010X222A1, we have compiled the UnitedHealthcare specific CG. We are not responsible for any changes and updates made to the IG. GETTING STARTED 2.1 EXCHANGING TRANSACTIONS WITH UNITEDHEALTHCARE UnitedHealthcare exchanges transactions with clearinghouses and direct submitters, also referred to as Trading Partners. Most transactions go through the Optum clearinghouse, OptumInsight, the managed gateway for UnitedHealthcare EDI transactions. 2.2 CLEARINGHOUSE CONNECTION Physicians, facilities and health care professionals should contact their current clearinghouse vendor to discuss their ability to support the 837 Health Care Claim: Professional transaction, as well as associated timeframes, costs, etc. This includes protocols for testing the exchange of transactions with UnitedHealthcare through your clearinghouse. Page 8 of 18 Optum: Physicians, facilities and health care professionals can submit and receive EDI transactions direct. Optum partners with providers to deliver the tools that help drive administrative simplification at minimal cost and realize the benefits originally intended by HIPAA — standard, low-cost claim transactions. • Please contact Optum Support at 800-341-6141 to get set up. • If interested in using Optum’s online solution, Intelligent EDI (IEDI), contact the Optum sales team at 866-367-9778, option 3, send an email to [email protected] or visit https://www.optum.com/campaign/fp/free-edi.html. 2.3 CERTIFICATION AND TESTING All trading partners who wish to submit 837P claim transactions to UnitedHealthcare via the ASC X12 837 (Version 005010X222A1), and receive corresponding EDI responses, must complete testing to ensure that their systems and connectivity are working correctly before any production transactions can be processed. For testing EDI transactions with UnitedHealthcare, care providers and health care professionals should contact their current clearinghouse vendor or Optum. CONNECTIVITY AND COMMUNICATION PROTOCOLS 3.1 PROCESS FLOW: BATCH 837 INSTITUTIONAL CLAIM 3.2 TRANSMISSION ADMINISTRATIVE PROCEDURES UnitedHealthcare supports both batch and real-time 837P claim transmissions. Contact your current clearinghouse vendor to discuss transmission types and availability. 3.3 RE-TRANSMISSION PROCEDURES Physicians, facilities and health care professionals should contact their current clearinghouse vendor for information on whether resubmission is allowed or what data corrections need to be made for a successful response. 3.4 COMMUNICATION PROTOCOL SPECIFICATIONS Physicians, facilities and health care professionals should contact their current clearinghouse for communication protocols with UnitedHealthcare. Provider or Provider’s Clearinghouse Clearinghouse UnitedHealthcare Claim Files Claim Files 1st Level 999/277PRE ACKs and Reports 2nd Level 277 ACK Page 9 of 18 3.5 PASSWORDS Physicians, facilities and health care professionals should contact their current clearinghouse vendor to discuss password policies. 3.6 SYSTEM AVAILABILITY UnitedHealthcare will accept 837 claim transaction submissions at any time, 24 hours per day, 7 days a week. Unplanned system outages may occur occasionally and impact our ability to accept or immediately process incoming transactions. UnitedHealthcare will send an email communication for scheduled and unplanned outages. 3.7 COSTS TO CONNECT Clearinghouse Connection: Physicians, facilities and health care professionals should contact their current clearinghouse vendor or Optum to discuss costs. Optum: • Optum Support – 800-341-6141 • Optum’s online solution, Intelligent EDI (IEDI) − Call 866-367-9778, option 3 − Email [email protected] − Visit https://www.optum.com/campaign/fp/free-edi.html CONTACT INFORMATION 4.1 EDI SUPPORT Most questions can be answered by referring to the EDI section of our resource library at UHCprovider.com > Menu > Resource Library > Electronic Data Interchange (EDI): https://www.uhcprovider.com/en/resource-library/edi.html. View the EDI 837: Electronic Claims page for information specific to 837 Claim transactions. If you need assistance with an EDI 837 transaction accepted by UnitedHealthcare, please contact EDI Support by: • Using our EDI Transaction Support Form • Sending an email to [email protected] • Calling 800-842-1109 For questions related to submitting transactions through a clearinghouse, please contact your clearinghouse or software vendor directly. 4.2 EDI TECHNICAL SUPPORT Physicians, facilities and health care professionals should contact their current clearinghouse vendor or Optum for technical support. If using Optum, contact their technical support team at 800-225-8951, option 6. For issues with encounters, send an email to the Encounter Data Collection Team: [email protected] Page 10 of 18 4.3 PROVIDER SERVICES Provider Services should be contacted at 877-842-3210 instead of EDI Support if you have questions regarding 837 Claim transactions that do not pertain to EDI. Provider Services is available Monday - Friday, 7 am - 7 pm in the provider’s time zone. 4.4 APPLICABLE WEBSITES/EMAIL Companion Guides: https://www.uhcprovider.com/en/resource-library/edi/edi-companion-guides.html Optum: https://www.optum.com OptumInsight/Optum EDI Client Center - https://www.enshealth.com UnitedHealthcare Administrative Guide: https://www.uhcprovider.com/content/dam/provider/docs/public/admin- guides/UnitedHealthcare_Administrative_Guide_2017.pdf UnitedHealthcare EDI Support: [email protected] or EDI Transaction Support Form UnitedHealthcare EDI Education website: https://www.uhcprovider.com/en/resource-library/edi.html Washington Publishing Company: http://www.wpc-edi.com CONTROL SEGMENTS/ENVELOPES 5.1 ISA-IEA Transactions transmitted during a session or as a batch are identified by an interchange header segment (ISA) and trailer segment (IEA) which form the envelope enclosing the transmission. Each ISA marks the beginning of the transmission (batch) and provides sender and receiver identification. The table below represents only those fields that UnitedHealthcare requires a specific value in or has additional guidance on what the value should be. The table does not represent all of the fields necessary for a successful transaction; the TR3 should be reviewed for that information. LOOP ID Reference NAME Values Notes/Comments None ISA ISA Interchange Control Header ISA05 Interchange ID Qualifier ZZ ZZ =	EDI-837P-CG-005010X222A1.pdf
or what data corrections need to be made for a successful response. 3.4 COMMUNICATION PROTOCOL SPECIFICATIONS Physicians, facilities and health care professionals should contact their current clearinghouse for communication protocols with UnitedHealthcare. Provider or Provider’s Clearinghouse Clearinghouse UnitedHealthcare Claim Files Claim Files 1st Level 999/277PRE ACKs and Reports 2nd Level 277 ACK Page 9 of 18 3.5 PASSWORDS Physicians, facilities and health care professionals should contact their current clearinghouse vendor to discuss password policies. 3.6 SYSTEM AVAILABILITY UnitedHealthcare will accept 837 claim transaction submissions at any time, 24 hours per day, 7 days a week. Unplanned system outages may occur occasionally and impact our ability to accept or immediately process incoming transactions. UnitedHealthcare will send an email communication for scheduled and unplanned outages. 3.7 COSTS TO CONNECT Clearinghouse Connection: Physicians, facilities and health care professionals should contact their current clearinghouse vendor or Optum to discuss costs. Optum: • Optum Support – 800-341-6141 • Optum’s online solution, Intelligent EDI (IEDI) − Call 866-367-9778, option 3 − Email [email protected] − Visit https://www.optum.com/campaign/fp/free-edi.html CONTACT INFORMATION 4.1 EDI SUPPORT Most questions can be answered by referring to the EDI section of our resource library at UHCprovider.com > Menu > Resource Library > Electronic Data Interchange (EDI): https://www.uhcprovider.com/en/resource-library/edi.html. View the EDI 837: Electronic Claims page for information specific to 837 Claim transactions. If you need assistance with an EDI 837 transaction accepted by UnitedHealthcare, please contact EDI Support by: • Using our EDI Transaction Support Form • Sending an email to [email protected] • Calling 800-842-1109 For questions related to submitting transactions through a clearinghouse, please contact your clearinghouse or software vendor directly. 4.2 EDI TECHNICAL SUPPORT Physicians, facilities and health care professionals should contact their current clearinghouse vendor or Optum for technical support. If using Optum, contact their technical support team at 800-225-8951, option 6. For issues with encounters, send an email to the Encounter Data Collection Team: [email protected] Page 10 of 18 4.3 PROVIDER SERVICES Provider Services should be contacted at 877-842-3210 instead of EDI Support if you have questions regarding 837 Claim transactions that do not pertain to EDI. Provider Services is available Monday - Friday, 7 am - 7 pm in the provider’s time zone. 4.4 APPLICABLE WEBSITES/EMAIL Companion Guides: https://www.uhcprovider.com/en/resource-library/edi/edi-companion-guides.html Optum: https://www.optum.com OptumInsight/Optum EDI Client Center - https://www.enshealth.com UnitedHealthcare Administrative Guide: https://www.uhcprovider.com/content/dam/provider/docs/public/admin- guides/UnitedHealthcare_Administrative_Guide_2017.pdf UnitedHealthcare EDI Support: [email protected] or EDI Transaction Support Form UnitedHealthcare EDI Education website: https://www.uhcprovider.com/en/resource-library/edi.html Washington Publishing Company: http://www.wpc-edi.com CONTROL SEGMENTS/ENVELOPES 5.1 ISA-IEA Transactions transmitted during a session or as a batch are identified by an interchange header segment (ISA) and trailer segment (IEA) which form the envelope enclosing the transmission. Each ISA marks the beginning of the transmission (batch) and provides sender and receiver identification. The table below represents only those fields that UnitedHealthcare requires a specific value in or has additional guidance on what the value should be. The table does not represent all of the fields necessary for a successful transaction; the TR3 should be reviewed for that information. LOOP ID Reference NAME Values Notes/Comments None ISA ISA Interchange Control Header ISA05 Interchange ID Qualifier ZZ ZZ = Mutually defined ISA06 Interchange Sender ID [Submitter ID] This is the Submitter ID assigned by UnitedHealthcare. ISA08 Interchange Receiver ID 87726 (claims) UnitedHealthcare Payer ID -Right pad as needed with spaces to 15 characters. 5.2 GS-GE EDI transactions of a similar nature and destined for one trading partner may be gathered into a functional group, identified by a functional group header segment (GS) and a functional group trailer segment (GE). Each GS segment marks the beginning of a functional group. There can be many functional groups within an interchange envelope. The number of GS/GE functional groups that exist in a transmission may vary. Page 11 of 18 The below table represents only those fields that UnitedHealthcare requires a specific value in or has additional guidance on what the value should be. The table does not represent all of the fields necessary for a successful transaction; the TR3 should be reviewed for that information. LOOP ID Reference NAME Values Notes/Comments None GS Functional Group Header Required Header GS03 Application Receiver’s Code 87726 (claims) UnitedHealthcare Payer ID Code GS08 Version/Release/Industry Identifier Code 005010X222A1 Version expected to be received by UnitedHealthcare 5.3 ST-SE The beginning of each individual transaction is identified using a transaction set header segment (ST). The end of every transaction is marked by a transaction set trailer segment (SE). For real time transactions, there will always be one ST and SE combination. An 837 file can only contain 837 transactions. The below table represents only those fields that UnitedHealthcare requires a specific value in or has additional guidance on what the value should be. The table does not represent all of the fields necessary for a successful transaction; the TR3 should be reviewed for that information. LOOP ID Reference NAME Codes Notes/Comments None ST Transaction Set Header Required Header ST03 Implementation Convention Reference 005010X222A1 Version expected to be received by UnitedHealthcare 5.4 CONTROL SEGMENT HIERARCHY ISA - Interchange Control Header segment GS - Functional Group Header segment ST - Transaction Set Header segment First 837 Transaction SE - Transaction Set Trailer segment ST - Transaction Set Header segment Second 837 Transaction SE - Transaction Set Trailer segment ST - Transaction Set Header segment Third 837 Transaction SE - Transaction Set Trailer segment GE - Functional Group Trailer segment IEA - Interchange Control Trailer segment 5.5 CONTROL SEGMENT NOTES The ISA data segment is a fixed length record and all fields must be supplied. Fields not populated with actual data must be filled with space. Page 12 of 18 1. The first element separator (byte 4) in the ISA segment defines the element separator to be used through the entire interchange. 2. The ISA segment terminator (byte 106) defines the segment terminator used throughout the entire interchange. 3. ISA16 defines the component element 5.6 FILE DELIMITERS UnitedHealthcare requests that you use the following delimiters on your 270 file. If used as delimiters, these characters (* : ~ ^ ) must not be submitted within the data content of the transaction sets. Please contact UnitedHealthcare if there is a need to use a delimiter other than the following: 1. Data Element: The recommended data element delimiter is an asterisk () 2. Data Segment: The recommended data segment delimiter is a tilde (~) 3. Component Element: ISA16 defines the component element delimiter is to be used throughout the entire transaction. The recommended component-element delimiter is a colon (:) 4. Repetition Separator: ISA11 defines the repetition separator to be used throughout the entire transaction. The recommended repetition separator is a caret (^) PAYER SPECIFIC BUSINESS RULES AND LIMITATIONS 6.1 ELECTRONIC CLAIM SUBMISSION GUIDELINES Following these guidelines will help you submit most of your claims electronically, without paper forms or attachments. Services Guidelines Allergy Procedure Codes Instead of submitting medical notes, use the EDI Notes Field to indicate number of doses, vials or injections as well as the dose schedule. Corrected Claims Most corrected claims can be sent electronically. Submit a corrected claim as an 837 transaction with frequency code 7 to indicate replacement of a previous claim (Loop 2300 CLM05-3). Go to UHCprovider.com/ediclaimtips for more information. If unable to submit with EDI, submit as a claim reconsideration in the claimsLink tool. Learn more online: https://www.uhcprovider.com/en/claims-payments- billing/claimslink-self-service-tool.html In Network / Out of Network Under the capitated delegated agreement with UnitedHealthcare to support Medicare Advantage EOB for Part C, all encounter submissions must reflect whether the services provided to the member is “in network” or “out of network.” Any finalized claim or encounter that contains a service that is out of network should be reported using claim adjustment reason code (CARC) 242 – Services Not Provided by Network/Primary Care Provider, at the service line level. Interest Payments Under the capitated delegated agreement with UnitedHealthcare to submit encounter data, any finalized claim in part or in its entirety that contains interest payments must display these payments using a claim adjustment reason code (CARC) 225 – Payment or Interest Paid by Payer. This code should only be used for plan to plan encounter reporting. According to Section 1.1.1.1 of the 005010X222A1, balancing to the claim payment involves the subtraction of adjustments from the service line payment total. A positive dollar amount for interest would reduce the payment of the claim. A negative dollar amount would increase the payment on the claim. As a result, reporting the payment of interest by a prior payer in the 837 would require a “negative dollar” amount in order to balance. Page 13 of 18 Laboratory Services When performed in the office on an urgent basis, use modifier “ST” in the modifier field. Lifetime Events A lifetime event is described as a medical procedure that can only occur once in a lifetime. Such events include but are not limited to Hysterectomy, Prostatectomy, Appendectomy, and Amputations, etc. Lifetime events must be reported with a unit value of only 1. Medicare Primary claims When Medicare is primary, check your Medicare Explanation of Benefits (EOB) for Code MA-18 to indicate the claim has been forwarded to the secondary carrier. If it hasn’t been forwarded or has been sent to the wrong carrier, then submit the claim and the EOB/Coordination of Benefits (COB) information electronically. More information on Medicare Crossover is online in the Secondary/COB or Tertiary Claims section: https://www.uhcprovider.com/en/resource- library/edi/edi-quick-tips-claims.html Participating Physician Covering Primary Care Physician (PCP) When a UnitedHealthcare participating physician is covering for a PCP, use the EDI Notes Field* to indicate “Covering for Dr. X” instead of submitting an attachment. Rejected Claims Claim rejections that appear on clearinghouse reports have not been accepted by UnitedHealthcare and should be corrected and resubmitted electronically. Required Member Cost Share / Revenue Reporting For Commercial and Medicare Advantage plans, UnitedHealthcare requires1 contracted providers to submit current, complete and accurate encounter data including member cost share/revenue weekly in order to effectively track member cost share. UnitedHealthcare welcomes and encourages your encounter submissions more frequently than weekly (e.g., twice a week, daily). Greater encounter submission frequency allows us to more effectively administer products where member cost share administration is essential. 1Centers for Medicare & Medicaid Services mandate for Maximum Allowable Out-of-Pocket Cost Amount for Medicare Parts A and B Services 75 FR 19709, effective Jan. 1, 2011 Secondary Claims When another commercial insurance plan is primary and UnitedHealthcare is secondary, the secondary claim can be submitted electronically. Information from the primary payer’s EOB/COB can be included in the electronic claim. More information on submitting electronic Secondary/COB or Tertiary Claims, including COB Electronic Claim Requirements and Specifications, is online: https://www.uhcprovider.com/en/resource-library/edi/edi-quick-tips-claims.html Sequestration As required by federal law under a sequestration order dated March 1, 2013, Medicare Fee-For-Service claims with dates of service or dates of discharge on or after April 1, 2013, incur a two percent reduction in Medicare payment. [Source: Center for Medicare and Medicaid Services]. Under the capitated delegated agreement with UnitedHealthcare to submit encounter data, any finalized claim in part or in entirety that contains a reduction in payment due to “sequestration” should be reported to UnitedHealthcare using claim adjustment reason code (CARC) 253 – Sequestration. Sequestration reduction should be presented at the service line level. “Tracers” or Re-Bills It isn’t necessary to send a paper claim backup for a claim sent electronically: • Please allow 20-30 business days for your claim(s) to be processed. • To avoid duplicate claim denials, check the status of your claim as a 276/277 EDI transaction or using Link instead of submitting a tracer. Unspecified CPT and HCPCS codes Unlisted and Unspecified Service or Procedure Codes can be submitted an electronic claim, however, UnitedHealthcare will need to review medical notes in order to process these claims. Attachments requested can be uploaded using the claimsLink app. More information on submitting unspecified codes on an electronic claim is online: https://www.uhcprovider.com/en/resource-library/edi/edi-quick-tips-claims.html Page 14 of 18 Voids and Replacements A “replacement’ encounter should be sent to UnitedHealthcare when an element of data on the encounter was either not previously reported or when there is an element of data that needs to be corrected. A replacement encounter should contain a claim frequency code of [7] in Loop 2300 CLM05-3 segment. A “void” encounter should be sent to UnitedHealthcare when the previously submitted encounter should be eliminated. A void encounter must match the original	EDI-837P-CG-005010X222A1.pdf
Benefits (COB) information electronically. More information on Medicare Crossover is online in the Secondary/COB or Tertiary Claims section: https://www.uhcprovider.com/en/resource- library/edi/edi-quick-tips-claims.html Participating Physician Covering Primary Care Physician (PCP) When a UnitedHealthcare participating physician is covering for a PCP, use the EDI Notes Field* to indicate “Covering for Dr. X” instead of submitting an attachment. Rejected Claims Claim rejections that appear on clearinghouse reports have not been accepted by UnitedHealthcare and should be corrected and resubmitted electronically. Required Member Cost Share / Revenue Reporting For Commercial and Medicare Advantage plans, UnitedHealthcare requires1 contracted providers to submit current, complete and accurate encounter data including member cost share/revenue weekly in order to effectively track member cost share. UnitedHealthcare welcomes and encourages your encounter submissions more frequently than weekly (e.g., twice a week, daily). Greater encounter submission frequency allows us to more effectively administer products where member cost share administration is essential. 1Centers for Medicare & Medicaid Services mandate for Maximum Allowable Out-of-Pocket Cost Amount for Medicare Parts A and B Services 75 FR 19709, effective Jan. 1, 2011 Secondary Claims When another commercial insurance plan is primary and UnitedHealthcare is secondary, the secondary claim can be submitted electronically. Information from the primary payer’s EOB/COB can be included in the electronic claim. More information on submitting electronic Secondary/COB or Tertiary Claims, including COB Electronic Claim Requirements and Specifications, is online: https://www.uhcprovider.com/en/resource-library/edi/edi-quick-tips-claims.html Sequestration As required by federal law under a sequestration order dated March 1, 2013, Medicare Fee-For-Service claims with dates of service or dates of discharge on or after April 1, 2013, incur a two percent reduction in Medicare payment. [Source: Center for Medicare and Medicaid Services]. Under the capitated delegated agreement with UnitedHealthcare to submit encounter data, any finalized claim in part or in entirety that contains a reduction in payment due to “sequestration” should be reported to UnitedHealthcare using claim adjustment reason code (CARC) 253 – Sequestration. Sequestration reduction should be presented at the service line level. “Tracers” or Re-Bills It isn’t necessary to send a paper claim backup for a claim sent electronically: • Please allow 20-30 business days for your claim(s) to be processed. • To avoid duplicate claim denials, check the status of your claim as a 276/277 EDI transaction or using Link instead of submitting a tracer. Unspecified CPT and HCPCS codes Unlisted and Unspecified Service or Procedure Codes can be submitted an electronic claim, however, UnitedHealthcare will need to review medical notes in order to process these claims. Attachments requested can be uploaded using the claimsLink app. More information on submitting unspecified codes on an electronic claim is online: https://www.uhcprovider.com/en/resource-library/edi/edi-quick-tips-claims.html Page 14 of 18 Voids and Replacements A “replacement’ encounter should be sent to UnitedHealthcare when an element of data on the encounter was either not previously reported or when there is an element of data that needs to be corrected. A replacement encounter should contain a claim frequency code of [7] in Loop 2300 CLM05-3 segment. A “void” encounter should be sent to UnitedHealthcare when the previously submitted encounter should be eliminated. A void encounter must match the original encounter with the exception of the claim frequency type code and the payer assigned claim number. A void encounter should not contain “negative” values within the encounter. It should contain a claim frequency code of [8] in Loop 2300 CLM05-3 segment. The replacement or void encounter is required to be submitted with the “Original Reference Number” (Payer Claim Control Number) in Loop 2300 REF segment. REF01 must be [F8] and REF 02 must be the “Original Reference Number”. If the required information in Loop 2300 REF01 and REF02 is not submitted, the encounter will reject back to the submitter. 6.2 VALIDATION OF CLAIMS UnitedHealthcare applies two levels of editing to inbound HIPAA 837 files and claims: 1. Level 1 HIPAA Compliance: Claims passing Level 1 Compliance are assigned a UnitedHealthcare Payer Claim Control Number and are “accepted” for front end processing. 2. Level 2 Front End Validation: • Member match • Provider match • WEDI SNIP Level 1-5 validation • Level 1 HIPAA Compliance: 3. Encounters or claims passing front end validation are accepted into the UnitedHealthcare adjudication system for processing. 4. Encounters or claims that do not pass front end validation will be rejected and returned to the submitter. 5. Institutional Claims with the value 'II' (Standard Unique Health Identifier) in Subscriber Name, field NM108 will be rejected by UnitedHealthcare. If this situational segment is used, a value of MI should be sent. Note: Mandate date is still not decided for using the Standard Unique Health Identifier. ACKNOWLEDGEMENTS AND REPORTS 7.1 ACKNOWLEDGEMENTS TA1 – Transaction Acknowledgement This file informs the submitter that the transaction arrived and provides information about the syntactical quality of the Envelope of the submitted X12 file. UnitedHealthcare real-time will only respond with a TA1 when the X12 contains Envelope errors. The submitted 837 will need to be corrected and resubmitted. 999 – Functional Acknowledgement This file informs the submitter that the transaction arrived and provides information about the syntactical quality of the Functional Groups in a submitted X12 file. UnitedHealthcare will respond with a 999 when the X12 contains Functional errors. The submitted 837 will need to be corrected and resubmitted. Page 15 of 18 277PRE This file informs the submitter with more detail about why the claim failed validation. The 277PRE is generated when claims in the batch file failed Level 1 validation. If no claims failed Level 1 validation, then the 277PRE is not created. 277ACK This file informs the submitter of the disposition of their claims through Level 2 Front End Validation, it reports both accepted and rejected claims. 7.2 REPORT INVENTORY There are no known applicable reports. TRADING PARTNER AGREEMENTS 8.1 TRADING PARTNERS An EDI Trading Partner is defined as any UnitedHealthcare customer (provider, billing service, software vendor, clearinghouse, employer group, financial institution, etc.) that transmits to or receives electronic data from UnitedHealth Group. Payers have EDI Trading Partner Agreements that accompany the standard implementation guide to ensure the integrity of the electronic transaction process. The Trading Partner Agreement is related to the electronic exchange of information, whether the agreement is an entity or a part of a larger agreement, between each party to the agreement. TRANSACTION SPECIFIC INFORMATION The table below represents only those fields that UnitedHealthcare requires a specific value in or has additional guidance on what the value sent in the response means. The table does not represent all of the fields that will be returned in a successful transaction. The TR3 should be reviewed for that information. Loop Reference Name Values Notes/Comments None BHT Beginning of Hierarchical Transaction BHT02 Transaction Set Purpose Code 00 00 = Original 18 = Reissue Code identifying the purpose of the transaction. BHT06 Transaction Type Code CH CH = Chargeable Use CH when the transaction contains only fee for service claims or claims with at least one chargeable line item. 1000A Submitter Detail 1000A NM1 Submitter Name Required Segment 1000A NM109 Identification Code ETIN Federal Tax ID of the submitter. This number should be identical to the ISA06 and GS02 Federal Tax ID. 1000B Receiver Detail 1000B NM1 Receiver Name Required Segment 1000B NM103 Name Last or Organization Name UNITEDHEALTHCARE (BHT06 = CH) Receiver Name (Organization) Page 16 of 18 1000B NM108 Identification Code Qualifier 46 ETIN Code 1000B NM109 Identification Code 87726 (claims) UnitedHealthcare Payer ID 2000B Subscriber Information 2000B HL Subscriber Hierarchical Level UnitedHealthcare patients cannot be identified within Loop 2010CA. If a UnitedHealthcare patient can be uniquely identified by a unique Member Identification Number, then the patient is considered the subscriber and is identified at this level. When the patient is the subscriber, loops 2000C and 2010Ca are not sent. 2010BA Subscriber Name 2010BA NM1 Subscriber Name 2010BA NM108 Identification Code Qualifier MI MI is the only valid value at this time. Claims received with value II will be rejected. 2010BB Payer Name 2010BB NM1 Payer Name 2010BB NM103 Name Last or Organization Name UNITEDHEALTHCARE (BHT06 = CH) 2010BB NM108 Identification Code Qualifier PI PI = Payer Identifier 2010BB NM109 Identification Code 87726 (claims) 2010BB Billing Provider Secondary Identifier 2010BB REF Billing Provider Secondary Identifier Required Segment 2010BB REF02 Reference Identification 2300 Claim Information 2300 CLM Claim Information 2300 DTP Date-Initial Treatment Submit initial treatment 2300 DTP Date-Admission Submit Admission Date for Emergency Room (ER) visits when the patient is admitted from the ER. 2300 Health Care Information Codes 2300 HI Health Care Diagnosis Code 2300 HI01-1 Code List Qualifier Code ABK 2300 HI02-1 to HI12-1 Code List Qualifier Code ABF 2400 Professional Services 2400 SV1 Professional Service 2300 SV103 Unit or Basis for Measurement Code MJ Submit code MJ when reporting anesthesia minutes in Loop 2400 SV104 Page 17 of 18 2300 SV104 Quantity Units: Submit a maximum unit quantity of 999 per occurrence of Loop 2400 SV1. When unit quantity is greater than 999, submit multiple occurrences with up to 999 units per occurrence. Minutes: Submit quantity as minutes for time based anesthesia services using MJ qualifier in Loop 2400 SV103. 2400 Test Results 2400 MEA Test Results 2400 MEA01 Measurement Reference ID Code TR for Hematocrit Hematocrit (HCT) test level is requested on all claims with services for erythropoietin (EPO). 2400 MEA02 Measurement Qualifier R2 for Hematocrit To indicate test results being reported for Hematocrit 2400 MEA03 Measurement Value Submit Hematocrit test result value 2400 Other Information 2400 PS1 Purchased Service Information Submit Purchased Service Information when the contract between UnitedHealthcare and the provider indicates reimbursement based on a percentage of the invoice. 2400 HCP Line Pricing / Repricing Information Submit line pricing for repriced claims. 2410 LIN Drug Identification Submit NDC for all unlisted injectable drugs and for other injectable drugs when required per the contract between UnitedHealthcare and the provider. APPENDECIES 10.1 IMPLEMENTATION CHECKLIST The implementation check list will vary depending on your clearinghouse connection. A basic check list would be to: 1. Register with trading partner 2. Create and sign contract with trading partner 3. Establish connectivity 4. Send test transactions 5. If testing succeeds, proceed to send production transactions 10.2 FREQUENTLY ASKED QUESTIONS 1. Does this Companion Guide apply to all UnitedHealthcare payers and payer IDs? No. It’s applicable to UnitedHealthcare Commercial (87726), UnitedHealthcare Community Plan (87726 plus other payer IDs), UnitedHealthcare Medicare and Retirement (87726), UnitedHealthcare Oxford (06111), UnitedHealthcare Vision (00773), UnitedHealthcare West (87726) and Medica (94265). 2. How does UnitedHealthcare support, monitor and communicate expected and unexpected connectivity outages? Our systems do have planned outages. We will send an email communication for scheduled and unplanned outages. 3. If an 837 is successfully transmitted to UnitedHealthcare, are there any situations that would result in no response being sent back? Page 18 of 18 No. UnitedHealthcare will always send a response. Even if UnitedHealthcare systems are down and the transaction cannot be processed at the time of receipt, a response detailing the situation will be returned. 10.3 FILE NAMING CONVENTIONS Node Description Value ZipUnzip_ResponseType_<Batch ID>_<Submitter ID>_<DateTimeStamp>.RES ZipUnzip Responses will be sent as either zipped or unzipped depending on how UnitedHealthcare received the inbound batch file N - Unzipped Z - Zipped ResponseType Identifies the file response type 999 – Implementation Acknowledgement Batch ID Response file will include the batch number from the inbound batch file specified in ISA13 ISA13 Value from Inbound File Submitter ID The submitter ID on the inbound transaction must be equal to ISA06 value in the Interchange Control Header within the file ISA08 Value from Inbound File DateTimeStamp Date and time format is in the next column (time is expressed in military format as CDT/CST) MMDDYYYYHHMMSS	EDI-837P-CG-005010X222A1.pdf
2400 MEA02 Measurement Qualifier R2 for Hematocrit To indicate test results being reported for Hematocrit 2400 MEA03 Measurement Value Submit Hematocrit test result value 2400 Other Information 2400 PS1 Purchased Service Information Submit Purchased Service Information when the contract between UnitedHealthcare and the provider indicates reimbursement based on a percentage of the invoice. 2400 HCP Line Pricing / Repricing Information Submit line pricing for repriced claims. 2410 LIN Drug Identification Submit NDC for all unlisted injectable drugs and for other injectable drugs when required per the contract between UnitedHealthcare and the provider. APPENDECIES 10.1 IMPLEMENTATION CHECKLIST The implementation check list will vary depending on your clearinghouse connection. A basic check list would be to: 1. Register with trading partner 2. Create and sign contract with trading partner 3. Establish connectivity 4. Send test transactions 5. If testing succeeds, proceed to send production transactions 10.2 FREQUENTLY ASKED QUESTIONS 1. Does this Companion Guide apply to all UnitedHealthcare payers and payer IDs? No. It’s applicable to UnitedHealthcare Commercial (87726), UnitedHealthcare Community Plan (87726 plus other payer IDs), UnitedHealthcare Medicare and Retirement (87726), UnitedHealthcare Oxford (06111), UnitedHealthcare Vision (00773), UnitedHealthcare West (87726) and Medica (94265). 2. How does UnitedHealthcare support, monitor and communicate expected and unexpected connectivity outages? Our systems do have planned outages. We will send an email communication for scheduled and unplanned outages. 3. If an 837 is successfully transmitted to UnitedHealthcare, are there any situations that would result in no response being sent back? Page 18 of 18 No. UnitedHealthcare will always send a response. Even if UnitedHealthcare systems are down and the transaction cannot be processed at the time of receipt, a response detailing the situation will be returned. 10.3 FILE NAMING CONVENTIONS Node Description Value ZipUnzip_ResponseType_<Batch ID>_<Submitter ID>_<DateTimeStamp>.RES ZipUnzip Responses will be sent as either zipped or unzipped depending on how UnitedHealthcare received the inbound batch file N - Unzipped Z - Zipped ResponseType Identifies the file response type 999 – Implementation Acknowledgement Batch ID Response file will include the batch number from the inbound batch file specified in ISA13 ISA13 Value from Inbound File Submitter ID The submitter ID on the inbound transaction must be equal to ISA06 value in the Interchange Control Header within the file ISA08 Value from Inbound File DateTimeStamp Date and time format is in the next column (time is expressed in military format as CDT/CST) MMDDYYYYHHMMSS	EDI-837P-CG-005010X222A1.pdf
Page 1 of 12 Standard Companion Guide Refers to the Implementation Guide Based on X12 Version 005010X221A1 Health Care Claim Payment/Advice (835) Companion Guide Version Number 4.1 3/27/2024 Page 2 of 12 CHANGE LOG Version Release Date Changes 1.0 12/10/2010 Created 835 Companion Guide based on version 5010. 2.0 09/25/2017 Changed Clearinghouse name from Ingenix to OptumInsight; Reformatted entire document and updated various sections with current information, including hyperlinks and contacts. 3.0 09/28/2018 Updated Intelligent EDI hyperlink in section 2.3 and ERA Payer List hyperlink in section 4.1 4.0 05/11/2020 Updated Section 2.2 Clearinghouse Connections and Section 4.1 EDI Support 4.1 08/21/2020 Updated Sections 2.1, 3.4, 3.5, 4.3 4.2 3/27/2024 Updated Logo Page 3 of 12 PREFACE This companion guide (CG) to the Technical Report Type 3 (TR3) clarifies and specifies the data content when exchanging transactions electronically with UnitedHealthcare. Transactions based on this companion guide used in tandem with the TR3, also called 835 Health Care Claim Payment/Advice ASC X12 (005010X221A1), are compliant with both X12 syntax and related guides. This Companion Guide is intended to convey information that is within the framework of the TR3 adopted for use under HIPAA. The companion guide is not intended to convey information that in any way exceeds the requirements or usages of data expressed in the TR3. Page 4 of 12 Table of Contents CHANGE LOG......................................................................................................................................... 2 PREFACE ............................................................................................................................................... 3 1. INTRODUCTION .......................................................................................................................... 6 1.1 SCOPE ................................................................................................................................. 7 1.2 OVERVIEW........................................................................................................................... 7 1.3 REFERENCE .......................................................................................................................... 7 1.4 ADDITIONAL INFORMATION .................................................................................................. 7 2. GETTING STARTED ...................................................................................................................... 7 2.1 EXCHANGING TRANSACTIONS WITH UNITEDHEALTHCARE......................................................... 7 2.2 CLEARINGHOUSE CONNECTION .............................................................................................. 7 2.3 DIRECT CONNECTION .................................................................. Error! Bookmark not defined. 2.4 LINK .................................................................................................................................... 8 3. CONNECTIVITY AND COMMUNICATION PROTOCOLS ...................................................................... 8 3.1 PROCESS FLOW .................................................................................................................... 8 3.2 TRANSMISSION ADMINISTRATIVE PROCEDURES ...................................................................... 8 3.3 RE-TRANSMISSION PROCEDURES ........................................................................................... 8 3.4 COMMUNICATION PROTOCOL SPECIFICATIONS ....................................................................... 9 3.5 PASSWORDS ........................................................................................................................ 9 4. CONTACT INFORMATION............................................................................................................. 9 4.1 EDI SUPPORT ....................................................................................................................... 9 4.2 PROVIDER SERVICES ............................................................................................................. 9 4.3 APPLICABLE WEBSITES/EMAIL.............................................................................................. 10 5. CONTROL SEGMENTS/ENVELOPES .............................................................................................. 10 5.1 ISA-IEA .............................................................................................................................. 10 5.2 GS-GE................................................................................................................................ 10 5.3 ST-SE................................................................................................................................. 10 6. PAYER SPECIFIC BUSINESS RULES AND LIMITATIONS..................................................................... 10 6.1 CLAIM OVERPAYMENT RECOVERY ........................................................................................ 10 6.2 SECONDARY AND TERTIARY PAYMENT REPORTING ................................................................ 11 6.3 ENCOUNTER CLAIMS ........................................................................................................... 11 6.4 835 ENROLLMENTS ............................................................................................................. 11 6.5 LOST CHECK REPORTING...................................................................................................... 11 7. ACKNOWLEDGEMENTS AND REPORTS ........................................................................................ 11 Page 5 of 12 7.1 REPORT INVENTORY ........................................................................................................... 11 8. TRADING PARTNER AGREEMENTS .............................................................................................. 12 8.1 TRADING PARTNERS ........................................................................................................... 12 9. TRANSACTION SPECIFIC INFORMATION....................................................................................... 12 Page 6 of 12 1. INTRODUCTION This section describes how Technical Report Type 3 (TR3), also called 835 Health Care Claim Payment Advice ASC X12 (005010X221A1), adopted under HIPAA, will be detailed with the use of a table. The tables contain a row for each segment that UnitedHealth Group has included, in addition to the information contained in the TR3s. That information can: 1. Limit the repeat of loops, or segments 2. Limit the length of a simple data element 3. Specify a sub-set of the TR3’s internal code listings 4. Clarify the use of loops, segments, composite and simple data elements 5. Any other information tied directly to a loop, segment, and composite or simple data element pertinent to trading electronically with UnitedHealthcare In addition to the row for each segment, one or more additional rows are used to describe UnitedHealthcare’s usage for composite and simple data elements and for any other information. Notes and comments should be placed at the deepest level of detail. For example, a note about a code value should be placed on a row specifically for that code value, not in a general note about the segment. The table below specifies the columns and suggested use of the rows for the detailed description of the transaction set companion guides. The table contains a row for each segment that UnitedHealthcare has included, in addition to the information contained in the TR3s. The following table specifies the columns and suggested use of the rows for the detailed description of the transaction set companion guides: Page # Loop ID Reference Name Codes Length Notes/Comments 71 1000A NM1 Submitter Name This type of row always exists to indicate that a new segment has begun. It is always shaded at 10% and notes or comment about the segment itself goes in this cell. 114 2100C NM109 Subscriber Primary Identifier 15 This type of row exists to limit the length of the specified data element. 114 2100C NM108 Identification Code Qualifier MI This type of row exists when a note for a particular code value is required. For example, this note may say that value MI is the default. Not populating the first 3 columns makes it clear that the code value belongs to the row immediately above it. 184 2300 HI Principal Diagnosis Code 2300 HI01-2 Reference Identifier Qualifier BK This row illustrates how to indicate a component data element in the Reference column and also how to specify that only one code value is applicable. Page 7 of 12 1.1 SCOPE This document is to be used for the implementation of the TR3 HIPAA 5010 835 Health Care Claim Payment/Advice (referred to 835 claim payment in the rest of this document) for the purpose of reporting claim payment information from UnitedHealthcare. This document is to be used as a Companion Guide (CG) to the 835 Health Care Claim Payment/Advice ASC X12 (005010X221A1) Implementation Guide, also referred to as Technical Report Type 3 (TR3), not intended to replace the TR3. 1.2 OVERVIEW This CG will replace, in total, the previous UnitedHealthcare CG versions for Health Care Claim Payment/Advice and must be used in conjunction with the TR3 instructions. The CG is intended to assist you in implementing 835 claim payment transactions that meet UnitedHealthcare processing standards, by identifying pertinent structural and data related requirements and recommendations to more effectively complete EDI transactions with UnitedHealthcare. Updates to this companion guide will occur periodically and new documents will be posted in the Companion Guides section of our resource library and distributed to all registered trading partners with reasonable notice, or a minimum of 30 days, prior to implementation. In addition, all trading partners will receive an email with a summary of the updates and a link to the new documents posted online. 1.3 REFERENCE For more information regarding the ASC X12 Standards for Electronic Data Interchange 276/277 Health Care Claim Payment/Advice (005010X221A1) and to purchase copies of the TR3 documents, consult the Washington Publishing Company website. 1.4 ADDITIONAL INFORMATION The American National Standards Institute (ANSI) is the coordinator for information on national and international standards. In 1979 ANSI chartered the Accredited Standards Committee (ASC) X12 to develop uniform standards for electronic interchange of business transactions and eliminate the problem of non- standard electronic data communication. The objective of the ASC X12 committee is to develop standards to facilitate electronic interchange relating to all types of business transactions. The ANSI X12 standards is recognized by the United States as the standard for North America. Electronic Data Interchange (EDI) adoption has been proved to reduce the administrative burden on providers. 2. GETTING STARTED 2.1 EXCHANGING TRANSACTIONS WITH UNITEDHEALTHCARE UnitedHealthcare exchanges transactions with clearinghouses and direct submitters, also referred to as Trading Partners. Most transactions go through the Optum clearinghouse our managed gateway for EDI transactions. 2.2 CLEARINGHOUSE CONNECTION Physicians, facilities and health care professionals should contact their current clearinghouse vendor to discuss their ability to support the X12 Version 005010X221A1 835 claim payment transaction, as well as associated timeframes, costs, etc. This includes protocols for testing the exchange of transactions with UnitedHealthcare through your clearinghouse. Page 8 of 12 When utilizing a clearinghouse to receive the 835 claim payment transaction, contact the clearinghouse to facilitate the 835 enrollment process. Once the enrollment is complete, your software vendor or clearinghouse will provide instructions on how to download or view the 835 transaction. Go to UHCprovider.com/ediconnect for more information on clearinghouses and Optum solutions. 2.3 LINK Download the 835 claim payment file from the Electronic Payments & Statements (EPS) app in LINK. Enrollment in EPS is required for this capability and allows you to receive Electronic Funds Transfer (EFT) and Electronic Remittance Advice (ERA) for UnitedHealthcare Commercial, UnitedHealthcare Community Plan, UnitedHealthcare Medicare Solutions and UnitedHealthcare Oxford. More information about EPS including enrollment and assistance is available online. 3. CONNECTIVITY AND COMMUNICATION PROTOCOLS 3.1 PROCESS FLOW 3.2 TRANSMISSION ADMINISTRATIVE PROCEDURES The Direct Connection process can be used in batch mode (FTP or SFTP) using Web Services. Using these types of connections will allow you to either choose a manual process or automate your system. 3.3 RE-TRANSMISSION PROCEDURES Page 9 of 12 Trading Partners can request re-transmission of the entire 835 file by contacting EDI Support using our EDI Transaction Support Form, sending an email to [email protected] or calling 800-842-1109. The 835 file will be routed through the Trading Partner’s regular connectivity path. Please note the re-transmission is the entire 835 file, not a specified 835 contained within a file. Physicians and health care professionals that do not have a direct connection with UnitedHealthcare will need to contact the entity they are receiving the 835 file from to discuss how to receive a re-transmission. 3.4 COMMUNICATION PROTOCOL SPECIFICATIONS Clearinghouse Connection: Physicians and health care professionals should contact their current clearinghouse for communication protocols with UnitedHealthcare. Optum Connection: For communication protocols using Optum Intelligent EDI, please contact Optum at 866-367-9778, send an email to [email protected] or visit their website 3.5 PASSWORDS 1. Clearinghouse Connection: Physicians and health care professionals should contact their current clearinghouse vendor to discuss password policies. 2. CAQH CORE Connectivity: Optum is acting as a CORE connectivity proxy for UnitedHealthcare 835 health claim payment transactions. For information regarding passwords, please contact Optum. 4. CONTACT INFORMATION 4.1 EDI SUPPORT Most questions can be answered by referring to the EDI section of our resource library on UHCprovider.com. View the EDI 835: Electronic Remittance Advice (ERA) page for information specific to 835 health claim payment transactions. Enroll in Electronic Payments and Statements to receive your 835 files. Visit UHCprovider.com/contacts for 835 EDI Support. If you have questions related to submitting transactions through a clearinghouse, please contact your clearinghouse or software vendor directly. 4.2 PROVIDER SERVICES Provider Services should be contacted at 877-842-3210 instead of EDI Support if you have questions regarding the details of a member’s benefits. Provider Services is available Monday - Friday, 7 am - 7 pm in the provider’s time zone. Page 10 of 12 4.3 APPLICABLE WEBSITES/EMAIL CAQH CORE: http://www.caqh.org Companion Guides: https://www.uhcprovider.com/en/resource-library/edi/edi-companion-guides.html UnitedHealthcare EDI Support: UHCprovider.com/contacts UnitedHealthcare EDI website: https://www.uhcprovider.com/en/resource-library/edi.html Optum: https://www.optum.com/ Optum Intelligent EDI - https://www.optum.com/business/solutions/provider/claims-management- strategy/edi/intelligent-edi.html Washington Publishing Company - http://www.wpc-edi.com/reference/ 5. CONTROL SEGMENTS/ENVELOPES 5.1 ISA-IEA Transactions transmitted during a session or as a batch are identified by an interchange header segment (ISA) and trailer segment (IEA) which form the envelope enclosing the transmission. Each ISA marks the beginning of the transmission (batch) and provides sender and receiver identification. UnitedHealthcare uses the following delimiters on your 835 file: 1. Data Element: The first element separator following the ISA will define what Data Element Delimiter is used throughout the entire transaction. The Data Element Delimiter is an asterisk (*). 2. Segment: The last position in the ISA will define what Segment Element Delimiter is used throughout the entire transaction. The Segment Delimiter is a tilde (~). 3. Component-Element: Element ISA16 will define what Component-Element Delimiter is used throughout the entire transaction. The Component-Element Delimiter is a colon (:). 5.2 GS-GE EDI transactions of a similar nature and destined for one trading partner may be gathered into a functional group, identified by a functional group header segment (GS) and a functional group trailer segment (GE). Each GS segment marks the beginning of a functional group. There can be many functional groups within an interchange envelope. 5.3 ST-SE The beginning of each individual transaction is identified using a transaction set header segment (ST). The end of every transaction is marked by a transaction set trailer segment (SE). 6. PAYER SPECIFIC BUSINESS RULES AND LIMITATIONS 6.1 CLAIM OVERPAYMENT RECOVERY Claim Overpayment Recovery occurs when UnitedHealthcare identifies that a prior processed claim was overpaid. To recoup the overpayment, UNET Business will follow the steps outlined in method three provided in section 1.10.2.17 (Claim Overpayment Recovery) of the ASC X12 005010X221A1 835 implementation guide.	EDI-835-Companion-Guide-005010X221A1.pdf
health care professionals should contact their current clearinghouse for communication protocols with UnitedHealthcare. Optum Connection: For communication protocols using Optum Intelligent EDI, please contact Optum at 866-367-9778, send an email to [email protected] or visit their website 3.5 PASSWORDS 1. Clearinghouse Connection: Physicians and health care professionals should contact their current clearinghouse vendor to discuss password policies. 2. CAQH CORE Connectivity: Optum is acting as a CORE connectivity proxy for UnitedHealthcare 835 health claim payment transactions. For information regarding passwords, please contact Optum. 4. CONTACT INFORMATION 4.1 EDI SUPPORT Most questions can be answered by referring to the EDI section of our resource library on UHCprovider.com. View the EDI 835: Electronic Remittance Advice (ERA) page for information specific to 835 health claim payment transactions. Enroll in Electronic Payments and Statements to receive your 835 files. Visit UHCprovider.com/contacts for 835 EDI Support. If you have questions related to submitting transactions through a clearinghouse, please contact your clearinghouse or software vendor directly. 4.2 PROVIDER SERVICES Provider Services should be contacted at 877-842-3210 instead of EDI Support if you have questions regarding the details of a member’s benefits. Provider Services is available Monday - Friday, 7 am - 7 pm in the provider’s time zone. Page 10 of 12 4.3 APPLICABLE WEBSITES/EMAIL CAQH CORE: http://www.caqh.org Companion Guides: https://www.uhcprovider.com/en/resource-library/edi/edi-companion-guides.html UnitedHealthcare EDI Support: UHCprovider.com/contacts UnitedHealthcare EDI website: https://www.uhcprovider.com/en/resource-library/edi.html Optum: https://www.optum.com/ Optum Intelligent EDI - https://www.optum.com/business/solutions/provider/claims-management- strategy/edi/intelligent-edi.html Washington Publishing Company - http://www.wpc-edi.com/reference/ 5. CONTROL SEGMENTS/ENVELOPES 5.1 ISA-IEA Transactions transmitted during a session or as a batch are identified by an interchange header segment (ISA) and trailer segment (IEA) which form the envelope enclosing the transmission. Each ISA marks the beginning of the transmission (batch) and provides sender and receiver identification. UnitedHealthcare uses the following delimiters on your 835 file: 1. Data Element: The first element separator following the ISA will define what Data Element Delimiter is used throughout the entire transaction. The Data Element Delimiter is an asterisk (*). 2. Segment: The last position in the ISA will define what Segment Element Delimiter is used throughout the entire transaction. The Segment Delimiter is a tilde (~). 3. Component-Element: Element ISA16 will define what Component-Element Delimiter is used throughout the entire transaction. The Component-Element Delimiter is a colon (:). 5.2 GS-GE EDI transactions of a similar nature and destined for one trading partner may be gathered into a functional group, identified by a functional group header segment (GS) and a functional group trailer segment (GE). Each GS segment marks the beginning of a functional group. There can be many functional groups within an interchange envelope. 5.3 ST-SE The beginning of each individual transaction is identified using a transaction set header segment (ST). The end of every transaction is marked by a transaction set trailer segment (SE). 6. PAYER SPECIFIC BUSINESS RULES AND LIMITATIONS 6.1 CLAIM OVERPAYMENT RECOVERY Claim Overpayment Recovery occurs when UnitedHealthcare identifies that a prior processed claim was overpaid. To recoup the overpayment, UNET Business will follow the steps outlined in method three provided in section 1.10.2.17 (Claim Overpayment Recovery) of the ASC X12 005010X221A1 835 implementation guide. COSMOS business follows a combination of methods. Page 11 of 12 6.2 SECONDARY AND TERTIARY PAYMENT REPORTING UnitedHealthcare will report secondary and tertiary payment claims in the 835 transaction. On UNET, professional (physician) claim reporting will provide the payment information at the service line level with institutional claims reporting payment information at the claim level. No service level detail will be reported on institutional secondary and tertiary payment claims. Section 10.3 (Transaction Examples) provides examples of professional and institutional secondary claims reporting in the 835 transactions. On COSMOS, professional and institutional claims report payment information at the service line level. 6.3 ENCOUNTER CLAIMS UnitedHealthcare UNET 835s do not provide capitation payments in the 835 transaction, but will provide the Encounter claims processed under the capitation agreement. Encounter claims will be reported in the 835 transaction along with claims that fall outside of the capitation agreement. Section 10.3 (Transaction Examples) provides examples of encounter claim reporting in the 835 transaction. COSMOS does not report capitation payments or encounter claims in the 835 transaction. 6.4 835 ENROLLMENTS The 835 transaction enrollment registration will be done at the Federal Tax Identification Number level. Registrations for 835 at levels lower than the Federal Tax Identification Number do not currently exist. 6.5 LOST CHECK REPORTING Occasionally, the re-association process identifies a received remittance advice without the associated payment. This could result from situations like a lost check or misdirected EFT. Since there is no problem with the remittance information, the remittance advice will not be recreated. To handle the lost payment, COSMOS will follow the method 2 described in Section 1.10.2.3.1 (Lost and Reissued Payments) of the ASC X12 005010X221A1 835 Implementation Guide. 7. ACKNOWLEDGEMENTS AND REPORTS 7.1 REPORT INVENTORY No 835 reporting is available at this time. Page 12 of 12 8. TRADING PARTNER AGREEMENTS 8.1 TRADING PARTNERS An EDI Trading Partner is defined as any UnitedHealthcare customer (provider, billing service, software vendor, clearinghouse, employer group, financial institution, etc.) that transmits to, or receives electronic data from UnitedHealth Group. Payers have EDI Trading Partner Agreements that accompany the standard implementation guide to ensure the integrity of the electronic transaction process. The Trading Partner Agreement is related to the electronic exchange of information, whether the agreement is an entity or a part of a larger agreement, between each party to the agreement. For example, a Trading Partner Agreement may specify among other things, the roles and responsibilities of each party to the agreement in conducting standard transactions. 9. TRANSACTION SPECIFIC INFORMATION UnitedHealthcare has put together the following grid to assist you in designing and programming the information provided in 835 transactions. This Companion Guide is meant to illustrate the data provided by UnitedHealthcare for successful posting of Health Care Claim Payment/Advice transactions. The table contains a row for each segment that UnitedHealthcare has something additional, over and above, the information in the implementation guide. That information can: 1. Limit the repeat of loops or segments 2. Limit the length of a simple data element 3. Specify a sub-set of the implementation guide’s internal code listings 4. Clarify the use of loops, segments, composite and simple data elements 5. Any other information tied directly to a loop, segment, and composite or simple data element pertinent to trading electronically with UnitedHealthcare All segments, data elements and codes supported in the ASC X12N/005010X221A1 835 Implementation Guide are acceptable, however, all data may not be used in the processing of this transaction by UnitedHealthcare for an 835 transaction.	EDI-835-Companion-Guide-005010X221A1.pdf
837 Health Care Claim Companion Guides \| Version 2.8 January, 2024 \| i 837 Health Care Claim Companion Guides Version 2.8 January, 2024 For use with ASC X12N 837 Health Care Professional and Institutional Transactions Set Implementation Guides and Addenda (Version HIPAA 5010) www.carelonbehavioralhealth.com 837 Health Care Claim Companion Guides \| Version 2.8 January, 2024 \| ii CONTENTSIntroduction......................................................................................................................................................1 Audie nce and ContactInformation ..... ........................................................... ........................................... 4 ..........................................................................................................................2 Set-UpProcess Infor mation ................................ ................................................................ ..... ....................6 5 SupportedTransactionsandLimitations ..... ........................... ................................ ................................8 3.2. Submitter Form Information ............................................................................................7 4.1. Inbound Transactions Supported Testing ................................................................ ..... ........................... ................................ ..............................12 4.3. Delimiters Supported ......................................................................................................9 4.4. Maximum Limitations .................................................................................................... 10 5.1. Testing Workflow .......................................................................................................... 13 5.2. Testing Intro ................................................................................................................. 13 5.3. Validation Specifications ............................................................................................... 14 Imple mentation ................................ ................................................................ ..... ........................... ............. 17 5.6. Trading Partner Acceptance Testing Specifications and Requirements ......................... 15 6.1. Interchange Control Header Specifications ................................................................... 18 Profe ssional Claims TransactionSpecifications ..... ........................... ................................ .................24 6.4. Functional Group Trailer Specifications ......................................................................... 23 InstitutionalClaimTransactionSpecifications...................................................................................46 7.1. 837 Professional Claim Transaction Specifications .......................................................... 25 8.1. 837 Institutional Claim Transaction Specifications ......................................................... 41 837 Health Care Claim Companion Guides \| Version 2.8 January, 2024 \| iii VERSION CHANGES DATE Version 1.0 DRAFT Sept. 2016 Version 1.1-1.5 Format changes and Final Version Sept. 2016 Version 1.6 Format changes and Final Version March 2017 Version 1.7 Add Instructions for Atypical Providers April 2017 Version 1.8 Format changes and corrections April 2017 Version 1.9 Format changes and corrections May 2017 Version 2.0 Added Section 4.5 - Character Sets Supported (Page 3) Removed hard-coded GS03 value from Section 6.3 – Functional Group Header Specifications (Page 24) Added Code “U” and “W” as valid values for HI01-9 (Page 59) July 2017 Version 2.1 Format changes and corrections July 2017 Version 2.2 Correction to the description of 999 and 277CA generation by SNIP level. February 2018 Version 2.3 Section 5.6: Updated Passing Specifications May 2018 Version 2.4 Section 4.4 Updated to include business rules Section 5.4 Updated to exclude Snip 7 edits June 2018 Version 2.5 Updated Character Sets Supported June 2018 Version 2.6 Add Custom report response file details May 2021 Version 2.7 Add Custom report response file details November 2022 837 Health Care Claim Companion Guides \| Version 2.8 January, 2024 \| 1 C h a p t e r 1 Introduction 1.1. Introduction 1.2. What is HIPAA? 1.3. Purpose 837 Health Care Claim Companion Guides \| Version 2.8 January, 2024 \| 2 In an effort to reduce the administrative costs of health care across the nation, the Health Insurance Portability and Accountability Act (HIPAA) was passed in 1996. This legislation requires that health insurance payers in the United States comply with the electronic data interchange (EDI) standards for health care, established by the Secretary of Health and Human Services (HHS). For the health care industry to achieve the potential administrative cost savings with EDI, standard transactions and code sets have been developed and need to be implemented consistently by all organizations involved in the electronic exchange of data. The ANSI X12N 837 The Health Insurance Portability and Accountability Act (HIPAA) of 1996 mandates the establishment of national standards for electronic transmission of health data and ensuring privacy protection. The Administrative Simplification provisions of HIPAA, Title II, require the Department of Health and Human Services to establish national standards for electronic healthcare transactions and national identifiers for providers, health plans and employers. It also addresses the security and privacy of health data. Adopting these standards improves the efficiency and effectiveness of the nation’s healthcare system by encouraging the widespread use of electronic data interchange in health care. The purpose of this document is to provide the information necessary to submit claims/encounters electronically to Carelon Behavioral Health, Inc. This companion guide is to be used in conjunction with the ANSI X12N implementation guides. The information describes specific requirements for processing data within the payer’s system. The companion guide supplements, but does not contradict or replace any requirements in the implementation guide. The implementation guides can be obtained from the Washington Publishing Company by calling 1-800-972-4334 or are available for download on their web site at www.wpc-edi.com. Other important websites: ▪ Workgroup for Electronic Data Interchange (WEDI) – http://www.wedi.org ▪ United States Department of Health and Human Services (DHHS) – http://aspe.hhs.gov/ ▪ Centers for Medicare and Medicaid Services (CMS) – http://www.cms.gov ▪ National Council of Prescription Drug Programs (NCPDP) – http://www.ncpdp.org/ ▪ National Uniform Billing Committee (NUBC) – http://www.nubc.org/ ▪ Accredited Standards Committee (ASC X12) – http://www.x12.org/ This Document has been prepared as the Carelon Behavioral Health (Carelon) specific Companion Guide to the ASC X12 Implementation Guide(s). The objectives of the Carelon Companion Guide are: ▪ To describe the process to become an EDI Trading partner with Carelon Behavioral Health ▪ To describe the processes to set up, test, and make operational a trading partner with Carelon Behavioral Health 837 Health Care Claim Companion Guides \| Version 2.8 January, 2024 \| 3 ▪ To identify codes and data elements that are applicable to Carelon Behavioral Health. This document will be subject to revisions as new versions of the X12 837 Professional and Institutional Health Care Claim Transaction Set Implementation Guides are released. 837 Health Care Claim Companion Guides \| Version 2.8 January, 2024 \| 4 C h a p t e r 2 AudienceandContactInformation 2.1. Intended Audience 2.2. Contact Information 837 Health Care Claim Companion Guides \| Version 2.8 January, 2024 \| 5 The intended audience for this document is the technical department/team responsible for submitting electronic claims transactions to Carelon Behavioral Health. In addition, this information should be communicated and coordinated with the provider’s billing office in order to ensure the required billing information is provided to their billing agent/submitter. For HIPAA, 837 transactions, EDI, EDI Gateway, documentation and testing questions relating to Carelon, you can get answers by contacting any one of the following: ▪ EDI Helpdesk o Contact with EDI-related questions o 888-247-9311 o [email protected] ▪ Compliance Department o Contact for compliance/legal concerns 781-994-7500 o [email protected] 837 Health Care Claim Companion Guides \| Version 2.8 January, 2024 \| 6 C h a p t e r 3 Set-UpProcessInformation 3.1. Trading Partner Submitter Forms 3.2. Submitter Form Information 837 Health Care Claim Companion Guides \| Version 2.8 January, 2024 \| 7 Providers/trading partners interested in submitting electronic claim transactions must complete one of the following forms supplied by Carelon: a) Provider Connect Online Services Account Request Form b) Billing Agent Online Services Request Form (Clearinghouse Form) These forms can be downloaded from Carelon’s website at 3.2. or can be requested by contacting EDI Helpdesk at: Su bmitter Fo rm Information ▪ The Online Services Intermediary Authorization Form has to be completed by every provider who will be submitting via a clearinghouse. ▪ The Billing Agent Online Services Request Form would be completed by the clearinghouse on behalf of the healthcare provider(s). ▪ Complete the applicable form and return by FAX to 866-698-6032 or send by email to [email protected] ▪ When Carelon EDI receives the form, we will send you an email acknowledgement that indicates your setup has been completed with Carelon Helpdesk. This email will include the Carelon Submitter ID. A second email will be sent with the password attached. ▪ A submitter ID is assigned to each trading partner. You will utilize the submitter ID to access FileConnect, ProviderConnect, or SFTP for file transmission. 837 Health Care Claim Companion Guides \| Version 2.8 January, 2024 \| 8 C h a p t e r 4 Supported Transactions and Limitations 4.1. Inbound Transactions Supported 4.2. Response Transactions Supported 4.3. Delimiters Supported 4.4. Specific Limitations and Business Rules 837 Health Care Claim Companion Guides \| Version 2.8 January, 2024 \| 9 4.1. InboundTransactionsSupported This section is intended to identify the type and version of the ASC X12 837 Health Care Claim transactions that Carelon will accept. X12 FILE TYPE FILE NAME PURPOSE SOURCE 837P 837 Professional Health Care Claim ASC X12N 837 (005010X222A1) 837 Professional Health Care Claim Trading Partner 837I 837 Institutional Health Care Claim ASC X12N 837 (005010X223A2) 837 Institutional Health Care Claim Trading Partner 4.2. ResponseTransactionsSupported This section is intended to identify the response transactions supported by Carelon. X12 FILE TYPE FILE NAME PURPOSE SOURCETURNAROUND FROM TIME OF SUBMISSION TA1 Interchange Acknowledgement Acknowledgement to verify transmission has been received Carelon Day of Submission 999 Functional Acknowledgement Acknowledgement to verify the syntactical accuracy of the file (accept, reject, or accepted with errors) Carelon Day of Submission 277CA Claims Acknowledgement Provides a claim level acknowledgement for all claims received Carelon 4 Business days Report/ Text file Custom Report/Text file Only when invalid interchange ISA/GS header segments are sent and HIPAA compliant TA1 file is not possible Carelon Day of Submission 4.3. DelimitersSupported 837 Health Care Claim Companion Guides \| Version 2.8 January, 2024 \| 10 A delimiter is a character used to separate two data elements or sub-elements, or to terminate a segment. Delimiters are specified in the interchange header segment, ISA. The ISA segment is a 105-byte fixed length record. The data element separator is byte number 4; the component element separator is byte number 105; and the segment terminator is the byte that immediately follows the component element separator. Once specified in the interchange header, delimiters are not to be used in a data element value elsewhere in the transaction. Carelon requires utilizing the following default delimiters: DESCRIPTION DEFAULT DELIMITER Data element separator * (Asterisk) Sub-element separator : (Colon) Segment Terminator ~ (Tilde) Repetition Separator ^ (Carat) 4.4. SpecificBusinessRulesandLimitations The 837 transaction is designed to transmit one or more claims for each billing provider. The hierarchy of the looping structure is billing provider, subscriber, patient, claim level, and claim service line level. Each transaction set contains groups of logically related data in units called segments. The number of times a loop or segment may repeat in the transaction set structure is defined in the ASC X12 standard implementation guides. Some of these limitations are explicit, such as: ▪ The Claim Information loop (2300) is limited to 100 claims per patient. ▪ The system allows a maximum of one ISA/IEA envelope per 837 file. ▪ The Service Line loop (2400) is limited to 50 service lines per professional claim or 50 service lines per institutional claim. ▪ The ST/SE envelope can be a maximum of 5000 claims per transaction as long as the file does not exceed the maximum file size of 8MB. ▪ Atypical Providers – This refers to providers who are not traditional health care providers, and therefore, do not have an NPI number assigned. Any claims submitted for services provided by atypical providers must have their Tax ID Number in 2010AA REF02 (REF01=”EI” or “SY”), and their Medicaid or State assigned provider identifier in 2010BB REF02 (REF01 = “G2”) in lieu of a Billing Provider NPI or 2310A REF02 (REF01= “G2” ) in lieu of the Attending Provider NPI. ▪ Member and Provider Validation – Review of member data to ensure the member is covered by a Carelon policy. Review of provider data to ensure the correct provider record in our database is used for claims adjudication ▪ Duplicate Claim Check – When reviewing an Institutional claim, the following data elements are reviewed against claims received in the last 12 days: Patient control number, Member first and last name, Member address, Claim frequency code, Line level date of service, Revenue code, Procedure code, Total charge amount, and Billing provider NPI. When all data elements match the 837 Health Care Claim Companion Guides \| Version 2.8 January, 2024 \| 11 claim will be rejected as an exact duplicate. When reviewing a Professional claim, the following data elements are reviewed against claims received in the last 12 days: Patient control number, Member first and last name, Member address, Claim frequency code, Line level data of service, Place of service, Procedure code, Total charge amount, and Billing provider NPI. ▪ NCCI Edits – Using National Correct Coding Initiative guidelines we will review for the three possible edits: Procedure to procedure, Medically unlikely, and Add-on codes. 4.5. CharacterSetsSupported Carelon supports the Basic X12 Character Set: ▪ Uppercase Letters from A to Z ▪ Digits from 0 to 9 ▪ Special Characters: o ! o “ o & o ‘ o ( o ) o * o + o ,	837-health-care-claim-companion-guide.pdf
delimiters are not to be used in a data element value elsewhere in the transaction. Carelon requires utilizing the following default delimiters: DESCRIPTION DEFAULT DELIMITER Data element separator * (Asterisk) Sub-element separator : (Colon) Segment Terminator ~ (Tilde) Repetition Separator ^ (Carat) 4.4. SpecificBusinessRulesandLimitations The 837 transaction is designed to transmit one or more claims for each billing provider. The hierarchy of the looping structure is billing provider, subscriber, patient, claim level, and claim service line level. Each transaction set contains groups of logically related data in units called segments. The number of times a loop or segment may repeat in the transaction set structure is defined in the ASC X12 standard implementation guides. Some of these limitations are explicit, such as: ▪ The Claim Information loop (2300) is limited to 100 claims per patient. ▪ The system allows a maximum of one ISA/IEA envelope per 837 file. ▪ The Service Line loop (2400) is limited to 50 service lines per professional claim or 50 service lines per institutional claim. ▪ The ST/SE envelope can be a maximum of 5000 claims per transaction as long as the file does not exceed the maximum file size of 8MB. ▪ Atypical Providers – This refers to providers who are not traditional health care providers, and therefore, do not have an NPI number assigned. Any claims submitted for services provided by atypical providers must have their Tax ID Number in 2010AA REF02 (REF01=”EI” or “SY”), and their Medicaid or State assigned provider identifier in 2010BB REF02 (REF01 = “G2”) in lieu of a Billing Provider NPI or 2310A REF02 (REF01= “G2” ) in lieu of the Attending Provider NPI. ▪ Member and Provider Validation – Review of member data to ensure the member is covered by a Carelon policy. Review of provider data to ensure the correct provider record in our database is used for claims adjudication ▪ Duplicate Claim Check – When reviewing an Institutional claim, the following data elements are reviewed against claims received in the last 12 days: Patient control number, Member first and last name, Member address, Claim frequency code, Line level date of service, Revenue code, Procedure code, Total charge amount, and Billing provider NPI. When all data elements match the 837 Health Care Claim Companion Guides \| Version 2.8 January, 2024 \| 11 claim will be rejected as an exact duplicate. When reviewing a Professional claim, the following data elements are reviewed against claims received in the last 12 days: Patient control number, Member first and last name, Member address, Claim frequency code, Line level data of service, Place of service, Procedure code, Total charge amount, and Billing provider NPI. ▪ NCCI Edits – Using National Correct Coding Initiative guidelines we will review for the three possible edits: Procedure to procedure, Medically unlikely, and Add-on codes. 4.5. CharacterSetsSupported Carelon supports the Basic X12 Character Set: ▪ Uppercase Letters from A to Z ▪ Digits from 0 to 9 ▪ Special Characters: o ! o “ o & o ‘ o ( o ) o * o + o , o – o . o / o : o ; o ? o = o (space) 837 Health Care Claim Companion Guides \| Version 2.8 January, 2024 \| 12 C h a p t e r 5 Testing 5.1. Testing Workflow 5.2. Testing Intro 5.3. Validation Specifications 5.4. Compliance Testing Validation of Claims 5.5. National Provider Identifier Specifications 5.6. Trading Partner Acceptance Testing Specifications and Requirements 837 Health Care Claim Companion Guides \| Version 2.8 January, 2024 \| 13 5.1. TestingWorkflow 5.2. TestingIntro Carelon requires testing for all direct submitters submitting 837P and 837I transactions. Please follow the appropriate format specifications listed in the specific data requirements and submission directions. Test files must be submitted using the secure protocols and submission methodology selected during the set- up process. Once a test Submitter ID is set up for a trading partner, the submitter can begin to send claims transactions for testing. In order to test, it is imperative that a technical contact be established at the provider/ submitter organization. This contact must be able to monitor, change and submit the 837P and 837I transaction files to Carelon. This contact should be familiar with 837P, 837I, TA1, 277CA, and 999 X12 file transactions. During the testing process, Carelon will examine submitted transactions for required formats and elements, and will provide feedback during the testing process. This testing stage will continue until testing satisfaction is achieved on both sides and Carelon receives sign-off from the trading partner. Carelon’s testing procedures will validate the test file in its entirety. The entire file will either pass or fail validation. Carelon does not allow partial file submissions. If the file fails validation, a failure report will be provided explaining the failure messages for debugging. 837p & 837I Testing Work-Flow Testing Production Start Contact Carelon Complete Carelon submitter Form Create 837p & 837I test files Debug issues 837I & 837P Trading Partner Sign--off Response Files Email Acknowledgement Send Files to Carelon No Yes Initiate Trading Partner Set-up process Process Submitter Form/ Send email withAssign submitter ID End Pass? Process Sign-off and Move Trading partner into production Carelon Health Options Trading Partner 837 Health Care Claim Companion Guides \| Version 2.8 January, 2024 \| 14 Upon the completion of successful testing, Carelon will move the trading partner into our production system. The ID number must be used in all files submitted for production claims processing communicated and coordinated with the provider’s billing office in order to ensure the required billing information is provided to their billing agent/submitter. 5.3. ValidationSpecifications Initial validation is conducted at a batch level. If the batch file is not syntactically valid, the submitter will need to resubmit the corrected batch in its entirety. Secondary validation is conducted at a claim level. If claims are rejected on the claim level validation, the submitter will need to rebuild the corrected claims in a new batch and submit the new batch for validation. Do not resubmit the same batch after making the claim level corrections as this will cause any claims that have passed validation from the previous submission to duplicate in the system. 5.4. ComplianceTestingValidationofClaims The Workgroup for Electronic Data Interchange (WEDI) and the Strategic National Implementation Process (SNIP) have recommended seven types HIPAA compliance testing. Carelon will apply these validation edits during testing and production. Carelon applies the following edits to inbound HIPAA 837 files and claims: 1. SNIP Levels 1-6 Transaction Compliance Testing: SNIP-1: Integrity Testing – This is testing the basic syntax and integrity of the EDI transmission to include: valid segments, segment order, element attributes, numeric values in numeric data elements, X12 syntax and compliance with X12 rules. SNIP-2: Requirement Testing – This is testing for HIPAA Implementation Guide specific syntax such as repeat counts, qualifiers, codes, elements and segments. Also testing for required or intra-segment situational data elements and non-medical code sets whose values are noted in the guide via a code list or table. SNIP-3: Balance Testing – This is testing the transaction for balanced totals, financial balancing of claims or remittance advice and balancing of summary fields. SNIP-4: Situational Testing – This is testing of inter-segment situations and validation of situational fields based on rules in the Implementation Guide. SNIP-5: External Code Set Testing-This is testing of external code sets and tables specified within the Implementation Guide. This testing not only validates the code value but also verifies that the usage is appropriate for the particular transaction. SNIP-6: Product Type or Line of Service Testing – This is testing that the segments and elements required for certain health care services are present and formatted correctly. This type of testing only applies to a trading partner candidate that conducts the specific line of business or product type. 837 Health Care Claim Companion Guides \| Version 2.8 January, 2024 \| 15 For more information on SNIP & front end edits, the following sites can be referenced: ▪ Workgroup for Electronic Data Interchange (WEDI) – http://www.wedi.org/knowledge- center/health-it-compliance ▪ Centers for Medicare and Medicaid Services (CMS) – www.CMS.gov 5.5. NationalProviderIdentifierSpecifications Carelon Behavioral Health, in accordance with the HIPAA mandate will require covered entities to submit electronic claims with the NPI and taxonomy codes in the appropriate locations. The NPI is a standard provider identifier that will replace the provider numbers used in standard electronic transactions today and was adopted as a provision of HIPAA. The NPI Final Rule was published on January 23, 2004 and applies to all health care providers. Carelon Behavioral Health requires that all covered entities report their NPI prior to submitting electronic transactions containing an NPI. To update your provider NPI, please contact our National Provider Line at 800.397.1630. All electronic transactions for covered entities should contain the provider NPI, taxonomy code, employee identification number and zip code + the 4-digit postal code in the appropriate loops. Additional information on NPI including how to apply for a NPI can be found on the Centers for Medicare and Medicaid Services (CMS) website at: https://www.cms.gov/Regulations-and-Guidance/Administrative- Simplification/NationalProvIdentStand/apply.html. 5.6. TradingPartnerAcceptanceTestingSpecificationsand Requirements Trading partners are encouraged to submit a test file prior to submitting claims electronically to Carelon Behavioral Health. To submit claims electronically, trading partners must obtain an ID & Password from the Carelon Behavioral Health EDI Helpdesk. Based on the types of services provided, a trading partner may receive multiple submitter IDs. Test files will need to be submitted under all assigned submitter IDs. Trading partners who upgrade or change software are also encouraged to submit a test submission. Submitters will be notified via e-mail as to the results of the file validation. If the file failed validation, the e- mail message will provide explanations for the failure. Any error message that is not understood can be explained thoroughly by a Carelon Behavioral Health EDI Coordinator. After receiving notification that your test batch has passed validation, you will be asked to submit a sign- off document before submitting files to the “production” directories. Test files will go through SNIP Levels 1-6 Transaction Compliance Testing only. SNIP Level 7 Front-End Validation will be performed in production. 837 Health Care Claim Companion Guides \| Version 2.8 January, 2024 \| 16 Test sample: ▪ Provider and Member Data Samples ▪ 2 Files per Transaction Type (837I & 837P) ▪ 10 Claims Per File ▪ Submit with dates of service within the past month Passing Specification: ▪ 2 Files per Transaction Type accepted (837I & 837P) ▪ 10 out of 10 Claims per file passed front-end edits ▪ 100% Claim acceptance rate 837 Health Care Claim Companion Guides \| Version 2.8 January, 2024 \| 17 C h a p t e r 6 Implementation 6.1. Interchange Control Header Specifications 6.2. Interchange Control Trailer Specifications 6.3. Functional Group Header Specifications 6.4. Functional Group Trailer Specifications 837 Health Care Claim Companion Guides \| Version 2.8 January, 2024 \| 18 Seg Data Element Name Usage Comments Expected Value HEADER ISA INTERCHANGE R ISA01 Authorization Information Qualifier R Valid values: ‘03’ Additional Data Identification Use ‘03’ Additional Data Identification to indicate that a login ID will be present in ISA02. ISA02 Authorization Information R Information used for authorization. Use the Carelon Behavioral Health submitter ID as the login ID. Maximum 10 characters. ISA03 Security Information Qualifier R Valid values: ‘00’ No Security Information Present ‘01’ Password Use ‘01’ value to indicate that a password will be present in ISA04. Use ‘00’ value to indicate that no password will be present in ISA04. ISA04 Security Information R Additional security information identifying the sender. Use the Carelon Behavioral Health submitter ID password. Maximum 10 characters. ISA05 Interchange ID Qualifier R Use ‘ZZ’ or Refer to the implementation guide for a list of valid qualifiers. ISA06 Interchange Sender ID R Usually Submitter ID out to 15 characters. Refer to the implementation guide specifications. ISA07 Interchange ID Qualifier R Use ‘ZZ’ Mutually Defined. ISA08 Interchange Receiver ID R Use “BEACON963116116” ISA09 Interchange Date R Date format YYMMDD. The date (ISA09) is expected to be no more than seven days before the file is received. Any date that does not meet this criterion may cause the file to be rejected. 837 Health Care Claim Companion Guides \| Version 2.8 January, 2024 \| 19 Seg Data Element Name Usage Comments Expected Value	837-health-care-claim-companion-guide.pdf
an ID & Password from the Carelon Behavioral Health EDI Helpdesk. Based on the types of services provided, a trading partner may receive multiple submitter IDs. Test files will need to be submitted under all assigned submitter IDs. Trading partners who upgrade or change software are also encouraged to submit a test submission. Submitters will be notified via e-mail as to the results of the file validation. If the file failed validation, the e- mail message will provide explanations for the failure. Any error message that is not understood can be explained thoroughly by a Carelon Behavioral Health EDI Coordinator. After receiving notification that your test batch has passed validation, you will be asked to submit a sign- off document before submitting files to the “production” directories. Test files will go through SNIP Levels 1-6 Transaction Compliance Testing only. SNIP Level 7 Front-End Validation will be performed in production. 837 Health Care Claim Companion Guides \| Version 2.8 January, 2024 \| 16 Test sample: ▪ Provider and Member Data Samples ▪ 2 Files per Transaction Type (837I & 837P) ▪ 10 Claims Per File ▪ Submit with dates of service within the past month Passing Specification: ▪ 2 Files per Transaction Type accepted (837I & 837P) ▪ 10 out of 10 Claims per file passed front-end edits ▪ 100% Claim acceptance rate 837 Health Care Claim Companion Guides \| Version 2.8 January, 2024 \| 17 C h a p t e r 6 Implementation 6.1. Interchange Control Header Specifications 6.2. Interchange Control Trailer Specifications 6.3. Functional Group Header Specifications 6.4. Functional Group Trailer Specifications 837 Health Care Claim Companion Guides \| Version 2.8 January, 2024 \| 18 Seg Data Element Name Usage Comments Expected Value HEADER ISA INTERCHANGE R ISA01 Authorization Information Qualifier R Valid values: ‘03’ Additional Data Identification Use ‘03’ Additional Data Identification to indicate that a login ID will be present in ISA02. ISA02 Authorization Information R Information used for authorization. Use the Carelon Behavioral Health submitter ID as the login ID. Maximum 10 characters. ISA03 Security Information Qualifier R Valid values: ‘00’ No Security Information Present ‘01’ Password Use ‘01’ value to indicate that a password will be present in ISA04. Use ‘00’ value to indicate that no password will be present in ISA04. ISA04 Security Information R Additional security information identifying the sender. Use the Carelon Behavioral Health submitter ID password. Maximum 10 characters. ISA05 Interchange ID Qualifier R Use ‘ZZ’ or Refer to the implementation guide for a list of valid qualifiers. ISA06 Interchange Sender ID R Usually Submitter ID out to 15 characters. Refer to the implementation guide specifications. ISA07 Interchange ID Qualifier R Use ‘ZZ’ Mutually Defined. ISA08 Interchange Receiver ID R Use “BEACON963116116” ISA09 Interchange Date R Date format YYMMDD. The date (ISA09) is expected to be no more than seven days before the file is received. Any date that does not meet this criterion may cause the file to be rejected. 837 Health Care Claim Companion Guides \| Version 2.8 January, 2024 \| 19 Seg Data Element Name Usage Comments Expected Value ISA10 Interchange Time R Time format HHMM. Refer to the implementation guide specifications. ISA11 Interchange Control Standards Identifier R Delimiter used to separate repeated occurrences of a simple data element or a composite data structure. This value must be different than the data element separator, component element, and the segment terminator. Valid value: ‘^’ Repetition Separator Use the value specified in the implementation guide. ‘^’ ISA12 Interchange Control Version Number R Use the current standard approved for the ISA/IEA envelope. ‘00501’ ISA13 Interchange Control Number R The interchange control number in ISA13 must be identical to the associated interchange trailer IEA02. This value is defined by the sender’s system. If the sender does not wish to define a unique identifier, zero fill this element out to 9 Characters. ISA14 Acknowledgement Requested R This pertains to the TA1 acknowledgement. Valid values: ‘1’ Interchange Acknowledgement Requested Use ‘1’ Interchange Acknowledgement requested (TA1) ISA15 Usage Indicator R Valid values: ‘P’ Production ‘T’ Test The Usage Indicator should be set appropriately. Either can be used. ISA16 Component Element Separator R The delimiter must be a unique character not found in any of the data included in the transaction set. This element contains the delimiter that will be used to separate component data elements within a composite data structure. This value must be different from the data element separator and the segment terminator. Carelon Behavioral Health will accept any delimiter specified by the sender. The uniqueness of each delimiter will be verified. ‘:’ (colon) usually 837 Health Care Claim Companion Guides \| Version 2.8 January, 2024 \| 20 Seg Data Element Name Usage Comments Expected Value TRAILER IEA Interchange Control Trailer R IEA01 Number of Included Functional Groups Count the number of functional groups in the interchange Multiple functional groups may be sent in one ISA/IEA envelope. This is the count of the GS/GE functional groups included in the interchange structure. Limit the ISA/IEA envelope to one type of functional group i.e.functional identifier code ‘HC’ Health Care Claim (837). Segregate professional and institutional functional groups into separate ISA/IEA envelopes. IEA02 Interchange Control Number The interchange control number in IEA02 must be identical to the associated interchange header value sent in ISA13. The interchange control number in IEA02 will be compared to the number sent in ISA13. If the numbers do not match the file will be rejected. 837 Health Care Claim Companion Guides \| Version 2.8 January, 2024 \| 21 Seg Data Element Name Usage Comments Expected Value HEADER GS Functional Group Header R GS01 Functional Identifier Code R Code identifying a group of application related transaction sets. Valid value: ‘HC’ Health Care Claim (837) Use ‘HC’ – Health Care Claim GS02 Application Sender’s Code R Submitter ID Provided by Carelon GS03 Application Receiver’s Code R This field will identify how the file is received by Carelon Behavioral Health. Use “BEACON963116116” GS04 Date R Date format CCYYMMDD Refer to the implementation guide for specifics. GS05 Time R Time format HHMM Refer to the implementation guide for specifics. GS06 Group Control Number R The group control number in GS06, must be identical to the associated group trailer GE02. Assigned number originated and maintained by the sender. Recommend that GS06 be unique within all transmissions over a period of time to be determined by the sender. GS07 Responsible Agency Code R Code identifying the issuer of the standard. Valid value: ‘X’ -Accredited Standards Committee X12 Use ’X’ – Accredited Standards Committee X12 837 Health Care Claim Companion Guides \| Version 2.8 January, 2024 \| 22 GS08 Version/Release Industry ID Code R Professional Addenda Approved for Publication by ASC X12: ‘005010X222A1’ Institutional Addenda Approved for Publication by ASCX12: ‘005010X223A2’ Use ‘005010X222A1’ or ‘0051010X223A2’ Other standards will not be accepted 837 Health Care Claim Companion Guides \| Version 2.8 January, 2024 \| 23 Seg Data Element Name Usage Comments Expected Value TRAILER GE Functional Group Trailer R GE01 Number of Transaction Sets Included R Count of the number of transaction sets in the functional group. Multiple transaction sets may be sent in one GS/GE functional group. Only similar transaction sets may be included in the functional group. GE02 Group Control Number R The group control number in GE02 must be identical to the associated functional group header value sent in GS06. The group control number in GE02 will be compared to the number sent in GS06. If the numbers do not match the entire file will be rejected. 837 Health Care Claim Companion Guides \| Version 2.8 January, 2024 \| 24 C h a p t e r 7 Professional Claims Transaction Specifications 7.1. 837 Professional Claim Transaction Specifications 837 Health Care Claim Companion Guides \| Version 2.8 January, 2024 \| 25 837 Professional Claim Transaction Specifications Seg Data Element Name Usage Comments Expected Value HEADER ST Transaction Set Header R ST01 Transaction Set Identifier Code R Use ‘837’ Health Care Claim ST02 Transaction set control number R Assigned by sender. Must equal SE02 ST03 Transaction R Same as GS08 BHT Beginning of Hierarchical Transaction R BHT01 Hierarchical Structure Code R Valid values: ‘0019' Information Source, Subscriber, Dependent Use ‘0019’ BHT02 Transaction Set Purpose Code R Valid values: ‘00' Original ‘18 Reissue Case where the transmission was interrupted and the receiver requests that the batch be sent again. Use ‘00’ Original BHT03 Reference Identification R BHT03 is the number assigned by the originator to identify the transaction within the originator’s business application system. Assigned by sender BHT04 Date R BHT04 is the date the transaction was created within the business application system. CCYYMMDD BHT05 Time R BHT05 is the time the transaction was created within the business application system. HHMMSSDD BHT06 Transaction Type Code R Separate claim and encounter data into two separate ISA/IEA envelopes (files). ‘CH’ is used for Claims ‘RP’ is used for Encounters 837 Health Care Claim Companion Guides \| Version 2.8 January, 2024 \| 26 Seg Data Element Name Usage Comments Expected Value LOOP 1000A – SUBMITTER NM1 Submitter Name R NM101 Entity Identifier Code R Code identifier Code ‘41’ is used for Submitter NM102 Entity Type Qualifier R ‘1’- Person ‘2’- Non-Person Entity ‘1’- Person ‘2’- Non-Person Entity NM103 Last name of Physician or organization name R Name Last or Organization Name Name Last or Organization Name NM104 First Name of Physician S Name First Only used if NM102 = ‘1’ NM105 Middle Name of Physician S Name Middle Only used if NM102 = ‘1’ NM108 ID code Qualifier R ‘46’ Electronic Transmitter ID Number ‘46’ Electronic Transmitter ID Number NM109 Submitter Primary Identifier R This element contains the Electronic Transaction Identifier Number (ETIN). Use the Carelon Behavioral Health assigned submitter ID Maximum 10 characters. LOOP 1000B - RECEIVER NM1 Receiver Name R NM101 Entity ID Code R ‘40’ Receiver NM102 Entity Type Qualifier R ‘2’ Non-Person Entity NM103 Receiver Name R Name Last or Organization Name Use ‘CARELON BEHAVIORAL HEALTH, INC.’ NM108 ID Code R ‘46’ Identification Code Qualifier NM109 Receiver Primary Identifier R This element contains the Electronic Transaction Identifier Number (ETIN). Use ‘BEACON963116116’ 837 Health Care Claim Companion Guides \| Version 2.8 January, 2024 \| 27 Seg Data Element Name Usage Comments Expected Value LOOP 2000A - BILLING PROVIDER HL Billing Provider Level R HL01 Hierarchical ID Number R Sequence number incremented for each occurrence of HL HL03 Level Code R Use ‘20’ information Source HL04 Hierarchical Child Code R Use ‘1’ Additional Subordinate PRV Billing Provider Specialty Information S Required for atypical providers PRV01 Provider Code R ‘BI’ Billing PRV02 Reference Identification Qualifier R ‘PXC’ Health Care Provider Taxonomy Code PRV03 Reference Identification R Allowed value from External Code List 682. LOOP 2010AA – BILLING PROVIDER NAME NM1 Billing Provider Name R NM101 Entity ID Code R Use ‘85’ billing provider NM102 Entity Type Qualifier R Allowed values: ‘1’ for person ‘2’ for non-person Use ‘1’ for person Use ‘2’ for non-person 837 Health Care Claim Companion Guides \| Version 2.8 January, 2024 \| 28 Seg Data Element Name Usage Comments Expected Value NM103 Last Name or Organization Name R Billing Provider Last or Organizational Name NM104 Name First S Billing Provider First Name NM105 Name Middle S Billing Provider Middle Name NM107 Name Suffix S Billing Provider Name Suffix NM108 Billing Provider Identification Code Qualifier R Required for ALL NPI submitters, with the exception of atypical providers who have not been issued an NPI Number. For those atypical providers, The Billing Provider Secondary Identification (REF*G2) must be provided in Loop 2010BB. See Implementation Guide for additional information. Use Value- ‘XX’ NM109 Billing Provider Identifier R Covered entities send the National Provider ID (NPI) 837 Health Care Claim Companion Guides \| Version 2.8 January, 2024 \| 29 Seg Data Element Name Usage Comments Expected Value N3 Billing Provider Address R Must be a Physical Address, Not a P.O. Box. If the Pay-To Address is a P.O. Box, it must be sent in the Pay- To Address (Loop 2010AB). N301 Address Information R Billing Provider Address Line N302 Address Information Second Address Line S Billing Provider Second Address Line N4 Billing Provider City/State/Zip R N401 City R Billing Provider City N402 State R Billing Provider State N403 Zip R Billing Provider Zip 837 Health Care Claim Companion	837-health-care-claim-companion-guide.pdf
NM103 Last name of Physician or organization name R Name Last or Organization Name Name Last or Organization Name NM104 First Name of Physician S Name First Only used if NM102 = ‘1’ NM105 Middle Name of Physician S Name Middle Only used if NM102 = ‘1’ NM108 ID code Qualifier R ‘46’ Electronic Transmitter ID Number ‘46’ Electronic Transmitter ID Number NM109 Submitter Primary Identifier R This element contains the Electronic Transaction Identifier Number (ETIN). Use the Carelon Behavioral Health assigned submitter ID Maximum 10 characters. LOOP 1000B - RECEIVER NM1 Receiver Name R NM101 Entity ID Code R ‘40’ Receiver NM102 Entity Type Qualifier R ‘2’ Non-Person Entity NM103 Receiver Name R Name Last or Organization Name Use ‘CARELON BEHAVIORAL HEALTH, INC.’ NM108 ID Code R ‘46’ Identification Code Qualifier NM109 Receiver Primary Identifier R This element contains the Electronic Transaction Identifier Number (ETIN). Use ‘BEACON963116116’ 837 Health Care Claim Companion Guides \| Version 2.8 January, 2024 \| 27 Seg Data Element Name Usage Comments Expected Value LOOP 2000A - BILLING PROVIDER HL Billing Provider Level R HL01 Hierarchical ID Number R Sequence number incremented for each occurrence of HL HL03 Level Code R Use ‘20’ information Source HL04 Hierarchical Child Code R Use ‘1’ Additional Subordinate PRV Billing Provider Specialty Information S Required for atypical providers PRV01 Provider Code R ‘BI’ Billing PRV02 Reference Identification Qualifier R ‘PXC’ Health Care Provider Taxonomy Code PRV03 Reference Identification R Allowed value from External Code List 682. LOOP 2010AA – BILLING PROVIDER NAME NM1 Billing Provider Name R NM101 Entity ID Code R Use ‘85’ billing provider NM102 Entity Type Qualifier R Allowed values: ‘1’ for person ‘2’ for non-person Use ‘1’ for person Use ‘2’ for non-person 837 Health Care Claim Companion Guides \| Version 2.8 January, 2024 \| 28 Seg Data Element Name Usage Comments Expected Value NM103 Last Name or Organization Name R Billing Provider Last or Organizational Name NM104 Name First S Billing Provider First Name NM105 Name Middle S Billing Provider Middle Name NM107 Name Suffix S Billing Provider Name Suffix NM108 Billing Provider Identification Code Qualifier R Required for ALL NPI submitters, with the exception of atypical providers who have not been issued an NPI Number. For those atypical providers, The Billing Provider Secondary Identification (REFG2) must be provided in Loop 2010BB. See Implementation Guide for additional information. Use Value- ‘XX’ NM109 Billing Provider Identifier R Covered entities send the National Provider ID (NPI) 837 Health Care Claim Companion Guides \| Version 2.8 January, 2024 \| 29 Seg Data Element Name Usage Comments Expected Value N3 Billing Provider Address R Must be a Physical Address, Not a P.O. Box. If the Pay-To Address is a P.O. Box, it must be sent in the Pay- To Address (Loop 2010AB). N301 Address Information R Billing Provider Address Line N302 Address Information Second Address Line S Billing Provider Second Address Line N4 Billing Provider City/State/Zip R N401 City R Billing Provider City N402 State R Billing Provider State N403 Zip R Billing Provider Zip 837 Health Care Claim Companion Guides \| Version 2.8 January, 2024 \| 30 Seg Data Element Name Usage Comments Expected Value REF Billing Provider Tax Identification R When NPI is submitted in the NM108/09 of this loop, either the EIN or SSN of the provider must be carried in this REF segment. The value that Carelon receives in this element will be returned on the 1099. REF01 Reference Identification Qualifier R Allowed values: ‘EI’ Employer’s Identification Number ‘SY’ Social Security Number Use ‘EI’ if the Provider ID is EIN Use ‘SY’ if Provider ID is SSN REF02 Billing Provider Additional Identifier R EIN or SSN of the billing provider. REF Billing Provider UPIN/License Info S REF01 Reference ID Qualifier R Allowed values: ‘0B’ State License Number ‘1G’ Provider UPIN Number Use ‘1G’ for UPIN number (Medicaid Number) REF02 Reference ID R UPIN information LOOP 2010AB – PAY-TO ADDRESS NAME NM1 Pay-To-Address Name S This must be sent if the Pay-To Address is a P.O. Box. NM101 Entity ID Code R ‘87’ Pay-to Provider NM102 Entity Type Qualifier R Allowed Values: ‘1’ for person ‘2’ for non-person Use ‘1’ for person Use ‘2’ for non-person 837 Health Care Claim Companion Guides \| Version 2.8 January, 2024 \| 31 Seg Data Element Name Usage Comments Expected Value N3 Pay-To Address R N301 Address Information R First Address Line N302 Address Information S Second Address Line N4 Pay-To City/State/Zip R N401 City R N402 State R N403 Zip R 837 Health Care Claim Companion Guides \| Version 2.8 January, 2024 \| 32 Seg Data Element Name Usage Comments Expected Value LOOP 2000B SUBSCRIBER HIERARCHICAL LEVEL HL Subscriber Hierarchical level R HL01 Hierarchical Level R Assigned by sender HL02 Hierarchical Parent ID Number R Assigned by sender HL03 Hierarchical Level Code R Use ‘22’ for subscriber HL04 Hierarchical Child Code R Use ‘0’ if subscriber is the patient Use ‘1’ if subscriber is not the patient SBR Subscriber Information R SBR01 Payer Responsibility Sequence Number code R Use ‘P’ for Primary Use ‘S’ for Secondary Use ‘T’ for Tertiary SBR02 Individual Relationship Code S Use ‘18’ for Self SBR03 Subscriber Ref ID S Subscriber Group or Policy Number “5” , “20” , “32” , “161”, “MBHP” , “MAM” or “HEA” ‘5’ for Fallon Health ‘20’ for WellSense Health Plan – Massachusetts ‘32’ for WellSense New Hampshire Medicaid ‘161’ for WellSense Senior Care Options ‘183’ for WellSense Medicare Advantage (HMO) ‘MBHP’ or ‘MAM’ for Massachusetts Behavioral Health Partnership ‘HEA’ for Health New England 837 Health Care Claim Companion Guides \| Version 2.8 January, 2024 \| 33 Seg Data Element Name Usage Comments Expected Value SBR04 Name S Required when SBR03 is not used and the group name is available. “Fallon Health” or “WellSense Health Plan – Massachusetts” or “WellSense New Hampshire Medicaid” or “WellSense Senior Care Options” or “WellSense Medicare Advantage (HMO)” or “Massachusetts Behavioral Health Partnership” or “Health New England” LOOP 2010BA – SUBSCRIBER NAME NM1 Subscriber Name R NM101 Entity Id Code R Use ‘IL’ Insured or Subscriber NM102 Entity Type Qualifier R Use ‘1’ for person Use ‘2’ for Non-Person Entity NM103 Name or organization name R Name Last or Organization Name NM108 Identification Code Qualifier R An identifier must be present in the subscriber loop. Refer to Implementation Guide for further details. Use ‘MI’ Member Identification Number. NM109 Subscriber Primary Identifier R Member ID from Membership card Note: Medical Assistance Number can be used if applicable. LOOP 2010BB – PAYER NAME NM1 Payer Name R NM101 Entity ID code R Use ‘PR’ Payer 837 Health Care Claim Companion Guides \| Version 2.8 January, 2024 \| 34 Seg Data Element Name Usage Comments Expected Value NM102 Entity Type Qualifier R Use ‘2’ Non-Person Entity NM103 Payer Name R Destination payer name Use ‘CARELON BEHAVIORAL HEALTH, INC.’ NM108 Identification Code Qualifier R Valid values: ‘PI’ - Payer Identification ‘XV’ - HCFA Plan ID (when mandated) Use ‘PI’ Payer Identifier’ until the National Plan ID is mandated. NM109 Payer Identifier R Destination payer identifier Use ‘BEACON963116116’ REF Billing Provider Secondary Identification S This information is required if the provider is an atypical provider, who does not have an NPI present in the Billing Provider Loop (2010AA). REF01 Reference ID Qualifier R Valid values: ‘G2’ – Provider Commercial Number ‘LU’ – Location Number Use ‘G2’ Provider Commercial Number REF02 Reference ID R Medicaid or State assigned provider identifier. LOOP 2300 – CLAIM INFORMATION CLM Claim Information R CLM01 Patient Account Number R Patient Control Number Patient Control Number CLM02 Monetary Amount R Total Claim Charge Amount Total Claim Charge Amount CLM05-1 Facility Code Value R Place of service Place of service CLM05-2 Facility Code Qualifier R Use ‘B’ place of Service Codes for Professional Use ‘B’ place of Service Codes for Professional 837 Health Care Claim Companion Guides \| Version 2.8 January, 2024 \| 35 Seg Data Element Name Usage Comments Expected Value CLM05-3 Claim Frequency Type Code R 1 = Original 7 = Replacement 8 = Void/Cancel of Prior Claim REF Payer Claim Control Number S Required if Claim Frequency Type Code is 7, or 8 REF01 Reference Identification Qualifier R ‘F8’ Original Reference Number REF02 Original Reference Number R If this is a correction to a previously submitted claim use the Carelon Behavioral Health claim number. Enter the whole claim number without spaces or dashes. Include leading and trailing zeros. REF Transmission Intermediaries ID S REF01 Reference Identification Qualifier R Use ‘D9’ Claim Number REF02 Original Reference Number R Unique document control number NTE Claim Received Date S This segment is used only after accepted agreement between trading partners NTE01 Note Reference Code R The value must be ‘ADD’ for additional information ‘ADD’ – Additional Information 837 Health Care Claim Companion Guides \| Version 2.8 January, 2024 \| 36 Seg Data Element Name Usage Comments Expected Value NTE02 Date Note R Date Claim Received Must use format = CCYYMMDD (Pos. 1- 8) CCYYMMDD- Claim Receive Date HI Health Care Diagnosis Code R Do not include decimal point Diagnoses submitted must include all characters out to the furthest position as defined by the diagnosis coding system. HI01 Health Care Code Information R Principal Diagnosis HI01-1 Code List Qualifier Code R ABK- Principal Diagnosis- ICD10 HI01-2 Industry Code R Use ABK for ICD-10 Diagnosis when service date is 10/01/2015 and after. Use BK for ICD-9 Diagnosis when service date is 9/30/2015 and prior. HI02 Health Care Code Information S Additional Diagnosis HI02-1 Code List Qualifier Code R ABF- Diagnosis- ICD10 HI02-2 Industry Code R Use ABF for ICD-10 Diagnosis when service date is 10/01/2015 and after. Use BF for ICD-9 Diagnosis when service date is 9/30/2015 and prior. HI03 Code List Qualifier Code S Additional Diagnosis HI03-1 Code List Qualifier Code R ABF- Diagnosis- ICD10 HI03-2 Industry Code R Use ABF for ICD-10 Diagnosis when service date is 10/01/2015 and after. Use BF for ICD-9 Diagnosis when service date is 9/30/2015 and prior. 837 Health Care Claim Companion Guides \| Version 2.8 January, 2024 \| 37 Seg Data Element Name Usage Comments Expected Value HI04 Code List Qualifier Code S Additional Diagnosis HI04-1 Code List Qualifier Code R ABF- Diagnosis- ICD10 HI04-2 Industry Code R Use ABF for ICD-10 Diagnosis when service date is 10/01/2015 and after. Use BF for ICD-9 Diagnosis when service date is 9/30/2015 and prior. NM104 Name First S Referring Provider First Name Referring Provider First Name NM105 Name Middle S Referring Provider Middle Name Referring Provider Middle Name NM108 Identification Code Qualifier S Use Value – ‘XX’ NM109 Identification Code S This element contains the NPI for the Referring Provider. Use the NPI of the Referring Provider. LOOP 2310A – REFERRING PROVIDER NAME NM1 Attending Provider Name S 837 Health Care Claim Companion Guides \| Version 2.8 January, 2024 \| 38 Seg Data Element Name Usage Comments Expected Value NM101 Entity Id Code R Use ‘DN’ for Referring Provider Use ‘P3’ for Primary Cary Provider NM102 Entity Type Qualifier R Use ‘1’ for person NM103 Name or organization name R Referring Provider Last Name NM104 Name First S Referring Provider First Name NM105 Name Middle S Referring Provider Middle Name NM108 Identification Code Qualifier S Use Value – ‘XX’ NM109 Identification Code S This element contains the NPI for the Referring Provider. 837 Health Care Claim Companion Guides \| Version 2.8 January, 2024 \| 39 Seg Data Element Name Usage Comments Expected Value LOOP 2310B – RENDERING PROVIDER NAME NM1 Rendering Provider Name S NM101 Entity Id Code R Use ‘82’ for Rendering Provider NM102 Entity Type Qualifier R Use ‘1’ for person Use ‘2’ for Non-Person Entity NM103 Name or organization name R Rendering Provider Last or Organization Name NM104 Name First S Rendering Provider First Name NM105 Name Middle S Rendering Provider Middle Name NM108 Identification Code Qualifier S Use Value – ‘XX’ NM109 Identification Code S The NPI of the Rendering Provider. 837 Health Care Claim Companion Guides \| Version 2.8 January, 2024 \| 40 Seg Data Element Name Usage Comments Expected Value LOOP 2310C – SERVICE FACILITY NAME NM1 Service Location Name S This Segment should only be used when the Service Facility Address is different from the Billing Provider Address provided in Loop 2010AA. NM101 Entity	837-health-care-claim-companion-guide.pdf
Diagnosis HI01-1 Code List Qualifier Code R ABK- Principal Diagnosis- ICD10 HI01-2 Industry Code R Use ABK for ICD-10 Diagnosis when service date is 10/01/2015 and after. Use BK for ICD-9 Diagnosis when service date is 9/30/2015 and prior. HI02 Health Care Code Information S Additional Diagnosis HI02-1 Code List Qualifier Code R ABF- Diagnosis- ICD10 HI02-2 Industry Code R Use ABF for ICD-10 Diagnosis when service date is 10/01/2015 and after. Use BF for ICD-9 Diagnosis when service date is 9/30/2015 and prior. HI03 Code List Qualifier Code S Additional Diagnosis HI03-1 Code List Qualifier Code R ABF- Diagnosis- ICD10 HI03-2 Industry Code R Use ABF for ICD-10 Diagnosis when service date is 10/01/2015 and after. Use BF for ICD-9 Diagnosis when service date is 9/30/2015 and prior. 837 Health Care Claim Companion Guides \| Version 2.8 January, 2024 \| 37 Seg Data Element Name Usage Comments Expected Value HI04 Code List Qualifier Code S Additional Diagnosis HI04-1 Code List Qualifier Code R ABF- Diagnosis- ICD10 HI04-2 Industry Code R Use ABF for ICD-10 Diagnosis when service date is 10/01/2015 and after. Use BF for ICD-9 Diagnosis when service date is 9/30/2015 and prior. NM104 Name First S Referring Provider First Name Referring Provider First Name NM105 Name Middle S Referring Provider Middle Name Referring Provider Middle Name NM108 Identification Code Qualifier S Use Value – ‘XX’ NM109 Identification Code S This element contains the NPI for the Referring Provider. Use the NPI of the Referring Provider. LOOP 2310A – REFERRING PROVIDER NAME NM1 Attending Provider Name S 837 Health Care Claim Companion Guides \| Version 2.8 January, 2024 \| 38 Seg Data Element Name Usage Comments Expected Value NM101 Entity Id Code R Use ‘DN’ for Referring Provider Use ‘P3’ for Primary Cary Provider NM102 Entity Type Qualifier R Use ‘1’ for person NM103 Name or organization name R Referring Provider Last Name NM104 Name First S Referring Provider First Name NM105 Name Middle S Referring Provider Middle Name NM108 Identification Code Qualifier S Use Value – ‘XX’ NM109 Identification Code S This element contains the NPI for the Referring Provider. 837 Health Care Claim Companion Guides \| Version 2.8 January, 2024 \| 39 Seg Data Element Name Usage Comments Expected Value LOOP 2310B – RENDERING PROVIDER NAME NM1 Rendering Provider Name S NM101 Entity Id Code R Use ‘82’ for Rendering Provider NM102 Entity Type Qualifier R Use ‘1’ for person Use ‘2’ for Non-Person Entity NM103 Name or organization name R Rendering Provider Last or Organization Name NM104 Name First S Rendering Provider First Name NM105 Name Middle S Rendering Provider Middle Name NM108 Identification Code Qualifier S Use Value – ‘XX’ NM109 Identification Code S The NPI of the Rendering Provider. 837 Health Care Claim Companion Guides \| Version 2.8 January, 2024 \| 40 Seg Data Element Name Usage Comments Expected Value LOOP 2310C – SERVICE FACILITY NAME NM1 Service Location Name S This Segment should only be used when the Service Facility Address is different from the Billing Provider Address provided in Loop 2010AA. NM101 Entity Id Code R Use ‘77’ for Service Location NM102 Entity Type Qualifier R Use ‘2’ for Non-Person Entity NM103 Name or organization name R Service Location Organization Name NM108 Identification Code Qualifier S Use Value – ‘XX’ NM109 Identification Code S Use the NPI of the Service Facility Location N3 Address Information S N301 Address Line 1 R N302 Address Line 2 S N4 Consumer City/State/Zip Code R N401 City Name R N402 State S 837 Health Care Claim Companion Guides \| Version 2.8 January, 2024 \| 41 Seg Data Element Name Usage Comments Expected Value N403 Postal Code S LOOP 2320 – COORDINATION OF BENEFITS (COB) OTHER PAYER INFORMATION SBR Subscriber Information S SBR01 Payer responsibility R This loop is for OTHER PAYER ONLY. If there is another payer whose liability precedes Carelon Behavioral Health coverage, do not submit claim until you have received payment or denial from the other payer. Use ‘P’ - (Primary) Use ‘S’- (Secondary) Use ‘T’- (Tertiary) See Implementation Guide for additional Values SBR02 Individual Relationship Code R See Implementation Guide for other values Use ‘18’ - Self SBR03 Reference Identification S Group or Policy Number SBR04 Name S Other Insured Group Name SBR05 Insurance Type Code S See Implementation Guide for valid values SBR09 Claim Filing Indicator S See Implementation Guide for valid values AMT COB Payer Paid Amount R AMT01 Amount Qualifier R Payer Amount Paid Use ‘D’ - Payer Amount Paid AMT02 Monetary Amount R Amount Paid by the Other Payer AMT COB NON Covered Amount AMT01 Amount Qualifier Code R Non-covered charges -Actual Use ‘A8’ - Non-covered charges -Actual AMT02 Monetary Amount R Non-covered charge amount 837 Health Care Claim Companion Guides \| Version 2.8 January, 2024 \| 42 Seg Data Element Name Usage Comments Expected Value OI Other Insurance Coverage Information R OI03 Benefits Assignment R Use ‘N’- NO Use ‘W’- not applicable Use ‘Y’-YES OI04 Patient Signature Source S See Implementation Guide for valid values OI06 Release of Information Code R See Implementation Guide for valid values LOOP 2330A – OTHER SUBSCRIBER NAME INFORMATION NM1 S Required if Loop 2320 is present NM101 Entity ID R Use ‘IL’ - Insured or Subscriber NM102 Entity Type R Use ‘1’ – Person NM103 Last Name R NM104 First Name S NM105 Middle Name S NM107 Suffix S NM108 Identification Code R Use ‘MI’ - Member Identification Number NM109 Identification Number R Member Identification Number N3 Other Subscriber Address S N301 Address Information R Other Subscriber Address N4 Other Subscriber CityStateZIP S N401 City Name R Other Subscriber City Name N402 State R Other Subscriber State N403 ZIP R Other Subscriber Zip LOOP 2330B – OTHER PAYER NAME INFORMATION 837 Health Care Claim Companion Guides \| Version 2.8 January, 2024 \| 43 Seg Data Element Name Usage Comments Expected Value NM1 Other Payer Name R NM101 Entity Identifier R Use ‘PR’ - Payer NM102 Entity Type R Use ‘2’ -Non-Person Entity NM103 Organization Name R Name of Payer (Other Insurance Company) NM108 ID Code Qualifier R Use ‘PI’ - Payer Identification NM109 Identification Code R Payer ID N3 Other Payer Address S N301 Address Information R Address Information Address Information N4 Other Payer CityStateZIP R N401 City Name R City Name N402 State Name R State Name N403 Postal Code R ZIP Code ZIP Code DTP Claim Adjudication Date R DTP01 Date/Time Qualifier R Use ‘573’ Date Claim Paid DTP02 Format Qualifier R Use ‘D8’ DTP03 Adjudication Date R YYYYMMDD LOOP 2400 – SERVICE LINE LX Service Line Number R 837 Health Care Claim Companion Guides \| Version 2.8 January, 2024 \| 44 Seg Data Element Name Usage Comments Expected Value LX01 Assigned Number R Number Assigned for differentiation within a transaction set SV1 Professional Service R SV101 Composite Medical Procedure Identifier R SV101-1 Product/Service ID Qualifier R Use ‘HC’ Health Care Financing Administration Common Procedural Coding System (HCPCS) Codes Use HC to identify health care financing administration. Use common procedural coding system (HCPCS) codes. SV101-2 Procedure Code R Procedure Code Procedure Code SV101-3 Procedure Modifier S Modifiers must be billed in the order they appear on the benefit grid. SV101-4 Procedure Modifier S Modifiers must be billed in the order they appear on the benefit grid. SV101-5 Procedure Modifier S Modifiers must be billed in the order they appear on the benefit grid. SV101-6 Procedure Modifier S Modifiers must be billed in the order they appear on the benefit grid. SV104 Quantity R Use whole number unit values. DTP Date – Service Date R 837 Health Care Claim Companion Guides \| Version 2.8 January, 2024 \| 45 Seg Data Element Name Usage Comments Expected Value DTP01 Date/Time Qualifier R Use ‘472’ Service DTP02 Date Time Period Format Qualifier R Valid Values: ‘D8’ Date Expressed in Format CCYYMMDD ‘RD8’ Date Range Expressed in Format CCYYMMDD-CCYYMMDD Use ‘RD8’ to specify a range of dates. The from and through service dates should be sent for each service line. DTP03 Date Time Period R Service Date LOOP 2430 – LINE ADJUDICATION INFORMATION SVD Professional Service R SVD01 Payer ID R Payer Identification Code/Number SVD02 Monetary Amount R Paid Amount SVD03-1 Procedure Code/ID Qualifier R HC = HCPCS SVD03-2 Procedure Code/ID R SVD03-3 Modifiers S SVD03-4 Modifiers S SVD03-5 Modifiers S SVD03-6 Modifiers S 837 Health Care Claim Companion Guides \| Version 2.8 January, 2024 \| 46 C h a p t e r 8 Institutional Claim Transaction Specifications 8.1. 837 Institutional Claim Transaction Specifications 837 Health Care Claim Companion Guides \| Version 2.8 January, 2024 \| 41 Seg Data Element Name Usage Comments Expected Value HEADER ST Transaction Set Header R ST01 Transaction Set Identifier Code R Valid Value: ‘837’ Health Care Claim Use ‘837’ Health Care Claim ST02 Transaction set control number R Assigned by sender. Must equal SE02 ST03 Transaction R Same as GS08 BHT Beginning of Hierarchal Transaction R BHT01 Hierarchical Structure Code R Use ‘0019’ BHT02 Transaction Set Purpose Code R Valid Values: ‘00’ Original ‘18’ Reissue Reissue Case where the transmission was interrupted and the receiver requests that the batch be sent again. Use ‘00’ Original BHT03 Reference ID R Assigned by sender BHT04 Date R Transaction Set creation date ‘CCYYMMDD’ BHT05 Time R Transaction Set Creation Time ‘HHMM’ 837 Health Care Claim Companion Guides \| Version 2.8 January, 2024 \| 42 Seg Data Element Name Usage Comments Expected Value BHT06 Transaction Type Code R Valid Values: ‘31’ Subrogation Demand ‘CH’ Chargeable ‘RP’ Reporting Separate claim and encounter data into separate ISA/IEA envelopes (files). Use ‘CH’ for claims Use ‘RP’ for encounters. LOOP 1000A – SUBMITTER NAME NM1 Submitter Name R NM101 Entity Identifier Code R ‘41’ Submitter NM102 Entity Type Qualifier R ‘1’ person ‘2’ Non-Person Entity NM103 Name Last or Organization Name R Name NM104 Name First S Name First Only if NM102 = ‘1’ NM105 Name Middle S Name Middle Only if NM102 = ‘1’ NM108 ID code Qualifier R ‘46’ Electronic Transmitter ID number ‘46’ ETIN NM109 Submitter Primary Identifier R This element contains the Electronic Transaction Identifier Number (ETIN). Use the Carelon Behavioral Health assigned submitter ID. Maximum 10 characters. LOOP 1000B – RECEIVER NAME NM1 Receiver Name R NM101 Entity ID Code R ‘40’ Receiver 837 Health Care Claim Companion Guides \| Version 2.8 January, 2024 \| 43 Seg Data Element Name Usage Comments Expected Value NM102 Entity Type Qualifier R Use ‘2’ Non-Person Entity NM103 Receiver Name R Use ‘CARELON BEHAVIORAL HEALTH, INC.’ NM109 Receiver Primary Identifier R This element contains the Electronic Transaction Identifier Number (ETIN). Use ‘BEACON963116116’ LOOP 2010AA – BILLING PROVIDER NAME NM1 Billing Provider Name R NM101 Entity Identifier Code R ‘85’ Billing Provider NM102 Entity Type Qualifier R ‘2’ Non-Person Entity ‘2’ Non-Person Entity NM103 Name Last or Organization Name R Name Last or Organization NM108 Billing Provider Identification Code Qualifier R A business requirement by Carelon Behavioral Health. Use ‘XX’ Centers for Medicare and Medicaid Services National Provider Identifier NM109 Billing Provider Identifier R This element contains the NPI for the Billing N3 Billing Provider Address R Must be a Physical Address, Not a P.O. Box. If the Pay-To Address is a P.O. Box, it must be sent in the Pay- To Address (Loop 2010AB). N301 Address R Billing Provider Address Billing Provider Address N4 Billing Provider City, State, ZIP R N401 City Name R City Name N402 State R State 837 Health Care Claim Companion Guides \| Version 2.8 January, 2024 \| 44 Seg Data Element Name Usage Comments Expected Value N403 ZIP R ZIP REF Billing Provider Tax Identification R REF01 Reference Identification Qualifier R Use ‘EI’ REF02 Billing Provider Additional Identifier R EIN of the billing provider. LOOP 2010AB – PAY-TO-ADDRESS NAME NM1 Billing Provider Name R NM101 Entity Identifier Code R ‘87’ Pay-To Provider NM102 Entity Type Qualifier R ‘2’ Non-Person Entity ‘2’ Non-Person Entity 837 Health Care Claim Companion Guides \| Version 2.8 January, 2024 \| 45 Seg Data Element Name Usage Comments Expected Value N3 Pay-to Provider Address R N301 Address R Pay-to Provider Address 1 N302 Address R Pay-to Provider Address 2 N4 Pay-to Provider City, State, ZIP R N401 City Name R City Name N402 State R State N403 ZIP R ZIP LOOP 2000B SUBSCRIBER	837-health-care-claim-companion-guide.pdf
Date R Transaction Set creation date ‘CCYYMMDD’ BHT05 Time R Transaction Set Creation Time ‘HHMM’ 837 Health Care Claim Companion Guides \| Version 2.8 January, 2024 \| 42 Seg Data Element Name Usage Comments Expected Value BHT06 Transaction Type Code R Valid Values: ‘31’ Subrogation Demand ‘CH’ Chargeable ‘RP’ Reporting Separate claim and encounter data into separate ISA/IEA envelopes (files). Use ‘CH’ for claims Use ‘RP’ for encounters. LOOP 1000A – SUBMITTER NAME NM1 Submitter Name R NM101 Entity Identifier Code R ‘41’ Submitter NM102 Entity Type Qualifier R ‘1’ person ‘2’ Non-Person Entity NM103 Name Last or Organization Name R Name NM104 Name First S Name First Only if NM102 = ‘1’ NM105 Name Middle S Name Middle Only if NM102 = ‘1’ NM108 ID code Qualifier R ‘46’ Electronic Transmitter ID number ‘46’ ETIN NM109 Submitter Primary Identifier R This element contains the Electronic Transaction Identifier Number (ETIN). Use the Carelon Behavioral Health assigned submitter ID. Maximum 10 characters. LOOP 1000B – RECEIVER NAME NM1 Receiver Name R NM101 Entity ID Code R ‘40’ Receiver 837 Health Care Claim Companion Guides \| Version 2.8 January, 2024 \| 43 Seg Data Element Name Usage Comments Expected Value NM102 Entity Type Qualifier R Use ‘2’ Non-Person Entity NM103 Receiver Name R Use ‘CARELON BEHAVIORAL HEALTH, INC.’ NM109 Receiver Primary Identifier R This element contains the Electronic Transaction Identifier Number (ETIN). Use ‘BEACON963116116’ LOOP 2010AA – BILLING PROVIDER NAME NM1 Billing Provider Name R NM101 Entity Identifier Code R ‘85’ Billing Provider NM102 Entity Type Qualifier R ‘2’ Non-Person Entity ‘2’ Non-Person Entity NM103 Name Last or Organization Name R Name Last or Organization NM108 Billing Provider Identification Code Qualifier R A business requirement by Carelon Behavioral Health. Use ‘XX’ Centers for Medicare and Medicaid Services National Provider Identifier NM109 Billing Provider Identifier R This element contains the NPI for the Billing N3 Billing Provider Address R Must be a Physical Address, Not a P.O. Box. If the Pay-To Address is a P.O. Box, it must be sent in the Pay- To Address (Loop 2010AB). N301 Address R Billing Provider Address Billing Provider Address N4 Billing Provider City, State, ZIP R N401 City Name R City Name N402 State R State 837 Health Care Claim Companion Guides \| Version 2.8 January, 2024 \| 44 Seg Data Element Name Usage Comments Expected Value N403 ZIP R ZIP REF Billing Provider Tax Identification R REF01 Reference Identification Qualifier R Use ‘EI’ REF02 Billing Provider Additional Identifier R EIN of the billing provider. LOOP 2010AB – PAY-TO-ADDRESS NAME NM1 Billing Provider Name R NM101 Entity Identifier Code R ‘87’ Pay-To Provider NM102 Entity Type Qualifier R ‘2’ Non-Person Entity ‘2’ Non-Person Entity 837 Health Care Claim Companion Guides \| Version 2.8 January, 2024 \| 45 Seg Data Element Name Usage Comments Expected Value N3 Pay-to Provider Address R N301 Address R Pay-to Provider Address 1 N302 Address R Pay-to Provider Address 2 N4 Pay-to Provider City, State, ZIP R N401 City Name R City Name N402 State R State N403 ZIP R ZIP LOOP 2000B SUBSCRIBER HIERARCHICAL LEVEL Subscriber Hierarchical Level HL01 Hierarchical ID number R Unique number assigned by sender Unique number assigned by sender HL02 Hierarchical Parent ID number Unique number assigned by sender Unique number assigned by sender HL03 Hierarchical Level Code R ‘22’ Subscriber ‘22’ Subscriber HL04 Child Code R Use ‘0’ if subscriber is the patient Use ‘1’ if subscriber is not the patient Use ‘0’ if subscriber is the patient Use ‘1’ if subscriber is not the patient 837 Health Care Claim Companion Guides \| Version 2.8 January, 2024 \| 46 Seg Data Element Name Usage Comments Expected Value Subscriber Information R SBR01 Payer Responsibility Sequence Number code R Use ‘P’ for Primary Use ‘S’ for Secondary Use ‘T’ for Tertiary SBR02 Individual Relationship Code S Use ‘18’ for Self SBR03 Subscriber Ref ID S “5” , “20” , “32” , “161”, “MBHP” , “MAM” or “HEA” ‘5’ for Fallon Health ‘20’ for WellSense Health Plan – Massachusetts ‘32’ for WellSense New Hampshire Medicaid ‘161’ for WellSense Senior Care Options ‘183’ for WellSense Medicare Advantage (HMO) ‘MBHP’ or ‘MAM’ for Massachusetts Behavioral Health Partnership ‘HEA’ for Health New England SBR04 Name S “Fallon Health” or “WellSense Health Plan – Massachusetts” or “WellSense New Hampshire Medicaid” or “WellSense Senior Care Options” or “WellSense Medicare Advantage (HMO)” or “Massachusetts Behavioral Health Partnership” or “Health New England” LOOP 2010BB – PAYER NAME NM1 Payer Name R NM101 Entity ID code R ‘PR’ Payer NM102 Entity Type Qualifier R ‘2’ Non-Person Entity NM103 Payer Name R Destination payer name. Use ‘CARELON BEHAVIORAL HEALTH, INC.’ 837 Health Care Claim Companion Guides \| Version 2.8 January, 2024 \| 47 Seg Data Element Name Usage Comments Expected Value NM108 Identification Code Qualifier R Valid values: ‘PI’ Payer Identification ‘XV’ HCFA Plan ID (when mandated) Use ‘PI’ Payer Identifier until the National Plan ID is mandated. NM109 Payer Identifier R Destination payer identifier ‘Use “BEACON963116116” LOOP 2300 – CLAIM INFORMATION CLM Claim Information R CLM01 Claim Submitter ID R Claim Submitter’s Patient Control Number CLM02 Monetary Amount R Total Claim Charge Amount CLM05-1 Facility Code Value R Facility Type Code CLM05-2 Facility Code Qualifier R ‘A’ Uniform Billing Claim Form CLM05-3 Claim Frequency Type Code R 1 = Original 7 = Replacement 8 = Void DTP Discharge Hour S DTP01 Date/Time Qualifier R Use ‘096’ - Discharge DTP02 Date Time Qualifier R ‘TM’ DTP03 Date Time Period R ‘HHMM’ DTP Statement Date S DTP01 Date/Time Qualifier R Use ‘434’ -Statement 837 Health Care Claim Companion Guides \| Version 2.8 January, 2024 \| 48 Seg Data Element Name Usage Comments Expected Value DTP02 Date Time Period Format Qualifier R ‘RD8’ Range of Dates Expressed in Format (CCYYMMDD-CCYYMMDD) DTP03 Date Time Period R Statement from and to Date DTP Admission Date/Hour S DTP01 Date/Time Qualifier R Use ‘435’ Admission DTP02 Date/Time Format Qualifier R Valid Values: ‘D8’ Date Expressed in Format CCYYMMDD. ‘DT’ Date and Time Expressed in Format CCYYMMDDHHMM Use ‘DT’- Date and Time Expressed in format (CCYYMMDDHHMM) DTP03 Date Time Period R Admission Date and Hour CL1 Institutional Claim Code R CL101 Admission Type Code R Code indicating the priority of this admission From Code Source 231 CL102 Admission Source Code R Code indicating the source of this admission From Code Source 230 CL103 Patient Status Code R Code indicating patient status as of the “statement covers through date” From Code Source 239 PWK Claim Supplemental Information S PWK02 Attachment Transmission Code R ‘AA’ Available on Request at Provider Site. Use ‘AA’ Available on Request at Provider Site. 837 Health Care Claim Companion Guides \| Version 2.8 January, 2024 \| 49 Seg Data Element Name Usage Comments Expected Value REF Payer Claim Control Number S Required if Claim Frequency Type Code is 7 or 8 REF01 Reference Identification Qualifier R ‘F8’ Original Reference Number REF02 Original Reference Number R If this is a correction to a previously submitted claim use the CarelonBehavioral Health claim number. Enter the whole clai number without spaces or dashes. Include leading and trailing zeros. REF Transmission Intermediaries ID S This segment is used only after accepted agreement between trading partners REF01 Reference Identification Qualifier R The value must be ‘D9’ for Unique document control number ‘D9’ Unique document control number REF02 Original Reference Number R Unique document control number Unique document control number NTE Claim Received Date S This segment is used only after accepted agreement between trading partners NTE01 Note Reference Code R The value must be ‘UPI’ for additional information ‘UPI’ – Additional Information 837 Health Care Claim Companion Guides \| Version 2.8 January, 2024 \| 50 Seg Data Element Name Usage Comments Expected Value NTE02 Date Note R Date Claim Received Must use format = CCYYMMDD (Pos. 1- 8) CCYYMMDD- Claim Receive Date HI Principal Diagnosis R HI01-1 Code List Qualifier Code R BK - Principal Diagnosis – ICD-9 ABK- Principal Diagnosis- ICD10 HI01-2 Industry Code R Use ‘ABK’ for ICD-10 Diagnosis when service date is 10/01/2015 and after. Use ‘BK’ for ICD-9 Diagnosis when service date is 9/30/2015 and prior. HI01-9 Yes/No Condition or Response Code S Present on Admission Indicator ‘N’ for No ‘U’ for Unknown ‘W’ for Not Applicable ‘Y’ for Yes HI Admitting Diagnosis S HI01-1 Code List Qualifier Code R BJ - Admitting Diagnosis – ICD-9 ABJ- Admitting Diagnosis- ICD10 837 Health Care Claim Companion Guides \| Version 2.8 January, 2024 \| 51 Seg Data Element Name Usage Comments Expected Value HI01-2 Industry Code R Use ‘ABJ’ for ICD-10 Diagnosis when service date is 10/01/2015 and after. Use ‘BJ’ for ICD-9 Diagnosis when service date is 9/30/2015 and prior. HI Patient’s Reason for Visit S HI01-1 Code List Qualifier Code R PR – Patient reason for visit – ICD-9 APR- Patient reason for visit - ICD10 HI01-2 Industry Code R Use ‘APR’ for ICD-10 when service date is 10/01/2015 and after. Use ‘PR’ for ICD-9 when service date is 9/30/2015 and prior. HI External Cause of Injury S HI01-1 Code List Qualifier Code R BN – External cause of injury – ICD-9 ABN- External cause of injury - ICD10 HI01-2 Industry Code R Use ‘ABN’ for ICD-10 when service date is 10/01/2015 and after. HI Other Diagnosis Information S HI01-1 Code List Qualifier Code R BF - Other Diagnosis – ICD-9 ABF- Other Diagnosis- ICD10 837 Health Care Claim Companion Guides \| Version 2.8 January, 2024 \| 52 Seg Data Element Name Usage Comments Expected Value HI01-2 Industry Code R Use ‘ABF’ for ICD-10 Diagnosis when service date is 10/01/2015 and after. Use ‘BF’ for ICD-9 Diagnosis when service date is 9/30/2015 and prior. HI Principal Procedure Information S HI01-1 Code List Qualifier Code R BR - Principal Procedure – ICD-9 BBR- Principal Procedure- ICD10 HI01-2 Industry Code R Use ‘BBR’ when service date is 10/01/2015 and after. Use ‘BR’ when service date is 9/30/2015 and prior. HI Other Procedure Information S HI01-1 Code List Qualifier Code R BQ - Other Procedure – ICD-9 BBQ- Other Procedure- ICD10 HI01-2 Industry Code R Use BBQ when service date is 10/01/2015 and after. Use BQ when service date is 9/30/2015 and prior. LOOP 2310A – ATTENDING PROVIDER NAME NM1 Attending Provider Name S 837 Health Care Claim Companion Guides \| Version 2.8 January, 2024 \| 53 Seg Data Element Name Usage Comments Expected Value NM101 Entity ID Code R ‘71’ Attending Physician ‘71’ Attending Physician NM102 Entity Type Qualifier R ‘1’ Person ‘1’ Person NM103 Name Last or Organization Name R Name Last or Organization Name Name Last or Organization Name NM104 Name First S Attending Provider First Name Attending Provider First Name NM105 Name MI S Attending Provider Middle Name Attending Provider Middle Name NM108 ID Code Qualifier R Required for ALL NPI submitters, with the exceptions of atypical providers who have not been issued an NPI Number. For the atypical providers, the Attending Provider secondary Identification (REF*G2) must be provided in Loop 2310A. See Implementation Guide for additional information. Use ‘XX’ – Centers for Medicare and Medicaid NPI NM109 ID Code R Attending Provider Primary Identifier Attending Provider Primary Identifier PRV Attending Provider Specialty Information S 837 Health Care Claim Companion Guides \| Version 2.8 January, 2024 \| 54 Seg Data Element Name Usage Comments Expected Value PRV01 Provider Code R Use ‘AT’ -Attending Use ‘AT’ -Attending PRV02 Reference ID Qualifier R Use ‘PXC’- Provider Taxonomy Code Use ‘PXC’- Provider Taxonomy Code PRV03 Reference ID R Provider Taxonomy Code Provider Taxonomy Code REF Attending Provider Secondary ID S REF01 Reference ID Qualifier R ‘G2’ Provider Commercial, Medicaid, Medicare Number ‘1G’ UPIN number ‘G2’ Provider Commercial, Medicaid, Medicare Number ‘1G’ UPIN number REF02 Reference ID R LOOP 2310E- SERVICE FACILITY LOCATION NAME NM1 Service Facility Location Name S NM101 Entity ID code R Use ‘77’ – Service Location Use ‘77’ – Service Location NM102 Entity Type Qualifier R ‘2’ – Non-person Entity ‘2’ – Non-person Entity 837 Health Care Claim Companion Guides \| Version 2.8 January, 2024 \| 55 Seg Data Element Name Usage Comments Expected Value NM103 Provider Site name R Provider Site Name Provider Site Name NM108 ID Code Qualifier R ‘XX’ Centers for Medicare and Medicaid NPI ‘XX’ NM109 ID Code R ID Code ID Code LOOP 2320 –	837-health-care-claim-companion-guide.pdf
date is 10/01/2015 and after. HI Other Diagnosis Information S HI01-1 Code List Qualifier Code R BF - Other Diagnosis – ICD-9 ABF- Other Diagnosis- ICD10 837 Health Care Claim Companion Guides \| Version 2.8 January, 2024 \| 52 Seg Data Element Name Usage Comments Expected Value HI01-2 Industry Code R Use ‘ABF’ for ICD-10 Diagnosis when service date is 10/01/2015 and after. Use ‘BF’ for ICD-9 Diagnosis when service date is 9/30/2015 and prior. HI Principal Procedure Information S HI01-1 Code List Qualifier Code R BR - Principal Procedure – ICD-9 BBR- Principal Procedure- ICD10 HI01-2 Industry Code R Use ‘BBR’ when service date is 10/01/2015 and after. Use ‘BR’ when service date is 9/30/2015 and prior. HI Other Procedure Information S HI01-1 Code List Qualifier Code R BQ - Other Procedure – ICD-9 BBQ- Other Procedure- ICD10 HI01-2 Industry Code R Use BBQ when service date is 10/01/2015 and after. Use BQ when service date is 9/30/2015 and prior. LOOP 2310A – ATTENDING PROVIDER NAME NM1 Attending Provider Name S 837 Health Care Claim Companion Guides \| Version 2.8 January, 2024 \| 53 Seg Data Element Name Usage Comments Expected Value NM101 Entity ID Code R ‘71’ Attending Physician ‘71’ Attending Physician NM102 Entity Type Qualifier R ‘1’ Person ‘1’ Person NM103 Name Last or Organization Name R Name Last or Organization Name Name Last or Organization Name NM104 Name First S Attending Provider First Name Attending Provider First Name NM105 Name MI S Attending Provider Middle Name Attending Provider Middle Name NM108 ID Code Qualifier R Required for ALL NPI submitters, with the exceptions of atypical providers who have not been issued an NPI Number. For the atypical providers, the Attending Provider secondary Identification (REF*G2) must be provided in Loop 2310A. See Implementation Guide for additional information. Use ‘XX’ – Centers for Medicare and Medicaid NPI NM109 ID Code R Attending Provider Primary Identifier Attending Provider Primary Identifier PRV Attending Provider Specialty Information S 837 Health Care Claim Companion Guides \| Version 2.8 January, 2024 \| 54 Seg Data Element Name Usage Comments Expected Value PRV01 Provider Code R Use ‘AT’ -Attending Use ‘AT’ -Attending PRV02 Reference ID Qualifier R Use ‘PXC’- Provider Taxonomy Code Use ‘PXC’- Provider Taxonomy Code PRV03 Reference ID R Provider Taxonomy Code Provider Taxonomy Code REF Attending Provider Secondary ID S REF01 Reference ID Qualifier R ‘G2’ Provider Commercial, Medicaid, Medicare Number ‘1G’ UPIN number ‘G2’ Provider Commercial, Medicaid, Medicare Number ‘1G’ UPIN number REF02 Reference ID R LOOP 2310E- SERVICE FACILITY LOCATION NAME NM1 Service Facility Location Name S NM101 Entity ID code R Use ‘77’ – Service Location Use ‘77’ – Service Location NM102 Entity Type Qualifier R ‘2’ – Non-person Entity ‘2’ – Non-person Entity 837 Health Care Claim Companion Guides \| Version 2.8 January, 2024 \| 55 Seg Data Element Name Usage Comments Expected Value NM103 Provider Site name R Provider Site Name Provider Site Name NM108 ID Code Qualifier R ‘XX’ Centers for Medicare and Medicaid NPI ‘XX’ NM109 ID Code R ID Code ID Code LOOP 2320 – COORDINATION OF BENEFITS (COB) OTHER PAYER INFORMATION AMT COB Payer Paid Amount R AMT01 Amount Qualifier Code R Use ‘D’ – Payer Amount Paid AMT02 Monetary Amount R When submitting claims with multiple claim lines where not all claim lines have a COB relationship; send separate claims. Amount Paid by the Other Payer. LOOP 2400 – SERVICE LINE NUMBER LX Service Line Number R LX01 Assigned Number R Counter. Assigned by Sender Counter. Assigned by Sender SV2 Institutional Service Line R SV201 Product/Service ID R Service Line Revenue Code Service Line Revenue Code SV202-1 Product/Service ID Qualifier R ‘HC’ Health Care Financing Administration Common Procedural Coding System (HCPCS) codes ‘HC’ Health Care Financing Administration Common Procedural Coding System (HCPCS) codes SV202-2 Product/Service ID R Procedure Code Procedure Code SV202-3 Product/Service Modifier S Modifier 1 Modifier 1 837 Health Care Claim Companion Guides \| Version 2.8 January, 2024 \| 56 Seg Data Element Name Usage Comments Expected Value SV202-4 Product/Service Modifier S Modifier 2 Modifier 2 SV202-5 Product/Service Modifier S Modifier 3 Modifier 3 SV205 Quantity S Service Units Use whole number unit values. DTP Service Date S DTP01 Date/Time Qualifier R ‘472’- Service ‘472’- Service DTP02 Date Time Period Qualifier R ‘D8’- CCYYMMDD ‘RD8’- range of dates(CCYYMMDD- CCYYMMDD) ‘D8’- CCYYMMDD ‘RD8’- range of dates(CCYYMMDD- CCYYMMDD) DTP03 Date Time Period R Service Date Service Date LOOP 2430 – LINE ADJUDICATION INFORMATION SVD Professional Service R SVD06 Assigned Number R Number of Units Paid for by Other Payer Whole Units Only	837-health-care-claim-companion-guide.pdf
835 - Companion Guide June 28, 2022 ● 005010X221A1/835 1 835 Health Care Claim Payment/Advice Companion Guide Refers to ASC X12 835 Technical Report Type 3 Guide HIPAA/V5010X221A1 Version: 1.1 Publication: June 28, 2022 Author: Delta Dental 835 - Companion Guide June 28, 2022 ● 005010X221A1/835 2 Disclosure Statement This document is Copyright © 2013 by Delta Dental of California. All rights reserved. It may be freely redistributed in its entirety provided that this copyright notice is not removed. It may not be sold for profit or used in commercial documents without the written permission of the copyright holder. This document is provided “as is” without any express or implied warranty. Note that the copyright on the underlying ASC X12 Standards is held by DISA on behalf of ASC X12. Preface This Companion Guide to the ASC X12N Implementation Guides and associated errata adopted under HIPAA clarifies and specifies the data content when exchanging electronically with Delta Dental of California. Transmissions based on this companion guide, used in tandem with the X12N Technical Report Type 3 Guides are compliant with both X12 syntax and those guides. This Companion Guide is intended to convey information that is within the framework of the ASC X12N Implementation Guides adopted for use under HIPAA. The Companion Guide is not intended to convey information that in any way exceeds the requirements or usages of data expressed in the Implementation Technical Report Type 3 Guides. 835 - Companion Guide June 28, 2022 ● 005010X221A1/835 3 Table of Contents 1 Introduction .............................................................................................................. 5 1.1 Scope ............................................................................................................................ 5 1.2 Overview ....................................................................................................................... 5 1.3 References .................................................................................................................... 5 2 Getting Started ......................................................................................................... 7 2.1 Working with Delta Dental of California ......................................................................... 7 2.2 Trading Partner Registration ......................................................................................... 7 2.3 Trading Partner Enrollment/Onboarding ........................................................................ 7 3 Notes to the Trading Partners ................................................................................. 8 3.1 Business Use and Purpose ........................................................................................... 8 3.2 Claims Types ................................................................................................................ 8 3.3 Data Sources ................................................................................................................ 8 3.4 Generation Frequency................................................................................................... 8 3.5 Data Content/Structure.................................................................................................. 9 3.6 Validation/Balancing ...................................................................................................... 9 3.7 Delimeters ..................................................................................................................... 9 3.8 Other ............................................................................................................................. 9 4 Testing with the Payer ........................................................................................... 10 4.1 Testing Requirements ................................................................................................. 10 4.2 Provider 835 Request Enrollment File ......................................................................... 11 4.3 Provider 835 Request Header Record Layout ............................................................. 11 4.4 Provider 835 Request Detail Record Layout ................................................................ 13 5 Connectivity with the Payer / Communications .................................................. 15 5.1 Transmission Administrative Procedures..................................................................... 15 5.1.1 Re-transmission procedures .............................................................................. 15 5.2 Communication Protocols Specifications ..................................................................... 15 5.3 Passwords .................................................................................................................. 15 6 Contact information ............................................................................................... 16 6.1 EDI Customer Service ................................................................................................. 16 6.2 Provider Service Number ............................................................................................ 16 6.3 Applicable websites / e-mail ........................................................................................ 16 835 - Companion Guide June 28, 2022 ● 005010X221A1/835 4 7 Control Segments / Envelopes ............................................................................. 17 7.1 ISA Interchange Control Header ................................................................................. 17 7.2 GS Functional Group Header ...................................................................................... 17 7.3 ST Transaction Set Header ......................................................................................... 18 7.4 BPR Financial Information ........................................................................................... 19 7.5 TRN Reassociation Trace Number .............................................................................. 21 7.6 REF Receiver Identification ......................................................................................... 21 7.7 N1 Payer Identification ................................................................................................ 22 7.8 PER Payer WEB Site .................................................................................................. 22 7.9 N1 Payee Identification ............................................................................................... 23 7.10 N3 Payee Address ...................................................................................................... 24 7.11 N4 Payee City, State, Zip Code ................................................................................... 24 7.12 REF Payee Additional Identification ............................................................................ 24 7.13 CLP Claim Payment Information ................................................................................. 24 7.14 NM1 Patient Name ...................................................................................................... 25 7.15 NM1 Insured Name ..................................................................................................... 26 7.16 NM1 Service Provider Name ....................................................................................... 27 7.17 REF Rendering Provider Identification (Loop 2100) .................................................... 29 7.18 SVC Service Payment Information .............................................................................. 29 7.19 REF Service Identification ........................................................................................... 29 7.20 REF Line Control Number ........................................................................................... 29 7.21 REF Rendering Provider Information (2110) ............................................................... 29 7.22 REF HealthCare Policy Identification ........................................................................... 30 7.23 PLB Provider Adjustments .......................................................................................... 30 8 Acknowledgements ............................................................................................... 31 8.1 999 Functional Acknowledgment ................................................................................. 31 8.2 TA1 Interchange Acknowledgment .............................................................................. 31 Document Revision History ....................................................................................... 32 835 - Companion Guide June 28, 2022 ● 005010X221A1/835 5 1 Introduction Under the Administrative Simplification provisions of the Health Insurance Portability and Accountability Act (HIPAA) of 1996, the Secretary of the Department of Health and Human Services (HHS) is directed to adopt standards to support the electronic exchange of administrative and financial health care transactions. The purpose of the Administrative Simplification portion of HIPAA is enable health information to be exchanged electronically and to adopt standards for those transactions. 1.1 Scope This companion guide is intended for all Trading Partners interested in exchanging HIPAA compliant X12 transactions with any of Enterprise Delta Dental Payers. It is intended to be used in conjunction with X12N Implementation Guides and is not intended to contradict or exceed X12 standards. It contains information about specific Delta Dental of California requirements for processing following X12N Implementation Guides: Health Care Claim Payment/Advice 835 Implementation Guide ASC X12 Standards for Electronic Data Interchange Technical Report Type 3 (TR3), version 005010X221A1 All instructions in this document are written using information known at the time of publication and are subject to change. 1.2 Overview The purpose of this document is to introduce and provide information about Delta Dental’s Enterprise solution for receiving 835 transactions. This document covers how Delta Dental will work with Trading Partners on testing, connectivity, contact information, control segments/envelopes, payer specific business rules and limitations, acknowledgements, and trading partner agreements. 1.3 References 835 - Companion Guide June 28, 2022 ● 005010X221A1/835 6 The ASC X12N 835 (version 005010X221A1) Technical Report Type 3 guide for Health Care Claim Payment/Advice (835) has been established as the standard for payments transactions and is available at http://store.x12.org/store/healthcare- 5010-original-guides. Delta Dental of California’s documentation on transactions for Trading Partners is located at: http://www.deltadentalins.com/dentists/edi-support.html. 835 - Companion Guide June 28, 2022 ● 005010X221A1/835 7 2 Getting Started 2.1 Working with Delta Dental of California Entities interested in receiving 835/Electronic Remittance Advice (ERA) via the Delta Dental enterprise solution should email or call the Delta Dental EDI contact related to Trading Partner Relations. 2.2 Trading Partner Registration New entities must submit in writing or email a request to become a Trading Partner to the Delta Dental of California EDI contact related to Trading Partner Relations. Delta Dental reserves the right to have new Trading Partners use existing Trading Partner connections. In the request, submitter must include the following information: Contact Name Company Name Address, City, State and Zip E-Mail address of contact Telephone of contact Number of Delta Enterprise Provider Clients Served 2.3 Trading Partner Enrollment/Onboarding All Trading Partners, Clearinghouses, and Providers groups will be provided with applicable agreement during enrollment/onboarding period. 835 - Companion Guide June 28, 2022 ● 005010X221A1/835 8 3 Notes to the Trading Partners 3.1 Business Use and Purpose This document provides a statement of the 835 utilization requirements unique to Delta Dental processing. Clearinghouses and Trading Partners must use this guide in conjunction with the 835 Health Care Claim Payment/Advice Transaction Implementation Guide (TR3). 3.2 Claims Types The supported claim types are as follows: 1. Dental Claims 2. Dental Pre-Treatment Estimates Delta Dental’s Notes for the Trading Partners: DeltaCare claims/encounters and Delta Vision claim types are not supported at this time. This will be part of DeltaCare Phase 2 conversion targeted by end of 1st QTR 2014. 3.3 Data Sources Remittance Advices and Pre-treatment Estimates returned in the 835 include finalized claims/pre-treatment estimates from the following submission sources: 1. Electronic claims (837D) 2. Paper claims 3. Manually-entered/System-generated claims to Delta Dental's claims adjudication system Delta Dental’s Notes for the Trading Partners: Once Provider Groups/Providers are enrolled to receive 835/ERA, the applicable 835/ERA will be generated and sent after each Payment Processing (PP) cycle regardless of the submission sources. 3.4 Generation Frequency 1. Delta Dental's system produces Individual Remittance Advice and Pre-Treatment Estimate transactions once a week for each Delta Dental payer. This is based on weekly Payment Processing (PP) schedules defined for each Delta Dental payer. 2. The Individual Remittance Advice and/or Pre-Treatment Estimate transactions are batched at the end of the day into an 835 EDI file. The 835 EDI files are batched based on specific Trading Partner/Delta Dental Payers. If a system 835 - Companion Guide June 28, 2022 ● 005010X221A1/835 9 limitation or agreed transmission size limitation is met, multiple 835 EDI files may be generated for each TP/Payers. 3. Batching of X12 835 transactions occurs once a day after each Payment Processing (PP) cycles. 3.5 Data Content/Structure 1. An 835 transaction will have one Interchange Group (ISA/IEA), one Functional Group (GS/GE), and may have one or more Transaction Sets (ST/SE). 2. A Transaction Set (ST/SE) may contain either an individual Pre-Treatment Estimate or an Individual Remittance Advice. 3. A Remittance Advice will reflect claims and service lines details associated with a payment. 4. Adjustments will be returned in 2110 Service Payment Information Loop, CAS segment. The CAS segment in 2100 Claim Payment Information loop is not utilized by Delta Dental. 3.6 Validation/Balancing HIPAA Validation levels 1, 2, and 3 will be performed on the generated 835 EDI file(s). The amounts reported in the 835 will be balanced at the service line, claim, and transaction levels. 3.7 Delimeters Segment Separator ~ (tilde) Data Element Separator * (asterisk) Sub-element Separator : (colon) Repetition Separator ^ (caret) 3.8 Other 1. Only Delta Dental-utilized loops and segments are included in this companion guide. 2. Data elements not utilized by Delta Dental are noted accordingly as "Not Utilized". 3. Codes not utilized by Delta Dental are excluded from this guide. 4. Supplemental notes (Delta Dental's Note for the Trading Partner), if applicable, are added at the segment or data element level. 835 - Companion Guide June 28, 2022 ● 005010X221A1/835 10 4 Testing with the Payer 4.1 Testing Requirements Trading Partner will use the following steps to test with any of Enterprise Delta Dental Payers. Step 1: Trading Partner Registration Trading Partner should contact Delta Dental of California to complete and submit the Trading Partner Agreement Form for registration process. Step 2: Trading Partner Authentication Delta Dental will verify the information on the Trading Partner Agreement Form and will approve the Submitter ID requests. Step 3: Trading Partner Validation/Testing Testing environment will be setup between Trading Partners and Delta Dental to allow for end-to-end system integration and Trading Partner Validation (TPV). Trading Partner should will receive 835/ERAs test transactions and verify that all systems involved can properly receive and process X12 compliant transactions. The Usage Indicator (ISA15) on 835/ERA’s must be “T”. Step 4: Trading Partner Implementation Once Trading Partner Validation (TPV) and end-to-end system integration testing is complete, a Trading Partner will be migrated to Production environment and can begin to receive and process 835/ERA transactions. The Usage Indicator (ISA15) on 835/ERA’s must be “P”. 835 - Companion Guide June 28, 2022 ● 005010X221A1/835 11 4.2 Provider 835 Request Enrollment File Trading Partners who are interested in setting up Providers for 835/ERA must submit Provider Enrollment File. The following information must be provided to setup any Providers to receive 835/ERA. Fixed Length Records = 200 Bytes File Type = Text File Name = DLTAP835.txt 4.3 Provider 835 Request Enrollment File Notifications Delta Dental will perform a series of file level validations on each 835 provider enrollment file based on the specifications outlined in section 4.4 and 4.5 of this document. If a provider enrollment file fails any of the validation at either the header level or the detail level the corresponding trading partner/sender will receive a file processing failure notification via email with the below mentioned information and none of the provider records from the file will be enrolled for the 835 ERA until the file is corrected and resubmitted. Notification Method – Email Sender – [email protected] Subject – Provider 835 Enrollment File Processing Failure On ‘Date MM/DD/YYYY’ Body – File ‘provider 835 enrollment file name’ has failed file format validations and will not be processed further by Delta Dental. Please correct and resubmit the file to ensure enrollment of the corresponding providers for the 835 ERA process. For further inquiries or questions please reach out to [email protected]. Thank you, Delta Dental 835 - Companion Guide June 28, 2022 ● 005010X221A1/835 12 4.4 Provider 835 Request Header Record Layout Field Name Description Length Start Position Technical Specification Record Type PR0 identifiers Header 3 1 Must contain a value or PR0. This is Uppercase PR followed by the number zero. File ID Identifies that this is a file of Provider ID's that have requested electronic remittance 9 4 Must contain a	companion-guide-835.pdf
Codes not utilized by Delta Dental are excluded from this guide. 4. Supplemental notes (Delta Dental's Note for the Trading Partner), if applicable, are added at the segment or data element level. 835 - Companion Guide June 28, 2022 ● 005010X221A1/835 10 4 Testing with the Payer 4.1 Testing Requirements Trading Partner will use the following steps to test with any of Enterprise Delta Dental Payers. Step 1: Trading Partner Registration Trading Partner should contact Delta Dental of California to complete and submit the Trading Partner Agreement Form for registration process. Step 2: Trading Partner Authentication Delta Dental will verify the information on the Trading Partner Agreement Form and will approve the Submitter ID requests. Step 3: Trading Partner Validation/Testing Testing environment will be setup between Trading Partners and Delta Dental to allow for end-to-end system integration and Trading Partner Validation (TPV). Trading Partner should will receive 835/ERAs test transactions and verify that all systems involved can properly receive and process X12 compliant transactions. The Usage Indicator (ISA15) on 835/ERA’s must be “T”. Step 4: Trading Partner Implementation Once Trading Partner Validation (TPV) and end-to-end system integration testing is complete, a Trading Partner will be migrated to Production environment and can begin to receive and process 835/ERA transactions. The Usage Indicator (ISA15) on 835/ERA’s must be “P”. 835 - Companion Guide June 28, 2022 ● 005010X221A1/835 11 4.2 Provider 835 Request Enrollment File Trading Partners who are interested in setting up Providers for 835/ERA must submit Provider Enrollment File. The following information must be provided to setup any Providers to receive 835/ERA. Fixed Length Records = 200 Bytes File Type = Text File Name = DLTAP835.txt 4.3 Provider 835 Request Enrollment File Notifications Delta Dental will perform a series of file level validations on each 835 provider enrollment file based on the specifications outlined in section 4.4 and 4.5 of this document. If a provider enrollment file fails any of the validation at either the header level or the detail level the corresponding trading partner/sender will receive a file processing failure notification via email with the below mentioned information and none of the provider records from the file will be enrolled for the 835 ERA until the file is corrected and resubmitted. Notification Method – Email Sender – [email protected] Subject – Provider 835 Enrollment File Processing Failure On ‘Date MM/DD/YYYY’ Body – File ‘provider 835 enrollment file name’ has failed file format validations and will not be processed further by Delta Dental. Please correct and resubmit the file to ensure enrollment of the corresponding providers for the 835 ERA process. For further inquiries or questions please reach out to [email protected]. Thank you, Delta Dental 835 - Companion Guide June 28, 2022 ● 005010X221A1/835 12 4.4 Provider 835 Request Header Record Layout Field Name Description Length Start Position Technical Specification Record Type PR0 identifiers Header 3 1 Must contain a value or PR0. This is Uppercase PR followed by the number zero. File ID Identifies that this is a file of Provider ID's that have requested electronic remittance 9 4 Must contain a value of P835REQST. All letters must be uppercase. Record Count Total Number of PR1 Provider 835 Request Records Sent on File 9 13 Numeric Left Pad with Zeros Trading Partner Name Identifies Trading Partner. 15 22 Alphanumeric - case sensitive Right Pad with Spaces : Valid Values are: EMDEON EHG TESIA QSI SecureEDI Trading Partner Receiver ID Identifies Trading Partner. 8 37 Alphanumeric - case sensitive: for EMDEON value is 'DDNEIC00' for EHG value is 'DDSRIX00' for TESIA value is 'DDTESX00' for QSI value is 'DDQSIX00' for SecureEDI value is 'DDSEDI00' 835 - Companion Guide June 28, 2022 ● 005010X221A1/835 13 Create Date Date File was created 8 45 CCYYMMDD - must be valid date Application Reciever Code Value to be populated on 835's 15 53 Value to be determinied by Trading Partner Filler 133 68 Spaces 835 - Companion Guide June 28, 2022 ● 005010X221A1/835 14 4.5 Provider 835 Request Detail Record Layout Field Name Description Length Start Position Technical Specification Record Type PR1 Identifiers Provider Request Detail Record 3 1 PR1 Provider Group Tax ID Number TIN of Provider Group Requesting electronic 835 9 4 Alphanumeric - Right Pad with Spaces Provider Group Name Name of Group Provider 30 13 Alphanumeric - Right Pad with Spaces Provider Group NPI NPI for the Group Provider. This is the Type 2 NPI. 30 43 Alphanumeric - Right Pad with Spaces Provider Group 835 Dual Delivery Requested Indicates whether or not 835 Dual Delivery is requested or waived. Dual Delivery refers to the 835 start-up period where the provider will receive both paper and electronic 835's 1 73 Alphanumeric Y = Provider Group wants 835 dual Delivery. They will receive both paper and electronic 835's for the number of days specified in Provider Group Dual Delivery Days. N = Provider Group waives 835 dual delivery period. This Provider Group wants to only receive electronic 835's once they are setup up. NOTE: If this field is left blank or contains any value other than 'N' or 'Y', the default value of 'Y' will be used. 835 - Companion Guide June 28, 2022 ● 005010X221A1/835 15 Provider Group Dual Delivery Days 2 74 Alphanumeric - Right Pad with Spaces This is the number of days (1 - 99) during which a provider group will receive both paper and electronic 835's. Note: This field is ignored when Dual Delivery Requested is 'N'. When the Dual Delivery Requested is 'Y' and this field is "0" or non_numeric, the default of 31 days will be used. Keep in mind that Delta Dental only pays claims weekly so if the days is set low it is possible that the Dual Delivery Period will end before any 835's are generated. Filler 125 76 Spaces 835 - Companion Guide June 28, 2022 ● 005010X221A1/835 16 5 Connectivity with the Payer / Communications 5.1 Transmission Administrative Procedures Trading Partner must use Delta Dental’s designated secured FTP drop zone - https://ftp.delta.org/ to login and retrieve 835 X12 files. Trading Partner using the designated FTP drop zone must use authorized User ID and Password to login and retrieve 835 X12 files. 5.1.1 Re-transmission procedures Trading Partners must send a request to Delta Dental’s EDI Contact for any missing 835 X12 files for re-transmission. 5.2 Communication Protocols Specifications The Delta Dental enterprise solution for 835 transactions supports transactions formatted according to the ASC X12 Standards for Electronic Data Interchange Technical Report Type 3 (TR3). 5.3 Passwords Delta Dental of California security policies requires Trading Partners to use authorized User ID and Password to login via the designated secured FTP site https://ftp.delta.org/. 835 - Companion Guide June 28, 2022 ● 005010X221A1/835 17 6 Contact information 6.1 EDI Customer Service Trading Partner Relations Manager: Rajkumar Narayanaswamy Phone Number: 415.802.9243 Email Address: [email protected] Operation Hours: Monday through Friday between 8:00 a.m. and 5:00 p.m., Pacific Standard Time Excluding the following major holidays: New Year’s Day (1/1) Martin Luther King’s Day (3rd Monday in January) President’s Day (3rd Monday in February) Memorial Day (Last Monday in May) Independence Day (7/4) Labor Day (1st Monday in September) Thanksgiving Day (4th Thursday in November) Day after Thanksgiving Day (4th Friday in November) Christmas Eve (12/24) Christmas Day (12/25) 6.2 Provider Service Number If you have questions regarding information related to subscribers that are non- technical, contact center information can be found at the following: http://www.deltadentalins.com/about/contact/ 6.3 Applicable websites / e-mail http://www.deltadentalins.com/about/contact/ http://www.deltadentalins.com/dentists/edi-support.html 835 - Companion Guide June 28, 2022 ● 005010X221A1/835 18 7 Control Segments / Envelopes 7.1 ISA Interchange Control Header Delta Dental's Notes for the Trading Partner: The Table describes the value specifically required by Delta Dental 835 transaction within the ISA Header. The Delta Dental 835 transaction does not expect any custom values for the IEA segment. Please follow the rules as specified by the TR3. Loop ID Segment / Element ID Data Element Name Codes Delta Dental Notes N/A ISA ISA01 Authorization Information Qualifier 00 ISA02 Authorized Information 10 Blank Spaces ISA03 Security Information Qualifier 00 ISA05 Interchange ID Qualifier ZZ ISA04 Security Information 10 Blank Spaces ISA06 Interchange Sender ID 942411167 ISA07 Interchange ID Qualifier ZZ ISA08 Interchange Receiver ID As specified for each Trading Partner ISA09 Interchange Date YYMMDD ISA10 Interchange Time HHMM ISA11 Repetition Separator ^ ISA12 Interchange Control Version Number 00501 ISA13 Interchange Control Number 000000001 Starts with 000000001 ISA14 Acknowledgment Requested 0 0 – No ACK (TA1 or 999) Requested; 1 - No ACK (TA1 or 999) Requested ISA15 Interchange Usage Indicator T/P T –Test Data; P –Production Data ISA16 Component Element Separator : 7.2 GS Functional Group Header Delta Dental's Notes for the Trading Partner: 835 - Companion Guide June 28, 2022 ● 005010X221A1/835 19 The table below describes Delta Dental of California’s use of the functional group control segments. It includes a description of expected application sender and receiver codes. Also included in this section is a description concerning how Delta Dental of California expects functional groups to be sent and how Delta Dental of California will send functional groups. These discussions will describe how similar transaction sets will be packaged and Delta Dental of California’s use of functional group control numbers. The Delta Dental 835 transaction does not expect any custom values for the GE segment. Please follow the rules as specified by the TR3 for the GE segment. Loop ID Segment / Element ID Data Element Name Codes Delta Dental Notes N/A GS GS01 Functional Identifier Code HP GS02 Application Sender's Code 942411167 GS03 Application Receiver's Code As specified for each Trading Partner GS04 Date YYYYMMDD GS05 Time HHMM GS06 Group Control Number 1 GS07 Responsible Agency Code X GS08 Version / Release / Industry Identifier Code 005010X221A1 7.3 ST Transaction Set Header Delta Dental's Notes for the Trading Partner: The Delta Dental 835 does not expect any custom values for the ST segments. Please follow the rules as specified by the TR3. Loop ID Segment / Element ID Data Element Name Codes Delta Dental Notes N/A ST ST01 Transaction Set Identifier Code 835 ST02 Transaction Set Control Number Starts with 0001 or 000000001 835 - Companion Guide June 28, 2022 ● 005010X221A1/835 19 7.4 BPR Financial Information Delta Dental's Notes for the Trading Partner: BPR05 through BPR10 and BPR12 through BPR15 are sent when BPR04 is “ACH”. Loop ID Segment / Element ID Data Element Name Codes Delta Dental Notes N/A BPR BPR01 Transaction Handling Code H - Notification Only; I - Remittance Information Only BPR02 Monetary Amount Total Actual Provider Payment Amount including Interest BPR03 Credit/Debit Flag Code C - Credit As specified for each Trading Partner BPR04 Payment Method Code ACH - Automated Clearing House (ACH); CHK – Check; NON - Non-Payment Data BPR05 Payment Format Code CCP- Cash Concentration/Disbursement plus Addenda (CCD+) (ACH) BPR06 (DFI) ID Number Qualifier 01 - ABA Transit Routing Number Including Check Digits (9 digits); 04 - Canadian Bank Branch and Institution Number BPR07 (DFI) Identification Number External Code List Name: 91 Description: Canadian Financial Institution Branch and Institution Number External Code List Name: 60 Description: (DFI) Identification Number 835 - Companion Guide June 28, 2022 ● 005010X221A1/835 20 External Code List Name: 4 Description: ABA Routing Number BPR08 Account Number Qualifier DA - Demand Deposit BPR09 Account Number BPR10 Originating Company Identifier Payer Tax ID prefixed with "1 BPR11 Originating Company Supplemental Payer ID from Delta Dental's system, may or may not be identical to the Payer ID from submitted claim. BPR12 (DFI) ID Number Qualifier 01 - ABA Transit Routing Number Including Check Digits (9 digits); 04 - Canadian Bank Branch and Institution Number BPR13 (DFI) Identification Number External Code List Name: 91 Description: Canadian Financial Institution Branch and Institution Number External Code List Name: 60 Description: (DFI) Identification Number External Code List Name: 4 Description: ABA Routing Number BPR14 Account Number Qualifier DA- Demand Deposit; SG – Savings BPR15 Account Number BPR16 Date Possible values: Check Issue Date (when BPR04 value is "CHK") 835 - Companion Guide June 28, 2022 ● 005010X221A1/835 21 EFT Effective Date (when BPR04 value is "ACH") Claim Receipt Date (when BPR04 value is "NON") 7.5 TRN Reassociation Trace Number Loop ID Segment / Element ID Data Element Name Codes Delta Dental Notes N/A TRN TRN01 Trace	companion-guide-835.pdf
The Delta Dental 835 transaction does not expect any custom values for the GE segment. Please follow the rules as specified by the TR3 for the GE segment. Loop ID Segment / Element ID Data Element Name Codes Delta Dental Notes N/A GS GS01 Functional Identifier Code HP GS02 Application Sender's Code 942411167 GS03 Application Receiver's Code As specified for each Trading Partner GS04 Date YYYYMMDD GS05 Time HHMM GS06 Group Control Number 1 GS07 Responsible Agency Code X GS08 Version / Release / Industry Identifier Code 005010X221A1 7.3 ST Transaction Set Header Delta Dental's Notes for the Trading Partner: The Delta Dental 835 does not expect any custom values for the ST segments. Please follow the rules as specified by the TR3. Loop ID Segment / Element ID Data Element Name Codes Delta Dental Notes N/A ST ST01 Transaction Set Identifier Code 835 ST02 Transaction Set Control Number Starts with 0001 or 000000001 835 - Companion Guide June 28, 2022 ● 005010X221A1/835 19 7.4 BPR Financial Information Delta Dental's Notes for the Trading Partner: BPR05 through BPR10 and BPR12 through BPR15 are sent when BPR04 is “ACH”. Loop ID Segment / Element ID Data Element Name Codes Delta Dental Notes N/A BPR BPR01 Transaction Handling Code H - Notification Only; I - Remittance Information Only BPR02 Monetary Amount Total Actual Provider Payment Amount including Interest BPR03 Credit/Debit Flag Code C - Credit As specified for each Trading Partner BPR04 Payment Method Code ACH - Automated Clearing House (ACH); CHK – Check; NON - Non-Payment Data BPR05 Payment Format Code CCP- Cash Concentration/Disbursement plus Addenda (CCD+) (ACH) BPR06 (DFI) ID Number Qualifier 01 - ABA Transit Routing Number Including Check Digits (9 digits); 04 - Canadian Bank Branch and Institution Number BPR07 (DFI) Identification Number External Code List Name: 91 Description: Canadian Financial Institution Branch and Institution Number External Code List Name: 60 Description: (DFI) Identification Number 835 - Companion Guide June 28, 2022 ● 005010X221A1/835 20 External Code List Name: 4 Description: ABA Routing Number BPR08 Account Number Qualifier DA - Demand Deposit BPR09 Account Number BPR10 Originating Company Identifier Payer Tax ID prefixed with "1 BPR11 Originating Company Supplemental Payer ID from Delta Dental's system, may or may not be identical to the Payer ID from submitted claim. BPR12 (DFI) ID Number Qualifier 01 - ABA Transit Routing Number Including Check Digits (9 digits); 04 - Canadian Bank Branch and Institution Number BPR13 (DFI) Identification Number External Code List Name: 91 Description: Canadian Financial Institution Branch and Institution Number External Code List Name: 60 Description: (DFI) Identification Number External Code List Name: 4 Description: ABA Routing Number BPR14 Account Number Qualifier DA- Demand Deposit; SG – Savings BPR15 Account Number BPR16 Date Possible values: Check Issue Date (when BPR04 value is "CHK") 835 - Companion Guide June 28, 2022 ● 005010X221A1/835 21 EFT Effective Date (when BPR04 value is "ACH") Claim Receipt Date (when BPR04 value is "NON") 7.5 TRN Reassociation Trace Number Loop ID Segment / Element ID Data Element Name Codes Delta Dental Notes N/A TRN TRN01 Trace Type Code 1 - Current Transaction Trace Numbers TRN02 Reference Identification TRN03 Originating Company Identifier Payer Tax ID prefixed with "1" TRN04 Reference Identification Payer ID from Delta Dental's system, may or may not be identical to the Payer ID from submitted claim. 7.6 REF Receiver Identification Loop ID Segment / Element ID Data Element Name Codes Delta Dental Notes N/A REF REF01 Reference Identification Qualifier EV - Receiver Identification Number REF02 Reference Identification Delta Dental's Notes for the Trading Partner: Trading Partner ID 835 - Companion Guide June 28, 2022 ● 005010X221A1/835 22 7.7 N1 Payer Identification Loop ID Segment / Element ID Data Element Name Codes Delta Dental Notes 1000A N1 N101 Entity Identifier Code PR – Payer N102 Name Please refer to Delta Dental Enterprise Programs and corresponding Payer ID below. N103 Identification Code Qualifier XV - Centers for Medicare and Medicaid Services Plan ID N104 Identification Code External Code List Name: 540 Description: Centers for Medicare and Medicaid Services Plan ID Delta Dental Program Payer ID Delta Dental of California 77777 Delta Dental of Delaware 51022 Delta Dental of West Virginia 31096 Delta Dental of District of Columbia 52147 Delta Dental of Pennsylvania 23166 Delta Dental of New York 11198 Delta Dental Insurance Company (AL, FL, GA, LA, MS, MT, NV, UT, TX) 94276 American Association of Retired Personnel (AARP) AARP1 Community Partnership Program – California (CPP-CA) CPPCA Texas Cook’s Children CPPCC Delta Dental of Puerto Rico 660436769 7.8 PER Payer WEB Site Delta Dental's Notes for the Trading Partner: When the REF/Healthcare Policy Identifier segment is required, the corresponding 1000A/Payer Identification loop, PER/Payer Web Site also needs to be included in the 5010 835/Remittance Advice Transaction. 835 - Companion Guide June 28, 2022 ● 005010X221A1/835 23 Loop ID Segment / Element ID Data Element Name Codes Delta Dental Notes 1000A PER PER01 Contact Function Code IC - Information Contact PER03 Communication Number Qualifier UR Uniform Resource Locator (URL) URL will be provided once it becomes available PER04 Communication Number 7.9 N1 Payee Identification Loop ID Segment / Element ID Data Element Name Codes Delta Dental Notes 1000B N1 N101 Entity Identifier Code PE - Payee N102 Name Possible Values: Organization Name Individual Name (format is Last Name, First Name, Middle Name) N103 Identification Code Qualifier FI - Federal Taxpayer's Identification Number; XX - Centers for Medicare and Medicaid Services National Provider Identifier N104 Identification Code External Code List Name: 537 Description: Centers for Medicare and Medicaid Services National Provider Identifier External Code List Name: 540 Description: Centers for Medicare and Medicaid Services Plan ID Possible values: NPI from Delta Dental's system that is associated to the providers on the payment/claim. May or may not be identical to the NPI from submitted claim Tax ID, when there is no NPI in Delta Dental's system that is associated to the Providers on the payment/claim. 835 - Companion Guide June 28, 2022 ● 005010X221A1/835 24 7.10 N3 Payee Address Delta Dental's Notes for the Trading Partner: Payee address from Delta Dental's system is sent. 7.11 N4 Payee City, State, Zip Code Delta Dental's Notes for the Trading Partner: Payee address from Delta Dental's system is sent. 7.12 REF Payee Additional Identification Delta Dental's Notes for the Trading Partner: This segment is generated when the NPI identifier (XX) is sent on N103 (N1 – Payee Identification segment). Loop ID Segment / Element ID Data Element Name Codes Delta Dental Notes 1000B REF REF01 Reference Identification Qualifier 0B - State License Number D3 - National Council for Prescription Drug Programs Pharmacy Number PQ - Payee Identification TJ - Federal Taxpayer's Identification Number TJ – Federal Taxpayer’s Identification Number will be used for this implementation REF02 Reference Identification External Code List Name: 307 Description: National Council for Prescription Drug Programs Pharmacy Number Tax ID from Delta Dental's system that is associated to the providers on the payment/claim. 7.13 CLP Claim Payment Information Loop ID Segment / Element ID Data Element Name Codes Delta Dental Notes 835 - Companion Guide June 28, 2022 ● 005010X221A1/835 25 2100 CLP CLP01 Claim Submitter's Identifier For electronic claims (837D): Submitted Patient Control Number (PCN) For paper claims: Patient Control Number (PCN) For manually-entered claims and system generated claims without PCN: "0" (zero) CLP02 Claim Status Code 1 - Processed as Primary; 2 - Processed as Secondary; 3 - Processed as Tertiary; 4 – Denied; 22 - Reversal of Previous Payment; 25 - Predetermination Pricing Only - No Payment CLP03 Monetary Amount Total Claim Charge Amount CLP04 Monetary Amount Claim Payment Amount CLP05 Monetary Amount Patient Responsibility Amount CLP06 Claim Filing Indicator Code 15 - Indemnity Insurance CLP07 Reference Identification Delta Dental-assigned Claim ID (Document Control Number – DCN) CLP08 Facility Code Value 7.14 NM1 Patient Name Delta Dental's Notes for the Trading Partner: Delta Dental-assigned patient information may or may not be identical to the patient information from submitted 837D Electronic or paper claims. 835 - Companion Guide June 28, 2022 ● 005010X221A1/835 26 Loop ID Segment / Element ID Data Element Name Codes Delta Dental Notes 2100 NM1 NM101 Entity Identifier Code QC - Patient NM102 Entity Type Qualifier 1 – Person NM103 Name Last or Organization Name Delta Dental will swap Last Name from submitted 837D Electronic or Paper claim if available. NM104 Name First Delta Dental will swap First Name from submitted 837D Electronic or Paper claim if available NM105 Name Middle Delta Dental will swap Middle Name from submitted 837D Electronic or Paper claims if available NM107 Name Suffix NM108 Identification Code Qualifier 34 - Social Security Number; HN - Health Insurance Claim (HIC) Number; II - Standard Unique Health Identifier for each Individual in the United States; MI - Member Identification Number; MR - Medicaid Recipient Identification Number Delta Dental will use MI - Member Identification Number NM109 Identification Code Delta Dental will swap Identification Code from submitted 837D Electronic Claims or Paper claims if available 7.15 NM1 Insured Name Delta Dental's Notes for the Trading Partner: This segment is generated when Patient is NOT the Insured. 835 - Companion Guide June 28, 2022 ● 005010X221A1/835 27 Delta Dental-assigned patient information may or may not be identical to the patient information from submitted 837D Electronic or paper claims. Loop ID Segment / Element ID Data Element Name Codes Delta Dental Notes 2100 NM1 NM101 Entity Identifier Code IL - Insured or Subscriber NM102 Entity Type Qualifier 1 - Person; 2 - Non-Person Entity NM103 Name Last or Organization Name Delta Dental will swap Last Name from submitted 837D Electronic or Paper claim if available NM104 Name First Delta Dental will swap First Name from submitted 837D Electronic or Paper claim if available NM105 Name Middle Delta Dental will swap Middle Name from submitted 837D Electronic or Paper claims if available NM107 Name Suffix NM108 Identification Code Qualifier FI - Federal Taxpayer's Identification Number; II - Standard Unique Health Identifier for each Individual in the United States; MI - Member Identification Number Delta Dental will use MI - Member Identification Number NM109 Identification Code Delta Dental will swap Identification Code from submitted 837D Electronic Claims or Paper claims if available 7.16 NM1 Service Provider Name Delta Dental's Notes for the Trading Partner: NPI is required when enrolling Providers to receive 835/ERA from Delta Dental. 835 - Companion Guide June 28, 2022 ● 005010X221A1/835 28 Loop ID Segment / Element ID Data Element Name Codes Delta Dental Notes 2100 NM1 NM101 Entity Identifier Code 82 - Rendering Provider NM102 Entity Type Qualifier 1 - Person; 2 - Non-Person Entity NM103 Name Last or Organization Name NM104 Name First NM105 Name Middle NM107 Name Suffix NM108 Identification Code Qualifier BD - Blue Cross Provider Number; BS - Blue Shield Provider Number; FI - Federal Taxpayer's Identification Number; MC - Medicaid Provider Number PC Provider Commercial Number; SL State License Number; UP - Unique Physician Identification Number (UPIN); XX - Centers for Medicare and Medicaid Services National Provider Identifier Delta Dental will use XX - Centers for Medicare and Medicaid Services National Provider Identifier NM109 Identification Code NPI from Delta Dental's system that is associated to the Rendering Provider on the claim. May or may not be identical to the NPI from submitted claim 835 - Companion Guide June 28, 2022 ● 005010X221A1/835 29 7.17 REF Rendering Provider Identification (Loop 2100) Delta Dental's Notes for the Trading Partner: Rendering Provider Identifiers from submitted claim are returned as received. 7.18 SVC Service Payment Information Loop ID Segment / Element ID Data Element Name Codes Delta Dental Notes 2110 SVC SVC02 Monetary Amount Line Item Charge Amount SVC03 Monetary Amount Line Item Payment Amount 7.19 REF Service Identification Loop ID Segment / Element ID Data Element Name Codes Delta Dental Notes 2110 REF REF02 Reference Identification External Code List Name: 468 Description: Ambulatory Payment Classification Line Item Control Number from submitted claim 7.20 REF Line Control Number Loop ID Segment / Element ID Data Element Name Codes Delta Dental Notes 2110 REF REF01 Reference Identification Qualifier 6R - Provider Control Number REF02 Reference Identification 7.21 REF Rendering Provider Information (2110) Delta Dental's Notes for the Trading Partner: 835 - Companion Guide June 28, 2022 ● 005010X221A1/835 30 Service Line Rendering Provider Identifier	companion-guide-835.pdf
not be identical to the patient information from submitted 837D Electronic or paper claims. Loop ID Segment / Element ID Data Element Name Codes Delta Dental Notes 2100 NM1 NM101 Entity Identifier Code IL - Insured or Subscriber NM102 Entity Type Qualifier 1 - Person; 2 - Non-Person Entity NM103 Name Last or Organization Name Delta Dental will swap Last Name from submitted 837D Electronic or Paper claim if available NM104 Name First Delta Dental will swap First Name from submitted 837D Electronic or Paper claim if available NM105 Name Middle Delta Dental will swap Middle Name from submitted 837D Electronic or Paper claims if available NM107 Name Suffix NM108 Identification Code Qualifier FI - Federal Taxpayer's Identification Number; II - Standard Unique Health Identifier for each Individual in the United States; MI - Member Identification Number Delta Dental will use MI - Member Identification Number NM109 Identification Code Delta Dental will swap Identification Code from submitted 837D Electronic Claims or Paper claims if available 7.16 NM1 Service Provider Name Delta Dental's Notes for the Trading Partner: NPI is required when enrolling Providers to receive 835/ERA from Delta Dental. 835 - Companion Guide June 28, 2022 ● 005010X221A1/835 28 Loop ID Segment / Element ID Data Element Name Codes Delta Dental Notes 2100 NM1 NM101 Entity Identifier Code 82 - Rendering Provider NM102 Entity Type Qualifier 1 - Person; 2 - Non-Person Entity NM103 Name Last or Organization Name NM104 Name First NM105 Name Middle NM107 Name Suffix NM108 Identification Code Qualifier BD - Blue Cross Provider Number; BS - Blue Shield Provider Number; FI - Federal Taxpayer's Identification Number; MC - Medicaid Provider Number PC Provider Commercial Number; SL State License Number; UP - Unique Physician Identification Number (UPIN); XX - Centers for Medicare and Medicaid Services National Provider Identifier Delta Dental will use XX - Centers for Medicare and Medicaid Services National Provider Identifier NM109 Identification Code NPI from Delta Dental's system that is associated to the Rendering Provider on the claim. May or may not be identical to the NPI from submitted claim 835 - Companion Guide June 28, 2022 ● 005010X221A1/835 29 7.17 REF Rendering Provider Identification (Loop 2100) Delta Dental's Notes for the Trading Partner: Rendering Provider Identifiers from submitted claim are returned as received. 7.18 SVC Service Payment Information Loop ID Segment / Element ID Data Element Name Codes Delta Dental Notes 2110 SVC SVC02 Monetary Amount Line Item Charge Amount SVC03 Monetary Amount Line Item Payment Amount 7.19 REF Service Identification Loop ID Segment / Element ID Data Element Name Codes Delta Dental Notes 2110 REF REF02 Reference Identification External Code List Name: 468 Description: Ambulatory Payment Classification Line Item Control Number from submitted claim 7.20 REF Line Control Number Loop ID Segment / Element ID Data Element Name Codes Delta Dental Notes 2110 REF REF01 Reference Identification Qualifier 6R - Provider Control Number REF02 Reference Identification 7.21 REF Rendering Provider Information (2110) Delta Dental's Notes for the Trading Partner: 835 - Companion Guide June 28, 2022 ● 005010X221A1/835 30 Service Line Rendering Provider Identifier from submitted claims are returned as received. 7.22 REF HealthCare Policy Identification Delta Dental's Notes for the Trading Partner: The REF/Healthcare Policy Identifier is required to be included in the 2110/Service Payment Information loop when specific CARC values are included in a related CAS segment. Loop ID Segment / Element ID Data Element Name Codes Delta Dental Notes 2110 REF REF01 Reference Identification Qualifier 0K - Policy Form Identifying Number REF02 Reference Identification 7.23 PLB Provider Adjustments Loop ID Segment / Element ID Data Element Name Codes Delta Dental Notes N/A PLB PLB02 Date December 31st of the payment year Add Provider Enrollment specifications. 835 - Companion Guide June 28, 2022 ● 005010X221A1/835 31 8 Acknowledgements Only one response will be required for each 835 transaction that is transmitted to the Trading Partners – a TA1 or 999. The 835 Health Care Claim Payment/Advice sent by Delta Dental must be HIPAA compliant. 8.1 999 Functional Acknowledgment When ACK (ISA14 = 1) is requested by Delta Dental, Exchange or Trading Partners must issue a 999 Acknowledgment for Health Care Insurance (005010X231 or 005010X231A) when an 835 fails validation of WEDI SNIP Type 1-3 HIPAA edits. Delta Dental does not expect positive acknowledgments for successful 835 transmissions and validation. The purpose of the 999 Acknowledgment (Reject) is to identify critical errors within the 835 request based on the ASC X12N 835 (version 005010X221A1) Technical Report Type 3 (TR3) guide. Delta Dental will review the 999 to determine what errors occurred. 8.2 TA1 Interchange Acknowledgment The TA1 Interchange Acknowledgement is used by the 835 transaction to communicate the rejection of a 835 transaction based on errors encountered with X12 compliance, formatting, or specific requirements of the ISA/IEA Interchange segments. 835 - Companion Guide June 28, 2022 ● 005010X221A1/835 32 Document Revision History Version Date Description of Changes Author 0.1 7/26/2013 Initial Draft Vanessa Nguyen 0.2 10/08/2013 Added Payer Specific Business Rules & Limitations Vanessa Nguyen 0.3 10/16/2013 Modified several sections for clarify Bernadette Abdon 1.0 10/31/2013 Final Draft Bernadette Abdon 1.1 06/28/2022 Added section 4.3 (enrollment file notifications) Shiv Uppal 835 - Companion Guide June 28, 2022 ● 005010X221A1/835 33	companion-guide-835.pdf
State of Washington 837 Professional Healthcare Claim Companion Guide Prepared by: CNSI August 2012 WAMMIS-CG-837P-CLAIMS-5010-01-01 Disclaimer This companion guide contains data clarifications derived from specific business rules that apply exclusively to Washington State Medicaid processing for Washington State HCA. The guide also includes useful information about sending and receiving data to and from the Washington State ProviderOne system. State of Washington ProviderOne 5010 837 Professional Companion Guide iii WAMMIS-CG-837P-CLAIMS-5010-01-01 Revision History Document revisions are maintained in this document through the Revision History Table shown below. All revisions made to this companion guide after the creation date is noted along with the date, page affected, and reason for the change. Revision Level Date Page Description Change Summary WAMMIS-CG- 837CLAIMS-5010-01-01 12/17/10 Initial Document WAMMIS-CG-837P- CLAIMS-5010-01-01 02/11/11 Review comments incorporated WAMMIS-CG-837P- CLAIMS-5010-01-01 8/20/2012 Update per ASC X12 recommendations State of Washington ProviderOne 5010 837 Professional Companion Guide iv WAMMIS-CG-837P-CLAIMS-5010-01-01 Contents Disclaimer ............................................................................................................................ ii Revision History ....................................................................................................................... iii 1 Introduction ........................................................................................................................ 5 1.1 Document Purpose ................................................................................................... 5 1.1.1 Intended Users .................................................................................................... 6 1.1.2 Relationship to HIPAA Implementation Guides .................................................... 6 1.2 Transmission Schedule ............................................................................................ 6 2 Technical Infrastructure and Procedures......................................................................... 7 2.1 Technical Environment ............................................................................................. 7 2.1.1 Communication Requirements ............................................................................. 7 2.1.2 Testing Process ................................................................................................... 7 2.1.3 Who to contact for assistance .............................................................................. 8 2.2 Upload batches via Web Interface ........................................................................... 9 2.3 Set-up, Directory, and File Naming Convention .................................................... 14 2.3.1 SFTP Set-up ...................................................................................................... 14 2.3.2 SFTP Directory Naming Convention .................................................................. 14 2.3.3 File Naming Convention ..................................................................................... 15 2.4 Transaction Standards ........................................................................................... 16 2.4.1 General Information ........................................................................................... 16 2.4.2 Data Format ....................................................................................................... 16 2.4.3 Data Interchange Conventions ........................................................................... 17 2.4.4 17 2.4.5 Acknowledgement Procedures ........................................................................... 17 2.4.6 Rejected Transmissions and Transactions ......................................................... 17 3 Transaction Specifications ............................................................................................. 18 5010 837 Professional Companion Guide 5 WAMMIS-CG-837P-CLAIMS-5010-01-01 1 Introduction The Administrative Simplification provisions of the Health Insurance Portability and Accountability Act of 1996 (HIPAA, Title II) includes requirements that national standards be established for electronic health care transactions, and national identifiers for providers, health plans, and employers. This requires Washington State Health Care Authority (HCA) to adopt standards to support the electronic exchange of administrative and financial health care transactions between covered entities (health care providers, health plans, and healthcare clearinghouses). The intent of these standards is to improve the efficiency and effectiveness of the nation's health care system by encouraging widespread use of electronic data interchange standards in health care. The intent of the law is that all electronic transactions for which standards are specified must be conducted according to the standards. These standards were developed by processes that included significant public and private sector input. 1.1 Document Purpose Companion Guides are used to clarify the exchange of information on HIPAA transactions between the HCA ProviderOne system and its trading partners. HCA defines trading partners as covered entities that either submit or retrieve HIPAA batch transactions to and from ProviderOne. This Companion Guide is intended for trading partner use in conjunction with the ASC X12N Implementation Guides listed below. The ASC X12 TR3s that detail the full requirements for all HIPAA mandated transactions are available at http://store.x12.org/store/ The Standard Implementation Guide for Claim Transaction is:  Healthcare Claim: Professional (837) 005010X222 HCA has also incorporated all of the approved 837 Professional Addenda listed below.  Healthcare Claim: Professional (837) 005010X222A1 5010 837 Professional Companion Guide 6 WAMMIS-CG-837P-CLAIMS-5010-01-01 1.1.1 Intended Users Companion Guides are to be used by members/technical staff of trading partners who are responsible for electronic transaction/file exchanges. 1.1.2 Relationship to HIPAA Implementation Guides Companion Guides are intended to supplement the HIPAA Implementation Guides for each of the HIPAA transactions. Rules for format, content, and field values can be found in the Implementation Guides. This Companion Guide describes the technical interface environment with HCA, including connectivity requirements and protocols, and electronic interchange procedures. This guide also provides specific information on data elements and the values required for transactions sent to or received from HCA. Companion Guides are intended to supplement rather than replace the standard Implementation Guide for each transaction set. The information in these documents is not intended to:  Modify the definition, data condition, or use of any data element or segment in the standard Implementation Guides.  Add any additional data elements or segments to the defined data set.  Utilize any code or data values that are not valid in the standard Implementation Guides.  Change the meaning or intent of any implementation specifications in the standard Implementation Guides. 1.2 Transmission Schedule N/A 5010 837 Professional Companion Guide 7 WAMMIS-CG-837P-CLAIMS-5010-01-01 2 Technical Infrastructure and Procedures 2.1 Technical Environment 2.1.1 Communication Requirements This section will describe how trading partners can send 837 Transactions to HCA using two methods:  Secure File Transfer Protocol (SFTP)  ProviderOne Web Portal 2.1.2 Testing Process Completion of the testing process must occur prior to submitting electronic transactions in production to ProviderOne. Testing is conducted to ensure the following levels of HIPAA compliance: 1. Level 1 – Syntactical integrity: Testing of the EDI file for valid segments, segment order, element attributes, testing for numeric values in numeric data elements, validation of X12 or NCPDP syntax, and compliance with X12 and NCPDP rules. 2. Level 2 – Syntactical requirements: Testing for HIPAA Implementation Guide-specific syntax requirements, such as limits on repeat counts, used and not used qualifiers, codes, elements and segments. It will also include testing for HIPAA required or intra-segment situational data elements, testing for non-medical code sets as laid out in the Implementation Guide, and values and codes noted in the Implementation Guide via an X12 code list or table. Additional testing may be required in the future to verify any changes made to the ProviderOne system. Changes to the formats may also require additional testing. Assistance is available throughout the testing process. Trading Partner Testing Procedures 1. ProviderOne companion guides and trading partner enrollment package are available for download via the web at http://hrsa.dshs.wa.gov/hipaa 2. The Trading Partner completes the Trading Partner Agreement and submits the signed agreement to HCA. Submit to: HCA HIPAA EDI Department PO Box 45562 Olympia, WA 98504-5562 5010 837 Professional Companion Guide 8 WAMMIS-CG-837P-CLAIMS-5010-01-01 For Questions call 1-800-562-3022 ext. 16137 3. The trading partner is assigned a Submitter ID, Domain, Logon User ID and password. 4. The trading partner submits all HIPAA test files through the ProviderOne web portal or Secure File Transfer Protocol (SFTP).  Web Portal URL: https://www.waproviderone.org/edi  SFTP URL: sftp://ftp.waproviderone.org/ 5. The trading partner downloads acknowledgements for the test file from the ProviderOne web portal or SFTP. 6. If ProviderOne system generates a positive TA1 and positive 999 acknowledgements, the file is successfully accepted. The trading partner is then approved to send 837 HIPAA files in production. 7. If the test file generates a negative TA1 or negative 999 acknowledgments, then the submission is unsuccessful and the file is rejected. The trading partner needs to resolve all the errors reported on the negative TA1 or negative 999 and resubmit the file for test. Trading partners will continue to test in the testing environment until they receive a positive TA1 and positive 999. 2.1.3 Who to contact for assistance  Email: [email protected] o All emails result in the assignment of a Ticket Number for problem tracking  Information required for initial email: o Name o Phone Number o Email Address o 7 digit ProviderOne ID Number o NPI o HIPAA File Name o Detailed Description of Issue o HIPAA Transaction  Information required for follow up call(s): o Assigned Ticket Number 5010 837 Professional Companion Guide 9 WAMMIS-CG-837P-CLAIMS-5010-01-01 2.2 Upload batches via Web Interface Log into the ProviderOne Portal, select the appropriate security profile and the following options will be viewable to the user: Scroll down to the HIPAA heading to manage the submission and retrieval of HIPAA transactions. 5010 837 Professional Companion Guide 10 WAMMIS-CG-837P-CLAIMS-5010-01-01 Follow these steps to upload a HIPAA file: Click on the Upload link On the file upload page click on the Browse button to attach HIPAA file from local file system. After selecting the file from the local file system, press OK to start the upload. 5010 837 Professional Companion Guide 11 WAMMIS-CG-837P-CLAIMS-5010-01-01 Once the Ok button is selected, a confirmation message is displayed on the screen along with transmission details. This message only means the file was submitted. To determine if the file was successfully validated and processed go back to the ProviderOne main page, select Retrieve HIPAA Batch Response, and follow these steps:  Select 837 from the Transaction Type drop down menu  There are 3 filter boxes available that contain the following filter criteria that you can use to search for your submitted HIPAA file o File Name o ProviderOne ID o Response Date o Upload/Sent Date  An example of a search would be %Your ProviderOne ID% o The % are considered wildcard searches  Click on Go once you entered all the necessary filters. Keep in mind you can enter up to 3 filters to refine the search of your submitted HIPAA transaction  All the HIPAA transactions that match your search criteria should return on the page  Click on the down arrow in the Upload/Sent Date column to sort the most current files to least current files  Now look for Accepted or Rejected in the Acknowledgement Status Column. Accepted means the file will be processed. Rejected means the file will not be processed due to errors. Partial means some of the file was processed but not all of it due to errors. 5010 837 Professional Companion Guide 12 WAMMIS-CG-837P-CLAIMS-5010-01-01  The Custom Report is a user friendly report that lets you know what caused the file to reject Be sure to scroll to the right side of the screen to see all of the transactions available. 5010 837 Professional Companion Guide 13 WAMMIS-CG-837P-CLAIMS-5010-01-01 5010 837 Professional Companion Guide 14 WAMMIS-CG-837P-CLAIMS-5010-01-01 2.3 Set-up, Directory, and File Naming Convention 2.3.1 SFTP Set-up Trading partners can email [email protected] for information on establishing connections through the SFTP server. Upon completion of set-up, they will receive additional instructions on SFTP usage. 2.3.2 SFTP Directory Naming Convention There would be two categories of folders under Trading Partner’s SFTP folders: 1. TEST – Trading Partners should submit and receive their test files under this root folder 2. PROD – Trading Partners should submit and receive their production files under this root folder Following folder will be available under TEST/PROD folder within SFTP root of the Trading Partner: ‘HIPAA_Inbound’ - This folder should be used to drop the HIPAA Inbound files that needs to be submitted to HCA ‘HIPAA_Ack’ - Trading partner should look for acknowledgements to the files submitted in this folder. TA1, 999 and custom report will be available for all the files submitted by the Trading Partner ‘HIPAA_Outbound’ – HIPAA outbound transactions generated by HCA will be available in this folder ‘HIPAA_Error’ – Any inbound file that is not processed, HIPAA compliant, or is not recognized by ProviderOne will be moved to this folder ‘HIPAA Working’ – There is no functional use for this folder at this time 5010 837 Professional Companion Guide 15 WAMMIS-CG-837P-CLAIMS-5010-01-01 Folder structure will appear as: 2.3.3 File Naming Convention The HIPAA Subsystem Package is responsible for assisting ProviderOne activities related to Electronic Transfer and processing of Health Care and Health Encounter Data, with a few exceptions or limitations. HIPAA files are named: For Inbound transactions: HIPAA.<TPId>.<datetimestamp>.<originalfilename>.<dat> Example of file name: HIPAA.101721500.122620072100_P_1.dat  <TPId> is the Trading Partner Id  <datetimestamp> is the Date timestamp  <originalfilename> is the original file name which is submitted by the trading partner.  All HIPAA submitted files MUST BE .dat files or they will not be processed 5010 837 Professional Companion Guide 16 WAMMIS-CG-837P-CLAIMS-5010-01-01 2.4 Transaction Standards 2.4.1 General Information HIPAA standards are specified in the Implementation Guide for each mandated transaction and modified by authorized Addenda. Currently, the 837 transaction has one Addendum. This Addendum has been adopted as final and is incorporated into HCA requirements. An overview of requirements specific to the transaction can be found in the 837 Implementation Guide. Implementation Guides contain information related to:  Format and content of interchanges and functional groups  Format and content of the header, detailer and trailer segments specific to the transaction  Code sets and values authorized for use in	837-Professional-CG-2012.pdf
 Now look for Accepted or Rejected in the Acknowledgement Status Column. Accepted means the file will be processed. Rejected means the file will not be processed due to errors. Partial means some of the file was processed but not all of it due to errors. 5010 837 Professional Companion Guide 12 WAMMIS-CG-837P-CLAIMS-5010-01-01  The Custom Report is a user friendly report that lets you know what caused the file to reject Be sure to scroll to the right side of the screen to see all of the transactions available. 5010 837 Professional Companion Guide 13 WAMMIS-CG-837P-CLAIMS-5010-01-01 5010 837 Professional Companion Guide 14 WAMMIS-CG-837P-CLAIMS-5010-01-01 2.3 Set-up, Directory, and File Naming Convention 2.3.1 SFTP Set-up Trading partners can email [email protected] for information on establishing connections through the SFTP server. Upon completion of set-up, they will receive additional instructions on SFTP usage. 2.3.2 SFTP Directory Naming Convention There would be two categories of folders under Trading Partner’s SFTP folders: 1. TEST – Trading Partners should submit and receive their test files under this root folder 2. PROD – Trading Partners should submit and receive their production files under this root folder Following folder will be available under TEST/PROD folder within SFTP root of the Trading Partner: ‘HIPAA_Inbound’ - This folder should be used to drop the HIPAA Inbound files that needs to be submitted to HCA ‘HIPAA_Ack’ - Trading partner should look for acknowledgements to the files submitted in this folder. TA1, 999 and custom report will be available for all the files submitted by the Trading Partner ‘HIPAA_Outbound’ – HIPAA outbound transactions generated by HCA will be available in this folder ‘HIPAA_Error’ – Any inbound file that is not processed, HIPAA compliant, or is not recognized by ProviderOne will be moved to this folder ‘HIPAA Working’ – There is no functional use for this folder at this time 5010 837 Professional Companion Guide 15 WAMMIS-CG-837P-CLAIMS-5010-01-01 Folder structure will appear as: 2.3.3 File Naming Convention The HIPAA Subsystem Package is responsible for assisting ProviderOne activities related to Electronic Transfer and processing of Health Care and Health Encounter Data, with a few exceptions or limitations. HIPAA files are named: For Inbound transactions: HIPAA.<TPId>.<datetimestamp>.<originalfilename>.<dat> Example of file name: HIPAA.101721500.122620072100_P_1.dat  <TPId> is the Trading Partner Id  <datetimestamp> is the Date timestamp  <originalfilename> is the original file name which is submitted by the trading partner.  All HIPAA submitted files MUST BE .dat files or they will not be processed 5010 837 Professional Companion Guide 16 WAMMIS-CG-837P-CLAIMS-5010-01-01 2.4 Transaction Standards 2.4.1 General Information HIPAA standards are specified in the Implementation Guide for each mandated transaction and modified by authorized Addenda. Currently, the 837 transaction has one Addendum. This Addendum has been adopted as final and is incorporated into HCA requirements. An overview of requirements specific to the transaction can be found in the 837 Implementation Guide. Implementation Guides contain information related to:  Format and content of interchanges and functional groups  Format and content of the header, detailer and trailer segments specific to the transaction  Code sets and values authorized for use in the transaction  Allowed exceptions to specific transaction requirements Transmission sizes are limited based on two factors:  Number of Segments/Records allowed by HCA  HCA file size limitations HCA limits the size of the transaction (ST-SE envelope) to a maximum of 5,000 CLM segments. HCA limits a file size to 50 MB while uploading HIPAA files through the ProviderOne web portal and 100 MB through SFTP. 2.4.2 Data Format Delimiters The ProviderOne will use the following delimiters on outbound transactions:  Data element separator - Asterisk ( * )  Sub-element Separator - colon ( : )  Segment Terminator - Tilde ( ~ ) 5010 837 Professional Companion Guide 17 WAMMIS-CG-837P-CLAIMS-5010-01-01 Phone Numbers Phone numbers are presented as contiguous number strings, without dashes or parenthesis markers. For example, the phone number (800) 555-1212 should be presented as 8005551212. Area codes should always be included. 2.4.3 Data Interchange Conventions When accepting 837 Healthcare Claim transactions from trading partners, HCA follows HIPAA standards. These standards involve Interchange (ISA/IEA) and Functional Group (GS/GE) Segments or “outer envelopes”. All 837 Transactions should follow the HIPAA guideline. Please refer to the 837 Implementation Guide for ISA/IEA envelop, GS/GE functional group and ST/SE transaction specifications. Specific information on how individual data elements are populated by HCA on ISA/IEA and GS/GE envelopes are shown in the table beginning later in this section. The ISA/IEA Interchange Envelope, unlike most ASC X12 data structures has fixed field length. The entire data length of the data element should be considered and padded with spaces if the data element length is less than the field length. 2.4.4 Acknowledgement Procedures Once the file is submitted by the trading partner and is successfully received by the ProviderOne system, a response in the form of TA1 and 999 acknowledgment transactions will be placed in appropriate folder (on the SFTP server) of the trading partner. The ProviderOne system generates positive TA1 and positive 999 acknowledgements, if the submitted HIPAA file meets HIPAA standards related to syntax and data integrity. For files, which do not meet the HIPAA standards a negative TA1 and/or negative 999 are generated and sent to the trading partner. 2.4.5 Rejected Transmissions and Transactions 837 Healthcare Claims will be rejected if the file does not meet HIPAA standards for syntax, data integrity and structure (Strategic National Implementation Process (SNIP) type 1 and 2). 5010 837 Professional Companion Guide 18 WAMMIS-CG-837P-CLAIMS-5010-01-01 3 Transaction Specifications 837 PROFESSIONAL Page Loop Segment Data Element Element Name Comments INTERCHANGE CONTROL HEADER Appendix C.4 ENVELOPE ISA 01 Authorization Information Qualifier Please use '00' Appendix C.4 ENVELOPE ISA 03 Security Information Qualifier Please use '00' Appendix C.4 ENVELOPE ISA 05 Interchange ID Qualifier Please use 'ZZ' Appendix C.4 ENVELOPE ISA 06 Interchange Sender ID Please use the 9-digit ProviderOne ID followed by spaces Appendix C.5 ENVELOPE ISA 07 Interchange ID Qualifier Please use 'ZZ' Appendix C.5 ENVELOPE ISA 08 Interchange Receiver ID Please enter '77045' followed by spaces Appendix C.5 ENVELOPE ISA 11 Interchange Control Standards Identifier Please Use '^' 5010 837 Professional Companion Guide 19 WAMMIS-CG-837P-CLAIMS-5010-01-01 Appendix C.6 ENVELOPE ISA 16 Component Element Separator Please use ':' FUNCTIONAL GROUP HEADER Appendix C.7 ENVELOPE GS 02 Application Sender’s Code Please use the 9-digit ProviderOne ID. This should be same as ISA06 and Loop 1000A, Data Element NM109 Appendix C.7 ENVELOPE GS 03 Application Receiver’s Code Please use '77045' Beginning of Hierarchical Transaction 71 HEADER BHT 02 Transaction Set Purpose Code Please use '00' 72 HEADER BHT 06 Claim or Encounter Indicator Transaction Type Code Please use ‘CH’ Loop ID 1000A - Submitter Name 75 1000A NM1 09 Identification Code Please use the 9-digit ProviderOne ID This should be same as ISA06 and GS02 Loop ID 1000B - Receiver Name 80 1000B NM1 03 Name Last or Organization Name Please use 'WA State HCA' 80 1000B NM1 09 Identification Code Please use ‘77045’ 5010 837 Professional Companion Guide 20 WAMMIS-CG-837P-CLAIMS-5010-01-01 Loop ID 2000A - Billing Provider Specialty Information 83 2000A PRV NOTE: HCA requires the PRV segment to be submitted as the Taxonomy Code impacts adjudication Loop ID 2000B - Subscriber Information 119 2000B SBR 09 Claim Filing Indicator Code Please use 'MC' Loop ID 2010BA - Subscriber Name 123 2010BA NM1 09 Identification code Please enter 11 digit ProviderOne Client ID ProviderOne Client ID is 9 numeric digits followed by 'WA' Example is 123456789WA Loop ID 2010BA - Subscriber Demographic Information 127 2010BA DMG NOTE: HCA requires the DMG segment to be submitted as the patient is always the subscriber Loop ID 2010BB - Payer Name 134 2010BB NM1 03 Name Last or Organization Name Please use 'WA State HCA' 134 2010BB NM1 09 Identification Code Please use '77045' 5010 837 Professional Companion Guide 21 WAMMIS-CG-837P-CLAIMS-5010-01-01 Payer Address 135 2010BB N3 01 Address Information Please use 'Claims Processing' 135 2010BB N3 02 Address Information Please use 'PO BOX 9248' Payer City/State/Zip Code 136 2010BB N4 01 City Name Please use 'Olympia' 136 2010BB N4 02 State or Province Code Please use 'WA' 137 2010BB N4 03 Postal Code Please use '98504' Loop ID 2300 - Payer Claim Control Number 196 2300 REF 02 Reference Identification Please enter the 18 digit Transaction Control Number (TCN) of claim when CLM05-3 indicates the claim is an replacement or void Loop ID 2310B - Rendering Provider Specialty Information 265 2310B PRV NOTE: If the Rendering Provider NPI is submitted HCA requires the PRV segment to be submitted as the Taxonomy Code impacts adjudication Loop ID 2320 - Other Subscriber Information 298 2320 SBR 09 Claim filing indicator code Use 'MB' for provider submitted Medicare Part B Crossover Claims	837-Professional-CG-2012.pdf
State of Washington 837 Professional and Institutional Encounter Data Companion Guide Prepared by: CNSI WAMMIS-CG837ENC-5010-01-12 November 2023 Disclaimer This companion guide contains data clarifications derived from specific business rules that apply exclusively to Washington State Medicaid processing for Washington State HCA. The guide also includes useful information about sending and receiving data to and from the Washington State ProviderOne system. State of Washington ProviderOne 5010 837 Encounter Companion Guide iii WAMMIS-CG-837ENC-5010-01-12 Revision History Documented revisions are maintained in this document through the use of the Revision History Table shown below. All revisions made to this companion guide after the creation date are noted along with the date, page affected, and reason for the change. Revision Level Date Page Description Change Summary WAMMIS-CG837ENC- 5010-01-02 12/27/10 Initial Document WAMMIS-CG837ENC- 5010-01-03 02/02/2012 Version Number updated as a result of changes listed below Professional Encounter Functional Group Header – GS02 02/02/2012 Correction Changed element description to read, “Please use the 9-digit alphanumeric submitter ID assigned during the enrollment process. This should be the same as Loop 1000A Data Element NM109 e.g. 1234567AA Professional Encounter Loop 1000A Submitter Name 02/02/2012 Correction NM109 – Removed “followed by spaces” from instructions Professional Encounter Loop 2010AA Billing Provider Name 02/02/2012 Correction NM102 – Changed description to read, “Please use the appropriate code” NM103 – Changed description to read, “Enter the Organization Name or the Last Name of the provider who billed the MCO or RSN” Professional Encounter Loop 2010BA Subscriber City/State/Zip Code 02/02/2012 Correction Removed identified use of element N404 – Country Code Professional Encounter Loop 2010BB Billing Provider Secondary Identification 02/02/2012 Correction Corrected Loop reference for elements REF01 and REF02 to read 2010BB. Previously elements were referenced to Loop 2010 AA Professional Encounter Loop 2410 – Drug Information -LIN Segments -CTP Segments 02/02/2012 Addition Added situation reference to use of Loop 2410 Drug Information when required for Managed Care Encounter submission State of Washington ProviderOne 5010 837 Encounter Companion Guide iv WAMMIS-CG-837ENC-5010-01-12 Institutional Encounter Functional Group Header – GS02 02/02/2012 Correction Changed element description to read, “Please use the 9-digit alphanumeric submitter ID assigned during the enrollment process. This should be the same as Loop 1000A Data Element NM109 e.g. 1234567AA Institutional Encounter Functional Group Header – GS02 02/02/2012 Correction Changed element description to read, “Please use the 9-digit alphanumeric submitter ID assigned during the enrollment process. This should be the same as Loop 1000A Data Element NM109 e.g. 1234567AA Institutional Encounter Loop 1000A Submitter Name 02/02/2012 Correction NM109 – Removed “followed by spaces” from instructions Institutional Encounter Loop 2010AA Billing Provider Name 02/02/2012 Correction NM103 – Changed description to read, “Enter the Organization Name or the Last Name of the provider who billed the MCO or RSN” Institutional Encounter Loop 2010BB 02/02/2012 Correction Payer Name Title incorrectly reference Loop 2010BC. Technical Specifications have been updated to correctly reference 2010BB Institutional Encounter Loop 2410 – Drug Information -LIN Segments -CTP Segments 02/02/2012 Addition Added situation reference to use of Loop 2410 Drug Information when required for Managed Care Encounter submission WAMMIS-CG837ENC- 5010-01-04 02/27/2012 Version number updated due to the inclusion of full Companion Guide Boilerplate information WAMMIS-CG837ENC- 5010-01-05 06/2013 Update per ASC X12 recommendations WAMMIS-CG837ENC- 5010-01-06 06/01/2017 Updated to reflect additional HCP requirements for encounter submissions Updated to reflect use of Loop 2400, data elements HCP11 and HCP12 for 837 Professional Encounters State of Washington ProviderOne 5010 837 Encounter Companion Guide v WAMMIS-CG-837ENC-5010-01-12 Updated to reflect use of Loop 2300 and 2400, data elements HCP11 and HCP12 for 837 Institutional Encounters WAMMIS-CG837ENC- 5010-01-07 11/07/2018 Addition Updated to add Agency Number Site ID WAMMIS-CG837ENC- 5010-01-07 11/07/2018 Addition Updated to add requirement for Evidence-Based Practice (EBP) codes WAMMIS-CG837ENC- 5010-01-07 11/07/2018 Updates Updated references for Regional Support Network (RSN) to Behavioral Health Organization (BHO) WAMMIS-CG837ENC- 5010-01-07 3/13/2019 Updates Changed reference from “Agency Number Site ID” to “Site-Specific, Department of Health Licensure Number WAMMIS-CG837ENC- 5010-01-07 3/13/2019 Addition Updated to reflect use of Loop 2300 for Prior Authorization WAMMIS-CG837ENC- 5010-01-08 4/14/2020 Updates Updated verbiage, screen prints and web links. WAMMIS-CG837ENC- 5010-01-09 5/27/2022 Addition Addition of HCP 03 segments in Professional and Institutional at both Header and Line levels WAMMIS-CG837ENC- 5010-01-10 09/01/2022 Update Update instructions in the comments sections for 2000B SBR03 and 2010BA NM109 WAMMIS-CG837ENC- 5010-01-11 06/26/2023 Addition Addition of requirements for Electronic Visit Verification (EVV) data for Home Health services. WAMMIS-CG837ENC- 5010-01-12 10/17/2023 Addition Addition of Rendering Provider to 837I to meet Electronic Visit Verification (EVV) data for Home Health services requirements. State of Washington ProviderOne 5010 837 Encounter Companion Guide vi WAMMIS-CG-837ENC-5010-01-12 Contents Disclaimer ............................................................................................................................ ii Revision History ....................................................................................................................... iii 1 Introduction ........................................................................................................................ 7 1.1 Document Purpose ................................................................................................... 7 1.1.1 Intended Users .................................................................................................... 8 1.1.2 Relationship to HIPAA Implementation Guides .................................................... 8 1.2 Transmission Schedule ............................................................................................ 8 2 Technical Infrastructure and Procedures......................................................................... 9 2.1 Technical Environment ............................................................................................. 9 2.1.1 Communication Requirements ............................................................................. 9 2.1.2 Testing Process ................................................................................................... 9 2.1.3 Who to contact for assistance ............................................................................ 10 2.2 Upload batches via Web Interface ......................................................................... 11 2.3 Set-up, Directory, and File Naming Convention .................................................... 16 2.3.1 SFTP Set-up ...................................................................................................... 16 2.3.2 SFTP Directory Naming Convention .................................................................. 16 2.3.3 File Naming Convention ..................................................................................... 17 2.4 Transaction Standards ........................................................................................... 18 2.4.1 General Information ........................................................................................... 18 2.4.2 Data Format ....................................................................................................... 18 2.4.3 Data Interchange Conventions ........................................................................... 19 2.4.4 Acknowledgement Procedures ........................................................................... 19 2.4.5 Rejected Transmissions and Transactions ......................................................... 19 3 Transaction Specifications .................................................................................................. 20 State of Washington ProviderOne 5010 837 Encounter Companion Guide 7 WAMMIS-CG-837ENC-5010-01-12 1 Introduction The Administrative Simplification provisions of the Health Insurance Portability and Accountability Act of 1996 (HIPAA, Title II) includes requirements that national standards be established for electronic health care transactions, and national identifiers for providers, health plans, and employers. This requires Washington State Health Care Authority (HCA) to adopt standards to support the electronic exchange of administrative and financial health care transactions between covered entities (health care providers, health plans, and healthcare clearinghouses). The intent of these standards is to improve the efficiency and effectiveness of the nation's health care system by encouraging widespread use of electronic data interchange standards in health care. The intent of the law is that all electronic transactions for which standards are specified must be conducted according to the standards. These standards were developed by processes that included significant public and private sector input. Encounters are not HIPAA named transactions and the 837I and 837P Implementation Guides were used as a foundation to construct the standardized HCA encounter reporting process. 1.1 Document Purpose Companion Guides are used to clarify the exchange of information on HIPAA transactions between the HCA ProviderOne system and its trading partners. HCA defines trading partners as covered entities that either submit or retrieve HIPAA batch transactions to and from ProviderOne. This Companion Guide is intended for trading partner use in conjunction with the ASC X12N Implementation Guides listed below. The ASC X12 TR3s that detail the full requirements for all HIPAA mandated transactions are available at http://store.x12.org/store/ The Standard Implementation Guides for Claim Transaction is: Healthcare Claim/(Encounters): Professional (837) 005010X222 Healthcare Claim/(Encounters): Institutional (837) 005010X223 HCA has also incorporated all of the approved 837 Professional and 837 Institutional Addenda listed below. Healthcare Claim/(Encounters): Professional (837) 005010X222A1 Healthcare Claim/(Encounters): Institutional (837) 005010X223A1 Healthcare Claim/(Encounters): Institutional (837) 005010X223A2 State of Washington ProviderOne 5010 837 Encounter Companion Guide 8 WAMMIS-CG-837ENC-5010-01-12 1.1.1 Intended Users Companion Guides are to be used by members/technical staff of trading partners who are responsible for electronic transaction/file exchanges. 1.1.2 Relationship to HIPAA Implementation Guides Companion Guides are intended to supplement the HIPAA Implementation Guides for each of the HIPAA transactions. Rules for format, content, and field values can be found in the Implementation Guides. This Companion Guide describes the technical interface environment with HCA, including connectivity requirements and protocols, and electronic interchange procedures. This guide also provides specific information on data elements and the values required for transactions sent to or received from HCA. Companion Guides are intended to supplement rather than replace the standard Implementation Guide for each transaction set. The information in these documents is not intended to: • Modify the definition, data condition, or use of any data element or segment in the standard Implementation Guides. • Add any additional data elements or segments to the defined data set. • Utilize any code or data values that are not valid in the standard Implementation Guides. • Change the meaning or intent of any implementation specifications in the standard Implementation Guides. 1.2 Transmission Schedule N/A State of Washington ProviderOne 5010 837 Encounter Companion Guide 9 WAMMIS-CG-837ENC-5010-01-12 2 Technical Infrastructure and Procedures 2.1 Technical Environment 2.1.1 Communication Requirements This section will describe how trading partners can send 837 Encounters Transactions to HCA using 2 methods: ▪ Secure File Transfer Protocol (SFTP) ▪ ProviderOne Web Portal 2.1.2 Testing Process Completion of the testing process must occur prior to submitting electronic transactions in production to ProviderOne. Testing is conducted to ensure the following levels of HIPAA compliance: 1. Level 1 – Syntactical integrity: Testing of the EDI file for valid segments, segment order, element attributes, testing for numeric values in numeric data elements, validation of X12 or NCPDP syntax, and compliance with X12 and NCPDP rules. 2. Level 2 – Syntactical requirements: Testing for HIPAA Implementation Guide-specific syntax requirements, such as limits on repeat counts, used and not used qualifiers, codes, elements and segments. It will also include testing for HIPAA required or intra-segment situational data elements, testing for non-medical code sets as laid out in the Implementation Guide, and values and codes noted in the Implementation Guide via an X12 code list or table. Additional testing may be required in the future to verify any changes made to the ProviderOne system. Changes to the ANSI formats may also require additional testing. Assistance is available throughout the testing process. Trading Partner Testing Procedures 1. ProviderOne companion guides and trading partner enrollment package are available for download via the web at: HIPAA Electronic Data Interchange (EDI) \| Washington State Health Care Authority 2. The Trading Partner completes the Trading Partner Agreement and submits the signed agreement to HCA. Submit to: HCA HIPAA EDI Department 626 8th Avenue SE PO Box 45564 State of Washington ProviderOne 5010 837 Encounter Companion Guide 10 WAMMIS-CG-837ENC-5010-01-12 Olympia, WA 98504-5564 For Questions call 1-800-562-3022 ext 16137 3. The trading partner is assigned a Submitter ID, Domain, Logon User ID and password. 4. The trading partner submits all HIPAA test files through the ProviderOne web portal or Secure File Transfer Protocol (SFTP). ▪ Web Portal URL: https://www.waproviderone.org/edi ▪ SFTP URL: sftp://ftp.waproviderone.org/ 5. The trading partner downloads acknowledgements for the test file from the ProviderOne web portal or SFTP. 6. If ProviderOne system generates a positive TA1 and positive 999 acknowledgement, the file is successfully accepted. The trading partner is then approved to send X12N 837 Encounters files in production. 7. If the test file generates a negative TA1 or negative 999 acknowledgment, then the submission is unsuccessful and the file is rejected. The trading partner needs to resolve all the errors that are reported on the negative TA1 or negative 999 and resubmit the file for test. Trading partners will continue to test in the testing environment until they receive a positive TA1 and positive 999. 2.1.3 Who to contact for assistance Email: [email protected] o All emails result in the assignment of a Ticket Number for problem tracking • Information required for initial email: o Name o Phone Number o Email Address o 7 Digit domain/ProviderOne ID o Transaction you are inquiring about o File Name o Detailed description of concern • Information required for follow up call(s): o Assigned Ticket Number State of Washington ProviderOne 5010 837 Encounter Companion Guide 11 WAMMIS-CG-837ENC-5010-01-12 2.2 Upload batches via Web Interface Once logged into the ProviderOne Portal, select the Admin Tab and the following options will be presented to the user: Scroll down to the HIPAA options on the right side to manage the HIPAA transactions. State of Washington ProviderOne 5010 837 Encounter Companion Guide 12 WAMMIS-CG-837ENC-5010-01-12 In the HIPAA section, the user can Submit file and Retrieve Acknowledgement/Response as shown below: State of Washington ProviderOne 5010 837 Encounter Companion Guide 13 WAMMIS-CG-837ENC-5010-01-12 In order to upload a file, the following steps are followed: Click on the Upload button to upload a HIPAA file On file upload page click on the Browse button to attach HIPAA file	837-Encounters-CG.pdf
and not used qualifiers, codes, elements and segments. It will also include testing for HIPAA required or intra-segment situational data elements, testing for non-medical code sets as laid out in the Implementation Guide, and values and codes noted in the Implementation Guide via an X12 code list or table. Additional testing may be required in the future to verify any changes made to the ProviderOne system. Changes to the ANSI formats may also require additional testing. Assistance is available throughout the testing process. Trading Partner Testing Procedures 1. ProviderOne companion guides and trading partner enrollment package are available for download via the web at: HIPAA Electronic Data Interchange (EDI) \| Washington State Health Care Authority 2. The Trading Partner completes the Trading Partner Agreement and submits the signed agreement to HCA. Submit to: HCA HIPAA EDI Department 626 8th Avenue SE PO Box 45564 State of Washington ProviderOne 5010 837 Encounter Companion Guide 10 WAMMIS-CG-837ENC-5010-01-12 Olympia, WA 98504-5564 For Questions call 1-800-562-3022 ext 16137 3. The trading partner is assigned a Submitter ID, Domain, Logon User ID and password. 4. The trading partner submits all HIPAA test files through the ProviderOne web portal or Secure File Transfer Protocol (SFTP). ▪ Web Portal URL: https://www.waproviderone.org/edi ▪ SFTP URL: sftp://ftp.waproviderone.org/ 5. The trading partner downloads acknowledgements for the test file from the ProviderOne web portal or SFTP. 6. If ProviderOne system generates a positive TA1 and positive 999 acknowledgement, the file is successfully accepted. The trading partner is then approved to send X12N 837 Encounters files in production. 7. If the test file generates a negative TA1 or negative 999 acknowledgment, then the submission is unsuccessful and the file is rejected. The trading partner needs to resolve all the errors that are reported on the negative TA1 or negative 999 and resubmit the file for test. Trading partners will continue to test in the testing environment until they receive a positive TA1 and positive 999. 2.1.3 Who to contact for assistance Email: [email protected] o All emails result in the assignment of a Ticket Number for problem tracking • Information required for initial email: o Name o Phone Number o Email Address o 7 Digit domain/ProviderOne ID o Transaction you are inquiring about o File Name o Detailed description of concern • Information required for follow up call(s): o Assigned Ticket Number State of Washington ProviderOne 5010 837 Encounter Companion Guide 11 WAMMIS-CG-837ENC-5010-01-12 2.2 Upload batches via Web Interface Once logged into the ProviderOne Portal, select the Admin Tab and the following options will be presented to the user: Scroll down to the HIPAA options on the right side to manage the HIPAA transactions. State of Washington ProviderOne 5010 837 Encounter Companion Guide 12 WAMMIS-CG-837ENC-5010-01-12 In the HIPAA section, the user can Submit file and Retrieve Acknowledgement/Response as shown below: State of Washington ProviderOne 5010 837 Encounter Companion Guide 13 WAMMIS-CG-837ENC-5010-01-12 In order to upload a file, the following steps are followed: Click on the Upload button to upload a HIPAA file On file upload page click on the Browse button to attach HIPAA file from local file system. After selecting the file from the local file system, press OK to start the upload. State of Washington ProviderOne 5010 837 Encounter Companion Guide 14 WAMMIS-CG-837ENC-5010-01-12 Once the file is uploaded to the ProviderOne system success/failure message is displayed on the screen along with transmission details. State of Washington ProviderOne 5010 837 Encounter Companion Guide 15 WAMMIS-CG-837ENC-5010-01-12 Select Retrieve Acknowledgement/Response option from the HIPAA screen to retrieve Acknowledgements/Responses (TA1, 999, 271, 277, 820, 834, 835, or 277U) as shown below: State of Washington ProviderOne 5010 837 Encounter Companion Guide 16 WAMMIS-CG-837ENC-5010-01-12 2.3 Set-up, Directory, and File Naming Convention 2.3.1 SFTP Set-up Trading partners can contact [email protected] for information on establishing connections through the FTP server. Upon completion of set-up, they will receive additional instructions on FTP usage. 2.3.2 SFTP Directory Naming Convention There would be two categories of folders under Trading Partner’s SFPT folders: 1. TEST – Trading Partners should submit and receive their test files under this root folder 2. PROD – Trading Partners should submit and receive their production files under this root folder 3. README – This folder will include messages regarding password update requirements, outage information and general SFTP messages. Following folder will be available under TEST/PROD folder within SFTP root of the Trading Partner: ‘HIPAA_Inbound’ - This folder should be used to drop the Inbound files that need to be submitted to HCA ‘HIPAA_Ack’ - Trading partner should look for acknowledgements to the files submitted in this folder. TA1, 999 and custom error report will be available for all the files submitted by the Trading Partner ‘HIPAA_Outbound’ – X12 outbound transactions generated by HCA will be available in this folder ‘HIPAA_Error’ – Any inbound file that is not HIPAA compliant or is not recognized by ProviderOne will be moved to this folder ‘HIPAA Working’ – There is no functional use for this folder at this time State of Washington ProviderOne 5010 837 Encounter Companion Guide 17 WAMMIS-CG-837ENC-5010-01-12 Folder structure will appear as: 2.3.3 File Naming Convention The HIPAA Subsystem Package is responsible for assisting ProviderOne activities related to Electronic Transfer and processing of Health Care and Health Encounter Data, with a few exceptions or limitations. HIPAA files are named: For Inbound transactions: HIPAA.<TPId>.<datetimestamp>.<originalfilename>.<dat> Example of file name: HIPAA.101721500.122620072100_P_1.dat ▪ <TPId> is the Trading Partner Id ▪ <datetimestamp> is the Date timestamp ▪ <originalfilename> is the original file name which is submitted by the trading partner. ▪ All HIPAA submitted files MUST BE .dat files or they will not be processed State of Washington ProviderOne 5010 837 Encounter Companion Guide 18 WAMMIS-CG-837ENC-5010-01-12 2.4 Transaction Standards 2.4.1 General Information HIPAA standards are specified in the Implementation Guide for each mandated transaction and modified by authorized Addenda. Encounter Transactions utilize both the 837P and 837I Implementation Guides. Currently, the 837P has one Addendum and the 837I transaction has two Addenda. These Addenda have been adopted as final and are incorporated into HCA requirements. An overview of requirements specific to the transaction can be found in the 837P and 837I Implementation Guides. Implementation Guides contain information related to: • Format and content of interchanges and functional groups • Format and content of the header, detailer and trailer segments specific to the transaction • Code sets and values authorized for use in the transaction • Allowed exceptions to specific transaction requirements Transmission sizes are limited based on two factors: • Number of Segments/Records allowed by HIPAA Standards • HCA file size limitations HIPAA standards limits the size of the transaction (ST-SE envelope) to a maximum of 5000 CLM segments. HCA limits a file size to 50 MB while uploading HIPAA files through the ProviderOne web portal and 100 MB through FTP. 2.4.2 Data Format Delimiters The ProviderOne will use the following delimiters on outbound transactions: • Data element separator, Asterisk, ( * ) • Sub-element Separator, Colon, ( : ) State of Washington ProviderOne 5010 837 Encounter Companion Guide 19 WAMMIS-CG-837ENC-5010-01-12 • Segment Terminator, Tilde, ( ~ ) • Repetition Separator, Caret, (^) 2.4.3 Data Interchange Conventions When accepting 837 Encounters transactions from trading partners, HCA follows HIPAA standards. These standards involve Interchange (ISA/IEA) and Functional Group (GS/GE) Segments or “outer envelopes”. All 837 Encounters Transactions should follow the HIPAA guideline. Please refer to the 837 Implementation Guide for ISA/IEA envelop, GS/GE functional group and ST/SE transaction specifications. The ISA/IEA Interchange Envelope, unlike most ASC X12 data structures has fixed field length. The entire data length of the data element should be considered and padded with spaces if the data element length is less than the field length. 2.4.4 Acknowledgement Procedures Once the file is submitted by the trading partner and is successfully received by the ProviderOne system, a response in the form of TA1 and 999 acknowledgment transactions will be placed in appropriate folder (on the SFTP server) of the trading partner. The ProviderOne system generates positive TA1 and positive 999 acknowledgements, if the submitted HIPAA file meets HIPAA standards related to syntax and data integrity. For files that do not meet the HIPAA standards, a negative TA1 and/or negative 999 are generated and sent to the trading partner. 2.4.5 Rejected Transmissions and Transactions 837 Encounters will be rejected if the file does not meet HIPAA standards for syntax, data integrity and structure (Strategic National Implementation Process (SNIP) type 1 and 2). State of Washington ProviderOne 5010 837 Encounter Companion Guide 20 WAMMIS-CG-837ENC-5010-01-12 3 Transaction Specifications 837 Professional Encounters Page Loop Segment Data Element Element Name Comments Interchange Control Header (ISA) App.C Envelope ISA 01 Authorization Information Qualifier Please use '00'. App.C Envelope ISA 03 Security Information Qualifier Please use '00'. App.C Envelope ISA 05 Interchange ID Qualifier Please use 'ZZ'. App.C Envelope ISA 06 Interchange Sender ID Please use the nine-digit alphanumeric submitter ID assigned during the enrollment process, followed by spaces (e.g. 1234567AA). App.C Envelope ISA 07 Interchange ID Qualifier Please use 'ZZ'. App.C Envelope ISA 08 Interchanger Receiver ID Please enter '77045' followed by spaces. App.C Envelope ISA 11 Repetition Separator Please use ‘^’. App.C Envelope ISA 16 Component Element Separator Please use ':'. Functional Group Header (GS) App.C Envelope GS 02 Application Sender Code Please use the nine-digit alphanumeric submitter ID assigned during the enrollment process. This should be the same as Loop 1000A, Data Element NM109 (e.g. 1234567AA). App.C Envelope GS 03 Applications Receivers Code Please use '77045'. Beginning Hierarchical Transaction (BHT) State of Washington ProviderOne 5010 837 Encounter Companion Guide 21 WAMMIS-CG-837ENC-5010-01-12 71 Header BHT 02 Transaction Set Purpose Code Please use ‘00’. 72 Header BHT 06 Claim or Encounter Indicator Please use ‘RP’ for encounter. Submitter Name (Loop 1000A) 75 1000A NM1 09 Submitter ID Please use the nine-digit alphanumeric submitter ID assigned during the enrollment process (e.g. 1234567AA). This should be the same as ISA06 and GS02. Receiver Name (1000B) 80 1000B NM1 03 Receiver Name Please enter ‘WA State HCA’. 80 1000B NM1 09 Receiver Primary Identifier Please use ‘77045’. Billing Provider Specialty Information (2000A) 83 2000A PRV NOTE: For medical and behavioral health encounters this must always be the taxonomy for the provider who billed the MCO. Billing Provider Name (2010AA) 88 2010AA NM1 NOTE: For medical and behavioral health encounters this must always be the provider who billed the MCO. Subscriber Information (Loop 2000B) 117 2000B SBR 03 Reference Identification SBR03 is not used for medical or behavioral health (BH) encounters submitted by MCOs. For encounters submitted by ASOs, the ASO unique consumer ID MUST be entered (even if already entered in NM109). 118 2000B SBR 09 Claim Filing Indicator Code. Please enter ‘MC’. Subscriber Name (Loop 2010BA) State of Washington ProviderOne 5010 837 Encounter Companion Guide 22 WAMMIS-CG-837ENC-5010-01-12 123 2010BA NM1 09 Identification Code For medical and behavioral health (BH) encounters submitted by MCOs for Medicaid clients, please enter the ProviderOne Client ID. This ID is 11 digits in length and is alphanumeric in the following format: nine numeric digits followed by ‘WA’. Example: 123456789WA For encounters submitted by ASOs, one of the following MUST be entered: 1) The ProviderOne Client ID; or 2) The ASO unique consumer ID (i.e., this is the same information reported in Loop 2000B SBR03.) Subscriber Address (Loop 2010BA) 124 2010BA N3 NOTE: For homeless clients please enter ‘unknown’ in N301. Subscriber City/State/ZIP Code (Loop 2010BA) 125 2010BA N4 NOTE: For homeless clients please enter the city, state and zip code for the service provider. Subscriber Demographic Information (Loop 2010BA) 127 2010BA DMG NOTE: HCA requires the DMG segment to be submitted as the patient is always the subscriber. Payer Name (Loop 2010BB) 133 2010BB NM1 03 Payer Name – Name last/Organization Name Please enter ’WA State HCA’. 133 2010BB NM1 09 Payer ID Please use ‘77045’. Billing Provider Secondary Identification (Loop 2010BB) 140 2010BB REF Note: This segment is used to identify the MCO and ASO ProviderOne ID. State of Washington ProviderOne 5010 837 Encounter Companion Guide 23 WAMMIS-CG-837ENC-5010-01-12 140 2010BB REF 01 Billing Provider Secondary ID Qualifier Please use ‘G2’ to identify the ProviderOne ID. 141 2010BB REF 02 Billing Provider Secondary ID Please enter nine-digit alphanumeric ProviderOne ID. Claim Information (Loop 2300) Date – Admission (Loop 2300) 176 2300 DTP NOTE: Used only for medical and BH encounters submitted by MCOs	837-Encounters-CG.pdf
use the nine-digit alphanumeric submitter ID assigned during the enrollment process. This should be the same as Loop 1000A, Data Element NM109 (e.g. 1234567AA). App.C Envelope GS 03 Applications Receivers Code Please use '77045'. Beginning Hierarchical Transaction (BHT) State of Washington ProviderOne 5010 837 Encounter Companion Guide 21 WAMMIS-CG-837ENC-5010-01-12 71 Header BHT 02 Transaction Set Purpose Code Please use ‘00’. 72 Header BHT 06 Claim or Encounter Indicator Please use ‘RP’ for encounter. Submitter Name (Loop 1000A) 75 1000A NM1 09 Submitter ID Please use the nine-digit alphanumeric submitter ID assigned during the enrollment process (e.g. 1234567AA). This should be the same as ISA06 and GS02. Receiver Name (1000B) 80 1000B NM1 03 Receiver Name Please enter ‘WA State HCA’. 80 1000B NM1 09 Receiver Primary Identifier Please use ‘77045’. Billing Provider Specialty Information (2000A) 83 2000A PRV NOTE: For medical and behavioral health encounters this must always be the taxonomy for the provider who billed the MCO. Billing Provider Name (2010AA) 88 2010AA NM1 NOTE: For medical and behavioral health encounters this must always be the provider who billed the MCO. Subscriber Information (Loop 2000B) 117 2000B SBR 03 Reference Identification SBR03 is not used for medical or behavioral health (BH) encounters submitted by MCOs. For encounters submitted by ASOs, the ASO unique consumer ID MUST be entered (even if already entered in NM109). 118 2000B SBR 09 Claim Filing Indicator Code. Please enter ‘MC’. Subscriber Name (Loop 2010BA) State of Washington ProviderOne 5010 837 Encounter Companion Guide 22 WAMMIS-CG-837ENC-5010-01-12 123 2010BA NM1 09 Identification Code For medical and behavioral health (BH) encounters submitted by MCOs for Medicaid clients, please enter the ProviderOne Client ID. This ID is 11 digits in length and is alphanumeric in the following format: nine numeric digits followed by ‘WA’. Example: 123456789WA For encounters submitted by ASOs, one of the following MUST be entered: 1) The ProviderOne Client ID; or 2) The ASO unique consumer ID (i.e., this is the same information reported in Loop 2000B SBR03.) Subscriber Address (Loop 2010BA) 124 2010BA N3 NOTE: For homeless clients please enter ‘unknown’ in N301. Subscriber City/State/ZIP Code (Loop 2010BA) 125 2010BA N4 NOTE: For homeless clients please enter the city, state and zip code for the service provider. Subscriber Demographic Information (Loop 2010BA) 127 2010BA DMG NOTE: HCA requires the DMG segment to be submitted as the patient is always the subscriber. Payer Name (Loop 2010BB) 133 2010BB NM1 03 Payer Name – Name last/Organization Name Please enter ’WA State HCA’. 133 2010BB NM1 09 Payer ID Please use ‘77045’. Billing Provider Secondary Identification (Loop 2010BB) 140 2010BB REF Note: This segment is used to identify the MCO and ASO ProviderOne ID. State of Washington ProviderOne 5010 837 Encounter Companion Guide 23 WAMMIS-CG-837ENC-5010-01-12 140 2010BB REF 01 Billing Provider Secondary ID Qualifier Please use ‘G2’ to identify the ProviderOne ID. 141 2010BB REF 02 Billing Provider Secondary ID Please enter nine-digit alphanumeric ProviderOne ID. Claim Information (Loop 2300) Date – Admission (Loop 2300) 176 2300 DTP NOTE: Used only for medical and BH encounters submitted by MCOs when appropriate. Not used for ASO submitted encounters. Date – Discharge (Loop 2300) 177 2300 DTP NOTE: Used only for medical and BH encounters submitted by MCOs when appropriate. Not used for ASO submitted encounters. Prior Authorization (Loop 2300) REF 01 Reference Identification Qualifier Please enter ‘G1’. REF 02 Reference Identification Please enter the nine-digit Evidence-Based Practice (EBP) code. Payer Claim Control Number (Loop 2300) 196 2300 REF 02 Reference Identification Please enter the 18 digit Transaction Control Number (TCN) of claim when CLM05-3 indicates the claim is a replacement or void. Medical Record Number (Loop 2300) 204 2300 REF Used only for ASO submitted encounters when appropriate. Not used for medical or BH encounters submitted by MCOs. Claim Pricing/Repricing Information (Loop 2300) State of Washington ProviderOne 5010 837 Encounter Companion Guide 24 WAMMIS-CG-837ENC-5010-01-12 253 2300 HCP NOTE: Used only for medical and BH encounters submitted by MCOs when appropriate. Not used for ASO submitted encounters. 253 2300 HCP 01 Pricing/Repricing Methodology Please enter based on how the MCO reimbursed the claim: ‘00’ = Claim denied by MCO; or ‘02’ = MCO paid a non-capitated amount; or ‘07’ = MCO paid based on a capitation arrangement. 253 2300 HCP 02 Monetary Amount – Total Claim Paid Amount MCOs to report the ‘Amount Paid’ (amount that MCO paid) to the Billing/Pay-to provider or $0.00 if MCO denied the claim. 253 2300 HCP 03 Monetary Amount MCO Allowed Amount (Usual and Customary) Referring Provider Name (Loop 2310A) 258 2310A NM1 NOTE: Used only for medical and BH encounters submitted by MCOs when appropriate. Not used for ASO submitted encounters. Referring Provider Secondary Identification (Loop 2310A) 260 2310A REF NOTE: Used only for medical and BH encounters submitted by MCOs when appropriate. Not used for ASO submitted encounters. Rendering Provider Name (Loop 2310B) 263 2310B NM1 NOTE: Used only for medical and BH encounters submitted by MCOs. Not used for encounters submitted by ASOs as professional encounters are not reported below the CMHA level. Service Facility Location Secondary Identification (Loop 2310C) State of Washington ProviderOne 5010 837 Encounter Companion Guide 25 WAMMIS-CG-837ENC-5010-01-12 275 2310C REF 01 Reference Identification Qualifier Please enter ‘G2’. 276 2310C REF 02 Reference Identification Please enter the site-specific, Department of Health (DOH) License Number. Provide just the certification number and do not include preceding characters (i.e., BHA.FS.60872639). DO NOT use the DSHS-DBHR Legacy License Number. Other Subscriber Information (Loop 2320) 298 2320 SBR 09 Claim Filing Indicator Code Please use 'MB' when submitting Medicare Crossover Claims; otherwise use ‘MC’. Line Note (Loop 2400) 465 2400 NTE 01 Note Reference Code MCO – use appropriate code. ASO – use ‘ADD’. 465 2400 NTE 02 Line Note Text MCO – use as needed per the IG. ASO – refer to BHDS data dictionary. Line Pricing/Re-pricing Information (Loop 2400) 413 2400 HCP NOTE: Used only for medical and BH encounters submitted by MCOs when appropriate. Not used for ASO submitted encounters. 413 2400 HCP 01 Pricing/Re- pricing Methodology Please enter based on how the MCO reimbursed the claim: ‘00’ = Claim denied by MCO; or ‘02’ = MCO paid a non-capitated amount; or ‘07’ = MCO paid based on a capitation arrangement. 413 2400 HCP 02 Monetary Amount – Total Claim Paid Amount MCOs to report the ‘Amount Paid’ (amount that MCO paid) to the Billing/Pay-to provider or $0.00 if MCO denied the claim. State of Washington ProviderOne 5010 837 Encounter Companion Guide 26 WAMMIS-CG-837ENC-5010-01-12 413 2400 HCP 03 Monetary Amount MCO Allowed Amount (Usual and Customary) 420 2400 HCP 11 Unit or Basis For Measurement Code MCOs to use appropriate unit qualifier per IG. 420 2400 HCP 12 Quantity MCOs to report number of paid units. Rendering Provider Name (Loop 2420A) 431 2420A NM1 NOTE: Not used for ASO submitted encounters as professional encounters are not reported below the CMHA level. Service Facility Location Secondary Identification (Loop 2420C) 447 2420C REF 01 Reference Identification Qualifier Please enter ‘G2’. 448 2420C REF 02 Reference Identification Please enter the site-specific, Department of Health (DOH) License Number. Provide just the certification number and do not include preceding characters (i.e., BHA.FS.60872639). DO NOT use the DSHS-DBHR Legacy License Number. 837 Institutional Encounters Page Loop Segment Data Element Element Name Comments INTERCHANGE CONTROL HEADER App.C.4 ENVELOPE ISA 01 Authorization Information Qualifier Please use '00'. App.C.4 ENVELOPE ISA 03 Security Information Qualifier Please use '00'. State of Washington ProviderOne 5010 837 Encounter Companion Guide 27 WAMMIS-CG-837ENC-5010-01-12 App.C.4 ENVELOPE ISA 05 Interchange ID Qualifier Please use 'ZZ'. App.C.4 ENVELOPE ISA 06 Interchange Sender ID Please use the nine- digit alphanumeric submitter ID assigned during the enrollment process followed by spaces (e.g. 1234567AA). App.C.5 ENVELOPE ISA 07 Interchange ID Qualifier Please use 'ZZ'. App.C.5 ENVELOPE ISA 08 Interchange Receiver ID Please enter '77045' followed by spaces. App.C.5 ENVELOPE ISA 11 Repetition Separator Please use ‘^’. App.C.6 ENVELOPE ISA 16 Component Element Separator Please use ':'. FUNCTIONAL GROUP HEADER App.C.7 ENVELOPE GS 02 Application Sender’s Code Please use the nine- digit alphanumeric submitter ID assigned during the enrollment process. This should be the same as Loop 1000A, Data Element NM109 (e.g. 1234567AA). App.C.7 ENVELOPE GS 03 Application Receiver’s Code Please use ‘77045’. Beginning of Hierarchical Transaction 68 HEADER BHT 02 Transaction Set Purpose Code Please use ‘00’ for Original. 69 HEADER BHT 06 Transaction Type Code Please use ‘RP’ for encounters. Loop ID 1000A - Submitter Name State of Washington ProviderOne 5010 837 Encounter Companion Guide 28 WAMMIS-CG-837ENC-5010-01-12 72 1000A NM1 09 Identification Code Please use the nine- digit alphanumeric submitter ID assigned during the enrollment process (e.g. 1234567AA). Loop ID 1000B - Receiver Name 77 1000B NM1 03 Name Last or Organization Name Please use 'WA State HCA'. 77 1000B NM1 09 Identification Code Please use ‘77045’. Billing Provider Specialty Information 80 2000A PRV NOTE: For medical and BH encounters this must always be the taxonomy for the provider who billed the MCO. Loop ID 2010AA - Billing Provider Name 85 2010AA NM1 NOTE: For medical and BH encounters this must always be the provider who billed the MCO. Subscriber Information 110 2000B SBR 03 Group or Policy number SBR03 is not used for medical or BH encounters submitted by MCOs. For encounters submitted by ASOs, the ASO unique consumer ID MUST be entered (even if already entered in 2010BA NM109). 110 2000B SBR 09 Claim Filing Indicator Code Please use 'MC'. Loop ID 2010BA - Subscriber Name State of Washington ProviderOne 5010 837 Encounter Companion Guide 29 WAMMIS-CG-837ENC-5010-01-12 114 2010BA NM1 09 Identification code For medical and BH encounters submitted by MCOs for Medicaid clients, please enter the ProviderOne Client ID. This ID is 11 digits in length and is alphanumeric in the following format: nine numeric digits followed by ‘WA’. Example: 123456789WA For encounters submitted by ASOs, one of the following MUST be entered: 1) The ProviderOne Client ID; or 2) The ASO unique consumer ID (i.e., this is the same information reported in Loop 2000B SBR03.) Subscriber Address 115 2010BA N3 NOTE: For homeless clients please enter ‘unknown’ in N301. Subscriber City/State/Zip Code 116 2010BA N4 NOTE: For homeless clients please enter the city, state and zip code for the service provider. Subscriber Demographic Information State of Washington ProviderOne 5010 837 Encounter Companion Guide 30 WAMMIS-CG-837ENC-5010-01-12 118 2010BA DMG NOTE: HCA requires the DMG segment to be submitted as the patient is always the subscriber. Loop ID 2010BB - Payer Name 123 2010BB NM1 03 Last Name or Organization Name Please use 'WA State HCA’. 123 2010BB NM1 09 Identification Code Please use '77045'. Billing Provider Secondary Identification 129 2010BB REF 01 Reference Identification Qualifier Please use ‘G2’. 130 2010BB REF 02 Reference Identification Please enter nine- digit, ProviderOne ID for the MCO or ASO here. Loop ID 2300 - Claim Information 145 2300 CLM 05-1 Facility Code Value MCO - Please enter appropriate place of service code. ASO – Facility Code Value must be ‘11’ . Prior Authorization (Loop 2300) REF 01 Reference Identification Qualifier Please enter ‘G1’. REF 02 Reference Identification Please enter the nine- digit Evidence-Based Practice (EBP) code. Loop ID 2300 - Payer Claim Control Number 166 2300 REF 02 Reference Identification Please enter the 18 digit Transaction Control Number (TCN) of claim when CLM05-3 indicates the claim is a replacement or void. Diagnosis Related Group (DRG) Information State of Washington ProviderOne 5010 837 Encounter Companion Guide 31 WAMMIS-CG-837ENC-5010-01-12 218 2300 HI NOTE: Not used on ASO submitted encounters. Principle Procedure Information 240 2300 HI NOTE: Not used on ASO submitted encounters. Other Procedure Information 243 2300 HI NOTE: Not used on ASO submitted encounters. Other Procedure Information Value Information (Code) 284 2300 HI NOTE: Not used on ASO submitted encounters. Claim Pricing/Repricing Information 314 2300 HCP NOTE: Not used on ASO submitted encounters. 314 2300 HCP 01 Pricing Methodology Please enter based on how the MCO reimbursed the claim: ‘00’ = Claim denied by MCO; or ‘02’ = MCO paid a non-capitated amount; or ‘07’ = MCO paid based on a capitation arrangement. 314 2300 HCP 02 Monetary Amount MCOs to report the ‘Amount Paid’ (amount that MCO paid) to the Billing/Pay-to provider or $0.00 if MCO denied the claim. State of Washington ProviderOne 5010 837 Encounter	837-Encounters-CG.pdf
for medical or BH encounters submitted by MCOs. For encounters submitted by ASOs, the ASO unique consumer ID MUST be entered (even if already entered in 2010BA NM109). 110 2000B SBR 09 Claim Filing Indicator Code Please use 'MC'. Loop ID 2010BA - Subscriber Name State of Washington ProviderOne 5010 837 Encounter Companion Guide 29 WAMMIS-CG-837ENC-5010-01-12 114 2010BA NM1 09 Identification code For medical and BH encounters submitted by MCOs for Medicaid clients, please enter the ProviderOne Client ID. This ID is 11 digits in length and is alphanumeric in the following format: nine numeric digits followed by ‘WA’. Example: 123456789WA For encounters submitted by ASOs, one of the following MUST be entered: 1) The ProviderOne Client ID; or 2) The ASO unique consumer ID (i.e., this is the same information reported in Loop 2000B SBR03.) Subscriber Address 115 2010BA N3 NOTE: For homeless clients please enter ‘unknown’ in N301. Subscriber City/State/Zip Code 116 2010BA N4 NOTE: For homeless clients please enter the city, state and zip code for the service provider. Subscriber Demographic Information State of Washington ProviderOne 5010 837 Encounter Companion Guide 30 WAMMIS-CG-837ENC-5010-01-12 118 2010BA DMG NOTE: HCA requires the DMG segment to be submitted as the patient is always the subscriber. Loop ID 2010BB - Payer Name 123 2010BB NM1 03 Last Name or Organization Name Please use 'WA State HCA’. 123 2010BB NM1 09 Identification Code Please use '77045'. Billing Provider Secondary Identification 129 2010BB REF 01 Reference Identification Qualifier Please use ‘G2’. 130 2010BB REF 02 Reference Identification Please enter nine- digit, ProviderOne ID for the MCO or ASO here. Loop ID 2300 - Claim Information 145 2300 CLM 05-1 Facility Code Value MCO - Please enter appropriate place of service code. ASO – Facility Code Value must be ‘11’ . Prior Authorization (Loop 2300) REF 01 Reference Identification Qualifier Please enter ‘G1’. REF 02 Reference Identification Please enter the nine- digit Evidence-Based Practice (EBP) code. Loop ID 2300 - Payer Claim Control Number 166 2300 REF 02 Reference Identification Please enter the 18 digit Transaction Control Number (TCN) of claim when CLM05-3 indicates the claim is a replacement or void. Diagnosis Related Group (DRG) Information State of Washington ProviderOne 5010 837 Encounter Companion Guide 31 WAMMIS-CG-837ENC-5010-01-12 218 2300 HI NOTE: Not used on ASO submitted encounters. Principle Procedure Information 240 2300 HI NOTE: Not used on ASO submitted encounters. Other Procedure Information 243 2300 HI NOTE: Not used on ASO submitted encounters. Other Procedure Information Value Information (Code) 284 2300 HI NOTE: Not used on ASO submitted encounters. Claim Pricing/Repricing Information 314 2300 HCP NOTE: Not used on ASO submitted encounters. 314 2300 HCP 01 Pricing Methodology Please enter based on how the MCO reimbursed the claim: ‘00’ = Claim denied by MCO; or ‘02’ = MCO paid a non-capitated amount; or ‘07’ = MCO paid based on a capitation arrangement. 314 2300 HCP 02 Monetary Amount MCOs to report the ‘Amount Paid’ (amount that MCO paid) to the Billing/Pay-to provider or $0.00 if MCO denied the claim. State of Washington ProviderOne 5010 837 Encounter Companion Guide 32 WAMMIS-CG-837ENC-5010-01-12 314 2300 HCP 03 Monetary Amount MCO Allowed Amount (Usual and Customary) 316 2300 HCP 11 Unit or Basis For Measurement Code MCOs to use appropriate unit qualifier per IG. 316 2300 HCP 12 Quantity MCOs to report number of paid units. Attending Provider Name 319 2310A NM1 NOTE: For ASO submitted institutional encounters the attending provider will always be the E&T Center, based on the decision not to report below the E&T Center level. Loop ID 2310D - Rendering Provider Name 336 2310D NM1 Rendering Provider Name Enter the provider rendering service and NPI for Electronic Visit Verification (EVV) on Home Health Services claims. *If different rendering provider for each service line, submit in 2420C for each service line. Service Facility Location Secondary Identification (2310E) 342 2310E NM1 Enter Clients service location in the example format below, for Electronic Visit Verification (EVV) on Home Health State of Washington ProviderOne 5010 837 Encounter Companion Guide 33 WAMMIS-CG-837ENC-5010-01-12 Services encounter claims. Example: NM1✽77✽2✽Clients Location (Home or otherwise) NOTE: Submitting this segment triggers the requirement for N3 and N4 in the same loop. 347 2310E REF 01 Reference Identification Qualifier Please enter ‘G2’. 348 2310E REF 02 Reference Identification Please enter the site-specific, Department of Health (DOH) License Number. Provide just the certification number and do not include preceding characters (i.e., BHA.FS.60872639). DO NOT use the DSHS-DBHR Legacy License Number. Other Subscriber Information (Loop 2320) 356 2320 SBR 09 Claim Filing Indicator Code Use ‘MA’ when submitting Medicare; otherwise use ‘MC’. Institutional Service Line (Loop 2400) 424 2400 SV2 01 Product/Service ID MCO – Please enter the revenue code for inpatient encounters using NUBC as code source. ASO – Must always use revenue code ‘0124’. State of Washington ProviderOne 5010 837 Encounter Companion Guide 34 WAMMIS-CG-837ENC-5010-01-12 425 2400 SV2 02 Service Line Procedure Code MCO – Please refer to the IG. For outpatient encounters when HCPCS/CPT code exists at line level. ASO – Not used. 425 2400 SV2 SV202-1 Product/Service ID Qualifier MCO – Required if outpatient encounter and HCPCS/CPT code exists at line level. ASO – Not used. 426 2400 SV2 SV202-2 Product/Service ID MCO – Please enter the primary procedure code. This is required for outpatient encounters and must be submitted with HCPCS/CPT procedure code (not ICD9/ICD10 procedure code). ASO – Not used. 426 2400 SV2 SV202-3 Procedure Modifier MCO – Please enter the procedure code modifier. This is required for outpatient encounters and if it clarifies the procedure. ASO – Not used. State of Washington ProviderOne 5010 837 Encounter Companion Guide 35 WAMMIS-CG-837ENC-5010-01-12 427 2400 SV2 SV202-7 Time the service begins and ends. Enter service begin and end times in HHMM-HHMM format for Electronic Visit Verification (EVV) on Home Health Services encounter claims. Date - Service Date (Loop 2400) 434 2400 DTP NOTE: Not used for ASO submitted encounters. Line Pricing/Re-pricing Information (Loop 2400) 443 2400 HCP NOTE: Used only for medical and BH encounters submitted by MCOs when appropriate. Not used for ASO submitted encounters. 443 2400 HCP 01 Pricing Methodology Please enter based on how the MCO reimbursed the claim: ‘00’ = Claim denied by MCO; or ‘02’ = MCO paid a non-capitated amount; or ‘07’ = MCO paid based on a capitation arrangement. 443 2400 HCP 02 Monetary Amount MCOs to report the ‘Amount Paid’ (amount that MCO paid) to the Billing/Pay-to provider or $0.00 if MCO denied the claim. State of Washington ProviderOne 5010 837 Encounter Companion Guide 36 WAMMIS-CG-837ENC-5010-01-12 443 2400 HCP 03 Monetary Amount MCO Allowed Amount (Usual and Customary) 447 2400 HCP 11 Unit or Basis For Measurement Code MCOs to use appropriate unit qualifier per IG. 447 2400 HCP 12 Quantity MCOs to report number of paid units. LIN – Drug Information (Loop 2410) 450 2410 LIN NOTE: Not used for ASO submitted encounters. CTP – Drug Quantity 452 2410 CTP NOTE: Not used for ASO submitted encounters. Loop ID 2420C - Rendering Provider Name 336 2420C NM1 Rendering Provider Name Enter the provider rendering service and NPI for Electronic Visit Verification (EVV) on Home Health Services claims.	837-Encounters-CG.pdf
Stedi maintains this guide based on public documentation from Texas Medicaid & Healthcare Partnerships (TMHP). Contact Texas Medicaid & Healthcare Partnerships (TMHP) for official EDI specifications. To report any errors in this guide, please contact us. X12 837 837 Health Care Claim: Professional (X222/A2/A1) X12 Release 5010 Revised January 18, 2024 Go to Stedi Network This X12 Transaction Set contains the format and establishes the data contents of the Health Care Claim Transaction Set (837) for use within the context of an Electronic Data Interchange (EDI) environment. This transaction set can be used to submit health care claim billing information, encounter information, or both, from providers of health care services to payers, either directly or via intermediary billers and claims clearinghouses. It can also be used to transmit health care claims and billing payment information between payers with different payment responsibilities where coordination of benefits is required or between payers and regulatory agencies to monitor the rendering, billing, and/or payment of health care services within a specific health care/insurance industry segment. For purposes of this standard, providers of health care products or services may include entities such as physicians, hospitals and other medical facilities or suppliers, dentists, and pharmacies, and entities providing medical information to meet regulatory requirements. The payer refers to a third party entity that pays claims or administers the insurance product or benefit or both. For example, a payer may be an insurance company, health maintenance organization (HMO), preferred provider organization (PPO), government agency (Medicare, Medicaid, Civilian Health and Medical Program of the Uniformed Services (CHAMPUS), etc.) or an entity such as a third party administrator (TPA) or third party organization (TPO) that may be contracted by one of those groups. A regulatory agency is an entity responsible, by law or rule, for administering and monitoring a statutory benefits program or a specific health care/insurance industry segment. Delimiters ~ Segment * Element > Component ^ Repetition View the latest version of this implementation guide as an interactive webpage https://www.stedi.com/app/guides/view/tmhp/837-health-care-claim-professional- x222a2a1/01HMBZ8Y6XYRFK1ZR16EKD50N6 POWERED BY Build EDI implementation guides at stedi.com 1/30/25, 11:53 AM Texas Medicaid & Healthcare Partnerships (TMHP) 837 837 Health Care Claim: Professional (X222/A2/A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/tmhp/837-health-care-claim-professional-x222a2a1/01HMBZ8Y6XYRFK1ZR16EKD50N6 1/552 Overview ISA - Interchange Control Header Max use 1 Required GS - Functional Group Header Max use 1 Required Heading ST 0050 Transaction Set Header Max use 1 Required BHT 0100 Beginning of Hierarchical Transaction Max use 1 Required Submitter Name Loop NM1 0200 Submitter Name Max use 1 Required PER 0450 Submitter EDI Contact Information Max use 2 Required Receiver Name Loop NM1 0200 Receiver Name Max use 1 Required Detail Billing Provider Hierarchical Level Loop HL 0010 Hierarchical Level Max use 1 Required PRV 0030 Billing Provider Specialty Information Max use 1 Optional CUR 0100 Foreign Currency Information Max use 1 Optional Billing Provider Name Loop NM1 0150 Billing Provider Name Max use 1 Required N3 0250 Billing Provider Address Max use 1 Required N4 0300 Billing Provider City, State, ZIP Code Max use 1 Required REF 0350 Billing Provider Tax Identification Max use 1 Required REF 0350 Billing Provider UPIN/License Information Max use 2 Optional PER 0400 Billing Provider Contact Information Max use 2 Optional Pay-to Address Name Loop NM1 0150 Pay-to Address Name Max use 1 Required N3 0250 Pay-to Address - ADDRESS Max use 1 Required N4 0300 Pay-To Address City, State, ZIP Code Max use 1 Required Pay-To Plan Name Loop NM1 0150 Pay-To Plan Name Max use 1 Required N3 0250 Pay-to Plan Address Max use 1 Required N4 0300 Pay-To Plan City, State, ZIP Code Max use 1 Required REF 0350 Pay-to Plan Secondary Identification Max use 1 Optional REF 0350 Pay-To Plan Tax Identification Number Max use 1 Required 1/30/25, 11:53 AM Texas Medicaid & Healthcare Partnerships (TMHP) 837 837 Health Care Claim: Professional (X222/A2/A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/tmhp/837-health-care-claim-professional-x222a2a1/01HMBZ8Y6XYRFK1ZR16EKD50N6 2/552 2300 Loop CLM 1300 Health Claim Max use 1 Required REF 1800 Referral Number Max use 30 Optional NTE 1900 Claim Note Max use 20 Optional HI 2310 Health Care Information Codes Max use 25 Optional Subscriber Hierarchical Level Loop HL 0010 Hierarchical Level Max use 1 Required SBR 0050 Subscriber Information Max use 1 Required PAT 0070 Patient Information Max use 1 Optional Subscriber Name Loop NM1 0150 Subscriber Name Max use 1 Required N3 0250 Subscriber Address Max use 1 Optional N4 0300 Subscriber City, State, ZIP Code Max use 1 Optional DMG 0320 Subscriber Demographic Information Max use 1 Optional REF 0350 Property and Casualty Claim Number Max use 1 Optional REF 0350 Subscriber Secondary Identification Max use 1 Optional PER 0400 Property and Casualty Subscriber Contact Information Max use 1 Optional Payer Name Loop NM1 0150 Payer Name Max use 1 Required N3 0250 Payer Address Max use 1 Optional N4 0300 Payer City, State, ZIP Code Max use 1 Optional REF 0350 Billing Provider Secondary Identification Max use 2 Optional REF 0350 Payer Secondary Identification Max use 3 Optional Claim Information Loop CLM 1300 Claim Information Max use 1 Required DTP 1350 Date - Accident Max use 1 Optional DTP 1350 Date - Acute Manifestation Max use 1 Optional DTP 1350 Date - Admission Max use 1 Optional DTP 1350 Date - Assumed and Relinquished Care Dates Max use 2 Optional DTP 1350 Date - Authorized Return to Work Max use 1 Optional DTP 1350 Date - Disability Dates Max use 1 Optional DTP 1350 Date - Discharge Max use 1 Optional DTP 1350 Date - Hearing and Vision Prescription Date Max use 1 Optional DTP 1350 Date - Initial Treatment Date Max use 1 Optional 1/30/25, 11:53 AM Texas Medicaid & Healthcare Partnerships (TMHP) 837 837 Health Care Claim: Professional (X222/A2/A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/tmhp/837-health-care-claim-professional-x222a2a1/01HMBZ8Y6XYRFK1ZR16EKD50N6 3/552 DTP 1350 Date - Last Menstrual Period Max use 1 Optional DTP 1350 Date - Last Seen Date Max use 1 Optional DTP 1350 Date - Last Worked Max use 1 Optional DTP 1350 Date - Last X-ray Date Max use 1 Optional DTP 1350 Date - Onset of Current Illness or Symptom Max use 1 Optional DTP 1350 Date - Property and Casualty Date of First Contact Max use 1 Optional DTP 1350 Date - Repricer Received Date Max use 1 Optional PWK 1550 Claim Supplemental Information Max use 10 Optional CN1 1600 Contract Information Max use 1 Optional AMT 1750 Patient Amount Paid Max use 1 Optional REF 1800 Adjusted Repriced Claim Number Max use 1 Optional REF 1800 Care Plan Oversight Max use 1 Optional REF 1800 Claim Identifier For Transmission Intermediaries Max use 1 Optional REF 1800 Clinical Laboratory Improvement Amendment (CLIA) Number Max use 1 Optional REF 1800 Demonstration Project Identifier Max use 1 Optional REF 1800 Investigational Device Exemption Number Max use 1 Optional REF 1800 Mammography Certification Number Max use 1 Optional REF 1800 Mandatory Medicare (Section 4081) Crossover Indicator Max use 1 Optional REF 1800 Medical Record Number Max use 1 Optional REF 1800 Payer Claim Control Number Max use 1 Optional REF 1800 Prior Authorization Max use 1 Optional REF 1800 Referral Number Max use 1 Optional REF 1800 Repriced Claim Number Max use 1 Optional REF 1800 Service Authorization Exception Code Max use 1 Optional K3 1850 File Information Max use 10 Optional NTE 1900 Claim Note Max use 1 Optional CR1 1950 Ambulance Transport Information Max use 1 Optional CR2 2000 Spinal Manipulation Service Information Max use 1 Optional CRC 2200 Ambulance Certification Max use 3 Optional CRC 2200 EPSDT Referral Max use 1 Optional CRC 2200 Homebound Indicator Max use 1 Optional CRC 2200 Patient Condition Information: Vision Max use 3 Optional HI 2310 Anesthesia Related Procedure Max use 1 Optional HI 2310 Condition Information Max use 2 Optional 1/30/25, 11:53 AM Texas Medicaid & Healthcare Partnerships (TMHP) 837 837 Health Care Claim: Professional (X222/A2/A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/tmhp/837-health-care-claim-professional-x222a2a1/01HMBZ8Y6XYRFK1ZR16EKD50N6 4/552 HI 2310 Health Care Diagnosis Code Max use 1 Required HCP 2410 Claim Pricing/Repricing Information Max use 1 Optional Referring Provider Name Loop NM1 2500 Referring Provider Name Max use 1 Required REF 2710 Referring Provider Secondary Identification Max use 3 Optional Rendering Provider Name Loop NM1 2500 Rendering Provider Name Max use 1 Required PRV 2550 Rendering Provider Specialty Information Max use 1 Optional REF 2710 Rendering Provider Secondary Identification Max use 4 Optional Service Facility Location Name Loop NM1 2500 Service Facility Location Name Max use 1 Required N3 2650 Service Facility Location Address Max use 1 Required N4 2700 Service Facility Location City, State, ZIP Code Max use 1 Required REF 2710 Service Facility Location Secondary Identification Max use 3 Optional PER 2750 Service Facility Contact Information Max use 1 Optional Supervising Provider Name Loop NM1 2500 Supervising Provider Name Max use 1 Required REF 2710 Supervising Provider Secondary Identification Max use 4 Optional Ambulance Pick-up Location Loop NM1 2500 Ambulance Pick-up Location Max use 1 Required N3 2650 Ambulance Pick-up Location Address Max use 1 Required N4 2700 Ambulance Pick-up Location City, State, ZIP Code Max use 1 Required Ambulance Drop-off Location Loop NM1 2500 Ambulance Drop-off Location Max use 1 Required N3 2650 Ambulance Drop-off Location Address Max use 1 Required N4 2700 Ambulance Drop-off Location City, State, ZIP Code Max use 1 Required Other Subscriber Information Loop SBR 2900 Other Subscriber Information Max use 1 Required CAS 2950 Claim Level Adjustments Max use 5 Optional AMT 3000 Coordination of Benefits (COB) Payer Paid Amount Max use 1 Optional AMT 3000 Coordination of Benefits (COB) Total Non- Covered Amount Max use 1 Optional AMT 3000 Remaining Patient Liability Max use 1 Optional 1/30/25, 11:53 AM Texas Medicaid & Healthcare Partnerships (TMHP) 837 837 Health Care Claim: Professional (X222/A2/A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/tmhp/837-health-care-claim-professional-x222a2a1/01HMBZ8Y6XYRFK1ZR16EKD50N6 5/552 OI 3100 Other Insurance Coverage Information Max use 1 Required MOA 3200 Outpatient Adjudication Information Max use 1 Optional Other Subscriber Name Loop NM1 3250 Other Subscriber Name Max use 1 Required N3 3320 Other Subscriber Address Max use 1 Optional N4 3400 Other Subscriber City, State, ZIP Code Max use 1 Optional REF 3550 Other Subscriber Secondary Identification Max use 1 Optional Other Payer Name Loop NM1 3250 Other Payer Name Max use 1 Required N3 3320 Other Payer Address Max use 1 Optional N4 3400 Other Payer City, State, ZIP Code Max use 1 Optional DTP 3450 Claim Check or Remittance Date Max use 1 Optional REF 3550 Other Payer Claim Adjustment Indicator Max use 1 Optional REF 3550 Other Payer Claim Control Number Max use 1 Optional REF 3550 Other Payer Prior Authorization Number Max use 1 Optional REF 3550 Other Payer Referral Number Max use 1 Optional REF 3550 Other Payer Secondary Identifier Max use 2 Optional Other Payer Referring Provider Loop NM1 3250 Other Payer Referring Provider Max use 1 Required REF 3550 Other Payer Referring Provider Secondary Identification Max use 3 Required Other Payer Rendering Provider Loop NM1 3250 Other Payer Rendering Provider Max use 1 Required REF 3550 Other Payer Rendering Provider Secondary Identification Max use 3 Required Other Payer Service Facility Location Loop NM1 3250 Other Payer Service Facility Location Max use 1 Required REF 3550 Other Payer Service Facility Location Secondary Identification Max use 3 Required Other Payer Supervising Provider Loop NM1 3250 Other Payer Supervising Provider Max use 1 Required REF 3550 Other Payer Supervising Provider Secondary Identification Max use 3 Required Other Payer Billing Provider Loop NM1 3250 Other Payer Billing Provider Max use 1 Required REF 3550 Other Payer Billing Provider Secondary Identification Max use 2 Required 1/30/25, 11:53 AM Texas Medicaid & Healthcare Partnerships (TMHP) 837 837 Health Care Claim: Professional (X222/A2/A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/tmhp/837-health-care-claim-professional-x222a2a1/01HMBZ8Y6XYRFK1ZR16EKD50N6 6/552 Service Line Number Loop LX 3650 Service Line Number Max use 1 Required SV1 3700 Professional Service Max use 1 Required SV5 4000 Durable Medical Equipment Service Max use 1 Optional PWK 4200 Durable Medical Equipment Certificate of Medical Necessity Indicator Max use 1 Optional PWK 4200 Line Supplemental Information Max use 10 Optional CR1 4250 Ambulance Transport Information Max use 1 Optional CR3 4350 Durable Medical Equipment Certification Max use 1 Optional CRC 4500 Ambulance Certification Max use 3 Optional CRC 4500 Condition Indicator/Durable Medical Equipment Max use 1 Optional CRC 4500 Hospice Employee Indicator Max use 1 Optional DTP 4550 Date - Begin Therapy Date Max use	Texas Medicaid and Healthcare Partnerships.pdf
1 Required Other Subscriber Information Loop SBR 2900 Other Subscriber Information Max use 1 Required CAS 2950 Claim Level Adjustments Max use 5 Optional AMT 3000 Coordination of Benefits (COB) Payer Paid Amount Max use 1 Optional AMT 3000 Coordination of Benefits (COB) Total Non- Covered Amount Max use 1 Optional AMT 3000 Remaining Patient Liability Max use 1 Optional 1/30/25, 11:53 AM Texas Medicaid & Healthcare Partnerships (TMHP) 837 837 Health Care Claim: Professional (X222/A2/A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/tmhp/837-health-care-claim-professional-x222a2a1/01HMBZ8Y6XYRFK1ZR16EKD50N6 5/552 OI 3100 Other Insurance Coverage Information Max use 1 Required MOA 3200 Outpatient Adjudication Information Max use 1 Optional Other Subscriber Name Loop NM1 3250 Other Subscriber Name Max use 1 Required N3 3320 Other Subscriber Address Max use 1 Optional N4 3400 Other Subscriber City, State, ZIP Code Max use 1 Optional REF 3550 Other Subscriber Secondary Identification Max use 1 Optional Other Payer Name Loop NM1 3250 Other Payer Name Max use 1 Required N3 3320 Other Payer Address Max use 1 Optional N4 3400 Other Payer City, State, ZIP Code Max use 1 Optional DTP 3450 Claim Check or Remittance Date Max use 1 Optional REF 3550 Other Payer Claim Adjustment Indicator Max use 1 Optional REF 3550 Other Payer Claim Control Number Max use 1 Optional REF 3550 Other Payer Prior Authorization Number Max use 1 Optional REF 3550 Other Payer Referral Number Max use 1 Optional REF 3550 Other Payer Secondary Identifier Max use 2 Optional Other Payer Referring Provider Loop NM1 3250 Other Payer Referring Provider Max use 1 Required REF 3550 Other Payer Referring Provider Secondary Identification Max use 3 Required Other Payer Rendering Provider Loop NM1 3250 Other Payer Rendering Provider Max use 1 Required REF 3550 Other Payer Rendering Provider Secondary Identification Max use 3 Required Other Payer Service Facility Location Loop NM1 3250 Other Payer Service Facility Location Max use 1 Required REF 3550 Other Payer Service Facility Location Secondary Identification Max use 3 Required Other Payer Supervising Provider Loop NM1 3250 Other Payer Supervising Provider Max use 1 Required REF 3550 Other Payer Supervising Provider Secondary Identification Max use 3 Required Other Payer Billing Provider Loop NM1 3250 Other Payer Billing Provider Max use 1 Required REF 3550 Other Payer Billing Provider Secondary Identification Max use 2 Required 1/30/25, 11:53 AM Texas Medicaid & Healthcare Partnerships (TMHP) 837 837 Health Care Claim: Professional (X222/A2/A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/tmhp/837-health-care-claim-professional-x222a2a1/01HMBZ8Y6XYRFK1ZR16EKD50N6 6/552 Service Line Number Loop LX 3650 Service Line Number Max use 1 Required SV1 3700 Professional Service Max use 1 Required SV5 4000 Durable Medical Equipment Service Max use 1 Optional PWK 4200 Durable Medical Equipment Certificate of Medical Necessity Indicator Max use 1 Optional PWK 4200 Line Supplemental Information Max use 10 Optional CR1 4250 Ambulance Transport Information Max use 1 Optional CR3 4350 Durable Medical Equipment Certification Max use 1 Optional CRC 4500 Ambulance Certification Max use 3 Optional CRC 4500 Condition Indicator/Durable Medical Equipment Max use 1 Optional CRC 4500 Hospice Employee Indicator Max use 1 Optional DTP 4550 Date - Begin Therapy Date Max use 1 Optional DTP 4550 DATE - Certification Revision/Recertification Date Max use 1 Optional DTP 4550 Date - Initial Treatment Date Max use 1 Optional DTP 4550 Date - Last Certification Date Max use 1 Optional DTP 4550 Date - Last Seen Date Max use 1 Optional DTP 4550 Date - Last X-ray Date Max use 1 Optional DTP 4550 Date - Prescription Date Max use 1 Optional DTP 4550 Date - Service Date Max use 1 Required DTP 4550 Date - Shipped Date Max use 1 Optional DTP 4550 Date - Test Date Max use 2 Optional QTY 4600 Ambulance Patient Count Max use 1 Optional QTY 4600 Obstetric Anesthesia Additional Units Max use 1 Optional MEA 4620 Test Result Max use 5 Optional CN1 4650 Contract Information Max use 1 Optional REF 4700 Adjusted Repriced Line Item Reference Number Max use 1 Optional REF 4700 Clinical Laboratory Improvement Amendment (CLIA) Number Max use 1 Optional REF 4700 Immunization Batch Number Max use 1 Optional REF 4700 Line Item Control Number Max use 1 Optional REF 4700 Mammography Certification Number Max use 1 Optional REF 4700 Prior Authorization Max use 5 Optional REF 4700 Referral Number Max use 5 Optional REF 4700 Referring Clinical Laboratory Improvement Amendment (CLIA) Facility Identification Max use 1 Optional 1/30/25, 11:53 AM Texas Medicaid & Healthcare Partnerships (TMHP) 837 837 Health Care Claim: Professional (X222/A2/A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/tmhp/837-health-care-claim-professional-x222a2a1/01HMBZ8Y6XYRFK1ZR16EKD50N6 7/552 REF 4700 Repriced Line Item Reference Number Max use 1 Optional AMT 4750 Postage Claimed Amount Max use 1 Optional AMT 4750 Sales Tax Amount Max use 1 Optional K3 4800 File Information Max use 10 Optional NTE 4850 Line Note Max use 1 Optional NTE 4850 Third Party Organization Notes Max use 1 Optional PS1 4880 Purchased Service Information Max use 1 Optional HCP 4920 Line Pricing/Repricing Information Max use 1 Optional Drug Identification Loop LIN 4930 Drug Identification Max use 1 Required CTP 4940 Drug Quantity Max use 1 Required REF 4950 Prescription or Compound Drug Association Number Max use 1 Optional Rendering Provider Name Loop NM1 5000 Rendering Provider Name Max use 1 Required PRV 5050 Rendering Provider Specialty Information Max use 1 Optional REF 5250 Rendering Provider Secondary Identification Max use 20 Optional Purchased Service Provider Name Loop NM1 5000 Purchased Service Provider Name Max use 1 Required REF 5250 Purchased Service Provider Secondary Identification Max use 20 Optional Service Facility Location Name Loop NM1 5000 Service Facility Location Name Max use 1 Required N3 5140 Service Facility Location Address Max use 1 Required N4 5200 Service Facility Location City, State, ZIP Code Max use 1 Required REF 5250 Service Facility Location Secondary Identification Max use 3 Optional Supervising Provider Name Loop NM1 5000 Supervising Provider Name Max use 1 Required REF 5250 Supervising Provider Secondary Identification Max use 20 Optional Ordering Provider Name Loop NM1 5000 Ordering Provider Name Max use 1 Required N3 5140 Ordering Provider Address Max use 1 Optional N4 5200 Ordering Provider City, State, ZIP Code Max use 1 Optional REF 5250 Ordering Provider Secondary Identification Max use 20 Optional PER 5300 Ordering Provider Contact Information Max use 1 Optional 1/30/25, 11:53 AM Texas Medicaid & Healthcare Partnerships (TMHP) 837 837 Health Care Claim: Professional (X222/A2/A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/tmhp/837-health-care-claim-professional-x222a2a1/01HMBZ8Y6XYRFK1ZR16EKD50N6 8/552 Referring Provider Name Loop NM1 5000 Referring Provider Name Max use 1 Required REF 5250 Referring Provider Secondary Identification Max use 20 Optional Ambulance Pick-up Location Loop NM1 5000 Ambulance Pick-up Location Max use 1 Required N3 5140 Ambulance Pick-up Location Address Max use 1 Required N4 5200 Ambulance Pick-up Location City, State, ZIP Code Max use 1 Required Ambulance Drop-off Location Loop NM1 5000 Ambulance Drop-off Location Max use 1 Required N3 5140 Ambulance Drop-off Location Address Max use 1 Required N4 5200 Ambulance Drop-off Location City, State, ZIP Code Max use 1 Required Line Adjudication Information Loop SVD 5400 Line Adjudication Information Max use 1 Required CAS 5450 Line Adjustment Max use 5 Optional DTP 5500 Line Check or Remittance Date Max use 1 Required AMT 5505 Remaining Patient Liability Max use 1 Optional Form Identification Code Loop LQ 5510 Form Identification Code Max use 1 Required FRM 5520 Supporting Documentation Max use 99 Required Patient Hierarchical Level Loop HL 0010 Hierarchical Level Max use 1 Required PAT 0070 Patient Information Max use 1 Required Patient Name Loop NM1 0150 Patient Name Max use 1 Required N3 0250 Patient Address Max use 1 Required N4 0300 Patient City, State, ZIP Code Max use 1 Required DMG 0320 Patient Demographic Information Max use 1 Required REF 0350 Property and Casualty Claim Number Max use 1 Optional REF 0350 Property and Casualty Patient Identifier Max use 1 Optional PER 0400 Property and Casualty Patient Contact Information Max use 1 Optional Claim Information Loop CLM 1300 Claim Information Max use 1 Required DTP 1350 Date - Accident Max use 1 Optional 1/30/25, 11:53 AM Texas Medicaid & Healthcare Partnerships (TMHP) 837 837 Health Care Claim: Professional (X222/A2/A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/tmhp/837-health-care-claim-professional-x222a2a1/01HMBZ8Y6XYRFK1ZR16EKD50N6 9/552 DTP 1350 Date - Acute Manifestation Max use 1 Optional DTP 1350 Date - Admission Max use 1 Optional DTP 1350 Date - Assumed and Relinquished Care Dates Max use 2 Optional DTP 1350 Date - Authorized Return to Work Max use 1 Optional DTP 1350 Date - Disability Dates Max use 1 Optional DTP 1350 Date - Discharge Max use 1 Optional DTP 1350 Date - Hearing and Vision Prescription Date Max use 1 Optional DTP 1350 Date - Initial Treatment Date Max use 1 Optional DTP 1350 Date - Last Menstrual Period Max use 1 Optional DTP 1350 Date - Last Seen Date Max use 1 Optional DTP 1350 Date - Last Worked Max use 1 Optional DTP 1350 Date - Last X-ray Date Max use 1 Optional DTP 1350 Date - Onset of Current Illness or Symptom Max use 1 Optional DTP 1350 Date - Property and Casualty Date of First Contact Max use 1 Optional DTP 1350 Date - Repricer Received Date Max use 1 Optional PWK 1550 Claim Supplemental Information Max use 10 Optional CN1 1600 Contract Information Max use 1 Optional AMT 1750 Patient Amount Paid Max use 1 Optional REF 1800 Adjusted Repriced Claim Number Max use 1 Optional REF 1800 Care Plan Oversight Max use 1 Optional REF 1800 Claim Identifier For Transmission Intermediaries Max use 1 Optional REF 1800 Clinical Laboratory Improvement Amendment (CLIA) Number Max use 1 Optional REF 1800 Demonstration Project Identifier Max use 1 Optional REF 1800 Investigational Device Exemption Number Max use 1 Optional REF 1800 Mammography Certification Number Max use 1 Optional REF 1800 Mandatory Medicare (Section 4081) Crossover Indicator Max use 1 Optional REF 1800 Medical Record Number Max use 1 Optional REF 1800 Payer Claim Control Number Max use 1 Optional REF 1800 Prior Authorization Max use 1 Optional REF 1800 Referral Number Max use 1 Optional REF 1800 Repriced Claim Number Max use 1 Optional REF 1800 Service Authorization Exception Code Max use 1 Optional K3 1850 File Information Max use 10 Optional NTE 1900 Claim Note Max use 1 Optional 1/30/25, 11:53 AM Texas Medicaid & Healthcare Partnerships (TMHP) 837 837 Health Care Claim: Professional (X222/A2/A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/tmhp/837-health-care-claim-professional-x222a2a1/01HMBZ8Y6XYRFK1ZR16EKD50N6 10/552 CR1 1950 Ambulance Transport Information Max use 1 Optional CR2 2000 Spinal Manipulation Service Information Max use 1 Optional CRC 2200 Ambulance Certification Max use 3 Optional CRC 2200 EPSDT Referral Max use 1 Optional CRC 2200 Homebound Indicator Max use 1 Optional CRC 2200 Patient Condition Information: Vision Max use 3 Optional HI 2310 Anesthesia Related Procedure Max use 1 Optional HI 2310 Condition Information Max use 2 Optional HI 2310 Health Care Diagnosis Code Max use 1 Required HCP 2410 Claim Pricing/Repricing Information Max use 1 Optional Referring Provider Name Loop NM1 2500 Referring Provider Name Max use 1 Required REF 2710 Referring Provider Secondary Identification Max use 3 Optional Rendering Provider Name Loop NM1 2500 Rendering Provider Name Max use 1 Required PRV 2550 Rendering Provider Specialty Information Max use 1 Optional REF 2710 Rendering Provider Secondary Identification Max use 4 Optional Service Facility Location Name Loop NM1 2500 Service Facility Location Name Max use 1 Required N3 2650 Service Facility Location Address Max use 1 Required N4 2700 Service Facility Location City, State, ZIP Code Max use 1 Required REF 2710 Service Facility Location Secondary Identification Max use 3 Optional PER 2750 Service Facility Contact Information Max use 1 Optional Supervising Provider Name Loop NM1 2500 Supervising Provider Name Max use 1 Required REF 2710 Supervising Provider Secondary Identification Max use 4 Optional Ambulance Pick-up Location Loop NM1 2500 Ambulance Pick-up Location Max use 1 Required N3 2650 Ambulance Pick-up Location Address Max use 1 Required N4 2700 Ambulance Pick-up Location City, State, ZIP Code Max use 1 Required Ambulance Drop-off Location Loop NM1 2500 Ambulance Drop-off Location Max use 1 Required N3 2650 Ambulance Drop-off Location Address Max use 1 Required 1/30/25, 11:53 AM Texas Medicaid & Healthcare Partnerships (TMHP) 837 837 Health Care Claim: Professional (X222/A2/A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/tmhp/837-health-care-claim-professional-x222a2a1/01HMBZ8Y6XYRFK1ZR16EKD50N6 11/552 N4 2700 Ambulance Drop-off Location City, State, ZIP Code Max use 1 Required Other Subscriber Information Loop SBR 2900	Texas Medicaid and Healthcare Partnerships.pdf
1 Optional AMT 1750 Patient Amount Paid Max use 1 Optional REF 1800 Adjusted Repriced Claim Number Max use 1 Optional REF 1800 Care Plan Oversight Max use 1 Optional REF 1800 Claim Identifier For Transmission Intermediaries Max use 1 Optional REF 1800 Clinical Laboratory Improvement Amendment (CLIA) Number Max use 1 Optional REF 1800 Demonstration Project Identifier Max use 1 Optional REF 1800 Investigational Device Exemption Number Max use 1 Optional REF 1800 Mammography Certification Number Max use 1 Optional REF 1800 Mandatory Medicare (Section 4081) Crossover Indicator Max use 1 Optional REF 1800 Medical Record Number Max use 1 Optional REF 1800 Payer Claim Control Number Max use 1 Optional REF 1800 Prior Authorization Max use 1 Optional REF 1800 Referral Number Max use 1 Optional REF 1800 Repriced Claim Number Max use 1 Optional REF 1800 Service Authorization Exception Code Max use 1 Optional K3 1850 File Information Max use 10 Optional NTE 1900 Claim Note Max use 1 Optional 1/30/25, 11:53 AM Texas Medicaid & Healthcare Partnerships (TMHP) 837 837 Health Care Claim: Professional (X222/A2/A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/tmhp/837-health-care-claim-professional-x222a2a1/01HMBZ8Y6XYRFK1ZR16EKD50N6 10/552 CR1 1950 Ambulance Transport Information Max use 1 Optional CR2 2000 Spinal Manipulation Service Information Max use 1 Optional CRC 2200 Ambulance Certification Max use 3 Optional CRC 2200 EPSDT Referral Max use 1 Optional CRC 2200 Homebound Indicator Max use 1 Optional CRC 2200 Patient Condition Information: Vision Max use 3 Optional HI 2310 Anesthesia Related Procedure Max use 1 Optional HI 2310 Condition Information Max use 2 Optional HI 2310 Health Care Diagnosis Code Max use 1 Required HCP 2410 Claim Pricing/Repricing Information Max use 1 Optional Referring Provider Name Loop NM1 2500 Referring Provider Name Max use 1 Required REF 2710 Referring Provider Secondary Identification Max use 3 Optional Rendering Provider Name Loop NM1 2500 Rendering Provider Name Max use 1 Required PRV 2550 Rendering Provider Specialty Information Max use 1 Optional REF 2710 Rendering Provider Secondary Identification Max use 4 Optional Service Facility Location Name Loop NM1 2500 Service Facility Location Name Max use 1 Required N3 2650 Service Facility Location Address Max use 1 Required N4 2700 Service Facility Location City, State, ZIP Code Max use 1 Required REF 2710 Service Facility Location Secondary Identification Max use 3 Optional PER 2750 Service Facility Contact Information Max use 1 Optional Supervising Provider Name Loop NM1 2500 Supervising Provider Name Max use 1 Required REF 2710 Supervising Provider Secondary Identification Max use 4 Optional Ambulance Pick-up Location Loop NM1 2500 Ambulance Pick-up Location Max use 1 Required N3 2650 Ambulance Pick-up Location Address Max use 1 Required N4 2700 Ambulance Pick-up Location City, State, ZIP Code Max use 1 Required Ambulance Drop-off Location Loop NM1 2500 Ambulance Drop-off Location Max use 1 Required N3 2650 Ambulance Drop-off Location Address Max use 1 Required 1/30/25, 11:53 AM Texas Medicaid & Healthcare Partnerships (TMHP) 837 837 Health Care Claim: Professional (X222/A2/A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/tmhp/837-health-care-claim-professional-x222a2a1/01HMBZ8Y6XYRFK1ZR16EKD50N6 11/552 N4 2700 Ambulance Drop-off Location City, State, ZIP Code Max use 1 Required Other Subscriber Information Loop SBR 2900 Other Subscriber Information Max use 1 Required CAS 2950 Claim Level Adjustments Max use 5 Optional AMT 3000 Coordination of Benefits (COB) Payer Paid Amount Max use 1 Optional AMT 3000 Coordination of Benefits (COB) Total Non- Covered Amount Max use 1 Optional AMT 3000 Remaining Patient Liability Max use 1 Optional OI 3100 Other Insurance Coverage Information Max use 1 Required MOA 3200 Outpatient Adjudication Information Max use 1 Optional Other Subscriber Name Loop NM1 3250 Other Subscriber Name Max use 1 Required N3 3320 Other Subscriber Address Max use 1 Optional N4 3400 Other Subscriber City, State, ZIP Code Max use 1 Optional REF 3550 Other Subscriber Secondary Identification Max use 1 Optional Other Payer Name Loop NM1 3250 Other Payer Name Max use 1 Required N3 3320 Other Payer Address Max use 1 Optional N4 3400 Other Payer City, State, ZIP Code Max use 1 Optional DTP 3450 Claim Check or Remittance Date Max use 1 Optional REF 3550 Other Payer Claim Adjustment Indicator Max use 1 Optional REF 3550 Other Payer Claim Control Number Max use 1 Optional REF 3550 Other Payer Prior Authorization Number Max use 1 Optional REF 3550 Other Payer Referral Number Max use 1 Optional REF 3550 Other Payer Secondary Identifier Max use 2 Optional Other Payer Referring Provider Loop NM1 3250 Other Payer Referring Provider Max use 1 Required REF 3550 Other Payer Referring Provider Secondary Identification Max use 3 Required Other Payer Rendering Provider Loop NM1 3250 Other Payer Rendering Provider Max use 1 Required REF 3550 Other Payer Rendering Provider Secondary Identification Max use 3 Required Other Payer Service Facility Location Loop NM1 3250 Other Payer Service Facility Location Max use 1 Required 1/30/25, 11:53 AM Texas Medicaid & Healthcare Partnerships (TMHP) 837 837 Health Care Claim: Professional (X222/A2/A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/tmhp/837-health-care-claim-professional-x222a2a1/01HMBZ8Y6XYRFK1ZR16EKD50N6 12/552 REF 3550 Other Payer Service Facility Location Secondary Identification Max use 3 Required Other Payer Supervising Provider Loop NM1 3250 Other Payer Supervising Provider Max use 1 Required REF 3550 Other Payer Supervising Provider Secondary Identification Max use 3 Required Other Payer Billing Provider Loop NM1 3250 Other Payer Billing Provider Max use 1 Required REF 3550 Other Payer Billing Provider Secondary Identification Max use 2 Required Service Line Number Loop LX 3650 Service Line Number Max use 1 Required SV1 3700 Professional Service Max use 1 Required SV5 4000 Durable Medical Equipment Service Max use 1 Optional PWK 4200 Durable Medical Equipment Certificate of Medical Necessity Indicator Max use 1 Optional PWK 4200 Line Supplemental Information Max use 10 Optional CR1 4250 Ambulance Transport Information Max use 1 Optional CR3 4350 Durable Medical Equipment Certification Max use 1 Optional CRC 4500 Ambulance Certification Max use 3 Optional CRC 4500 Condition Indicator/Durable Medical Equipment Max use 1 Optional CRC 4500 Hospice Employee Indicator Max use 1 Optional DTP 4550 Date - Begin Therapy Date Max use 1 Optional DTP 4550 DATE - Certification Revision/Recertification Date Max use 1 Optional DTP 4550 Date - Initial Treatment Date Max use 1 Optional DTP 4550 Date - Last Certification Date Max use 1 Optional DTP 4550 Date - Last Seen Date Max use 1 Optional DTP 4550 Date - Last X-ray Date Max use 1 Optional DTP 4550 Date - Prescription Date Max use 1 Optional DTP 4550 Date - Service Date Max use 1 Required DTP 4550 Date - Shipped Date Max use 1 Optional DTP 4550 Date - Test Date Max use 2 Optional QTY 4600 Ambulance Patient Count Max use 1 Optional QTY 4600 Obstetric Anesthesia Additional Units Max use 1 Optional MEA 4620 Test Result Max use 5 Optional CN1 4650 Contract Information Max use 1 Optional 1/30/25, 11:53 AM Texas Medicaid & Healthcare Partnerships (TMHP) 837 837 Health Care Claim: Professional (X222/A2/A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/tmhp/837-health-care-claim-professional-x222a2a1/01HMBZ8Y6XYRFK1ZR16EKD50N6 13/552 REF 4700 Adjusted Repriced Line Item Reference Number Max use 1 Optional REF 4700 Clinical Laboratory Improvement Amendment (CLIA) Number Max use 1 Optional REF 4700 Immunization Batch Number Max use 1 Optional REF 4700 Line Item Control Number Max use 1 Optional REF 4700 Mammography Certification Number Max use 1 Optional REF 4700 Prior Authorization Max use 5 Optional REF 4700 Referral Number Max use 5 Optional REF 4700 Referring Clinical Laboratory Improvement Amendment (CLIA) Facility Identification Max use 1 Optional REF 4700 Repriced Line Item Reference Number Max use 1 Optional AMT 4750 Postage Claimed Amount Max use 1 Optional AMT 4750 Sales Tax Amount Max use 1 Optional K3 4800 File Information Max use 10 Optional NTE 4850 Line Note Max use 1 Optional NTE 4850 Third Party Organization Notes Max use 1 Optional PS1 4880 Purchased Service Information Max use 1 Optional HCP 4920 Line Pricing/Repricing Information Max use 1 Optional Drug Identification Loop LIN 4930 Drug Identification Max use 1 Required CTP 4940 Drug Quantity Max use 1 Required REF 4950 Prescription or Compound Drug Association Number Max use 1 Optional Rendering Provider Name Loop NM1 5000 Rendering Provider Name Max use 1 Required PRV 5050 Rendering Provider Specialty Information Max use 1 Optional REF 5250 Rendering Provider Secondary Identification Max use 20 Optional Purchased Service Provider Name Loop NM1 5000 Purchased Service Provider Name Max use 1 Required REF 5250 Purchased Service Provider Secondary Identification Max use 20 Optional Service Facility Location Name Loop NM1 5000 Service Facility Location Name Max use 1 Required N3 5140 Service Facility Location Address Max use 1 Required N4 5200 Service Facility Location City, State, ZIP Code Max use 1 Required REF 5250 Service Facility Location Secondary Identification Max use 3 Optional 1/30/25, 11:53 AM Texas Medicaid & Healthcare Partnerships (TMHP) 837 837 Health Care Claim: Professional (X222/A2/A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/tmhp/837-health-care-claim-professional-x222a2a1/01HMBZ8Y6XYRFK1ZR16EKD50N6 14/552 Supervising Provider Name Loop NM1 5000 Supervising Provider Name Max use 1 Required REF 5250 Supervising Provider Secondary Identification Max use 20 Optional Ordering Provider Name Loop NM1 5000 Ordering Provider Name Max use 1 Required N3 5140 Ordering Provider Address Max use 1 Optional N4 5200 Ordering Provider City, State, ZIP Code Max use 1 Optional REF 5250 Ordering Provider Secondary Identification Max use 20 Optional PER 5300 Ordering Provider Contact Information Max use 1 Optional Referring Provider Name Loop NM1 5000 Referring Provider Name Max use 1 Required REF 5250 Referring Provider Secondary Identification Max use 20 Optional Ambulance Pick-up Location Loop NM1 5000 Ambulance Pick-up Location Max use 1 Required N3 5140 Ambulance Pick-up Location Address Max use 1 Required N4 5200 Ambulance Pick-up Location City, State, ZIP Code Max use 1 Required Ambulance Drop-off Location Loop NM1 5000 Ambulance Drop-off Location Max use 1 Required N3 5140 Ambulance Drop-off Location Address Max use 1 Required N4 5200 Ambulance Drop-off Location City, State, ZIP Code Max use 1 Required Line Adjudication Information Loop SVD 5400 Line Adjudication Information Max use 1 Required CAS 5450 Line Adjustment Max use 5 Optional DTP 5500 Line Check or Remittance Date Max use 1 Required AMT 5505 Remaining Patient Liability Max use 1 Optional Form Identification Code Loop LQ 5510 Form Identification Code Max use 1 Required FRM 5520 Supporting Documentation Max use 99 Required SE 5550 Transaction Set Trailer Max use 1 Required GE - Functional Group Trailer Max use 1 Required IEA - Interchange Control Trailer Max use 1 Required 1/30/25, 11:53 AM Texas Medicaid & Healthcare Partnerships (TMHP) 837 837 Health Care Claim: Professional (X222/A2/A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/tmhp/837-health-care-claim-professional-x222a2a1/01HMBZ8Y6XYRFK1ZR16EKD50N6 15/552 ISA Interchange Control Header To start and identify an interchange of zero or more functional groups and interchange- related control segments Example ISA00 00 XXXXXXXXXXXXXXXX XXXXXXXXXXXXXXXXXX2501302312^0050100000000 0XX>~ Max use 1 Required ISA-01 I01 Authorization Information Qualifier Identifier (ID) Required Code identifying the type of information in the Authorization Information 00 No Authorization Information Present (No Meaningful Information in I02) ISA-02 I02 Authorization Information Min 10 Max 10 String (AN) Required Information used for additional identification or authorization of the interchange sender or the data in the interchange; the type of information is set by the Authorization Information Qualifier (I01) ISA-03 I03 Security Information Qualifier Identifier (ID) Required Code identifying the type of information in the Security Information 00 No Security Information Present (No Meaningful Information in I04) ISA-04 I04 Security Information Min 10 Max 10 String (AN) Required This is used for identifying the security information about the interchange sender or the data in the interchange; the type of information is set by the Security Information Qualifier (I03) ISA-05 I05 Interchange ID Qualifier Min 2 Max 2 Identifier (ID) Required Code indicating the system/method of code structure used to designate the sender or receiver ID element being qualified Codes ISA-06 I06 Interchange Sender ID Min 15 Max 15 String (AN) Required Identification code published by the sender for other parties to use as the receiver ID to route data to them; the sender always codes this value in the sender ID element ISA-07 I05 Interchange ID Qualifier Min 2 Max 2 Identifier (ID) Required Code indicating the system/method of code structure used to designate the sender or receiver ID element being qualified Codes ISA-08 I07 Interchange Receiver ID Min 15 Max 15 String (AN) Required 1/30/25, 11:53 AM Texas Medicaid & Healthcare Partnerships (TMHP) 837 837 Health Care Claim: Professional (X222/A2/A1)	Texas Medicaid and Healthcare Partnerships.pdf
Information Max use 1 Optional Referring Provider Name Loop NM1 5000 Referring Provider Name Max use 1 Required REF 5250 Referring Provider Secondary Identification Max use 20 Optional Ambulance Pick-up Location Loop NM1 5000 Ambulance Pick-up Location Max use 1 Required N3 5140 Ambulance Pick-up Location Address Max use 1 Required N4 5200 Ambulance Pick-up Location City, State, ZIP Code Max use 1 Required Ambulance Drop-off Location Loop NM1 5000 Ambulance Drop-off Location Max use 1 Required N3 5140 Ambulance Drop-off Location Address Max use 1 Required N4 5200 Ambulance Drop-off Location City, State, ZIP Code Max use 1 Required Line Adjudication Information Loop SVD 5400 Line Adjudication Information Max use 1 Required CAS 5450 Line Adjustment Max use 5 Optional DTP 5500 Line Check or Remittance Date Max use 1 Required AMT 5505 Remaining Patient Liability Max use 1 Optional Form Identification Code Loop LQ 5510 Form Identification Code Max use 1 Required FRM 5520 Supporting Documentation Max use 99 Required SE 5550 Transaction Set Trailer Max use 1 Required GE - Functional Group Trailer Max use 1 Required IEA - Interchange Control Trailer Max use 1 Required 1/30/25, 11:53 AM Texas Medicaid & Healthcare Partnerships (TMHP) 837 837 Health Care Claim: Professional (X222/A2/A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/tmhp/837-health-care-claim-professional-x222a2a1/01HMBZ8Y6XYRFK1ZR16EKD50N6 15/552 ISA Interchange Control Header To start and identify an interchange of zero or more functional groups and interchange- related control segments Example ISA00 00 XXXXXXXXXXXXXXXX XXXXXXXXXXXXXXXXXX2501302312^0050100000000 0XX>~ Max use 1 Required ISA-01 I01 Authorization Information Qualifier Identifier (ID) Required Code identifying the type of information in the Authorization Information 00 No Authorization Information Present (No Meaningful Information in I02) ISA-02 I02 Authorization Information Min 10 Max 10 String (AN) Required Information used for additional identification or authorization of the interchange sender or the data in the interchange; the type of information is set by the Authorization Information Qualifier (I01) ISA-03 I03 Security Information Qualifier Identifier (ID) Required Code identifying the type of information in the Security Information 00 No Security Information Present (No Meaningful Information in I04) ISA-04 I04 Security Information Min 10 Max 10 String (AN) Required This is used for identifying the security information about the interchange sender or the data in the interchange; the type of information is set by the Security Information Qualifier (I03) ISA-05 I05 Interchange ID Qualifier Min 2 Max 2 Identifier (ID) Required Code indicating the system/method of code structure used to designate the sender or receiver ID element being qualified Codes ISA-06 I06 Interchange Sender ID Min 15 Max 15 String (AN) Required Identification code published by the sender for other parties to use as the receiver ID to route data to them; the sender always codes this value in the sender ID element ISA-07 I05 Interchange ID Qualifier Min 2 Max 2 Identifier (ID) Required Code indicating the system/method of code structure used to designate the sender or receiver ID element being qualified Codes ISA-08 I07 Interchange Receiver ID Min 15 Max 15 String (AN) Required 1/30/25, 11:53 AM Texas Medicaid & Healthcare Partnerships (TMHP) 837 837 Health Care Claim: Professional (X222/A2/A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/tmhp/837-health-care-claim-professional-x222a2a1/01HMBZ8Y6XYRFK1ZR16EKD50N6 16/552 Identification code published by the receiver of the data; When sending, it is used by the sender as their sending ID, thus other parties sending to them will use this as a receiving ID to route data to them ISA-09 I08 Interchange Date YYMMDD format Date (DT) Required Date of the interchange ISA-10 I09 Interchange Time HHMM format Time (TM) Required Time of the interchange ISA-11 I65 Repetition Separator Min 1 Max 1 String (AN) Required Type is not applicable; the repetition separator is a delimiter and not a data element; this field provides the delimiter used to separate repeated occurrences of a simple data element or a composite data structure; this value must be different than the data element separator, component element separator, and the segment terminator ^ Repetition Separator ISA-12 I11 Interchange Control Version Number Identifier (ID) Required Code specifying the version number of the interchange control segments 00501 Standards Approved for Publication by ASC X12 Procedures Review Board through October 2003 ISA-13 I12 Interchange Control Number Min 9 Max 9 Numeric (N0) Required A control number assigned by the interchange sender ISA-14 I13 Acknowledgment Requested Min 1 Max 1 Identifier (ID) Required Code indicating sender's request for an interchange acknowledgment 0 No Interchange Acknowledgment Requested 1 Interchange Acknowledgment Requested (TA1) ISA-15 I14 Interchange Usage Indicator Min 1 Max 1 Identifier (ID) Required Code indicating whether data enclosed by this interchange envelope is test, production or information I Information P Production Data T Test Data ISA-16 I15 Component Element Separator Min 1 Max 1 String (AN) Required Type is not applicable; the component element separator is a delimiter and not a data element; this field provides the delimiter used to separate component data elements within a composite data structure; this value must be different than the data element separator and the segment terminator > Component Element Separator 1/30/25, 11:53 AM Texas Medicaid & Healthcare Partnerships (TMHP) 837 837 Health Care Claim: Professional (X222/A2/A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/tmhp/837-health-care-claim-professional-x222a2a1/01HMBZ8Y6XYRFK1ZR16EKD50N6 17/552 GS Functional Group Header To indicate the beginning of a functional group and to provide control information Example GSHCXXXXXXX202501310137000000000XX005010X 222A2~ Max use 1 Required GS-01 479 Functional Identifier Code Identifier (ID) Required Code identifying a group of application related transaction sets HC Health Care Claim (837) GS-02 142 Application Sender's Code Min 2 Max 15 String (AN) Required Code identifying party sending transmission; codes agreed to by trading partners GS-03 124 Application Receiver's Code Min 2 Max 15 String (AN) Required Code identifying party receiving transmission; codes agreed to by trading partners GS-04 373 Date CCYYMMDD format Date (DT) Required Date expressed as CCYYMMDD where CC represents the first two digits of the calendar year GS-05 337 Time HHMM, HHMMSS, HHMMSSD, or HHMMSSDD format Time (TM) Required Time expressed in 24-hour clock time as follows: HHMM, or HHMMSS, or HHMMSSD, or HHMMSSDD, where H = hours (00-23), M = minutes (00-59), S = integer seconds (00-59) and DD = decimal seconds; decimal seconds are expressed as follows: D = tenths (0-9) and DD = hundredths (00-99) GS-06 28 Group Control Number Min 1 Max 9 Numeric (N0) Required Assigned number originated and maintained by the sender GS-07 455 Responsible Agency Code Min 1 Max 2 Identifier (ID) Required Code identifying the issuer of the standard; this code is used in conjunction with Data Element 480 T Transportation Data Coordinating Committee (TDCC) X Accredited Standards Committee X12 GS-08 480 Version / Release / Industry Identifier Code String (AN) Required Code indicating the version, release, subrelease, and industry identifier of the EDI standard being used, including the GS and GE segments; if code in DE455 in GS segment is X, then in DE 480 positions 1-3 are the version number; positions 4-6 are the release and subrelease, level of the version; and positions 7-12 are the industry or trade association identifiers (optionally assigned by user); if code in DE455 in GS segment is T, then other formats are allowed 1/30/25, 11:53 AM Texas Medicaid & Healthcare Partnerships (TMHP) 837 837 Health Care Claim: Professional (X222/A2/A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/tmhp/837-health-care-claim-professional-x222a2a1/01HMBZ8Y6XYRFK1ZR16EKD50N6 18/552 005010X222A2 1/30/25, 11:53 AM Texas Medicaid & Healthcare Partnerships (TMHP) 837 837 Health Care Claim: Professional (X222/A2/A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/tmhp/837-health-care-claim-professional-x222a2a1/01HMBZ8Y6XYRFK1ZR16EKD50N6 19/552 Heading ST 0050 Heading > ST Transaction Set Header To indicate the start of a transaction set and to assign a control number Example ST8370001005010X222A2~ Max use 1 Required ST-01 143 Transaction Set Identifier Code Identifier (ID) Required Code uniquely identifying a Transaction Set The transaction set identifier (ST01) is used by the translation routines of the interchange partners to select the appropriate transaction set definition (e.g., 810 selects the Invoice Transaction Set). 837 Health Care Claim ST-02 329 Transaction Set Control Number Min 4 Max 9 Numeric (N) Required Identifying control number that must be unique within the transaction set functional group assigned by the originator for a transaction set Usage notes The Transaction Set Control Number in ST02 and SE02 must be identical. The number must be unique within a specific interchange (ISA-IEA), but can repeat in other interchanges. ST-03 1705 Implementation Guide Version Name String (AN) Required Reference assigned to identify Implementation Convention The implementation convention reference (ST03) is used by the translation routines of the interchange partners to select the appropriate implementation convention to match the transaction set definition. When used, this implementation convention reference takes precedence over the implementation reference specified in the GS08. Usage notes This element must be populated with the guide identifier named in Section 1.2. This field contains the same value as GS08. Some translator products strip off the ISA and GS segments prior to application (ST-SE) processing. Providing the information from the GS08 at this level will ensure that the appropriate application mapping is used at translation time. 005010X222A2 1/30/25, 11:53 AM Texas Medicaid & Healthcare Partnerships (TMHP) 837 837 Health Care Claim: Professional (X222/A2/A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/tmhp/837-health-care-claim-professional-x222a2a1/01HMBZ8Y6XYRFK1ZR16EKD50N6 20/552 BHT 0100 Heading > BHT Beginning of Hierarchical Transaction To define the business hierarchical structure of the transaction set and identify the business application purpose and reference data, i.e., number, date, and time Usage notes The second example denotes the case where the entire transaction set contains ENCOUNTERS. Example BHT001918XXX202501310810*RP~ Max use 1 Required BHT-01 1005 Hierarchical Structure Code Identifier (ID) Required Code indicating the hierarchical application structure of a transaction set that utilizes the HL segment to define the structure of the transaction set 0019 Information Source, Subscriber, Dependent BHT-02 353 Transaction Set Purpose Code Identifier (ID) Required Code identifying purpose of transaction set Usage notes BHT02 is intended to convey the electronic transmission status of the 837 batch contained in this ST-SE envelope. The terms "original" and "reissue" refer to the electronic transmission status of the 837 batch, not the billing status. 00 Original Original transmissions are transmissions which have never been sent to the receiver. 18 Reissue If a transmission was disrupted and the receiver requests a retransmission, the sender uses "Reissue" to indicate the transmission has been previously sent. BHT-03 127 Originator Application Transaction Identifier Min 1 Max 50 String (AN) Required Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier BHT03 is the number assigned by the originator to identify the transaction within the originator's business application system. Usage notes The inventory file number of the transmission assigned by the submitter's system. This number operates as a batch control number. This field is limited to 30 characters. BHT-04 373 Transaction Set Creation Date CCYYMMDD format Date (DT) Required Date expressed as CCYYMMDD where CC represents the first two digits of the calendar year BHT04 is the date the transaction was created within the business application system. Usage notes This is the date that the original submitter created the claim file from their business application system. BHT-05 337 Transaction Set Creation Time HHMM, HHMMSS, HHMMSSD, or HHMMSSDD format Time (TM) Required 1/30/25, 11:53 AM Texas Medicaid & Healthcare Partnerships (TMHP) 837 837 Health Care Claim: Professional (X222/A2/A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/tmhp/837-health-care-claim-professional-x222a2a1/01HMBZ8Y6XYRFK1ZR16EKD50N6 21/552 Time expressed in 24-hour clock time as follows: HHMM, or HHMMSS, or HHMMSSD, or HHMMSSDD, where H = hours (00-23), M = minutes (00-59), S = integer seconds (00-59) and DD = decimal seconds; decimal seconds are expressed as follows: D = tenths (0-9) and DD = hundredths (00-99) BHT05 is the time the transaction was created within the business application system. Usage notes This is the time that the original submitter created the claim file from their business application system. BHT-06 640 Claim or Encounter Identifier Identifier (ID) Required Code specifying the type of transaction 31 Subrogation Demand The subrogation demand code is only for use by state Medicaid agencies performing post payment recovery claiming with willing trading partners. NOTE: At the time of this writing, Subrogation Demand is not a HIPAA mandated use of the 837 transaction. CH Chargeable Use CH when the transaction contains only fee for service claims or claims with at least one chargeable line item. If it is not clear whether a transaction contains claims or capitated encounters, or if the transaction contains a mix of claims and capitated encounters, use CH. RP Reporting Use	Texas Medicaid and Healthcare Partnerships.pdf
notes The second example denotes the case where the entire transaction set contains ENCOUNTERS. Example BHT001918XXX202501310810RP~ Max use 1 Required BHT-01 1005 Hierarchical Structure Code Identifier (ID) Required Code indicating the hierarchical application structure of a transaction set that utilizes the HL segment to define the structure of the transaction set 0019 Information Source, Subscriber, Dependent BHT-02 353 Transaction Set Purpose Code Identifier (ID) Required Code identifying purpose of transaction set Usage notes BHT02 is intended to convey the electronic transmission status of the 837 batch contained in this ST-SE envelope. The terms "original" and "reissue" refer to the electronic transmission status of the 837 batch, not the billing status. 00 Original Original transmissions are transmissions which have never been sent to the receiver. 18 Reissue If a transmission was disrupted and the receiver requests a retransmission, the sender uses "Reissue" to indicate the transmission has been previously sent. BHT-03 127 Originator Application Transaction Identifier Min 1 Max 50 String (AN) Required Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier BHT03 is the number assigned by the originator to identify the transaction within the originator's business application system. Usage notes The inventory file number of the transmission assigned by the submitter's system. This number operates as a batch control number. This field is limited to 30 characters. BHT-04 373 Transaction Set Creation Date CCYYMMDD format Date (DT) Required Date expressed as CCYYMMDD where CC represents the first two digits of the calendar year BHT04 is the date the transaction was created within the business application system. Usage notes This is the date that the original submitter created the claim file from their business application system. BHT-05 337 Transaction Set Creation Time HHMM, HHMMSS, HHMMSSD, or HHMMSSDD format Time (TM) Required 1/30/25, 11:53 AM Texas Medicaid & Healthcare Partnerships (TMHP) 837 837 Health Care Claim: Professional (X222/A2/A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/tmhp/837-health-care-claim-professional-x222a2a1/01HMBZ8Y6XYRFK1ZR16EKD50N6 21/552 Time expressed in 24-hour clock time as follows: HHMM, or HHMMSS, or HHMMSSD, or HHMMSSDD, where H = hours (00-23), M = minutes (00-59), S = integer seconds (00-59) and DD = decimal seconds; decimal seconds are expressed as follows: D = tenths (0-9) and DD = hundredths (00-99) BHT05 is the time the transaction was created within the business application system. Usage notes This is the time that the original submitter created the claim file from their business application system. BHT-06 640 Claim or Encounter Identifier Identifier (ID) Required Code specifying the type of transaction 31 Subrogation Demand The subrogation demand code is only for use by state Medicaid agencies performing post payment recovery claiming with willing trading partners. NOTE: At the time of this writing, Subrogation Demand is not a HIPAA mandated use of the 837 transaction. CH Chargeable Use CH when the transaction contains only fee for service claims or claims with at least one chargeable line item. If it is not clear whether a transaction contains claims or capitated encounters, or if the transaction contains a mix of claims and capitated encounters, use CH. RP Reporting Use RP when the entire ST-SE envelope contains only capitated encounters. Use RP when the transaction is being sent to an entity (usually not a payer or a normal provider payer transmission intermediary) for purposes other than adjudication of a claim. Such an entity could be a state health data agency which is using the 837 for health data reporting purposes. 1/30/25, 11:53 AM Texas Medicaid & Healthcare Partnerships (TMHP) 837 837 Health Care Claim: Professional (X222/A2/A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/tmhp/837-health-care-claim-professional-x222a2a1/01HMBZ8Y6XYRFK1ZR16EKD50N6 22/552 1000A Submitter Name Loop Max 1 Required Variants (all may be used) Receiver Name Loop NM1 0200 Heading > Submitter Name Loop > NM1 Submitter Name To supply the full name of an individual or organizational entity Usage notes The submitter is the entity responsible for the creation and formatting of this transaction. Example NM1411XXXXXXXXXXX*46XXX~ Max use 1 Required NM1-01 98 Entity Identifier Code Identifier (ID) Required Code identifying an organizational entity, a physical location, property or an individual 41 Submitter NM1-02 1065 Entity Type Qualifier Identifier (ID) Required Code qualifying the type of entity NM102 qualifies NM103. 1 Person 2 Non-Person Entity NM1-03 1035 Submitter Last or Organization Name Min 1 Max 60 String (AN) Required Individual last name or organizational name NM1-04 1036 Submitter First Name Min 1 Max 35 String (AN) Optional Individual first name NM1-05 1037 Submitter Middle Name or Initial Min 1 Max 25 String (AN) Optional Individual middle name or initial NM1-08 66 Identification Code Qualifier Identifier (ID) Required Code designating the system/method of code structure used for Identification Code (67) 46 Electronic Transmitter Identification Number (ETIN) Established by trading partner agreement NM1-09 67 Submitter Identifier Min 2 Max 80 String (AN) Required 1/30/25, 11:53 AM Texas Medicaid & Healthcare Partnerships (TMHP) 837 837 Health Care Claim: Professional (X222/A2/A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/tmhp/837-health-care-claim-professional-x222a2a1/01HMBZ8Y6XYRFK1ZR16EKD50N6 23/552 Code identifying a party or other code 1/30/25, 11:53 AM Texas Medicaid & Healthcare Partnerships (TMHP) 837 837 Health Care Claim: Professional (X222/A2/A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/tmhp/837-health-care-claim-professional-x222a2a1/01HMBZ8Y6XYRFK1ZR16EKD50N6 24/552 PER 0450 Heading > Submitter Name Loop > PER Submitter EDI Contact Information To identify a person or office to whom administrative communications should be directed Usage notes When the communication number represents a telephone number in the United States and other countries using the North American Dialing Plan (for voice, data, fax, etc.), the communication number must always include the area code and phone number using the format AAABBBCCCC where AAA is the area code, BBB is the telephone number prefix, and CCCC is the telephone number. Therefore, the following telephone number (555) 555-1234 would be represented as 5555551234. Do not submit long distance access numbers, such as "1", in the telephone number. Telephone extensions, when applicable, must be submitted in the next element immediately following the telephone number. When submitting telephone extensions, only submit the numeric extension. Do not include data that indicates an extension, such as "ext" or "x-". The contact information in this segment identifies the person in the submitter organization who deals with data transmission issues. If data transmission problems arise, this is the person to contact in the submitter organization. There are 2 repetitions of the PER segment to allow for six possible combinations of communication numbers including extensions. Example PERICXXXXFXXXXXFXXXFXXXXX~ If either Communication Number Qualifier (PER-05) or Communication Number (PER-06) is present, then the other is required If either Communication Number Qualifier (PER-07) or Communication Number (PER-08) is present, then the other is required Max use 2 Required PER-01 366 Contact Function Code Identifier (ID) Required Code identifying the major duty or responsibility of the person or group named IC Information Contact PER-02 93 Submitter Contact Name Min 1 Max 60 String (AN) Optional Free-form name PER-03 365 Communication Number Qualifier Identifier (ID) Required Code identifying the type of communication number EM Electronic Mail FX Facsimile TE Telephone PER-04 364 Communication Number Min 1 Max 256 String (AN) Required Complete communications number including country or area code when applicable PER-05 365 Communication Number Qualifier Identifier (ID) Optional Code identifying the type of communication number 1/30/25, 11:53 AM Texas Medicaid & Healthcare Partnerships (TMHP) 837 837 Health Care Claim: Professional (X222/A2/A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/tmhp/837-health-care-claim-professional-x222a2a1/01HMBZ8Y6XYRFK1ZR16EKD50N6 25/552 1000A Submitter Name Loop end EM Electronic Mail EX Telephone Extension FX Facsimile TE Telephone PER-06 364 Communication Number Min 1 Max 256 String (AN) Optional Complete communications number including country or area code when applicable PER-07 365 Communication Number Qualifier Identifier (ID) Optional Code identifying the type of communication number EM Electronic Mail EX Telephone Extension FX Facsimile TE Telephone PER-08 364 Communication Number Min 1 Max 256 String (AN) Optional Complete communications number including country or area code when applicable 1/30/25, 11:53 AM Texas Medicaid & Healthcare Partnerships (TMHP) 837 837 Health Care Claim: Professional (X222/A2/A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/tmhp/837-health-care-claim-professional-x222a2a1/01HMBZ8Y6XYRFK1ZR16EKD50N6 26/552 1000B Receiver Name Loop Max 1 Required Variants (all may be used) Submitter Name Loop 1000B Receiver Name Loop end Heading end NM1 0200 Heading > Receiver Name Loop > NM1 Receiver Name To supply the full name of an individual or organizational entity Example NM1402TMHP***46617591011CMSP~ Max use 1 Required NM1-01 98 Entity Identifier Code Identifier (ID) Required Code identifying an organizational entity, a physical location, property or an individual 40 Receiver NM1-02 1065 Entity Type Qualifier Identifier (ID) Required Code qualifying the type of entity NM102 qualifies NM103. 2 Non-Person Entity NM1-03 1035 Receiver Name String (AN) Required Individual last name or organizational name TMHP NM1-08 66 Identification Code Qualifier Identifier (ID) Required Code designating the system/method of code structure used for Identification Code (67) 46 Electronic Transmitter Identification Number (ETIN) NM1-09 67 Receiver Primary Identifier String (AN) Required Code identifying a party or other code 617591011CMSP 1/30/25, 11:53 AM Texas Medicaid & Healthcare Partnerships (TMHP) 837 837 Health Care Claim: Professional (X222/A2/A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/tmhp/837-health-care-claim-professional-x222a2a1/01HMBZ8Y6XYRFK1ZR16EKD50N6 27/552 Detail 2000A Billing Provider Hierarchical Level Loop Max >1 Required HL 0010 Detail > Billing Provider Hierarchical Level Loop > HL Hierarchical Level To identify dependencies among and the content of hierarchically related groups of data segments Example HL1201~ Max use 1 Required HL-01 628 Hierarchical ID Number Min 1 Max 12 String (AN) Required A unique number assigned by the sender to identify a particular data segment in a hierarchical structure HL01 shall contain a unique alphanumeric number for each occurrence of the HL segment in the transaction set. For example, HL01 could be used to indicate the number of occurrences of the HL segment, in which case the value of HL01 would be "1" for the initial HL segment and would be incremented by one in each subsequent HL segment within the transaction. HL-03 735 Hierarchical Level Code Identifier (ID) Required Code defining the characteristic of a level in a hierarchical structure HL03 indicates the context of the series of segments following the current HL segment up to the next occurrence of an HL segment in the transaction. For example, HL03 is used to indicate that subsequent segments in the HL loop form a logical grouping of data referring to shipment, order, or item-level information. 20 Information Source HL-04 736 Hierarchical Child Code Identifier (ID) Optional Code indicating if there are hierarchical child data segments subordinate to the level being described HL04 indicates whether or not there are subordinate (or child) HL segments related to the current HL segment. 1 Additional Subordinate HL Data Segment in This Hierarchical Structure. 1/30/25, 11:53 AM Texas Medicaid & Healthcare Partnerships (TMHP) 837 837 Health Care Claim: Professional (X222/A2/A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/tmhp/837-health-care-claim-professional-x222a2a1/01HMBZ8Y6XYRFK1ZR16EKD50N6 28/552 PRV 0030 Detail > Billing Provider Hierarchical Level Loop > PRV Billing Provider Specialty Information To specify the identifying characteristics of a provider Usage notes Required when the payer's adjudication is known to be impacted by the provider taxonomy code. If not required by this implementation guide, do not send. Example PRVBIPXCXX~ Max use 1 Optional PRV-01 1221 Provider Code Identifier (ID) Required Code identifying the type of provider BI Billing PRV-02 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification PXC Health Care Provider Taxonomy Code PRV-03 127 Provider Taxonomy Code Min 1 Max 50 String (AN) Required Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier Usage notes The Taxonomy code must be the Taxonomy code on file with Texas Medicaid. 1/30/25, 11:53 AM Texas Medicaid & Healthcare Partnerships (TMHP) 837 837 Health Care Claim: Professional (X222/A2/A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/tmhp/837-health-care-claim-professional-x222a2a1/01HMBZ8Y6XYRFK1ZR16EKD50N6 29/552 CUR 0100 Detail > Billing Provider Hierarchical Level Loop > CUR Foreign Currency Information To specify the currency (dollars, pounds, francs, etc.) used in a transaction Usage notes Required when the amounts represented in this transaction are currencies other than the United States dollar. If not required by this implementation guide, do not send. It is REQUIRED that all amounts reported within the transaction are of the currency named in this segment. If this segment is not used, then it is required that all amounts in this transaction be expressed in US dollars. Example CUR85*XXX~ Max use 1 Optional CUR-01 98 Entity Identifier Code Identifier (ID) Required Code identifying an organizational entity, a physical location, property or an individual 85 Billing Provider CUR-02 100 Currency Code Min 3	Texas Medicaid and Healthcare Partnerships.pdf
A unique number assigned by the sender to identify a particular data segment in a hierarchical structure HL01 shall contain a unique alphanumeric number for each occurrence of the HL segment in the transaction set. For example, HL01 could be used to indicate the number of occurrences of the HL segment, in which case the value of HL01 would be "1" for the initial HL segment and would be incremented by one in each subsequent HL segment within the transaction. HL-03 735 Hierarchical Level Code Identifier (ID) Required Code defining the characteristic of a level in a hierarchical structure HL03 indicates the context of the series of segments following the current HL segment up to the next occurrence of an HL segment in the transaction. For example, HL03 is used to indicate that subsequent segments in the HL loop form a logical grouping of data referring to shipment, order, or item-level information. 20 Information Source HL-04 736 Hierarchical Child Code Identifier (ID) Optional Code indicating if there are hierarchical child data segments subordinate to the level being described HL04 indicates whether or not there are subordinate (or child) HL segments related to the current HL segment. 1 Additional Subordinate HL Data Segment in This Hierarchical Structure. 1/30/25, 11:53 AM Texas Medicaid & Healthcare Partnerships (TMHP) 837 837 Health Care Claim: Professional (X222/A2/A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/tmhp/837-health-care-claim-professional-x222a2a1/01HMBZ8Y6XYRFK1ZR16EKD50N6 28/552 PRV 0030 Detail > Billing Provider Hierarchical Level Loop > PRV Billing Provider Specialty Information To specify the identifying characteristics of a provider Usage notes Required when the payer's adjudication is known to be impacted by the provider taxonomy code. If not required by this implementation guide, do not send. Example PRVBIPXCXX~ Max use 1 Optional PRV-01 1221 Provider Code Identifier (ID) Required Code identifying the type of provider BI Billing PRV-02 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification PXC Health Care Provider Taxonomy Code PRV-03 127 Provider Taxonomy Code Min 1 Max 50 String (AN) Required Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier Usage notes The Taxonomy code must be the Taxonomy code on file with Texas Medicaid. 1/30/25, 11:53 AM Texas Medicaid & Healthcare Partnerships (TMHP) 837 837 Health Care Claim: Professional (X222/A2/A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/tmhp/837-health-care-claim-professional-x222a2a1/01HMBZ8Y6XYRFK1ZR16EKD50N6 29/552 CUR 0100 Detail > Billing Provider Hierarchical Level Loop > CUR Foreign Currency Information To specify the currency (dollars, pounds, francs, etc.) used in a transaction Usage notes Required when the amounts represented in this transaction are currencies other than the United States dollar. If not required by this implementation guide, do not send. It is REQUIRED that all amounts reported within the transaction are of the currency named in this segment. If this segment is not used, then it is required that all amounts in this transaction be expressed in US dollars. Example CUR85XXX~ Max use 1 Optional CUR-01 98 Entity Identifier Code Identifier (ID) Required Code identifying an organizational entity, a physical location, property or an individual 85 Billing Provider CUR-02 100 Currency Code Min 3 Max 3 Identifier (ID) Required Code (Standard ISO) for country in whose currency the charges are specified Usage notes The submitter must use the Currency Code, not the Country Code, for this element. For example the Currency Code CAD = Canadian dollars would be valid, while CA = Canada would be invalid. 1/30/25, 11:53 AM Texas Medicaid & Healthcare Partnerships (TMHP) 837 837 Health Care Claim: Professional (X222/A2/A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/tmhp/837-health-care-claim-professional-x222a2a1/01HMBZ8Y6XYRFK1ZR16EKD50N6 30/552 2010AA Billing Provider Name Loop Max 1 Required Variants (all may be used) Pay-to Address Name Loop Pay-To Plan Name Loop NM1 0150 Detail > Billing Provider Hierarchical Level Loop > Billing Provider Name Loop > NM1 Billing Provider Name To supply the full name of an individual or organizational entity Usage notes Beginning on the NPI compliance date: When the Billing Provider is an organization health care provider, the organization health care provider's NPI or its subpart's NPI is reported in NM109. When a health care provider organization has determined that it needs to enumerate its subparts, it will report the NPI of a subpart as the Billing Provider. The subpart reported as the Billing Provider MUST always represent the most detailed level of enumeration as determined by the organization health care provider and MUST be the same identifier sent to any trading partner. For additional explanation, see section 1.10.3 Organization Health Care Provider Subpart Presentation. Prior to the NPI compliance date, proprietary identifiers necessary for the receiver to identify the Billing Provider entity are to be reported in the REF segment of Loop ID- 2010BB. The Taxpayer Identifying Number (TIN) of the Billing Provider to be used for 1099 purposes must be reported in the REF segment of this loop. The Billing Provider may be an individual only when the health care provider performing services is an independent, unincorporated entity. In these cases, the Billing Provider is the individual whose social security number is used for 1099 purposes. That individual's NPI is reported in NM109, and the individual's Tax Identification Number must be reported in the REF segment of this loop. The individual's NPI must be reported when the individual provider is eligible for an NPI. See section 1.10.1 (Providers who are Not Eligible for Enumeration). When the individual or the organization is not a health care provider and, thus, not eligible to receive an NPI (For example, personal care services, carpenters, etc), the Billing Provider should be the legal entity. However, willing trading partners may agree upon varying definitions. Proprietary identifiers necessary for the receiver to identify the entity are to be reported in the Loop ID-2010BB REF, Billing Provider Secondary Identification segment. The TIN to be used for 1099 purposes must be reported in the REF (Tax Identification Number) segment of this loop. Example NM1852XXXXXXXXXXXXXX*XXXXXXXXXX~ If either Identification Code Qualifier (NM1-08) or Billing Provider Identifier (NM1-09) is present, then the other is required Max use 1 Required NM1-01 98 Entity Identifier Code Identifier (ID) Required Code identifying an organizational entity, a physical location, property or an individual 85 Billing Provider NM1-02 1065 Entity Type Qualifier Identifier (ID) Required Code qualifying the type of entity NM102 qualifies NM103. 1 Person 2 Non-Person Entity NM1-03 1035 Billing Provider Last or Organizational Name Min 1 Max 60 String (AN) Required 1/30/25, 11:53 AM Texas Medicaid & Healthcare Partnerships (TMHP) 837 837 Health Care Claim: Professional (X222/A2/A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/tmhp/837-health-care-claim-professional-x222a2a1/01HMBZ8Y6XYRFK1ZR16EKD50N6 31/552 Individual last name or organizational name NM1-04 1036 Billing Provider First Name Min 1 Max 35 String (AN) Optional Individual first name NM1-05 1037 Billing Provider Middle Name or Initial Min 1 Max 25 String (AN) Optional Individual middle name or initial NM1-07 1039 Billing Provider Name Suffix Min 1 Max 10 String (AN) Optional Suffix to individual name NM1-08 66 Identification Code Qualifier Identifier (ID) Optional Code designating the system/method of code structure used for Identification Code (67) XX Centers for Medicare and Medicaid Services National Provider Identifier NM1-09 67 Billing Provider Identifier Min 2 Max 80 String (AN) Optional Code identifying a party or other code Usage notes National Provider ID (NPI) must be submitted unless the provider has an Atypical Provider Identifier (API) assigned which will be reported in Loop 2010BB. 1/30/25, 11:53 AM Texas Medicaid & Healthcare Partnerships (TMHP) 837 837 Health Care Claim: Professional (X222/A2/A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/tmhp/837-health-care-claim-professional-x222a2a1/01HMBZ8Y6XYRFK1ZR16EKD50N6 32/552 N3 0250 Detail > Billing Provider Hierarchical Level Loop > Billing Provider Name Loop > N3 Billing Provider Address To specify the location of the named party Usage notes The Billing Provider Address must be a street address. Post Office Box or Lock Box addresses are to be sent in the Pay-To Address Loop (Loop ID-2010AB), if necessary. Example N3XXXXXX~ Max use 1 Required N3-01 166 Billing Provider Address Line Min 1 Max 55 String (AN) Required Address information Usage notes The Billing Provider address must be the address on file with Texas Medicaid. N3-02 166 Billing Provider Address Line Min 1 Max 55 String (AN) Optional Address information 1/30/25, 11:53 AM Texas Medicaid & Healthcare Partnerships (TMHP) 837 837 Health Care Claim: Professional (X222/A2/A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/tmhp/837-health-care-claim-professional-x222a2a1/01HMBZ8Y6XYRFK1ZR16EKD50N6 33/552 N4 0300 Detail > Billing Provider Hierarchical Level Loop > Billing Provider Name Loop > N4 Billing Provider City, State, ZIP Code To specify the geographic place of the named party Example N4XXXXXXXXXXXXXXXXXXX~ Only one of Billing Provider State or Province Code (N4-02) or Country Subdivision Code (N4-07) may be present If Country Subdivision Code (N4-07) is present, then Country Code (N4-04) is required Max use 1 Required N4-01 19 Billing Provider City Name Min 2 Max 30 String (AN) Required Free-form text for city name A combination of either N401 through N404, or N405 and N406 may be adequate to specify a location. Usage notes The Billing Provider city name must be the city name on file with Texas Medicaid. N4-02 156 Billing Provider State or Province Code Min 2 Max 2 Identifier (ID) Optional Code (Standard State/Province) as defined by appropriate government agency N402 is required only if city name (N401) is in the U.S. or Canada. N4-03 116 Billing Provider Postal Zone or ZIP Code Min 3 Max 15 Identifier (ID) Optional Code defining international postal zone code excluding punctuation and blanks (zip code for United States) Usage notes The Billing Provider ZIP Code (9 digits) name must be the ZIP Code on file with Texas Medicaid. N4-04 26 Country Code Min 2 Max 3 Identifier (ID) Optional Code identifying the country Usage notes Use the alpha-2 country codes from Part 1 of ISO 3166. N4-07 1715 Country Subdivision Code Min 1 Max 3 Identifier (ID) Optional Code identifying the country subdivision Usage notes Use the country subdivision codes from Part 2 of ISO 3166. 1/30/25, 11:53 AM Texas Medicaid & Healthcare Partnerships (TMHP) 837 837 Health Care Claim: Professional (X222/A2/A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/tmhp/837-health-care-claim-professional-x222a2a1/01HMBZ8Y6XYRFK1ZR16EKD50N6 34/552 REF 0350 Detail > Billing Provider Hierarchical Level Loop > Billing Provider Name Loop > REF Billing Provider Tax Identification To specify identifying information Usage notes The submitted code must match what is on file with Texas Medicaid Example REFSYX~ Variants (all may be used) REF Billing Provider UPIN/License Information Max use 1 Required REF-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification EI Employer's Identification Number The Employer's Identification Number must be a string of exactly nine numbers with no separators. For example, "001122333" would be valid, while sending "001-12-2333" or "00-1122333" would be invalid. SY Social Security Number The Social Security Number must be a string of exactly nine numbers with no separators. For example, sending "111002222" would be valid, while sending "111-00-2222" would be invalid. REF-02 127 Billing Provider Tax Identification Number Min 1 Max 50 String (AN) Required Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier 1/30/25, 11:53 AM Texas Medicaid & Healthcare Partnerships (TMHP) 837 837 Health Care Claim: Professional (X222/A2/A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/tmhp/837-health-care-claim-professional-x222a2a1/01HMBZ8Y6XYRFK1ZR16EKD50N6 35/552 REF 0350 Detail > Billing Provider Hierarchical Level Loop > Billing Provider Name Loop > REF Billing Provider UPIN/License Information To specify identifying information Usage notes Required prior to the mandated HIPAA National Provider Identifier (NPI) implementation date when a UPIN and/or license number is necessary for the receiver to identify the provider. OR Required on or after the mandated NPI implementation date when NM109 of this loop is not used and a UPIN or license number is necessary for the receiver to identify the provider. If not required by this implementation guide, do not send. Payer specific secondary identifiers are reported in the Loop ID-2010BB REF, Billing Provider Secondary Identification. Example REF0B*XXXXX~ Variants (all may be used) REF Billing Provider Tax Identification Max use 2 Optional REF-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification 0B State License Number 1G Provider UPIN Number UPINs must be formatted as either X99999 or XXX999. REF-02 127 Billing Provider License and/or UPIN Information Min 1 Max 50 String (AN) Required Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier 1/30/25, 11:53 AM Texas Medicaid & Healthcare Partnerships (TMHP) 837 837 Health Care Claim: Professional (X222/A2/A1) - Stedi	Texas Medicaid and Healthcare Partnerships.pdf
Max 15 Identifier (ID) Optional Code defining international postal zone code excluding punctuation and blanks (zip code for United States) Usage notes The Billing Provider ZIP Code (9 digits) name must be the ZIP Code on file with Texas Medicaid. N4-04 26 Country Code Min 2 Max 3 Identifier (ID) Optional Code identifying the country Usage notes Use the alpha-2 country codes from Part 1 of ISO 3166. N4-07 1715 Country Subdivision Code Min 1 Max 3 Identifier (ID) Optional Code identifying the country subdivision Usage notes Use the country subdivision codes from Part 2 of ISO 3166. 1/30/25, 11:53 AM Texas Medicaid & Healthcare Partnerships (TMHP) 837 837 Health Care Claim: Professional (X222/A2/A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/tmhp/837-health-care-claim-professional-x222a2a1/01HMBZ8Y6XYRFK1ZR16EKD50N6 34/552 REF 0350 Detail > Billing Provider Hierarchical Level Loop > Billing Provider Name Loop > REF Billing Provider Tax Identification To specify identifying information Usage notes The submitted code must match what is on file with Texas Medicaid Example REFSYX~ Variants (all may be used) REF Billing Provider UPIN/License Information Max use 1 Required REF-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification EI Employer's Identification Number The Employer's Identification Number must be a string of exactly nine numbers with no separators. For example, "001122333" would be valid, while sending "001-12-2333" or "00-1122333" would be invalid. SY Social Security Number The Social Security Number must be a string of exactly nine numbers with no separators. For example, sending "111002222" would be valid, while sending "111-00-2222" would be invalid. REF-02 127 Billing Provider Tax Identification Number Min 1 Max 50 String (AN) Required Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier 1/30/25, 11:53 AM Texas Medicaid & Healthcare Partnerships (TMHP) 837 837 Health Care Claim: Professional (X222/A2/A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/tmhp/837-health-care-claim-professional-x222a2a1/01HMBZ8Y6XYRFK1ZR16EKD50N6 35/552 REF 0350 Detail > Billing Provider Hierarchical Level Loop > Billing Provider Name Loop > REF Billing Provider UPIN/License Information To specify identifying information Usage notes Required prior to the mandated HIPAA National Provider Identifier (NPI) implementation date when a UPIN and/or license number is necessary for the receiver to identify the provider. OR Required on or after the mandated NPI implementation date when NM109 of this loop is not used and a UPIN or license number is necessary for the receiver to identify the provider. If not required by this implementation guide, do not send. Payer specific secondary identifiers are reported in the Loop ID-2010BB REF, Billing Provider Secondary Identification. Example REF0BXXXXX~ Variants (all may be used) REF Billing Provider Tax Identification Max use 2 Optional REF-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification 0B State License Number 1G Provider UPIN Number UPINs must be formatted as either X99999 or XXX999. REF-02 127 Billing Provider License and/or UPIN Information Min 1 Max 50 String (AN) Required Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier 1/30/25, 11:53 AM Texas Medicaid & Healthcare Partnerships (TMHP) 837 837 Health Care Claim: Professional (X222/A2/A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/tmhp/837-health-care-claim-professional-x222a2a1/01HMBZ8Y6XYRFK1ZR16EKD50N6 36/552 PER 0400 Detail > Billing Provider Hierarchical Level Loop > Billing Provider Name Loop > PER Billing Provider Contact Information To identify a person or office to whom administrative communications should be directed Usage notes Required when this information is different than that contained in the Loop ID-1000A - Submitter PER segment. If not required by this implementation guide, do not send.; When the communication number represents a telephone number in the United States and other countries using the North American Dialing Plan (for voice, data, fax, etc.), the communication number must always include the area code and phone number using the format AAABBBCCCC where AAA is the area code, BBB is the telephone number prefix, and CCCC is the telephone number. Therefore, the following telephone number (555) 555-1234 would be represented as 5555551234. Do not submit long distance access numbers, such as "1", in the telephone number. Telephone extensions, when applicable, must be submitted in the next element immediately following the telephone number. When submitting telephone extensions, only submit the numeric extension. Do not include data that indicates an extension, such as "ext" or "x-". There are 2 repetitions of the PER segment to allow for six possible combinations of communication numbers including extensions. Example PERICXTEXXXFXXXXXXXTEXX~ If either Communication Number Qualifier (PER-05) or Communication Number (PER-06) is present, then the other is required If either Communication Number Qualifier (PER-07) or Communication Number (PER-08) is present, then the other is required Max use 2 Optional PER-01 366 Contact Function Code Identifier (ID) Required Code identifying the major duty or responsibility of the person or group named IC Information Contact PER-02 93 Billing Provider Contact Name Min 1 Max 60 String (AN) Optional Free-form name PER-03 365 Communication Number Qualifier Identifier (ID) Required Code identifying the type of communication number EM Electronic Mail FX Facsimile TE Telephone PER-04 364 Communication Number Min 1 Max 256 String (AN) Required Complete communications number including country or area code when applicable PER-05 365 Communication Number Qualifier Identifier (ID) Optional Code identifying the type of communication number EM Electronic Mail EX Telephone Extension FX Facsimile TE Telephone 1/30/25, 11:53 AM Texas Medicaid & Healthcare Partnerships (TMHP) 837 837 Health Care Claim: Professional (X222/A2/A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/tmhp/837-health-care-claim-professional-x222a2a1/01HMBZ8Y6XYRFK1ZR16EKD50N6 37/552 2010AA Billing Provider Name Loop end PER-06 364 Communication Number Min 1 Max 256 String (AN) Optional Complete communications number including country or area code when applicable PER-07 365 Communication Number Qualifier Identifier (ID) Optional Code identifying the type of communication number EM Electronic Mail EX Telephone Extension FX Facsimile TE Telephone PER-08 364 Communication Number Min 1 Max 256 String (AN) Optional Complete communications number including country or area code when applicable 1/30/25, 11:53 AM Texas Medicaid & Healthcare Partnerships (TMHP) 837 837 Health Care Claim: Professional (X222/A2/A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/tmhp/837-health-care-claim-professional-x222a2a1/01HMBZ8Y6XYRFK1ZR16EKD50N6 38/552 2010AB Pay-to Address Name Loop Max 1 Optional Variants (all may be used) Billing Provider Name Loop Pay-To Plan Name Loop NM1 0150 Detail > Billing Provider Hierarchical Level Loop > Pay-to Address Name Loop > NM1 Pay-to Address Name To supply the full name of an individual or organizational entity Usage notes Required when the address for payment is different than that of the Billing Provider. If not required by this implementation guide, do not send.; The purpose of Loop ID-2010AB has changed from previous versions. Loop ID-2010AB only contains address information when different from the Billing Provider Address. There are no applicable identifiers for Pay-To Address information. Example NM1871~ Max use 1 Required NM1-01 98 Entity Identifier Code Identifier (ID) Required Code identifying an organizational entity, a physical location, property or an individual 87 Pay-to Provider NM1-02 1065 Entity Type Qualifier Identifier (ID) Required Code qualifying the type of entity NM102 qualifies NM103. 1 Person 2 Non-Person Entity 1/30/25, 11:53 AM Texas Medicaid & Healthcare Partnerships (TMHP) 837 837 Health Care Claim: Professional (X222/A2/A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/tmhp/837-health-care-claim-professional-x222a2a1/01HMBZ8Y6XYRFK1ZR16EKD50N6 39/552 N3 0250 Detail > Billing Provider Hierarchical Level Loop > Pay-to Address Name Loop > N3 Pay-to Address - ADDRESS To specify the location of the named party Example N3XXXXXXX~ Max use 1 Required N3-01 166 Pay-To Address Line Min 1 Max 55 String (AN) Required Address information N3-02 166 Pay-To Address Line Min 1 Max 55 String (AN) Optional Address information 1/30/25, 11:53 AM Texas Medicaid & Healthcare Partnerships (TMHP) 837 837 Health Care Claim: Professional (X222/A2/A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/tmhp/837-health-care-claim-professional-x222a2a1/01HMBZ8Y6XYRFK1ZR16EKD50N6 40/552 2010AB Pay-to Address Name Loop end N4 0300 Detail > Billing Provider Hierarchical Level Loop > Pay-to Address Name Loop > N4 Pay-To Address City, State, ZIP Code To specify the geographic place of the named party Example N4XXXXXXXXXXXXXXXXXX~ Only one of Pay-to Address State Code (N4-02) or Country Subdivision Code (N4-07) may be present If Country Subdivision Code (N4-07) is present, then Country Code (N4-04) is required Max use 1 Required N4-01 19 Pay-to Address City Name Min 2 Max 30 String (AN) Required Free-form text for city name A combination of either N401 through N404, or N405 and N406 may be adequate to specify a location. N4-02 156 Pay-to Address State Code Min 2 Max 2 Identifier (ID) Optional Code (Standard State/Province) as defined by appropriate government agency N402 is required only if city name (N401) is in the U.S. or Canada. N4-03 116 Pay-to Address Postal Zone or ZIP Code Min 3 Max 15 Identifier (ID) Optional Code defining international postal zone code excluding punctuation and blanks (zip code for United States) N4-04 26 Country Code Min 2 Max 3 Identifier (ID) Optional Code identifying the country Usage notes Use the alpha-2 country codes from Part 1 of ISO 3166. N4-07 1715 Country Subdivision Code Min 1 Max 3 Identifier (ID) Optional Code identifying the country subdivision Usage notes Use the country subdivision codes from Part 2 of ISO 3166. 1/30/25, 11:53 AM Texas Medicaid & Healthcare Partnerships (TMHP) 837 837 Health Care Claim: Professional (X222/A2/A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/tmhp/837-health-care-claim-professional-x222a2a1/01HMBZ8Y6XYRFK1ZR16EKD50N6 41/552 2010AC Pay-To Plan Name Loop Max 1 Optional Variants (all may be used) Billing Provider Name Loop Pay-to Address Name Loop NM1 0150 Detail > Billing Provider Hierarchical Level Loop > Pay-To Plan Name Loop > NM1 Pay-To Plan Name To supply the full name of an individual or organizational entity Usage notes Required when willing trading partners agree to use this implementation for their subrogation payment requests. This loop may only be used when BHT06 = 31. Example NM1PE2XX***XVXXXXX~ Max use 1 Required NM1-01 98 Entity Identifier Code Identifier (ID) Required Code identifying an organizational entity, a physical location, property or an individual PE Payee PE is used to indicate the subrogated payee. NM1-02 1065 Entity Type Qualifier Identifier (ID) Required Code qualifying the type of entity NM102 qualifies NM103. 2 Non-Person Entity NM1-03 1035 Pay-To Plan Organizational Name Min 1 Max 60 String (AN) Required Individual last name or organizational name NM1-08 66 Identification Code Qualifier Identifier (ID) Required Code designating the system/method of code structure used for Identification Code (67) Usage notes Use code value "PI" when reporting Payor Identification. Use code value "XV" when reporting Health Plan ID (HPID) or Other Entity Identifier (OEID). Prior to the mandated implementation date for Health Plan Identifier, willing trading partners may agree to: Follow a dual use approach in which both the HPID or OEID and the Payor Identification are sent. Send XV qualifier in NM108 with HPID or OEID in NM109 and the Payor Identification, that would have been sent using qualifier PI, in the corresponding REF segment using qualifier 2U (Payer Identification Number). OR Follow an early implementation approach in which the HPID or OEID is sent in NM109. PI Payor Identification XV Centers for Medicare and Medicaid Services PlanID 1/30/25, 11:53 AM Texas Medicaid & Healthcare Partnerships (TMHP) 837 837 Health Care Claim: Professional (X222/A2/A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/tmhp/837-health-care-claim-professional-x222a2a1/01HMBZ8Y6XYRFK1ZR16EKD50N6 42/552 NM1-09 67 Pay-To Plan Primary Identifier Min 2 Max 80 String (AN) Required Code identifying a party or other code 1/30/25, 11:53 AM Texas Medicaid & Healthcare Partnerships (TMHP) 837 837 Health Care Claim: Professional (X222/A2/A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/tmhp/837-health-care-claim-professional-x222a2a1/01HMBZ8Y6XYRFK1ZR16EKD50N6 43/552 N3 0250 Detail > Billing Provider Hierarchical Level Loop > Pay-To Plan Name Loop > N3 Pay-to Plan Address To specify the location of the named party Example N3XXXXXXXXXXXX~ Max use 1 Required N3-01 166 Pay-To Plan Address Line Min 1 Max 55 String (AN) Required Address information N3-02 166 Pay-To Plan Address Line Min 1 Max 55 String (AN) Optional Address information 1/30/25, 11:53 AM Texas Medicaid & Healthcare Partnerships (TMHP) 837 837 Health Care Claim: Professional (X222/A2/A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/tmhp/837-health-care-claim-professional-x222a2a1/01HMBZ8Y6XYRFK1ZR16EKD50N6 44/552 N4 0300 Detail > Billing Provider Hierarchical Level Loop > Pay-To Plan Name Loop > N4 Pay-To Plan City, State, ZIP Code To specify the geographic place of the named party Example N4XXXXXXXXXXXXXX~ Only one of Pay-To Plan State or Province Code (N4-02) or Country Subdivision Code (N4-07) may be present If Country Subdivision Code (N4-07) is present, then Country Code (N4-04) is required Max use 1 Required N4-01 19 Pay-To Plan City Name Min 2 Max 30 String (AN) Required Free-form text for city name A combination of either N401 through N404, or N405 and N406 may be adequate	Texas Medicaid and Healthcare Partnerships.pdf
> Pay-To Plan Name Loop > NM1 Pay-To Plan Name To supply the full name of an individual or organizational entity Usage notes Required when willing trading partners agree to use this implementation for their subrogation payment requests. This loop may only be used when BHT06 = 31. Example NM1PE2XX***XVXXXXX~ Max use 1 Required NM1-01 98 Entity Identifier Code Identifier (ID) Required Code identifying an organizational entity, a physical location, property or an individual PE Payee PE is used to indicate the subrogated payee. NM1-02 1065 Entity Type Qualifier Identifier (ID) Required Code qualifying the type of entity NM102 qualifies NM103. 2 Non-Person Entity NM1-03 1035 Pay-To Plan Organizational Name Min 1 Max 60 String (AN) Required Individual last name or organizational name NM1-08 66 Identification Code Qualifier Identifier (ID) Required Code designating the system/method of code structure used for Identification Code (67) Usage notes Use code value "PI" when reporting Payor Identification. Use code value "XV" when reporting Health Plan ID (HPID) or Other Entity Identifier (OEID). Prior to the mandated implementation date for Health Plan Identifier, willing trading partners may agree to: Follow a dual use approach in which both the HPID or OEID and the Payor Identification are sent. Send XV qualifier in NM108 with HPID or OEID in NM109 and the Payor Identification, that would have been sent using qualifier PI, in the corresponding REF segment using qualifier 2U (Payer Identification Number). OR Follow an early implementation approach in which the HPID or OEID is sent in NM109. PI Payor Identification XV Centers for Medicare and Medicaid Services PlanID 1/30/25, 11:53 AM Texas Medicaid & Healthcare Partnerships (TMHP) 837 837 Health Care Claim: Professional (X222/A2/A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/tmhp/837-health-care-claim-professional-x222a2a1/01HMBZ8Y6XYRFK1ZR16EKD50N6 42/552 NM1-09 67 Pay-To Plan Primary Identifier Min 2 Max 80 String (AN) Required Code identifying a party or other code 1/30/25, 11:53 AM Texas Medicaid & Healthcare Partnerships (TMHP) 837 837 Health Care Claim: Professional (X222/A2/A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/tmhp/837-health-care-claim-professional-x222a2a1/01HMBZ8Y6XYRFK1ZR16EKD50N6 43/552 N3 0250 Detail > Billing Provider Hierarchical Level Loop > Pay-To Plan Name Loop > N3 Pay-to Plan Address To specify the location of the named party Example N3XXXXXXXXXXXX~ Max use 1 Required N3-01 166 Pay-To Plan Address Line Min 1 Max 55 String (AN) Required Address information N3-02 166 Pay-To Plan Address Line Min 1 Max 55 String (AN) Optional Address information 1/30/25, 11:53 AM Texas Medicaid & Healthcare Partnerships (TMHP) 837 837 Health Care Claim: Professional (X222/A2/A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/tmhp/837-health-care-claim-professional-x222a2a1/01HMBZ8Y6XYRFK1ZR16EKD50N6 44/552 N4 0300 Detail > Billing Provider Hierarchical Level Loop > Pay-To Plan Name Loop > N4 Pay-To Plan City, State, ZIP Code To specify the geographic place of the named party Example N4XXXXXXXXXXXXXX~ Only one of Pay-To Plan State or Province Code (N4-02) or Country Subdivision Code (N4-07) may be present If Country Subdivision Code (N4-07) is present, then Country Code (N4-04) is required Max use 1 Required N4-01 19 Pay-To Plan City Name Min 2 Max 30 String (AN) Required Free-form text for city name A combination of either N401 through N404, or N405 and N406 may be adequate to specify a location. N4-02 156 Pay-To Plan State or Province Code Min 2 Max 2 Identifier (ID) Optional Code (Standard State/Province) as defined by appropriate government agency N402 is required only if city name (N401) is in the U.S. or Canada. N4-03 116 Pay-To Plan Postal Zone or ZIP Code Min 3 Max 15 Identifier (ID) Optional Code defining international postal zone code excluding punctuation and blanks (zip code for United States) N4-04 26 Country Code Min 2 Max 3 Identifier (ID) Optional Code identifying the country Usage notes Use the alpha-2 country codes from Part 1 of ISO 3166. N4-07 1715 Country Subdivision Code Min 1 Max 3 Identifier (ID) Optional Code identifying the country subdivision Usage notes Use the country subdivision codes from Part 2 of ISO 3166. 1/30/25, 11:53 AM Texas Medicaid & Healthcare Partnerships (TMHP) 837 837 Health Care Claim: Professional (X222/A2/A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/tmhp/837-health-care-claim-professional-x222a2a1/01HMBZ8Y6XYRFK1ZR16EKD50N6 45/552 REF 0350 Detail > Billing Provider Hierarchical Level Loop > Pay-To Plan Name Loop > REF Pay-to Plan Secondary Identification To specify identifying information Usage notes Required when an additional identification number to that provided in the NM109 of this loop is necessary to identify the entity. If not required by this implementation guide, do not send. Example REFNFXXXXX~ Variants (all may be used) REF Pay-To Plan Tax Identification Number Max use 1 Optional REF-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification 2U Payer Identification Number This code is only allowed when the qualifier XV is reported in NM108 of this loop. FY Claim Office Number NF National Association of Insurance Commissioners (NAIC) Code REF-02 127 Pay-to Plan Secondary Identifier Min 1 Max 50 String (AN) Required Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier 1/30/25, 11:53 AM Texas Medicaid & Healthcare Partnerships (TMHP) 837 837 Health Care Claim: Professional (X222/A2/A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/tmhp/837-health-care-claim-professional-x222a2a1/01HMBZ8Y6XYRFK1ZR16EKD50N6 46/552 2010AC Pay-To Plan Name Loop end REF 0350 Detail > Billing Provider Hierarchical Level Loop > Pay-To Plan Name Loop > REF Pay-To Plan Tax Identification Number To specify identifying information Example REFEIXX~ Variants (all may be used) REF Pay-to Plan Secondary Identification Max use 1 Required REF-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification EI Employer's Identification Number The Employer's Identification Number must be a string of exactly nine numbers with no separators. For example, "001122333" would be valid, while sending "001-12-2333" or "00-1122333" would be invalid. REF-02 127 Pay-To Plan Tax Identification Number Min 1 Max 50 String (AN) Required Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier 1/30/25, 11:53 AM Texas Medicaid & Healthcare Partnerships (TMHP) 837 837 Health Care Claim: Professional (X222/A2/A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/tmhp/837-health-care-claim-professional-x222a2a1/01HMBZ8Y6XYRFK1ZR16EKD50N6 47/552 2300 Loop Max >1 Optional CLM 1300 Detail > Billing Provider Hierarchical Level Loop > 2300 Loop > CLM Health Claim To specify basic data about the claim Example CLMXXXX~ Max use 1 Required CLM-01 1028 Claim Submitter's Identifier Min 1 Max 38 String (AN) Required Identifier used to track a claim from creation by the health care provider through payment 1/30/25, 11:53 AM Texas Medicaid & Healthcare Partnerships (TMHP) 837 837 Health Care Claim: Professional (X222/A2/A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/tmhp/837-health-care-claim-professional-x222a2a1/01HMBZ8Y6XYRFK1ZR16EKD50N6 48/552 REF 1800 Detail > Billing Provider Hierarchical Level Loop > 2300 Loop > REF Referral Number To specify identifying information Example REFXXXXXXXXXXX~ Max use 30 Optional REF-01 128 Reference Identification Qualifier Min 2 Max 3 Identifier (ID) Required Code qualifying the Reference Identification REF-02 127 Referral Number Min 8 Max 8 String (AN) Required Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier Usage notes REF02 must contain a valid referral number when applicable. 1/30/25, 11:53 AM Texas Medicaid & Healthcare Partnerships (TMHP) 837 837 Health Care Claim: Professional (X222/A2/A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/tmhp/837-health-care-claim-professional-x222a2a1/01HMBZ8Y6XYRFK1ZR16EKD50N6 49/552 NTE 1900 Detail > Billing Provider Hierarchical Level Loop > 2300 Loop > NTE Claim Note To transmit information in a free-form format, if necessary, for comment or special instruction Example NTEADDXXX~ Max use 20 Optional NTE-01 363 Note Reference Code Identifier (ID) Required Code identifying the functional area or purpose for which the note applies ADD Additional Information NTE-02 352 Description Min 1 Max 5 String (AN) Required A free-form description to clarify the related data elements and their content Usage notes To submit Billing Provider Service Group, enter the appropriate Service Group code for Billing Provider. NTE01 = ‘ADD’ NTE02 Positions 24-28 (left justified) (Refer to Long Term Care Reference Codes, under the LTC and Acute Care Reference Codes dropdown, on the TMHP.com website – https://www.tmhp.com/topics/edi) 1/30/25, 11:53 AM Texas Medicaid & Healthcare Partnerships (TMHP) 837 837 Health Care Claim: Professional (X222/A2/A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/tmhp/837-health-care-claim-professional-x222a2a1/01HMBZ8Y6XYRFK1ZR16EKD50N6 50/552 2300 Loop end HI 2310 Detail > Billing Provider Hierarchical Level Loop > 2300 Loop > HI Health Care Information Codes To supply information related to the delivery of health care Usage notes Texas Medicaid will only capture the first 4 diagnosis codes (HI01 to HI04) for processing the file. Example HI~ Max use 25 Optional 1/30/25, 11:53 AM Texas Medicaid & Healthcare Partnerships (TMHP) 837 837 Health Care Claim: Professional (X222/A2/A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/tmhp/837-health-care-claim-professional-x222a2a1/01HMBZ8Y6XYRFK1ZR16EKD50N6 51/552 2000B Subscriber Hierarchical Level Loop Max >1 Required HL 0010 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > HL Hierarchical Level To identify dependencies among and the content of hierarchically related groups of data segments Example HL21221~ Max use 1 Required HL-01 628 Hierarchical ID Number Min 1 Max 12 String (AN) Required A unique number assigned by the sender to identify a particular data segment in a hierarchical structure HL01 shall contain a unique alphanumeric number for each occurrence of the HL segment in the transaction set. For example, HL01 could be used to indicate the number of occurrences of the HL segment, in which case the value of HL01 would be "1" for the initial HL segment and would be incremented by one in each subsequent HL segment within the transaction. HL-02 734 Hierarchical Parent ID Number Min 1 Max 12 String (AN) Required Identification number of the next higher hierarchical data segment that the data segment being described is subordinate to HL02 identifies the hierarchical ID number of the HL segment to which the current HL segment is subordinate. HL-03 735 Hierarchical Level Code Identifier (ID) Required Code defining the characteristic of a level in a hierarchical structure HL03 indicates the context of the series of segments following the current HL segment up to the next occurrence of an HL segment in the transaction. For example, HL03 is used to indicate that subsequent segments in the HL loop form a logical grouping of data referring to shipment, order, or item-level information. 22 Subscriber HL-04 736 Hierarchical Child Code Identifier (ID) Optional Code indicating if there are hierarchical child data segments subordinate to the level being described HL04 indicates whether or not there are subordinate (or child) HL segments related to the current HL segment. 0 No Subordinate HL Segment in This Hierarchical Structure. 1 Additional Subordinate HL Data Segment in This Hierarchical Structure. 1/30/25, 11:53 AM Texas Medicaid & Healthcare Partnerships (TMHP) 837 837 Health Care Claim: Professional (X222/A2/A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/tmhp/837-health-care-claim-professional-x222a2a1/01HMBZ8Y6XYRFK1ZR16EKD50N6 52/552 SBR 0050 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > SBR Subscriber Information To record information specific to the primary insured and the insurance carrier for that insured Example SBRC18XXXXXXXXXXX16****14~ Max use 1 Required SBR-01 1138 Payer Responsibility Sequence Number Code Identifier (ID) Required Code identifying the insurance carrier's level of responsibility for a payment of a claim Usage notes Within a given claim, the various values for the Payer Responsibility Sequence Number Code (other than value "U") may occur no more than once. A Payer Responsibility Four B Payer Responsibility Five C Payer Responsibility Six D Payer Responsibility Seven E Payer Responsibility Eight F Payer Responsibility Nine G Payer Responsibility Ten H Payer Responsibility Eleven P Primary S Secondary T Tertiary U Unknown This code may only be used in payer to payer COB claims when the original payer determined the presence of this coverage from eligibility files received from this payer or when the original claim did not provide the responsibility sequence for this payer. SBR-02 1069 Individual Relationship Code Identifier (ID) Optional Code indicating the relationship between two individuals or entities SBR02 specifies the relationship to the person insured. 18 Self SBR-03 127 Subscriber Group or Policy Number Min 1 Max 50 String (AN) Optional Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier SBR03 is policy or group number. Usage notes This is not the number uniquely identifying the subscriber. The unique subscriber number is submitted in Loop ID-2010BA-NM109. SBR-04 93 Subscriber Group Name Min 1 Max 60 String (AN) Optional Free-form name SBR04 is plan name. SBR-05 1336 Insurance Type Code Identifier (ID) Optional Code identifying the type of insurance policy within a specific insurance program 1/30/25, 11:53 AM Texas Medicaid & Healthcare Partnerships (TMHP) 837 837 Health Care Claim:	Texas Medicaid and Healthcare Partnerships.pdf
734 Hierarchical Parent ID Number Min 1 Max 12 String (AN) Required Identification number of the next higher hierarchical data segment that the data segment being described is subordinate to HL02 identifies the hierarchical ID number of the HL segment to which the current HL segment is subordinate. HL-03 735 Hierarchical Level Code Identifier (ID) Required Code defining the characteristic of a level in a hierarchical structure HL03 indicates the context of the series of segments following the current HL segment up to the next occurrence of an HL segment in the transaction. For example, HL03 is used to indicate that subsequent segments in the HL loop form a logical grouping of data referring to shipment, order, or item-level information. 22 Subscriber HL-04 736 Hierarchical Child Code Identifier (ID) Optional Code indicating if there are hierarchical child data segments subordinate to the level being described HL04 indicates whether or not there are subordinate (or child) HL segments related to the current HL segment. 0 No Subordinate HL Segment in This Hierarchical Structure. 1 Additional Subordinate HL Data Segment in This Hierarchical Structure. 1/30/25, 11:53 AM Texas Medicaid & Healthcare Partnerships (TMHP) 837 837 Health Care Claim: Professional (X222/A2/A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/tmhp/837-health-care-claim-professional-x222a2a1/01HMBZ8Y6XYRFK1ZR16EKD50N6 52/552 SBR 0050 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > SBR Subscriber Information To record information specific to the primary insured and the insurance carrier for that insured Example SBRC18XXXXXXXXXXX16*14~ Max use 1 Required SBR-01 1138 Payer Responsibility Sequence Number Code Identifier (ID) Required Code identifying the insurance carrier's level of responsibility for a payment of a claim Usage notes Within a given claim, the various values for the Payer Responsibility Sequence Number Code (other than value "U") may occur no more than once. A Payer Responsibility Four B Payer Responsibility Five C Payer Responsibility Six D Payer Responsibility Seven E Payer Responsibility Eight F Payer Responsibility Nine G Payer Responsibility Ten H Payer Responsibility Eleven P Primary S Secondary T Tertiary U Unknown This code may only be used in payer to payer COB claims when the original payer determined the presence of this coverage from eligibility files received from this payer or when the original claim did not provide the responsibility sequence for this payer. SBR-02 1069 Individual Relationship Code Identifier (ID) Optional Code indicating the relationship between two individuals or entities SBR02 specifies the relationship to the person insured. 18 Self SBR-03 127 Subscriber Group or Policy Number Min 1 Max 50 String (AN) Optional Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier SBR03 is policy or group number. Usage notes This is not the number uniquely identifying the subscriber. The unique subscriber number is submitted in Loop ID-2010BA-NM109. SBR-04 93 Subscriber Group Name Min 1 Max 60 String (AN) Optional Free-form name SBR04 is plan name. SBR-05 1336 Insurance Type Code Identifier (ID) Optional Code identifying the type of insurance policy within a specific insurance program 1/30/25, 11:53 AM Texas Medicaid & Healthcare Partnerships (TMHP) 837 837 Health Care Claim: Professional (X222/A2/A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/tmhp/837-health-care-claim-professional-x222a2a1/01HMBZ8Y6XYRFK1ZR16EKD50N6 53/552 12 Medicare Secondary Working Aged Beneficiary or Spouse with Employer Group Health Plan 13 Medicare Secondary End-Stage Renal Disease Beneficiary in the Mandated Coordination Period with an Employer's Group Health Plan 14 Medicare Secondary, No-fault Insurance including Auto is Primary 15 Medicare Secondary Worker's Compensation 16 Medicare Secondary Public Health Service (PHS)or Other Federal Agency 41 Medicare Secondary Black Lung 42 Medicare Secondary Veteran's Administration 43 Medicare Secondary Disabled Beneficiary Under Age 65 with Large Group Health Plan (LGHP) 47 Medicare Secondary, Other Liability Insurance is Primary SBR-09 1032 Claim Filing Indicator Code Identifier (ID) Required Code identifying type of claim 11 Other Non-Federal Programs 12 Preferred Provider Organization (PPO) 13 Point of Service (POS) 14 Exclusive Provider Organization (EPO) 15 Indemnity Insurance 16 Health Maintenance Organization (HMO) Medicare Risk 17 Dental Maintenance Organization AM Automobile Medical BL Blue Cross/Blue Shield CH Champus CI Commercial Insurance Co. DS Disability FI Federal Employees Program HM Health Maintenance Organization LM Liability Medical MA Medicare Part A MB Medicare Part B MC Medicaid OF Other Federal Program Use code OF when submitting Medicare Part D claims. TV Title V VA Veterans Affairs Plan WC Workers' Compensation Health Claim ZZ Mutually Defined Use Code ZZ when Type of Insurance is not known. 1/30/25, 11:53 AM Texas Medicaid & Healthcare Partnerships (TMHP) 837 837 Health Care Claim: Professional (X222/A2/A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/tmhp/837-health-care-claim-professional-x222a2a1/01HMBZ8Y6XYRFK1ZR16EKD50N6 54/552 PAT 0070 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > PAT Patient Information To supply patient information Usage notes Required when the patient is the subscriber or considered to be the subscriber and at least one of the element requirements are met. If not required by this implementation guide, do not send. Example PAT**D8XXXX0100Y~ If either Date Time Period Format Qualifier (PAT-05) or Patient Death Date (PAT-06) is present, then the other is required If either Unit or Basis for Measurement Code (PAT-07) or Patient Weight (PAT-08) is present, then the other is required Max use 1 Optional PAT-05 1250 Date Time Period Format Qualifier Identifier (ID) Optional Code indicating the date format, time format, or date and time format D8 Date Expressed in Format CCYYMMDD PAT-06 1251 Patient Death Date Min 1 Max 35 String (AN) Optional Expression of a date, a time, or range of dates, times or dates and times PAT06 is the date of death. PAT-07 355 Unit or Basis for Measurement Code Identifier (ID) Optional Code specifying the units in which a value is being expressed, or manner in which a measurement has been taken 01 Actual Pounds PAT-08 81 Patient Weight Min 1 Max 10 Decimal number (R) Optional Numeric value of weight PAT08 is the patient's weight. PAT-09 1073 Pregnancy Indicator Identifier (ID) Optional Code indicating a Yes or No condition or response PAT09 indicates whether the patient is pregnant or not pregnant. Code "Y" indicates the patient is pregnant; code "N" indicates the patient is not pregnant. Usage notes For this implementation, the listed value takes precedence over the semantic note. Y Yes 1/30/25, 11:53 AM Texas Medicaid & Healthcare Partnerships (TMHP) 837 837 Health Care Claim: Professional (X222/A2/A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/tmhp/837-health-care-claim-professional-x222a2a1/01HMBZ8Y6XYRFK1ZR16EKD50N6 55/552 2010BA Subscriber Name Loop Max 1 Required Variants (all may be used) Payer Name Loop NM1 0150 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Subscriber Name Loop > NM1 Subscriber Name To supply the full name of an individual or organizational entity Usage notes In worker's compensation or other property and casualty claims, the "subscriber" may be a non-person entity (for example, the employer). However, this varies by state. Example NM1IL1XXXXXXXXXXXXX*XXMIXXX~ If either Identification Code Qualifier (NM1-08) or Subscriber Primary Identifier (NM1-09) is present, then the other is required Max use 1 Required NM1-01 98 Entity Identifier Code Identifier (ID) Required Code identifying an organizational entity, a physical location, property or an individual IL Insured or Subscriber NM1-02 1065 Entity Type Qualifier Identifier (ID) Required Code qualifying the type of entity NM102 qualifies NM103. 1 Person 2 Non-Person Entity NM1-03 1035 Subscriber Last Name Min 1 Max 60 String (AN) Required Individual last name or organizational name NM1-04 1036 Subscriber First Name Min 1 Max 35 String (AN) Optional Individual first name NM1-05 1037 Subscriber Middle Name or Initial Min 1 Max 25 String (AN) Optional Individual middle name or initial NM1-07 1039 Subscriber Name Suffix Min 1 Max 10 String (AN) Optional Suffix to individual name Usage notes Examples: I, II, III, IV, Jr, Sr This data element is used only to indicate generation or patronymic. NM1-08 66 Identification Code Qualifier Identifier (ID) Optional 1/30/25, 11:53 AM Texas Medicaid & Healthcare Partnerships (TMHP) 837 837 Health Care Claim: Professional (X222/A2/A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/tmhp/837-health-care-claim-professional-x222a2a1/01HMBZ8Y6XYRFK1ZR16EKD50N6 56/552 Code designating the system/method of code structure used for Identification Code (67) II Standard Unique Health Identifier for each Individual in the United States Required if the HIPAA Individual Patient Identifier is mandated use. If not required, use value `MI' instead. MI Member Identification Number The code MI is intended to be the subscriber's identification number as assigned by the payer. (For example, Insured's ID, Subscriber's ID, Health Insurance Claim Number (HIC), etc.) MI is also intended to be used in claims submitted to the Indian Health Service/Contract Health Services (IHS/CHS) Fiscal Intermediary for the purpose of reporting the Tribe Residency Code (Tribe County State). In the event that a Social Security Number (SSN) is also available on an IHS/CHS claim, put the SSN in REF02. When sending the Social Security Number as the Member ID, it must be a string of exactly nine numbers with no separators. For example, sending "111002222" would be valid, while sending "111-00-2222" would be invalid. NM1-09 67 Subscriber Primary Identifier Min 2 Max 80 String (AN) Optional Code identifying a party or other code 1/30/25, 11:53 AM Texas Medicaid & Healthcare Partnerships (TMHP) 837 837 Health Care Claim: Professional (X222/A2/A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/tmhp/837-health-care-claim-professional-x222a2a1/01HMBZ8Y6XYRFK1ZR16EKD50N6 57/552 N3 0250 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Subscriber Name Loop > N3 Subscriber Address To specify the location of the named party Usage notes Required when the patient is the subscriber or considered to be the subscriber. If not required by this implementation guide, do not send. Example N3XXXXXXXXX~ Max use 1 Optional N3-01 166 Subscriber Address Line Min 1 Max 55 String (AN) Required Address information N3-02 166 Subscriber Address Line Min 1 Max 55 String (AN) Optional Address information 1/30/25, 11:53 AM Texas Medicaid & Healthcare Partnerships (TMHP) 837 837 Health Care Claim: Professional (X222/A2/A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/tmhp/837-health-care-claim-professional-x222a2a1/01HMBZ8Y6XYRFK1ZR16EKD50N6 58/552 N4 0300 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Subscriber Name Loop > N4 Subscriber City, State, ZIP Code To specify the geographic place of the named party Usage notes Required when the patient is the subscriber or considered to be the subscriber. If not required by this implementation guide, do not send. Example N4XXXXXXXXXXXXXXXXXXX~ Only one of Subscriber State Code (N4-02) or Country Subdivision Code (N4-07) may be present If Country Subdivision Code (N4-07) is present, then Country Code (N4-04) is required Max use 1 Optional N4-01 19 Subscriber City Name Min 2 Max 30 String (AN) Required Free-form text for city name A combination of either N401 through N404, or N405 and N406 may be adequate to specify a location. N4-02 156 Subscriber State Code Min 2 Max 2 Identifier (ID) Optional Code (Standard State/Province) as defined by appropriate government agency N402 is required only if city name (N401) is in the U.S. or Canada. N4-03 116 Subscriber Postal Zone or ZIP Code Min 3 Max 15 Identifier (ID) Optional Code defining international postal zone code excluding punctuation and blanks (zip code for United States) N4-04 26 Country Code Min 2 Max 3 Identifier (ID) Optional Code identifying the country Usage notes Use the alpha-2 country codes from Part 1 of ISO 3166. N4-07 1715 Country Subdivision Code Min 1 Max 3 Identifier (ID) Optional Code identifying the country subdivision Usage notes Use the country subdivision codes from Part 2 of ISO 3166. 1/30/25, 11:53 AM Texas Medicaid & Healthcare Partnerships (TMHP) 837 837 Health Care Claim: Professional (X222/A2/A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/tmhp/837-health-care-claim-professional-x222a2a1/01HMBZ8Y6XYRFK1ZR16EKD50N6 59/552 DMG 0320 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Subscriber Name Loop > DMG Subscriber Demographic Information To supply demographic information Usage notes Required when the patient is the subscriber or considered to be the subscriber. If not required by this implementation guide, do not send. Example DMGD8XXU~ Max use 1 Optional DMG-01 1250 Date Time Period Format Qualifier Identifier (ID) Required Code indicating the date format, time format, or date and time format D8 Date Expressed in Format CCYYMMDD DMG-02 1251 Subscriber Birth Date Min 1 Max 35 String (AN) Required Expression of a date, a time, or range of dates, times or dates and times DMG02 is the date of birth. DMG-03 1068 Subscriber Gender Code Identifier (ID) Required Code indicating the sex of the individual F Female M Male U Unknown 1/30/25, 11:53 AM Texas Medicaid & Healthcare Partnerships (TMHP) 837 837	Texas Medicaid and Healthcare Partnerships.pdf
specify the location of the named party Usage notes Required when the patient is the subscriber or considered to be the subscriber. If not required by this implementation guide, do not send. Example N3XXXXXXXXX~ Max use 1 Optional N3-01 166 Subscriber Address Line Min 1 Max 55 String (AN) Required Address information N3-02 166 Subscriber Address Line Min 1 Max 55 String (AN) Optional Address information 1/30/25, 11:53 AM Texas Medicaid & Healthcare Partnerships (TMHP) 837 837 Health Care Claim: Professional (X222/A2/A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/tmhp/837-health-care-claim-professional-x222a2a1/01HMBZ8Y6XYRFK1ZR16EKD50N6 58/552 N4 0300 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Subscriber Name Loop > N4 Subscriber City, State, ZIP Code To specify the geographic place of the named party Usage notes Required when the patient is the subscriber or considered to be the subscriber. If not required by this implementation guide, do not send. Example N4XXXXXXXXXXXXXXXXXXX~ Only one of Subscriber State Code (N4-02) or Country Subdivision Code (N4-07) may be present If Country Subdivision Code (N4-07) is present, then Country Code (N4-04) is required Max use 1 Optional N4-01 19 Subscriber City Name Min 2 Max 30 String (AN) Required Free-form text for city name A combination of either N401 through N404, or N405 and N406 may be adequate to specify a location. N4-02 156 Subscriber State Code Min 2 Max 2 Identifier (ID) Optional Code (Standard State/Province) as defined by appropriate government agency N402 is required only if city name (N401) is in the U.S. or Canada. N4-03 116 Subscriber Postal Zone or ZIP Code Min 3 Max 15 Identifier (ID) Optional Code defining international postal zone code excluding punctuation and blanks (zip code for United States) N4-04 26 Country Code Min 2 Max 3 Identifier (ID) Optional Code identifying the country Usage notes Use the alpha-2 country codes from Part 1 of ISO 3166. N4-07 1715 Country Subdivision Code Min 1 Max 3 Identifier (ID) Optional Code identifying the country subdivision Usage notes Use the country subdivision codes from Part 2 of ISO 3166. 1/30/25, 11:53 AM Texas Medicaid & Healthcare Partnerships (TMHP) 837 837 Health Care Claim: Professional (X222/A2/A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/tmhp/837-health-care-claim-professional-x222a2a1/01HMBZ8Y6XYRFK1ZR16EKD50N6 59/552 DMG 0320 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Subscriber Name Loop > DMG Subscriber Demographic Information To supply demographic information Usage notes Required when the patient is the subscriber or considered to be the subscriber. If not required by this implementation guide, do not send. Example DMGD8XXU~ Max use 1 Optional DMG-01 1250 Date Time Period Format Qualifier Identifier (ID) Required Code indicating the date format, time format, or date and time format D8 Date Expressed in Format CCYYMMDD DMG-02 1251 Subscriber Birth Date Min 1 Max 35 String (AN) Required Expression of a date, a time, or range of dates, times or dates and times DMG02 is the date of birth. DMG-03 1068 Subscriber Gender Code Identifier (ID) Required Code indicating the sex of the individual F Female M Male U Unknown 1/30/25, 11:53 AM Texas Medicaid & Healthcare Partnerships (TMHP) 837 837 Health Care Claim: Professional (X222/A2/A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/tmhp/837-health-care-claim-professional-x222a2a1/01HMBZ8Y6XYRFK1ZR16EKD50N6 60/552 REF 0350 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Subscriber Name Loop > REF Property and Casualty Claim Number To specify identifying information Usage notes Required when the services included in this claim are to be considered as part of a property and casualty claim. If not required by this implementation guide, do not send. This is a property and casualty payer-assigned claim number. Providers receive this number from the property and casualty payer during eligibility determinations or some other communication with that payer. See Section 1.4.2, Property and Casualty, for additional information about property and casualty claims.; This segment is not a HIPAA requirement as of this writing. Example REFY4X~ Variants (all may be used) REF Subscriber Secondary Identification Max use 1 Optional REF-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification Y4 Agency Claim Number REF-02 127 Property Casualty Claim Number Min 1 Max 50 String (AN) Required Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier 1/30/25, 11:53 AM Texas Medicaid & Healthcare Partnerships (TMHP) 837 837 Health Care Claim: Professional (X222/A2/A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/tmhp/837-health-care-claim-professional-x222a2a1/01HMBZ8Y6XYRFK1ZR16EKD50N6 61/552 REF 0350 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Subscriber Name Loop > REF Subscriber Secondary Identification To specify identifying information Usage notes Required when an additional identification number to that provided in NM109 of this loop is necessary for the claim processor to identify the entity. If not required by this implementation guide, do not send. Example REFSYXX~ Variants (all may be used) REF Property and Casualty Claim Number Max use 1 Optional REF-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification SY Social Security Number The Social Security Number must be a string of exactly nine numbers with no separators. For example, sending "111002222" would be valid, while sending "111-00-2222" would be invalid. REF-02 127 Subscriber Supplemental Identifier Min 1 Max 50 String (AN) Required Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier 1/30/25, 11:53 AM Texas Medicaid & Healthcare Partnerships (TMHP) 837 837 Health Care Claim: Professional (X222/A2/A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/tmhp/837-health-care-claim-professional-x222a2a1/01HMBZ8Y6XYRFK1ZR16EKD50N6 62/552 PER 0400 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Subscriber Name Loop > PER Property and Casualty Subscriber Contact Information To identify a person or office to whom administrative communications should be directed Usage notes Required for Property and Casualty claims when this information is deemed necessary by the submitter. If not required by this implementation guide, do not send. When the communication number represents a telephone number in the United States and other countries using the North American Dialing Plan (for voice, data, fax, etc.), the communication number must always include the area code and phone number using the format AAABBBCCCC where AAA is the area code, BBB is the telephone number prefix, and CCCC is the telephone number. Therefore, the following telephone number (555) 555-1234 would be represented as 5555551234. Do not submit long distance access numbers, such as "1", in the telephone number. Telephone extensions, when applicable, must be submitted in the next element immediately following the telephone number. When submitting telephone extensions, only submit the numeric extension. Do not include data that indicates an extension, such as "ext" or "x-". Example PERICXXTEXXXXEXX~ If either Communication Number Qualifier (PER-05) or Communication Number (PER-06) is present, then the other is required Max use 1 Optional PER-01 366 Contact Function Code Identifier (ID) Required Code identifying the major duty or responsibility of the person or group named IC Information Contact PER-02 93 Name Min 1 Max 60 String (AN) Optional Free-form name PER-03 365 Communication Number Qualifier Identifier (ID) Required Code identifying the type of communication number TE Telephone PER-04 364 Communication Number Min 1 Max 256 String (AN) Required Complete communications number including country or area code when applicable PER-05 365 Communication Number Qualifier Identifier (ID) Optional Code identifying the type of communication number EX Telephone Extension PER-06 364 Communication Number Min 1 Max 256 String (AN) Optional Complete communications number including country or area code when applicable 1/30/25, 11:53 AM Texas Medicaid & Healthcare Partnerships (TMHP) 837 837 Health Care Claim: Professional (X222/A2/A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/tmhp/837-health-care-claim-professional-x222a2a1/01HMBZ8Y6XYRFK1ZR16EKD50N6 63/552 2010BA Subscriber Name Loop end 1/30/25, 11:53 AM Texas Medicaid & Healthcare Partnerships (TMHP) 837 837 Health Care Claim: Professional (X222/A2/A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/tmhp/837-health-care-claim-professional-x222a2a1/01HMBZ8Y6XYRFK1ZR16EKD50N6 64/552 2010BB Payer Name Loop Max 1 Required Variants (all may be used) Subscriber Name Loop NM1 0150 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Payer Name Loop > NM1 Payer Name To supply the full name of an individual or organizational entity Usage notes This is the destination payer. For the purposes of this implementation the term payer is synonymous with several other terms, such as, repricer and third party administrator. Example NM1PR2TDMHMR****PI617591011CMSP~ Max use 1 Required NM1-01 98 Entity Identifier Code Identifier (ID) Required Code identifying an organizational entity, a physical location, property or an individual PR Payer NM1-02 1065 Entity Type Qualifier Identifier (ID) Required Code qualifying the type of entity NM102 qualifies NM103. 2 Non-Person Entity NM1-03 1035 Payer Name String (AN) Required Individual last name or organizational name TDHS TDHS/TDMHMR TDMHMR NM1-08 66 Identification Code Qualifier Identifier (ID) Required Code designating the system/method of code structure used for Identification Code (67) Usage notes Use code value "PI" when reporting Payor Identification. Use code value "XV" when reporting Health Plan ID (HPID) or Other Entity Identifier (OEID). Prior to the mandated implementation date for Health Plan Identifier, willing trading partners may agree to: Follow a dual use approach in which both the HPID or OEID and the Payor Identification are sent. Send XV qualifier in NM108 with HPID or OEID in NM109 and the Payor Identification, that would have been sent using qualifier PI, in the corresponding REF segment using qualifier 2U (Payer Identification Number). OR Follow an early implementation approach in which the HPID or OEID is sent in NM109. PI Payor Identification XV Centers for Medicare and Medicaid Services PlanID 1/30/25, 11:53 AM Texas Medicaid & Healthcare Partnerships (TMHP) 837 837 Health Care Claim: Professional (X222/A2/A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/tmhp/837-health-care-claim-professional-x222a2a1/01HMBZ8Y6XYRFK1ZR16EKD50N6 65/552 NM1-09 67 Payer Identifier String (AN) Required Code identifying a party or other code 617591011CMSP 1/30/25, 11:53 AM Texas Medicaid & Healthcare Partnerships (TMHP) 837 837 Health Care Claim: Professional (X222/A2/A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/tmhp/837-health-care-claim-professional-x222a2a1/01HMBZ8Y6XYRFK1ZR16EKD50N6 66/552 N3 0250 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Payer Name Loop > N3 Payer Address To specify the location of the named party Usage notes Required when the payer address is available and the submitter intends for the claim to be printed on paper at the next EDI location (for example, a clearinghouse). If not required by this implementation guide, do not send. Example N3XXXX~ Max use 1 Optional N3-01 166 Payer Address Line Min 1 Max 55 String (AN) Required Address information N3-02 166 Payer Address Line Min 1 Max 55 String (AN) Optional Address information 1/30/25, 11:53 AM Texas Medicaid & Healthcare Partnerships (TMHP) 837 837 Health Care Claim: Professional (X222/A2/A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/tmhp/837-health-care-claim-professional-x222a2a1/01HMBZ8Y6XYRFK1ZR16EKD50N6 67/552 N4 0300 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Payer Name Loop > N4 Payer City, State, ZIP Code To specify the geographic place of the named party Usage notes Required when the payer address is available and the submitter intends for the claim to be printed on paper at the next EDI location (for example, a clearinghouse). If not required by this implementation guide, do not send. Example N4XXXXXXXXXXXXXXXXX~ Only one of Payer State or Province Code (N4-02) or Country Subdivision Code (N4-07) may be present If Country Subdivision Code (N4-07) is present, then Country Code (N4-04) is required Max use 1 Optional N4-01 19 Payer City Name Min 2 Max 30 String (AN) Required Free-form text for city name A combination of either N401 through N404, or N405 and N406 may be adequate to specify a location. N4-02 156 Payer State or Province Code Min 2 Max 2 Identifier (ID) Optional Code (Standard State/Province) as defined by appropriate government agency N402 is required only if city name (N401) is in the U.S. or Canada. N4-03 116 Payer Postal Zone or ZIP Code Min 3 Max 15 Identifier (ID) Optional Code defining international postal zone code excluding punctuation and blanks (zip code for United States) N4-04 26 Country Code Min 2 Max 3 Identifier (ID) Optional Code identifying the country Usage notes Use the alpha-2 country codes from Part 1 of ISO 3166. N4-07 1715 Country Subdivision Code Min 1 Max 3 Identifier (ID) Optional Code identifying the country subdivision Usage notes Use the country subdivision codes from Part 2 of ISO 3166. 1/30/25, 11:53 AM Texas Medicaid & Healthcare Partnerships (TMHP) 837 837 Health Care Claim: Professional (X222/A2/A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/tmhp/837-health-care-claim-professional-x222a2a1/01HMBZ8Y6XYRFK1ZR16EKD50N6 68/552 REF 0350 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Payer Name	Texas Medicaid and Healthcare Partnerships.pdf
HPID or OEID is sent in NM109. PI Payor Identification XV Centers for Medicare and Medicaid Services PlanID 1/30/25, 11:53 AM Texas Medicaid & Healthcare Partnerships (TMHP) 837 837 Health Care Claim: Professional (X222/A2/A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/tmhp/837-health-care-claim-professional-x222a2a1/01HMBZ8Y6XYRFK1ZR16EKD50N6 65/552 NM1-09 67 Payer Identifier String (AN) Required Code identifying a party or other code 617591011CMSP 1/30/25, 11:53 AM Texas Medicaid & Healthcare Partnerships (TMHP) 837 837 Health Care Claim: Professional (X222/A2/A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/tmhp/837-health-care-claim-professional-x222a2a1/01HMBZ8Y6XYRFK1ZR16EKD50N6 66/552 N3 0250 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Payer Name Loop > N3 Payer Address To specify the location of the named party Usage notes Required when the payer address is available and the submitter intends for the claim to be printed on paper at the next EDI location (for example, a clearinghouse). If not required by this implementation guide, do not send. Example N3XXXX~ Max use 1 Optional N3-01 166 Payer Address Line Min 1 Max 55 String (AN) Required Address information N3-02 166 Payer Address Line Min 1 Max 55 String (AN) Optional Address information 1/30/25, 11:53 AM Texas Medicaid & Healthcare Partnerships (TMHP) 837 837 Health Care Claim: Professional (X222/A2/A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/tmhp/837-health-care-claim-professional-x222a2a1/01HMBZ8Y6XYRFK1ZR16EKD50N6 67/552 N4 0300 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Payer Name Loop > N4 Payer City, State, ZIP Code To specify the geographic place of the named party Usage notes Required when the payer address is available and the submitter intends for the claim to be printed on paper at the next EDI location (for example, a clearinghouse). If not required by this implementation guide, do not send. Example N4XXXXXXXXXXXXXXXXX~ Only one of Payer State or Province Code (N4-02) or Country Subdivision Code (N4-07) may be present If Country Subdivision Code (N4-07) is present, then Country Code (N4-04) is required Max use 1 Optional N4-01 19 Payer City Name Min 2 Max 30 String (AN) Required Free-form text for city name A combination of either N401 through N404, or N405 and N406 may be adequate to specify a location. N4-02 156 Payer State or Province Code Min 2 Max 2 Identifier (ID) Optional Code (Standard State/Province) as defined by appropriate government agency N402 is required only if city name (N401) is in the U.S. or Canada. N4-03 116 Payer Postal Zone or ZIP Code Min 3 Max 15 Identifier (ID) Optional Code defining international postal zone code excluding punctuation and blanks (zip code for United States) N4-04 26 Country Code Min 2 Max 3 Identifier (ID) Optional Code identifying the country Usage notes Use the alpha-2 country codes from Part 1 of ISO 3166. N4-07 1715 Country Subdivision Code Min 1 Max 3 Identifier (ID) Optional Code identifying the country subdivision Usage notes Use the country subdivision codes from Part 2 of ISO 3166. 1/30/25, 11:53 AM Texas Medicaid & Healthcare Partnerships (TMHP) 837 837 Health Care Claim: Professional (X222/A2/A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/tmhp/837-health-care-claim-professional-x222a2a1/01HMBZ8Y6XYRFK1ZR16EKD50N6 68/552 REF 0350 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Payer Name Loop > REF Billing Provider Secondary Identification To specify identifying information Usage notes Required prior to the mandated NPI Implementation Date when an additional identification number is necessary for the receiver to identify the provider. OR Required on or after the mandated NPI Implementation Date when NM109 in Loop 2010AA is not used and an identification number other than the NPI is necessary for the receiver to identify the provider. If not required by this implementation guide, do not send. Example REFG2XXXX~ Variants (all may be used) REF Payer Secondary Identification Max use 2 Optional REF-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification Usage notes If the provider has an API instead of an NPI, the API must be sent in the REF02. G2 Provider Commercial Number This code designates a proprietary provider number for the destination payer identified in the Payer Name loop, Loop ID-2010BB, associated with this claim. This is to be used by all payers including: Medicare, Medicaid, Blue Cross, etc. LU Location Number REF-02 127 Billing Provider Secondary Identifier Min 1 Max 50 String (AN) Required Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier 1/30/25, 11:53 AM Texas Medicaid & Healthcare Partnerships (TMHP) 837 837 Health Care Claim: Professional (X222/A2/A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/tmhp/837-health-care-claim-professional-x222a2a1/01HMBZ8Y6XYRFK1ZR16EKD50N6 69/552 2010BB Payer Name Loop end REF 0350 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Payer Name Loop > REF Payer Secondary Identification To specify identifying information Usage notes Required when an additional identification number to that provided in the NM109 of this loop is necessary to identify the entity. If not required by this implementation guide, do not send. Example REFEIXXXXX~ Variants (all may be used) REF Billing Provider Secondary Identification Max use 3 Optional REF-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification 2U Payer Identification Number This code is only allowed when the qualifier XV is reported in NM108 of this loop. EI Employer's Identification Number The Employer's Identification Number must be a string of exactly nine numbers with no separators. For example, "001122333" would be valid, while sending "001-12-2333" or "00-1122333" would be invalid. FY Claim Office Number NF National Association of Insurance Commissioners (NAIC) Code REF-02 127 Payer Secondary Identifier Min 1 Max 50 String (AN) Required Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier 1/30/25, 11:53 AM Texas Medicaid & Healthcare Partnerships (TMHP) 837 837 Health Care Claim: Professional (X222/A2/A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/tmhp/837-health-care-claim-professional-x222a2a1/01HMBZ8Y6XYRFK1ZR16EKD50N6 70/552 2300 Claim Information Loop Max 100 Optional CLM 1300 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > CLM Claim Information To specify basic data about the claim Usage notes The developers of this implementation guide recommend that trading partners limit the size of the transaction (ST-SE envelope) to a maximum of 5000 CLM segments. There is no recommended limit to the number of ST-SE transactions within a GS-GE or ISA- IEA. Willing trading partners can agree to set limits higher. For purposes of this documentation, the claim detail information is presented only in the dependent level. Specific claim detail information can be given in either the subscriber or the dependent hierarchical level. Because of this, the claim information is said to "float." Claim information is positioned in the same hierarchical level that describes its owner-participant, either the subscriber or the dependent. In other words, the claim information, Loop ID-2300, is placed following Loop ID-2010BB in the Subscriber Hierarchical Level (HL) when patient information is sent in Loop ID-2010BA of the Subscriber HL. Claim information is placed in the Patient HL when the patient information is sent in Loop ID-2010CA of the Patient HL. When the patient is the subscriber or is considered to be the subscriber, Loop ID-2000C and Loop ID-2010CA are not sent. See Subscriber/Patient HL Segment explanation in section 1.4.3.2.2.1 for details. Example CLMXXXX0**X>B>XNCYIPOA>XXX>>XX>XX03** **1~ Max use 1 Required CLM-01 1028 Patient Control Number Min 1 Max 38 String (AN) Required Identifier used to track a claim from creation by the health care provider through payment Usage notes The number that the submitter transmits in this position is echoed back to the submitter in the 835 and other transactions. This permits the submitter to use the value in this field as a key in the submitter's system to match the claim to the payment information returned in the 835 transaction. The two recommended identifiers are either the Patient Account Number or the Claim Number in the billing submitter's patient management system. The developers of this implementation guide strongly recommend that submitters use unique numbers for this field for each individual claim. When Loop ID-2010AC is present, CLM01 represents the subrogated Medicaid agency's claim number (ICN/DCN) from their original 835 CLP07 - Payer Claim Control Number. See Section 1.4.1.4 of the front matter for a description of post payment recovery claims for subrogated Medicaid agencies. The maximum number of characters to be supported for this field is `20'. Characters beyond the maximum are not required to be stored nor returned by any 837-receiving system. CLM-02 782 Total Claim Charge Amount Min 1 Max 15 Decimal number (R) Required Monetary amount CLM02 is the total amount of all submitted charges of service segments for this claim. Usage notes The Total Claim Charge Amount must be greater than or equal to zero. The total claim charge amount must balance to the sum of all service line charge amounts reported in the Professional Service (SV1) segments for this claim. 1/30/25, 11:53 AM Texas Medicaid & Healthcare Partnerships (TMHP) 837 837 Health Care Claim: Professional (X222/A2/A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/tmhp/837-health-care-claim-professional-x222a2a1/01HMBZ8Y6XYRFK1ZR16EKD50N6 71/552 CLM-05 C023 Health Care Service Location Information To provide information that identifies the place of service or the type of bill related to the location at which a health care service was rendered Max use 1 Required C023-01 1331 Place of Service Code Min 1 Max 2 String (AN) Required Code identifying where services were, or may be, performed; the first and second positions of the Uniform Bill Type Code for Institutional Services or the Place of Service Codes for Professional or Dental Services. C023-02 1332 Facility Code Qualifier Identifier (ID) Required Code identifying the type of facility referenced C023-02 qualifies C023-01 and C023-03. B Place of Service Codes for Professional or Dental Services C023-03 1325 Claim Frequency Code Min 1 Max 1 Identifier (ID) Required Code specifying the frequency of the claim; this is the third position of the Uniform Billing Claim Form Bill Type CLM-06 1073 Provider or Supplier Signature Indicator Identifier (ID) Required Code indicating a Yes or No condition or response CLM06 is provider signature on file indicator. A "Y" value indicates the provider signature is on file; an "N" value indicates the provider signature is not on file. N No Y Yes CLM-07 1359 Assignment or Plan Participation Code Identifier (ID) Required Code indicating whether the provider accepts assignment Usage notes Within this element the context of the word assignment is related to the relationship between the provider and the payer. This is NOT the field for reporting whether the patient has or has not assigned benefits to the provider. The benefit assignment indicator is in CLM08. A Assigned Required when the provider accepts assignment and/or has a participation agreement with the destination payer. OR Required when the provider does not accept assignment and/or have a participation agreement, but is advising the payer to adjudicate this specific claim under participating provider benefits as allowed under certain plans. B Assignment Accepted on Clinical Lab Services Only Required when the provider accepts assignment for Clinical Lab Services only. C Not Assigned Required when neither codes A' nor B' apply. CLM-08 1073 Benefits Assignment Certification Indicator Identifier (ID) Required Code indicating a Yes or No condition or response CLM08 is assignment of benefits indicator. A "Y" value indicates insured or authorized person authorizes benefits to be assigned to the provider; an "N" value indicates benefits have not been assigned to the provider. 1/30/25, 11:53 AM Texas Medicaid & Healthcare Partnerships (TMHP) 837 837 Health Care Claim: Professional (X222/A2/A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/tmhp/837-health-care-claim-professional-x222a2a1/01HMBZ8Y6XYRFK1ZR16EKD50N6 72/552 Usage notes This element answers the question whether or not the insured has authorized the plan to remit payment directly to the provider. N No W Not Applicable Use code `W' when the patient refuses to assign benefits. Y Yes CLM-09 1363 Release of Information Code Identifier (ID) Required Code indicating whether the provider has on file a signed statement by the patient authorizing the release of medical data to other organizations Usage notes The Release of Information response is limited to the information carried in this claim. I Informed Consent to Release Medical Information for Conditions or Diagnoses Regulated by Federal Statutes Required when the provider has not collected a signature AND state or federal laws do not require a signature be collected. Y Yes, Provider has a Signed Statement Permitting Release of Medical Billing Data Related to a Claim Required when the provider has collected a signature. OR Required when state or federal laws require a	Texas Medicaid and Healthcare Partnerships.pdf
second positions of the Uniform Bill Type Code for Institutional Services or the Place of Service Codes for Professional or Dental Services. C023-02 1332 Facility Code Qualifier Identifier (ID) Required Code identifying the type of facility referenced C023-02 qualifies C023-01 and C023-03. B Place of Service Codes for Professional or Dental Services C023-03 1325 Claim Frequency Code Min 1 Max 1 Identifier (ID) Required Code specifying the frequency of the claim; this is the third position of the Uniform Billing Claim Form Bill Type CLM-06 1073 Provider or Supplier Signature Indicator Identifier (ID) Required Code indicating a Yes or No condition or response CLM06 is provider signature on file indicator. A "Y" value indicates the provider signature is on file; an "N" value indicates the provider signature is not on file. N No Y Yes CLM-07 1359 Assignment or Plan Participation Code Identifier (ID) Required Code indicating whether the provider accepts assignment Usage notes Within this element the context of the word assignment is related to the relationship between the provider and the payer. This is NOT the field for reporting whether the patient has or has not assigned benefits to the provider. The benefit assignment indicator is in CLM08. A Assigned Required when the provider accepts assignment and/or has a participation agreement with the destination payer. OR Required when the provider does not accept assignment and/or have a participation agreement, but is advising the payer to adjudicate this specific claim under participating provider benefits as allowed under certain plans. B Assignment Accepted on Clinical Lab Services Only Required when the provider accepts assignment for Clinical Lab Services only. C Not Assigned Required when neither codes A' nor B' apply. CLM-08 1073 Benefits Assignment Certification Indicator Identifier (ID) Required Code indicating a Yes or No condition or response CLM08 is assignment of benefits indicator. A "Y" value indicates insured or authorized person authorizes benefits to be assigned to the provider; an "N" value indicates benefits have not been assigned to the provider. 1/30/25, 11:53 AM Texas Medicaid & Healthcare Partnerships (TMHP) 837 837 Health Care Claim: Professional (X222/A2/A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/tmhp/837-health-care-claim-professional-x222a2a1/01HMBZ8Y6XYRFK1ZR16EKD50N6 72/552 Usage notes This element answers the question whether or not the insured has authorized the plan to remit payment directly to the provider. N No W Not Applicable Use code `W' when the patient refuses to assign benefits. Y Yes CLM-09 1363 Release of Information Code Identifier (ID) Required Code indicating whether the provider has on file a signed statement by the patient authorizing the release of medical data to other organizations Usage notes The Release of Information response is limited to the information carried in this claim. I Informed Consent to Release Medical Information for Conditions or Diagnoses Regulated by Federal Statutes Required when the provider has not collected a signature AND state or federal laws do not require a signature be collected. Y Yes, Provider has a Signed Statement Permitting Release of Medical Billing Data Related to a Claim Required when the provider has collected a signature. OR Required when state or federal laws require a signature be collected. CLM-10 1351 Patient Signature Source Code Identifier (ID) Optional Code indicating how the patient or subscriber authorization signatures were obtained and how they are being retained by the provider P Signature generated by provider because the patient was not physically present for services Signature generated by an entity other than the patient according to State or Federal law. CLM-11 C024 Related Causes Information To identify one or more related causes and associated state or country information Usage notes Required when the services provided are employment related or the result of an accident. If not required by this implementation guide, do not send. Max use 1 Optional C024-01 1362 Related Causes Code Identifier (ID) Required Code identifying an accompanying cause of an illness, injury or an accident AA Auto Accident EM Employment OA Other Accident C024-02 1362 Related Causes Code Min 2 Max 3 Identifier (ID) Optional Code identifying an accompanying cause of an illness, injury or an accident C024-04 156 Auto Accident State or Province Code Min 2 Max 2 Identifier (ID) Optional Code (Standard State/Province) as defined by appropriate government agency C024-04 and C024-05 apply only to auto accidents when C024-01, C024-02, or C024-03 is equal to "AA". 1/30/25, 11:53 AM Texas Medicaid & Healthcare Partnerships (TMHP) 837 837 Health Care Claim: Professional (X222/A2/A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/tmhp/837-health-care-claim-professional-x222a2a1/01HMBZ8Y6XYRFK1ZR16EKD50N6 73/552 C024-05 26 Country Code Min 2 Max 3 Identifier (ID) Optional Code identifying the country CLM-12 1366 Special Program Indicator Identifier (ID) Optional Code indicating the Special Program under which the services rendered to the patient were performed 02 Physically Handicapped Children's Program This code is used for Medicaid claims only. 03 Special Federal Funding This code is used for Medicaid claims only. 05 Disability This code is used for Medicaid claims only. 09 Second Opinion or Surgery This code is used for Medicaid claims only. CLM-20 1514 Delay Reason Code Identifier (ID) Optional Code indicating the reason why a request was delayed 1 Proof of Eligibility Unknown or Unavailable 2 Litigation 3 Authorization Delays 4 Delay in Certifying Provider 5 Delay in Supplying Billing Forms 6 Delay in Delivery of Custom-made Appliances 7 Third Party Processing Delay 8 Delay in Eligibility Determination 9 Original Claim Rejected or Denied Due to a Reason Unrelated to the Billing Limitation Rules 10 Administration Delay in the Prior Approval Process 11 Other 15 Natural Disaster 1/30/25, 11:53 AM Texas Medicaid & Healthcare Partnerships (TMHP) 837 837 Health Care Claim: Professional (X222/A2/A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/tmhp/837-health-care-claim-professional-x222a2a1/01HMBZ8Y6XYRFK1ZR16EKD50N6 74/552 DTP 1350 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > DTP Date - Accident To specify any or all of a date, a time, or a time period Usage notes Required when CLM11-1 or CLM11-2 has a value of AA' or OA'. OR Required when CLM11-1 or CLM11-2 has a value of `EM' and this claim is the result of an accident. If not required by this implementation guide, do not send. Example DTP439D8XXXXXX~ Variants (all may be used) DTP Date - Acute Manifestation DTP Date - Admission DTP Date - Assumed and Relinquished Care Dates DTP Date - Authorized Return to Work DTP Date - Disability Dates DTP Date - Discharge DTP Date - Hearing and Vision Prescription Date DTP Date - Initial Treatment Date DTP Date - Last Menstrual Period DTP Date - Last Seen Date DTP Date - Last Worked DTP Date - Last X-ray Date DTP Date - Onset of Current Illness or Symptom DTP Date - Property and Casualty Date of First Contact DTP Date - Repricer Received Date Max use 1 Optional DTP-01 374 Date Time Qualifier Identifier (ID) Required Code specifying type of date or time, or both date and time 439 Accident DTP-02 1250 Date Time Period Format Qualifier Identifier (ID) Required Code indicating the date format, time format, or date and time format DTP02 is the date or time or period format that will appear in DTP03. D8 Date Expressed in Format CCYYMMDD DTP-03 1251 Accident Date Min 1 Max 35 String (AN) Required Expression of a date, a time, or range of dates, times or dates and times 1/30/25, 11:53 AM Texas Medicaid & Healthcare Partnerships (TMHP) 837 837 Health Care Claim: Professional (X222/A2/A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/tmhp/837-health-care-claim-professional-x222a2a1/01HMBZ8Y6XYRFK1ZR16EKD50N6 75/552 DTP 1350 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > DTP Date - Acute Manifestation To specify any or all of a date, a time, or a time period Usage notes Required when Loop ID-2300 CR208 = "A" or "M", the claim involves spinal manipulation, and the payer is Medicare. If not required by this implementation guide, do not send. Example DTP453D8X~ Variants (all may be used) DTP Date - Accident DTP Date - Admission DTP Date - Assumed and Relinquished Care Dates DTP Date - Authorized Return to Work DTP Date - Disability Dates DTP Date - Discharge DTP Date - Hearing and Vision Prescription Date DTP Date - Initial Treatment Date DTP Date - Last Menstrual Period DTP Date - Last Seen Date DTP Date - Last Worked DTP Date - Last X-ray Date DTP Date - Onset of Current Illness or Symptom DTP Date - Property and Casualty Date of First Contact DTP Date - Repricer Received Date Max use 1 Optional DTP-01 374 Date Time Qualifier Identifier (ID) Required Code specifying type of date or time, or both date and time 453 Acute Manifestation of a Chronic Condition DTP-02 1250 Date Time Period Format Qualifier Identifier (ID) Required Code indicating the date format, time format, or date and time format DTP02 is the date or time or period format that will appear in DTP03. D8 Date Expressed in Format CCYYMMDD DTP-03 1251 Acute Manifestation Date Min 1 Max 35 String (AN) Required Expression of a date, a time, or range of dates, times or dates and times 1/30/25, 11:53 AM Texas Medicaid & Healthcare Partnerships (TMHP) 837 837 Health Care Claim: Professional (X222/A2/A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/tmhp/837-health-care-claim-professional-x222a2a1/01HMBZ8Y6XYRFK1ZR16EKD50N6 76/552 DTP 1350 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > DTP Date - Admission To specify any or all of a date, a time, or a time period Usage notes Required on all ambulance claims when the patient was known to be admitted to the hospital. OR Required on all claims involving inpatient medical visits. If not required by this implementation guide, do not send. Example DTP435D8XXXX~ Variants (all may be used) DTP Date - Accident DTP Date - Acute Manifestation DTP Date - Assumed and Relinquished Care Dates DTP Date - Authorized Return to Work DTP Date - Disability Dates DTP Date - Discharge DTP Date - Hearing and Vision Prescription Date DTP Date - Initial Treatment Date DTP Date - Last Menstrual Period DTP Date - Last Seen Date DTP Date - Last Worked DTP Date - Last X-ray Date DTP Date - Onset of Current Illness or Symptom DTP Date - Property and Casualty Date of First Contact DTP Date - Repricer Received Date Max use 1 Optional DTP-01 374 Date Time Qualifier Identifier (ID) Required Code specifying type of date or time, or both date and time 435 Admission DTP-02 1250 Date Time Period Format Qualifier Identifier (ID) Required Code indicating the date format, time format, or date and time format DTP02 is the date or time or period format that will appear in DTP03. D8 Date Expressed in Format CCYYMMDD DTP-03 1251 Related Hospitalization Admission Date Min 1 Max 35 String (AN) Required Expression of a date, a time, or range of dates, times or dates and times 1/30/25, 11:53 AM Texas Medicaid & Healthcare Partnerships (TMHP) 837 837 Health Care Claim: Professional (X222/A2/A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/tmhp/837-health-care-claim-professional-x222a2a1/01HMBZ8Y6XYRFK1ZR16EKD50N6 77/552 DTP 1350 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > DTP Date - Assumed and Relinquished Care Dates To specify any or all of a date, a time, or a time period Usage notes Required to indicate "assumed care date" or "relinquished care date" when providers share post-operative care (global surgery claims). If not required by this implementation guide, do not send. Assumed Care Date is the date care was assumed by another provider during post- operative care. Relinquished Care Date is the date the provider filing this claim ceased post-operative care. See Medicare guidelines for further explanation of these dates. Example: Surgeon "A" relinquished post-operative care to Physician "B" five days after surgery. When Surgeon "A" submits a claim, "A" will use code "091 - Report End" to indicate the day the surgeon relinquished care of this patient to Physician "B". When Physician "B" submits a claim, "B" will use code "090 - Report Start" to indicate the date they assumed care of this patient from Surgeon "A". Example DTP090D8XX~ Variants (all may be used) DTP Date - Accident DTP Date - Acute Manifestation DTP Date - Admission DTP Date - Authorized Return to Work DTP Date - Disability Dates DTP Date - Discharge DTP Date - Hearing and Vision Prescription Date DTP Date - Initial Treatment Date DTP Date - Last Menstrual	Texas Medicaid and Healthcare Partnerships.pdf
Claim Information Loop > DTP Date - Admission To specify any or all of a date, a time, or a time period Usage notes Required on all ambulance claims when the patient was known to be admitted to the hospital. OR Required on all claims involving inpatient medical visits. If not required by this implementation guide, do not send. Example DTP435D8XXXX~ Variants (all may be used) DTP Date - Accident DTP Date - Acute Manifestation DTP Date - Assumed and Relinquished Care Dates DTP Date - Authorized Return to Work DTP Date - Disability Dates DTP Date - Discharge DTP Date - Hearing and Vision Prescription Date DTP Date - Initial Treatment Date DTP Date - Last Menstrual Period DTP Date - Last Seen Date DTP Date - Last Worked DTP Date - Last X-ray Date DTP Date - Onset of Current Illness or Symptom DTP Date - Property and Casualty Date of First Contact DTP Date - Repricer Received Date Max use 1 Optional DTP-01 374 Date Time Qualifier Identifier (ID) Required Code specifying type of date or time, or both date and time 435 Admission DTP-02 1250 Date Time Period Format Qualifier Identifier (ID) Required Code indicating the date format, time format, or date and time format DTP02 is the date or time or period format that will appear in DTP03. D8 Date Expressed in Format CCYYMMDD DTP-03 1251 Related Hospitalization Admission Date Min 1 Max 35 String (AN) Required Expression of a date, a time, or range of dates, times or dates and times 1/30/25, 11:53 AM Texas Medicaid & Healthcare Partnerships (TMHP) 837 837 Health Care Claim: Professional (X222/A2/A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/tmhp/837-health-care-claim-professional-x222a2a1/01HMBZ8Y6XYRFK1ZR16EKD50N6 77/552 DTP 1350 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > DTP Date - Assumed and Relinquished Care Dates To specify any or all of a date, a time, or a time period Usage notes Required to indicate "assumed care date" or "relinquished care date" when providers share post-operative care (global surgery claims). If not required by this implementation guide, do not send. Assumed Care Date is the date care was assumed by another provider during post- operative care. Relinquished Care Date is the date the provider filing this claim ceased post-operative care. See Medicare guidelines for further explanation of these dates. Example: Surgeon "A" relinquished post-operative care to Physician "B" five days after surgery. When Surgeon "A" submits a claim, "A" will use code "091 - Report End" to indicate the day the surgeon relinquished care of this patient to Physician "B". When Physician "B" submits a claim, "B" will use code "090 - Report Start" to indicate the date they assumed care of this patient from Surgeon "A". Example DTP090D8XX~ Variants (all may be used) DTP Date - Accident DTP Date - Acute Manifestation DTP Date - Admission DTP Date - Authorized Return to Work DTP Date - Disability Dates DTP Date - Discharge DTP Date - Hearing and Vision Prescription Date DTP Date - Initial Treatment Date DTP Date - Last Menstrual Period DTP Date - Last Seen Date DTP Date - Last Worked DTP Date - Last X-ray Date DTP Date - Onset of Current Illness or Symptom DTP Date - Property and Casualty Date of First Contact DTP Date - Repricer Received Date Max use 2 Optional DTP-01 374 Date Time Qualifier Identifier (ID) Required Code specifying type of date or time, or both date and time 090 Report Start Assumed Care Date - Use code "090" to indicate the date the provider filing this claim assumed care from another provider during post-operative care. 091 Report End Relinquished Care Date - Use code "091" to indicate the date the provider filing this claim relinquished post-operative care to another provider. DTP-02 1250 Date Time Period Format Qualifier Identifier (ID) Required Code indicating the date format, time format, or date and time format DTP02 is the date or time or period format that will appear in DTP03. D8 Date Expressed in Format CCYYMMDD DTP-03 1251 Assumed or Relinquished Care Date Min 1 Max 35 String (AN) Required 1/30/25, 11:53 AM Texas Medicaid & Healthcare Partnerships (TMHP) 837 837 Health Care Claim: Professional (X222/A2/A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/tmhp/837-health-care-claim-professional-x222a2a1/01HMBZ8Y6XYRFK1ZR16EKD50N6 78/552 Expression of a date, a time, or range of dates, times or dates and times 1/30/25, 11:53 AM Texas Medicaid & Healthcare Partnerships (TMHP) 837 837 Health Care Claim: Professional (X222/A2/A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/tmhp/837-health-care-claim-professional-x222a2a1/01HMBZ8Y6XYRFK1ZR16EKD50N6 79/552 DTP 1350 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > DTP Date - Authorized Return to Work To specify any or all of a date, a time, or a time period Usage notes Required on claims where this information is necessary for adjudication of the claim (for example, workers compensation claims involving absence from work). If not required by this implementation guide, do not send. Example DTP296D8XXXXX~ Variants (all may be used) DTP Date - Accident DTP Date - Acute Manifestation DTP Date - Admission DTP Date - Assumed and Relinquished Care Dates DTP Date - Disability Dates DTP Date - Discharge DTP Date - Hearing and Vision Prescription Date DTP Date - Initial Treatment Date DTP Date - Last Menstrual Period DTP Date - Last Seen Date DTP Date - Last Worked DTP Date - Last X-ray Date DTP Date - Onset of Current Illness or Symptom DTP Date - Property and Casualty Date of First Contact DTP Date - Repricer Received Date Max use 1 Optional DTP-01 374 Date Time Qualifier Identifier (ID) Required Code specifying type of date or time, or both date and time 296 Initial Disability Period Return To Work This is the date the provider has authorized the patient to return to work. DTP-02 1250 Date Time Period Format Qualifier Identifier (ID) Required Code indicating the date format, time format, or date and time format DTP02 is the date or time or period format that will appear in DTP03. D8 Date Expressed in Format CCYYMMDD DTP-03 1251 Work Return Date Min 1 Max 35 String (AN) Required Expression of a date, a time, or range of dates, times or dates and times 1/30/25, 11:53 AM Texas Medicaid & Healthcare Partnerships (TMHP) 837 837 Health Care Claim: Professional (X222/A2/A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/tmhp/837-health-care-claim-professional-x222a2a1/01HMBZ8Y6XYRFK1ZR16EKD50N6 80/552 DTP 1350 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > DTP Date - Disability Dates To specify any or all of a date, a time, or a time period Usage notes Required on claims involving disability where, in the judgment of the provider, the patient was or will be unable to perform the duties normally associated with his/her work. OR Required on non-HIPAA claims (for example workers compensation or property and casualty) when required by the claims processor. If not required by this implementation guide, do not send. Example DTP314D8XXX~ Variants (all may be used) DTP Date - Accident DTP Date - Acute Manifestation DTP Date - Admission DTP Date - Assumed and Relinquished Care Dates DTP Date - Authorized Return to Work DTP Date - Discharge DTP Date - Hearing and Vision Prescription Date DTP Date - Initial Treatment Date DTP Date - Last Menstrual Period DTP Date - Last Seen Date DTP Date - Last Worked DTP Date - Last X-ray Date DTP Date - Onset of Current Illness or Symptom DTP Date - Property and Casualty Date of First Contact DTP Date - Repricer Received Date Max use 1 Optional DTP-01 374 Date Time Qualifier Identifier (ID) Required Code specifying type of date or time, or both date and time 314 Disability Use code 314 when both disability start and end date are being reported. 360 Initial Disability Period Start Use code 360 if patient is currently disabled and disability end date is unknown. 361 Initial Disability Period End Use code 361 if patient is no longer disabled and the start date is unknown. DTP-02 1250 Date Time Period Format Qualifier Identifier (ID) Required Code indicating the date format, time format, or date and time format DTP02 is the date or time or period format that will appear in DTP03. D8 Date Expressed in Format CCYYMMDD Use code D8 when DTP01 is 360 or 361. RD8 Range of Dates Expressed in Format CCYYMMDD-CCYYMMDD Use code RD8 when DTP01 is 314. DTP-03 1251 Disability From Date Min 1 Max 35 String (AN) Required 1/30/25, 11:53 AM Texas Medicaid & Healthcare Partnerships (TMHP) 837 837 Health Care Claim: Professional (X222/A2/A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/tmhp/837-health-care-claim-professional-x222a2a1/01HMBZ8Y6XYRFK1ZR16EKD50N6 81/552 Expression of a date, a time, or range of dates, times or dates and times 1/30/25, 11:53 AM Texas Medicaid & Healthcare Partnerships (TMHP) 837 837 Health Care Claim: Professional (X222/A2/A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/tmhp/837-health-care-claim-professional-x222a2a1/01HMBZ8Y6XYRFK1ZR16EKD50N6 82/552 DTP 1350 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > DTP Date - Discharge To specify any or all of a date, a time, or a time period Usage notes Required for inpatient claims when the patient was discharged from the facility and the discharge date is known. If not required by this implementation guide, do not send. Example DTP096D8XXXXX~ Variants (all may be used) DTP Date - Accident DTP Date - Acute Manifestation DTP Date - Admission DTP Date - Assumed and Relinquished Care Dates DTP Date - Authorized Return to Work DTP Date - Disability Dates DTP Date - Hearing and Vision Prescription Date DTP Date - Initial Treatment Date DTP Date - Last Menstrual Period DTP Date - Last Seen Date DTP Date - Last Worked DTP Date - Last X-ray Date DTP Date - Onset of Current Illness or Symptom DTP Date - Property and Casualty Date of First Contact DTP Date - Repricer Received Date Max use 1 Optional DTP-01 374 Date Time Qualifier Identifier (ID) Required Code specifying type of date or time, or both date and time 096 Discharge DTP-02 1250 Date Time Period Format Qualifier Identifier (ID) Required Code indicating the date format, time format, or date and time format DTP02 is the date or time or period format that will appear in DTP03. D8 Date Expressed in Format CCYYMMDD DTP-03 1251 Related Hospitalization Discharge Date Min 1 Max 35 String (AN) Required Expression of a date, a time, or range of dates, times or dates and times 1/30/25, 11:53 AM Texas Medicaid & Healthcare Partnerships (TMHP) 837 837 Health Care Claim: Professional (X222/A2/A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/tmhp/837-health-care-claim-professional-x222a2a1/01HMBZ8Y6XYRFK1ZR16EKD50N6 83/552 DTP 1350 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > DTP Date - Hearing and Vision Prescription Date To specify any or all of a date, a time, or a time period Usage notes Required on claims where a prescription has been written for hearing devices or vision frames and lenses and it is being billed on this claim. If not required by this implementation guide, do not send. Example DTP471D8XXXX~ Variants (all may be used) DTP Date - Accident DTP Date - Acute Manifestation DTP Date - Admission DTP Date - Assumed and Relinquished Care Dates DTP Date - Authorized Return to Work DTP Date - Disability Dates DTP Date - Discharge DTP Date - Initial Treatment Date DTP Date - Last Menstrual Period DTP Date - Last Seen Date DTP Date - Last Worked DTP Date - Last X-ray Date DTP Date - Onset of Current Illness or Symptom DTP Date - Property and Casualty Date of First Contact DTP Date - Repricer Received Date Max use 1 Optional DTP-01 374 Date Time Qualifier Identifier (ID) Required Code specifying type of date or time, or both date and time 471 Prescription DTP-02 1250 Date Time Period Format Qualifier Identifier (ID) Required Code indicating the date format, time format, or date and time format DTP02 is the date or time or period format that will appear in DTP03. D8 Date Expressed in Format CCYYMMDD DTP-03 1251 Prescription Date Min 1 Max 35 String (AN) Required Expression of a date, a time, or range of dates, times or dates and times 1/30/25, 11:53 AM Texas Medicaid & Healthcare Partnerships (TMHP) 837 837 Health Care Claim: Professional (X222/A2/A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/tmhp/837-health-care-claim-professional-x222a2a1/01HMBZ8Y6XYRFK1ZR16EKD50N6 84/552 DTP	Texas Medicaid and Healthcare Partnerships.pdf
DTP096D8XXXXX~ Variants (all may be used) DTP Date - Accident DTP Date - Acute Manifestation DTP Date - Admission DTP Date - Assumed and Relinquished Care Dates DTP Date - Authorized Return to Work DTP Date - Disability Dates DTP Date - Hearing and Vision Prescription Date DTP Date - Initial Treatment Date DTP Date - Last Menstrual Period DTP Date - Last Seen Date DTP Date - Last Worked DTP Date - Last X-ray Date DTP Date - Onset of Current Illness or Symptom DTP Date - Property and Casualty Date of First Contact DTP Date - Repricer Received Date Max use 1 Optional DTP-01 374 Date Time Qualifier Identifier (ID) Required Code specifying type of date or time, or both date and time 096 Discharge DTP-02 1250 Date Time Period Format Qualifier Identifier (ID) Required Code indicating the date format, time format, or date and time format DTP02 is the date or time or period format that will appear in DTP03. D8 Date Expressed in Format CCYYMMDD DTP-03 1251 Related Hospitalization Discharge Date Min 1 Max 35 String (AN) Required Expression of a date, a time, or range of dates, times or dates and times 1/30/25, 11:53 AM Texas Medicaid & Healthcare Partnerships (TMHP) 837 837 Health Care Claim: Professional (X222/A2/A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/tmhp/837-health-care-claim-professional-x222a2a1/01HMBZ8Y6XYRFK1ZR16EKD50N6 83/552 DTP 1350 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > DTP Date - Hearing and Vision Prescription Date To specify any or all of a date, a time, or a time period Usage notes Required on claims where a prescription has been written for hearing devices or vision frames and lenses and it is being billed on this claim. If not required by this implementation guide, do not send. Example DTP471D8XXXX~ Variants (all may be used) DTP Date - Accident DTP Date - Acute Manifestation DTP Date - Admission DTP Date - Assumed and Relinquished Care Dates DTP Date - Authorized Return to Work DTP Date - Disability Dates DTP Date - Discharge DTP Date - Initial Treatment Date DTP Date - Last Menstrual Period DTP Date - Last Seen Date DTP Date - Last Worked DTP Date - Last X-ray Date DTP Date - Onset of Current Illness or Symptom DTP Date - Property and Casualty Date of First Contact DTP Date - Repricer Received Date Max use 1 Optional DTP-01 374 Date Time Qualifier Identifier (ID) Required Code specifying type of date or time, or both date and time 471 Prescription DTP-02 1250 Date Time Period Format Qualifier Identifier (ID) Required Code indicating the date format, time format, or date and time format DTP02 is the date or time or period format that will appear in DTP03. D8 Date Expressed in Format CCYYMMDD DTP-03 1251 Prescription Date Min 1 Max 35 String (AN) Required Expression of a date, a time, or range of dates, times or dates and times 1/30/25, 11:53 AM Texas Medicaid & Healthcare Partnerships (TMHP) 837 837 Health Care Claim: Professional (X222/A2/A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/tmhp/837-health-care-claim-professional-x222a2a1/01HMBZ8Y6XYRFK1ZR16EKD50N6 84/552 DTP 1350 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > DTP Date - Initial Treatment Date To specify any or all of a date, a time, or a time period Usage notes Required when the Initial Treatment Date is known to impact adjudication for claims involving spinal manipulation, physical therapy, occupational therapy, speech language pathology, dialysis, optical refractions, or pregnancy. If not required by this implementation guide, do not send. Dates in Loop ID-2300 apply to all service lines within Loop ID-2400 unless a DTP segment occurs in Loop ID-2400 with the same value in DTP01. In that case, the DTP in Loop ID-2400 overrides the DTP in Loop ID-2300 for that service line only. Example DTP454D8XXX~ Variants (all may be used) DTP Date - Accident DTP Date - Acute Manifestation DTP Date - Admission DTP Date - Assumed and Relinquished Care Dates DTP Date - Authorized Return to Work DTP Date - Disability Dates DTP Date - Discharge DTP Date - Hearing and Vision Prescription Date DTP Date - Last Menstrual Period DTP Date - Last Seen Date DTP Date - Last Worked DTP Date - Last X-ray Date DTP Date - Onset of Current Illness or Symptom DTP Date - Property and Casualty Date of First Contact DTP Date - Repricer Received Date Max use 1 Optional DTP-01 374 Date Time Qualifier Identifier (ID) Required Code specifying type of date or time, or both date and time 454 Initial Treatment DTP-02 1250 Date Time Period Format Qualifier Identifier (ID) Required Code indicating the date format, time format, or date and time format DTP02 is the date or time or period format that will appear in DTP03. D8 Date Expressed in Format CCYYMMDD DTP-03 1251 Initial Treatment Date Min 1 Max 35 String (AN) Required Expression of a date, a time, or range of dates, times or dates and times 1/30/25, 11:53 AM Texas Medicaid & Healthcare Partnerships (TMHP) 837 837 Health Care Claim: Professional (X222/A2/A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/tmhp/837-health-care-claim-professional-x222a2a1/01HMBZ8Y6XYRFK1ZR16EKD50N6 85/552 DTP 1350 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > DTP Date - Last Menstrual Period To specify any or all of a date, a time, or a time period Usage notes Required when, in the judgment of the provider, the services on this claim are related to the patient's pregnancy. If not required by this implementation guide, do not send. Example DTP484D8XX~ Variants (all may be used) DTP Date - Accident DTP Date - Acute Manifestation DTP Date - Admission DTP Date - Assumed and Relinquished Care Dates DTP Date - Authorized Return to Work DTP Date - Disability Dates DTP Date - Discharge DTP Date - Hearing and Vision Prescription Date DTP Date - Initial Treatment Date DTP Date - Last Seen Date DTP Date - Last Worked DTP Date - Last X-ray Date DTP Date - Onset of Current Illness or Symptom DTP Date - Property and Casualty Date of First Contact DTP Date - Repricer Received Date Max use 1 Optional DTP-01 374 Date Time Qualifier Identifier (ID) Required Code specifying type of date or time, or both date and time 484 Last Menstrual Period DTP-02 1250 Date Time Period Format Qualifier Identifier (ID) Required Code indicating the date format, time format, or date and time format DTP02 is the date or time or period format that will appear in DTP03. D8 Date Expressed in Format CCYYMMDD DTP-03 1251 Last Menstrual Period Date Min 1 Max 35 String (AN) Required Expression of a date, a time, or range of dates, times or dates and times 1/30/25, 11:53 AM Texas Medicaid & Healthcare Partnerships (TMHP) 837 837 Health Care Claim: Professional (X222/A2/A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/tmhp/837-health-care-claim-professional-x222a2a1/01HMBZ8Y6XYRFK1ZR16EKD50N6 86/552 DTP 1350 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > DTP Date - Last Seen Date To specify any or all of a date, a time, or a time period Usage notes Required when claims involve services for routine foot care and it is known to impact the payer's adjudication process. If not required by this implementation guide, do not send. This is the date that the patient was seen by the attending or supervising physician for the qualifying medical condition related to the services performed. Dates in Loop ID-2300 apply to all service lines within Loop ID-2400 unless a DTP segment occurs in Loop ID-2400 with the same value in DTP01. In that case, the DTP in Loop ID-2400 overrides the DTP in Loop ID-2300 for that service line only. Example DTP304D8XXXXXX~ Variants (all may be used) DTP Date - Accident DTP Date - Acute Manifestation DTP Date - Admission DTP Date - Assumed and Relinquished Care Dates DTP Date - Authorized Return to Work DTP Date - Disability Dates DTP Date - Discharge DTP Date - Hearing and Vision Prescription Date DTP Date - Initial Treatment Date DTP Date - Last Menstrual Period DTP Date - Last Worked DTP Date - Last X-ray Date DTP Date - Onset of Current Illness or Symptom DTP Date - Property and Casualty Date of First Contact DTP Date - Repricer Received Date Max use 1 Optional DTP-01 374 Date Time Qualifier Identifier (ID) Required Code specifying type of date or time, or both date and time 304 Latest Visit or Consultation DTP-02 1250 Date Time Period Format Qualifier Identifier (ID) Required Code indicating the date format, time format, or date and time format DTP02 is the date or time or period format that will appear in DTP03. D8 Date Expressed in Format CCYYMMDD DTP-03 1251 Last Seen Date Min 1 Max 35 String (AN) Required Expression of a date, a time, or range of dates, times or dates and times 1/30/25, 11:53 AM Texas Medicaid & Healthcare Partnerships (TMHP) 837 837 Health Care Claim: Professional (X222/A2/A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/tmhp/837-health-care-claim-professional-x222a2a1/01HMBZ8Y6XYRFK1ZR16EKD50N6 87/552 DTP 1350 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > DTP Date - Last Worked To specify any or all of a date, a time, or a time period Usage notes Required on claims where this information is necessary for adjudication of the claim (for example, workers compensation claims involving absence from work). If not required by this implementation guide, do not send. Example DTP297D8XXXX~ Variants (all may be used) DTP Date - Accident DTP Date - Acute Manifestation DTP Date - Admission DTP Date - Assumed and Relinquished Care Dates DTP Date - Authorized Return to Work DTP Date - Disability Dates DTP Date - Discharge DTP Date - Hearing and Vision Prescription Date DTP Date - Initial Treatment Date DTP Date - Last Menstrual Period DTP Date - Last Seen Date DTP Date - Last X-ray Date DTP Date - Onset of Current Illness or Symptom DTP Date - Property and Casualty Date of First Contact DTP Date - Repricer Received Date Max use 1 Optional DTP-01 374 Date Time Qualifier Identifier (ID) Required Code specifying type of date or time, or both date and time 297 Initial Disability Period Last Day Worked DTP-02 1250 Date Time Period Format Qualifier Identifier (ID) Required Code indicating the date format, time format, or date and time format DTP02 is the date or time or period format that will appear in DTP03. D8 Date Expressed in Format CCYYMMDD DTP-03 1251 Last Worked Date Min 1 Max 35 String (AN) Required Expression of a date, a time, or range of dates, times or dates and times 1/30/25, 11:53 AM Texas Medicaid & Healthcare Partnerships (TMHP) 837 837 Health Care Claim: Professional (X222/A2/A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/tmhp/837-health-care-claim-professional-x222a2a1/01HMBZ8Y6XYRFK1ZR16EKD50N6 88/552 DTP 1350 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > DTP Date - Last X-ray Date To specify any or all of a date, a time, or a time period Usage notes Required when claim involves spinal manipulation and an x-ray was taken. If not required by this implementation guide, do not send. Dates in Loop ID-2300 apply to all service lines within Loop ID-2400 unless a DTP segment occurs in Loop ID-2400 with the same value in DTP01. In that case, the DTP in Loop ID-2400 overrides the DTP in Loop ID-2300 for that service line only. Example DTP455D8*XXXX~ Variants (all may be used) DTP Date - Accident DTP Date - Acute Manifestation DTP Date - Admission DTP Date - Assumed and Relinquished Care Dates DTP Date - Authorized Return to Work DTP Date - Disability Dates DTP Date - Discharge DTP Date - Hearing and Vision Prescription Date DTP Date - Initial Treatment Date DTP Date - Last Menstrual Period DTP Date - Last Seen Date DTP Date - Last Worked DTP Date - Onset of Current Illness or Symptom DTP Date - Property and Casualty Date of First Contact DTP Date - Repricer Received Date Max use 1 Optional DTP-01 374 Date Time Qualifier Identifier (ID) Required Code specifying type of date or time, or both date and time 455 Last X-Ray DTP-02 1250 Date Time Period Format Qualifier Identifier (ID) Required Code indicating the date format, time	Texas Medicaid and Healthcare Partnerships.pdf
time, or a time period Usage notes Required on claims where this information is necessary for adjudication of the claim (for example, workers compensation claims involving absence from work). If not required by this implementation guide, do not send. Example DTP297D8XXXX~ Variants (all may be used) DTP Date - Accident DTP Date - Acute Manifestation DTP Date - Admission DTP Date - Assumed and Relinquished Care Dates DTP Date - Authorized Return to Work DTP Date - Disability Dates DTP Date - Discharge DTP Date - Hearing and Vision Prescription Date DTP Date - Initial Treatment Date DTP Date - Last Menstrual Period DTP Date - Last Seen Date DTP Date - Last X-ray Date DTP Date - Onset of Current Illness or Symptom DTP Date - Property and Casualty Date of First Contact DTP Date - Repricer Received Date Max use 1 Optional DTP-01 374 Date Time Qualifier Identifier (ID) Required Code specifying type of date or time, or both date and time 297 Initial Disability Period Last Day Worked DTP-02 1250 Date Time Period Format Qualifier Identifier (ID) Required Code indicating the date format, time format, or date and time format DTP02 is the date or time or period format that will appear in DTP03. D8 Date Expressed in Format CCYYMMDD DTP-03 1251 Last Worked Date Min 1 Max 35 String (AN) Required Expression of a date, a time, or range of dates, times or dates and times 1/30/25, 11:53 AM Texas Medicaid & Healthcare Partnerships (TMHP) 837 837 Health Care Claim: Professional (X222/A2/A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/tmhp/837-health-care-claim-professional-x222a2a1/01HMBZ8Y6XYRFK1ZR16EKD50N6 88/552 DTP 1350 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > DTP Date - Last X-ray Date To specify any or all of a date, a time, or a time period Usage notes Required when claim involves spinal manipulation and an x-ray was taken. If not required by this implementation guide, do not send. Dates in Loop ID-2300 apply to all service lines within Loop ID-2400 unless a DTP segment occurs in Loop ID-2400 with the same value in DTP01. In that case, the DTP in Loop ID-2400 overrides the DTP in Loop ID-2300 for that service line only. Example DTP455D8XXXX~ Variants (all may be used) DTP Date - Accident DTP Date - Acute Manifestation DTP Date - Admission DTP Date - Assumed and Relinquished Care Dates DTP Date - Authorized Return to Work DTP Date - Disability Dates DTP Date - Discharge DTP Date - Hearing and Vision Prescription Date DTP Date - Initial Treatment Date DTP Date - Last Menstrual Period DTP Date - Last Seen Date DTP Date - Last Worked DTP Date - Onset of Current Illness or Symptom DTP Date - Property and Casualty Date of First Contact DTP Date - Repricer Received Date Max use 1 Optional DTP-01 374 Date Time Qualifier Identifier (ID) Required Code specifying type of date or time, or both date and time 455 Last X-Ray DTP-02 1250 Date Time Period Format Qualifier Identifier (ID) Required Code indicating the date format, time format, or date and time format DTP02 is the date or time or period format that will appear in DTP03. D8 Date Expressed in Format CCYYMMDD DTP-03 1251 Last X-Ray Date Min 1 Max 35 String (AN) Required Expression of a date, a time, or range of dates, times or dates and times 1/30/25, 11:53 AM Texas Medicaid & Healthcare Partnerships (TMHP) 837 837 Health Care Claim: Professional (X222/A2/A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/tmhp/837-health-care-claim-professional-x222a2a1/01HMBZ8Y6XYRFK1ZR16EKD50N6 89/552 DTP 1350 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > DTP Date - Onset of Current Illness or Symptom To specify any or all of a date, a time, or a time period Usage notes Required for the initial medical service or visit performed in response to a medical emergency when the date is available and is different than the date of service. If not required by this implementation guide, do not send. This date is the onset of acute symptoms for the current illness or condition. Example DTP431D8X~ Variants (all may be used) DTP Date - Accident DTP Date - Acute Manifestation DTP Date - Admission DTP Date - Assumed and Relinquished Care Dates DTP Date - Authorized Return to Work DTP Date - Disability Dates DTP Date - Discharge DTP Date - Hearing and Vision Prescription Date DTP Date - Initial Treatment Date DTP Date - Last Menstrual Period DTP Date - Last Seen Date DTP Date - Last Worked DTP Date - Last X-ray Date DTP Date - Property and Casualty Date of First Contact DTP Date - Repricer Received Date Max use 1 Optional DTP-01 374 Date Time Qualifier Identifier (ID) Required Code specifying type of date or time, or both date and time 431 Onset of Current Symptoms or Illness DTP-02 1250 Date Time Period Format Qualifier Identifier (ID) Required Code indicating the date format, time format, or date and time format DTP02 is the date or time or period format that will appear in DTP03. D8 Date Expressed in Format CCYYMMDD DTP-03 1251 Onset of Current Illness or Injury Date Min 1 Max 35 String (AN) Required Expression of a date, a time, or range of dates, times or dates and times 1/30/25, 11:53 AM Texas Medicaid & Healthcare Partnerships (TMHP) 837 837 Health Care Claim: Professional (X222/A2/A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/tmhp/837-health-care-claim-professional-x222a2a1/01HMBZ8Y6XYRFK1ZR16EKD50N6 90/552 DTP 1350 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > DTP Date - Property and Casualty Date of First Contact To specify any or all of a date, a time, or a time period Usage notes Required for Property and Casualty claims when state mandated. If not required by this implementation guide, do not send. This is the date the patient first consulted the service provider for this condition. The date of first contact is the date the patient first consulted the provider by any means. It is not necessarily the Initial Treatment Date. Example DTP444D8XXXX~ Variants (all may be used) DTP Date - Accident DTP Date - Acute Manifestation DTP Date - Admission DTP Date - Assumed and Relinquished Care Dates DTP Date - Authorized Return to Work DTP Date - Disability Dates DTP Date - Discharge DTP Date - Hearing and Vision Prescription Date DTP Date - Initial Treatment Date DTP Date - Last Menstrual Period DTP Date - Last Seen Date DTP Date - Last Worked DTP Date - Last X-ray Date DTP Date - Onset of Current Illness or Symptom DTP Date - Repricer Received Date Max use 1 Optional DTP-01 374 Date Time Qualifier Identifier (ID) Required Code specifying type of date or time, or both date and time 444 First Visit or Consultation DTP-02 1250 Date Time Period Format Qualifier Identifier (ID) Required Code indicating the date format, time format, or date and time format DTP02 is the date or time or period format that will appear in DTP03. D8 Date Expressed in Format CCYYMMDD DTP-03 1251 Date Time Period Min 1 Max 35 String (AN) Required Expression of a date, a time, or range of dates, times or dates and times 1/30/25, 11:53 AM Texas Medicaid & Healthcare Partnerships (TMHP) 837 837 Health Care Claim: Professional (X222/A2/A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/tmhp/837-health-care-claim-professional-x222a2a1/01HMBZ8Y6XYRFK1ZR16EKD50N6 91/552 DTP 1350 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > DTP Date - Repricer Received Date To specify any or all of a date, a time, or a time period Usage notes Required when a repricer is passing the claim onto the payer. If not required by this implementation guide, do not send. Example DTP050D8X~ Variants (all may be used) DTP Date - Accident DTP Date - Acute Manifestation DTP Date - Admission DTP Date - Assumed and Relinquished Care Dates DTP Date - Authorized Return to Work DTP Date - Disability Dates DTP Date - Discharge DTP Date - Hearing and Vision Prescription Date DTP Date - Initial Treatment Date DTP Date - Last Menstrual Period DTP Date - Last Seen Date DTP Date - Last Worked DTP Date - Last X-ray Date DTP Date - Onset of Current Illness or Symptom DTP Date - Property and Casualty Date of First Contact Max use 1 Optional DTP-01 374 Date Time Qualifier Identifier (ID) Required Code specifying type of date or time, or both date and time 050 Received DTP-02 1250 Date Time Period Format Qualifier Identifier (ID) Required Code indicating the date format, time format, or date and time format DTP02 is the date or time or period format that will appear in DTP03. D8 Date Expressed in Format CCYYMMDD DTP-03 1251 Repricer Received Date Min 1 Max 35 String (AN) Required Expression of a date, a time, or range of dates, times or dates and times 1/30/25, 11:53 AM Texas Medicaid & Healthcare Partnerships (TMHP) 837 837 Health Care Claim: Professional (X222/A2/A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/tmhp/837-health-care-claim-professional-x222a2a1/01HMBZ8Y6XYRFK1ZR16EKD50N6 92/552 PWK 1550 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > PWK Claim Supplemental Information To identify the type or transmission or both of paperwork or supporting information Usage notes Required when there is a paper attachment following this claim. OR Required when attachments are sent electronically (PWK02 = EL) but are transmitted in another functional group (for example, 275) rather than by paper. PWK06 is then used to identify the attached electronic documentation. The number in PWK06 is carried in the TRN of the electronic attachment. OR Required when the provider deems it necessary to identify additional information that is being held at the provider's office and is available upon request by the payer (or appropriate entity), but the information is not being submitted with the claim. Use the value of "AA" in PWK02 to convey this specific use of the PWK segment. If not required by this implementation guide, do not send. Example PWK11BM*ACXXXXXXX~ If either Identification Code Qualifier (PWK-05) or Attachment Control Number (PWK-06) is present, then the other is required Max use 10 Optional PWK-01 755 Attachment Report Type Code Identifier (ID) Required Code indicating the title or contents of a document, report or supporting item 03 Report Justifying Treatment Beyond Utilization Guidelines 04 Drugs Administered 05 Treatment Diagnosis 06 Initial Assessment 07 Functional Goals 08 Plan of Treatment 09 Progress Report 10 Continued Treatment 11 Chemical Analysis 13 Certified Test Report 15 Justification for Admission 21 Recovery Plan A3 Allergies/Sensitivities Document A4 Autopsy Report AM Ambulance Certification AS Admission Summary B2 Prescription B3 Physician Order B4 Referral Form BR Benchmark Testing Results BS Baseline BT Blanket Test Results CB Chiropractic Justification CK Consent Form(s) CT Certification D2 Drug Profile Document DA Dental Models DB Durable Medical Equipment Prescription DG Diagnostic Report DJ Discharge Monitoring Report DS Discharge Summary EB Explanation of Benefits (Coordination of Benefits or Medicare Secondary Payor) HC Health Certificate HR Health Clinic Records I5 Immunization Record 1/30/25, 11:53 AM Texas Medicaid & Healthcare Partnerships (TMHP) 837 837 Health Care Claim: Professional (X222/A2/A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/tmhp/837-health-care-claim-professional-x222a2a1/01HMBZ8Y6XYRFK1ZR16EKD50N6 93/552 IR State School Immunization Records LA Laboratory Results M1 Medical Record Attachment MT Models NN Nursing Notes OB Operative Note OC Oxygen Content Averaging Report OD Orders and Treatments Document OE Objective Physical Examination (including vital signs) Document OX Oxygen Therapy Certification OZ Support Data for Claim P4 Pathology Report P5 Patient Medical History Document PE Parenteral or Enteral Certification PN Physical Therapy Notes PO Prosthetics or Orthotic Certification PQ Paramedical Results PY Physician's Report PZ Physical Therapy Certification RB Radiology Films RR Radiology Reports RT Report of Tests and Analysis Report RX Renewable Oxygen Content Averaging Report SG Symptoms Document V5 Death Notification XP Photographs PWK-02 756 Attachment Transmission Code Identifier (ID) Required Code defining timing, transmission method or format by which reports are to be sent AA Available on Request at Provider Site This means that the additional information is not being sent with the claim at this time. Instead, it is available to the payer (or appropriate entity) at their request. BM By Mail EL Electronically Only Indicates that the attachment is being transmitted in a separate X12 functional group. EM E-Mail FT File Transfer Required when	Texas Medicaid and Healthcare Partnerships.pdf
paperwork or supporting information Usage notes Required when there is a paper attachment following this claim. OR Required when attachments are sent electronically (PWK02 = EL) but are transmitted in another functional group (for example, 275) rather than by paper. PWK06 is then used to identify the attached electronic documentation. The number in PWK06 is carried in the TRN of the electronic attachment. OR Required when the provider deems it necessary to identify additional information that is being held at the provider's office and is available upon request by the payer (or appropriate entity), but the information is not being submitted with the claim. Use the value of "AA" in PWK02 to convey this specific use of the PWK segment. If not required by this implementation guide, do not send. Example PWK11BM**ACXXXXXXX~ If either Identification Code Qualifier (PWK-05) or Attachment Control Number (PWK-06) is present, then the other is required Max use 10 Optional PWK-01 755 Attachment Report Type Code Identifier (ID) Required Code indicating the title or contents of a document, report or supporting item 03 Report Justifying Treatment Beyond Utilization Guidelines 04 Drugs Administered 05 Treatment Diagnosis 06 Initial Assessment 07 Functional Goals 08 Plan of Treatment 09 Progress Report 10 Continued Treatment 11 Chemical Analysis 13 Certified Test Report 15 Justification for Admission 21 Recovery Plan A3 Allergies/Sensitivities Document A4 Autopsy Report AM Ambulance Certification AS Admission Summary B2 Prescription B3 Physician Order B4 Referral Form BR Benchmark Testing Results BS Baseline BT Blanket Test Results CB Chiropractic Justification CK Consent Form(s) CT Certification D2 Drug Profile Document DA Dental Models DB Durable Medical Equipment Prescription DG Diagnostic Report DJ Discharge Monitoring Report DS Discharge Summary EB Explanation of Benefits (Coordination of Benefits or Medicare Secondary Payor) HC Health Certificate HR Health Clinic Records I5 Immunization Record 1/30/25, 11:53 AM Texas Medicaid & Healthcare Partnerships (TMHP) 837 837 Health Care Claim: Professional (X222/A2/A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/tmhp/837-health-care-claim-professional-x222a2a1/01HMBZ8Y6XYRFK1ZR16EKD50N6 93/552 IR State School Immunization Records LA Laboratory Results M1 Medical Record Attachment MT Models NN Nursing Notes OB Operative Note OC Oxygen Content Averaging Report OD Orders and Treatments Document OE Objective Physical Examination (including vital signs) Document OX Oxygen Therapy Certification OZ Support Data for Claim P4 Pathology Report P5 Patient Medical History Document PE Parenteral or Enteral Certification PN Physical Therapy Notes PO Prosthetics or Orthotic Certification PQ Paramedical Results PY Physician's Report PZ Physical Therapy Certification RB Radiology Films RR Radiology Reports RT Report of Tests and Analysis Report RX Renewable Oxygen Content Averaging Report SG Symptoms Document V5 Death Notification XP Photographs PWK-02 756 Attachment Transmission Code Identifier (ID) Required Code defining timing, transmission method or format by which reports are to be sent AA Available on Request at Provider Site This means that the additional information is not being sent with the claim at this time. Instead, it is available to the payer (or appropriate entity) at their request. BM By Mail EL Electronically Only Indicates that the attachment is being transmitted in a separate X12 functional group. EM E-Mail FT File Transfer Required when the actual attachment is maintained by an attachment warehouse or similar vendor. FX By Fax PWK-05 66 Identification Code Qualifier Identifier (ID) Optional Code designating the system/method of code structure used for Identification Code (67) PWK05 and PWK06 may be used to identify the addressee by a code number. AC Attachment Control Number PWK-06 67 Attachment Control Number Min 2 Max 80 String (AN) Optional Code identifying a party or other code Usage notes PWK06 is used to identify the attached electronic documentation. The number in PWK06 is carried in the TRN of the electronic attachment. For the purpose of this implementation, the maximum field length is 50. 1/30/25, 11:53 AM Texas Medicaid & Healthcare Partnerships (TMHP) 837 837 Health Care Claim: Professional (X222/A2/A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/tmhp/837-health-care-claim-professional-x222a2a1/01HMBZ8Y6XYRFK1ZR16EKD50N6 94/552 1/30/25, 11:53 AM Texas Medicaid & Healthcare Partnerships (TMHP) 837 837 Health Care Claim: Professional (X222/A2/A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/tmhp/837-health-care-claim-professional-x222a2a1/01HMBZ8Y6XYRFK1ZR16EKD50N6 95/552 CN1 1600 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > CN1 Contract Information To specify basic data about the contract or contract line item Usage notes The developers of this implementation guide note that the CN1 segment is for use only for post-adjudicated claims, which do not meet the definition of a health care claim under HIPAA. Consequently, at the time of this writing, the CN1 segment is for non- HIPAA use only. Required when the submitter is contractually obligated to supply this information on post-adjudicated claims. If not required by this implementation guide, do not send. Example CN105000000000000000000000X000X~ Max use 1 Optional CN1-01 1166 Contract Type Code Identifier (ID) Required Code identifying a contract type 01 Diagnosis Related Group (DRG) 02 Per Diem 03 Variable Per Diem 04 Flat 05 Capitated 06 Percent 09 Other CN1-02 782 Contract Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount CN102 is the contract amount. CN1-03 332 Contract Percentage Min 1 Max 6 Decimal number (R) Optional Percent given in decimal format (e.g., 0.0 through 100.0 represents 0% through 100%) CN103 is the allowance or charge percent. CN1-04 127 Contract Code Min 1 Max 50 String (AN) Optional Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier CN104 is the contract code. CN1-05 338 Terms Discount Percentage Min 1 Max 6 Decimal number (R) Optional Terms discount percentage, expressed as a percent, available to the purchaser if an invoice is paid on or before the Terms Discount Due Date CN1-06 799 Contract Version Identifier Min 1 Max 30 String (AN) Optional Revision level of a particular format, program, technique or algorithm 1/30/25, 11:53 AM Texas Medicaid & Healthcare Partnerships (TMHP) 837 837 Health Care Claim: Professional (X222/A2/A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/tmhp/837-health-care-claim-professional-x222a2a1/01HMBZ8Y6XYRFK1ZR16EKD50N6 96/552 CN106 is an additional identifying number for the contract. 1/30/25, 11:53 AM Texas Medicaid & Healthcare Partnerships (TMHP) 837 837 Health Care Claim: Professional (X222/A2/A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/tmhp/837-health-care-claim-professional-x222a2a1/01HMBZ8Y6XYRFK1ZR16EKD50N6 97/552 AMT 1750 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > AMT Patient Amount Paid To indicate the total monetary amount Usage notes Required when patient has made payment specifically toward this claim. If not required by this implementation guide, do not send. Patient Amount Paid refers to the sum of all amounts paid on the claim by the patient or his or her representative(s). Example AMTF50~ Max use 1 Optional AMT-01 522 Amount Qualifier Code Identifier (ID) Required Code to qualify amount F5 Patient Amount Paid AMT-02 782 Patient Amount Paid Min 1 Max 15 Decimal number (R) Required Monetary amount 1/30/25, 11:53 AM Texas Medicaid & Healthcare Partnerships (TMHP) 837 837 Health Care Claim: Professional (X222/A2/A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/tmhp/837-health-care-claim-professional-x222a2a1/01HMBZ8Y6XYRFK1ZR16EKD50N6 98/552 REF 1800 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > REF Adjusted Repriced Claim Number To specify identifying information Usage notes Required when this information is deemed necessary by the repricer. The segment is not completed by providers. The information is completed by repricers only. If not required by this implementation guide, do not send. This information is specific to the destination payer reported in Loop ID-2010BB. Example REF9CXXXXX~ Variants (all may be used) REF Care Plan Oversight REF Claim Identifier For Transmission Intermediaries REF Clinical Laboratory Improvement Amendment (CLIA) Number REF Demonstration Project Identifier REF Investigational Device Exemption Number REF Mammography Certification Number REF Mandatory Medicare (Section 4081) Crossover Indicator REF Medical Record Number REF Payer Claim Control Number REF Prior Authorization REF Referral Number REF Repriced Claim Number REF Service Authorization Exception Code Max use 1 Optional REF-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification 9C Adjusted Repriced Claim Reference Number REF-02 127 Adjusted Repriced Claim Reference Number Min 1 Max 50 String (AN) Required Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier 1/30/25, 11:53 AM Texas Medicaid & Healthcare Partnerships (TMHP) 837 837 Health Care Claim: Professional (X222/A2/A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/tmhp/837-health-care-claim-professional-x222a2a1/01HMBZ8Y6XYRFK1ZR16EKD50N6 99/552 REF 1800 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > REF Care Plan Oversight To specify identifying information Usage notes Required when the physician is billing Medicare for Care Plan Oversight (CPO). If not required by this implementation guide, do not send. This is the number of the home health agency or hospice providing Medicare covered services to the patient for the period during which CPO services were furnished. Prior to the mandated HIPAA National Provider Identifier (NPI) implementation date this number is the Medicare Number. On or after the mandated HIPAA National Provider Identifier (NPI) implementation date this is the NPI. Example REF1JXX~ Variants (all may be used) REF Adjusted Repriced Claim Number REF Claim Identifier For Transmission Intermediaries REF Clinical Laboratory Improvement Amendment (CLIA) Number REF Demonstration Project Identifier REF Investigational Device Exemption Number REF Mammography Certification Number REF Mandatory Medicare (Section 4081) Crossover Indicator REF Medical Record Number REF Payer Claim Control Number REF Prior Authorization REF Referral Number REF Repriced Claim Number REF Service Authorization Exception Code Max use 1 Optional REF-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification 1J Facility ID Number REF-02 127 Care Plan Oversight Number Min 1 Max 50 String (AN) Required Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier 1/30/25, 11:53 AM Texas Medicaid & Healthcare Partnerships (TMHP) 837 837 Health Care Claim: Professional (X222/A2/A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/tmhp/837-health-care-claim-professional-x222a2a1/01HMBZ8Y6XYRFK1ZR16EKD50N6 100/552 REF 1800 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > REF Claim Identifier For Transmission Intermediaries To specify identifying information Usage notes Required when this information is deemed necessary by transmission intermediaries (Automated Clearinghouses, and others) who need to attach their own unique claim number. If not required by this implementation guide, do not send. Although this REF is supplied for transmission intermediaries to attach their own unique claim number to a claim, 837-recipients are not required under HIPAA to return this number in any HIPAA transaction. Trading partners may voluntarily agree to this interaction if they wish. Example REFD9XXXXXX~ Variants (all may be used) REF Adjusted Repriced Claim Number REF Care Plan Oversight REF Clinical Laboratory Improvement Amendment (CLIA) Number REF Demonstration Project Identifier REF Investigational Device Exemption Number REF Mammography Certification Number REF Mandatory Medicare (Section 4081) Crossover Indicator REF Medical Record Number REF Payer Claim Control Number REF Prior Authorization REF Referral Number REF Repriced Claim Number REF Service Authorization Exception Code Max use 1 Optional REF-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification Usage notes Number assigned by clearinghouse, van, etc. D9 Claim Number REF-02 127 Value Added Network Trace Number Min 1 Max 50 String (AN) Required Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier Usage notes The value carried in this element is limited to a maximum of 20 positions. 1/30/25, 11:53 AM Texas Medicaid & Healthcare Partnerships (TMHP) 837 837 Health Care Claim: Professional (X222/A2/A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/tmhp/837-health-care-claim-professional-x222a2a1/01HMBZ8Y6XYRFK1ZR16EKD50N6 101/552 REF 1800 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > REF Clinical Laboratory Improvement Amendment (CLIA) Number To specify identifying information Usage notes Required for all CLIA certified facilities performing CLIA covered laboratory services. If not required by this implementation guide, do not send. If a CLIA number is indicated at the line level (Loop ID-2400) in addition to the claim level (Loop ID-2300), that would indicate an exception to the CLIA number at the claim level for that individual line. In cases where this claim contains both in-house and outsourced laboratory services, the CLIA Number for laboratory services performed by the Billing or Rendering Provider is reported in this loop. The CLIA number for laboratory services which were outsourced is reported in Loop ID-2400. Example REFX4XXXX~ Variants (all may be used) REF Adjusted Repriced Claim Number REF Care Plan Oversight REF Claim Identifier For Transmission Intermediaries REF Demonstration Project Identifier REF Investigational Device Exemption Number REF Mammography	Texas Medicaid and Healthcare Partnerships.pdf
Code Max use 1 Optional REF-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification 1J Facility ID Number REF-02 127 Care Plan Oversight Number Min 1 Max 50 String (AN) Required Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier 1/30/25, 11:53 AM Texas Medicaid & Healthcare Partnerships (TMHP) 837 837 Health Care Claim: Professional (X222/A2/A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/tmhp/837-health-care-claim-professional-x222a2a1/01HMBZ8Y6XYRFK1ZR16EKD50N6 100/552 REF 1800 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > REF Claim Identifier For Transmission Intermediaries To specify identifying information Usage notes Required when this information is deemed necessary by transmission intermediaries (Automated Clearinghouses, and others) who need to attach their own unique claim number. If not required by this implementation guide, do not send. Although this REF is supplied for transmission intermediaries to attach their own unique claim number to a claim, 837-recipients are not required under HIPAA to return this number in any HIPAA transaction. Trading partners may voluntarily agree to this interaction if they wish. Example REFD9XXXXXX~ Variants (all may be used) REF Adjusted Repriced Claim Number REF Care Plan Oversight REF Clinical Laboratory Improvement Amendment (CLIA) Number REF Demonstration Project Identifier REF Investigational Device Exemption Number REF Mammography Certification Number REF Mandatory Medicare (Section 4081) Crossover Indicator REF Medical Record Number REF Payer Claim Control Number REF Prior Authorization REF Referral Number REF Repriced Claim Number REF Service Authorization Exception Code Max use 1 Optional REF-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification Usage notes Number assigned by clearinghouse, van, etc. D9 Claim Number REF-02 127 Value Added Network Trace Number Min 1 Max 50 String (AN) Required Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier Usage notes The value carried in this element is limited to a maximum of 20 positions. 1/30/25, 11:53 AM Texas Medicaid & Healthcare Partnerships (TMHP) 837 837 Health Care Claim: Professional (X222/A2/A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/tmhp/837-health-care-claim-professional-x222a2a1/01HMBZ8Y6XYRFK1ZR16EKD50N6 101/552 REF 1800 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > REF Clinical Laboratory Improvement Amendment (CLIA) Number To specify identifying information Usage notes Required for all CLIA certified facilities performing CLIA covered laboratory services. If not required by this implementation guide, do not send. If a CLIA number is indicated at the line level (Loop ID-2400) in addition to the claim level (Loop ID-2300), that would indicate an exception to the CLIA number at the claim level for that individual line. In cases where this claim contains both in-house and outsourced laboratory services, the CLIA Number for laboratory services performed by the Billing or Rendering Provider is reported in this loop. The CLIA number for laboratory services which were outsourced is reported in Loop ID-2400. Example REFX4XXXX~ Variants (all may be used) REF Adjusted Repriced Claim Number REF Care Plan Oversight REF Claim Identifier For Transmission Intermediaries REF Demonstration Project Identifier REF Investigational Device Exemption Number REF Mammography Certification Number REF Mandatory Medicare (Section 4081) Crossover Indicator REF Medical Record Number REF Payer Claim Control Number REF Prior Authorization REF Referral Number REF Repriced Claim Number REF Service Authorization Exception Code Max use 1 Optional REF-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification X4 Clinical Laboratory Improvement Amendment Number REF-02 127 Clinical Laboratory Improvement Amendment Number Min 1 Max 50 String (AN) Required Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier 1/30/25, 11:53 AM Texas Medicaid & Healthcare Partnerships (TMHP) 837 837 Health Care Claim: Professional (X222/A2/A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/tmhp/837-health-care-claim-professional-x222a2a1/01HMBZ8Y6XYRFK1ZR16EKD50N6 102/552 REF 1800 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > REF Demonstration Project Identifier To specify identifying information Usage notes Required when it is necessary to identify claims which are atypical in ways such as content, purpose, and/or payment, as could be the case for a demonstration or other special project, or a clinical trial. If not required by this implementation guide, do not send. Example REFP4XX~ Variants (all may be used) REF Adjusted Repriced Claim Number REF Care Plan Oversight REF Claim Identifier For Transmission Intermediaries REF Clinical Laboratory Improvement Amendment (CLIA) Number REF Investigational Device Exemption Number REF Mammography Certification Number REF Mandatory Medicare (Section 4081) Crossover Indicator REF Medical Record Number REF Payer Claim Control Number REF Prior Authorization REF Referral Number REF Repriced Claim Number REF Service Authorization Exception Code Max use 1 Optional REF-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification P4 Project Code REF-02 127 Demonstration Project Identifier Min 1 Max 50 String (AN) Required Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier 1/30/25, 11:53 AM Texas Medicaid & Healthcare Partnerships (TMHP) 837 837 Health Care Claim: Professional (X222/A2/A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/tmhp/837-health-care-claim-professional-x222a2a1/01HMBZ8Y6XYRFK1ZR16EKD50N6 103/552 REF 1800 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > REF Investigational Device Exemption Number To specify identifying information Usage notes Required when claim involves a Food and Drug Administration (FDA) assigned investigational device exemption (IDE) number. When more than one IDE applies, they must be split into separate claims. If not required by this implementation guide, do not send. Example REFLXXX~ Variants (all may be used) REF Adjusted Repriced Claim Number REF Care Plan Oversight REF Claim Identifier For Transmission Intermediaries REF Clinical Laboratory Improvement Amendment (CLIA) Number REF Demonstration Project Identifier REF Mammography Certification Number REF Mandatory Medicare (Section 4081) Crossover Indicator REF Medical Record Number REF Payer Claim Control Number REF Prior Authorization REF Referral Number REF Repriced Claim Number REF Service Authorization Exception Code Max use 1 Optional REF-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification LX Qualified Products List REF-02 127 Investigational Device Exemption Identifier Min 1 Max 50 String (AN) Required Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier 1/30/25, 11:53 AM Texas Medicaid & Healthcare Partnerships (TMHP) 837 837 Health Care Claim: Professional (X222/A2/A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/tmhp/837-health-care-claim-professional-x222a2a1/01HMBZ8Y6XYRFK1ZR16EKD50N6 104/552 REF 1800 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > REF Mammography Certification Number To specify identifying information Usage notes Required when mammography services are rendered by a certified mammography provider. If not required by this implementation guide, do not send. Example REFEWXXXXXX~ Variants (all may be used) REF Adjusted Repriced Claim Number REF Care Plan Oversight REF Claim Identifier For Transmission Intermediaries REF Clinical Laboratory Improvement Amendment (CLIA) Number REF Demonstration Project Identifier REF Investigational Device Exemption Number REF Mandatory Medicare (Section 4081) Crossover Indicator REF Medical Record Number REF Payer Claim Control Number REF Prior Authorization REF Referral Number REF Repriced Claim Number REF Service Authorization Exception Code Max use 1 Optional REF-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification EW Mammography Certification Number REF-02 127 Mammography Certification Number Min 1 Max 50 String (AN) Required Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier 1/30/25, 11:53 AM Texas Medicaid & Healthcare Partnerships (TMHP) 837 837 Health Care Claim: Professional (X222/A2/A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/tmhp/837-health-care-claim-professional-x222a2a1/01HMBZ8Y6XYRFK1ZR16EKD50N6 105/552 REF 1800 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > REF Mandatory Medicare (Section 4081) Crossover Indicator To specify identifying information Usage notes Required when the submitter is Medicare and the claim is a Medigap or COB crossover claim. If not required by this implementation guide, do not send. Example REFF5XX~ Variants (all may be used) REF Adjusted Repriced Claim Number REF Care Plan Oversight REF Claim Identifier For Transmission Intermediaries REF Clinical Laboratory Improvement Amendment (CLIA) Number REF Demonstration Project Identifier REF Investigational Device Exemption Number REF Mammography Certification Number REF Medical Record Number REF Payer Claim Control Number REF Prior Authorization REF Referral Number REF Repriced Claim Number REF Service Authorization Exception Code Max use 1 Optional REF-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification F5 Medicare Version Code REF-02 127 Medicare Section 4081 Indicator Min 1 Max 50 String (AN) Required Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier Usage notes The allowed values for this element are: Y 4081 N Regular crossover 1/30/25, 11:53 AM Texas Medicaid & Healthcare Partnerships (TMHP) 837 837 Health Care Claim: Professional (X222/A2/A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/tmhp/837-health-care-claim-professional-x222a2a1/01HMBZ8Y6XYRFK1ZR16EKD50N6 106/552 REF 1800 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > REF Medical Record Number To specify identifying information Usage notes Required when the provider needs to identify for future inquiries, the actual medical record of the patient identified in either Loop ID-2010BA or Loop ID-2010CA for this episode of care. If not required by this implementation guide, do not send. Example REFEAXXXXX~ Variants (all may be used) REF Adjusted Repriced Claim Number REF Care Plan Oversight REF Claim Identifier For Transmission Intermediaries REF Clinical Laboratory Improvement Amendment (CLIA) Number REF Demonstration Project Identifier REF Investigational Device Exemption Number REF Mammography Certification Number REF Mandatory Medicare (Section 4081) Crossover Indicator REF Payer Claim Control Number REF Prior Authorization REF Referral Number REF Repriced Claim Number REF Service Authorization Exception Code Max use 1 Optional REF-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification EA Medical Record Identification Number REF-02 127 Medical Record Number Min 1 Max 50 String (AN) Required Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier 1/30/25, 11:53 AM Texas Medicaid & Healthcare Partnerships (TMHP) 837 837 Health Care Claim: Professional (X222/A2/A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/tmhp/837-health-care-claim-professional-x222a2a1/01HMBZ8Y6XYRFK1ZR16EKD50N6 107/552 REF 1800 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > REF Payer Claim Control Number To specify identifying information Usage notes Required when CLM05-3 (Claim Frequency Code) indicates this claim is a replacement or void to a previously adjudicated claim. If not required by this implementation guide, do not send. This information is specific to the destination payer reported in Loop ID-2010BB. Example REFF8XXXX~ Variants (all may be used) REF Adjusted Repriced Claim Number REF Care Plan Oversight REF Claim Identifier For Transmission Intermediaries REF Clinical Laboratory Improvement Amendment (CLIA) Number REF Demonstration Project Identifier REF Investigational Device Exemption Number REF Mammography Certification Number REF Mandatory Medicare (Section 4081) Crossover Indicator REF Medical Record Number REF Prior Authorization REF Referral Number REF Repriced Claim Number REF Service Authorization Exception Code Max use 1 Optional REF-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification F8 Original Reference Number REF-02 127 Payer Claim Control Number Min 1 Max 50 String (AN) Required Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier 1/30/25, 11:53 AM Texas Medicaid & Healthcare Partnerships (TMHP) 837 837 Health Care Claim: Professional (X222/A2/A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/tmhp/837-health-care-claim-professional-x222a2a1/01HMBZ8Y6XYRFK1ZR16EKD50N6 108/552 REF 1800 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > REF Prior Authorization To specify identifying information Usage notes Generally, preauthorization numbers are assigned by the payer or UMO to authorize a service prior to its being performed. The UMO (Utilization Management Organization) is generally the entity empowered to make a decision regarding the outcome of a health services review or the owner of information. The prior authorization number carried in this REF is specific to the destination payer reported in the Loop ID-2010BB. If other payers have similar numbers for this claim, report that information in the Loop ID-2330 loop REF which holds that payer's information. Numbers at this position apply to the entire claim unless they are overridden in the REF segment in Loop ID-2400. A reference identification is considered to be overridden if the value in REF01 is the same in both the Loop ID-2300 REF segment and the Loop ID-2400 REF segment. In that case, the Loop ID-2400 REF applies only to that specific line.	Texas Medicaid and Healthcare Partnerships.pdf

Subsets and Splits