{"text_format":"3","workbook":"xlsx","n_sheets":17,"sheets":["Intro","837P Mapping","837P CG","837I Mapping","837I CG","837D Mapping","837D CG","837 FAQ","277CA Mapping","277CA CG ","Edits","421 Mapping","276 Mapping","277 Mapping","276 and 277 CG","Response File FAQ","Revision History"],"not_rendered":{"images":7,"external_links":4,"defined_names":62,"comments":2},"read":"whole","date_system":"1900"}

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[]
[]
[]
[{"$nulls":11},"Mapping Legend","Description"]
[{"$nulls":11},"Loop Id","This property lists the X12 Implementation Guide Loop ID"]
[{"$nulls":11},"Segment Id","This property lists the X12 Implementation Guide Segment ID"]
[{"$nulls":11},"Element Position","This property lists the X12 Implementation Guide Element Position"]
[{"$nulls":11},"Loop/Segment/Element Name","This property lists the X12 Implementation Guide Element Name"]
[{"$nulls":11},"Usage","This property lists the X12 Implementation Guide Industry Usage"]
[{"$nulls":11},"Repeat","This property lists the X12 Implementation Guide Repetition"]
[{"$nulls":11},"Condition Indicator","This property lists the X12 Implementation Guide Requirement Designator"]
[{"$nulls":11},"Data Type","This property lists the X12 Implementation Guide Data Type"]
[{"$nulls":11},"Minimum","This property lists the X12 Implementation Guide Min Length allowed"]
[{"$nulls":11},"Maximum","This property lists the X12 Implementation Guide Max Length allowed"]
["Contents",{"$nulls":10},"Implementation Guide Code List","This property lists the X12 Implementation Guide List of standard codes (if present)"]
["837P Mapping",{"$nulls":10},"PRISM Usage","This property is specific to PRISM and defines PRISM Usage for the X12 element"]
["837P Companion Guide",{"$nulls":10},"PRISM Values/Constants","This property is specific to PRISM and defines PRISM specific instructions or subset/constant values of the X12 element"]
["837I Mapping",{"$nulls":11},"The color signifies a Loop in the X12 Mapping Document"]
["837I Companion Guide",{"$nulls":11},"The color signifies a Segment within a Loop in the X12 Mapping Document"]
["837D Mapping",{"$nulls":11},"The color signifies a Composite Element in the X12 Mapping Document"]
["837D Companion Guide"]
["837 FAQ"]
["277CA Mapping"]
["277CA Companion Guide"]
["421 Mapping"]
["Edits"]
["Response File FAQ"]
["Revision History"]

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["Loop Id","Segment Id","Element Pos","Loop/Segment/Element Name","Usage","Condition Design/ator","Repeat","Data Type","Minimum","Maximum","Implementation Guide Code list","PRISM Usage","PRISM Values/Constants"]
[null,"Segment Id","Element Pos","Loop/Segment/Element Name","Usage","Condition Designator","Repeat","Data Type","Minimum","Maximum","Implementation Guide Code list",null,"PRISM Values (FFS/XOver)"]
[null,"ISA","","Interchange Control Header","R","M",1,{"$nulls":4},"R"]
[null,"ISA","ISA01","Authorization Information Qualifier","R","M",1,"ID",2,2,"00 No Authorization Information Present (No Meaningful Information in I02)\n03 Additional Data Identification","R","\"00\""]
[null,"ISA","ISA02","Authorization Information","R","M",1,"AN",10,10,null,"R","\"          \""]
[null,"ISA","ISA03","Security Information Qualifier","R","M",1,"ID",2,2,"00 No Security Information Present (No Meaningful Information in I04)\n01 Password","R","\"00\""]
[null,"ISA","ISA04","Security Information","R","M",1,"AN",10,10,null,"R","\"          \""]
[null,"ISA","ISA05","Interchange ID Qualifier","R","M",1,"ID",2,2,"01 Duns (Dun & Bradstreet)\n14 Duns Plus Suffix\n20 Health Industry Number (HIN) \n27 Carrier Identification Number as assigned by Health Care Financing Administration (HCFA)\n28 Fiscal Intermediary Identification Number as assigned by Health Care Financing Administration (HCFA)\n29 Medicare Provider and Supplier Identification Number as assigned by Health Care Financing Administration (HCFA)\n30 U.S. Federal Tax Identification Number\n33 national Association of Insurance Commissioners Company Code (naIC)\nZZ Mutually Defined","R","\"ZZ\""]
[null,"ISA","ISA06","Interchange Sender ID","R","M",1,"AN",15,15,null,"R","n/a"]
[null,"ISA","ISA07","Interchange ID Qualifier","R","M",1,"ID",2,2,"01 Duns (Dun & Bradstreet)\n14 Duns Plus Suffix\n20 Health Industry Number (HIN) \n27 Carrier Identification Number as assigned by Health Care Financing Administration (HCFA)\n28 Fiscal Intermediary Identification Number as assigned by Health Care Financing Administration (HCFA)\n29 Medicare Provider and Supplier Identification Number as assigned by Health Care Financing Administration (HCFA)\n30 U.S. Federal Tax Identification Number\n33 national Association of Insurance Commissioners Company Code (naIC)\nZZ Mutually Defined","R","\"ZZ\""]
[null,"ISA","ISA08","Interchange Receiver ID","R","M",1,"AN",15,15,null,"R","Medicaid FFS: \"HT000004-001\" \nEncounter: \"HT000004-002\" \nCrossover: \"HT000004-005\" \nMedicaid Atypical: \"HT000004-801\" \nTest MCO: \"HT000004-003\"\nTest FFS: \"HT000004-004\""]
[null,"ISA","ISA09","Interchange Date","R","M",1,"DT",6,6,null,"R","SYSDATE\nFormat: YYMMDD"]
[null,"ISA","ISA10","Interchange Time","R","M",1,"TM",4,4,null,"R","SYSDATE\nFormat: HHMM"]
[null,"ISA","ISA11","Repetition Separator","R","M",1,null,1,1,null,"R","\"^\""]
[null,"ISA","ISA12","Interchange Control Version Number","R","M",1,"ID",5,5,"00501 Standards Approved for Publication by ASC X12 Procedures Review Board through October 2003 ","R","\"00501\""]
[null,"ISA","ISA13","Interchange Control Number","R","M",1,"N0",9,9,null,"R","n/a"]
[null,"ISA","ISA14","Acknowledgment Requested","R","M",1,"ID",1,1,"0 No Interchange Acknowledgment Requested\n1 Interchange Acknowledgment Requested (TA1) ","R","\"1\""]
[null,"ISA","ISA15","Interchange Usage Indicator","R","M",1,"ID",1,1,"P Production Data\nT Test Data","R","n/a"]
[null,"ISA","ISA16","Component Element Separator","R","M",1,null,1,1,null,"R","\":\""]
[null,"GS","","Functional Group Header","R","M",1,{"$nulls":4},"R"]
[null,"GS","GS01","Functional Identifier Code","R","M",1,"ID",2,2,"HC Health Care Claim (837)","R","\"HC\""]
[null,"GS","GS02","Application Sender's Code","R","M",1,"AN",2,15,null,"R","n/a"]
[null,"GS","GS03","Application Receiver's Code","R","M",1,"AN",2,15,null,"R","Medicaid FFS: \"HT000004-001\" \nEncounter: \"HT000004-002\" \nCrossover: \"HT000004-005\" \nMedicaid Atypical: \"HT000004-801\" \nTest MCO: \"HT000004-003\"\nTest FFS: \"HT000004-004\""]
[null,"GS","GS04","Date","R","M",1,"DT",8,8,null,"R","SYSDATE\nFormat: CCYYMMDD "]
[null,"GS","GS05","Time","R","M",1,"TM",4,8,null,"R","SYSDATE\nFormat: HHMM"]
[null,"GS","GS06","Group Control Number","R","M",1,"N0",1,9,null,"R","n/a"]
[null,"GS","GS07","Responsible Agency Code","R","M",1,"ID",1,2,"X Accredited Standards Committee X12 ","R","\"X\""]
[null,"GS","GS08","Version / Release / Industry Identifier Code","R","M",1,"AN",1,12,"005010X222A1 Standards Approved for Publication by ASC X12 Procedures Review Board through October 2003","R","\"005010X222A1\""]
[null,"ST","","Transaction Set Header","R","M",1,{"$nulls":4},"R"]
[null,"ST","ST01","Transaction Set Identifier Code","R","M",1,"ID",3,3,"837 Health Care Claim ","R","\"837\""]
[null,"ST","ST02","Transaction Set Control Number","R","M",1,"AN",4,9,null,"R","n/a"]
[null,"ST","ST03","Implementation Convention Reference","R","O",1,"AN",1,35,"005010X222A1","R","005010X222A1\""]
[null,"BHT","","Beginning of Hierarchical Transaction","R","M",1,{"$nulls":4},"R"]
[null,"BHT","BHT01","Hierarchical Structure Code","R","M",1,"ID",4,4,"0019 Information Source, Subscriber, Dependent ","RNS","n/a"]
[null,"BHT","BHT02","Transaction Set Purpose Code","R","M",1,"ID",2,2,"00 Original\n18 Reissue ","R","\"00\" "]
[null,"BHT","BHT03","Reference Identification","R","O",1,"AN",1,50,null,"R","n/a"]
[null,"BHT","BHT04","Date","R","O",1,"DT",8,8,null,"R","SYSDATE\nFormat: CCYYMMDD "]
[null,"BHT","BHT05","Time","R","O",1,"TM",4,8,null,"R","SYSDATE\nFormat: HHMM"]
[null,"BHT","BHT06","Transaction Type Code","R","O",1,"ID",2,2,"31 Subrogation Demand\nCH Chargeable \nRP Reporting ","R","Non-Encounter: \"CH\" \nEncounter: \"RP\""]
["1000A",null,"","Submitter Name","R","O",1,{"$nulls":4},"R"]
["1000A","NM1","","Submitter Name","R","O",1,{"$nulls":4},"R"]
["1000A","NM1","NM101","Entity Identifier Code","R","M",1,"ID",2,3,"41 Submitter\n","RNS","n/a"]
["1000A","NM1","NM102","Entity Type Qualifier","R","M",1,"ID",1,1,"1 Person\n2 Non-Person Entity","RNS","n/a"]
["1000A","NM1","NM103","Name Last or Organization Name","R","X",1,"AN",1,60,null,"R","n/a"]
["1000A","NM1","NM104","Name First","S","O",1,"AN",1,35,null,"S","n/a"]
["1000A","NM1","NM105","Name Middle","S","O",1,"AN",1,25,null,"S","n/a"]
["1000A","NM1","NM108","Identification Code Qualifier","R","X",1,"ID",1,2,"46 Electronic Transmitter Identification Number (ETIN) ","R","\"46\""]
["1000A","NM1","NM109","Identification Code","R","X",1,"AN",2,80,null,"R","n/a"]
["1000A","PER","","Submitter EDI Contact Information","R","O",2,{"$nulls":4},"R"]
["1000A","PER","PER01","Contact Function Code","R","M",1,"ID",2,2,"IC Information Contact ","RNS","n/a"]
["1000A","PER","PER02","Name","S","O",1,"AN",1,60,null,"S","n/a"]
["1000A","PER","PER03","Communication Number Qualifier","R","X",1,"ID",2,2,"EM Electronic Mail\nFX Facsimile\nTE Telephone","R","n/a"]
["1000A","PER","PER04","Communication Number","R","X",1,"AN",1,256,null,"R","n/a"]
["1000A","PER","PER05","Communication Number Qualifier","S","X",1,"ID",2,2,"EM Electronic Mail\nEX Telephone Extension\nFX Facsimile\nTE Telephone","S","n/a"]
["1000A","PER","PER06","Communication Number","S","X",1,"AN",1,256,null,"S","n/a"]
["1000A","PER","PER07","Communication Number Qualifier","S","X",1,"ID",2,2,"EM Electronic Mail\nEX Telephone Extension\nFX Facsimile\nTE Telephone","S","n/a"]
["1000A","PER","PER08","Communication Number","S","X",1,"AN",1,256,null,"S","n/a"]
["1000B",null,"","Receiver Name","R","O",1,{"$nulls":4},"R"]
["1000B","NM1","","Receiver Name","R","O",1,{"$nulls":4},"R"]
["1000B","NM1","NM101","Entity Identifier Code","R","M",1,"ID",2,3,"40 Receiver ","RNS","n/a"]
["1000B","NM1","NM102","Entity Type Qualifier","R","M",1,"ID",1,1,"2 Non-Person Entity\n","RNS","n/a"]
["1000B","NM1","NM103","Name Last or Organization Name","R","X",1,"AN",1,60,null,"RNS","n/a"]
["1000B","NM1","NM108","Identification Code Qualifier","R","X",1,"ID",1,2,"46 Electronic Transmitter Identification Number (ETIN) ","RNS","n/a"]
["1000B","NM1","NM109","Identification Code","R","X",1,"AN",2,80,null,"RNS","n/a"]
["2000A",null,"","Billing Provider Hierarchical Level","R","M",">1",{"$nulls":4},"R"]
["2000A","HL","","Billing Provider Hierarchical Level","R","M",1,{"$nulls":4},"R"]
["2000A","HL","HL01","Hierarchical ID Number","R","M",1,"AN",1,12,null,"RNS","n/a"]
["2000A","HL","HL03","Hierarchical Level Code","R","M",1,"ID",1,2,"20 Information Source\n","RNS","n/a"]
["2000A","HL","HL04","Hierarchical Child Code","R","O",1,"ID",1,1,"1 Additional Subordinate HL Data Segment in This Hierarchical Structure.\n","RNS","n/a"]
["2000A","PRV","","Billing Provider Specialty Information","S","O",1,{"$nulls":4},"S"]
["2000A","PRV","PRV01","Provider Code","R","M",1,"ID",1,3,"BI Billing ","RNS","n/a"]
["2000A","PRV","PRV02","Reference Identification Qualifier","R","X",1,"ID",2,3,"PXC Health Care Provider Taxonomy Code\n","RNS","n/a"]
["2000A","PRV","PRV03","Reference Identification","R","X",1,"AN",1,50,null,"R","n/a"]
["2000A","CUR","","Foreign Currency Information","S","O",1,{"$nulls":4},"S"]
["2000A","CUR","CUR01","Entity Identifier Code","R","M",1,"ID",2,3,"85 Billing Provider","RNS","n/a"]
["2000A","CUR","CUR02","Currency Code","R","M",1,"ID",3,3,null,"R","n/a"]
["2010AA",null,"","Billing Provider Name","R","O",1,{"$nulls":4},"R"]
["2010AA","NM1","","Billing Provider Name","R","O",1,{"$nulls":4},"R"]
["2010AA","NM1","NM101","Entity Identifier Code","R","M",1,"ID",2,3,"85 Billing Provider","RNS","n/a"]
["2010AA","NM1","NM102","Entity Type Qualifier","R","M",1,"ID",1,1,"1 Person\n2 Non-Person Entity","RNS","n/a"]
["2010AA","NM1","NM103","Name Last or Organization Name","R","X",1,"AN",1,60,null,"R","n/a"]
["2010AA","NM1","NM104","Name First","S","O",1,"AN",1,35,null,"S","n/a"]
["2010AA","NM1","NM105","Name Middle","S","O",1,"AN",1,25,null,"S","n/a"]
["2010AA","NM1","NM107","Name Suffix","S","O",1,"AN",1,10,null,"S","n/a"]
["2010AA","NM1","NM108","Identification Code Qualifier","S","X",1,"ID",1,2,"XX Centers for Medicare and Medicaid Services national Provider Identifier","S","\"XX\""]
["2010AA","NM1","NM109","Identification Code","S","X",1,"AN",2,80,null,"S","n/a"]
["2010AA","N3","","Billing Provider Address","R","O",1,{"$nulls":4},"R"]
["2010AA","N3","N301","Address Information","R","M",1,"AN",1,55,null,"R","n/a"]
["2010AA","N3","N302","Address Information","S","O",1,"AN",1,55,null,"S","n/a"]
["2010AA","N4","","Billing Provider City, State, ZIP Code","R","O",1,{"$nulls":4},"R"]
["2010AA","N4","N401","City Name","R","O",1,"AN",2,30,null,"R","n/a"]
["2010AA","N4","N402","State or Province Code","S","X",1,"ID",2,2,null,"S","n/a"]
["2010AA","N4","N403","Postal Code","S","O",1,"ID",3,15,null,"S","n/a"]
["2010AA","N4","N404","Country Code","S","X",1,"ID",2,3,null,"S","n/a"]
["2010AA","N4","N407","Country Subdivision Code","S","X",1,"ID",1,3,null,"SNS","n/a"]
["2010AA","REF","","Billing Provider Tax Identification","R","O",1,{"$nulls":4},"R"]
["2010AA","REF","REF01","Reference Identification Qualifier","R","M",1,"ID",2,3,"EI Employer’s Identification Number\nSY Social Security Number","R","n/a"]
["2010AA","REF","REF02","Reference Identification","R","X",1,"AN",1,50,null,"R","n/a"]
["2010AA","REF","","Billing Provider UPIN/License Information","S","O",2,{"$nulls":4},"S"]
["2010AA","REF","REF01","Reference Identification Qualifier","R","M",1,"ID",2,3,"0B State License Number\n1G Provider UPIN Number","R","n/a"]
["2010AA","REF","REF02","Reference Identification","R","X",1,"AN",1,50,null,"R","n/a"]
["2010AA","PER","","Billing Provider Contact Information","S","O",2,{"$nulls":4},"S"]
["2010AA","PER","PER01","Contact Function Code","R","M",1,"ID",2,2,"IC Information Contact ","RNS","n/a"]
["2010AA","PER","PER02","Name","S","O",1,"AN",1,60,null,"S","n/a"]
["2010AA","PER","PER03","Communication Number Qualifier","R","X",1,"ID",2,2,"EM Electronic Mail\nFX Facsimile\nTE Telephone","R","n/a"]
["2010AA","PER","PER04","Communication Number","R","X",1,"AN",1,256,null,"R","n/a"]
["2010AA","PER","PER05","Communication Number Qualifier","S","X",1,"ID",2,2,"EM Electronic Mail\nEX Telephone Extension\nFX Facsimile\nTE Telephone","S","n/a"]
["2010AA","PER","PER06","Communication Number","S","X",1,"AN",1,256,null,"S","n/a"]
["2010AA","PER","PER07","Communication Number Qualifier","S","X",1,"ID",2,2,"EM Electronic Mail\nEX Telephone Extension\nFX Facsimile\nTE Telephone","S","n/a"]
["2010AA","PER","PER08","Communication Number","S","X",1,"AN",1,256,null,"S","n/a"]
["2010AB",null,"","Pay-to Address Name","S","O",1,{"$nulls":4},"S"]
["2010AB","NM1","","Pay-to Address Name","S","O",1,{"$nulls":4},"S"]
["2010AB","NM1","NM101","Entity Identifier Code","R","M",1,"ID",2,3,"87 Pay-to Provider\n","RNS","n/a"]
["2010AB","NM1","NM102","Entity Type Qualifier","R","M",1,"ID",1,1,"1 Person\n2 Non-Person Entity","RNS","n/a"]
["2010AB","N3","","Pay-To Address - ADDRESS","R","O",1,{"$nulls":4},"R"]
["2010AB","N3","N301","Address Information","R","M",1,"AN",1,55,null,"R","n/a"]
["2010AB","N3","N302","Address Information","S","O",1,"AN",1,55,null,"S","n/a"]
["2010AB","N4","","Pay-to Address City, State, ZIP Code","R","O",1,{"$nulls":4},"R"]
["2010AB","N4","N401","City Name","R","O",1,"AN",2,30,null,"R","n/a"]
["2010AB","N4","N402","State or Province Code","S","X",1,"ID",2,2,null,"S","n/a"]
["2010AB","N4","N403","Postal Code","S","O",1,"ID",3,15,null,"S","n/a"]
["2010AB","N4","N404","Country Code","S","X",1,"ID",2,3,null,"S","n/a"]
["2010AB","N4","N407","Country Subdivision Code","S","X",1,"ID",1,3,null,"S","n/a"]
["2010AC",null,"","Pay-To Plan Name","S","O",1,{"$nulls":4},"S"]
["2010AC","NM1","","Pay-To Plan Name","S","O",1,{"$nulls":4},"S"]
["2010AC","NM1","NM101","Entity Identifier Code","R","M",1,"ID",2,3,"PE Payee ","RNS","n/a"]
["2010AC","NM1","NM102","Entity Type Qualifier","R","M",1,"ID",1,1,"\n2 Non-Person Entity","RNS","n/a"]
["2010AC","NM1","NM103","Name Last or Organization Name","R","X",1,"AN",1,60,null,"R","n/a"]
["2010AC","NM1","NM108","Identification Code Qualifier","R","X",1,"ID",1,2,"PI Payor Identification\nXV Centers for Medicare and Medicaid Services PlanI","R","n/a"]
["2010AC","NM1","NM109","Identification Code","R","X",1,"AN",2,80,null,"R","n/a"]
["2010AC","N3","","Pay-To Plan Address","R","O",1,{"$nulls":4},"R"]
["2010AC","N3","N301","Address Information","R","M",1,"AN",1,55,null,"R","n/a"]
["2010AC","N3","N302","Address Information","S","O",1,"AN",1,55,null,"S","n/a"]
["2010AC","N4","","Pay-To Plan City, State, ZIP Code","R","O",1,{"$nulls":4},"R"]
["2010AC","N4","N401","City Name","R","O",1,"AN",2,30,null,"R","n/a"]
["2010AC","N4","N402","State or Province Code","S","X",1,"ID",2,2,null,"S","n/a"]
["2010AC","N4","N403","Postal Code","S","O",1,"ID",3,15,null,"S","n/a"]
["2010AC","N4","N404","Country Code","S","X",1,"ID",2,3,null,"S","n/a"]
["2010AC","N4","N407","Country Subdivision Code","S","X",1,"ID",1,3,null,"S","n/a"]
["2010AC","REF","","Pay-To Plan Secondary Identification","S","O",1,{"$nulls":4},"S"]
["2010AC","REF","REF01","Reference Identification Qualifier","R","M",1,"ID",2,3,"2U Payer Identification Number\nFY Claim Office Number\nNF national Association of Insurance Commissioners (naIC) Code","R","n/a"]
["2010AC","REF","REF02","Reference Identification","R","X",1,"AN",1,50,null,"R","n/a"]
["2010AC","REF","","Pay-To Plan Tax Identification Number","R","O",1,{"$nulls":4},"R"]
["2010AC","REF","REF01","Reference Identification Qualifier","R","M",1,"ID",2,3,"EI Employer’s Identification Number","RNS","n/a"]
["2010AC","REF","REF02","Reference Identification","R","X",1,"AN",1,50,null,"R","n/a"]
["2000B",null,"","Subscriber Hierarchical Level","R","M",">1",{"$nulls":4},"R"]
["2000B","HL","","Subscriber Hierarchical Level","R","M",1,{"$nulls":4},"R"]
["2000B","HL","HL01","Hierarchical ID Number","R","M",1,"AN",1,12,null,"RNS","n/a"]
["2000B","HL","HL02","Hierarchical Parent ID Number","R","O",1,"AN",1,12,null,"RNS","n/a"]
["2000B","HL","HL03","Hierarchical Level Code","R","M",1,"ID",1,2,"22 Subscriber ","RNS","n/a"]
["2000B","HL","HL04","Hierarchical Child Code","R","O",1,"ID",1,1,"0 No Subordinate HL Segment in This Hierarchical Structure.\n1 Additional Subordinate HL Data Segment in This Hierarchical Structure","RNS","n/a"]
["2000B","SBR","","Subscriber Information","R","O",1,{"$nulls":4},"R"]
["2000B","SBR","SBR01","Payer Responsibility Sequence Number Code","R","M",1,"ID",1,1,"A Payer Responsibility Four\nB Payer Responsibility Five\nC Payer Responsibility Six\nD Payer Responsibility Seven\nE Payer Responsibility Eight\nF Payer Responsibility Nine\nG Payer Responsibility Ten\nH Payer Responsibility Eleven\nP Primary\nS Secondary\nT Tertiary\nU Unknown","R","n/a"]
["2000B","SBR","SBR02","Individual Relationship Code","S","O",1,"ID",2,2,"18 Self ","S","n/a"]
["2000B","SBR","SBR03","Reference Identification","S","O",1,"AN",1,50,null,"S","n/a"]
["2000B","SBR","SBR04","Name","S","O",1,"AN",1,60,null,"S","n/a"]
["2000B","SBR","SBR05","Insurance Type Code","S","O",1,"ID",1,3,"12 Medicare Secondary Working Aged Beneficiary or Spouse with Employer Group Health Plan\n13 Medicare Secondary End-Stage Renal Disease Beneficiary in the Mandated Coordination Period with an Employer’s Group Health Plan\n14 Medicare Secondary, No-fault Insurance including Auto is Primary\n15 Medicare Secondary Worker’s Compensation\n16 Medicare Secondary Public Health Service (PHS)or Other Federal Agency\n41 Medicare Secondary Black Lung\n42 Medicare Secondary Veteran’s Administration\n43 Medicare Secondary Disabled Beneficiary Under Age 65 with Large Group Health Plan (LGHP)\n47 Medicare Secondary, Other Liability Insurance is Primary ","S","n/a"]
["2000B","SBR","SBR09","Claim Filing Indicator Code","S","O",1,"ID",1,2,"11 Other Non-Federal Programs\n12 Preferred Provider Organization (PPO)\n13 Point of Service (POS)\n14 Exclusive Provider Organization (EPO)\n15 Indemnity Insurance\n16 Health Maintenance Organization (HMO) Medicare Risk\n17 Dental Maintenance Organization\nAM Automobile Medical\nBL Blue Cross/Blue Shield\nCH Champus\nCI Commercial Insurance Co.\nDS Disability\nFI Federal Employees Program\nHM Health Maintenance Organization\nLM Liability Medical\nMA Medicare Part A\nMB Medicare Part B\nMC Medicaid\nOF Other Federal Program\nTV Title V\nVA Veterans Affairs Plan\nWC Workers’ Compensation Health Claim\nZZ Mutually Define","S","n/a"]
["2000B","PAT","","Patient Information","S","O",1,{"$nulls":4},"S"]
["2000B","PAT","PAT05","Date Time Period Format Qualifier","S","X",1,"ID",2,3,"D8 Date Expressed in Format CCYYMMDD","SNS","n/a"]
["2000B","PAT","PAT06","Date Time Period","S","X",1,"AN",1,35,null,"S","n/a"]
["2000B","PAT","PAT07","Unit or Basis for Measurement Code","S","X",1,"ID",2,2,"01 Actual Pounds ","S","n/a"]
["2000B","PAT","PAT08","Weight","S","X",1,"R",1,10,null,"S","n/a"]
["2000B","PAT","PAT09","Yes/No Condition or Response Code","S","O",1,"ID",1,1,"Y Yes\n","S","n/a"]
["2010BA",null,"","Subscriber Name","R","O",1,{"$nulls":4},"R"]
["2010BA","NM1","","Subscriber Name","R","O",1,{"$nulls":4},"R"]
["2010BA","NM1","NM101","Entity Identifier Code","R","M",1,"ID",2,3,"IL Insured or Subscriber\n","RNS","n/a"]
["2010BA","NM1","NM102","Entity Type Qualifier","R","M",1,"ID",1,1,"1 Person\n2 Non-Person Entity","RNS","n/a"]
["2010BA","NM1","NM103","Name Last or Organization Name","R","X",1,"AN",1,60,null,"R","n/a"]
["2010BA","NM1","NM104","Name First","S","O",1,"AN",1,35,null,"S","n/a"]
["2010BA","NM1","NM105","Name Middle","S","O",1,"AN",1,25,null,"S","n/a"]
["2010BA","NM1","NM107","Name Suffix","S","O",1,"AN",1,10,null,"S","n/a"]
["2010BA","NM1","NM108","Identification Code Qualifier","S","X",1,"ID",1,2,"II Standard Unique Health Identifier for each Individual in the United States\nMI Member Identification Number","S","n/a"]
["2010BA","NM1","NM109","Identification Code","S","X",1,"AN",2,80,null,"S","n/a"]
["2010BA","N3","","Subscriber Address","S","O",1,{"$nulls":4},"S"]
["2010BA","N3","N301","Address Information","R","M",1,"AN",1,55,null,"R","n/a"]
["2010BA","N3","N302","Address Information","S","O",1,"AN",1,55,null,"S","n/a"]
["2010BA","N4","","Subscriber City, State, ZIP Code","S","O",1,{"$nulls":4},"S"]
["2010BA","N4","N401","City Name","R","O",1,"AN",2,30,null,"R","n/a"]
["2010BA","N4","N402","State or Province Code","S","X",1,"ID",2,2,null,"S","n/a"]
["2010BA","N4","N403","Postal Code","S","O",1,"ID",3,15,null,"S","n/a"]
["2010BA","N4","N404","Country Code","S","X",1,"ID",2,3,null,"S","n/a"]
["2010BA","N4","N407","Country Subdivision Code","S","X",1,"ID",1,3,null,"S","n/a"]
["2010BA","DMG","","Subscriber Demographic Information","S","O",1,{"$nulls":4},"S"]
["2010BA","DMG","DMG01","Date Time Period Format Qualifier","R","X",1,"ID",2,3,"D8 Date Expressed in Format CCYYMMDD ","RNS","n/a"]
["2010BA","DMG","DMG02","Date Time Period","R","X",1,"AN",1,35,null,"R","n/a"]
["2010BA","DMG","DMG03","Gender Code","R","O",1,"ID",1,1,"F Female\nM Male\nU Unknown ","R","n/a"]
["2010BA","REF","","Subscriber Secondary Identification","S","O",1,{"$nulls":4},"S"]
["2010BA","REF","REF01","Reference Identification Qualifier","R","M",1,"ID",2,3,"SY Social Security Number ","R","n/a"]
["2010BA","REF","REF02","Reference Identification","R","X",1,"AN",1,50,null,"R","n/a"]
["2010BA","REF","","Property and Casualty Claim Number","S","O",1,{"$nulls":4},"S"]
["2010BA","REF","REF01","Reference Identification Qualifier","R","M",1,"ID",2,3,"Y4 Agency Claim Number","RNS","n/a"]
["2010BA","REF","REF02","Reference Identification","R","X",1,"AN",1,50,null,"R","n/a"]
["2010BA","PER","","Property and Casualty Subscriber Contact Information","S","O",1,{"$nulls":4},"S"]
["2010BA","PER","PER01","Contact Function Code","R","M",1,"ID",2,2,"IC Information Contact","RNS","n/a"]
["2010BA","PER","PER02","Name","S","O",1,"AN",1,60,null,"S","n/a"]
["2010BA","PER","PER03","Communication Number Qualifier","R","X",1,"ID",2,2,"TE Telephone ","R","n/a"]
["2010BA","PER","PER04","Communication Number","R","X",1,"AN",1,256,null,"R","n/a"]
["2010BA","PER","PER05","Communication Number Qualifier","S","X",1,"ID",2,2,"EX Telephone Extension ","S","n/a"]
["2010BA","PER","PER06","Communication Number","S","X",1,"AN",1,256,null,"S","n/a"]
["2010BB",null,"","Payer Name","R","O",1,{"$nulls":4},"R"]
["2010BB","NM1","","Payer Name","R","O",1,{"$nulls":4},"R"]
["2010BB","NM1","NM101","Entity Identifier Code","R","M",1,"ID",2,3,"PR Payer\n","RNS","n/a"]
["2010BB","NM1","NM102","Entity Type Qualifier","R","M",1,"ID",1,1,"2 Non-Person Entity ","RNS","n/a"]
["2010BB","NM1","NM103","Name Last or Organization Name","R","X",1,"AN",1,60,null,"RNS","n/a"]
["2010BB","NM1","NM108","Identification Code Qualifier","R","X",1,"ID",1,2,"PI Payor Identification\nXV Centers for Medicare and Medicaid Services PlanID","RNS","n/a"]
["2010BB","NM1","NM109","Identification Code","R","X",1,"AN",2,80,null,"RNS","n/a"]
["2010BB","N3","","Payer Address","S","O",1,{"$nulls":4},"S"]
["2010BB","N3","N301","Address Information","R","M",1,"AN",1,55,null,"RNS","n/a"]
["2010BB","N3","N302","Address Information","S","O",1,"AN",1,55,null,"SNS","n/a"]
["2010BB","N4","","Payer City, State, ZIP Code","S","O",1,{"$nulls":4},"S"]
["2010BB","N4","N401","City Name","R","O",1,"AN",2,30,null,"RNS","n/a"]
["2010BB","N4","N402","State or Province Code","S","X",1,"ID",2,2,null,"SNS","n/a"]
["2010BB","N4","N403","Postal Code","S","O",1,"ID",3,15,null,"SNS","n/a"]
["2010BB","N4","N404","Country Code","S","X",1,"ID",2,3,null,"SNS","n/a"]
["2010BB","N4","N407","Country Subdivision Code","S","X",1,"ID",1,3,null,"SNS","n/a"]
["2010BB","REF","","Payer Secondary Identification","S","O",3,{"$nulls":4},"S"]
["2010BB","REF","REF01","Reference Identification Qualifier","R","M",1,"ID",2,3,"2U Payer Identification Number\nEI Employer’s Identification Number\nFY Claim Office Number\nNF national Association of Insurance Commissioners (naIC) Code","RNS","n/a"]
["2010BB","REF","REF02","Reference Identification","R","X",1,"AN",1,50,null,"RNS","n/a"]
["2010BB","REF","","Billing Provider Secondary Identification","S","O",2,{"$nulls":4},"S"]
["2010BB","REF","REF01","Reference Identification Qualifier","R","M",1,"ID",2,3,"G2 Provider Commercial Number\nLU Location Number","R","n/a"]
["2010BB","REF","REF02","Reference Identification","R","X",1,"AN",1,50,null,"R","n/a"]
["2000C",null,"","Patient Hierarchical Level","S","O",">1",{"$nulls":4},"NU"]
["2000C","HL","","Patient Hierarchical Level","S","O",1,{"$nulls":4},"NU"]
["2000C","HL","HL01","Hierarchical ID Number","R","M",1,"AN",1,12,null,"NU","n/a"]
["2000C","HL","HL02","Hierarchical Parent ID Number","R","O",1,"AN",1,12,null,"NU","n/a"]
["2000C","HL","HL03","Hierarchical Level Code","R","M",1,"ID",1,2,"23 Dependent ","NU","n/a"]
["2000C","HL","HL04","Hierarchical Child Code","R","O",1,"ID",1,1,"0 No Subordinate HL Segment in This Hierarchical Structure.\n","NU","n/a"]
["2000C","PAT","","Patient Information","R","O",1,{"$nulls":4},"NU"]
["2000C","PAT","PAT01","Individual Relationship Code","R","O",1,"ID",2,2,"01 Spouse\n19 Child\n20 Employee\n21 Unknown\n39 Organ Donor\n40 Cadaver Donor\n53 Life Partner\nG8 Other Relationship","NU","n/a"]
["2000C","PAT","PAT05","Date Time Period Format Qualifier","S","X",1,"ID",2,3,"D8 Date Expressed in Format CCYYMMDD ","NU","n/a"]
["2000C","PAT","PAT06","Date Time Period","S","X",1,"AN",1,35,null,"NU","n/a"]
["2000C","PAT","PAT07","Unit or Basis for Measurement Code","S","X",1,"ID",2,2,"01 Actual Pounds ","NU","n/a"]
["2000C","PAT","PAT08","Weight","S","X",1,"R",1,10,null,"NU","n/a"]
["2000C","PAT","PAT09","Yes/No Condition or Response Code","S","O",1,"ID",1,1,"Y Yes\n","NU","n/a"]
["2010CA",null,"","Patient Name","R","O",1,{"$nulls":4},"NU"]
["2010CA","NM1","","Patient Name","R","O",1,{"$nulls":4},"NU"]
["2010CA","NM1","NM101","Entity Identifier Code","R","M",1,"ID",2,3,"QC Patient ","NU","n/a"]
["2010CA","NM1","NM102","Entity Type Qualifier","R","M",1,"ID",1,1,"1 Person\n","NU","n/a"]
["2010CA","NM1","NM103","Name Last or Organization Name","R","X",1,"AN",1,60,null,"NU","n/a"]
["2010CA","NM1","NM104","Name First","S","O",1,"AN",1,35,null,"NU","n/a"]
["2010CA","NM1","NM105","Name Middle","S","O",1,"AN",1,25,null,"NU","n/a"]
["2010CA","NM1","NM107","Name Suffix","S","O",1,"AN",1,10,null,"NU","n/a"]
["2010CA","N3","","Patient Address","R","O",1,{"$nulls":4},"NU"]
["2010CA","N3","N301","Address Information","R","M",1,"AN",1,55,null,"NU","n/a"]
["2010CA","N3","N302","Address Information","S","O",1,"AN",1,55,null,"NU","n/a"]
["2010CA","N4","","Patient City, State, ZIP Code","R","O",1,{"$nulls":4},"NU"]
["2010CA","N4","N401","City Name","R","O",1,"AN",2,30,null,"NU","n/a"]
["2010CA","N4","N402","State or Province Code","S","X",1,"ID",2,2,null,"NU","n/a"]
["2010CA","N4","N403","Postal Code","S","O",1,"ID",3,15,null,"NU","n/a"]
["2010CA","N4","N404","Country Code","S","X",1,"ID",2,3,null,"NU","n/a"]
["2010CA","N4","N407","Country Subdivision Code","S","X",1,"ID",1,3,null,"NU","n/a"]
["2010CA","DMG","","Patient Demographic Information","R","O",1,{"$nulls":4},"NU"]
["2010CA","DMG","DMG01","Date Time Period Format Qualifier","R","X",1,"ID",2,3,"D8 Date Expressed in Format CCYYMMDD ","NU","n/a"]
["2010CA","DMG","DMG02","Date Time Period","R","X",1,"AN",1,35,null,"NU","n/a"]
["2010CA","DMG","DMG03","Gender Code","R","O",1,"ID",1,1,"F Female\nM Male\nU Unknow","NU","n/a"]
["2010CA","REF","","Property and Casualty Claim Number","S","O",1,{"$nulls":4},"NU"]
["2010CA","REF","REF01","Reference Identification Qualifier","R","M",1,"ID",2,3,"Y4 Agency Claim Number ","NU","n/a"]
["2010CA","REF","REF02","Reference Identification","R","X",1,"AN",1,50,null,"NU","n/a"]
["2010CA","REF","","Property and Casualty Patient Identifier","S","O",1,{"$nulls":4},"NU"]
["2010CA","REF","REF01","Reference Identification Qualifier","R","M",1,"ID",2,3,"1W Member Identification Number \nSY Social Security Number","NU","n/a"]
["2010CA","REF","REF02","Reference Identification","R","X",1,"AN",1,50,null,"NU","n/a"]
["2010CA","PER","","Property and Casualty Patient Contact Information","S","O",1,{"$nulls":4},"NU"]
["2010CA","PER","PER01","Contact Function Code","R","M",1,"ID",2,2,"IC Information Contact ","NU","n/a"]
["2010CA","PER","PER02","Name","S","O",1,"AN",1,60,null,"NU","n/a"]
["2010CA","PER","PER03","Communication Number Qualifier","R","X",1,"ID",2,2,"TE Telephone ","NU","n/a"]
["2010CA","PER","PER04","Communication Number","R","X",1,"AN",1,256,null,"NU","n/a"]
["2010CA","PER","PER05","Communication Number Qualifier","S","X",1,"ID",2,2,"EX Telephone Extension ","NU","n/a"]
["2010CA","PER","PER06","Communication Number","S","X",1,"AN",1,256,null,"NU","n/a"]
[2300,null,"","Claim Information","R","O",100,{"$nulls":4},"R"]
[2300,"CLM","","Claim Information","R","O",1,{"$nulls":4},"R"]
[2300,"CLM","CLM01","Claim Submitter's Identifier","R","M",1,"AN",1,38,null,"R","n/a"]
[2300,"CLM","CLM02","Monetary Amount","R","O",1,"R",1,18,null,"R","n/a"]
[2300,"CLM","CLM05","Health Care Service Location Information","R","O",1,{"$nulls":4},"R"]
[2300,"CLM","CLM05-1","Facility Code Value","R","M",1,"AN",1,2,null,"R","n/a"]
[2300,"CLM","CLM05-2","Facility Code Qualifier","R","O",null,"ID",1,2,"B Place of Service Codes for Professional or Dental Services\n","R","\"B\""]
[2300,"CLM","CLM05-3","Claim Frequency Type Code","R","O",1,"ID",1,1,null,"R","n/a"]
[2300,"CLM","CLM06","Yes/No Condition or Response Code","R","O",1,"ID",1,1,"N No\nY Yes","R","n/a"]
[2300,"CLM","CLM07","Provider Accept Assignment Code","R","O",1,"ID",1,1,"A Assigned\nB Assignment Accepted on Clinical Lab Services Only\nC Not Assigned","R","n/a"]
[2300,"CLM","CLM08","Yes/No Condition or Response Code","R","O",1,"ID",1,1,"N No\nW Not Applicable\nY Yes\n","R","n/a"]
[2300,"CLM","CLM09","Release of Information Code","R","O",1,"ID",1,1,"I Informed Consent to Release Medical Information for Conditions or Diagnoses Regulated by Federal Statutes\nY Yes, Provider has a Signed Statement Permitting Release of Medical Billing Data Related to a Claim","R","n/a"]
[2300,"CLM","CLM10","Patient Signature Source Code","S","O",1,"ID",1,1,"P Signature generated by provider because the patient was not physically present for services","S","n/a"]
[2300,"CLM","CLM11","Related Causes Information","S","O",1,{"$nulls":4},"S"]
[2300,"CLM","CLM11-1","Related-Causes Code","R","M",1,"ID",2,3,"AA Auto Accident\nEM Employment\nOA Other Accident\n","R","n/a"]
[2300,"CLM","CLM11-2","Related-Causes Code","S","O",1,"ID",2,3,"AA Auto Accident\nEM Employment\nOA Other Accident\n","S","n/a"]
[2300,"CLM","CLM11-4","State or Province Code","S","O",1,"ID",2,2,null,"S","n/a"]
[2300,"CLM","CLM11-5","Country Code","S","O",1,"ID",2,3,null,"S","n/a"]
[2300,"CLM","CLM12","Special Program Code","S","O",1,"ID",2,3,"02 Physically Handicapped Children’s Program\n03 Special Federal Funding \n05 Disability \n09 Second Opinion or Surgery ","S","n/a"]
[2300,"CLM","CLM20","Delay Reason Code","S","O",1,"ID",1,2,"1 Proof of Eligibility Unknown or Unavailable\n2 Litigation\n3 Authorization Delays\n4 Delay in Certifying Provider\n5 Delay in Supplying Billing Forms\n6 Delay in Delivery of Custom-made Appliances\n7 Third Party Processing Delay\n8 Delay in Eligibility Determination\n9 Original Claim Rejected or Denied Due to a Reason Unrelated to the Billing Limitation Rules\n10 Administration Delay in the Prior Approval Process\n11 Other\n15 natural Disaster\n","S","n/a"]
[2300,"DTP","","Date - Onset of Current Illness or Symptom","S","O",1,{"$nulls":4},"S"]
[2300,"DTP","DTP01","Date/Time Qualifier","R","M",1,"ID",3,3,"431 Onset of Current Symptoms or Illness","RNS","n/a"]
[2300,"DTP","DTP02","Date Time Period Format Qualifier","R","M",1,"ID",2,3,"D8 Date Expressed in Format CCYYMMDD ","RNS","n/a"]
[2300,"DTP","DTP03","Date Time Period","R","M",1,"AN",1,35,null,"R","n/a"]
[2300,"DTP","","Date - Initial Treatment Date","S","O",1,{"$nulls":4},"S"]
[2300,"DTP","DTP01","Date/Time Qualifier","R","M",1,"ID",3,3,"454 Initial Treatment ","RNS","n/a"]
[2300,"DTP","DTP02","Date Time Period Format Qualifier","R","M",1,"ID",2,3,"D8 Date Expressed in Format CCYYMMDD ","RNS","n/a"]
[2300,"DTP","DTP03","Date Time Period","R","M",1,"AN",1,35,null,"R","n/a"]
[2300,"DTP","","Date - Last Seen Date","S","O",1,{"$nulls":4},"S"]
[2300,"DTP","DTP01","Date/Time Qualifier","R","M",1,"ID",3,3,"304 Latest Visit or Consultation ","RNS","n/a"]
[2300,"DTP","DTP02","Date Time Period Format Qualifier","R","M",1,"ID",2,3,"D8 Date Expressed in Format CCYYMMDD ","RNS","n/a"]
[2300,"DTP","DTP03","Date Time Period","R","M",1,"AN",1,35,null,"R","n/a"]
[2300,"DTP","","Date - Acute Manifestation","S","O",1,{"$nulls":4},"S"]
[2300,"DTP","DTP01","Date/Time Qualifier","R","M",1,"ID",3,3,"453 Acute Manifestation of a Chronic Condition ","RNS","n/a"]
[2300,"DTP","DTP02","Date Time Period Format Qualifier","R","M",1,"ID",2,3,"D8 Date Expressed in Format CCYYMMDD ","RNS","n/a"]
[2300,"DTP","DTP03","Date Time Period","R","M",1,"AN",1,35,null,"R","n/a"]
[2300,"DTP","","Date - Accident","S","O",1,{"$nulls":4},"S"]
[2300,"DTP","DTP01","Date/Time Qualifier","R","M",1,"ID",3,3,"439 Accident ","RNS","n/a"]
[2300,"DTP","DTP02","Date Time Period Format Qualifier","R","M",1,"ID",2,3,"D8 Date Expressed in Format CCYYMMDD ","RNS","n/a"]
[2300,"DTP","DTP03","Date Time Period","R","M",1,"AN",1,35,"CCYYMMDD","R","n/a"]
[2300,"DTP","","Date - Last Menstrual Period","S","O",1,{"$nulls":4},"S"]
[2300,"DTP","DTP01","Date/Time Qualifier","R","M",1,"ID",3,3,"484 Last Menstrual Period ","RNS","n/a"]
[2300,"DTP","DTP02","Date Time Period Format Qualifier","R","M",1,"ID",2,3,"D8 Date Expressed in Format CCYYMMDD ","RNS","n/a"]
[2300,"DTP","DTP03","Date Time Period","R","M",1,"AN",1,35,null,"R","n/a"]
[2300,"DTP","","Date - Last X-ray Date","S","O",1,{"$nulls":4},"S"]
[2300,"DTP","DTP01","Date/Time Qualifier","R","M",1,"ID",3,3,"455 Last X-Ray ","RNS","n/a"]
[2300,"DTP","DTP02","Date Time Period Format Qualifier","R","M",1,"ID",2,3,"D8 Date Expressed in Format CCYYMMDD ","RNS","n/a"]
[2300,"DTP","DTP03","Date Time Period","R","M",1,"AN",1,35,null,"R","n/a"]
[2300,"DTP","","Date - Hearing and Vision Prescription Date","S","O",1,{"$nulls":4},"S"]
[2300,"DTP","DTP01","Date/Time Qualifier","R","M",1,"ID",3,3,"471 Prescription ","RNS","n/a"]
[2300,"DTP","DTP02","Date Time Period Format Qualifier","R","M",1,"ID",2,3,"D8 Date Expressed in Format CCYYMMDD ","RNS","n/a"]
[2300,"DTP","DTP03","Date Time Period","R","M",1,"AN",1,35,null,"R","n/a"]
[2300,"DTP","","Date - Disability Dates","S","O",1,{"$nulls":4},"S"]
[2300,"DTP","DTP01","Date/Time Qualifier","R","M",1,"ID",3,3,"314 Disability \n360 Initial Disability Period Start \n361 Initial Disability Period End ","RNS","n/a"]
[2300,"DTP","DTP02","Date Time Period Format Qualifier","R","M",1,"ID",2,3,"D8 Date Expressed in Format CCYYMMDD \nRD8 Range of Dates Expressed in Format CCYYMMDDCCYYMMDD ","RNS","n/a"]
[2300,"DTP","DTP03","Date Time Period","R","M",1,"AN",1,35,null,"R","n/a"]
[2300,"DTP","","Date - Last Worked","S","O",1,{"$nulls":4},"S"]
[2300,"DTP","DTP01","Date/Time Qualifier","R","M",1,"ID",3,3,"297 Initial Disability Period Last Day Worked ","RNS","n/a"]
[2300,"DTP","DTP02","Date Time Period Format Qualifier","R","M",1,"ID",2,3,"D8 Date Expressed in Format CCYYMMDD ","RNS","n/a"]
[2300,"DTP","DTP03","Date Time Period","R","M",1,"AN",1,35,null,"R","n/a"]
[2300,"DTP","","Date - Authorized Return to Work","S","O",1,{"$nulls":4},"S"]
[2300,"DTP","DTP01","Date/Time Qualifier","R","M",1,"ID",3,3,"296 Initial Disability Period Return To Work ","RNS","n/a"]
[2300,"DTP","DTP02","Date Time Period Format Qualifier","R","M",1,"ID",2,3,"D8 Date Expressed in Format CCYYMMDD ","RNS","n/a"]
[2300,"DTP","DTP03","Date Time Period","R","M",1,"AN",1,35,null,"R","n/a"]
[2300,"DTP","","Date - Admission","S","O",1,{"$nulls":4},"S"]
[2300,"DTP","DTP01","Date/Time Qualifier","R","M",1,"ID",3,3,"435 Admission ","RNS","n/a"]
[2300,"DTP","DTP02","Date Time Period Format Qualifier","R","M",1,"ID",2,3,"D8 Date Expressed in Format CCYYMMDD ","RNS","n/a"]
[2300,"DTP","DTP03","Date Time Period","R","M",1,"AN",1,35,null,"R","n/a"]
[2300,"DTP","","Date - Discharge","S","O",1,{"$nulls":4},"S"]
[2300,"DTP","DTP01","Date/Time Qualifier","R","M",1,"ID",3,3,"096 Discharge ","RNS","n/a"]
[2300,"DTP","DTP02","Date Time Period Format Qualifier","R","M",1,"ID",2,3,"D8 Date Expressed in Format CCYYMMDD ","RNS","n/a"]
[2300,"DTP","DTP03","Date Time Period","R","M",1,"AN",1,35,null,"R","n/a"]
[2300,"DTP","","Date - Assumed and Relinquished Care Dates","S","O",2,{"$nulls":4},"S"]
[2300,"DTP","DTP01","Date/Time Qualifier","R","M",1,"ID",3,3,"090 Report Start \n091 Report End ","RNS","n/a"]
[2300,"DTP","DTP02","Date Time Period Format Qualifier","R","M",1,"ID",2,3,"D8 Date Expressed in Format CCYYMMDD ","RNS","n/a"]
[2300,"DTP","DTP03","Date Time Period","R","M",1,"AN",1,35,null,"R","n/a"]
[2300,"DTP","","Property and Casualty Date of First Contact","S","O",1,{"$nulls":4},"S"]
[2300,"DTP","DTP01","Date/Time Qualifier","R","M",1,"ID",3,3,"444 First Visit or Consultation","RNS","n/a"]
[2300,"DTP","DTP02","Date Time Period Format Qualifier","R","M",1,"ID",2,3,"D8 Date Expressed in Format CCYYMMDD ","RNS","n/a"]
[2300,"DTP","DTP03","Date Time Period","R","M",1,"AN",1,35,null,"R","n/a"]
[2300,"DTP","","Date - Repricer Received Date","S","O",1,{"$nulls":4},"S"]
[2300,"DTP","DTP01","Date/Time Qualifier","R","M",1,"ID",3,3,"050 Received ","RNS","n/a"]
[2300,"DTP","DTP02","Date Time Period Format Qualifier","R","M",1,"ID",2,3,"D8 Date Expressed in Format CCYYMMDD ","RNS","n/a"]
[2300,"DTP","DTP03","Date Time Period","R","M",1,"AN",1,35,null,"R","n/a"]
[2300,"PWK","","Claim Supplemental Information","S","O",10,{"$nulls":4},"S"]
[2300,"PWK","PWK01","Report Type Code","R","M",1,"ID",2,2,"03 Report Justifying Treatment Beyond Utilization\nGuidelines\n04 Drugs Administered\n05 Treatment Diagnosis\n06 Initial Assessment\n07 Functional Goals\n08 Plan of Treatment\n09 Progress Report\n10 Continued Treatment\n11 Chemical Analysis\n13 Certified Test Report\n15 Justification for Admission\n21 Recovery Plan\nA3 Allergies/Sensitivities Document\nA4 Autopsy Report\nAM Ambulance Certification\nAS Admission Summary\nB2 Prescription\nB3 Physician Order\nB4 Referral Form\nBR Benchmark Testing Results\nBS Baseline\nBT Blanket Test Results\nCB Chiropractic Justification\nCK Consent Form(s)\nCT Certification\nD2 Drug Profile Document\nDA Dental Models\nDB Durable Medical Equipment Prescription\nDG Diagnostic Report\nDJ Discharge Monitoring Report\nDS Discharge Summary\nEB Explanation of Benefits (Coordination of Benefits or\nMedicare Secondary Payor)\nHC Health Certificate\nHR Health Clinic Records\nI5 Immunization Record\nIR State School Immunization Records\nLA Laboratory Results\nM1 Medical Record Attachment\nMT Models\nNN Nursing Notes\nOB Operative Note\nOC Oxygen Content Averaging Report\nOD Orders and Treatments Document\nOE Objective Physical Examination (including vital\nsigns) Document\nOX Oxygen Therapy Certification\nOZ Support Data for Claim\nP4 Pathology Report\nP5 Patient Medical History Document\nPE Parenteral or Enteral Certification\nPN Physical Therapy Notes\nPO Prosthetics or Orthotic Certification\nPQ Paramedical Results\nPY Physician’s Report\nPZ Physical Therapy Certification\nRB Radiology Films\nRR Radiology Reports\nRT Report of Tests and Analysis Report\nRX Renewable Oxygen Content Averaging Report\nSG Symptoms Document\nV5 Death Notification\nXP Photographs","R","n/a"]
[2300,"PWK","PWK02","Report Transmission Code","R","O",1,"ID",1,2,"AA Available on Request at Provider Site\nBM By Mail\nEL Electronically Only \nEM E-Mail\nFT File Transfer \nFX By Fax ","R","n/a"]
[2300,"PWK","PWK05","Identification Code Qualifier","S","X",1,"ID",1,2,"AC Attachment Control Number ","S","n/a"]
[2300,"PWK","PWK06","Identification Code","S","X",1,"AN",2,80,null,"S","n/a"]
[2300,"CN1","","Contract Information","S","O",1,{"$nulls":4},"S"]
[2300,"CN1","CN101","Contract Type Code","R","M",1,"ID",2,2,"01 Diagnosis Related Group (DRG)\n02 Per Diem\n03 Variable Per Diem\n04 Flat\n05 Capitated\n06 Percent\n09 Other ","R","n/a"]
[2300,"CN1","CN102","Monetary Amount","S","O",1,"R",1,18,null,"S","n/a"]
[2300,"CN1","CN103","Percent, Decimal Format","S","O",1,"R",1,6,null,"S","n/a"]
[2300,"CN1","CN104","Reference Identification","S","O",1,"AN",1,50,null,"S","n/a"]
[2300,"CN1","CN105","Terms Discount Percent","S","O",1,"R",1,6,null,"S","n/a"]
[2300,"CN1","CN106","Version Identifier","S","O",1,"AN",1,30,null,"S","n/a"]
[2300,"AMT","","Patient Amount Paid","S","O",1,{"$nulls":4},"S"]
[2300,"AMT","AMT01","Amount Qualifier Code","R","M",1,"ID",1,3,"F5 Patient Amount Paid","RNS","n/a"]
[2300,"AMT","AMT02","Monetary Amount","R","M",1,"R",1,18,null,"R","n/a"]
[2300,"REF","","Service Authorization Exception Code","S","O",1,{"$nulls":4},"S"]
[2300,"REF","REF01","Reference Identification Qualifier","R","M",1,"ID",2,3,"4N Special Payment Reference Number ","RNS","n/a"]
[2300,"REF","REF02","Reference Identification","R","X",1,"AN",1,50,"1 Immediate/Urgent Care \n2 Services Rendered in a Retroactive Period \n3 Emergency Care \n4 Client has Temporary Medicaid \n5 Request from County for Second Opinion to Determine if Recipient Can Work \n6 Request for Override Pending \n7 Special Handling\n","R","n/a"]
[2300,"REF","","Mandatory Medicare (Section 4081) Crossover Indicator","S","O",1,{"$nulls":4},"S"]
[2300,"REF","REF01","Reference Identification Qualifier","R","M",1,"ID",2,3,"F5 Medicare Version Code ","RNS","n/a"]
[2300,"REF","REF02","Reference Identification","R","X",1,"AN",1,50,"Y 4081 \nN Regular crossover","R","n/a"]
[2300,"REF","","Mammography Certification Number","S","O",1,{"$nulls":4},"S"]
[2300,"REF","REF01","Reference Identification Qualifier","R","M",1,"ID",2,3,"EW Mammography Certification Number ","RNS","n/a"]
[2300,"REF","REF02","Reference Identification","R","X",1,"AN",1,50,null,"R","n/a"]
[2300,"REF","","Referral Number","S","O",1,{"$nulls":4},"S"]
[2300,"REF","REF01","Reference Identification Qualifier","R","M",1,"ID",2,3,"9F Referral Number ","RNS","n/a"]
[2300,"REF","REF02","Reference Identification","R","X",1,"AN",1,50,null,"R","n/a"]
[2300,"REF","","Prior Authorization","S","O",1,{"$nulls":4},"S"]
[2300,"REF","REF01","Reference Identification Qualifier","R","M",1,"ID",2,3,"G1 Prior Authorization Number\n","RNS","n/a"]
[2300,"REF","REF02","Reference Identification","R","X",1,"AN",1,50,null,"R","n/a"]
[2300,"REF","","Payer Claim Control Number","S","O",1,{"$nulls":4},"S"]
[2300,"REF","REF01","Reference Identification Qualifier","R","M",1,"ID",2,3,"F8 Original Reference Number ","RNS","n/a"]
[2300,"REF","REF02","Reference Identification","R","X",1,"AN",1,50,null,"R","n/a"]
[2300,"REF","","Clinical Laboratory Improvement Amendment (CLIA) Number","S","O",1,{"$nulls":4},"S"]
[2300,"REF","REF01","Reference Identification Qualifier","R","M",1,"ID",2,3,"X4 Clinical Laboratory Improvement Amendment Number\n","RNS","n/a"]
[2300,"REF","REF02","Reference Identification","R","X",1,"AN",1,50,null,"R","n/a"]
[2300,"REF","","Repriced Claim Number","S","O",1,{"$nulls":4},"S"]
[2300,"REF","REF01","Reference Identification Qualifier","R","M",1,"ID",2,3,"9A  Repriced Claim Reference Number","RNS","n/a"]
[2300,"REF","REF02","Reference Identification","R","X",1,"AN",1,50,null,"R","n/a"]
[2300,"REF","","Adjusted Repriced Claim Number","S","O",1,{"$nulls":4},"S"]
[2300,"REF","REF01","Reference Identification Qualifier","R","M",1,"ID",2,3,"9C Adjusted Repriced Claim Reference Number ","RNS","n/a"]
[2300,"REF","REF02","Reference Identification","R","X",1,"AN",1,50,null,"R","n/a"]
[2300,"REF","","Investigational Device Exemption Number","S","O",1,{"$nulls":4},"S"]
[2300,"REF","REF01","Reference Identification Qualifier","R","M",1,"ID",2,3,"LX Qualified Products List ","RNS","n/a"]
[2300,"REF","REF02","Reference Identification","R","X",1,"AN",1,50,null,"R","n/a"]
[2300,"REF","","Claim Identifier For Transmission Intermediaries","S","O",1,{"$nulls":4},"S"]
[2300,"REF","REF01","Reference Identification Qualifier","R","M",1,"ID",2,3,"D9 Claim Number\n","RNS","n/a"]
[2300,"REF","REF02","Reference Identification","R","X",1,"AN",1,50,null,"R","n/a"]
[2300,"REF","","Medical Record Number","S","O",1,{"$nulls":4},"S"]
[2300,"REF","REF01","Reference Identification Qualifier","R","M",1,"ID",2,3,"EA Medical Record Identification Number","RNS","n/a"]
[2300,"REF","REF02","Reference Identification","R","X",1,"AN",1,50,null,"R","n/a"]
[2300,"REF","","Demonstration Project Identifier","S","O",1,{"$nulls":4},"S"]
[2300,"REF","REF01","Reference Identification Qualifier","R","M",1,"ID",2,3,"P4 Project Code ","RNS","n/a"]
[2300,"REF","REF02","Reference Identification","R","X",1,"AN",1,50,null,"R","n/a"]
[2300,"REF","","Care Plan Oversight","S","O",1,{"$nulls":4},"S"]
[2300,"REF","REF01","Reference Identification Qualifier","R","M",1,"ID",2,3,"1J Facility ID Number ","RNS","n/a"]
[2300,"REF","REF02","Reference Identification","R","X",1,"AN",1,50,null,"R","n/a"]
[2300,"K3","","File Information","S","O",10,{"$nulls":4},"S"]
[2300,"K3","K301","Fixed Format Information","R","M",1,"AN",1,80,null,"R","n/a"]
[2300,"NTE","","Claim Note","S","O",1,{"$nulls":4},"S"]
[2300,"NTE","NTE01","Note Reference Code","R","O",1,"ID",3,3,"ADD Additional Information\nCER Certification narrative\nDCP Goals, Rehabilitation Potential, or Discharge Plan\nDGN Diagnosis Description\nTPO Third Party Organization Notes","R","n/a"]
[2300,"NTE","NTE02","Description","R","M",1,"AN",1,80,null,"R","n/a"]
[2300,"CR1","","Ambulance Transport Information","S","O",1,{"$nulls":4},"S"]
[2300,"CR1","CR101","Unit or Basis for Measurement Code","S","X",1,"ID",2,2,"LB Pound ","S","n/a"]
[2300,"CR1","CR102","Weight","S","X",1,"R",1,10,null,"S","n/a"]
[2300,"CR1","CR104","Ambulance Transport Reason Code","R","O",1,"ID",1,1,"A Patient was transported to nearest facility for care of symptoms, complaints, or both\nB Patient was transported for the benefit of a preferred physician\nC Patient was transported for the nearness of family members\nD Patient was transported for the care of a specialist or for availability of specialized equipment\nE Patient Transferred to Rehabilitation Facility ","R","n/a"]
[2300,"CR1","CR105","Unit or Basis for Measurement Code","R","X",1,"ID",2,2,"DH Miles\n","R","n/a"]
[2300,"CR1","CR106","Quantity","R","X",1,"R",1,15,null,"R","n/a"]
[2300,"CR1","CR109","Description","S","O",1,"AN",1,80,null,"S","n/a"]
[2300,"CR1","CR110","Description","S","O",1,"AN",1,80,null,"S","n/a"]
[2300,"CR2","","Spinal Manipulation Service Information","S","O",1,{"$nulls":4},"S"]
[2300,"CR2","CR208","Nature of Condition Code","R","O",1,"ID",1,1,"A Acute Condition\nC Chronic Condition\nD Non-acute\nE Non-Life Threatening\nF Routine\nG Symptomatic\nM Acute Manifestation of a Chronic Condition ","R","n/a"]
[2300,"CR2","CR210","Description","S","O",1,"AN",1,80,null,"S","n/a"]
[2300,"CR2","CR211","Description","S","O",1,"AN",1,80,null,"S","n/a"]
[2300,"CRC","","Ambulance Certification","S","O",3,{"$nulls":4},"S"]
[2300,"CRC","CRC01","Code Category","R","M",1,"ID",2,2,"07 Ambulance Certification\n","RNS","n/a"]
[2300,"CRC","CRC02","Yes/No Condition or Response Code","R","M",1,"ID",1,1,"N No\nY Yes ","R","n/a"]
[2300,"CRC","CRC03","Condition Indicator","R","M",1,"ID",2,3,"01 Patient was admitted to a hospital\n04 Patient was moved by stretcher\n05 Patient was unconscious or in shock\n06 Patient was transported in an emergency situation\n07 Patient had to be physically restrained\n08 Patient had visible hemorrhaging\n09 Ambulance service was medically necessary\n12 Patient is confined to a bed or chair ","R","n/a"]
[2300,"CRC","CRC04","Condition Indicator","S","O",1,"ID",2,3,"01 Patient was admitted to a hospital\n04 Patient was moved by stretcher\n05 Patient was unconscious or in shock\n06 Patient was transported in an emergency situation\n07 Patient had to be physically restrained\n08 Patient had visible hemorrhaging\n09 Ambulance service was medically necessary\n12 Patient is confined to a bed or chair ","S","n/a"]
[2300,"CRC","CRC05","Condition Indicator","S","O",1,"ID",2,3,"01 Patient was admitted to a hospital\n04 Patient was moved by stretcher\n05 Patient was unconscious or in shock\n06 Patient was transported in an emergency situation\n07 Patient had to be physically restrained\n08 Patient had visible hemorrhaging\n09 Ambulance service was medically necessary\n12 Patient is confined to a bed or chair ","S","n/a"]
[2300,"CRC","CRC06","Condition Indicator","S","O",1,"ID",2,3,"01 Patient was admitted to a hospital\n04 Patient was moved by stretcher\n05 Patient was unconscious or in shock\n06 Patient was transported in an emergency situation\n07 Patient had to be physically restrained\n08 Patient had visible hemorrhaging\n09 Ambulance service was medically necessary\n12 Patient is confined to a bed or chair ","S","n/a"]
[2300,"CRC","CRC07","Condition Indicator","S","O",1,"ID",2,3,"01 Patient was admitted to a hospital\n04 Patient was moved by stretcher\n05 Patient was unconscious or in shock\n06 Patient was transported in an emergency situation\n07 Patient had to be physically restrained\n08 Patient had visible hemorrhaging\n09 Ambulance service was medically necessary\n12 Patient is confined to a bed or chair ","S","n/a"]
[2300,"CRC","","Patient Condition Information: Vision","S","O",3,{"$nulls":4},"S"]
[2300,"CRC","CRC01","Code Category","R","M",1,"ID",2,2,"E1 Spectacle Lenses\nE2 Contact Lenses\nE3 Spectacle Frames ","R","n/a"]
[2300,"CRC","CRC02","Yes/No Condition or Response Code","R","M",1,"ID",1,1,"N No\nY Yes\n","R","n/a"]
[2300,"CRC","CRC03","Condition Indicator","R","M",1,"ID",2,3,"L1 General Standard of 20 Degree or .5 Diopter Sphere or Cylinder Change Met\nL2 Replacement Due to Loss or Theft\nL3 Replacement Due to Breakage or Damage\nL4 Replacement Due to Patient Preference\nL5 Replacement Due to Medical Reason ","R","n/a"]
[2300,"CRC","CRC04","Condition Indicator","S","O",1,"ID",2,3,"L1 General Standard of 20 Degree or .5 Diopter Sphere or Cylinder Change Met\nL2 Replacement Due to Loss or Theft\nL3 Replacement Due to Breakage or Damage\nL4 Replacement Due to Patient Preference\nL5 Replacement Due to Medical Reason ","S","n/a"]
[2300,"CRC","CRC05","Condition Indicator","S","O",1,"ID",2,3,"L1 General Standard of 20 Degree or .5 Diopter Sphere or Cylinder Change Met\nL2 Replacement Due to Loss or Theft\nL3 Replacement Due to Breakage or Damage\nL4 Replacement Due to Patient Preference\nL5 Replacement Due to Medical Reason ","S","n/a"]
[2300,"CRC","CRC06","Condition Indicator","S","O",1,"ID",2,3,"L1 General Standard of 20 Degree or .5 Diopter Sphere or Cylinder Change Met\nL2 Replacement Due to Loss or Theft\nL3 Replacement Due to Breakage or Damage\nL4 Replacement Due to Patient Preference\nL5 Replacement Due to Medical Reason ","S","n/a"]
[2300,"CRC","CRC07","Condition Indicator","S","O",1,"ID",2,3,"L1 General Standard of 20 Degree or .5 Diopter Sphere or Cylinder Change Met\nL2 Replacement Due to Loss or Theft\nL3 Replacement Due to Breakage or Damage\nL4 Replacement Due to Patient Preference\nL5 Replacement Due to Medical Reason ","S","n/a"]
[2300,"CRC","","Homebound Indicator","S","O",1,{"$nulls":4},"S"]
[2300,"CRC","CRC01","Code Category","R","M",1,"ID",2,2,"75 Functional Limitations ","R","n/a"]
[2300,"CRC","CRC02","Yes/No Condition or Response Code","R","M",1,"ID",1,1,"Y Yes\n","R","n/a"]
[2300,"CRC","CRC03","Condition Indicator","R","M",1,"ID",2,3,"IH Independent at Home ","R","n/a"]
[2300,"CRC","","EPSDT Referral","S","O",1,{"$nulls":4},"S"]
[2300,"CRC","CRC01","Code Category","R","M",1,"ID",2,2,"ZZ Mutually Defined ","R","n/a"]
[2300,"CRC","CRC02","Yes/No Condition or Response Code","R","M",1,"ID",1,1,"N No \nY Yes ","R","n/a"]
[2300,"CRC","CRC03","Condition Indicator","R","M",1,"ID",2,3,"AV Available - Not Used \nNU Not Used\nS2 Under Treatment\nST New Services Requested","R","n/a"]
[2300,"CRC","CRC04","Condition Indicator","S","O",1,"ID",2,3,"AV Available - Not Used \nNU Not Used\nS2 Under Treatment\nST New Services Requested","S","n/a"]
[2300,"CRC","CRC05","Condition Indicator","S","O",1,"ID",2,3,"AV Available - Not Used \nNU Not Used\nS2 Under Treatment\nST New Services Requested","S","n/a"]
[2300,"HI","","Health Care Diagnosis Code","R","O",1,{"$nulls":4},"R"]
[2300,"HI","HI01","Health Care Code Information","R","M",1,{"$nulls":4},"R"]
[2300,"HI","HI01-1","Code List Qualifier Code","R","M",1,"ID",1,3,"BK International Classification of Diseases Clinical Modification (ICD-9-CM) Principal Diagnosis\nABK International Classification of Diseases Clinical Modification (ICD-10-CM) Principal Diagnosis ","RNS","n/a"]
[2300,"HI","HI01-2","Industry Code","R","M",1,"AN",1,30,null,"R","n/a"]
[2300,"HI","HI02","Health Care Code Information","S","O",1,{"$nulls":4},"S"]
[2300,"HI","HI02-1","Code List Qualifier Code","R","M",1,"ID",1,3,"BF International Classification of Diseases Clinical Modification (ICD-9-CM) Diagnosis\nABF International Classification of Diseases Clinical Modification (ICD-10-CM) Diagnosis","RNS","n/a"]
[2300,"HI","HI02-2","Industry Code","R","M",1,"AN",1,30,null,"R","n/a"]
[2300,"HI","HI03","Health Care Code Information","S","O",1,{"$nulls":4},"S"]
[2300,"HI","HI03-1","Code List Qualifier Code","R","M",1,"ID",1,3,"BF International Classification of Diseases Clinical Modification (ICD-9-CM) Diagnosis\nABF International Classification of Diseases Clinical Modification (ICD-10-CM) Diagnosis","RNS","n/a"]
[2300,"HI","HI03-2","Industry Code","R","M",1,"AN",1,30,null,"R","n/a"]
[2300,"HI","HI04","Health Care Code Information","S","O",1,{"$nulls":4},"S"]
[2300,"HI","HI04-1","Code List Qualifier Code","R","M",1,"ID",1,3,"BF International Classification of Diseases Clinical Modification (ICD-9-CM) Diagnosis\nABF International Classification of Diseases Clinical Modification (ICD-10-CM) Diagnosis","RNS","n/a"]
[2300,"HI","HI04-2","Industry Code","R","M",1,"AN",1,30,null,"R","n/a"]
[2300,"HI","HI05","Health Care Code Information","S","O",1,{"$nulls":4},"S"]
[2300,"HI","HI05-1","Code List Qualifier Code","R","M",1,"ID",1,3,"BF International Classification of Diseases Clinical Modification (ICD-9-CM) Diagnosis\nABF International Classification of Diseases Clinical Modification (ICD-10-CM) Diagnosis","RNS","n/a"]
[2300,"HI","HI05-2","Industry Code","R","M",1,"AN",1,30,null,"R","n/a"]
[2300,"HI","HI06","Health Care Code Information","S","O",1,{"$nulls":4},"S"]
[2300,"HI","HI06-1","Code List Qualifier Code","R","M",1,"ID",1,3,"BF International Classification of Diseases Clinical Modification (ICD-9-CM) Diagnosis\nABF International Classification of Diseases Clinical Modification (ICD-10-CM) Diagnosis","RNS","n/a"]
[2300,"HI","HI06-2","Industry Code","R","M",1,"AN",1,30,null,"R","n/a"]
[2300,"HI","HI07","Health Care Code Information","S","O",1,{"$nulls":4},"S"]
[2300,"HI","HI07-1","Code List Qualifier Code","R","M",1,"ID",1,3,"BF International Classification of Diseases Clinical Modification (ICD-9-CM) Diagnosis\nABF International Classification of Diseases Clinical Modification (ICD-10-CM) Diagnosis","RNS","n/a"]
[2300,"HI","HI07-2","Industry Code","R","M",1,"AN",1,30,null,"R","n/a"]
[2300,"HI","HI08","Health Care Code Information","S","O",1,{"$nulls":4},"S"]
[2300,"HI","HI08-1","Code List Qualifier Code","R","M",1,"ID",1,3,"BF International Classification of Diseases Clinical Modification (ICD-9-CM) Diagnosis\nABF International Classification of Diseases Clinical Modification (ICD-10-CM) Diagnosis","RNS","n/a"]
[2300,"HI","HI08-2","Industry Code","R","M",1,"AN",1,30,null,"R","n/a"]
[2300,"HI","HI09","Health Care Code Information","S","O",1,{"$nulls":4},"S"]
[2300,"HI","HI09-1","Code List Qualifier Code","R","M",1,"ID",1,3,"BF International Classification of Diseases Clinical Modification (ICD-9-CM) Diagnosis\nABF International Classification of Diseases Clinical Modification (ICD-10-CM) Diagnosis","RNS","n/a"]
[2300,"HI","HI09-2","Industry Code","R","M",1,"AN",1,30,null,"R","n/a"]
[2300,"HI","HI10","Health Care Code Information","S","O",1,{"$nulls":4},"S"]
[2300,"HI","HI10-1","Code List Qualifier Code","R","M",1,"ID",1,3,"BF International Classification of Diseases Clinical Modification (ICD-9-CM) Diagnosis\nABF International Classification of Diseases Clinical Modification (ICD-10-CM) Diagnosis","RNS","n/a"]
[2300,"HI","HI10-2","Industry Code","R","M",1,"AN",1,30,null,"R","n/a"]
[2300,"HI","HI11","Health Care Code Information","S","O",1,{"$nulls":4},"S"]
[2300,"HI","HI11-1","Code List Qualifier Code","R","M",1,"ID",1,3,"BF International Classification of Diseases Clinical Modification (ICD-9-CM) Diagnosis\nABF International Classification of Diseases Clinical Modification (ICD-10-CM) Diagnosis","RNS","n/a"]
[2300,"HI","HI11-2","Industry Code","R","M",1,"AN",1,30,null,"R","n/a"]
[2300,"HI","HI12","Health Care Code Information","S","O",1,{"$nulls":4},"S"]
[2300,"HI","HI12-1","Code List Qualifier Code","R","M",1,"ID",1,3,"BF International Classification of Diseases Clinical Modification (ICD-9-CM) Diagnosis\nABF International Classification of Diseases Clinical Modification (ICD-10-CM) Diagnosis","RNS","n/a"]
[2300,"HI","HI12-2","Industry Code","R","M",1,"AN",1,30,null,"R","n/a"]
[2300,"HI","","Anesthesia Related Procedure","S","O",1,{"$nulls":4},"S"]
[2300,"HI","HI01","Health Care Code Information","R","M",1,{"$nulls":4},"R"]
[2300,"HI","HI01-1","Code List Qualifier Code","R","M",1,"ID",1,3,"BP Health Care Financing Administration Common Procedural Coding System Principal Procedure","RNS","n/a"]
[2300,"HI","HI01-2","Industry Code","R","M",1,"AN",1,30,null,"R","n/a"]
[2300,"HI","HI02","Health Care Code Information","S","O",1,{"$nulls":4},"S"]
[2300,"HI","HI02-1","Code List Qualifier Code","R","M",1,"ID",1,3,"BO Health Care Financing Administration Common Procedural Coding System\n","RNS","n/a"]
[2300,"HI","HI02-2","Industry Code","R","M",1,"AN",1,30,null,"R","n/a"]
[2300,"HI","","Condition Information","S","O",2,{"$nulls":4},"S"]
[2300,"HI","HI01","Health Care Code Information","R","M",1,{"$nulls":4},"R"]
[2300,"HI","HI01-1","Code List Qualifier Code","R","M",1,"ID",1,3,"BG Condition\n","RNS","n/a"]
[2300,"HI","HI01-2","Industry Code","R","M",1,"AN",1,30,null,"R","n/a"]
[2300,"HI","HI02","Health Care Code Information","S","O",1,{"$nulls":4},"S"]
[2300,"HI","HI02-1","Code List Qualifier Code","R","M",1,"ID",1,3,"BG Condition\n","RNS","n/a"]
[2300,"HI","HI02-2","Industry Code","R","M",1,"AN",1,30,null,"R","n/a"]
[2300,"HI","HI03","Health Care Code Information","S","O",1,{"$nulls":4},"S"]
[2300,"HI","HI03-1","Code List Qualifier Code","R","M",1,"ID",1,3,"BG Condition\n","RNS","n/a"]
[2300,"HI","HI-03-2","Industry Code","R","M",1,"AN",1,30,null,"R","n/a"]
[2300,"HI","HI04","Health Care Code Information","S","O",1,{"$nulls":4},"S"]
[2300,"HI","HI04-1","Code List Qualifier Code","R","M",1,"ID",1,3,"BG Condition\n","RNS","n/a"]
[2300,"HI","HI04-2","Industry Code","R","M",1,"AN",1,30,null,"R","n/a"]
[2300,"HI","HI05","Health Care Code Information","S","O",1,{"$nulls":4},"S"]
[2300,"HI","HI05-1","Code List Qualifier Code","R","M",1,"ID",1,3,"BG Condition\n","RNS","n/a"]
[2300,"HI","HI05-2","Industry Code","R","M",1,"AN",1,30,null,"R","n/a"]
[2300,"HI","HI06","Health Care Code Information","S","O",1,{"$nulls":4},"S"]
[2300,"HI","HI06-1","Code List Qualifier Code","R","M",1,"ID",1,3,"BG Condition\n","RNS","n/a"]
[2300,"HI","HI06-2","Industry Code","R","M",1,"AN",1,30,null,"R","n/a"]
[2300,"HI","HI07","Health Care Code Information","S","O",1,{"$nulls":4},"S"]
[2300,"HI","HI07-1","Code List Qualifier Code","R","M",1,"ID",1,3,"BG Condition\n","RNS","n/a"]
[2300,"HI","HI07-2","Industry Code","R","M",1,"AN",1,30,null,"R","n/a"]
[2300,"HI","HI08","Health Care Code Information","S","O",1,{"$nulls":4},"S"]
[2300,"HI","HI08-1","Code List Qualifier Code","R","M",1,"ID",1,3,"BG Condition\n","RNS","n/a"]
[2300,"HI","HI08-2","Industry Code","R","M",1,"AN",1,30,null,"R","n/a"]
[2300,"HI","HI09","Health Care Code Information","S","O",1,{"$nulls":4},"S"]
[2300,"HI","HI09-1","Code List Qualifier Code","R","M",1,"ID",1,3,"BG Condition\n","RNS","n/a"]
[2300,"HI","HI09-2","Industry Code","R","M",1,"AN",1,30,null,"R","n/a"]
[2300,"HI","HI10","Health Care Code Information","S","O",1,{"$nulls":4},"S"]
[2300,"HI","HI10-1","Code List Qualifier Code","R","M",1,"ID",1,3,"BG Condition\n","RNS","n/a"]
[2300,"HI","HI10-2","Industry Code","R","M",1,"AN",1,30,null,"R","n/a"]
[2300,"HI","HI11","Health Care Code Information","S","O",1,{"$nulls":4},"S"]
[2300,"HI","HI11-1","Code List Qualifier Code","R","M",1,"ID",1,3,"BG Condition\n","RNS","n/a"]
[2300,"HI","HI11-2","Industry Code","R","M",1,"AN",1,30,null,"R","n/a"]
[2300,"HI","HI12","Health Care Code Information","S","O",1,{"$nulls":4},"S"]
[2300,"HI","HI12-1","Code List Qualifier Code","R","M",1,"ID",1,3,"BG Condition\n","RNS","n/a"]
[2300,"HI","HI12-2","Industry Code","R","M",1,"AN",1,30,null,"R","n/a"]
[2300,"HCP","","Claim Pricing/Repricing Information","S","O",1,{"$nulls":4},"S"]
[2300,"HCP","HCP01","Pricing Methodology","R","X",1,"ID",2,2,"00 Zero Pricing (Not Covered Under Contract)\n01 Priced as Billed at 100%\n02 Priced at the Standard Fee Schedule\n03 Priced at a Contractual Percentage\n04 Bundled Pricing\n05 Peer Review Pricing\n07 Flat Rate Pricing\n08 Combination Pricing\n09 Maternity Pricing\n10 Other Pricing\n11 Lower of Cost\n12 Ratio of Cost\n13 Cost Reimbursed\n14 Adjustment Pricing ","R","n/a"]
[2300,"HCP","HCP02","Monetary Amount","R","O",1,"R",1,18,null,"R","n/a"]
[2300,"HCP","HCP03","Monetary Amount","S","O",1,"R",1,18,null,"S","n/a"]
[2300,"HCP","HCP04","Reference Identification","S","O",1,"AN",1,50,null,"S","n/a"]
[2300,"HCP","HCP05","Rate","S","O",1,"R",1,9,null,"S","n/a"]
[2300,"HCP","HCP06","Reference Identification","S","O",1,"AN",1,50,null,"S","n/a"]
[2300,"HCP","HCP07","Monetary Amount","S","O",1,"R",1,18,null,"S","n/a"]
[2300,"HCP","HCP13","Reject Reason Code","S","X",1,"ID",2,2,"T1 Cannot Identify Provider as TPO (Third Party Organization) Participant\nT2 Cannot Identify Payer as TPO (Third Party Organization) Participant\nT3 Cannot Identify Insured as TPO (Third Party Organization) Participant\nT4 Payer name or Identifier Missing\nT5 Certification Information Missing\nT6 Claim does not contain enough information for repricing\n","S","n/a"]
[2300,"HCP","HCP14","Policy Compliance Code","S","O",1,"ID",1,2,"1 Procedure Followed (Compliance)\n2 Not Followed - Call Not Made (Non-Compliance Call Not Made)\n3 Not Medically Necessary (Non-Compliance NonMedically Necessary)\n4 Not Followed Other (Non-Compliance Other)\n5 Emergency Admit to Non-Network Hospital ","S","n/a"]
[2300,"HCP","HCP15","Exception Code","S","O",1,"ID",1,2,"1 Non-Network Professional Provider in Network Hospital\n2 Emergency Care\n3 Services or Specialist not in Network\n4 Out-of-Service Area\n5 State Mandates\n6 Other","S","n/a"]
["2310A",null,"","Referring Provider Name","S","O",2,{"$nulls":4},"S"]
["2310A","NM1","","Referring Provider Name","S","O",1,{"$nulls":4},"S"]
["2310A","NM1","NM101","Entity Identifier Code","R","M",1,"ID",2,3,"DN Referring Provider \nP3 Primary Care Provider ","RNS","n/a"]
["2310A","NM1","NM102","Entity Type Qualifier","R","M",1,"ID",1,1,"1 Person ","RNS","n/a"]
["2310A","NM1","NM103","Name Last or Organization Name","R","X",1,"AN",1,60,null,"R","n/a"]
["2310A","NM1","NM104","Name First","S","O",1,"AN",1,35,null,"S","n/a"]
["2310A","NM1","NM105","Name Middle","S","O",1,"AN",1,25,null,"S","n/a"]
["2310A","NM1","NM107","Name Suffix","S","O",1,"AN",1,10,null,"S","n/a"]
["2310A","NM1","NM108","Identification Code Qualifier","S","X",1,"ID",1,2,"XX Centers for Medicare and Medicaid Services national Provider Identifier\n","S","n/a"]
["2310A","NM1","NM109","Identification Code","S","X",1,"AN",2,80,null,"S","n/a"]
["2310A","REF","","Referring Provider Secondary Identification","S","O",3,{"$nulls":4},"S"]
["2310A","REF","REF01","Reference Identification Qualifier","R","M",1,"ID",2,3,"0B State License Number\n1G Provider UPIN Number\nG2 Provider Commercial Number ","R","n/a"]
["2310A","REF","REF02","Reference Identification","R","X",1,"AN",1,50,null,"R","n/a"]
["2310B",null,"","Rendering Provider Name","S","O",1,{"$nulls":4},"S"]
["2310B","NM1","","Rendering Provider Name","S","O",1,{"$nulls":4},"S"]
["2310B","NM1","NM101","Entity Identifier Code","R","M",1,"ID",2,3,"82 Rendering Provider ","RNS","n/a"]
["2310B","NM1","NM102","Entity Type Qualifier","R","M",1,"ID",1,1,"1 Person\n2 Non-Person Entity ","RNS","n/a"]
["2310B","NM1","NM103","Name Last or Organization Name","R","X",1,"AN",1,60,null,"R","n/a"]
["2310B","NM1","NM104","Name First","S","O",1,"AN",1,35,null,"S","n/a"]
["2310B","NM1","NM105","Name Middle","S","O",1,"AN",1,25,null,"S","n/a"]
["2310B","NM1","NM107","Name Suffix","S","O",1,"AN",1,10,null,"S","n/a"]
["2310B","NM1","NM108","Identification Code Qualifier","S","X",1,"ID",1,2,"XX Centers for Medicare and Medicaid Services national Provider Identifier\n","S","n/a"]
["2310B","NM1","NM109","Identification Code","S","X",1,"AN",2,80,null,"S","n/a"]
["2310B","PRV","","Rendering Provider Specialty Information","S","O",1,{"$nulls":4},"S"]
["2310B","PRV","PRV01","Provider Code","R","M",1,"ID",1,3,"PE Performing ","RNS","n/a"]
["2310B","PRV","PRV02","Reference Identification Qualifier","R","X",1,"ID",2,3,"PXC Health Care Provider Taxonomy Code\n","RNS","n/a"]
["2310B","PRV","PRV03","Reference Identification","R","X",1,"AN",1,50,null,"R","n/a"]
["2310B","REF","","Rendering Provider Secondary Identification","S","O",4,{"$nulls":4},"S"]
["2310B","REF","REF01","Reference Identification Qualifier","R","M",1,"ID",2,3,"0B State License Number\n1G Provider UPIN Number \nG2 Provider Commercial Number\nLU Location Number ","R","n/a"]
["2310B","REF","REF02","Reference Identification","R","X",1,"AN",1,50,null,"R","n/a"]
["2310C",null,"","Service Facility Location Name","S","O",1,{"$nulls":4},"S"]
["2310C","NM1","","Service Facility Location Name","S","O",1,{"$nulls":4},"S"]
["2310C","NM1","NM101","Entity Identifier Code","R","M",1,"ID",2,3,"77 Service Location ","RNS","n/a"]
["2310C","NM1","NM102","Entity Type Qualifier","R","M",1,"ID",1,1,"2 Non-Person Entity ","RNS","n/a"]
["2310C","NM1","NM103","Name Last or Organization Name","R","X",1,"AN",1,60,null,"R","n/a"]
["2310C","NM1","NM108","Identification Code Qualifier","S","X",1,"ID",1,2,"XX Centers for Medicare and Medicaid Services national Provider Identifier\n","S","n/a"]
["2310C","NM1","NM109","Identification Code","S","X",1,"AN",2,80,null,"S","n/a"]
["2310C","N3","","Service Facility Location Address","R","O",1,{"$nulls":4},"R"]
["2310C","N3","N301","Address Information","R","M",1,"AN",1,55,null,"R","n/a"]
["2310C","N3","N302","Address Information","S","O",1,"AN",1,55,null,"S","n/a"]
["2310C","N4","","Service Facility Location City, State, ZIP Code","R","O",1,{"$nulls":4},"R"]
["2310C","N4","N401","City Name","R","O",1,"AN",2,30,null,"R","n/a"]
["2310C","N4","N402","State or Province Code","S","X",1,"ID",2,2,null,"S","n/a"]
["2310C","N4","N403","Postal Code","S","O",1,"ID",3,15,null,"S","n/a"]
["2310C","N4","N404","Country Code","S","X",1,"ID",2,3,null,"S","n/a"]
["2310C","N4","N407","Country Subdivision Code","S","X",1,"ID",1,3,null,"SNS","n/a"]
["2310C","REF","","Service Facility Location Secondary Identification","S","O",3,{"$nulls":4},"S"]
["2310C","REF","REF01","Reference Identification Qualifier","R","M",1,"ID",2,3,"0B State License Number\nG2 Provider Commercial Number \nLU Location Number\n","R","n/a"]
["2310C","REF","REF02","Reference Identification","R","X",1,"AN",1,50,null,"R","n/a"]
["2310C","PER","","Service Facility Contact Information","S","O",1,{"$nulls":4},"S"]
["2310C","PER","PER01","Contact Function Code","R","M",1,"ID",2,2,"IC information Contact ","RNS","n/a"]
["2310C","PER","PER02","Name","S","O",1,"AN",1,60,null,"S","n/a"]
["2310C","PER","PER03","Communication Number Qualifier","R","X",1,"ID",2,2,"TE Telephone ","R","n/a"]
["2310C","PER","PER04","Communication Number","R","X",1,"AN",1,256,null,"R","n/a"]
["2310C","PER","PER05","Communication Number Qualifier","S","X",1,"ID",2,2,"EX Telephone Extension\n","S","n/a"]
["2310C","PER","PER06","Communication Number","S","X",1,"AN",1,256,null,"S","n/a"]
["2310D",null,"","Supervising Provider Name","S","O",1,{"$nulls":4},"S"]
["2310D","NM1","","Supervising Provider Name","S","O",1,{"$nulls":4},"S"]
["2310D","NM1","NM101","Entity Identifier Code","R","M",1,"ID",2,3,"DQ Supervising Physician","RNS","n/a"]
["2310D","NM1","NM102","Entity Type Qualifier","R","M",1,"ID",1,1,"1 Person","RNS","n/a"]
["2310D","NM1","NM103","Name Last or Organization Name","R","X",1,"AN",1,60,null,"R","n/a"]
["2310D","NM1","NM104","Name First","S","O",1,"AN",1,35,null,"S","n/a"]
["2310D","NM1","NM105","Name Middle","S","O",1,"AN",1,25,null,"S","n/a"]
["2310D","NM1","NM107","Name Suffix","S","O",1,"AN",1,10,null,"S","n/a"]
["2310D","NM1","NM108","Identification Code Qualifier","S","X",1,"ID",1,2,"XX Centers for Medicare and Medicaid Services national Provider Identifier","S","n/a"]
["2310D","NM1","NM109","Identification Code","S","X",1,"AN",2,80,null,"S","n/a"]
["2310D","REF","","Supervising Provider Secondary Identification","S","O",4,{"$nulls":4},"S"]
["2310D","REF","REF01","Reference Identification Qualifier","R","M",1,"ID",2,3,"0B State License Number  \n1G Provider UPIN Number\nG2  Provider Commercial Number\nLU Location Number","R","n/a"]
["2310D","REF","REF02","Reference Identification","R","X",1,"AN",1,50,null,"R","n/a"]
["2310E",null,"","Ambulance Pick-up Location","S","O",1,{"$nulls":4},"S"]
["2310E","NM1","","Ambulance Pick-up Location","S","O",1,{"$nulls":4},"S"]
["2310E","NM1","NM101","Entity Identifier Code","R","M",1,"ID",2,3,"PW Pickup Address","RNS","n/a"]
["2310E","NM1","NM102","Entity Type Qualifier","R","M",1,"ID",1,1,"2 Non-Person Entity","RNS","n/a"]
["2310E","N3","","Ambulance Pick-up Location Address","R","O",1,{"$nulls":4},"R"]
["2310E","N3","N301","Address Information","R","M",1,"AN",1,55,null,"R","n/a"]
["2310E","N3","N302","Address Information","S","O",1,"AN",1,55,null,"S","n/a"]
["2310E","N4","","Ambulance Pick-up Location City, State, Zip Code","R","O",1,{"$nulls":4},"R"]
["2310E","N4","N401","City Name","R","O",1,"AN",2,30,null,"R","n/a"]
["2310E","N4","N402","State or Province Code","S","X",1,"ID",2,2,null,"S","n/a"]
["2310E","N4","N403","Postal Code","S","O",1,"ID",3,15,null,"S","n/a"]
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["2310E","N4","N407","Country Subdivision Code","S","X",1,"ID",1,3,null,"S","n/a"]
["2310F",null,"","Ambulance Drop-off Location","S","O",1,{"$nulls":4},"S"]
["2310F","NM1","","Ambulance Drop-off Location","S","O",1,{"$nulls":4},"S"]
["2310F","NM1","NM101","Entity Identifier Code","R","M",1,"ID",2,3,"45 Drop-off Location","RNS","n/a"]
["2310F","NM1","NM102","Entity Type Qualifier","R","M",1,"ID",1,1,"2 Non-Person Entity","RNS","n/a"]
["2310F","NM1","NM103","Name Last or Organization Name","S","X",1,"AN",1,60,null,"S","n/a"]
["2310F","N3","","Ambulance Drop-off Location Address","R","O",1,{"$nulls":4},"R"]
["2310F","N3","N301","Address Information","R","M",1,"AN",1,55,null,"R","n/a"]
["2310F","N3","N302","Address Information","S","O",1,"AN",1,55,null,"S","n/a"]
["2310F","N4","","Ambulance Drop-off Location City, State, Zip Code","R","O",1,{"$nulls":4},"R"]
["2310F","N4","N401","City Name","R","O",1,"AN",2,30,null,"R","n/a"]
["2310F","N4","N402","State or Province Code","S","X",1,"ID",2,2,null,"S","n/a"]
["2310F","N4","N403","Postal Code","S","O",1,"ID",3,15,null,"S","n/a"]
["2310F","N4","N404","Country Code","S","X",1,"ID",2,3,null,"S","n/a"]
["2310F","N4","N407","Country Subdivision Code","S","X",1,"ID",1,3,null,"S","n/a"]
[2320,null,"","Other Subscriber Information","S","O",10,{"$nulls":4},"S"]
[2320,"SBR","","Other Subscriber Information","S","O",1,{"$nulls":4},"S"]
[2320,"SBR","SBR01","Payer Responsibility Sequence Number Code","R","M",1,"ID",1,1,"A Payer Responsibility Four\nB Payer Responsibility Five\nC Payer Responsibility Six\nD Payer Responsibility Seven\nE Payer Responsibility Eight\nF Payer Responsibility Nine\nG Payer Responsibility Ten\nH Payer Responsibility Eleven\nP Primary\nS Secondary\nT Tertiary\nU Unknown","R","n/a"]
[2320,"SBR","SBR02","Individual Relationship Code","R","O",1,"ID",2,2,"01 Spouse\n18 Self\n19 Child\n20 Employee\n21 Unknown\n39 Organ Donor\n40 Cadaver Donor\n53 Life Partner\nG8 Other Relationship","R","n/a"]
[2320,"SBR","SBR03","Reference Identification","S","O",1,"AN",1,50,null,"S","n/a"]
[2320,"SBR","SBR04","Name","S","O",1,"AN",1,60,null,"S","n/a"]
[2320,"SBR","SBR05","Insurance Type Code","S","O",1,"ID",1,3,"12 Medicare Secondary Working Aged Beneficiary or Spouse with Employer Group Health Plan\n13 Medicare Secondary End-Stage Renal Disease Beneficiary in the Mandated Coordination Period with an Employer’s Group Health Plan\n14 Medicare Secondary, No-fault Insurance including Auto is Primary \n15 Medicare Secondary Worker’s Compensation\n16 Medicare Secondary Public Health Service (PHS)or Other Federal Agency,41 Medicare Secondary Black Lung\n42 Medicare Secondary Veteran’s Administration\n43 Medicare Secondary Disabled Beneficiary Under Age 65 with Large Group Health Plan (LGHP)\n47 Medicare Secondary, Other Liability Insurance is Primary","S","n/a"]
[2320,"SBR","SBR09","Claim Filing Indicator Code","S","O",1,"ID",1,2,"11 Other Non-Federal Programs\n12 Preferred Provider Organization (PPO)\n13 Point of Service (POS)\n14 Exclusive Provider Organization (EPO)\n15 Indemnity Insurance\n16 Health Maintenance Organization (HMO) Medicare Risk\n17 Dental Maintenance Organization\nAM Automobile Medical\nBL Blue Cross/Blue Shield\nCH Champus\nCI Commercial Insurance Co.\nDS Disability\nFI Federal Employees Program\nHM Health Maintenance Organization\nLM Liability Medical\nMA Medicare Part A\nMB Medicare Part B\nMC Medicaid\nOF Other Federal Program\nTV Title V\nVA Veterans Affairs Plan\nWC Workers’ Compensation Health Claim\nZZ Mutually Defined","S","n/a"]
[2320,"CAS","","Claim Level Adjustments","S","O",5,{"$nulls":4},"S"]
[2320,"CAS","CAS01","Claim Adjustment Group Code","R","M",1,"ID",1,2,"CO Contractual Obligations\nCR Correction and Reversals\nOA Other adjustments\nPI Payor Initiated Reductions\nPR Patient Responsibility","R","n/a"]
[2320,"CAS","CAS02","Claim Adjustment Reason Code","R","M",1,"ID",1,5,null,"R","n/a"]
[2320,"CAS","CAS03","Monetary Amount","R","M",1,"R",1,18,null,"R","n/a"]
[2320,"CAS","CAS04","Quantity","S","O",1,"R",1,15,null,"S","n/a"]
[2320,"CAS","CAS05","Claim Adjustment Reason Code","S","X",1,"ID",1,5,null,"S","n/a"]
[2320,"CAS","CAS06","Monetary Amount","S","X",1,"R",1,18,null,"S","n/a"]
[2320,"CAS","CAS07","Quantity","S","X",1,"R",1,15,null,"S","n/a"]
[2320,"CAS","CAS08","Claim Adjustment Reason Code","S","X",1,"ID",1,5,null,"S","n/a"]
[2320,"CAS","CAS09","Monetary Amount","S","X",1,"R",1,18,null,"S","n/a"]
[2320,"CAS","CAS10","Quantity","S","X",1,"R",1,15,null,"S","n/a"]
[2320,"CAS","CAS11","Claim Adjustment Reason Code","S","X",1,"ID",1,5,null,"S","n/a"]
[2320,"CAS","CAS12","Monetary Amount","S","X",1,"R",1,18,null,"S","n/a"]
[2320,"CAS","CAS13","Quantity","S","X",1,"R",1,15,null,"S","n/a"]
[2320,"CAS","CAS14","Claim Adjustment Reason Code","S","X",1,"ID",1,5,null,"S","n/a"]
[2320,"CAS","CAS15","Monetary Amount","S","X",1,"R",1,18,null,"S","n/a"]
[2320,"CAS","CAS16","Quantity","S","X",1,"R",1,15,null,"S","n/a"]
[2320,"CAS","CAS17","Claim Adjustment Reason Code","S","X",1,"ID",1,5,null,"S","n/a"]
[2320,"CAS","CAS18","Monetary Amount","S","X",1,"R",1,18,null,"S","n/a"]
[2320,"CAS","CAS19","Quantity","S","X",1,"R",1,15,null,"S","n/a"]
[2320,"AMT","","Coordination of Benefits (COB) Payer Paid Amount","S","O",1,{"$nulls":4},"S"]
[2320,"AMT","AMT01","Amount Qualifier Code","R","M",1,"ID",1,3,"D Payor Amount Paid","RNS","n/a"]
[2320,"AMT","AMT02","Monetary Amount","R","M",1,"R",1,18,null,"R","n/a"]
[2320,"AMT","","Coordination of Benefits (COB) Total Non-covered Amount","S","O",1,{"$nulls":4},"S"]
[2320,"AMT","AMT01","Amount Qualifier Code","R","M",1,"ID",1,3,"A8 Noncovered Charges - Actual","RNS","n/a"]
[2320,"AMT","AMT02","Monetary Amount","R","M",1,"R",1,18,null,"R","n/a"]
[2320,"AMT","","Remaining Patient Liability","S","O",1,{"$nulls":4},"S"]
[2320,"AMT","AMT01","Amount Qualifier Code","R","M",1,"ID",1,3,"EAF Amount Owed","RNS","n/a"]
[2320,"AMT","AMT02","Monetary Amount","R","M",1,"R",1,18,null,"R","n/a"]
[2320,"OI","","Other Insurance Coverage Information","R","O",1,{"$nulls":4},"R"]
[2320,"OI","OI03","Yes/No Condition or Response Code","R","O",1,"ID",1,1,"N No\nW Not Applicable\nY Yes","R","n/a"]
[2320,"OI","OI04","Patient Signature Source Code","S","O",1,"ID",1,1,"P Signature generated by provider because the patient was not physically present for services","S","n/a"]
[2320,"OI","OI06","Release of Information Code","R","O",1,"ID",1,1,null,"R","n/a"]
[2320,"MOA","","Outpatient loading edit Information","S","O",1,{"$nulls":4},"S"]
[2320,"MOA","MOA01","Percentage as Decimal","S","O",1,"R",1,10,null,"S","n/a"]
[2320,"MOA","MOA02","Monetary Amount","S","O",1,"R",1,18,null,"S","n/a"]
[2320,"MOA","MOA03","Reference Identification","S","O",1,"AN",1,50,null,"S","n/a"]
[2320,"MOA","MOA04","Reference Identification","S","O",1,"AN",1,50,null,"S","n/a"]
[2320,"MOA","MOA05","Reference Identification","S","O",1,"AN",1,50,null,"S","n/a"]
[2320,"MOA","MOA06","Reference Identification","S","O",1,"AN",1,50,null,"S","n/a"]
[2320,"MOA","MOA07","Reference Identification","S","O",1,"AN",1,50,null,"S","n/a"]
[2320,"MOA","MOA08","Monetary Amount","S","O",1,"R",1,18,null,"S","n/a"]
[2320,"MOA","MOA09","Monetary Amount","S","O",1,"R",1,18,null,"S","n/a"]
["2330A",null,"","Other Subscriber Name","R","O",1,{"$nulls":4},"R"]
["2330A","NM1","","Other Subscriber Name","R","O",1,{"$nulls":4},"R"]
["2330A","NM1","NM101","Entity Identifier Code","R","M",1,"ID",2,3,"IL Insured or Subscriber","RNS","n/a"]
["2330A","NM1","NM102","Entity Type Qualifier","R","M",1,"ID",1,1,"1 Person\n2 Non-Person Entity","RNS","n/a"]
["2330A","NM1","NM103","Name Last or Organization Name","R","X",1,"AN",1,60,null,"R","n/a"]
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["2330A","NM1","NM107","Name Suffix","S","O",1,"AN",1,10,null,"S","n/a"]
["2330A","NM1","NM108","Identification Code Qualifier","R","X",1,"ID",1,2,"II Standard Unique Health Identifier for each Individual\nin the United States\nMI Member Identification Number","R","n/a"]
["2330A","NM1","NM109","Identification Code","R","X",1,"AN",2,80,null,"R","n/a"]
["2330A","N3","","Other Subscriber Address","S","O",1,{"$nulls":4},"S"]
["2330A","N3","N301","Address Information","R","M",1,"AN",1,55,null,"R","n/a"]
["2330A","N3","N302","Address Information","S","O",1,"AN",1,55,null,"S","n/a"]
["2330A","N4","","Other Subscriber City, State, ZIP Code","S","O",1,{"$nulls":4},"S"]
["2330A","N4","N401","City Name","R","O",1,"AN",2,30,null,"R","n/a"]
["2330A","N4","N402","State or Province Code","S","X",1,"ID",2,2,null,"S","n/a"]
["2330A","N4","N403","Postal Code","S","O",1,"ID",3,15,null,"S","n/a"]
["2330A","N4","N404","Country Code","S","X",1,"ID",2,3,null,"S","n/a"]
["2330A","N4","N407","Country Subdivision Code","S","X",1,"ID",1,3,null,"S","n/a"]
["2330A","REF","","Other Subscriber Secondary Identification","S","O",1,{"$nulls":4},"S"]
["2330A","REF","REF01","Reference Identification Qualifier","R","M",1,"ID",2,3,"SY Social Security Number","R","n/a"]
["2330A","REF","REF02","Reference Identification","R","X",1,"AN",1,50,null,"R","n/a"]
["2330B",null,"","Other Payer Name","R","O",1,{"$nulls":4},"R"]
["2330B","NM1","","Other Payer Name","R","O",1,{"$nulls":4},"R"]
["2330B","NM1","NM101","Entity Identifier Code","R","M",1,"ID",2,3,"PR Payer","RNS","n/a"]
["2330B","NM1","NM102","Entity Type Qualifier","R","M",1,"ID",1,1,"2 Non-Person Entity","RNS","n/a"]
["2330B","NM1","NM103","Name Last or Organization Name","R","X",1,"AN",1,60,null,"R","n/a"]
["2330B","NM1","NM108","Identification Code Qualifier","R","X",1,"ID",1,2,"PI Payor Identification\nXV Centers for Medicare and Medicaid Services PlanID","R","n/a"]
["2330B","NM1","NM109","Identification Code","R","X",1,"AN",2,80,null,"R","n/a"]
["2330B","N3","","Other Payer Address","S","O",1,{"$nulls":4},"S"]
["2330B","N3","N301","Address Information","R","M",1,"AN",1,55,null,"R","n/a"]
["2330B","N3","N302","Address Information","S","O",1,"AN",1,55,null,"S","n/a"]
["2330B","N4","","Other Payer City, State, ZIP Code","S","O",1,{"$nulls":4},"S"]
["2330B","N4","N401","City Name","R","O",1,"AN",2,30,null,"R","n/a"]
["2330B","N4","N402","State or Province Code","S","X",1,"ID",2,2,null,"S","n/a"]
["2330B","N4","N403","Postal Code","S","O",1,"ID",3,15,null,"S","n/a"]
["2330B","N4","N404","Country Code","S","X",1,"ID",2,3,null,"S","n/a"]
["2330B","N4","N407","Country Subdivision Code","S","X",1,"ID",1,3,null,"S","n/a"]
["2330B","DTP","","Claim Check or Remittance Date","S","O",1,{"$nulls":4},"S"]
["2330B","DTP","DTP01","Date/Time Qualifier","R","M",1,"ID",3,3,"573 Date Claim Paid","RNS","n/a"]
["2330B","DTP","DTP02","Date Time Period Format Qualifier","R","M",1,"ID",2,3,"D8 Date Expressed in Format CCYYMMDD","RNS","n/a"]
["2330B","DTP","DTP03","Date Time Period","R","M",1,"AN",1,35,null,"R","n/a"]
["2330B","REF","","Other Payer Secondary Identifier","S","O",2,{"$nulls":4},"S"]
["2330B","REF","REF01","Reference Identification Qualifier","R","M",1,"ID",2,3,"2U Payer Identification Number\nEI Employer’s Identification Number\nFY Claim Office Number\nNF national Association of Insurance Commissioners (naIC) Code","R","n/a"]
["2330B","REF","REF02","Reference Identification","R","X",1,"AN",1,50,null,"R","n/a"]
["2330B","REF","","Other Payer Prior Authorization Number","S","O",1,{"$nulls":4},"S"]
["2330B","REF","REF01","Reference Identification Qualifier","R","M",1,"ID",2,3,"G1 Prior Authorization Number","RNS","n/a"]
["2330B","REF","REF02","Reference Identification","R","X",1,"AN",1,50,null,"R","n/a"]
["2330B","REF","","Other Payer Referral Number","S","O",1,{"$nulls":4},"S"]
["2330B","REF","REF01","Reference Identification Qualifier","R","M",1,"ID",2,3,"9F Referral Number","RNS","n/a"]
["2330B","REF","REF02","Reference Identification","R","X",1,"AN",1,50,null,"R","n/a"]
["2330B","REF","","Other Payer Claim Adjustment Indicator","S","O",1,{"$nulls":4},"S"]
["2330B","REF","REF01","Reference Identification Qualifier","R","M",1,"ID",2,3,"T4 Signal Code","RNS","n/a"]
["2330B","REF","REF02","Reference Identification","R","X",1,"AN",1,50,null,"R","n/a"]
["2330B","REF","","Other Payer Claim Control Number","S","O",1,{"$nulls":4},"S"]
["2330B","REF","REF01","Reference Identification Qualifier","R","M",1,"ID",2,3,"F8 Original Reference Number","RNS","n/a"]
["2330B","REF","REF02","Reference Identification","R","X",1,"AN",1,50,null,"R","n/a"]
["2330C",null,"","Other Payer Referring Provider","S","O",2,{"$nulls":4},"S"]
["2330C","NM1","","Other Payer Referring Provider","S","O",1,{"$nulls":4},"S"]
["2330C","NM1","NM101","Entity Identifier Code","R","M",1,"ID",2,3,"DN Referring Provider\nP3 Primary Care Provider","RNS","n/a"]
["2330C","NM1","NM102","Entity Type Qualifier","R","M",1,"ID",1,1,"1 Person","RNS","n/a"]
["2330C","REF","","Other Payer Referring Provider Secondary Identification","R","O",3,{"$nulls":4},"R"]
["2330C","REF","REF01","Reference Identification Qualifier","R","M",1,"ID",2,3,"0B State License Number\n1G Provider UPIN Number\nG2 Provider Commercial Number\n","R","n/a"]
["2330C","REF","REF02","Reference Identification","R","X",1,"AN",1,50,null,"R","n/a"]
["2330D",null,"","Other Payer Rendering Provider","S","O",1,{"$nulls":4},"S"]
["2330D","NM1","","Other Payer Rendering Provider","S","O",1,{"$nulls":4},"S"]
["2330D","NM1","NM101","Entity Identifier Code","R","M",1,"ID",2,3,"82 Rendering Provider","RNS","n/a"]
["2330D","NM1","NM102","Entity Type Qualifier","R","M",1,"ID",1,1,"1 Person\n2 Non-Person Entity","RNS","n/a"]
["2330D","REF","","Other Payer Rendering Provider Secondary Identification","R","O",3,{"$nulls":4},"R"]
["2330D","REF","REF01","Reference Identification Qualifier","R","M",1,"ID",2,3,"0B State License Number\n1G Provider UPIN Number\nG2 Provider Commercial Number\nLU Location Number","R","n/a"]
["2330D","REF","REF02","Reference Identification","R","X",1,"AN",1,50,null,"R","n/a"]
["2330E",null,"","Other Payer Service Facility Location","S","O",1,{"$nulls":4},"S"]
["2330E","NM1","","Other Payer Service Facility Location","S","O",1,{"$nulls":4},"S"]
["2330E","NM1","NM101","Entity Identifier Code","R","M",1,"ID",2,3,"77 Service Location","RNS","n/a"]
["2330E","NM1","NM102","Entity Type Qualifier","R","M",1,"ID",1,1,"2 Non-Person Entity","RNS","n/a"]
["2330E","REF","","Other Payer Service Facility Location Secondary Identification","R","O",3,{"$nulls":4},"R"]
["2330E","REF","REF01","Reference Identification Qualifier","R","M",1,"ID",2,3,"0B State License Number\nG2 Provider Commercial Number\nLU Location Number","R","n/a"]
["2330E","REF","REF02","Reference Identification","R","X",1,"AN",1,50,null,"R","n/a"]
["2330F",null,"","Other Payer Supervising Provider","S","O",1,{"$nulls":4},"S"]
["2330F","NM1","","Other Payer Supervising Provider","S","O",1,{"$nulls":4},"S"]
["2330F","NM1","NM101","Entity Identifier Code","R","M",1,"ID",2,3,"DQ Supervising Physician","RNS","n/a"]
["2330F","NM1","NM102","Entity Type Qualifier","R","M",1,"ID",1,1,"1 Person","RNS","n/a"]
["2330F","REF","","Other Payer Supervising Provider Secondary Identification","R","O",3,{"$nulls":4},"R"]
["2330F","REF","REF01","Reference Identification Qualifier","R","M",1,"ID",2,3,"0B State License Number\n1G Provider UPIN Number\nG2 Provider Commercial Number\nLU Location Number","R","n/a"]
["2330F","REF","REF02","Reference Identification","R","X",1,"AN",1,50,null,"R","n/a"]
["2330G","REF","","Other Payer Billing Provider","S","O",1,{"$nulls":4},"S"]
["2330G","NM1","","Other Payer Billing Provider","S","O",1,{"$nulls":4},"S"]
["2330G","NM1","NM101","Entity Identifier Code","R","M",1,"ID",2,3,"85 Billing Provider","RNS","n/a"]
["2330G","NM1","NM102","Entity Type Qualifier","R","M",1,"ID",1,1,"1 Person\n2 Non-Person Entity","RNS","n/a"]
["2330G","REF","","Other Payer Billing Provider Secondary Identification","R","O",2,{"$nulls":4},"R"]
["2330G","REF","REF01","Reference Identification Qualifier","R","M",1,"ID",2,3,"G2 Provider Commercial Number\nLU Location Number","R","n/a"]
["2330G","REF","REF02","Reference Identification","R","X",1,"AN",1,50,null,"R","n/a"]
[2400,null,"","Service Line Number","R","O",50,{"$nulls":4},"R"]
[2400,"LX","","Service Line Number","R","O",1,{"$nulls":4},"R"]
[2400,"LX","LX01","Assigned Number","R","M",1,"N0",1,6,null,"R","n/a"]
[2400,"SV1","","Professional Service","R","O",1,{"$nulls":4},"R"]
[2400,"SV1","SV101","Composite Medical Procedure Identifier","R","M",1,{"$nulls":4},"R"]
[2400,"SV1","SV101 -1","Product/Service ID Qualifier","R","M",1,"ID",2,2,"ER Jurisdiction Specific Procedure and Supply Codes\nHC Health Care Financing Administration Common Procedural Coding System (HCPCS) Codes\nIV Home Infusion EDI Coalition (HIEC) Product/Service Code\nWK Advanced Billing Concepts (ABC) Codes","R","n/a"]
[2400,"SV1","SV101 -2","Product/Service ID","R","M",1,"AN",1,48,null,"R","n/a"]
[2400,"SV1","SV101-3 ","Procedure Modifier","S","O",1,"AN",2,2,null,"S","n/a"]
[2400,"SV1","SV101-4","Procedure Modifier","S","O",1,"AN",2,2,null,"S","n/a"]
[2400,"SV1","SV101-5","Procedure Modifier","S","O",1,"AN",2,2,null,"S","n/a"]
[2400,"SV1","SV101-6","Procedure Modifier","S","O",1,"AN",2,2,null,"S","n/a"]
[2400,"SV1","SV101-7","Description","S","O",1,"AN",1,80,null,"S","n/a"]
[2400,"SV1","SV102","Monetary Amount","R","O",1,"R",1,18,null,"R","n/a"]
[2400,"SV1","SV103","Unit or Basis for Measurement Code","R","X",1,"ID",2,2,"MJ Minutes\nUN Unit","R","n/a"]
[2400,"SV1","SV104","Quantity","R","X",1,"R",1,15,null,"R","n/a"]
[2400,"SV1","SV105","Facility Code Value","S","O",1,"AN",1,2,null,"S","n/a"]
[2400,"SV1","SV107","Composite Diagnosis Code Pointer","R","O",1,{"$nulls":4},"R"]
[2400,"SV1","SV107-1","Diagnosis Code Pointer","R","M",1,"N0",1,2,null,"R","n/a"]
[2400,"SV1","SV107-2","Diagnosis Code Pointer","S","O",1,"N0",1,2,null,"S","n/a"]
[2400,"SV1","SV107-3","Diagnosis Code Pointer","S","O",1,"N0",1,2,null,"S","n/a"]
[2400,"SV1","SV107-4","Diagnosis Code Pointer","S","O",1,"N0",1,2,null,"S","n/a"]
[2400,"SV1","SV109","Yes/No Condition or Response Code","S","O",1,"ID",1,1,"Y Yes","S","n/a"]
[2400,"SV1","SV111","Yes/No Condition or Response Code","S","O",1,"ID",1,1,"Y Yes","S","n/a"]
[2400,"SV1","SV112","Yes/No Condition or Response Code","S","O",1,"ID",1,1,"Y Yes","S","n/a"]
[2400,"SV1","SV115","Copay Status Code","S","O",1,"ID",1,1,"0 Copay exempt","S","n/a"]
[2400,"SV5","","Durable Medical Equipment Service","S","O",1,{"$nulls":4},"S"]
[2400,"SV5","SV501","Composite Medical Procedure Identifier","R","M",1,{"$nulls":4},"R"]
[2400,"SV5","SV501-1","Product/Service ID Qualifier","R","M",1,"ID",2,2,"HC Health Care Financing Administration Common Procedural Coding System (HCPCS) Codes","R","n/a"]
[2400,"SV5","SV501-2","Product/Service ID","R","M",1,"AN",1,48,null,"R","n/a"]
[2400,"SV5","SV502","Unit or Basis for Measurement Code","R","M",1,"ID",2,2,"DA Days","R","n/a"]
[2400,"SV5","SV503","Quantity","R","M",1,"R",1,15,null,"R","n/a"]
[2400,"SV5","SV504","Monetary Amount","R","X",1,"R",1,18,null,"R","n/a"]
[2400,"SV5","SV505","Monetary Amount","R","X",1,"R",1,18,null,"R","n/a"]
[2400,"SV5","SV506","Frequency Code","R","X",1,"ID",1,1,"1 Weekly\n4 Monthly\n6 Daily","R","n/a"]
[2400,"PWK","","Line Supplemental Information","S","O",10,{"$nulls":4},"S"]
[2400,"PWK","PWK01","Report Type Code","R","M",1,"ID",2,2,"03 Report Justifying Treatment Beyond Utilization\nGuidelines\n04 Drugs Administered\n05 Treatment Diagnosis\n06 Initial Assessment\n07 Functional Goals\n08 Plan of Treatment\n09 Progress Report\n10 Continued Treatment\n11 Chemical Analysis\n13 Certified Test Report\n15 Justification for Admission\n21 Recovery Plan\nA3 Allergies/Sensitivities Document\nA4 Autopsy Report\nAM Ambulance Certification\nAS Admission Summary\nB2 Prescription\nB3 Physician Order\nB4 Referral Form\nBR Benchmark Testing Results\nBS Baseline\nBT Blanket Test Results\nCB Chiropractic Justification\nCK Consent Form(s)\nCT Certification\nD2 Drug Profile Document\nDA Dental Models\nDB Durable Medical Equipment Prescription\nDG Diagnostic Report\nDJ Discharge Monitoring Report\nDS Discharge Summary\nEB Explanation of Benefits (Coordination of Benefits or\nMedicare Secondary Payor)\nHC Health Certificate\nHR Health Clinic Records\nI5 Immunization Record\nASC X12N • INSURANCE SUBCOMMITTEE 005010X222 • 837 • 2400 • PWK\nTECHNICAL REPORT • TYPE 3 LINE SUPPLEMENTAL INFORMATION\nMAY 2006 363\nIR State School Immunization Records\nLA Laboratory Results\nM1 Medical Record Attachment\nMT Models\nNN Nursing Notes\nOB Operative Note\nOC Oxygen Content Averaging Report\nOD Orders and Treatments Document\nOE Objective Physical Examination (including vital\nsigns) Document\nOX Oxygen Therapy Certification\nOZ Support Data for Claim\nP4 Pathology Report\nP5 Patient Medical History Document\nPE Parenteral or Enteral Certification\nPN Physical Therapy Notes\nPO Prosthetics or Orthotic Certification\nPQ Paramedical Results\nPY Physician’s Report\nPZ Physical Therapy Certification\nRB Radiology Films\nRR Radiology Reports\nRT Report of Tests and Analysis Report\nRX Renewable Oxygen Content Averaging Report\nSG Symptoms Document\nV5 Death Notification\nXP Photographs","R","n/a"]
[2400,"PWK","PWK02","Report Transmission Code","R","O",1,"ID",1,2,"AA Available on Request at Provider Site\nBM By Mail\nEL Electronically Only\nEM E-Mail\nFT File Transfer\nFX By Fax","R","n/a"]
[2400,"PWK","PWK05","Identification Code Qualifier","S","X",1,"ID",1,2,"AC Attachment Control Number","S","n/a"]
[2400,"PWK","PWK06","Identification Code","S","X",1,"AN",2,80,null,"S","n/a"]
[2400,"PWK","","Durable Medical Equipment Certificate of Medical Necessity Indicator","S","O",1,{"$nulls":4},"S"]
[2400,"PWK","PWK01","Report Type Code","R","M",1,"ID",2,2,"CT Certification","R","n/a"]
[2400,"PWK","PWK02","Report Transmission Code","R","O",1,"ID",1,2,"AB Previously Submitted to Payer\nAD Certification Included in this Claim\nAF narrative Segment Included in this Claim\nAG No Documentation is Required\nNS Not Specified","R","n/a"]
[2400,"CR1","","Ambulance Transport Information","S","O",1,{"$nulls":4},"S"]
[2400,"CR1","CR101","Unit or Basis for Measurement Code","S","X",1,"ID",2,2,"LB Pound","S","n/a"]
[2400,"CR1","CR102","Weight","S","X",1,"R",1,10,null,"S","n/a"]
[2400,"CR1","CR104","Ambulance Transport Reason Code","R","O",1,"ID",1,1,"A Patient was transported to nearest facility for care of\nsymptoms, complaints, or both\nB Patient was transported for the benefit of a preferred\nphysician\nC Patient was transported for the nearness of family\nmembers\nD Patient was transported for the care of a specialist\nor for availability of specialized equipment\nE Patient Transferred to Rehabilitation Facility","R","n/a"]
[2400,"CR1","CR105","Unit or Basis for Measurement Code","R","X",1,"ID",2,2,"DH Miles","R","n/a"]
[2400,"CR1","CR106","Quantity","R","X",1,"R",1,15,null,"R","n/a"]
[2400,"CR1","CR109","Description","S","O",1,"AN",1,80,null,"S","n/a"]
[2400,"CR1","CR110","Description","S","O",1,"AN",1,80,null,"S","n/a"]
[2400,"CR3","","Durable Medical Equipment Certification","S","O",1,{"$nulls":4},"S"]
[2400,"CR3","CR301","Certification Type Code","R","O",1,"ID",1,1,"I Initial\nR Renewal\nS Revised","R","n/a"]
[2400,"CR3","CR302","Unit or Basis for Measurement Code","R","X",1,"ID",2,2,"MO Months","R","n/a"]
[2400,"CR3","CR303","Quantity","R","X",1,"R",1,15,null,"R","n/a"]
[2400,"CRC","","Ambulance Certification","S","O",3,{"$nulls":4},"S"]
[2400,"CRC","CRC01","Code Category","R","M",1,"ID",2,2,"07 Ambulance Certification","RNS","n/a"]
[2400,"CRC","CRC02","Yes/No Condition or Response Code","R","M",1,"ID",1,1," N No\nY Yes","R","n/a"]
[2400,"CRC","CRC03","Condition Indicator","R","M",1,"ID",2,3,"01 Patient was admitted to a hospital\n04 Patient was moved by stretcher\n05 Patient was unconscious or in shock\n06 Patient was transported in an emergency situation\n07 Patient had to be physically restrained\n08 Patient had visible hemorrhaging\n09 Ambulance service was medically necessary\n12 Patient is confined to a bed or chair","R","n/a"]
[2400,"CRC","CRC04","Condition Indicator","S","O",1,"ID",2,3,"01 Patient was admitted to a hospital\n04 Patient was moved by stretcher\n05 Patient was unconscious or in shock\n06 Patient was transported in an emergency situation\n07 Patient had to be physically restrained\n08 Patient had visible hemorrhaging\n09 Ambulance service was medically necessary\n12 Patient is confined to a bed or chair","S","n/a"]
[2400,"CRC","CRC05","Condition Indicator","S","O",1,"ID",2,3,"01 Patient was admitted to a hospital\n04 Patient was moved by stretcher\n05 Patient was unconscious or in shock\n06 Patient was transported in an emergency situation\n07 Patient had to be physically restrained\n08 Patient had visible hemorrhaging\n09 Ambulance service was medically necessary\n12 Patient is confined to a bed or chair","S","n/a"]
[2400,"CRC","CRC06","Condition Indicator","S","O",1,"ID",2,3,"01 Patient was admitted to a hospital\n04 Patient was moved by stretcher\n05 Patient was unconscious or in shock\n06 Patient was transported in an emergency situation\n07 Patient had to be physically restrained\n08 Patient had visible hemorrhaging\n09 Ambulance service was medically necessary\n12 Patient is confined to a bed or chair","S","n/a"]
[2400,"CRC","CRC07","Condition Indicator","S","O",1,"ID",2,3,"01 Patient was admitted to a hospital\n04 Patient was moved by stretcher\n05 Patient was unconscious or in shock\n06 Patient was transported in an emergency situation\n07 Patient had to be physically restrained\n08 Patient had visible hemorrhaging\n09 Ambulance service was medically necessary\n12 Patient is confined to a bed or chair","S","n/a"]
[2400,"CRC","","Hospice Employee Indicator","S","O",1,{"$nulls":4},"S"]
[2400,"CRC","CRC01","Code Category","R","M",1,"ID",2,2,"70 Hospice","R","n/a"]
[2400,"CRC","CRC02","Yes/No Condition or Response Code","R","M",1,"ID",1,1,"N No\nY Yes","R","n/a"]
[2400,"CRC","CRC03","Condition Indicator","R","M",1,"ID",2,3,"65 Open","R","n/a"]
[2400,"CRC","","Condition Indicator/Durable Medical Equipment","S","O",1,{"$nulls":4},"S"]
[2400,"CRC","CRC01","Code Category","R","M",1,"ID",2,2,"09 Durable Medical Equipment Certification","R","n/a"]
[2400,"CRC","CRC02","Yes/No Condition or Response Code","R","M",1,"ID",1,1,"N No\nY Yes","R","n/a"]
[2400,"CRC","CRC03","Condition Indicator","R","M",1,"ID",2,3,"38 Certification signed by the physician is on file at the\nsupplier’s office\nZV Replacement Item","R","n/a"]
[2400,"CRC","CRC04","Condition Indicator","S","O",1,"ID",2,3,"38 Certification signed by the physician is on file at the\nsupplier’s office\nZV Replacement Item","S","n/a"]
[2400,"DTP","","Date - Service Date","R","O",1,{"$nulls":4},"R"]
[2400,"DTP","DTP01","Date/Time Qualifier","R","M",1,"ID",3,3,"472 Service","RNS","n/a"]
[2400,"DTP","DTP02","Date Time Period Format Qualifier","R","M",1,"ID",2,3,"D8 Date Expressed in Format CCYYMMDD\nRD8 Range of Dates Expressed in Format CCYYMMDDCCYYMMDD","RNS","n/a"]
[2400,"DTP","DTP03","Date Time Period","R","M",1,"AN",1,35,null,"R","n/a"]
[2400,"DTP","","Date - Prescription Date","S","O",1,{"$nulls":4},"S"]
[2400,"DTP","DTP01","Date/Time Qualifier","R","M",1,"ID",3,3,"471 Prescription","RNS","n/a"]
[2400,"DTP","DTP02","Date Time Period Format Qualifier","R","M",1,"ID",2,3,"D8 Date Expressed in Format CCYYMMDD","RNS","n/a"]
[2400,"DTP","DTP03","Date Time Period","R","M",1,"AN",1,35,null,"R","n/a"]
[2400,"DTP","","DATE - Certification Revision/Recertification Date","S","O",1,{"$nulls":4},"S"]
[2400,"DTP","DTP01","Date/Time Qualifier","R","M",1,"ID",3,3,"607 Certification Revision","RNS","n/a"]
[2400,"DTP","DTP02","Date Time Period Format Qualifier","R","M",1,"ID",2,3,"D8 Date Expressed in Format CCYYMMDD","RNS","n/a"]
[2400,"DTP","DTP03","Date Time Period","R","M",1,"AN",1,35,null,"R","n/a"]
[2400,"DTP","","Date - Begin Therapy Date","S","O",1,{"$nulls":4},"S"]
[2400,"DTP","DTP01","Date/Time Qualifier","R","M",1,"ID",3,3,"463 Begin Therapy","RNS","n/a"]
[2400,"DTP","DTP02","Date Time Period Format Qualifier","R","M",1,"ID",2,3,"D8 Date Expressed in Format CCYYMMDD","RNS","n/a"]
[2400,"DTP","DTP03","Date Time Period","R","M",1,"AN",1,35,null,"R","n/a"]
[2400,"DTP","","Date - Last Certification Date","S","O",1,{"$nulls":4},"S"]
[2400,"DTP","DTP01","Date/Time Qualifier","R","M",1,"ID",3,3,"461 Last Certification","RNS","n/a"]
[2400,"DTP","DTP02","Date Time Period Format Qualifier","R","M",1,"ID",2,3,"D8 Date Expressed in Format CCYYMMDD","RNS","n/a"]
[2400,"DTP","DTP03","Date Time Period","R","M",1,"AN",1,35,null,"R","n/a"]
[2400,"DTP","","Date - Last Seen Date","S","O",1,{"$nulls":4},"S"]
[2400,"DTP","DTP01","Date/Time Qualifier","R","M",1,"ID",3,3,"304 Latest Visit or Consultation","RNS","n/a"]
[2400,"DTP","DTP02","Date Time Period Format Qualifier","R","M",1,"ID",2,3,"D8 Date Expressed in Format CCYYMMDD","RNS","n/a"]
[2400,"DTP","DTP03","Date Time Period","R","M",1,"AN",1,35,null,"R","n/a"]
[2400,"DTP","","Date - Test Date","S","O",2,{"$nulls":4},"S"]
[2400,"DTP","DTP01","Date/Time Qualifier","R","M",1,"ID",3,3,"738 Most Recent Hemoglobin or Hematocrit or Both\n739 Most Recent Serum Creatine","RNS","n/a"]
[2400,"DTP","DTP02","Date Time Period Format Qualifier","R","M",1,"ID",2,3,"D8 Date Expressed in Format CCYYMMDD","RNS","n/a"]
[2400,"DTP","DTP03","Date Time Period","R","M",1,"AN",1,35,null,"R","n/a"]
[2400,"DTP","","Date - Shipped Date","S","O",1,{"$nulls":4},"S"]
[2400,"DTP","DTP01","Date/Time Qualifier","R","M",1,"ID",3,3,"11 Shipped","RNS","n/a"]
[2400,"DTP","DTP02","Date Time Period Format Qualifier","R","M",1,"ID",2,3,"D8 Date Expressed in Format CCYYMMDD","RNS","n/a"]
[2400,"DTP","DTP03","Date Time Period","R","M",1,"AN",1,35,null,"R","n/a"]
[2400,"DTP","","Date - Last X-ray Date","S","O",1,{"$nulls":4},"S"]
[2400,"DTP","DTP01","Date/Time Qualifier","R","M",1,"ID",3,3,"455 Last X-Ray","RNS","n/a"]
[2400,"DTP","DTP02","Date Time Period Format Qualifier","R","M",1,"ID",2,3,"D8 Date Expressed in Format CCYYMMDD","RNS","n/a"]
[2400,"DTP","DTP03","Date Time Period","R","M",1,"AN",1,35,null,"R","n/a"]
[2400,"DTP","","Date - Initial Treatment Date","S","O",1,{"$nulls":4},"S"]
[2400,"DTP","DTP01","Date/Time Qualifier","R","M",1,"ID",3,3,"454 Initial Treatment","RNS","n/a"]
[2400,"DTP","DTP02","Date Time Period Format Qualifier","R","M",1,"ID",2,3,"D8 Date Expressed in Format CCYYMMDD","RNS","n/a"]
[2400,"DTP","DTP03","Date Time Period","R","M",1,"AN",1,35,null,"R","n/a"]
[2400,"QTY","","Ambulance Patient Count","S","O",1,{"$nulls":4},"S"]
[2400,"QTY","QTY01","Quantity Qualifier","R","M",1,"ID",2,2,"PT Patients","RNS","n/a"]
[2400,"QTY","QTY02","Quantity","R","X",1,"R",1,15,null,"R","n/a"]
[2400,"QTY","","Obstetric Anesthesia Additional Units","S","O",1,{"$nulls":4},"S"]
[2400,"QTY","QTY01","Quantity Qualifier","R","M",1,"ID",2,2,"FL Units","RNS","n/a"]
[2400,"QTY","QTY02","Quantity","R","X",1,"R",1,15,null,"R","n/a"]
[2400,"MEA","","Test Result","S","O",5,{"$nulls":4},"S"]
[2400,"MEA","MEA01","Measurement Reference ID Code","R","O",1,"ID",2,2,"OG Original,TR Test Results","R","n/a"]
[2400,"MEA","MEA02","Measurement Qualifier","R","O",1,"ID",1,3,"HT Height\nR1 Hemoglobin\nR2 Hematocrit\nR3 Epoetin Starting Dosage\nR4 Creatinine","R","n/a"]
[2400,"MEA","MEA03","Measurement Value","R","X",1,"R",1,20,null,"R","n/a"]
[2400,"CN1","","Contract Information","S","O",1,{"$nulls":4},"S"]
[2400,"CN1","CN101","Contract Type Code","R","M",1,"ID",2,2,"01 Diagnosis Related Group (DRG)\n02 Per Diem\n03 Variable Per Diem\n04 Flat\n05 Capitated\n06 Percent\n09 Other","R","n/a"]
[2400,"CN1","CN102","Monetary Amount","S","O",1,"R",1,18,null,"S","n/a"]
[2400,"CN1","CN103","Percent, Decimal Format","S","O",1,"R",1,6,null,"S","n/a"]
[2400,"CN1","CN104","Reference Identification","S","O",1,"AN",1,50,null,"S","n/a"]
[2400,"CN1","CN105","Terms Discount Percent","S","O",1,"R",1,6,null,"S","n/a"]
[2400,"CN1","CN106","Version Identifier","S","O",1,"AN",1,30,null,"S","n/a"]
[2400,"REF","","Repriced Line Item Reference Number","S","O",1,{"$nulls":4},"S"]
[2400,"REF","REF01","Reference Identification Qualifier","R","M",1,"ID",2,3,"9B Repriced Line Item Reference Number","RNS","n/a"]
[2400,"REF","REF02","Reference Identification","R","X",1,"AN",1,50,null,"R","n/a"]
[2400,"REF","","Adjusted Repriced Line Item Reference Number","S","O",1,{"$nulls":4},"S"]
[2400,"REF","REF01","Reference Identification Qualifier","R","M",1,"ID",2,3,"9D Adjusted Repriced Line Item Reference Number","RNS","n/a"]
[2400,"REF","REF02","Reference Identification","R","X",1,"AN",1,50,null,"R","n/a"]
[2400,"REF","","Prior Authorization","S","O",5,{"$nulls":4},"S"]
[2400,"REF","REF01","Reference Identification Qualifier","R","M",1,"ID",2,3,"G1 Prior Authorization Number","RNS","n/a"]
[2400,"REF","REF02","Reference Identification","R","X",1,"AN",1,50,null,"R","n/a"]
[2400,"REF","REF04","Reference Identifier","S","O",1,1,{"$nulls":3},"S"]
[2400,"REF","REF04 - 1","Reference Identification Qualifier","R","M",1,"ID",2,3,"2U Payer Identification Number","R","n/a"]
[2400,"REF","REF04 - 2","Reference Identification","R","M",1,"AN",1,50,null,"R","n/a"]
[2400,"REF","","Line Item Control Number","S","O",1,{"$nulls":4},"S"]
[2400,"REF","REF01","Reference Identification Qualifier","R","M",1,"ID",2,3,"6R Provider Control Number","RNS","n/a"]
[2400,"REF","REF02","Reference Identification","R","X",1,"AN",1,50,null,"R","n/a"]
[2400,"REF","","Mammography Certification Number","S","O",1,{"$nulls":4},"S"]
[2400,"REF","REF01","Reference Identification Qualifier","R","M",1,"ID",2,3,"EW Mammography Certification Number","RNS","n/a"]
[2400,"REF","REF02","Reference Identification","R","X",1,"AN",1,50,null,"R","n/a"]
[2400,"REF","","Clinical Laboratory Improvement Amendment (CLIA) Number","S","O",1,{"$nulls":4},"S"]
[2400,"REF","REF01","Reference Identification Qualifier","R","M",1,"ID",2,3,"X4 Clinical Laboratory Improvement Amendment Number","RNS","n/a"]
[2400,"REF","REF02","Reference Identification","R","X",1,"AN",1,50,null,"R","n/a"]
[2400,"REF","","Referring Clinical Laboratory Improvement Amendment (CLIA) Facility Identification","S","O",1,{"$nulls":4},"S"]
[2400,"REF","REF01","Reference Identification Qualifier","R","M",1,"ID",2,3,"F4 Facility Certification Number","RNS","n/a"]
[2400,"REF","REF02","Reference Identification","R","X",1,"AN",1,50,null,"R","n/a"]
[2400,"REF","","Immunization Batch Number","S","O",1,{"$nulls":4},"S"]
[2400,"REF","REF01","Reference Identification Qualifier","R","M",1,"ID",2,3,"BT Batch Number","RNS","n/a"]
[2400,"REF","REF02","Reference Identification","R","X",1,"AN",1,50,null,"R","n/a"]
[2400,"REF","","Referral Number","S","O",5,{"$nulls":4},"S"]
[2400,"REF","REF01","Reference Identification Qualifier","R","M",1,"ID",2,3,"9F Referral Number","RNS","n/a"]
[2400,"REF","REF02","Reference Identification","R","X",1,"AN",1,50,null,"R","n/a"]
[2400,"REF","REF04","Reference Identifier","S","O",1,1,{"$nulls":3},"S"]
[2400,"REF","REF04 - 1","Reference Identification Qualifier","R","M",1,"ID",2,3,"2U Payer Identification Number","R","n/a"]
[2400,"REF","REF04 - 2","Reference Identification","R","M",1,"AN",1,50,null,"R","n/a"]
[2400,"AMT","","Sales Tax Amount","S","O",1,{"$nulls":4},"S"]
[2400,"AMT","AMT01","Amount Qualifier Code","R","M",1,"ID",1,3,"T Tax","RNS","n/a"]
[2400,"AMT","AMT02","Monetary Amount","R","M",1,"R",1,18,null,"R","n/a"]
[2400,"AMT","","Postage Claimed Amount","S","O",1,{"$nulls":4},"S"]
[2400,"AMT","AMT01","Amount Qualifier Code","R","M",1,"ID",1,3,"F4 Postage Claimed","RNS","n/a"]
[2400,"AMT","AMT02","Monetary Amount","R","M",1,"R",1,18,null,"R","n/a"]
[2400,"K3","","File Information","S","O",10,{"$nulls":4},"S"]
[2400,"K3","K301","Fixed Format Information","R","M",1,"AN",1,80,null,"R","n/a"]
[2400,"NTE","","Line Note","S","O",1,{"$nulls":4},"S"]
[2400,"NTE","NTE01","Note Reference Code","R","O",1,"ID",3,3,"ADD Additional Information\nDCP Goals, Rehabilitation Potential, or Discharge Plans","R","n/a"]
[2400,"NTE","NTE02","Description","R","M",1,"AN",1,80,null,"R","n/a"]
[2400,"NTE","","Third Party Organization Notes","S","O",1,{"$nulls":4},"S"]
[2400,"NTE","NTE01","Note Reference Code","R","O",1,"ID",3,3,"TPO Third Party Organization Notes","RNS","n/a"]
[2400,"NTE","NTE02","Description","R","M",1,"AN",1,80,null,"R","n/a"]
[2400,"PS1","","Purchased Service Information","S","O",1,{"$nulls":4},"S"]
[2400,"PS1","PS101","Reference Identification","R","M",1,"AN",1,50,null,"R","n/a"]
[2400,"PS1","PS102","Monetary Amount","R","M",1,"R",1,18,null,"R","n/a"]
[2400,"HCP","","Line Pricing/Repricing Information","S","O",1,{"$nulls":4},"S"]
[2400,"HCP","HCP01","Pricing Methodology","R","X",1,"ID",2,2,"00 Zero Pricing (Not Covered Under Contract)\n01 Priced as Billed at 100%\n02 Priced at the Standard Fee Schedule\n03 Priced at a Contractual Percentage\n04 Bundled Pricing\n05 Peer Review Pricing\n06 Per Diem Pricing\n07 Flat Rate Pricing\n08 Combination Pricing\n09 Maternity Pricing\n10 Other Pricing\n11 Lower of Cost\n12 Ratio of Cost\n13 Cost Reimbursed\n14 Adjustment Pricing","R","n/a"]
[2400,"HCP","HCP02","Monetary Amount","R","O",1,"R",1,18,null,"R","n/a"]
[2400,"HCP","HCP03","Monetary Amount","S","O",1,"R",1,18,null,"S","n/a"]
[2400,"HCP","HCP04","Reference Identification","S","O",1,"AN",1,50,null,"S","n/a"]
[2400,"HCP","HCP05","Rate","S","O",1,"R",1,9,null,"S","n/a"]
[2400,"HCP","HCP06","Reference Identification","S","O",1,"AN",1,50,null,"S","n/a"]
[2400,"HCP","HCP07","Monetary Amount","S","O",1,"R",1,18,null,"S","n/a"]
[2400,"HCP","HCP09","Product/Service ID Qualifier","S","X",1,"ID",2,2,"ER Jurisdiction Specific Procedure and Supply Codes\nHC Health Care Financing Administration Common\nProcedural Coding System (HCPCS) Codes\nIV Home Infusion EDI Coalition (HIEC) Product/Service\nCode\nWK Advanced Billing Concepts (ABC) Codes","S","n/a"]
[2400,"HCP","HCP10","Product/Service ID","S","X",1,"AN",1,48,null,"S","n/a"]
[2400,"HCP","HCP11","Unit or Basis for Measurement Code","S","X",1,"ID",2,2,"MJ Minutes\nUN Unit","S","n/a"]
[2400,"HCP","HCP12","Quantity","S","X",1,"R",1,15,null,"S","n/a"]
[2400,"HCP","HCP13","Reject Reason Code","S","X",1,"ID",2,2,"T1 Cannot Identify Provider as TPO (Third Party\nOrganization) Participant\nT2 Cannot Identify Payer as TPO (Third Party\nOrganization) Participant\nT3 Cannot Identify Insured as TPO (Third Party\nOrganization) Participant\nT4 Payer name or Identifier Missing\nT5 Certification Information Missing\nT6 Claim does not contain enough information for repricing","S","n/a"]
[2400,"HCP","HCP14","Policy Compliance Code","S","O",1,"ID",1,2,"1 Procedure Followed (Compliance)\n2 Not Followed - Call Not Made (Non-Compliance Call\nNot Made)\n3 Not Medically Necessary (Non-Compliance Non-\nMedically Necessary)\n4 Not Followed Other (Non-Compliance Other)\n5 Emergency Admit to Non-Network Hospital","S","n/a"]
[2400,"HCP","HCP15","Exception Code","S","O",1,"ID",1,2,"1 Non-Network Professional Provider in Network\nHospital\n2 Emergency Care\n3 Services or Specialist not in Network\n4 Out-of-Service Area\n5 State Mandates\n6 Other","S","n/a"]
[2410,null,"","Drug Identification","S","O",1,{"$nulls":4},"S"]
[2410,"LIN","","Drug Identification","S","O",1,{"$nulls":4},"S"]
[2410,"LIN","LIN02","Product/Service ID Qualifier","R","M",1,"ID",2,2,"N4 national Drug Code in 5-4-2 Format\nEN EAN/UCC - 13, EO EAN/UCC - 8\nHI HIBC (Health Care Industry Bar Code) Supplier Labeling Standard Primary Data Message\nON Customer Order Number\nUK GTIN 14-digit Data Structure\nUP UCC - 12","R","n/a"]
[2410,"LIN","LIN03","Product/Service ID","R","M",1,"AN",1,48,null,"R","n/a"]
[2410,"CTP","","Drug Quantity","R","O",1,{"$nulls":4},"R"]
[2410,"CTP","CTP04","Quantity","R","X",1,"R",1,15,null,"R","n/a"]
[2410,"CTP","CTP05","Composite Unit of Measure","R","X",1,{"$nulls":4},"R"]
[2410,"CTP","CTP05 - 1","Unit or Basis for Measurement Code","R","M",1,"ID",2,2,"F2 International Unit\nGR Gram\nME Milligram\nML Milliliter\nUN Unit","R","n/a"]
[2410,"REF","","Prescription or Compound Drug Association Number","S","O",1,{"$nulls":4},"S"]
[2410,"REF","REF01","Reference Identification Qualifier","R","M",1,"ID",2,3,"VY Link Sequence Number\nXZ Pharmacy Prescription Number","R","n/a"]
[2410,"REF","REF02","Reference Identification","R","X",1,"AN",1,50,null,"R","n/a"]
["2420A",null,"","Rendering Provider Name","S","O",1,{"$nulls":4},"S"]
["2420A","NM1","","Rendering Provider Name","S","O",1,{"$nulls":4},"S"]
["2420A","NM1","NM101","Entity Identifier Code","R","M",1,"ID",2,3,"82 Rendering Provider","RNS","n/a"]
["2420A","NM1","NM102","Entity Type Qualifier","R","M",1,"ID",1,1,"1 Person\n2 Non-Person Entity","RNS","n/a"]
["2420A","NM1","NM103","Name Last or Organization Name","R","X",1,"AN",1,60,null,"R","n/a"]
["2420A","NM1","NM104","Name First","S","O",1,"AN",1,35,null,"S","n/a"]
["2420A","NM1","NM105","Name Middle","S","O",1,"AN",1,25,null,"S","n/a"]
["2420A","NM1","NM107","Name Suffix","S","O",1,"AN",1,10,null,"S","n/a"]
["2420A","NM1","NM108","Identification Code Qualifier","S","X",1,"ID",1,2,"XX Centers for Medicare and Medicaid Services national Provider Identifier","S","n/a"]
["2420A","NM1","NM109","Identification Code","S","X",1,"AN",2,80,null,"S","n/a"]
["2420A","PRV","","Rendering Provider Specialty Information","S","O",1,{"$nulls":4},"S"]
["2420A","PRV","PRV01","Provider Code","R","M",1,"ID",1,3,"PE Performing","RNS","n/a"]
["2420A","PRV","PRV02","Reference Identification Qualifier","R","X",1,"ID",2,3,"PXC Health Care Provider Taxonomy Code","RNS","n/a"]
["2420A","PRV","PRV03","Reference Identification","R","X",1,"AN",1,50,null,"R","n/a"]
["2420A","REF","","Rendering Provider Secondary Identification","S","O",20,{"$nulls":4},"S"]
["2420A","REF","REF01","Reference Identification Qualifier","R","M",1,"ID",2,3,"0B State License Number\n1G Provider UPIN Number\nG2 Provider Commercial Number\nLU Location Number","R","n/a"]
["2420A","REF","REF02","Reference Identification","R","X",1,"AN",1,50,null,"R","n/a"]
["2420A","REF","REF04","Reference Identifier","S","O",1,1,{"$nulls":3},"S"]
["2420A","REF","REF04 - 1","Reference Identification Qualifier","R","M",1,"ID",2,3,"2U Payer Identification Number","R","n/a"]
["2420A","REF","REF04 - 2","Reference Identification","R","M",1,"AN",1,50,null,"R","n/a"]
["2420B",null,"","Purchased Service Provider Name","S","O",1,{"$nulls":4},"S"]
["2420B","NM1","","Purchased Service Provider Name","S","O",1,{"$nulls":4},"S"]
["2420B","NM1","NM101","Entity Identifier Code","R","M",1,"ID",2,3,"QB Purchase Service Provider","RNS","n/a"]
["2420B","NM1","NM102","Entity Type Qualifier","R","M",1,"ID",1,1,"1 Person\n2 Non-Person Entity","RNS","n/a"]
["2420B","NM1","NM108","Identification Code Qualifier","S","X",1,"ID",1,2,"XX Centers for Medicare and Medicaid Services\nnational Provider Identifier","S","n/a"]
["2420B","NM1","NM109","Identification Code","S","X",1,"AN",2,80,null,"S","n/a"]
["2420B","REF","","Purchased Service Provider Secondary Identification","S","O",20,{"$nulls":4},"S"]
["2420B","REF","REF01","Reference Identification Qualifier","R","M",1,"ID",2,3,"0B State License Number\n1G Provider UPIN Number\nG2 Provider Commercial Number","R","n/a"]
["2420B","REF","REF02","Reference Identification","R","X",1,"AN",1,50,null,"R","n/a"]
["2420B","REF","REF04","REFERENCE IDENTIFIER","S","O",1,1,{"$nulls":3},"RNS","n/a"]
["2420B","REF","REF04 - 1","Reference Identification Qualifier","R","M",1,"ID",2,3,"2U Payer Identification Number","R","n/a"]
["2420B","REF","REF04 - 2","Reference Identification","R","M",1,"AN",1,50,null,"R","n/a"]
["2420C",null,"","Service Facility Location","S","O",1,{"$nulls":4},"S"]
["2420C","NM1","","Service Facility Location","S","O",1,{"$nulls":4},"S"]
["2420C","NM1","NM101","Entity Identifier Code","R","M",1,"ID",2,3,"77 Service Location","RNS","n/a"]
["2420C","NM1","NM102","Entity Type Qualifier","R","M",1,"ID",1,1,"2 Non-Person Entity","RNS","n/a"]
["2420C","NM1","NM103","Name Last or Organization Name","R","X",1,"AN",1,60,null,"R","n/a"]
["2420C","NM1","NM108","Identification Code Qualifier","S","X",1,"ID",1,2,"XX Centers for Medicare and Medicaid Services national Provider Identifier","S","n/a"]
["2420C","NM1","NM109","Identification Code","S","X",1,"AN",2,80,null,"S","n/a"]
["2420C","N3","","Service Facility Location Address","R","O",1,{"$nulls":4},"R"]
["2420C","N3","N301","Address Information","R","M",1,"AN",1,55,null,"R","n/a"]
["2420C","N3","N302","Address Information","S","O",1,"AN",1,55,null,"S","n/a"]
["2420C","N4","","Service Facility Location City, State, ZIP Code","R","O",1,{"$nulls":4},"R"]
["2420C","N4","N401","City Name","R","O",1,"AN",2,30,null,"R","n/a"]
["2420C","N4","N402","State or Province Code","S","X",1,"ID",2,2,null,"S","n/a"]
["2420C","N4","N403","Postal Code","S","O",1,"ID",3,15,null,"S","n/a"]
["2420C","N4","N404","Country Code","S","X",1,"ID",2,3,null,"S","n/a"]
["2420C","N4","N407","Country Subdivision Code","S","X",1,"ID",1,3,null,"SNS","n/a"]
["2420C","REF","","Service Facility Location Secondary Identification","S","O",3,{"$nulls":4},"S"]
["2420C","REF","REF01","Reference Identification Qualifier","R","M",1,"ID",2,3,"G2 Provider Commercial Number \nLU Location Number","R","n/a"]
["2420C","REF","REF02","Reference Identification","R","X",1,"AN",1,50,null,"R","n/a"]
["2420C","REF","REF04","REFERENCE IDENTIFIER","S","O",1,1,{"$nulls":3},"S"]
["2420C","REF","REF04 - 1","Reference Identification Qualifier","R","M",1,"ID",2,3,"2U Payer Identification Number","R","n/a"]
["2420C","REF","REF04 - 2","Reference Identification","R","M",1,"AN",1,50,null,"R","n/a"]
["2420D",null,"","Supervising Provider Name","S","O",1,{"$nulls":4},"S"]
["2420D","NM1","","Supervising Provider Name","S","O",1,{"$nulls":4},"S"]
["2420D","NM1","NM101","Entity Identifier Code","R","M",1,"ID",2,3,"DQ Supervising Physician","RNS","n/a"]
["2420D","NM1","NM102","Entity Type Qualifier","R","M",1,"ID",1,1,"1 Person","RNS","n/a"]
["2420D","NM1","NM103","Name Last or Organization Name","R","X",1,"AN",1,60,null,"R","n/a"]
["2420D","NM1","NM104","Name First","S","O",1,"AN",1,35,null,"S","n/a"]
["2420D","NM1","NM105","Name Middle","S","O",1,"AN",1,25,null,"S","n/a"]
["2420D","NM1","NM107","Name Suffix","S","O",1,"AN",1,10,null,"S","n/a"]
["2420D","NM1","NM108","Identification Code Qualifier","S","X",1,"ID",1,2,"XX Centers for Medicare and Medicaid Services national Provider Identifier","S","n/a"]
["2420D","NM1","NM109","Identification Code","S","X",1,"AN",2,80,null,"S","n/a"]
["2420D","REF","","Supervising Provider Secondary Identification","S","O",20,{"$nulls":4},"S"]
["2420D","REF","REF01","Reference Identification Qualifier","R","M",1,"ID",2,3,"0B State License Number\n1G Provider UPIN Number\nG2 Provider Commercial Number\nLU Location Number","R","n/a"]
["2420D","REF","REF02","Reference Identification","R","X",1,"AN",1,50,null,"R","n/a"]
["2420D","REF","REF04","Reference Identifier","S","O",1,{"$nulls":4},"S"]
["2420D","REF","REF04-1","Reference Identification Qualifier","R","M",1,"ID",2,3,"2U Payer Identification Number","R","n/a"]
["2420D","REF","REF04-2","Reference Identification Number","R","M",1,"AN",1,50,null,"R","n/a"]
["2420E",null,"","Ordering Provider Name","S","O",1,{"$nulls":4},"S"]
["2420E","NM1","","Ordering Provider Name","S","O",1,{"$nulls":4},"S"]
["2420E","NM1","NM101","Entity Identifier Code","R","M",1,"ID",2,3,"DK Ordering Physician","RNS","n/a"]
["2420E","NM1","NM102","Entity Type Qualifier","R","M",1,"ID",1,1,"1 Person","RNS","n/a"]
["2420E","NM1","NM103","Name Last or Organization Name","R","X",1,"AN",1,60,null,"R","n/a"]
["2420E","NM1","NM104","Name First","S","O",1,"AN",1,35,null,"S","n/a"]
["2420E","NM1","NM105","Name Middle","S","O",1,"AN",1,25,null,"S","n/a"]
["2420E","NM1","NM107","Name Suffix","S","O",1,"AN",1,10,null,"S","n/a"]
["2420E","NM1","NM108","Identification Code Qualifier","S","X",1,"ID",1,2,"XX Centers for Medicare and Medicaid Services national Provider Identifier","S","n/a"]
["2420E","NM1","NM109","Identification Code","S","X",1,"AN",2,80,null,"S","n/a"]
["2420E","N3","","Ordering Provider Address","S","O",1,{"$nulls":4},"S"]
["2420E","N3","N301","Address Information","R","M",1,"AN",1,55,null,"R","n/a"]
["2420E","N3","N302","Address Information","S","O",1,"AN",1,55,null,"S","n/a"]
["2420E","N4","","Ordering Provider City, State, ZIP Code","S","O",1,{"$nulls":4},"S"]
["2420E","N4","N401","City Name","R","O",1,"AN",2,30,null,"R","n/a"]
["2420E","N4","N402","State or Province Code","S","X",1,"ID",2,2,null,"S","n/a"]
["2420E","N4","N403","Postal Code","S","O",1,"ID",3,15,null,"S","n/a"]
["2420E","N4","N404","Country Code","S","X",1,"ID",2,3,null,"S","n/a"]
["2420E","N4","N407","Country Subdivision Code","S","X",1,"ID",1,3,null,"S","n/a"]
["2420E","REF","","Ordering Provider Secondary Identification","S","O",20,{"$nulls":4},"S"]
["2420E","REF","REF01","Reference Identification Qualifier","R","M",1,"ID",2,3,"0B State License Number\n1G Provider UPIN Number\nG2 Provider Commercial Number","R","n/a"]
["2420E","REF","REF02","Reference Identification","R","X",1,"AN",1,50,null,"R","n/a"]
["2420E","REF","REF04","Reference Identifier","S","O",1,{"$nulls":4},"S"]
["2420E","REF","REF04-1","Reference Identification Qualifier","R","M",1,"ID",2,3,"2U Payer Identification Number","R","n/a"]
["2420E","REF","REF04-2","Reference Identification Number","R","M",1,"AN",1,50,null,"R","n/a"]
["2420E","PER","","Ordering Provider Contact Information","S","O",1,{"$nulls":4},"S"]
["2420E","PER","PER01","Contact Function Code","R","M",1,"ID",2,2,"IC Information Contact","R","n/a"]
["2420E","PER","PER02","Name","S","O",1,"AN",1,60,null,"S","n/a"]
["2420E","PER","PER03","Communication Number Qualifier","R","X",1,"ID",2,2,"EM Electronic Mail\nFX Facsimile\nTE Telephone","R","n/a"]
["2420E","PER","PER04","Communication Number","R","X",1,"AN",1,256,null,"R","n/a"]
["2420E","PER","PER05","Communication Number Qualifier","S","X",1,"ID",2,2,"EM Electronic Mail\nEX Telephone Extension\nFX Facsimile\nTE Telephone","S","n/a"]
["2420E","PER","PER06","Communication Number","S","X",1,"AN",1,256,null,"S","n/a"]
["2420E","PER","PER07","Communication Number Qualifier","S","X",1,"ID",2,2,"EM Electronic Mail\nEX Telephone Extension\nFX Facsimile\nTE Telephone","S","n/a"]
["2420E","PER","PER08","Communication Number","S","X",1,"AN",1,256,null,"S","n/a"]
["2420F",null,"","Referring Provider Name","S","O",2,{"$nulls":4},"S"]
["2420F","NM1","","Referring Provider Name","S","O",1,{"$nulls":4},"S"]
["2420F","NM1","NM101","Entity Identifier Code","R","M",1,"ID",2,3,"DN Referring Provider\nP3 Primary Care Provider","RNS","n/a"]
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["2010AA","REF",null,"Billing Provider Tax Identification","R","O",1,{"$nulls":4},"R"]
["2010AA","REF","REF01","Reference Identification Qualifier","R","M",1,"ID",2,3,"EI Employer’s Identification Number ","R","n/a"]
["2010AA","REF","REF02","Reference Identification","R","X",1,"AN",1,50,null,"R","n/a"]
["2010AA","PER",null,"Billing Provider Contact Information","S","O",2,{"$nulls":4},"S"]
["2010AA","PER","PER01","Contact Function Code","R","M",1,"ID",2,2,"IC Information Contact ","RNS","n/a"]
["2010AA","PER","PER02","Name","S","O",1,"AN",1,60,null,"S","n/a"]
["2010AA","PER","PER03","Communication Number Qualifier","R","X",1,"ID",2,2,"EM Electronic Mail\nFX Facsimile\nTE Telephone ","R","n/a"]
["2010AA","PER","PER04","Communication Number","R","X",1,"AN",1,256,null,"R","n/a"]
["2010AA","PER","PER05","Communication Number Qualifier","S","X",1,"ID",2,2,"EM Electronic Mail\nEX Telephone Extension\nFX Facsimile\nTE Telephone\n","S","n/a"]
["2010AA","PER","PER06","Communication Number","S","X",1,"AN",1,256,null,"S","n/a"]
["2010AA","PER","PER07","Communication Number Qualifier","S","X",1,"ID",2,2,"EM Electronic Mail\nEX Telephone Extension\nFX Facsimile\nTE Telephone\n","S","n/a"]
["2010AA","PER","PER08","Communication Number","S","X",1,"AN",1,256,null,"S","n/a"]
["2010AB",null,null,"Pay-to Address Name","S","O",1,{"$nulls":4},"S"]
["2010AB","NM1",null,"Pay-to Address Name","S","O",1,{"$nulls":4},"S"]
["2010AB","NM1","NM101","Entity Identifier Code","R","M",1,"ID",2,3,"87 Pay-to Provider\n","RNS","n/a"]
["2010AB","NM1","NM102","Entity Type Qualifier","R","M",1,"ID",1,1,"2 Non-Person Entity ","RNS","n/a"]
["2010AB","N3",null,"Pay-To Address - ADDRESS","R","O",1,{"$nulls":4},"R"]
["2010AB","N3","N301","Address Information","R","M",1,"AN",1,55,null,"R","n/a"]
["2010AB","N3","N302","Address Information","S","O",1,"AN",1,55,null,"S","n/a"]
["2010AB","N4",null,"Pay-to Address City, State, ZIP Code","R","O",1,{"$nulls":4},"R"]
["2010AB","N4","N401","City Name","R","O",1,"AN",2,30,null,"R","n/a"]
["2010AB","N4","N402","State or Province Code","S","X",1,"ID",2,2,null,"S","n/a"]
["2010AB","N4","N403","Postal Code","S","O",1,"ID",3,15,null,"S","n/a"]
["2010AB","N4","N404","Country Code","S","X",1,"ID",2,3,null,"S","n/a"]
["2010AB","N4","N407","Country Subdivision Code","S","X",1,"ID",1,3,null,"S","n/a"]
["2010AC",null,null,"Pay-To Plan Name","S","O",1,{"$nulls":4},"S"]
["2010AC","NM1",null,"Pay-To Plan Name","S","O",1,{"$nulls":4},"S"]
["2010AC","NM1","NM101","Entity Identifier Code","R","M",1,"ID",2,3,"PE Payee ","RNS","n/a"]
["2010AC","NM1","NM102","Entity Type Qualifier","R","M",1,"ID",1,1,"2 Non-Person Entity ","RNS","n/a"]
["2010AC","NM1","NM103","Name Last or Organization Name","R","X",1,"AN",1,60,null,"R","n/a"]
["2010AC","NM1","NM108","Identification Code Qualifier","R","X",1,"ID",1,2,"PI Payor Identification\nXV Centers for Medicare and Medicaid Services PlanID\n","R","n/a"]
["2010AC","NM1","NM109","Identification Code","R","X",1,"AN",2,80,null,"R","n/a"]
["2010AC","N3",null,"Pay-To Plan Address","R","O",1,{"$nulls":4},"R"]
["2010AC","N3","N301","Address Information","R","M",1,"AN",1,55,null,"R","n/a"]
["2010AC","N3","N302","Address Information","S","O",1,"AN",1,55,null,"S","n/a"]
["2010AC","N4",null,"Pay-To Plan City/State/Zip Code","R","O",1,{"$nulls":4},"R"]
["2010AC","N4","N401","City Name","R","O",1,"AN",2,30,null,"R","n/a"]
["2010AC","N4","N402","State or Province Code","S","X",1,"ID",2,2,null,"S","n/a"]
["2010AC","N4","N403","Postal Code","S","O",1,"ID",3,15,null,"S","n/a"]
["2010AC","N4","N404","Country Code","S","X",1,"ID",2,3,null,"S","n/a"]
["2010AC","N4","N407","Country Subdivision Code","S","X",1,"ID",1,3,null,"S","n/a"]
["2010AC","REF",null,"Pay-To Plan Secondary Identification","S","O",1,{"$nulls":4},"S"]
["2010AC","REF","REF01","Reference Identification Qualifier","R","M",1,"ID",2,3,"2U Payer Identification Number \nFY Claim Office Number\nNF National Association of Insurance Commissioners (NAIC) Code\n","R","n/a"]
["2010AC","REF","REF02","Reference Identification","R","X",1,"AN",1,50,null,"R","n/a"]
["2010AC","REF",null,"Pay-To Tax Identification Number","R","O",1,{"$nulls":4},"R"]
["2010AC","REF","REF01","Reference Identification Qualifier","R","M",1,"ID",2,3,"EI Employer’s Identification Number ","RNS","n/a"]
["2010AC","REF","REF02","Reference Identification","R","X",1,"AN",1,50,null,"R","n/a"]
["2000B",null,null,"Subscriber Hierarchical Level","R","M",">1",{"$nulls":4},"R"]
["2000B","HL",null,"Subscriber Hierarchical Level","R","M",1,{"$nulls":4},"R"]
["2000B","HL","HL01","Hierarchical ID Number","R","M",1,"AN",1,12,null,"RNS","n/a"]
["2000B","HL","HL02","Hierarchical Parent ID Number","R","O",1,"AN",1,12,null,"RNS","n/a"]
["2000B","HL","HL03","Hierarchical Level Code","R","M",1,"ID",1,2,"22 Subscriber ","RNS","n/a"]
["2000B","HL","HL04","Hierarchical Child Code","R","O",1,"ID",1,1,"0 No Subordinate HL Segment in This Hierarchical Structure.\n1 Additional Subordinate HL Data Segment in This Hierarchical Structure.","RNS","n/a"]
["2000B","SBR",null,"Subscriber Information","R","O",1,{"$nulls":4},"R"]
["2000B","SBR","SBR01","Payer Responsibility Sequence Number Code","R","M",1,"ID",1,1,"A Payer Responsibility Four\nB Payer Responsibility Five\nC Payer Responsibility Six\nD Payer Responsibility Seven\nE Payer Responsibility Eight\nF Payer Responsibility Nine\nG Payer Responsibility Ten\nH Payer Responsibility Eleven\nP Primary\nS Secondary\nT Tertiary\nU Unknown","R","n/a"]
["2000B","SBR","SBR02","Individual Relationship Code","S","O",1,"ID",2,2,"18 Self ","S","n/a"]
["2000B","SBR","SBR03","Reference Identification","S","O",1,"AN",1,50,null,"S","n/a"]
["2000B","SBR","SBR04","Name","S","O",1,"AN",1,60,null,"S","n/a"]
["2000B","SBR","SBR09","Claim Filing Indicator Code","S","O",1,"ID",1,2,"11 Other Non-Federal Programs\n12 Preferred Provider Organization (PPO)\n13 Point of Service (POS)\n14 Exclusive Provider Organization (EPO)\n15 Indemnity Insurance\n16 Health Maintenance Organization (HMO) Medicare Risk\n17 Dental Maintenance Organization\nAM Automobile Medical\nBL Blue Cross/Blue Shield\nCH Champus\nCI Commercial Insurance Co.\nDS Disability\nFI Federal Employees Program\nHM Health Maintenance Organization\nLM Liability Medical\nMA Medicare Part A\nMB Medicare Part B\nMC Medicaid\nOF Other Federal Program \nTV Title V\nVA Veterans Affairs Plan\nWC Workers’ Compensation Health Claim\nZZ Mutually Defined ","S","n/a"]
["2010BA",null,null,"Subscriber Name","R","O",1,{"$nulls":4},"R"]
["2010BA","NM1",null,"Subscriber Name","R","O",1,{"$nulls":4},"R"]
["2010BA","NM1","NM101","Entity Identifier Code","R","M",1,"ID",2,3,"IL Insured or Subscriber\n","RNS","n/a"]
["2010BA","NM1","NM102","Entity Type Qualifier","R","M",1,"ID",1,1,"1 Person\n2 Non-Person Entity ","RNS","n/a"]
["2010BA","NM1","NM103","Name Last or Organization Name","R","X",1,"AN",1,60,null,"R","n/a"]
["2010BA","NM1","NM104","Name First","S","O",1,"AN",1,35,null,"S","n/a"]
["2010BA","NM1","NM105","Name Middle","S","O",1,"AN",1,25,null,"S","n/a"]
["2010BA","NM1","NM107","Name Suffix","S","O",1,"AN",1,10,null,"S","n/a"]
["2010BA","NM1","NM108","Identification Code Qualifier","S","X",1,"ID",1,2,"II Standard Unique Health Identifier for each Individual in the United States \nMI Member Identification Number","S","n/a"]
["2010BA","NM1","NM109","Identification Code","S","X",1,"AN",2,80,null,"S","n/a"]
["2010BA","N3",null,"Subscriber Address","S","O",1,{"$nulls":4},"S"]
["2010BA","N3","N301","Address Information","R","M",1,"AN",1,55,null,"R","n/a"]
["2010BA","N3","N302","Address Information","S","O",1,"AN",1,55,null,"S","n/a"]
["2010BA","N4",null,"Subscriber City, State, ZIP Code","S","O",1,{"$nulls":4},"S"]
["2010BA","N4","N401","City Name","R","O",1,"AN",2,30,null,"R","n/a"]
["2010BA","N4","N402","State or Province Code","S","X",1,"ID",2,2,null,"S","n/a"]
["2010BA","N4","N403","Postal Code","S","O",1,"ID",3,15,null,"S","n/a"]
["2010BA","N4","N404","Country Code","S","X",1,"ID",2,3,null,"S","n/a"]
["2010BA","N4","N407","Country Subdivision Code","S","X",1,"ID",1,3,null,"S","n/a"]
["2010BA","DMG",null,"Subscriber Demographic Information","S","O",1,{"$nulls":4},"S"]
["2010BA","DMG","DMG01","Date Time Period Format Qualifier","R","X",1,"ID",2,3,"D8 Date Expressed in Format CCYYMMDD","RNS","n/a"]
["2010BA","DMG","DMG02","Date Time Period","R","X",1,"AN",1,35,null,"R","n/a"]
["2010BA","DMG","DMG03","Gender Code","R","O",1,"ID",1,1,"F Female\nM Male\nU Unknown ","R","n/a"]
["2010BA","REF",null,"Subscriber Secondary Identification","S","O",1,{"$nulls":4},"S"]
["2010BA","REF","REF01","Reference Identification Qualifier","R","M",1,"ID",2,3,"SY Social Security Number ","R","n/a"]
["2010BA","REF","REF02","Reference Identification","R","X",1,"AN",1,50,null,"R","n/a"]
["2010BA","REF",null,"Property and Casualty Claim Number","S","O",1,{"$nulls":4},"S"]
["2010BA","REF","REF01","Reference Identification Qualifier","R","M",1,"ID",2,3,"Y4 Agency Claim Number ","RNS","n/a"]
["2010BA","REF","REF02","Reference Identification","R","X",1,"AN",1,50,null,"R","n/a"]
["2010BB",null,null,"Payer Name","R","O",1,{"$nulls":4},"R"]
["2010BB","NM1",null,"Payer Name","R","O",1,{"$nulls":4},"R"]
["2010BB","NM1","NM101","Entity Identifier Code","R","M",1,"ID",2,3,"PR Payer\n","RNS","n/a"]
["2010BB","NM1","NM102","Entity Type Qualifier","R","M",1,"ID",1,1,"2 Non-Person Entity ","RNS","n/a"]
["2010BB","NM1","NM103","Name Last or Organization Name","R","X",1,"AN",1,60,null,"RNS","n/a"]
["2010BB","NM1","NM108","Identification Code Qualifier","R","X",1,"ID",1,2,"PI Payor Identification\nXV Centers for Medicare and Medicaid Services PlanID","RNS","n/a"]
["2010BB","NM1","NM109","Identification Code","R","X",1,"AN",2,80,null,"RNS","n/a"]
["2010BB","N3",null,"Payer Address","S","O",1,{"$nulls":4},"S"]
["2010BB","N3","N301","Address Information","R","M",1,"AN",1,55,null,"RNS","n/a"]
["2010BB","N3","N302","Address Information","S","O",1,"AN",1,55,null,"SNS","n/a"]
["2010BB","N4",null,"Payer City, State, ZIP Code","S","O",1,{"$nulls":4},"S"]
["2010BB","N4","N401","City Name","R","O",1,"AN",2,30,null,"RNS","n/a"]
["2010BB","N4","N402","State or Province Code","S","X",1,"ID",2,2,null,"SNS","n/a"]
["2010BB","N4","N403","Postal Code","S","O",1,"ID",3,15,null,"SNS","n/a"]
["2010BB","N4","N404","Country Code","S","X",1,"ID",2,3,null,"SNS","n/a"]
["2010BB","N4","N407","Country Subdivision Code","S","X",1,"ID",1,3,null,"SNS","n/a"]
["2010BB","REF",null,"Payer Secondary Identification","S","O",3,{"$nulls":4},"S"]
["2010BB","REF","REF01","Reference Identification Qualifier","R","M",1,"ID",2,3,"2U Payer Identification Number\nEI Employer’s Identification Number\nFY Claim Office Number\nNF National Association of Insurance Commissioners (NAIC) Code","RNS","n/a"]
["2010BB","REF","REF02","Reference Identification","R","X",1,"AN",1,50,null,"RNS","n/a"]
["2010BB","REF",null,"Billing Provider Secondary Identification","S","O",1,{"$nulls":4},"S"]
["2010BB","REF","REF01","Reference Identification Qualifier","R","M",1,"ID",2,3,"G2 Provider Commercial Number \nLU Location Number\n","R","n/a"]
["2010BB","REF","REF02","Reference Identification","R","X",1,"AN",1,50,null,"R","n/a"]
["2000C",null,null,"Patient Hierarchical Level","S","O",">1",{"$nulls":4},"NU"]
["2000C","HL",null,"Patient Hierarchical Level","S","O",1,{"$nulls":4},"NU"]
["2000C","HL","HL01","Hierarchical ID Number","R","M",1,"AN",1,12,null,"NU","n/a"]
["2000C","HL","HL02","Hierarchical Parent ID Number","R","O",1,"AN",1,12,null,"NU","n/a"]
["2000C","HL","HL03","Hierarchical Level Code","R","M",1,"ID",1,2,"23 Dependent ","NU","n/a"]
["2000C","HL","HL04","Hierarchical Child Code","R","O",1,"ID",1,1,"0 No Subordinate HL Segment in This Hierarchical Structure","NU","n/a"]
["2000C","PAT",null,"Patient Information","R","O",1,{"$nulls":4},"NU"]
["2000C","PAT","PAT01","Individual Relationship Code","R","O",1,"ID",2,2,"01 Spouse\n19 Child\n20 Employee\n21 Unknown\n39 Organ Donor\n40 Cadaver Donor\n53 Life Partner\nG8 Other Relationship","NU","n/a"]
["2010CA",null,null,"Patient Name","R","O",1,{"$nulls":4},"NU"]
["2010CA","NM1",null,"Patient Name","R","O",1,{"$nulls":4},"NU"]
["2010CA","NM1","NM101","Entity Identifier Code","R","M",1,"ID",2,3,"QC Patient ","NU","n/a"]
["2010CA","NM1","NM102","Entity Type Qualifier","R","M",1,"ID",1,1,"1 Person\n","NU","n/a"]
["2010CA","NM1","NM103","Name Last or Organization Name","R","X",1,"AN",1,60,null,"NU","n/a"]
["2010CA","NM1","NM104","Name First","S","O",1,"AN",1,35,null,"NU","n/a"]
["2010CA","NM1","NM105","Name Middle","S","O",1,"AN",1,25,null,"NU","n/a"]
["2010CA","NM1","NM107","Name Suffix","S","O",1,"AN",1,10,null,"NU","n/a"]
["2010CA","N3",null,"Patient Address","R","O",1,{"$nulls":4},"NU"]
["2010CA","N3","N301","Address Information","R","M",1,"AN",1,55,null,"NU","n/a"]
["2010CA","N3","N302","Address Information","S","O",1,"AN",1,55,null,"NU","n/a"]
["2010CA","N4",null,"Patient City/State/ZIP Code","R","O",1,{"$nulls":4},"NU"]
["2010CA","N4","N401","City Name","R","O",1,"AN",2,30,null,"NU","n/a"]
["2010CA","N4","N402","State or Province Code","S","X",1,"ID",2,2,null,"NU","n/a"]
["2010CA","N4","N403","Postal Code","S","O",1,"ID",3,15,null,"NU","n/a"]
["2010CA","N4","N404","Country Code","S","X",1,"ID",2,3,null,"NU","n/a"]
["2010CA","N4","N407","Country Subdivision Code","S","X",1,"ID",1,3,null,"NU","n/a"]
["2010CA","DMG",null,"Patient Demographic Information","R","O",1,{"$nulls":4},"NU"]
["2010CA","DMG","DMG01","Date Time Period Format Qualifier","R","X",1,"ID",2,3,"D8 Date Expressed in Format CCYYMMDD","NU","n/a"]
["2010CA","DMG","DMG02","Date Time Period","R","X",1,"AN",1,35,null,"NU","n/a"]
["2010CA","DMG","DMG03","Gender Code","R","O",1,"ID",1,1,"F Female\nM Male\nU Unknown ","NU","n/a"]
["2010CA","REF",null,"Property and Casualty Claim Number","S","O",1,{"$nulls":4},"NU"]
["2010CA","REF","REF01","Reference Identification Qualifier","R","M",1,"ID",2,3,"Y4 Agency Claim Number ","NU","n/a"]
["2010CA","REF","REF02","Reference Identification","R","X",1,"AN",1,50,null,"NU","n/a"]
["2010CA","REF",null,"Property and Casualty Patient Identifier","S","O",1,{"$nulls":4},"NU"]
["2010CA","REF","REF01","Reference Identification Qualifier","R","M",1,"ID",2,3,"1W Member Identification Number \nSY Social Security Number","NU","n/a"]
["2010CA","REF","REF02","Reference Identification","R","X",1,"AN",1,50,null,"NU","n/a"]
[2300,null,null,"Claim information","R","O",100,{"$nulls":4},"R"]
[2300,"CLM",null,"Claim information","R","O",1,{"$nulls":4},"R"]
[2300,"CLM","CLM01","Claim Submitter's Identifier","R","M",1,"AN",1,38,null,"R","n/a"]
[2300,"CLM","CLM02","Monetary Amount","R","O",1,"R",1,18,null,"R","n/a"]
[2300,"CLM","CLM05","Health Care Service Location Information","R","O",1,{"$nulls":4},"R"]
[2300,"CLM","CLM05-1","Facility Code Value","R","M",1,"AN",1,2,null,"R","n/a"]
[2300,"CLM","CLM05-2","Facility Code Qualifier","R","O",1,"ID",1,2,"A Uniform Billing Claim Form Bill Type\n","R","n/a"]
[2300,"CLM","CLM05-3","Claim Frequency Type Code","R","O",1,"ID",1,1,null,"R","n/a"]
[2300,"CLM","CLM07","Provider Accept Assignment Code","R","O",1,"ID",1,1,"A Assigned \nB Assignment Accepted on Clinical Lab Services Only \nC Not Assigned ","R","n/a"]
[2300,"CLM","CLM08","Yes/No Condition or Response Code","R","O",1,"ID",1,1,"N No\nW Not Applicable \nY Yes\n","R","n/a"]
[2300,"CLM","CLM09","Release of Information Code","R","O",1,"ID",1,1,"I Informed Consent to Release Medical Information for Conditions or Diagnoses Regulated by Federal Statutes \nY Yes, Provider has a Signed Statement Permitting Release of Medical Billing Data Related to a Claim ","R","n/a"]
[2300,"CLM","CLM20","Delay Reason Code","S","O",1,"ID",1,2,"1 Proof of Eligibility Unknown or Unavailable\n2 Litigation\n3 Authorization Delays\n4 Delay in Certifying Provider\n5 Delay in Supplying Billing Forms\n6 Delay in Delivery of Custom-made Appliances\n7 Third Party Processing Delay\n8 Delay in Eligibility Determination\n9 Original Claim Rejected or Denied Due to a Reason Unrelated to the Billing Limitation Rules\n10 Administration Delay in the Prior Approval Process\n11 Other\n15 Natural Disaster\n","S","n/a"]
[2300,"DTP",null,"Discharge Hour","S","O",1,{"$nulls":4},"S"]
[2300,"DTP","DTP01","Date/Time Qualifier","R","M",1,"ID",3,3,"096 Discharge ","RNS","n/a"]
[2300,"DTP","DTP02","Date Time Period Format Qualifier","R","M",1,"ID",2,3,"TM Time Expressed in Format HHMM ","RNS","n/a"]
[2300,"DTP","DTP03","Date Time Period","R","M",1,"AN",1,35,null,"R","n/a"]
[2300,"DTP",null,"Statement Dates","R","O",1,{"$nulls":4},"R"]
[2300,"DTP","DTP01","Date/Time Qualifier","R","M",1,"ID",3,3,"434 Statement ","RNS","n/a"]
[2300,"DTP","DTP02","Date Time Period Format Qualifier","R","M",1,"ID",2,3,"RD8 Range of Dates Expressed in Format CCYYMMDDCCYYMMDD ","RNS","n/a"]
[2300,"DTP","DTP03","Date Time Period","R","M",1,"AN",1,35,null,"R","n/a"]
[2300,"DTP",null,"Admission Date/Hour","S","O",1,{"$nulls":4},"S"]
[2300,"DTP","DTP01","Date/Time Qualifier","R","M",1,"ID",3,3,"435 Admission ","RNS","n/a"]
[2300,"DTP","DTP02","Date Time Period Format Qualifier","R","M",1,"ID",2,3,"D8 Date Expressed in Format CCYYMMDD\nDT Date and Time Expressed in Format CCYYMMDDHHMM ","RNS","n/a"]
[2300,"DTP","DTP03","Date Time Period","R","M",1,"AN",1,35,null,"R","n/a"]
[2300,"DTP",null,"Date - Repricer Received Date","S","O",1,{"$nulls":4},"S"]
[2300,"DTP","DTP01","Date/Time Qualifier","R","M",1,"ID",3,3,"050 Received ","RNS","n/a"]
[2300,"DTP","DTP02","Date Time Period Format Qualifier","R","M",1,"ID",2,3,"D8 Date Expressed in Format CCYYMMDD ","RNS","n/a"]
[2300,"DTP","DTP03","Date Time Period","R","M",1,"AN",1,35,null,"R","n/a"]
[2300,"CL1",null,"Institutional Claim Code","R","O",1,{"$nulls":4},"R"]
[2300,"CL1","CL101","Admission Type Code","R","O",1,"ID",1,1,null,"R","n/a"]
[2300,"CL1","CL102","Admission Source Code","S","O",1,"ID",1,1,null,"S","n/a"]
[2300,"CL1","CL103","Patient Status Code","R","O",1,"ID",1,2,null,"R","n/a"]
[2300,"PWK",null,"Claim Supplemental Information","S","O",10,{"$nulls":4},"S"]
[2300,"PWK","PWK01","Report Type Code","R","M",1,"ID",2,2,"03 Report Justifying Treatment Beyond Utilization Guidelines\n04 Drugs Administered\n05 Treatment Diagnosis\n06 Initial Assessment\n07 Functional Goals\n08 Plan of Treatment\n09 Progress Report\n10 Continued Treatment\n11 Chemical Analysis\n13 Certified Test Report\n15 Justification for Admission\n21 Recovery Plan\nA3 Allergies/Sensitivities Document\nA4 Autopsy Report\nAM Ambulance Certification\nAS Admission Summary\nB2 Prescription\nB3 Physician Order\nB4 Referral Form\nBR Benchmark Testing Results\nBS Baseline\nBT Blanket Test Results\nCB Chiropractic Justification\nCK Consent Form(s)\nCT Certification\nD2 Drug Profile Document\nDA Dental Models\nDB Durable Medical Equipment Prescription\nDG Diagnostic Report\nDJ Discharge Monitoring Report\nDS Discharge Summary\nEB Explanation of Benefits (Coordination of Benefits or Medicare Secondary Payor)\nHC Health Certificate\nHR Health Clinic Records\nI5 Immunization Record\nIR State School Immunization Records\nLA Laboratory Results\nM1 Medical Record Attachment\nMT Models\nNN Nursing Notes\nOB Operative Note\nOC Oxygen Content Averaging Report\nOD Orders and Treatments Document\nOE Objective Physical Examination (including vital signs) Document\nOX Oxygen Therapy Certification\nOZ Support Data for Claim\nP4 Pathology Report\nP5 Patient Medical History Document\nPE Parenteral or Enteral Certification\nPN Physical Therapy Notes\nPO Prosthetics or Orthotic Certification\nPQ Paramedical Results\nPY Physician’s Report\nPZ Physical Therapy Certification\nRB Radiology Films\nRR Radiology Reports\nRT Report of Tests and Analysis Report\nRX Renewable Oxygen Content Averaging Report\nSG Symptoms Document\nV5 Death Notification\nXP Photographs","R","n/a"]
[2300,"PWK","PWK02","Report Transmission Code","R","O",1,"ID",1,2,"AA Available on Request at Provider Site \nBM By Mail\nEL Electronically Only \nEM E-Mail\nFT File Transfer \nFX By Fax ","R","n/a"]
[2300,"PWK","PWK05","Identification Code Qualifier","S","X",1,"ID",1,2,"AC Attachment Control Number","S","n/a"]
[2300,"PWK","PWK06","Identification Code","S","X",1,"AN",2,80,null,"S","n/a"]
[2300,"CN1",null,"Contract Information","S","O",1,{"$nulls":4},"S"]
[2300,"CN1","CN101","Contract Type Code","R","M",1,"ID",2,2,"01 Diagnosis Related Group (DRG)\n02 Per Diem\n03 Variable Per Diem\n04 Flat\n05 Capitated\n06 Percent\n09 Other ","R","n/a"]
[2300,"CN1","CN102","Monetary Amount","S","O",1,"R",1,18,null,"S","n/a"]
[2300,"CN1","CN103","Percent, Decimal Format","S","O",1,"R",1,6,null,"S","n/a"]
[2300,"CN1","CN104","Reference Identification","S","O",1,"AN",1,50,null,"S","n/a"]
[2300,"CN1","CN105","Terms Discount Percent","S","O",1,"R",1,6,null,"S","n/a"]
[2300,"CN1","CN106","Version Identifier","S","O",1,"AN",1,30,null,"S","n/a"]
[2300,"AMT",null,"Patient Estimated Amount Due","S","O",1,{"$nulls":4},"S"]
[2300,"AMT","AMT01","Amount Qualifier Code","R","M",1,"ID",1,3,"F3 Patient Responsibility - Estimated ","RNS","n/a"]
[2300,"AMT","AMT02","Monetary Amount","R","M",1,"R",1,18,null,"R","n/a"]
[2300,"REF",null,"Service Authorization Exception Code","S","O",1,{"$nulls":4},"S"]
[2300,"REF","REF01","Reference Identification Qualifier","R","M",1,"ID",2,3,"4N Special Payment Reference Number ","RNS","n/a"]
[2300,"REF","REF02","Reference Identification","R","X",1,"AN",1,50,"1 Immediate/Urgent Care \n2 Services Rendered in a Retroactive Period \n3 Emergency Care \n4 Client has Temporary Medicaid \n5 Request from County for Second Opinion to Determine if Recipient Can Work \n6 Request for Override Pending \n7 Special Handling\n\n","R","n/a"]
[2300,"REF",null,"Referral Number","S","O",1,{"$nulls":4},"S"]
[2300,"REF","REF01","Reference Identification Qualifier","R","M",1,"ID",2,3,"9F Referral Number ","RNS","n/a"]
[2300,"REF","REF02","Reference Identification","R","X",1,"AN",1,50,null,"R","n/a"]
[2300,"REF",null,"Prior Authorization","S","O",1,{"$nulls":4},"S"]
[2300,"REF","REF01","Reference Identification Qualifier","R","M",1,"ID",2,3,"G1 Prior Authorization Number\n","RNS","n/a"]
[2300,"REF","REF02","Reference Identification","R","X",1,"AN",1,50,null,"R","n/a"]
[2300,"REF",null,"Payer Claim Control Number","S","O",1,{"$nulls":4},"S"]
[2300,"REF","REF01","Reference Identification Qualifier","R","M",1,"ID",2,3,"F8 Original Reference Number ","RNS","n/a"]
[2300,"REF","REF02","Reference Identification","R","X",1,"AN",1,50,null,"R","n/a"]
[2300,"REF",null,"Repriced Claim Number","S","O",1,{"$nulls":4},"S"]
[2300,"REF","REF01","Reference Identification Qualifier","R","M",1,"ID",2,3,"9A Repriced Claim Reference Number ","RNS","n/a"]
[2300,"REF","REF02","Reference Identification","R","X",1,"AN",1,50,null,"R","n/a"]
[2300,"REF",null,"Adjusted Repriced Claim Number","S","O",1,{"$nulls":4},"S"]
[2300,"REF","REF01","Reference Identification Qualifier","R","M",1,"ID",2,3,"9C Adjusted Repriced Claim Reference Number ","RNS","n/a"]
[2300,"REF","REF02","Reference Identification","R","X",1,"AN",1,50,null,"R","n/a"]
[2300,"REF",null,"Investigational Device Exemption Number","S","O",5,{"$nulls":4},"S"]
[2300,"REF","REF01","Reference Identification Qualifier","R","M",1,"ID",2,3,"LX Qualified Products List ","RNS","n/a"]
[2300,"REF","REF02","Reference Identification","R","X",1,"AN",1,50,null,"R","n/a"]
[2300,"REF",null,"Claim Identifier For Transmission Intermediaries","S","O",1,{"$nulls":4},"S"]
[2300,"REF","REF01","Reference Identification Qualifier","R","M",1,"ID",2,3,"D9 Claim Number\n","RNS","n/a"]
[2300,"REF","REF02","Reference Identification","R","X",1,"AN",1,50,null,"R","n/a"]
[2300,"REF",null,"Auto Accident State","S","O",1,{"$nulls":4},"S"]
[2300,"REF","REF01","Reference Identification Qualifier","R","M",1,"ID",2,3,"LU Location Number ","RNS","n/a"]
[2300,"REF","REF02","Reference Identification","R","X",1,"AN",1,50,null,"R","n/a"]
[2300,"REF",null,"Medical Record Number","S","O",1,{"$nulls":4},"S"]
[2300,"REF","REF01","Reference Identification Qualifier","R","M",1,"ID",2,3,"EA Medical Record Identification Number ","RNS","n/a"]
[2300,"REF","REF02","Reference Identification","R","X",1,"AN",1,50,null,"R","n/a"]
[2300,"REF",null,"Demonstration Project Identifier","S","O",1,{"$nulls":4},"S"]
[2300,"REF","REF01","Reference Identification Qualifier","R","M",1,"ID",2,3,"P4 Project Code ","RNS","n/a"]
[2300,"REF","REF02","Reference Identification","R","X",1,"AN",1,50,null,"R","n/a"]
[2300,"REF",null,"Peer Review Organization (PRO) Approval Number","S","O",1,{"$nulls":4},"S"]
[2300,"REF","REF01","Reference Identification Qualifier","R","M",1,"ID",2,3,"G4 Peer Review Organization (PRO) Approval Number ","RNS","n/a"]
[2300,"REF","REF02","Reference Identification","R","X",1,"AN",1,50,null,"R","n/a"]
[2300,"K3",null,"File Information","S","O",10,{"$nulls":4},"S"]
[2300,"K3","K301","Fixed Format Information","R","M",1,"AN",1,80,null,"R","n/a"]
[2300,"NTE",null,"Claim Note","S","O",10,{"$nulls":4},"S"]
[2300,"NTE","NTE01","Note Reference Code","R","O",1,"ID",3,3,"ALG Allergies\nDCP Goals, Rehabilitation Potential, or Discharge Plans\nDGN Diagnosis Description\nDME Durable Medical Equipment (DME) and Supplies\nMED Medications\nNTR Nutritional Requirements\nODT Orders for Disciplines and Treatments\nRHB Functional Limitations, Reason Homebound, or Both\nRLH Reasons Patient Leaves Home\nRNH Times and Reasons Patient Not at Home\nSET Unusual Home, Social Environment, or Both\nSFM Safety Measures\nSPT Supplementary Plan of Treatment\nUPI Updated Information ","R","n/a"]
[2300,"NTE","NTE02","Description","R","M",1,"AN",1,80,null,"R","n/a"]
[2300,"NTE",null,"Billing Note","S","O",1,{"$nulls":4},"S"]
[2300,"NTE","NTE01","Note Reference Code","R","O",1,"ID",3,3,"ADD Additional Information ","R","n/a"]
[2300,"NTE","NTE02","Description","R","M",1,"AN",1,80,null,"R","n/a"]
[2300,"CRC",null,"EPSDT Referral","S","O",1,{"$nulls":4},"S"]
[2300,"CRC","CRC01","Code Category","R","M",1,"ID",2,2,"ZZ Mutually Defined ","R","n/a"]
[2300,"CRC","CRC02","Yes/No Condition or Response Code","R","M",1,"ID",1,1,"N No \nY Yes ","R","n/a"]
[2300,"CRC","CRC03","Condition Indicator","R","M",1,"ID",2,3,"AV Available - Not Used \nNU Not Used \nS2 Under Treatment\nST New Services Requested","R","n/a"]
[2300,"CRC","CRC04","Condition Indicator","S","O",1,"ID",2,3,"AV Available - Not Used \nNU Not Used \nS2 Under Treatment\nST New Services Requested","S","n/a"]
[2300,"CRC","CRC05","Condition Indicator","S","O",1,"ID",2,3,"AV Available - Not Used \nNU Not Used \nS2 Under Treatment\nST New Services Requested","S","n/a"]
[2300,"HI",null,"Principal Diagnosis","R","O",1,{"$nulls":4},"R"]
[2300,"HI","HI01","Health Care Code Information","R","M",1,{"$nulls":4},"R"]
[2300,"HI","HI01-1","Code List Qualifier Code","R","M",1,"ID",1,3,"ABK International Classification of Diseases Clinical Modification (ICD-10-CM) Principal Diagnosis \nBK International Classification of Diseases Clinical Modification (ICD-9-CM) Principal Diagnosis\n","RNS","n/a"]
[2300,"HI","HI01-2","Industry Code","R","M",1,"AN",1,30,null,"R","n/a"]
[2300,"HI","HI01-9","Yes/No Condition or Response Code","S","X",1,"ID",1,1,"N No\nU Unknown\nW Not Applicable\nY Yes ","S","n/a"]
[2300,"HI",null,"Admitting Diagnosis","S","O",1,{"$nulls":4},"S"]
[2300,"HI","HI01","Health Care Code Information","R","M",1,{"$nulls":4},"R"]
[2300,"HI","HI01-1","Code List Qualifier Code","R","M",1,"ID",1,3,"ABJ International Classification of Diseases Clinical Modification (ICD-10-CM) Admitting Diagnosis \nBJ International Classification of Diseases Clinical Modification (ICD-9-CM) Admitting Diagnosis\n","RNS","n/a"]
[2300,"HI","HI01-2","Industry Code","R","M",1,"AN",1,30,null,"R","n/a"]
[2300,"HI",null,"Patient's Reason For Visit","S","O",1,{"$nulls":4},"S"]
[2300,"HI","HI01","Health Care Code Information","R","M",1,{"$nulls":4},"R"]
[2300,"HI","HI01-1","Code List Qualifier Code","R","M",1,"ID",1,3,"APR International Classification of Diseases Clinical Modification (ICD-10-CM) Patient’s Reason for Visit \nPR International Classification of Diseases Clinical Modification (ICD-9-CM) Patient’s Reason for Visit","RNS","n/a"]
[2300,"HI","HI01-2","Industry Code","R","M",1,"AN",1,30,null,"R","n/a"]
[2300,"HI","HI02","Health Care Code Information","S","O",1,{"$nulls":4},"S"]
[2300,"HI","HI02-1","Code List Qualifier Code","R","M",1,"ID",1,3,"APR International Classification of Diseases Clinical Modification (ICD-10-CM) Patient’s Reason for Visit \nPR International Classification of Diseases Clinical Modification (ICD-9-CM) Patient’s Reason for Visit","RNS","n/a"]
[2300,"HI","HI02-2","Industry Code","R","M",1,"AN",1,30,null,"R","n/a"]
[2300,"HI","HI03","Health Care Code Information","S","O",1,{"$nulls":4},"S"]
[2300,"HI","HI03-1","Code List Qualifier Code","R","M",1,"ID",1,3,"APR International Classification of Diseases Clinical Modification (ICD-10-CM) Patient’s Reason for Visit \nPR International Classification of Diseases Clinical Modification (ICD-9-CM) Patient’s Reason for Visit","RNS","n/a"]
[2300,"HI","HI03-2","Industry Code","R","M",1,"AN",1,30,null,"R","n/a"]
[2300,"HI",null,"External Cause of Injury","S","O",1,{"$nulls":4},"S"]
[2300,"HI","HI01","Health Care Code Information","R","M",1,{"$nulls":4},"R"]
[2300,"HI","HI01-1","Code List Qualifier Code","R","M",1,"ID",1,3,"ABN International Classification of Diseases Clinical Modification (ICD-10-CM) External Cause of Injury Code \nBN International Classification of Diseases Clinical Modification (ICD-9-CM) External Cause of Injury Code (E-codes)\n","RNS","n/a"]
[2300,"HI","HI01-2","Industry Code","R","M",1,"AN",1,30,null,"R","n/a"]
[2300,"HI","HI01-9","Yes/No Condition or Response Code","S","X",1,"ID",1,1,"N No\nU Unknown\nW Not Applicable\nY Yes ","S","n/a"]
[2300,"HI","HI02","Health Care Code Information","S","O",1,{"$nulls":4},"S"]
[2300,"HI","HI02-1","Code List Qualifier Code","R","M",1,"ID",1,3,"ABN International Classification of Diseases Clinical Modification (ICD-10-CM) External Cause of Injury Code \nBN International Classification of Diseases Clinical Modification (ICD-9-CM) External Cause of Injury Code (E-codes)\n","RNS","n/a"]
[2300,"HI","HI02-2","Industry Code","R","M",1,"AN",1,30,null,"R","n/a"]
[2300,"HI","HI02-9","Yes/No Condition or Response Code","S","X",1,"ID",1,1,"N No\nU Unknown\nW Not Applicable\nY Yes ","S","n/a"]
[2300,"HI","HI03","Health Care Code Information","S","O",1,{"$nulls":4},"S"]
[2300,"HI","HI03-1","Code List Qualifier Code","R","M",1,"ID",1,3,"ABN International Classification of Diseases Clinical Modification (ICD-10-CM) External Cause of Injury Code \nBN International Classification of Diseases Clinical Modification (ICD-9-CM) External Cause of Injury Code (E-codes)\n","RNS","n/a"]
[2300,"HI","HI03-2","Industry Code","R","M",1,"AN",1,30,null,"R","n/a"]
[2300,"HI","HI03-9","Yes/No Condition or Response Code","S","X",1,"ID",1,1,"N No\nU Unknown\nW Not Applicable\nY Yes ","S","n/a"]
[2300,"HI","HI04","Health Care Code Information","S","O",1,{"$nulls":4},"S"]
[2300,"HI","HI04-1","Code List Qualifier Code","R","M",1,"ID",1,3,"ABN International Classification of Diseases Clinical Modification (ICD-10-CM) External Cause of Injury Code \nBN International Classification of Diseases Clinical Modification (ICD-9-CM) External Cause of Injury Code (E-codes)\n","RNS","n/a"]
[2300,"HI","HI04-2","Industry Code","R","M",1,"AN",1,30,null,"R","n/a"]
[2300,"HI","HI04-9","Yes/No Condition or Response Code","S","X",1,"ID",1,1,"N No\nU Unknown\nW Not Applicable\nY Yes ","S","n/a"]
[2300,"HI","HI05","Health Care Code Information","S","O",1,{"$nulls":4},"S"]
[2300,"HI","HI05-1","Code List Qualifier Code","R","M",1,"ID",1,3,"ABN International Classification of Diseases Clinical Modification (ICD-10-CM) External Cause of Injury Code \nBN International Classification of Diseases Clinical Modification (ICD-9-CM) External Cause of Injury Code (E-codes)\n","RNS","n/a"]
[2300,"HI","HI05-2","Industry Code","R","M",1,"AN",1,30,null,"R","n/a"]
[2300,"HI","HI05-9","Yes/No Condition or Response Code","S","X",1,"ID",1,1,"N No\nU Unknown\nW Not Applicable\nY Yes ","S","n/a"]
[2300,"HI","HI06","Health Care Code Information","S","O",1,{"$nulls":4},"S"]
[2300,"HI","HI06-1","Code List Qualifier Code","R","M",1,"ID",1,3,"ABN International Classification of Diseases Clinical Modification (ICD-10-CM) External Cause of Injury Code \nBN International Classification of Diseases Clinical Modification (ICD-9-CM) External Cause of Injury Code (E-codes)\n","RNS","n/a"]
[2300,"HI","HI06-2","Industry Code","R","M",1,"AN",1,30,null,"R","n/a"]
[2300,"HI","HI06-9","Yes/No Condition or Response Code","S","X",1,"ID",1,1,"N No\nU Unknown\nW Not Applicable\nY Yes ","S","n/a"]
[2300,"HI","HI07","Health Care Code Information","S","O",1,{"$nulls":4},"S"]
[2300,"HI","HI07-1","Code List Qualifier Code","R","M",1,"ID",1,3,"ABN International Classification of Diseases Clinical Modification (ICD-10-CM) External Cause of Injury Code \nBN International Classification of Diseases Clinical Modification (ICD-9-CM) External Cause of Injury Code (E-codes)\n","RNS","n/a"]
[2300,"HI","HI07-2","Industry Code","R","M",1,"AN",1,30,null,"R","n/a"]
[2300,"HI","HI07-9","Yes/No Condition or Response Code","S","X",1,"ID",1,1,"N No\nU Unknown\nW Not Applicable\nY Yes ","S","n/a"]
[2300,"HI","HI08","Health Care Code Information","S","O",1,{"$nulls":4},"S"]
[2300,"HI","HI08-1","Code List Qualifier Code","R","M",1,"ID",1,3,"ABN International Classification of Diseases Clinical Modification (ICD-10-CM) External Cause of Injury Code \nBN International Classification of Diseases Clinical Modification (ICD-9-CM) External Cause of Injury Code (E-codes)\n","RNS","n/a"]
[2300,"HI","HI08-2","Industry Code","R","M",1,"AN",1,30,null,"R","n/a"]
[2300,"HI","HI08-9","Yes/No Condition or Response Code","S","X",1,"ID",1,1,"N No\nU Unknown\nW Not Applicable\nY Yes ","S","n/a"]
[2300,"HI","HI09","Health Care Code Information","S","O",1,{"$nulls":4},"S"]
[2300,"HI","HI09-1","Code List Qualifier Code","R","M",1,"ID",1,3,"ABN International Classification of Diseases Clinical Modification (ICD-10-CM) External Cause of Injury Code \nBN International Classification of Diseases Clinical Modification (ICD-9-CM) External Cause of Injury Code (E-codes)\n","RNS","n/a"]
[2300,"HI","HI09-2","Industry Code","R","M",1,"AN",1,30,null,"R","n/a"]
[2300,"HI","HI09-9","Yes/No Condition or Response Code","S","X",1,"ID",1,1,"N No\nU Unknown\nW Not Applicable\nY Yes ","S","n/a"]
[2300,"HI","HI10","Health Care Code Information","S","O",1,{"$nulls":4},"S"]
[2300,"HI","HI10-1","Code List Qualifier Code","R","M",1,"ID",1,3,"ABN International Classification of Diseases Clinical Modification (ICD-10-CM) External Cause of Injury Code \nBN International Classification of Diseases Clinical Modification (ICD-9-CM) External Cause of Injury Code (E-codes)\n","RNS","n/a"]
[2300,"HI","HI10-2","Industry Code","R","M",1,"AN",1,30,null,"R","n/a"]
[2300,"HI","HI10-9","Yes/No Condition or Response Code","S","X",1,"ID",1,1,"N No\nU Unknown\nW Not Applicable\nY Yes ","S","n/a"]
[2300,"HI","HI11","Health Care Code Information","S","O",1,{"$nulls":4},"S"]
[2300,"HI","HI11-1","Code List Qualifier Code","R","M",1,"ID",1,3,"ABN International Classification of Diseases Clinical Modification (ICD-10-CM) External Cause of Injury Code \nBN International Classification of Diseases Clinical Modification (ICD-9-CM) External Cause of Injury Code (E-codes)\n","RNS","n/a"]
[2300,"HI","HI11-2","Industry Code","R","M",1,"AN",1,30,null,"R","n/a"]
[2300,"HI","HI11-9","Yes/No Condition or Response Code","S","X",1,"ID",1,1,"N No\nU Unknown\nW Not Applicable\nY Yes ","S","n/a"]
[2300,"HI","HI12","Health Care Code Information","S","O",1,{"$nulls":4},"S"]
[2300,"HI","HI12-1","Code List Qualifier Code","R","M",1,"ID",1,3,"ABN International Classification of Diseases Clinical Modification (ICD-10-CM) External Cause of Injury Code \nBN International Classification of Diseases Clinical Modification (ICD-9-CM) External Cause of Injury Code (E-codes)\n","RNS","n/a"]
[2300,"HI","HI12-2","Industry Code","R","M",1,"AN",1,30,null,"R","n/a"]
[2300,"HI","HI12-9","Yes/No Condition or Response Code","S","X",1,"ID",1,1,"N No\nU Unknown\nW Not Applicable\nY Yes ","S","n/a"]
[2300,"HI",null,"Diagnosis Related Group (DRG) Information","S","O",1,{"$nulls":4},"S"]
[2300,"HI","HI01","Health Care Code Information","R","M",1,{"$nulls":4},"R"]
[2300,"HI","HI01-1","Code List Qualifier Code","R","M",1,"ID",1,3,"DR Diagnosis Related Group (DRG)\n","RNS","n/a"]
[2300,"HI","HI01-2","Industry Code","R","M",1,"AN",1,30,null,"R","n/a"]
[2300,"HI",null,"Other Diagnosis Information","S","O",2,{"$nulls":4},"S"]
[2300,"HI","HI01","Health Care Code Information","R","M",1,{"$nulls":4},"R"]
[2300,"HI","HI01-1","Code List Qualifier Code","R","M",1,"ID",1,3,"ABF International Classification of Diseases Clinical Modification (ICD-10-CM) Diagnosis\nBF International Classification of Diseases Clinical Modification (ICD-9-CM) Diagnosis\n","RNS","n/a"]
[2300,"HI","HI01-2","Industry Code","R","M",1,"AN",1,30,null,"R","n/a"]
[2300,"HI","HI01-9","Yes/No Condition or Response Code","S","X",1,"ID",1,1,"N No\nU Unknown\nW Not Applicable\nY Yes ","S","n/a"]
[2300,"HI","HI02","Health Care Code Information","S","O",1,{"$nulls":4},"S"]
[2300,"HI","HI02-1","Code List Qualifier Code","R","M",1,"ID",1,3,"ABF International Classification of Diseases Clinical Modification (ICD-10-CM) Diagnosis\nBF International Classification of Diseases Clinical Modification (ICD-9-CM) Diagnosis\n","RNS","n/a"]
[2300,"HI","HI02-2","Industry Code","R","M",1,"AN",1,30,null,"R","n/a"]
[2300,"HI","HI02-9","Yes/No Condition or Response Code","S","X",1,"ID",1,1,"N No\nU Unknown\nW Not Applicable\nY Yes ","S","n/a"]
[2300,"HI","HI03","Health Care Code Information","S","O",1,{"$nulls":4},"S"]
[2300,"HI","HI03-1","Code List Qualifier Code","R","M",1,"ID",1,3,"ABF International Classification of Diseases Clinical Modification (ICD-10-CM) Diagnosis\nBF International Classification of Diseases Clinical Modification (ICD-9-CM) Diagnosis\n","RNS","n/a"]
[2300,"HI","HI03-2","Industry Code","R","M",1,"AN",1,30,null,"R","n/a"]
[2300,"HI","HI03-9","Yes/No Condition or Response Code","S","X",1,"ID",1,1,"N No\nU Unknown\nW Not Applicable\nY Yes ","S","n/a"]
[2300,"HI","HI04","Health Care Code Information","S","O",1,{"$nulls":4},"S"]
[2300,"HI","HI04-1","Code List Qualifier Code","R","M",1,"ID",1,3,"ABF International Classification of Diseases Clinical Modification (ICD-10-CM) Diagnosis\nBF International Classification of Diseases Clinical Modification (ICD-9-CM) Diagnosis\n","RNS","n/a"]
[2300,"HI","HI04-2","Industry Code","R","M",1,"AN",1,30,null,"R","n/a"]
[2300,"HI","HI04-9","Yes/No Condition or Response Code","S","X",1,"ID",1,1,"N No\nU Unknown\nW Not Applicable\nY Yes ","S","n/a"]
[2300,"HI","HI05","Health Care Code Information","S","O",1,{"$nulls":4},"S"]
[2300,"HI","HI05-1","Code List Qualifier Code","R","M",1,"ID",1,3,"ABF International Classification of Diseases Clinical Modification (ICD-10-CM) Diagnosis\nBF International Classification of Diseases Clinical Modification (ICD-9-CM) Diagnosis\n","RNS","n/a"]
[2300,"HI","HI05-2","Industry Code","R","M",1,"AN",1,30,null,"R","n/a"]
[2300,"HI","HI05-9","Yes/No Condition or Response Code","S","X",1,"ID",1,1,"N No\nU Unknown\nW Not Applicable\nY Yes ","S","n/a"]
[2300,"HI","HI06","Health Care Code Information","S","O",1,{"$nulls":4},"S"]
[2300,"HI","HI06-1","Code List Qualifier Code","R","M",1,"ID",1,3,"ABF International Classification of Diseases Clinical Modification (ICD-10-CM) Diagnosis\nBF International Classification of Diseases Clinical Modification (ICD-9-CM) Diagnosis\n","RNS","n/a"]
[2300,"HI","HI06-2","Industry Code","R","M",1,"AN",1,30,null,"R","n/a"]
[2300,"HI","HI06-9","Yes/No Condition or Response Code","S","X",1,"ID",1,1,"N No\nU Unknown\nW Not Applicable\nY Yes ","S","n/a"]
[2300,"HI","HI07","Health Care Code Information","S","O",1,{"$nulls":4},"S"]
[2300,"HI","HI07-1","Code List Qualifier Code","R","M",1,"ID",1,3,"ABF International Classification of Diseases Clinical Modification (ICD-10-CM) Diagnosis\nBF International Classification of Diseases Clinical Modification (ICD-9-CM) Diagnosis\n","RNS","n/a"]
[2300,"HI","HI07-2","Industry Code","R","M",1,"AN",1,30,null,"R","n/a"]
[2300,"HI","HI07-9","Yes/No Condition or Response Code","S","X",1,"ID",1,1,"N No\nU Unknown\nW Not Applicable\nY Yes ","S","n/a"]
[2300,"HI","HI08","Health Care Code Information","S","O",1,{"$nulls":4},"S"]
[2300,"HI","HI08-1","Code List Qualifier Code","R","M",1,"ID",1,3,"ABF International Classification of Diseases Clinical Modification (ICD-10-CM) Diagnosis\nBF International Classification of Diseases Clinical Modification (ICD-9-CM) Diagnosis\n","RNS","n/a"]
[2300,"HI","HI08-2","Industry Code","R","M",1,"AN",1,30,null,"R","n/a"]
[2300,"HI","HI08-9","Yes/No Condition or Response Code","S","X",1,"ID",1,1,"N No\nU Unknown\nW Not Applicable\nY Yes ","S","n/a"]
[2300,"HI","HI09","Health Care Code Information","S","O",1,{"$nulls":4},"S"]
[2300,"HI","HI09-1","Code List Qualifier Code","R","M",1,"ID",1,3,"ABF International Classification of Diseases Clinical Modification (ICD-10-CM) Diagnosis\nBF International Classification of Diseases Clinical Modification (ICD-9-CM) Diagnosis\n","RNS","n/a"]
[2300,"HI","HI09-2","Industry Code","R","M",1,"AN",1,30,null,"R","n/a"]
[2300,"HI","HI09-9","Yes/No Condition or Response Code","S","X",1,"ID",1,1,"N No\nU Unknown\nW Not Applicable\nY Yes ","S","n/a"]
[2300,"HI","HI10","Health Care Code Information","S","O",1,{"$nulls":4},"S"]
[2300,"HI","HI10-1","Code List Qualifier Code","R","M",1,"ID",1,3,"ABF International Classification of Diseases Clinical Modification (ICD-10-CM) Diagnosis\nBF International Classification of Diseases Clinical Modification (ICD-9-CM) Diagnosis\n","RNS","n/a"]
[2300,"HI","HI10-2","Industry Code","R","M",1,"AN",1,30,null,"R","n/a"]
[2300,"HI","HI10-9","Yes/No Condition or Response Code","S","X",1,"ID",1,1,"N No\nU Unknown\nW Not Applicable\nY Yes ","S","n/a"]
[2300,"HI","HI11","Health Care Code Information","S","O",1,{"$nulls":4},"S"]
[2300,"HI","HI11-1","Code List Qualifier Code","R","M",1,"ID",1,3,"ABF International Classification of Diseases Clinical Modification (ICD-10-CM) Diagnosis\nBF International Classification of Diseases Clinical Modification (ICD-9-CM) Diagnosis\n","RNS","n/a"]
[2300,"HI","HI11-2","Industry Code","R","M",1,"AN",1,30,null,"R","n/a"]
[2300,"HI","HI11-9","Yes/No Condition or Response Code","S","X",1,"ID",1,1,"N No\nU Unknown\nW Not Applicable\nY Yes ","S","n/a"]
[2300,"HI","HI12","Health Care Code Information","S","O",1,{"$nulls":4},"S"]
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[2300,"HI","HI11-1","Code List Qualifier Code","R","M",1,"ID",1,3,"BH Occurrence\n","RNS","n/a"]
[2300,"HI","HI11-2","Industry Code","R","M",1,"AN",1,30,null,"R","n/a"]
[2300,"HI","HI11-3","Date Time Period Format Qualifier","R","X",1,"ID",2,3,"D8 Date Expressed in Format CCYYMMDD ","RNS","n/a"]
[2300,"HI","HI11-4","Date Time Period","R","X",1,"AN",1,35,null,"R","n/a"]
[2300,"HI","HI12","Health Care Code Information","S","O",1,{"$nulls":4},"S"]
[2300,"HI","HI12-1","Code List Qualifier Code","R","M",1,"ID",1,3,"BH Occurrence\n","RNS","n/a"]
[2300,"HI","HI12-2","Industry Code","R","M",1,"AN",1,30,null,"R","n/a"]
[2300,"HI","HI12-3","Date Time Period Format Qualifier","R","X",1,"ID",2,3,"D8 Date Expressed in Format CCYYMMDD ","RNS","n/a"]
[2300,"HI","HI12-4","Date Time Period","R","X",1,"AN",1,35,null,"R","n/a"]
[2300,"HI",null,"Value Information","S","O",2,{"$nulls":4},"S"]
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[2300,"HI","HI01-1","Code List Qualifier Code","R","M",1,"ID",1,3,"BE Value\n","RNS","n/a"]
[2300,"HI","HI01-2","Industry Code","R","M",1,"AN",1,30,null,"R","n/a"]
[2300,"HI","HI01-5","Monetary Amount","R","O",1,"R",1,18,null,"R","n/a"]
[2300,"HI","HI02","Health Care Code Information","S","O",1,{"$nulls":4},"S"]
[2300,"HI","HI02-1","Code List Qualifier Code","R","M",1,"ID",1,3,"BE Value\n","RNS","n/a"]
[2300,"HI","HI02-2","Industry Code","R","M",1,"AN",1,30,null,"R","n/a"]
[2300,"HI","HI02-5","Monetary Amount","R","O",1,"R",1,18,null,"R","n/a"]
[2300,"HI","HI03","Health Care Code Information","S","O",1,{"$nulls":4},"S"]
[2300,"HI","HI03-1","Code List Qualifier Code","R","M",1,"ID",1,3,"BE Value\n","RNS","n/a"]
[2300,"HI","HI03-2","Industry Code","R","M",1,"AN",1,30,null,"R","n/a"]
[2300,"HI","HI03-5","Monetary Amount","R","O",1,"R",1,18,null,"R","n/a"]
[2300,"HI","HI04","Health Care Code Information","S","O",1,{"$nulls":4},"S"]
[2300,"HI","HI04-1","Code List Qualifier Code","R","M",1,"ID",1,3,"BE Value\n","RNS","n/a"]
[2300,"HI","HI04-2","Industry Code","R","M",1,"AN",1,30,null,"R","n/a"]
[2300,"HI","HI04-5","Monetary Amount","R","O",1,"R",1,18,null,"R","n/a"]
[2300,"HI","HI05","Health Care Code Information","S","O",1,{"$nulls":4},"S"]
[2300,"HI","HI05-1","Code List Qualifier Code","R","M",1,"ID",1,3,"BE Value\n","RNS","n/a"]
[2300,"HI","HI05-2","Industry Code","R","M",1,"AN",1,30,null,"R","n/a"]
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[2300,"HI","HI06","Health Care Code Information","S","O",1,{"$nulls":4},"S"]
[2300,"HI","HI06-1","Code List Qualifier Code","R","M",1,"ID",1,3,"BE Value\n","RNS","n/a"]
[2300,"HI","HI06-2","Industry Code","R","M",1,"AN",1,30,null,"R","n/a"]
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[2300,"HI","HI07-1","Code List Qualifier Code","R","M",1,"ID",1,3,"BE Value\n","RNS","n/a"]
[2300,"HI","HI07-2","Industry Code","R","M",1,"AN",1,30,null,"R","n/a"]
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[2300,"HI","HI08","Health Care Code Information","S","O",1,{"$nulls":4},"S"]
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[2300,"HI","HI10","Health Care Code Information","S","O",1,{"$nulls":4},"S"]
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[2300,"HI","HI12-2","Industry Code","R","M",1,"AN",1,30,null,"R","n/a"]
[2300,"HCP",null,"Claim Pricing/Repricing Information","S","O",1,{"$nulls":4},"S"]
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[2300,"HCP","HCP02","Monetary Amount","R","O",1,"R",1,18,null,"R","n/a"]
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[2300,"HCP","HCP04","Reference Identification","S","O",1,"AN",1,50,null,"S","n/a"]
[2300,"HCP","HCP05","Rate","S","O",1,"R",1,9,null,"S","n/a"]
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[2300,"HCP","HCP07","Monetary Amount","S","O",1,"R",1,18,null,"S","n/a"]
[2300,"HCP","HCP08","Product/Service ID","S","O",1,"AN",1,48,null,"S","n/a"]
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[2300,"HCP","HCP12","Quantity","S","X",1,"R",1,15,null,"S","n/a"]
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["2310E","NM1",null,"Service Facility Location Name","S","O",1,{"$nulls":4},"S"]
["2310E","NM1","NM101","Entity Identifier Code","R","M",1,"ID",2,3,"77 Service Location ","RNS","n/a"]
["2310E","NM1","NM102","Entity Type Qualifier","R","M",1,"ID",1,1,"2 Non-Person Entity","RNS","n/a"]
["2310E","NM1","NM103","Name Last or Organization Name","R","X",1,"AN",1,60,null,"R","n/a"]
["2310E","NM1","NM108","Identification Code Qualifier","S","X",1,"ID",1,2,"XX Centers for Medicare and Medicaid Services National Provider Identifier\n","S","n/a"]
["2310E","NM1","NM109","Identification Code","S","X",1,"AN",2,80,null,"S","n/a"]
["2310E","N3",null,"Service Facility Location Address","R","O",1,{"$nulls":4},"R"]
["2310E","N3","N301","Address Information","R","M",1,"AN",1,55,null,"R","n/a"]
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["2310E","N4",null,"Service Facility Location City/State/ZIP","R","O",1,{"$nulls":4},"R"]
["2310E","N4","N401","City Name","R","O",1,"AN",2,30,null,"R","n/a"]
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["2310E","N4","N407","Country Subdivision Code","S","X",1,"ID",1,3,null,"SNS","n/a"]
["2310E","REF",null,"Service Facility Secondary Identification","S","O",3,{"$nulls":4},"S"]
["2310E","REF","REF01","Reference Identification Qualifier","R","M",1,"ID",2,3,"0B State License Number\nG2 Provider Commercial Number \nLU Location Number\n","R","n/a"]
["2310E","REF","REF02","Reference Identification","R","X",1,"AN",1,50,null,"R","n/a"]
["2310F",null,null,"Referring Provider Name","S","O",1,{"$nulls":4},"S"]
["2310F","NM1",null,"Referring Provider Name","S","O",1,{"$nulls":4},"S"]
["2310F","NM1","NM101","Entity Identifier Code","R","M",1,"ID",2,3,"DN Referring Provider ","RNS","n/a"]
["2310F","NM1","NM102","Entity Type Qualifier","R","M",1,"ID",1,1,"1 Person ","RNS","n/a"]
["2310F","NM1","NM103","Name Last or Organization Name","R","X",1,"AN",1,60,null,"R","n/a"]
["2310F","NM1","NM104","Name First","S","O",1,"AN",1,35,null,"S","n/a"]
["2310F","NM1","NM105","Name Middle","S","O",1,"AN",1,25,null,"S","n/a"]
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["2310F","NM1","NM108","Identification Code Qualifier","S","X",1,"ID",1,2,"XX Centers for Medicare and Medicaid Services National Provider Identifier\n","S","n/a"]
["2310F","NM1","NM109","Identification Code","S","X",1,"AN",2,80,null,"S","n/a"]
["2310F","REF",null,"Referring Provider Secondary Identification","S","O",3,{"$nulls":4},"S"]
["2310F","REF","REF01","Reference Identification Qualifier","R","M",1,"ID",2,3,"0B State License Number\n1G Provider UPIN Number \nG2 Provider Commercial Number ","R","n/a"]
["2310F","REF","REF02","Reference Identification","R","X",1,"AN",1,50,null,"R","n/a"]
[2320,null,null,"Other Subscriber Information","S","O",10,{"$nulls":4},"S"]
[2320,"SBR",null,"Other Subscriber Information","S","O",1,{"$nulls":4},"S"]
[2320,"SBR","SBR01","Payer Responsibility Sequence Number Code","R","M",1,"ID",1,1,"A Payer Responsibility Four\nB Payer Responsibility Five\nC Payer Responsibility Six\nD Payer Responsibility Seven\nE Payer Responsibility Eight\nF Payer Responsibility Nine\nG Payer Responsibility Ten\nH Payer Responsibility Eleven\nP Primary\nS Secondary\nT Tertiary\nU Unknown ","R","n/a"]
[2320,"SBR","SBR02","Individual Relationship Code","R","O",1,"ID",2,2,"01 Spouse\n18 Self\n19 Child\n20 Employee\n21 Unknown\n39 Organ Donor\n40 Cadaver Donor\n53 Life Partner\nG8 Other Relationship\n","R","n/a"]
[2320,"SBR","SBR03","Reference Identification","S","O",1,"AN",1,50,null,"S","n/a"]
[2320,"SBR","SBR04","Name","S","O",1,"AN",1,60,null,"S","n/a"]
[2320,"SBR","SBR09","Claim Filing Indicator Code","S","O",1,"ID",1,2,"11 Other Non-Federal Programs\n12 Preferred Provider Organization (PPO)\n13 Point of Service (POS)\n14 Exclusive Provider Organization (EPO)\n15 Indemnity Insurance\n16 Health Maintenance Organization (HMO) Medicare Risk\n17 Dental Maintenance Organization\nAM Automobile Medical\nBL Blue Cross/Blue Shield\nCH Champus\nCI Commercial Insurance Co.\nDS Disability\nFI Federal Employees Program\nHM Health Maintenance Organization\nLM Liability Medical\nMA Medicare Part A\nMB Medicare Part B\nMC Medicaid\nOF Other Federal Program \nTV Title V\nVA Veterans Affairs Plan\nWC Workers’ Compensation Health Claim\nZZ Mutually Defined ","S","n/a"]
[2320,"CAS",null,"Claim Level Adjustments","S","O",5,{"$nulls":4},"S"]
[2320,"CAS","CAS01","Claim Adjustment Group Code","R","M",1,"ID",1,2,"CO Contractual Obligations\nCR Correction and Reversals\nOA Other adjustments\nPI Payor Initiated Reductions\nPR Patient Responsibility","R","n/a"]
[2320,"CAS","CAS02","Claim Adjustment Reason Code","R","M",1,"ID",1,5,null,"R","n/a"]
[2320,"CAS","CAS03","Monetary Amount","R","M",1,"R",1,18,null,"R","n/a"]
[2320,"CAS","CAS04","Quantity","S","O",1,"R",1,15,null,"S","n/a"]
[2320,"CAS","CAS05","Claim Adjustment Reason Code","S","X",1,"ID",1,5,null,"S","n/a"]
[2320,"CAS","CAS06","Monetary Amount","S","X",1,"R",1,18,null,"S","n/a"]
[2320,"CAS","CAS07","Quantity","S","X",1,"R",1,15,null,"S","n/a"]
[2320,"CAS","CAS08","Claim Adjustment Reason Code","S","X",1,"ID",1,5,null,"S","n/a"]
[2320,"CAS","CAS09","Monetary Amount","S","X",1,"R",1,18,null,"S","n/a"]
[2320,"CAS","CAS10","Quantity","S","X",1,"R",1,15,null,"S","n/a"]
[2320,"CAS","CAS11","Claim Adjustment Reason Code","S","X",1,"ID",1,5,null,"S","n/a"]
[2320,"CAS","CAS12","Monetary Amount","S","X",1,"R",1,18,null,"S","n/a"]
[2320,"CAS","CAS13","Quantity","S","X",1,"R",1,15,null,"S","n/a"]
[2320,"CAS","CAS14","Claim Adjustment Reason Code","S","X",1,"ID",1,5,null,"S","n/a"]
[2320,"CAS","CAS15","Monetary Amount","S","X",1,"R",1,18,null,"S","n/a"]
[2320,"CAS","CAS16","Quantity","S","X",1,"R",1,15,null,"S","n/a"]
[2320,"CAS","CAS17","Claim Adjustment Reason Code","S","X",1,"ID",1,5,null,"S","n/a"]
[2320,"CAS","CAS18","Monetary Amount","S","X",1,"R",1,18,null,"S","n/a"]
[2320,"CAS","CAS19","Quantity","S","X",1,"R",1,15,null,"S","n/a"]
[2320,"AMT",null,"Coordination of Benefits (COB) Payer Paid Amount","S","O",1,{"$nulls":4},"S"]
[2320,"AMT","AMT01","Amount Qualifier Code","R","M",1,"ID",1,3,"D Payor Amount Paid ","RNS","n/a"]
[2320,"AMT","AMT02","Monetary Amount","R","M",1,"R",1,18,null,"R","n/a"]
[2320,"AMT",null,"Remaining Patient Liability","S","O",1,{"$nulls":4},"S"]
[2320,"AMT","AMT01","Amount Qualifier Code","R","M",1,"ID",1,3,"EAF Amount Owed ","RNS","n/a"]
[2320,"AMT","AMT02","Monetary Amount","R","M",1,"R",1,18,null,"R","n/a"]
[2320,"AMT",null,"Coordination of Benefits (COB) Total Non-covered Amount","S","O",1,{"$nulls":4},"S"]
[2320,"AMT","AMT01","Amount Qualifier Code","R","M",1,"ID",1,3,"A8 Noncovered Charges - Actual ","RNS","n/a"]
[2320,"AMT","AMT02","Monetary Amount","R","M",1,"R",1,18,null,"R","n/a"]
[2320,"OI",null,"Other Insurance Coverage Information","R","O",1,{"$nulls":4},"R"]
[2320,"OI","OI03","Yes/No Condition or Response Code","R","O",1,"ID",1,1,"N No\nW Not Applicable \nY Yes ","R","n/a"]
[2320,"OI","OI06","Release of Information Code","R","O",1,"ID",1,1,"I Informed Consent to Release Medical Information for Conditions or Diagnoses Regulated by Federal Statutes \nY Yes, Provider has a Signed Statement Permitting Release of Medical Billing Data Related to a Claim ","R","n/a"]
[2320,"MIA",null,"Inpatient Adjudication Information","S","O",1,{"$nulls":4},"S"]
[2320,"MIA","MIA01","Quantity","R","M",1,"R",1,15,null,"R","n/a"]
[2320,"MIA","MIA03","Quantity","S","O",1,"R",1,15,null,"S","n/a"]
[2320,"MIA","MIA04","Monetary Amount","S","O",1,"R",1,18,null,"S","n/a"]
[2320,"MIA","MIA05","Reference Identification","S","O",1,"AN",1,50,null,"S","n/a"]
[2320,"MIA","MIA06","Monetary Amount","S","O",1,"R",1,18,null,"S","n/a"]
[2320,"MIA","MIA07","Monetary Amount","S","O",1,"R",1,18,null,"S","n/a"]
[2320,"MIA","MIA08","Monetary Amount","S","O",1,"R",1,18,null,"S","n/a"]
[2320,"MIA","MIA09","Monetary Amount","S","O",1,"R",1,18,null,"S","n/a"]
[2320,"MIA","MIA10","Monetary Amount","S","O",1,"R",1,18,null,"S","n/a"]
[2320,"MIA","MIA11","Monetary Amount","S","O",1,"R",1,18,null,"S","n/a"]
[2320,"MIA","MIA12","Monetary Amount","S","O",1,"R",1,18,null,"S","n/a"]
[2320,"MIA","MIA13","Monetary Amount","S","O",1,"R",1,18,null,"S","n/a"]
[2320,"MIA","MIA14","Monetary Amount","S","O",1,"R",1,18,null,"S","n/a"]
[2320,"MIA","MIA15","Quantity","S","O",1,"R",1,15,null,"S","n/a"]
[2320,"MIA","MIA16","Monetary Amount","S","O",1,"R",1,18,null,"S","n/a"]
[2320,"MIA","MIA17","Monetary Amount","S","O",1,"R",1,18,null,"S","n/a"]
[2320,"MIA","MIA18","Monetary Amount","S","O",1,"R",1,18,null,"S","n/a"]
[2320,"MIA","MIA19","Monetary Amount","S","O",1,"R",1,18,null,"S","n/a"]
[2320,"MIA","MIA20","Reference Identification","S","O",1,"AN",1,50,null,"S","n/a"]
[2320,"MIA","MIA21","Reference Identification","S","O",1,"AN",1,50,null,"S","n/a"]
[2320,"MIA","MIA22","Reference Identification","S","O",1,"AN",1,50,null,"S","n/a"]
[2320,"MIA","MIA23","Reference Identification","S","O",1,"AN",1,50,null,"S","n/a"]
[2320,"MIA","MIA24","Monetary Amount","S","O",1,"R",1,18,null,"S","n/a"]
[2320,"MOA",null,"Outpatient Adjudication Information","S","O",1,{"$nulls":4},"S"]
[2320,"MOA","MOA01","Percentage as Decimal","S","O",1,"R",1,10,null,"S","n/a"]
[2320,"MOA","MOA02","Monetary Amount","S","O",1,"R",1,18,null,"S","n/a"]
[2320,"MOA","MOA03","Reference Identification","S","O",1,"AN",1,50,null,"S","n/a"]
[2320,"MOA","MOA04","Reference Identification","S","O",1,"AN",1,50,null,"S","n/a"]
[2320,"MOA","MOA05","Reference Identification","S","O",1,"AN",1,50,null,"S","n/a"]
[2320,"MOA","MOA06","Reference Identification","S","O",1,"AN",1,50,null,"S","n/a"]
[2320,"MOA","MOA07","Reference Identification","S","O",1,"AN",1,50,null,"S","n/a"]
[2320,"MOA","MOA08","Monetary Amount","S","O",1,"R",1,18,null,"S","n/a"]
[2320,"MOA","MOA09","Monetary Amount","S","O",1,"R",1,18,null,"S","n/a"]
["2330A",null,null,"Other Subscriber Name","R","O",1,{"$nulls":4},"R"]
["2330A","NM1",null,"Other Subscriber Name","R","O",1,{"$nulls":4},"R"]
["2330A","NM1","NM101","Entity Identifier Code","R","M",1,"ID",2,3,"IL Insured or Subscriber","RNS","n/a"]
["2330A","NM1","NM102","Entity Type Qualifier","R","M",1,"ID",1,1,"1 Person\n2 Non-Person Entity ","RNS","n/a"]
["2330A","NM1","NM103","Name Last or Organization Name","R","X",1,"AN",1,60,null,"R","n/a"]
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["2330A","NM1","NM108","Identification Code Qualifier","R","X",1,"ID",1,2,"II Standard Unique Health Identifier for each Individual in the United States \nMI Member Identification Number ","R","n/a"]
["2330A","NM1","NM109","Identification Code","R","X",1,"AN",2,80,null,"R","n/a"]
["2330A","N3",null,"Other Subscriber Address","S","O",1,{"$nulls":4},"S"]
["2330A","N3","N301","Address Information","R","M",1,"AN",1,55,null,"R","n/a"]
["2330A","N3","N302","Address Information","S","O",1,"AN",1,55,null,"S","n/a"]
["2330A","N4",null,"Other Subscriber City/State/ZIP Code","S","O",1,{"$nulls":4},"S"]
["2330A","N4","N401","City Name","R","O",1,"AN",2,30,null,"R","n/a"]
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["2330A","N4","N407","Country Subdivision Code","S","X",1,"ID",1,3,null,"S","n/a"]
["2330A","REF",null,"Other Subscriber Secondary Information","S","O",2,{"$nulls":4},"S"]
["2330A","REF","REF01","Reference Identification Qualifier","R","M",1,"ID",2,3,"SY Social Security Number ","R","n/a"]
["2330A","REF","REF02","Reference Identification","R","X",1,"AN",1,50,null,"R","n/a"]
["2330B",null,null,"Other Payer Name","R","O",1,{"$nulls":4},"R"]
["2330B","NM1",null,"Other Payer Name","R","O",1,{"$nulls":4},"R"]
["2330B","NM1","NM101","Entity Identifier Code","R","M",1,"ID",2,3,"PR Payer ","RNS","n/a"]
["2330B","NM1","NM102","Entity Type Qualifier","R","M",1,"ID",1,1,"2 Non-Person Entity\n","RNS","n/a"]
["2330B","NM1","NM103","Name Last or Organization Name","R","X",1,"AN",1,60,null,"R","n/a"]
["2330B","NM1","NM108","Identification Code Qualifier","R","X",1,"ID",1,2,"PI Payor Identification\nXV Centers for Medicare and Medicaid Services PlanID\n","R","n/a"]
["2330B","NM1","NM109","Identification Code","R","X",1,"AN",2,80,null,"R","n/a"]
["2330B","N3",null,"Other Payer Address","S","O",1,{"$nulls":4},"S"]
["2330B","N3","N301","Address Information","R","M",1,"AN",1,55,null,"R","n/a"]
["2330B","N3","N302","Address Information","S","O",1,"AN",1,55,null,"S","n/a"]
["2330B","N4",null,"Other Payer City/State/ZIP Code","S","O",1,{"$nulls":4},"S"]
["2330B","N4","N401","City Name","R","O",1,"AN",2,30,null,"R","n/a"]
["2330B","N4","N402","State or Province Code","S","X",1,"ID",2,2,null,"S","n/a"]
["2330B","N4","N403","Postal Code","S","O",1,"ID",3,15,null,"S","n/a"]
["2330B","N4","N404","Country Code","S","X",1,"ID",2,3,null,"S","n/a"]
["2330B","N4","N407","Country Subdivision Code","S","X",1,"ID",1,3,null,"S","n/a"]
["2330B","DTP",null,"Claim Check Or Remittance Date","S","O",1,{"$nulls":4},"S"]
["2330B","DTP","DTP01","Date/Time Qualifier","R","M",1,"ID",3,3,"573 Date Claim Paid ","RNS","n/a"]
["2330B","DTP","DTP02","Date Time Period Format Qualifier","R","M",1,"ID",2,3,"D8 Date Expressed in Format CCYYMMDD","RNS","n/a"]
["2330B","DTP","DTP03","Date Time Period","R","M",1,"AN",1,35,null,"R","n/a"]
["2330B","REF",null,"Other Payer Secondary Identifier","S","O",2,{"$nulls":4},"S"]
["2330B","REF","REF01","Reference Identification Qualifier","R","M",1,"ID",2,3,"2U Payer Identification Number\nEI Employer’s Identification Number \nFY Claim Office Number\nNF National Association of Insurance Commissioners (NAIC) Code\n","R","n/a"]
["2330B","REF","REF02","Reference Identification","R","X",1,"AN",1,50,null,"R","n/a"]
["2330B","REF",null,"Other Payer Prior Authorization Number","S","O",1,{"$nulls":4},"S"]
["2330B","REF","REF01","Reference Identification Qualifier","R","M",1,"ID",2,3,"G1 Prior Authorization Number ","RNS","n/a"]
["2330B","REF","REF02","Reference Identification","R","X",1,"AN",1,50,null,"R","n/a"]
["2330B","REF",null,"Other Payer Referral Number","S","O",2,{"$nulls":4},"S"]
["2330B","REF","REF01","Reference Identification Qualifier","R","M",1,"ID",2,3,"9F Referral Number ","RNS","n/a"]
["2330B","REF","REF02","Reference Identification","R","X",1,"AN",1,50,null,"R","n/a"]
["2330B","REF",null,"Other Payer Claim Adjustment Indicator","S","O",1,{"$nulls":4},"S"]
["2330B","REF","REF01","Reference Identification Qualifier","R","M",1,"ID",2,3,"T4 Signal Code","RNS","n/a"]
["2330B","REF","REF02","Reference Identification","R","X",1,"AN",1,50,null,"R","n/a"]
["2330B","REF",null,"Other Payer Claim Control Number","S","O",1,{"$nulls":4},"S"]
["2330B","REF","REF01","Reference Identification Qualifier","R","M",1,"ID",2,3,"F8 Original Reference Number ","RNS","n/a"]
["2330B","REF","REF02","Reference Identification","R","X",1,"AN",1,50,null,"R","n/a"]
["2330C",null,null,"Other Payer Attending Provider","S","O",1,{"$nulls":4},"S"]
["2330C","NM1",null,"Other Payer Attending Provider","S","O",1,{"$nulls":4},"S"]
["2330C","NM1","NM101","Entity Identifier Code","R","M",1,"ID",2,3,"71 Attending Physician ","RNS","n/a"]
["2330C","NM1","NM102","Entity Type Qualifier","R","M",1,"ID",1,1,"1 Person ","RNS","n/a"]
["2330C","REF",null,"Other Payer Attending Provider Secondary Identification","R","O",4,{"$nulls":4},"R"]
["2330C","REF","REF01","Reference Identification Qualifier","R","M",1,"ID",2,3,"0B State License Number\n1G Provider UPIN Number\nG2 Provider Commercial Number\nLU Location Number\n \n","R","n/a"]
["2330C","REF","REF02","Reference Identification","R","X",1,"AN",1,50,null,"R","n/a"]
["2330D",null,null,"Other Payer Operating Physician","S","O",1,{"$nulls":4},"S"]
["2330D","NM1",null,"Other Payer Operating Physician","S","O",1,{"$nulls":4},"S"]
["2330D","NM1","NM101","Entity Identifier Code","R","M",1,"ID",2,3,"72 Operating Physician ","RNS","n/a"]
["2330D","NM1","NM102","Entity Type Qualifier","R","M",1,"ID",1,1,"1 Person ","RNS","n/a"]
["2330D","REF",null,"Other Payer Operating Physician Secondary Identification","R","O",4,{"$nulls":4},"R"]
["2330D","REF","REF01","Reference Identification Qualifier","R","M",1,"ID",2,3,"0B State License Number\n1G Provider UPIN Number \nG2 Provider Commercial Number \nLU Location Number\n","R","n/a"]
["2330D","REF","REF02","Reference Identification","R","X",1,"AN",1,50,null,"R","n/a"]
["2330E",null,null,"Other Payer Other Operating Physician","S","O",1,{"$nulls":4},"S"]
["2330E","NM1",null,"Other Payer Other Operating Physician","S","O",1,{"$nulls":4},"S"]
["2330E","NM1","NM101","Entity Identifier Code","R","M",1,"ID",2,3,"ZZ Mutually Defined ","RNS","n/a"]
["2330E","NM1","NM102","Entity Type Qualifier","R","M",1,"ID",1,1,"1 Person ","RNS","n/a"]
["2330E","REF",null,"Other Payer Other Operating Physician Secondary Identification","R","O",4,{"$nulls":4},"R"]
["2330E","REF","REF01","Reference Identification Qualifier","R","M",1,"ID",2,3,"0B State License Number\n1G Provider UPIN Number \nG2 Provider Commercial Number\nLU Location Number\n","R","n/a"]
["2330E","REF","REF02","Reference Identification","R","X",1,"AN",1,50,null,"R","n/a"]
["2330F",null,null,"Other Payer Service Facility Location","S","O",1,{"$nulls":4},"S"]
["2330F","NM1",null,"Other Payer Service Facility Location","S","O",1,{"$nulls":4},"S"]
["2330F","NM1","NM101","Entity Identifier Code","R","M",1,"ID",2,3,"77 Service Location ","RNS","n/a"]
["2330F","NM1","NM102","Entity Type Qualifier","R","M",1,"ID",1,1,"2 Non-Person Entity ","RNS","n/a"]
["2330F","REF",null,"Other Payer Service Facility Location Secondary Identification","R","O",3,{"$nulls":4},"R"]
["2330F","REF","REF01","Reference Identification Qualifier","R","M",1,"ID",2,3,"0B State License Number\nG2 Provider Commercial Number \nLU Location Number","R","n/a"]
["2330F","REF","REF02","Reference Identification","R","X",1,"AN",1,50,null,"R","n/a"]
["2330G",null,null,"Other Payer Rendering Provider Name","S","O",1,{"$nulls":4},"S"]
["2330G","NM1",null,"Other Payer Rendering Provider Name","S","O",1,{"$nulls":4},"S"]
["2330G","NM1","NM101","Entity Identifier Code","R","M",1,"ID",2,3,"82 Rendering Provider ","RNS","n/a"]
["2330G","NM1","NM102","Entity Type Qualifier","R","M",1,"ID",1,1,"1 Person ","RNS","n/a"]
["2330G","REF",null,"Other Payer Rendering Provider Secondary Identifier","R","O",4,{"$nulls":4},"R"]
["2330G","REF","REF01","Reference Identification Qualifier","R","M",1,"ID",2,3,"0B State License Number\n1G Provider UPIN Number\nG2 Provider Commercial Number \nLU Location Number","R","n/a"]
["2330G","REF","REF02","Reference Identification","R","X",1,"AN",1,50,null,"R","n/a"]
["2330H",null,null,"Other Payer Referring Provider","S","O",1,{"$nulls":4},"S"]
["2330H","NM1",null,"Other Payer Referring Provider","S","O",1,{"$nulls":4},"S"]
["2330H","NM1","NM101","Entity Identifier Code","R","M",1,"ID",2,3,"DN Referring Provider ","RNS","n/a"]
["2330H","NM1","NM102","Entity Type Qualifier","R","M",1,"ID",1,1,"1 Person ","RNS","n/a"]
["2330H","REF",null,"Other Payer Referring Provider Secondary Identification","R","O",3,{"$nulls":4},"R"]
["2330H","REF","REF01","Reference Identification Qualifier","R","M",1,"ID",2,3,"0B State License Number\n1G Provider UPIN Number \nG2 Provider Commercial Number ","R","n/a"]
["2330H","REF","REF02","Reference Identification","R","X",1,"AN",1,50,null,"R","n/a"]
["2330I",null,null,"Other Payer Billing Provider","S","O",1,{"$nulls":4},"S"]
["2330I","NM1",null,"Other Payer Billing Provider","S","O",1,{"$nulls":4},"S"]
["2330I","NM1","NM101","Entity Identifier Code","R","M",1,"ID",2,3,"85 Billing Provider ","RNS","n/a"]
["2330I","NM1","NM102","Entity Type Qualifier","R","M",1,"ID",1,1,"2 Non-Person Entity","RNS","n/a"]
["2330I","REF",null,"Other Payer Billing Provider Secondary Identifier","R","O",2,{"$nulls":4},"R"]
["2330I","REF","REF01","Reference Identification Qualifier","R","M",1,"ID",2,3,"G2 Provider Commercial Number \nLU Location Number ","R","n/a"]
["2330I","REF","REF02","Reference Identification","R","X",1,"AN",1,50,null,"R","n/a"]
[2400,null,null,"Service Line Number","R","O",999,{"$nulls":4},"R"]
[2400,"LX",null,"Service Line Number","R","O",1,{"$nulls":4},"R"]
[2400,"LX","LX01","Assigned Number","R","M",1,"N0",1,6,null,"R","n/a"]
[2400,"SV2",null,"Institutional Service Line","R","O",1,{"$nulls":4},"R"]
[2400,"SV2","SV201","Product/Service ID","R","X",1,"AN",1,48,null,"R","n/a"]
[2400,"SV2","SV202","Composite Medical Procedure Identifier","S","X",1,{"$nulls":4},"S"]
[2400,"SV2","SV202-1","Product/Service ID Qualifier","R","M",1,"ID",2,2,"ER Jurisdiction Specific Procedure and Supply Codes\nHC Health Care Financing Administration Common Procedural Coding System (HCPCS) Codes\nHP Health Insurance Prospective Payment System (HIPPS) Skilled Nursing Facility Rate Code\nIV Home Infusion EDI Coalition (HIEC) Product/Service Code\nWK Advanced Billing Concepts (ABC) Codes\n","R","n/a"]
[2400,"SV2","SV202-2","Product/Service ID","R","M",1,"AN",1,48,null,"R","n/a"]
[2400,"SV2","SV202-3","Procedure Modifier","S","O",1,"AN",2,2,null,"S","n/a"]
[2400,"SV2","SV202-4","Procedure Modifier","S","O",1,"AN",2,2,null,"S","n/a"]
[2400,"SV2","SV202-5","Procedure Modifier","S","O",1,"AN",2,2,null,"S","n/a"]
[2400,"SV2","SV202-6","Procedure Modifier","S","O",1,"AN",2,2,null,"S","n/a"]
[2400,"SV2","SV202-7","Description","S","O",1,"AN",1,80,null,"S","n/a"]
[2400,"SV2","SV203","Monetary Amount","R","O",1,"R",1,18,null,"R","n/a"]
[2400,"SV2","SV204","Unit or Basis for Measurement Code","R","X",1,"ID",2,2,"DA Days\nUN Unit ","R","n/a"]
[2400,"SV2","SV205","Quantity","R","X",1,"R",1,15,null,"R","n/a"]
[2400,"SV2","SV207","Monetary Amount","S","O",1,"R",1,18,null,"S","n/a"]
[2400,"PWK",null,"Line Supplemental Information","S","O",10,{"$nulls":4},"S"]
[2400,"PWK","PWK01","Report Type Code","R","M",1,"ID",2,2,"03 Report Justifying Treatment Beyond Utilization Guidelines\n04 Drugs Administered\n05 Treatment Diagnosis\n06 Initial Assessment\n07 Functional Goals\n08 Plan of Treatment\n09 Progress Report\n10 Continued Treatment\n11 Chemical Analysis\n13 Certified Test Report\n15 Justification for Admission\n21 Recovery Plan\nA3 Allergies/Sensitivities Document\nA4 Autopsy Report\nAM Ambulance Certification\nAS Admission Summary\nB2 Prescription\nB3 Physician Order\nB4 Referral Form\nBR Benchmark Testing Results\nBS Baseline\nBT Blanket Test Results\nCB Chiropractic Justification\nCK Consent Form(s)\nCT Certification\nD2 Drug Profile Document\nDA Dental Models\nDB Durable Medical Equipment Prescription\nDG Diagnostic Report\nDJ Discharge Monitoring Report\nDS Discharge Summary\nEB Explanation of Benefits (Coordination of Benefits or Medicare Secondary Payor)\nHC Health Certificate\nHR Health Clinic Records\nI5 Immunization Record\nIR State School Immunization Records\nLA Laboratory Results\nM1 Medical Record Attachment\nMT Models\nNN Nursing Notes\nOB Operative Note\nOC Oxygen Content Averaging Report\nOD Orders and Treatments Document\nOE Objective Physical Examination (including vital signs) Document\nOX Oxygen Therapy Certification\nOZ Support Data for Claim\nP4 Pathology Report\nP5 Patient Medical History Document\nPE Parenteral or Enteral Certification\nPN Physical Therapy Notes\nPO Prosthetics or Orthotic Certification\nPQ Paramedical Results\nPY Physician’s Report\nPZ Physical Therapy Certification\nRB Radiology Films\nRR Radiology Reports\nRT Report of Tests and Analysis Report\nRX Renewable Oxygen Content Averaging Report\nSG Symptoms Document\nV5 Death Notification\nXP Photographs","R","n/a"]
[2400,"PWK","PWK02","Report Transmission Code","R","O",1,"ID",1,2,"AA Available on Request at Provider Site\nBM By Mail\nEL Electronically Only \nEM E-Mail\nFT File Transfer \nFX By Fax ","R","n/a"]
[2400,"PWK","PWK05","Identification Code Qualifier","S","X",1,"ID",1,2,"AC Attachment Control Number ","S","n/a"]
[2400,"PWK","PWK06","Identification Code","S","X",1,"AN",2,80,null,"S","n/a"]
[2400,"DTP",null,"Date - Service Date","S","O",1,{"$nulls":4},"S"]
[2400,"DTP","DTP01","Date/Time Qualifier","R","M",1,"ID",3,3,"472 Service ","RNS","n/a"]
[2400,"DTP","DTP02","Date Time Period Format Qualifier","R","M",1,"ID",2,3,"D8 Date Expressed in Format CCYYMMDD\nRD8 Range of Dates Expressed in Format CCYYMMDDCCYYMMDD ","RNS","n/a"]
[2400,"DTP","DTP03","Date Time Period","R","M",1,"AN",1,35,null,"R","n/a"]
[2400,"REF",null,"Line Item Control Number","S","O",1,{"$nulls":4},"S"]
[2400,"REF","REF01","Reference Identification Qualifier","R","M",1,"ID",2,3,"6R Provider Control Number\n","RNS","n/a"]
[2400,"REF","REF02","Reference Identification","R","X",1,"AN",1,50,null,"R","n/a"]
[2400,"REF",null,"Repriced Line Item Reference Number","S","O",1,{"$nulls":4},"S"]
[2400,"REF","REF01","Reference Identification Qualifier","R","M",1,"ID",2,3,"9B Repriced Line Item Reference Number ","RNS","n/a"]
[2400,"REF","REF02","Reference Identification","R","X",1,"AN",1,50,null,"R","n/a"]
[2400,"REF",null,"Adjusted Repriced Line Item Reference Number","S","O",1,{"$nulls":4},"S"]
[2400,"REF","REF01","Reference Identification Qualifier","R","M",1,"ID",2,3,"9D Adjusted Repriced Line Item Reference Number ","RNS","n/a"]
[2400,"REF","REF02","Reference Identification","R","X",1,"AN",1,50,null,"R","n/a"]
[2400,"AMT",null,"Service Tax Amount","S","O",1,{"$nulls":4},"S"]
[2400,"AMT","AMT01","Amount Qualifier Code","R","M",1,"ID",1,3,"GT Goods and Services Tax ","RNS","n/a"]
[2400,"AMT","AMT02","Monetary Amount","R","M",1,"R",1,18,null,"R","n/a"]
[2400,"AMT",null,"Facility Tax Amount","S","O",1,{"$nulls":4},"S"]
[2400,"AMT","AMT01","Amount Qualifier Code","R","M",1,"ID",1,3,"N8 Miscellaneous Taxes ","RNS","n/a"]
[2400,"AMT","AMT02","Monetary Amount","R","M",1,"R",1,18,null,"R","n/a"]
[2400,"NTE",null,"Third Party Organization Notes","S","O",1,{"$nulls":4},"S"]
[2400,"NTE","NTE01","Note Reference Code","R","O",1,"ID",3,3,"TPO Third Party Organization Notes ","RNS","n/a"]
[2400,"NTE","NTE02","Description","R","M",1,"AN",1,80,null,"R","n/a"]
[2400,"HCP",null,"Line Pricing/Repricing Information","S","O",1,{"$nulls":4},"S"]
[2400,"HCP","HCP01","Pricing Methodology","R","X",1,"ID",2,2,"00 Zero Pricing (Not Covered Under Contract)\n01 Priced as Billed at 100%\n02 Priced at the Standard Fee Schedule\n03 Priced at a Contractual Percentage\n04 Bundled Pricing\n05 Peer Review Pricing\n06 Per Diem Pricing\n07 Flat Rate Pricing\n08 Combination Pricing\n09 Maternity Pricing\n10 Other Pricing\n11 Lower of Cost\n12 Ratio of Cost\n13 Cost Reimbursed\n14 Adjustment Pricing ","R","Encounter: \"00/02\""]
[2400,"HCP","HCP02","Monetary Amount","R","O",1,"R",1,18,null,"R","n/a"]
[2400,"HCP","HCP03","Monetary Amount","S","O",1,"R",1,18,null,"S","n/a"]
[2400,"HCP","HCP04","Reference Identification","S","O",1,"AN",1,50,null,"S","n/a"]
[2400,"HCP","HCO05","Rate","S","O",1,"R",1,9,null,"S","n/a"]
[2400,"HCP","HCP06","Reference Identification","S","O",1,"AN",1,50,null,"S","n/a"]
[2400,"HCP","HCP07","Monetary Amount","S","O",1,"R",1,18,null,"S","n/a"]
[2400,"HCP","HCP08","Product/Service ID","S","O",1,"AN",1,48,null,"S","n/a"]
[2400,"HCP","HCP09","Product/Service ID Qualifier","S","X",1,"ID",2,2,"ER Jurisdiction Specific Procedure and Supply Codes \nHC Health Care Financing Administration Common Procedural Coding System (HCPCS) Codes \nHP Health Insurance Prospective Payment System (HIPPS) Skilled Nursing Facility Rate Code\nIV Home Infusion EDI Coalition (HIEC) Product/Service Code \nWK Advanced Billing Concepts (ABC) Codes","S","n/a"]
[2400,"HCP","HCP10","Product/Service ID","S","X",1,"AN",1,48,null,"S","n/a"]
[2400,"HCP","HCP11","Unit or Basis for Measurement Code","S","X",1,"ID",2,2,"DA Days\nUN Unit ","S","n/a"]
[2400,"HCP","HCP12","Quantity","S","X",1,"R",1,15,null,"S","n/a"]
[2400,"HCP","HCP13","Reject Reason Code","S","X",1,"ID",2,2,"T1 Cannot Identify Provider as TPO (Third Party Organization) Participant\nT2 Cannot Identify Payer as TPO (Third Party Organization) Participant\nT3 Cannot Identify Insured as TPO (Third Party Organization) Participant\nT4 Payer Name or Identifier Missing\nT5 Certification Information Missing\nT6 Claim does not contain enough information for repricing\n","S","n/a"]
[2400,"HCP","HCP14","Policy Compliance Code","S","O",1,"ID",1,2,"1 Procedure Followed (Compliance)\n2 Not Followed - Call Not Made (Non-Compliance Call Not Made)\n3 Not Medically Necessary (Non-Compliance NonMedically Necessary)\n4 Not Followed Other (Non-Compliance Other)\n5 Emergency Admit to Non-Network Hospital","S","n/a"]
[2400,"HCP","HCP15","Exception Code","S","O",1,"ID",1,2,"1 Non-Network Professional Provider in Network Hospital\n2 Emergency Care\n3 Services or Specialist not in Network\n4 Out-of-Service Area\n5 State Mandates\n6 Other\n","S","n/a"]
[2410,null,null,"Drug Identification","S","O",1,{"$nulls":4},"S"]
[2410,"LIN",null,"Drug Identification","S","O",1,{"$nulls":4},"S"]
[2410,"LIN","LIN02","Product/Service ID Qualifier","R","M",1,"ID",2,2,"N4 National Drug Code in 5-4-2 Format\n","R","n/a"]
[2410,"LIN","LIN03","Product/Service ID","R","M",1,"AN",1,48,null,"R","n/a"]
[2410,"CTP",null,"Drug Quantity","R","O",1,{"$nulls":4},"R"]
[2410,"CTP","CPT04","Quantity","R","X",1,"R",1,15,null,"R","n/a"]
[2410,"CTP","CPT05","Composite Unit of Measure","R","X",1,{"$nulls":4},"R"]
[2410,"CTP","CPT05-1","Unit or Basis for Measurement Code","R","M",1,"ID",2,2,"F2 International Unit\nGR Gram\nME Milligram\nML Milliliter\nUN Unit","R","n/a"]
[2410,"REF",null,"Prescription or Compound Drug Association Number","S","O",1,{"$nulls":4},"S"]
[2410,"REF","REF01","Reference Identification Qualifier","R","M",1,"ID",2,3,"VY Link Sequence Number\nXZ Pharmacy Prescription Number\n","R","n/a"]
[2410,"REF","REF02","Reference Identification","R","X",1,"AN",1,50,null,"R","n/a"]
["2420A",null,null,"Operating Physician Name","S","O",1,{"$nulls":4},"S"]
["2420A","NM1",null,"Operating Physician Name","S","O",1,{"$nulls":4},"S"]
["2420A","NM1","NM101","Entity Identifier Code","R","M",1,"ID",2,3,"72 Operating Physician ","RNS","n/a"]
["2420A","NM1","NM102","Entity Type Qualifier","R","M",1,"ID",1,1,"1 Person ","RNS","n/a"]
["2420A","NM1","NM103","Name Last or Organization Name","R","X",1,"AN",1,60,null,"R","n/a"]
["2420A","NM1","NM104","Name First","S","O",1,"AN",1,35,null,"S","n/a"]
["2420A","NM1","NM105","Name Middle","S","O",1,"AN",1,25,null,"S","n/a"]
["2420A","NM1","NM107","Name Suffix","S","O",1,"AN",1,10,null,"S","n/a"]
["2420A","NM1","NM108","Identification Code Qualifier","S","X",1,"ID",1,2,"XX Centers for Medicare and Medicaid Services National Provider Identifier","S","n/a"]
["2420A","NM1","NM109","Identification Code","S","X",1,"AN",2,80,null,"S","n/a"]
["2420A","REF",null,"Operating Physician Secondary Identification","S","O",20,{"$nulls":4},"S"]
["2420A","REF","REF01","Reference Identification Qualifier","R","M",1,"ID",2,3,"0B State License Number\n1G Provider UPIN Number \nG2 Provider Commercial Number \nLU Location Number ","R","n/a"]
["2420A","REF","REF02","Reference Identification","R","X",1,"AN",1,50,null,"R","n/a"]
["2420A","REF","REF04","Reference Identifier","S","O",1,{"$nulls":4},"S"]
["2420A","REF","REF04 - 1","Reference Identification Qualifier","R","M",1,"ID",2,3,"2U Payer Identification Number ","R","n/a"]
["2420A","REF","REF04 - 2","Reference Identification","R","M",1,"AN",1,50,null,"R","n/a"]
["2420B",null,null,"Other Operating Physician Name","S","O",1,{"$nulls":4},"S"]
["2420B","NM1",null,"Other Operating Physician Name","S","O",1,{"$nulls":4},"S"]
["2420B","NM1","NM101","Entity Identifier Code","R","M",1,"ID",2,3,"ZZ Mutually Defined ","RNS","n/a"]
["2420B","NM1","NM102","Entity Type Qualifier","R","M",1,"ID",1,1,"1 Person ","RNS","n/a"]
["2420B","NM1","NM103","Name Last or Organization Name","R","X",1,"AN",1,60,null,"R","n/a"]
["2420B","NM1","NM104","Name First","S","O",1,"AN",1,35,null,"S","n/a"]
["2420B","NM1","NM105","Name Middle","S","O",1,"AN",1,25,null,"S","n/a"]
["2420B","NM1","NM107","Name Suffix","S","O",1,"AN",1,10,null,"S","n/a"]
["2420B","NM1","NM108","Identification Code Qualifier","S","X",1,"ID",1,2,"XX Centers for Medicare and Medicaid Services National Provider Identifier\n","S","n/a"]
["2420B","NM1","NM109","Identification Code","S","X",1,"AN",2,80,null,"S","n/a"]
["2420B","REF",null,"Other Operating Physician Secondary Identification","S","O",20,{"$nulls":4},"S"]
["2420B","REF","REF01","Reference Identification Qualifier","R","M",1,"ID",2,3,"0B State License Number\n1G Provider UPIN Number \nG2 Provider Commercial Number \nLU Location Number ","R","Encounter: \"G2\""]
["2420B","REF","REF02","Reference Identification","R","X",1,"AN",1,50,null,"R","n/a"]
["2420B","REF","REF04","Reference Identifier","S","O",1,{"$nulls":4},"S"]
["2420B","REF","REF04 - 1","Reference Identification Qualifier","R","M",1,"ID",2,3,"2U Payer Identification Number ","R","n/a"]
["2420B","REF","REF04 - 2","Reference Identification","R","M",1,"AN",1,50,null,"R","n/a"]
["2420C",null,null,"Rendering Provider Name","S","O",1,{"$nulls":4},"S"]
["2420C","NM1",null,"Rendering Provider Name","S","O",1,{"$nulls":4},"S"]
["2420C","NM1","NM101","Entity Identifier Code","R","M",1,"ID",2,3,"82 Rendering Provider ","RNS","n/a"]
["2420C","NM1","NM102","Entity Type Qualifier","R","M",1,"ID",1,1,"1 Person ","RNS","n/a"]
["2420C","NM1","NM103","Name Last or Organization Name","R","X",1,"AN",1,60,null,"R","n/a"]
["2420C","NM1","NM104","Name First","S","O",1,"AN",1,35,null,"S","n/a"]
["2420C","NM1","NM105","Name Middle","S","O",1,"AN",1,25,null,"S","n/a"]
["2420C","NM1","NM107","Name Suffix","S","O",1,"AN",1,10,null,"S","n/a"]
["2420C","NM1","NM108","Identification Code Qualifier","S","X",1,"ID",1,2,"XX Centers for Medicare and Medicaid Services National Provider Identifier\n","S","n/a"]
["2420C","NM1","NM109","Identification Code","S","X",1,"AN",2,80,null,"S","n/a"]
["2420C","REF",null,"Rendering Provider Secondary Identification","S","O",20,{"$nulls":4},"S"]
["2420C","REF","REF01","Reference Identification Qualifier","R","M",1,"ID",2,3,"0B State License Number\n1G Provider UPIN Number\nG2 Provider Commercial Number \nLU Location Number ","R","n/a"]
["2420C","REF","REF02","Reference Identification","R","X",1,"AN",1,50,null,"R","n/a"]
["2420C","REF","REF04","Reference Identifier","S","O",1,{"$nulls":4},"S"]
["2420C","REF","REF04 - 1","Reference Identification Qualifier","R","M",1,"ID",2,3,"2U Payer Identification Number ","R","n/a"]
["2420C","REF","REF04 - 2","Reference Identification","R","M",1,"AN",1,50,null,"R","n/a"]
["2420D",null,null,"Referring Provider Name","S","O",1,{"$nulls":4},"S"]
["2420D","NM1",null,"Referring Provider Name","S","O",1,{"$nulls":4},"S"]
["2420D","NM1","NM101","Entity Identifier Code","R","M",1,"ID",2,3,"DN Referring Provider ","RNS","n/a"]
["2420D","NM1","NM102","Entity Type Qualifier","R","M",1,"ID",1,1,"1 Person ","RNS","n/a"]
["2420D","NM1","NM103","Name Last or Organization Name","R","X",1,"AN",1,60,null,"R","n/a"]
["2420D","NM1","NM104","Name First","S","O",1,"AN",1,35,null,"S","n/a"]
["2420D","NM1","NM105","Name Middle","S","O",1,"AN",1,25,null,"S","n/a"]
["2420D","NM1","NM107","Name Suffix","S","O",1,"AN",1,10,null,"S","n/a"]
["2420D","NM1","NM108","Identification Code Qualifier","S","X",1,"ID",1,2,"XX Centers for Medicare and Medicaid Services National Provider Identifier\n","S","n/a"]
["2420D","NM1","NM109","Identification Code","S","X",1,"AN",2,80,null,"S","n/a"]
["2420D","REF",null,"Referring Provider Secondary Identification","S","O",20,{"$nulls":4},"S"]
["2420D","REF","REF01","Reference Identification Qualifier","R","M",1,"ID",2,3,"0B State License Number\n1G Provider UPIN Number \nG2 Provider Commercial Number ","R","n/a"]
["2420D","REF","REF02","Reference Identification","R","X",1,"AN",1,50,null,"R","n/a"]
["2420D","REF","REF04","Reference Identifier","S","O",1,{"$nulls":4},"S"]
["2420D","REF","REF04 - 1","Reference Identification Qualifier","R","M",1,"ID",2,3,"2U Payer Identification Number ","R","n/a"]
["2420D","REF","REF04 - 2","Reference Identification","R","M",1,"AN",1,50,null,"R","n/a"]
[2430,null,null,"Line Adjudication Information","S","O",15,{"$nulls":4},"S"]
[2430,"SVD",null,"Line Adjudication Information","S","O",1,{"$nulls":4},"S"]
[2430,"SVD","SVD01","Identification Code","R","M",1,"AN",2,80,null,"R","n/a"]
[2430,"SVD","SVD02","Monetary Amount","R","M",1,"R",1,18,null,"R","n/a"]
[2430,"SVD","SVD03","Composite Medical Procedure Identifier","S","O",1,{"$nulls":4},"S"]
[2430,"SVD","SVD03-1","Product/Service ID Qualifier","R","M",1,"ID",2,2,"ER Jurisdiction Specific Procedure and Supply Codes\nHC Health Care Financing Administration Common Procedural Coding System (HCPCS) Codes\nHP Health Insurance Prospective Payment System (HIPPS) Skilled Nursing Facility Rate Code\nIV Home Infusion EDI Coalition (HIEC) Product/Service Code\nWK Advanced Billing Concepts (ABC) Code","R","n/a"]
[2430,"SVD","SVD03-2","Product/Service ID","R","M",1,"AN",1,48,null,"R","n/a"]
[2430,"SVD","SVD03-3","Procedure Modifier","S","O",1,"AN",2,2,null,"S","n/a"]
[2430,"SVD","SVD03-4","Procedure Modifier","S","O",1,"AN",2,2,null,"S","n/a"]
[2430,"SVD","SVD03-5","Procedure Modifier","S","O",1,"AN",2,2,null,"S","n/a"]
[2430,"SVD","SVD03-6","Procedure Modifier","S","O",1,"AN",2,2,null,"S","n/a"]
[2430,"SVD","SVD03-7","Description","S","O",1,"AN",1,80,null,"S","n/a"]
[2430,"SVD","SVD04","Product/Service ID","R","O",1,"AN",1,48,null,"R","n/a"]
[2430,"SVD","SVD05","Quantity","R","O",1,"R",1,15,null,"R","n/a"]
[2430,"SVD","SVD06","Assigned Number","S","O",1,"N0",1,6,null,"S","n/a"]
[2430,"CAS",null,"Line Adjustment","S","O",5,{"$nulls":4},"S"]
[2430,"CAS","CAS01","Claim Adjustment Group Code","R","M",1,"ID",1,2,"CO Contractual Obligations\nCR Correction and Reversals\nOA Other adjustments\nPI Payor Initiated Reductions\nPR Patient Responsibility","R","n/a"]
[2430,"CAS","CAS02","Claim Adjustment Reason Code","R","M",1,"ID",1,5,null,"R","n/a"]
[2430,"CAS","CAS03","Monetary Amount","R","M",1,"R",1,18,null,"R","n/a"]
[2430,"CAS","CAS04","Quantity","S","O",1,"R",1,15,null,"S","n/a"]
[2430,"CAS","CAS05","Claim Adjustment Reason Code","S","X",1,"ID",1,5,null,"S","n/a"]
[2430,"CAS","CAS06","Monetary Amount","S","X",1,"R",1,18,null,"S","n/a"]
[2430,"CAS","CAS07","Quantity","S","X",1,"R",1,15,null,"S","n/a"]
[2430,"CAS","CAS08","Claim Adjustment Reason Code","S","X",1,"ID",1,5,null,"S","n/a"]
[2430,"CAS","CAS09","Monetary Amount","S","X",1,"R",1,18,null,"S","n/a"]
[2430,"CAS","CAS10","Quantity","S","X",1,"R",1,15,null,"S","n/a"]
[2430,"CAS","CAS11","Claim Adjustment Reason Code","S","X",1,"ID",1,5,null,"S","n/a"]
[2430,"CAS","CAS12","Monetary Amount","S","X",1,"R",1,18,null,"S","n/a"]
[2430,"CAS","CAS13","Quantity","S","X",1,"R",1,15,null,"S","n/a"]
[2430,"CAS","CAS14","Claim Adjustment Reason Code","S","X",1,"ID",1,5,null,"S","n/a"]
[2430,"CAS","CAS15","Monetary Amount","S","X",1,"R",1,18,null,"S","n/a"]
[2430,"CAS","CAS16","Quantity","S","X",1,"R",1,15,null,"S","n/a"]
[2430,"CAS","CAS17","Claim Adjustment Reason Code","S","X",1,"ID",1,5,null,"S","n/a"]
[2430,"CAS","CAS18","Monetary Amount","S","X",1,"R",1,18,null,"S","n/a"]
[2430,"CAS","CAS19","Quantity","S","X",1,"R",1,15,null,"S","n/a"]
[2430,"DTP",null,"Line Check or Remittance Date","R","O",1,{"$nulls":4},"R"]
[2430,"DTP","DPT01","Date/Time Qualifier","R","M",1,"ID",3,3,"573 Date Claim Paid ","RNS","n/a"]
[2430,"DTP","DPT02","Date Time Period Format Qualifier","R","M",1,"ID",2,3,"D8 Date Expressed in Format CCYYMMDD","RNS","n/a"]
[2430,"DTP","DPT03","Date Time Period","R","M",1,"AN",1,35,null,"R","n/a"]
[2430,"AMT",null,"Remaining Patient Liability","S","O",1,{"$nulls":4},"S"]
[2430,"AMT","AMT01","Amount Qualifier Code","R","M",1,"ID",1,3,"EAF Amount Owed ","RNS","n/a"]
[2430,"AMT","AMT02","Monetary Amount","R","M",1,"R",1,18,null,"R","n/a"]
[2430,"SE",null,"Transaction Set Trailer","R","M",1,{"$nulls":4},"R"]
[2430,"SE","SE01","Number of Segments Included","R","M",1,"N0",1,10,null,"R","n/a"]
[2430,"SE","SE02","Transaction Set Control Number","R","M",1,"AN",4,9,null,"R","n/a"]
[2430,"GE",null,"Functional Group Trailer","R","M",1,{"$nulls":4},"R"]
[2430,"GE","GE01","Number of Transaction Sets Included","R","M",1,"N0",1,6,null,"R","n/a"]
[2430,"GE","GE02","Group Control Number","R","M",1,"N0",1,9,null,"R","n/a"]
[2430,"IEA",null,"Interchange Control Trailer","R","M",1,{"$nulls":4},"R"]
[2430,"IEA","IEA01","Number of Included Functional Groups","R","M",1,"N0",1,5,null,"R","n/a"]
[2430,"IEA","IEA02","Interchange Control Number","R","M",1,"N0",9,9,null,"R","n/a"]

{"sheet":"837I CG","index":4,"n_rows":0,"n_cols":0,"rows_kept":0}

{"sheet":"837D Mapping","index":5,"n_rows":828,"n_cols":13,"rows_kept":828,"merged":[[0,0,1,0],[0,1,1,1],[0,2,1,2],[0,3,1,3],[0,4,1,4],[0,5,1,5],[0,6,1,6],[0,7,1,7],[0,8,1,8],[0,9,1,9],[0,10,1,10],[0,11,1,11],[0,12,1,12]]}
["Loop Id","Segment Id","Element Pos","Loop/Segment/Element Name","Usage","Condition Designator","Repeat","Data Type","Minimum","Maximum","Implementation Guide Code list","PRISM Usage","PRISM Values/Constants"]
[null,"Segment Id","Element Pos","Loop/Segment/Element Name","Usage","Condition Designator","Repeat","Data Type","Minimum","Maximum","Implementation Guide Code list",null,"PRISM Values (FFS/XOver)"]
[null,"ISA",null,"Interchange Control Header","R","M",1,{"$nulls":4},"R"]
[null,"ISA","ISA01","Authorization Information Qualifier","R","M",1,"ID",2,2,"00 No Authorization Information Present (No Meaningful Information in I02)\n03 Additional Data Identification","R","\"00\""]
[null,"ISA","ISA02","Authorization Information","R","M",1,"AN",10,10,null,"R","\"          \""]
[null,"ISA","ISA03","Security Information Qualifier","R","M",1,"ID",2,2,"00 No Security Information Present (No Meaningful Information in I04)\n01 Password","R","\"00\""]
[null,"ISA","ISA04","Security Information","R","M",1,"AN",10,10,null,"R","\"          \""]
[null,"ISA","ISA05","Interchange ID Qualifier","R","M",1,"ID",2,2,"01 Duns (Dun & Bradstreet),\n14 Duns Plus Suffix,\n20 Health Industry Number (HIN),\n27 Carrier Identification Number as assigned by Health Care Financing Administration (HCFA),\n28 Fiscal Intermediary Identification Number as assigned by Health Care Financing Administration (HCFA),\n29 Medicare Provider and Supplier Identification Number as assigned by Health Care Financing Administration (HCFA),\n30 U.S. Federal Tax Identification Number,\n33 National Association of Insurance Commissioners Company Code (NAIC),\nZZ Mutually Defined","R","\"ZZ\""]
[null,"ISA","ISA06","Interchange Sender ID","R","M",1,"AN",15,15,null,"R","n/a"]
[null,"ISA","ISA07","Interchange ID Qualifier","R","M",1,"ID",2,2,"01 Duns (Dun & Bradstreet),\n14 Duns Plus Suffix,\n20 Health Industry Number (HIN),\n27 Carrier Identification Number as assigned by Health Care Financing Administration (HCFA),\n28 Fiscal Intermediary Identification Number as assigned by Health Care Financing Administration (HCFA),\n29 Medicare Provider and Supplier Identification Number as assigned by Health Care Financing Administration (HCFA),\n30 U.S. Federal Tax Identification Number,\n33 National Association of Insurance Commissioners Company Code (NAIC),\nZZ Mutually Defined","R","\"ZZ\""]
[null,"ISA","ISA08","Interchange Receiver ID","R","M",1,"AN",15,15,null,"R","Medicaid FFS: \"HT000004-001\" \nEncounter: \"HT000004-002\" \nCrossover: \"HT000004-005\" \nMedicaid Atypical: \"HT000004-801\" \nTest MCO: \"HT000004-003\"\nTest FFS: \"HT000004-004\""]
[null,"ISA","ISA09","Interchange Date","R","M",1,"DT",6,6,null,"R","SYSDATE\nFormat: YYMMDD"]
[null,"ISA","ISA10","Interchange Time","R","M",1,"TM",4,4,null,"R","SYSDATE\nFormat: HHMM"]
[null,"ISA","ISA11","Repetition Separator","R","M",1,null,1,1,null,"R","\"^\""]
[null,"ISA","ISA12","Interchange Control Version Number","R","M",1,"ID",5,5,"00501 Standards Approved for Publication by ASC X12 Procedures Review Board through October 2003","R","\"00501\""]
[null,"ISA","ISA13","Interchange Control Number","R","M",1,"N0",9,9,null,"R","n/a"]
[null,"ISA","ISA14","Acknowledgment Requested","R","M",1,"ID",1,1,"0 No Interchange Acknowledgment Requested\n1 Interchange Acknowledgment Requested (TA1)","R","\"1\""]
[null,"ISA","ISA15","Interchange Usage Indicator","R","M",1,"ID",1,1,"P Production Data,\nT Test Data","R","\"P/T\""]
[null,"ISA","ISA16","Component Element Separator","R","M",1,null,1,1,null,"R","\":\""]
[null,"GS",null,"Functional Group Header","R","M",1,{"$nulls":4},"R"]
[null,"GS","GS01","Functional Identifier Code","R","M",1,"ID",2,2,"HC Health Care Claim (837)","R","\"HC\""]
[null,"GS","GS02","Application Sender's Code","R","M",1,"AN",2,15,null,"R","n/a"]
[null,"GS","GS03","Application Receiver's Code","R","M",1,"AN",2,15,null,"R","Medicaid FFS: \"HT000004-001\" \nEncounter: \"HT000004-002\" \nCrossover: \"HT000004-005\" \nMedicaid Atypical: \"HT000004-801\" \nTest MCO: \"HT000004-003\"\nTest FFS: \"HT000004-004\""]
[null,"GS","GS04","Date","R","M",1,"DT",8,8,null,"R","SYSDATE\nFormat: CCYYMMDD "]
[null,"GS","GS05","Time","R","M",1,"TM",4,8,null,"R","SYSDATE\nFormat: HHMM"]
[null,"GS","GS06","Group Control Number","R","M",1,"N0",1,9,null,"R","n/a"]
[null,"GS","GS07","Responsible Agency Code","R","M",1,"ID",1,2,"X Accredited Standards Committee X12","R","\"X\""]
[null,"GS","GS08","Version / Release / Industry Identifier Code","R","M",1,"AN",1,12,"005010X224A2 Standards Approved for Publication by ASC X12 Procedures Review Board through October 2003","R","\"005010X224A2\""]
[null,"ST",null,"Transaction Set Header","R","M",1,{"$nulls":4},"R"]
[null,"ST","ST01","Transaction Set Identifier Code","R","M",1,"ID",3,3,"837 Health Care Claim","R","\"837\""]
[null,"ST","ST02","Transaction Set Control Number","R","M",1,"AN",4,9,null,"R","n/a"]
[null,"ST","ST03","Implementation Convention Reference","R","O",1,"AN",1,35,null,"R","n/a"]
[null,"BHT","","Beginning of Hierarchical Transaction","R","M",1,{"$nulls":4},"R"]
[null,"BHT","BHT01","Hierarchical Structure Code","R","M",1,"ID",4,4,"0019 Information Source, Subscriber, Dependent","RNS","n/a"]
[null,"BHT","BHT02","Transaction Set Purpose Code","R","M",1,"ID",2,2,"00 Original,18 Reissue","R","\"00\" "]
[null,"BHT","BHT03","Reference Identification","R","O",1,"AN",1,50,null,"R","n/a"]
[null,"BHT","BHT04","Date","R","O",1,"DT",8,8,null,"R","SYSDATE\nFormat: CCYYMMDD "]
[null,"BHT","BHT05","Time","R","O",1,"TM",4,8,null,"R","SYSDATE\nFormat: HHMM"]
[null,"BHT","BHT06","Transaction Type Code","R","O",1,"ID",2,2,"31 Subrogation Demand\nCH Chargeable\nRP Reporting","R","Non-Encounter: \"CH\" \nEncounter: \"RP\""]
["1000A",null,"","Submitter Name","R","O",1,{"$nulls":4},"R"]
["1000A","NM1","","Submitter Name","R","O",1,{"$nulls":4},"R"]
["1000A","NM1","NM101","Entity Identifier Code","R","M",1,"ID",2,3,"41 Submitter","RNS","n/a"]
["1000A","NM1","NM102","Entity Type Qualifier","R","M",1,"ID",1,1,"1 Person,\n2 Non-Person Entity","RNS","n/a"]
["1000A","NM1","NM103","Name Last or Organization Name","R","X",1,"AN",1,60,null,"R","n/a"]
["1000A","NM1","NM104","Name First","S","O",1,"AN",1,35,null,"S","n/a"]
["1000A","NM1","NM105","Name Middle","S","O",1,"AN",1,25,null,"S","n/a"]
["1000A","NM1","NM108","Identification Code Qualifier","R","X",1,"ID",1,2,"46 Electronic Transmitter Identification Number (ETIN)","R","\"46\""]
["1000A","NM1","NM109","Identification Code","R","X",1,"AN",2,80,null,"R","n/a"]
["1000A","PER","","Submitter EDI Contact Information","R","O",2,{"$nulls":4},"R"]
["1000A","PER","PER01","Contact Function Code","R","M",1,"ID",2,2,"IC Information Contact","RNS","n/a"]
["1000A","PER","PER02","Name","S","O",1,"AN",1,60,null,"S","n/a"]
["1000A","PER","PER03","Communication Number Qualifier","R","X",1,"ID",2,2,"EM Electronic Mail,\nFX Facsimile,\nTE Telephone","R","n/a"]
["1000A","PER","PER04","Communication Number","R","X",1,"AN",1,256,null,"R","n/a"]
["1000A","PER","PER05","Communication Number Qualifier","S","X",1,"ID",2,2,"EM Electronic Mail \nEX Telephone Extension\nFX Facsimile\nTE Telephone","S","n/a"]
["1000A","PER","PER06","Communication Number","S","X",1,"AN",1,256,null,"S","n/a"]
["1000A","PER","PER07","Communication Number Qualifier","S","X",1,"ID",2,2,"EM Electronic Mail\nEX Telephone Extension\nFX Facsimile\nTE Telephone","S","n/a"]
["1000A","PER","PER08","Communication Number","R","X",1,"AN",1,256,null,"R","n/a"]
["1000B",null,"","Receiver Name","R","O",1,{"$nulls":4},"R"]
["1000B","NM1","","Receiver Name","R","O",1,{"$nulls":4},"R"]
["1000B","NM1","NM101","Entity Identifier Code","R","M",1,"ID",2,3,"40 Receiver","RNS","n/a"]
["1000B","NM1","NM102","Entity Type Qualifier","R","M",1,"ID",1,1,"2 Non-Person Entity","RNS","n/a"]
["1000B","NM1","NM103","Name Last or Organization Name","R","X",1,"AN",1,60,null,"RNS","n/a"]
["1000B","NM1","NM108","Identification Code Qualifier","R","X",1,"ID",1,2,"46 Electronic Transmitter Identification Number (ETIN)","RNS","n/a"]
["1000B","NM1","NM109","Identification Code","R","X",1,"AN",2,80,null,"RNS","\"HT000004-001\" (Medicaid FFS and Paper)\n\"HT000004-002\" (Encounter)\n\"HT000004-005\" (Crossover)\n\"HT000004-801\" (Medicaid Atypical)\n\"HT000004-003\" (Test MCO)\n\"HT000004-004\" (Test FFS)"]
["2000A",null,"","Billing Provider Hierarchical Level","R","M",">1",{"$nulls":4},"R"]
["2000A","HL","","Billing Provider Hierarchical Level","R","M",1,{"$nulls":4},"R"]
["2000A","HL","HL01","Hierarchical ID Number","R","M",1,"AN",1,12,null,"RNS","n/a"]
["2000A","HL","HL03","Hierarchical Level Code","R","M",1,"ID",1,2,"20 Information Source","RNS","n/a"]
["2000A","HL","HL04","Hierarchical Child Code","R","O",1,"ID",1,1,"1 Additional Subordinate HL Data Segment in This Hierarchical Structure.","RNS","n/a"]
["2000A","PRV","","Billing Provider Specialty Information","S","O",1,{"$nulls":4},"S"]
["2000A","PRV","PRV01","Provider Code","R","M",1,"ID",1,3,"BI Billing","RNS","n/a"]
["2000A","PRV","PRV02","Reference Identification Qualifier","R","X",1,"ID",2,3,"PXC Health Care Provider Taxonomy Code","RNS","n/a"]
["2000A","PRV","PRV03","Reference Identification","R","X",1,"AN",1,50,null,"R","n/a"]
["2000A","CUR","","Foreign Currency Information","S","O",1,{"$nulls":4},"S"]
["2000A","CUR","CUR01","Entity Identifier Code","R","M",1,"ID",2,3,"85 Billing Provider","RNS","n/a"]
["2000A","CUR","CUR02","Currency Code","R","M",1,"ID",3,3,null,"R","\"USD\""]
["2010AA",null,"","Billing Provider Name","R","O",1,{"$nulls":4},"R"]
["2010AA","NM1","","Billing Provider Name","R","O",1,{"$nulls":4},"R"]
["2010AA","NM1","NM101","Entity Identifier Code","R","M",1,"ID",2,3,"85 Billing Provider","RNS","n/a"]
["2010AA","NM1","NM102","Entity Type Qualifier","R","M",1,"ID",1,1,"1 Person,\n2 Non-Person Entity","RNS","n/a"]
["2010AA","NM1","NM103","Name Last or Organization Name","R","X",1,"AN",1,60,null,"R","n/a"]
["2010AA","NM1","NM104","Name First","S","O",1,"AN",1,35,null,"S","n/a"]
["2010AA","NM1","NM105","Name Middle","S","O",1,"AN",1,25,null,"S","n/a"]
["2010AA","NM1","NM107","Name Suffix","S","O",1,"AN",1,10,null,"S","n/a"]
["2010AA","NM1","NM108","Identification Code Qualifier","S","X",1,"ID",1,2,"XX Centers for Medicare and Medicaid Services National Provider Identifier","S","n/a"]
["2010AA","NM1","NM109","Identification Code","S","X",1,"AN",2,80,null,"S","n/a"]
["2010AA","N3","","Billing Provider Address","R","O",1,{"$nulls":4},"R"]
["2010AA","N3","N301","Address Information","R","M",1,"AN",1,55,null,"R","n/a"]
["2010AA","N3","N302","Address Information","S","O",1,"AN",1,55,null,"S","n/a"]
["2010AA","N4","","Billing Provider City, State, ZIP Code","R","O",1,{"$nulls":4},"R"]
["2010AA","N4","N401","City Name","R","O",1,"AN",2,30,null,"R","n/a"]
["2010AA","N4","N402","State or Province Code","S","X",1,"ID",2,2,null,"S","n/a"]
["2010AA","N4","N403","Postal Code","S","O",1,"ID",3,15,null,"S","n/a"]
["2010AA","N4","N404","Country Code","S","X",1,"ID",2,3,null,"S","n/a"]
["2010AA","N4","N407","Country Subdivision Code","S","X",1,"ID",1,3,null,"S","n/a"]
["2010AA","REF","","Billing Provider Tax Identification","R","O",1,{"$nulls":4},"R"]
["2010AA","REF","REF01","Reference Identification Qualifier","R","M",1,"ID",2,3,"EI Employer’s Identification Number\nSY Social Security Number","R","n/a"]
["2010AA","REF","REF02","Reference Identification","R","X",1,"AN",1,50,null,"R","n/a"]
["2010AA","REF","","Billing Provider UPIN/License Information","S","O",2,{"$nulls":4},"S"]
["2010AA","REF","REF01","Reference Identification Qualifier","R","M",1,"ID",2,3,"0B State License Number\n1G Provider UPIN Number","R","n/a"]
["2010AA","REF","REF02","Reference Identification","R","X",1,"AN",1,50,null,"R","n/a"]
["2010AA","PER","","Billing Provider Contact Information","S","O",2,{"$nulls":4},"S"]
["2010AA","PER","PER01","Contact Function Code","R","M",1,"ID",2,2,"IC Information Contact","RNS","n/a"]
["2010AA","PER","PER02","Name","S","O",1,"AN",1,60,null,"S","n/a"]
["2010AA","PER","PER03","Communication Number Qualifier","R","X",1,"ID",2,2,"EM Electronic Mail\nFX Facsimile\nTE Telephone","R","n/a"]
["2010AA","PER","PER04","Communication Number","R","X",1,"AN",1,256,null,"R","n/a"]
["2010AA","PER","PER05","Communication Number Qualifier","S","X",1,"ID",2,2,"EM Electronic Mail\nEX Telephone Extension\nFX Facsimile\nTE Telephone","S","n/a"]
["2010AA","PER","PER06","Communication Number","S","X",1,"AN",1,256,null,"S","n/a"]
["2010AA","PER","PER07","Communication Number Qualifier","S","X",1,"ID",2,2,"EM Electronic Mail\nEX Telephone Extension\nFX Facsimile\nTE Telephone","S","n/a"]
["2010AA","PER","PER08","Communication Number","S","X",1,"AN",1,256,null,"S","n/a"]
["2010AB",null,"","Pay-to Address Name","S","O",1,{"$nulls":4},"S"]
["2010AB","NM1","","Pay-to Address Name","S","O",1,{"$nulls":4},"S"]
["2010AB","NM1","NM101","Entity Identifier Code","R","M",1,"ID",2,3,"87 Pay-to Provider","RNS","n/a"]
["2010AB","NM1","NM102","Entity Type Qualifier","R","M",1,"ID",1,1,"1 Person,\n2 Non-Person Entity","RNS","n/a"]
["2010AB","N3","","Pay-to Address - ADDRESS","R","O",1,{"$nulls":4},"R"]
["2010AB","N3","N301","Address Information","R","M",1,"AN",1,55,null,"R","n/a"]
["2010AB","N3","N302","Address Information","S","O",1,"AN",1,55,null,"S","n/a"]
["2010AB","N4","","Pay-to Address - City, State, ZIP Code","R","O",1,{"$nulls":4},"R"]
["2010AB","N4","N401","City Name","R","O",1,"AN",2,30,null,"R","n/a"]
["2010AB","N4","N402","State or Province Code","S","X",1,"ID",2,2,null,"S","n/a"]
["2010AB","N4","N403","Postal Code","S","O",1,"ID",3,15,null,"S","n/a"]
["2010AB","N4","N404","Country Code","S","X",1,"ID",2,3,null,"S","n/a"]
["2010AB","N4","N407","Country Subdivision Code","S","X",1,"ID",1,3,null,"S","n/a"]
["2010AC",null,"","Pay-To Plan Name","S","O",1,{"$nulls":4},"S"]
["2010AC","NM1","","Pay-To Plan Name","S","O",1,{"$nulls":4},"S"]
["2010AC","NM1","NM101","Entity Identifier Code","R","M",1,"ID",2,3,"PE Payee","RNS","n/a"]
["2010AC","NM1","NM102","Entity Type Qualifier","R","M",1,"ID",1,1,"2 Non-Person Entity","RNS","n/a"]
["2010AC","NM1","NM103","Name Last or Organization Name","R","X",1,"AN",1,60,null,"R","n/a"]
["2010AC","NM1","NM108","Identification Code Qualifier","R","X",1,"ID",1,2,"PI Payor Identification,\nXV Centers for Medicare and Medicaid Services PlanID","R","n/a"]
["2010AC","NM1","NM109","Identification Code","R","X",1,"AN",2,80,null,"R","n/a"]
["2010AC","N3","","Pay-To Plan Address","R","O",1,{"$nulls":4},"R"]
["2010AC","N3","N301","Address Information","R","M",1,"AN",1,55,null,"R","n/a"]
["2010AC","N3","N302","Address Information","S","O",1,"AN",1,55,null,"S","n/a"]
["2010AC","N4","","Pay-To Plan City, State, Zip Code","R","O",1,{"$nulls":4},"R"]
["2010AC","N4","N401","City Name","R","O",1,"AN",2,30,null,"R","n/a"]
["2010AC","N4","N402","State or Province Code","S","X",1,"ID",2,2,null,"S","n/a"]
["2010AC","N4","N403","Postal Code","S","O",1,"ID",3,15,null,"S","n/a"]
["2010AC","N4","N404","Country Code","S","X",1,"ID",2,3,null,"S","n/a"]
["2010AC","N4","N407","Country Subdivision Code","S","X",1,"ID",1,3,null,"S","n/a"]
["2010AC","REF","","Pay-To Plan Secondary Identification","S","O",1,{"$nulls":4},"S"]
["2010AC","REF","REF01","Reference Identification Qualifier","R","M",1,"ID",2,3,"2U Payer Identification Number\nFY Claim Office Number\nNF National Association of Insurance Commissioners\n(NAIC) Code","R","n/a"]
["2010AC","REF","REF02","Reference Identification","R","X",1,"AN",1,50,null,"R","n/a"]
["2010AC","REF","","Pay-To Plan Tax Identification Number","R","O",1,{"$nulls":4},"R"]
["2010AC","REF","REF01","Reference Identification Qualifier","R","M",1,"ID",2,3,"EI Employer’s Identification Number","RNS","n/a"]
["2010AC","REF","REF02","Reference Identification","R","X",1,"AN",1,50,null,"R","n/a"]
["2000B",null,"","Subscriber Hierarchical Level","R","M",">1",{"$nulls":4},"R"]
["2000B","HL","","Subscriber Hierarchical Level","R","M",1,{"$nulls":4},"R"]
["2000B","HL","HL01","Hierarchical ID Number","R","M",1,"AN",1,12,null,"RNS","n/a"]
["2000B","HL","HL02","Hierarchical Parent ID Number","R","O",1,"AN",1,12,null,"RNS","n/a"]
["2000B","HL","HL03","Hierarchical Level Code","R","M",1,"ID",1,2,"22 Subscriber","RNS","n/a"]
["2000B","HL","HL04","Hierarchical Child Code","R","O",1,"ID",1,1,"0 No Subordinate HL Segment in This Hierarchical Structure.,\n1 Additional Subordinate HL Data Segment in This Hierarchical Structure.","RNS","n/a"]
["2000B","SBR","","Subscriber Information","R","O",1,{"$nulls":4},"R"]
["2000B","SBR","SBR01","Payer Responsibility Sequence Number Code","R","M",1,"ID",1,1,"A Payer Responsibility Four\nB Payer Responsibility Five\nC Payer Responsibility Six\nD Payer Responsibility Seven\nE Payer Responsibility Eight\nF Payer Responsibility Nine\nG Payer Responsibility Ten\nH Payer Responsibility Eleven\nP Primary\nS Secondary\nT Tertiary\nU Unknown","R","n/a"]
["2000B","SBR","SBR02","Individual Relationship Code","S","O",1,"ID",2,2,"18 Self","S","n/a"]
["2000B","SBR","SBR03","Reference Identification","S","O",1,"AN",1,50,null,"S","n/a"]
["2000B","SBR","SBR04","Name","S","O",1,"AN",1,60,null,"S","n/a"]
["2000B","SBR","SBR05","Insurance Type Code","S","O",1,"ID",1,3,"12 Medicare Secondary Working Aged Beneficiary or\nSpouse with Employer Group Health Plan\n13 Medicare Secondary End-Stage Renal Disease\nBeneficiary in the Mandated Coordination Period\nwith an Employer’s Group Health Plan\n14 Medicare Secondary, No-fault Insurance including\nAuto is Primary\n15 Medicare Secondary Worker’s Compensation\n16 Medicare Secondary Public Health Service (PHS)or\nOther Federal Agency\n41 Medicare Secondary Black Lung\n42 Medicare Secondary Veteran’s Administration\n43 Medicare Secondary Disabled Beneficiary Under\nAge 65 with Large Group Health Plan (LGHP)\n47 Medicare Secondary, Other Liability Insurance is\nPrimary","S","n/a"]
["2000B","SBR","SBR09","Claim Filing Indicator Code","S","O",1,"ID",1,2,"11 Other Non-Federal Programs\n12 Preferred Provider Organization (PPO)\n13 Point of Service (POS)\n14 Exclusive Provider Organization (EPO)\n15 Indemnity Insurance\n16 Health Maintenance Organization (HMO) Medicare Risk\n17 Dental Maintenance Organization\nAM Automobile Medical\nBL Blue Cross/Blue Shield\nCH Champus\nCI Commercial Insurance Co.\nDS Disability\nFI Federal Employees Program\nHM Health Maintenance Organization\nLM Liability Medical\nMA Medicare Part A\nMB Medicare Part B\nMC Medicaid\nOF Other Federal Program\nTV Title V\nVA Veterans Affairs Plan\nWC Workers’ Compensation Health Claim\nZZ Mutually Defined (ZZ when Type of Insurance is not known.)","S","n/a"]
["2010BA",null,"","Subscriber Name","R","O",1,{"$nulls":4},"R"]
["2010BA","NM1","","Subscriber Name","R","O",1,{"$nulls":4},"R"]
["2010BA","NM1","NM101","Entity Identifier Code","R","M",1,"ID",2,3,"IL Insured or Subscriber","RNS","n/a"]
["2010BA","NM1","NM102","Entity Type Qualifier","R","M",1,"ID",1,1,"1 Person\n2 Non-Person Entity","RNS","n/a"]
["2010BA","NM1","NM103","Name Last or Organization Name","R","X",1,"AN",1,60,null,"R","n/a"]
["2010BA","NM1","NM104","Name First","S","O",1,"AN",1,35,null,"S","n/a"]
["2010BA","NM1","NM105","Name Middle","S","O",1,"AN",1,25,null,"S","n/a"]
["2010BA","NM1","NM107","Name Suffix","S","O",1,"AN",1,10,null,"S","n/a"]
["2010BA","NM1","NM108","Identification Code Qualifier","S","X",1,"ID",1,2,"II Standard Unique Health Identifier for each Individual\nin the United States,\nMI Member Identification Number","S","n/a"]
["2010BA","NM1","NM109","Identification Code","S","X",1,"AN",2,80,null,"S","n/a"]
["2010BA","N3","","Subscriber Address","S","O",1,{"$nulls":4},"S"]
["2010BA","N3","N301","Address Information","R","M",1,"AN",1,55,null,"R","n/a"]
["2010BA","N3","N302","Address Information","S","O",1,"AN",1,55,null,"S","n/a"]
["2010BA","N4","","Subscriber City, State, ZIP Code","R","O",1,{"$nulls":4},"R"]
["2010BA","N4","N401","City Name","R","O",1,"AN",2,30,null,"R","n/a"]
["2010BA","N4","N402","State or Province Code","S","X",1,"ID",2,2,null,"S","n/a"]
["2010BA","N4","N403","Postal Code","S","O",1,"ID",3,15,null,"S","n/a"]
["2010BA","N4","N404","Country Code","S","X",1,"ID",2,3,null,"S","n/a"]
["2010BA","N4","N407","Country Subdivision Code","S","X",1,"ID",1,3,null,"S","n/a"]
["2010BA","DMG","","Subscriber Demographic Information","S","O",1,{"$nulls":4},"S"]
["2010BA","DMG","DMG01","Date Time Period Format Qualifier","R","X",1,"ID",2,3,"D8 Date Expressed in Format CCYYMMDD","RNS","n/a"]
["2010BA","DMG","DMG02","Date Time Period","R","X",1,"AN",1,35,null,"R","n/a"]
["2010BA","DMG","DMG03","Gender Code","R","O",1,"ID",1,1,"F Female\nM Male\nU Unknown","R","n/a"]
["2010BA","REF","","Subscriber Secondary Identification","S","O",1,{"$nulls":4},"S"]
["2010BA","REF","REF01","Reference Identification Qualifier","R","M",1,"ID",2,3,"SY Social Security Number","R","n/a"]
["2010BA","REF","REF02","Reference Identification","R","X",1,"AN",1,50,null,"R","n/a"]
["2010BA","REF","","Property and Casualty Claim Number","S","O",1,{"$nulls":4},"S"]
["2010BA","REF","REF01","Reference Identification Qualifier","R","M",1,"ID",2,3,"Y4 Agency Claim Number","RNS","n/a"]
["2010BA","REF","REF02","Reference Identification","R","X",1,"AN",1,50,null,"R","n/a"]
["2010BB",null,"","Payer Name","R","O",1,{"$nulls":4},"R"]
["2010BB","NM1","","Payer Name","R","O",1,{"$nulls":4},"R"]
["2010BB","NM1","NM101","Entity Identifier Code","R","M",1,"ID",2,3,"PR Payer","RNS","n/a"]
["2010BB","NM1","NM102","Entity Type Qualifier","R","M",1,"ID",1,1,"2 Non-Person Entity","RNS","n/a"]
["2010BB","NM1","NM103","Name Last or Organization Name","R","X",1,"AN",1,60,null,"RNS","n/a"]
["2010BB","NM1","NM108","Identification Code Qualifier","R","X",1,"ID",1,2,"PI Payor Identification\nXV Centers for Medicare and Medicaid Services PlanID","RNS","n/a"]
["2010BB","NM1","NM109","Identification Code","R","X",1,"AN",2,80,null,"RNS","n/a"]
["2010BB","N3","","Payer Address","S","O",1,{"$nulls":4},"S"]
["2010BB","N3","N301","Address Information","R","M",1,"AN",1,55,null,"RNS","n/a"]
["2010BB","N3","N302","Address Information","S","O",1,"AN",1,55,null,"SNS","n/a"]
["2010BB","N4","","Payer City, State, ZIP Code","R","O",1,{"$nulls":4},"R"]
["2010BB","N4","N401","City Name","R","O",1,"AN",2,30,null,"RNS","n/a"]
["2010BB","N4","N402","State or Province Code","S","X",1,"ID",2,2,null,"SNS","n/a"]
["2010BB","N4","N403","Postal Code","S","O",1,"ID",3,15,null,"SNS","n/a"]
["2010BB","N4","N404","Country Code","S","X",1,"ID",2,3,null,"SNS","n/a"]
["2010BB","N4","N407","Country Subdivision Code","S","X",1,"ID",1,3,null,"SNS","n/a"]
["2010BB","REF","","Payer Secondary Identification","S","O",3,{"$nulls":4},"S"]
["2010BB","REF","REF01","Reference Identification Qualifier","R","M",1,"ID",2,3,"2U Payer Identification Number\nEI Employer’s Identification Number\nFY Claim Office Number\nNF National Association of Insurance Commissioners\n(NAIC) Code","RNS","n/a"]
["2010BB","REF","REF02","Reference Identification","R","X",1,"AN",1,50,null,"RNS","n/a"]
["2010BB","REF","","Billing Provider Secondary Identification","S","O",1,{"$nulls":4},"S"]
["2010BB","REF","REF01","Reference Identification Qualifier","R","M",1,"ID",2,3,"G2 Provider Commercial Number\nLU Location Number","R","n/a"]
["2010BB","REF","REF02","Reference Identification","R","X",1,"AN",1,50,null,"R","n/a"]
["2000C","HL","","Patient Hierarchical Level","S","O",1,{"$nulls":4},"NU"]
["2000C","HL","HL01","Hierarchical ID Number","R","M",1,"AN",1,12,null,"NU","n/a"]
["2000C","HL","HL02","Hierarchical Parent ID Number","R","O",1,"AN",1,12,null,"NU","n/a"]
["2000C","HL","HL03","Hierarchical Level Code","R","M",1,"ID",1,2,"23 Dependent","NU","n/a"]
["2000C","HL","HL04","Hierarchical Child Code","R","O",1,"ID",1,1,"0 No Subordinate HL Segment in This Hierarchical\nStructure.","NU","n/a"]
["2000C","PAT","","Patient Information","R","O",1,{"$nulls":4},"NU"]
["2000C","PAT","PAT01","Individual Relationship Code","R","O",1,"ID",2,2,"01 Spouse\n19 Child\n20 Employee\n21 Unknown\n39 Organ Donor\n40 Cadaver Donor\n53 Life Partner\nG8 Other Relationship","NU","n/a"]
["2010CA",null,"","Patient Name","R","O",1,{"$nulls":4},"NU"]
["2010CA",null,"","Patient Name","R","O",1,{"$nulls":4},"NU"]
["2010CA","NM1","NM101","Entity Identifier Code","R","M",1,"ID",2,3,"QC Patient","NU","n/a"]
["2010CA","NM1","NM102","Entity Type Qualifier","R","M",1,"ID",1,1,"1 Person","NU","n/a"]
["2010CA","NM1","NM103","Name Last or Organization Name","R","X",1,"AN",1,60,null,"NU","n/a"]
["2010CA","NM1","NM104","Name First","S","O",1,"AN",1,35,null,"NU","n/a"]
["2010CA","NM1","NM105","Name Middle","S","O",1,"AN",1,25,null,"NU","n/a"]
["2010CA","NM1","NM107","Name Suffix","S","O",1,"AN",1,10,null,"NU","n/a"]
["2010CA","N3","","Patient Address","R","O",1,{"$nulls":4},"NU"]
["2010CA","N3","N301","Address Information","R","M",1,"AN",1,55,null,"NU","n/a"]
["2010CA","N3","N302","Address Information","S","O",1,"AN",1,55,null,"NU","n/a"]
["2010CA","N4","","Patient City, State, ZIP Code","R","O",1,{"$nulls":4},"NU"]
["2010CA","N4","N401","City Name","R","O",1,"AN",2,30,null,"NU","n/a"]
["2010CA","N4","N402","State or Province Code","S","X",1,"ID",2,2,null,"NU","n/a"]
["2010CA","N4","N403","Postal Code","S","O",1,"ID",3,15,null,"NU","n/a"]
["2010CA","N4","N404","Country Code","S","X",1,"ID",2,3,null,"NU","n/a"]
["2010CA","N4","N407","Country Subdivision Code","S","X",1,"ID",1,3,null,"NU","n/a"]
["2010CA","DMG","","Patient Demographic Information","R","O",1,{"$nulls":4},"NU"]
["2010CA","DMG","DMG01","Date Time Period Format Qualifier","R","X",1,"ID",2,3,"D8 Date Expressed in Format CCYYMMDD","NU","n/a"]
["2010CA","DMG","DMG02","Date Time Period","R","X",1,"AN",1,35,null,"NU","n/a"]
["2010CA","DMG","DMG03","Gender Code","R","O",1,"ID",1,1,"F Female\nM Male\nU Unknown","NU","n/a"]
["2010CA","REF","","Property and Casualty Claim Number","S","O",1,{"$nulls":4},"NU"]
["2010CA","REF","REF01","Reference Identification Qualifier","R","M",1,"ID",2,3,"Y4 Agency Claim Number","NU","n/a"]
["2010CA","REF","REF02","Reference Identification","R","X",1,"AN",1,50,null,"NU","n/a"]
["2010CA","REF","","Property and Casualty Patient Identifier","S","O",1,{"$nulls":4},"NU"]
["2010CA","REF","REF01","Reference Identification Qualifier","R","M",1,"ID",2,3,"1W Property and Casualty Patient Identifier,SY Property and Casualty Patient Identifier","NU","n/a"]
["2010CA","REF","REF02","Reference Identification","R","X",1,"AN",1,50,null,"NU","n/a"]
[2300,null,"","Claim Information","R","O",100,{"$nulls":4},"R"]
[2300,"CLM","","Claim Information","R","O",1,{"$nulls":4},"R"]
[2300,"CLM","CLM01","Claim Submitter's Identifier","R","M",1,"AN",1,38,null,"R","n/a"]
[2300,"CLM","CLM02","Monetary Amount","R","O",1,"R",1,18,null,"R","n/a"]
[2300,"CLM","CLM05","Health Care Service Location Information","R","O",1]
[2300,"CLM","CLM05 - 1","Facility Code Value","R","M",1,"AN",1,2,null,"R","n/a"]
[2300,"CLM","CLM05 - 2","Facility Code Qualifier","R","O",1,"ID",1,2,"B Place of Service Codes for Professional or Dental Services","R","n/a"]
[2300,"CLM","CLM05 - 3","Claim Frequency Type Code","R","O",1,"ID",1,1,null,"R","n/a"]
[2300,"CLM","CLM06","Yes/No Condition or Response Code","R","O",1,"ID",1,1,"N No\nY Yes","R","n/a"]
[2300,"CLM","CLM07","Provider Accept Assignment Code","R","O",1,"ID",1,1,"A Assigned,\nC Not Assigned","R","n/a"]
[2300,"CLM","CLM08","Yes/No Condition or Response Code","R","O",1,"ID",1,1,"N No\nW Not Applicable\nY Yes","R","n/a"]
[2300,"CLM","CLM09","Release of Information Code","R","O",1,"ID",1,1,"I Informed Consent to Release Medical Information for Conditions or Diagnoses Regulated by Federal Statutes\nY Yes, Provider has a Signed Statement Permitting Release of Medical Billing Data Related to a Claim","R","n/a"]
[2300,"CLM","CLM11","Related Causes Information","S","O",1,{"$nulls":4},"S"]
[2300,"CLM","CLM11 - 1","Related-Causes Code","R","M",1,"ID",2,3,"AA Auto Accident\nEM Employment\nOA Other Accident","R","n/a"]
[2300,"CLM","CLM11 - 2","Related-Causes Code","S","O",1,"ID",2,3,"AA Auto Accident\nEM Employment\nOA Other Accident","S","n/a"]
[2300,"CLM","CLM11 - 4","State or Province Code","S","O",1,"ID",2,2,null,"S","n/a"]
[2300,"CLM","CLM11 - 5","Country Code","S","O",1,"ID",2,3,null,"S","n/a"]
[2300,"CLM","CLM12","Special Program Code","S","O",1,"ID",2,3,"01 Early & Periodic Screening, Diagnosis, and\nTreatment (EPSDT) or Child Health Assessment\nProgram (CHAP)\n02 Physically Handicapped Children’s Program\n03 Special Federal Funding\n05 Disability","S","n/a"]
[2300,"CLM","CLM19","Claim Submission Reason Code","S","O",1,"ID",2,2,"PB-Predetermination of Dental Benefits","S","n/a"]
[2300,"CLM","CLM20","Delay Reason Code","S","O",1,"ID",1,2,"1 Proof of Eligibility Unknown or Unavailable\n2 Litigation\n3 Authorization Delays\n4 Delay in Certifying Provider\n5 Delay in Supplying Billing Forms\n6 Delay in Delivery of Custom-made Appliances\n7 Third Party Processing Delay\n8 Delay in Eligibility Determination\n9 Original Claim Rejected or Denied Due to a Reason\nUnrelated to the Billing Limitation Rules\n10 Administration Delay in the Prior Approval Process\n11 Other\n15 Natural Disaster","S","n/a"]
[2300,"DTP","","Date - Accident","S","O",1,{"$nulls":4},"S"]
[2300,"DTP","DTP01","Date/Time Qualifier","R","M",1,"ID",3,3,"439 Accident","RNS","\"439\""]
[2300,"DTP","DTP02","Date Time Period Format Qualifier","R","M",1,"ID",2,3,"D8 Date Expressed in Format CCYYMMDD","RNS","n/a"]
[2300,"DTP","DTP03","Date Time Period","R","M",1,"AN",1,35,null,"R","n/a"]
[2300,"DTP","","Date - Appliance Placement","S","O",1,{"$nulls":4},"S"]
[2300,"DTP","DTP01","Date/Time Qualifier","R","M",1,"ID",3,3,"452 Appliance Placement","RNS","\"452\""]
[2300,"DTP","DTP02","Date Time Period Format Qualifier","R","M",1,"ID",2,3,"D8 Date Expressed in Format CCYYMMDD","RNS","n/a"]
[2300,"DTP","DTP03","Date Time Period","R","M",1,"AN",1,35,null,"R","n/a"]
[2300,"DTP","","Date - Service Date","S","O",1,{"$nulls":4},"S"]
[2300,"DTP","DTP01","Date/Time Qualifier","R","M",1,"ID",3,3,"472 Service","RNS","\"472\""]
[2300,"DTP","DTP02","Date Time Period Format Qualifier","R","M",1,"ID",2,3,"D8 Date Expressed in Format CCYYMMDD\nRD8 Range of Dates Expressed in Format CCYYMMDDCCYYMMDD","RNS","n/a"]
[2300,"DTP","DTP03","Date Time Period","R","M",1,"AN",1,35,null,"R","n/a"]
[2300,"DTP","","Date - Repricer Received Date","S","O",1,{"$nulls":4},"S"]
[2300,"DTP","DTP01","Date/Time Qualifier","R","M",1,"ID",3,3,"050 Received","RNS","\"050\""]
[2300,"DTP","DTP02","Date Time Period Format Qualifier","R","M",1,"ID",2,3,"D8 Date Expressed in Format CCYYMMDD","RNS","n/a"]
[2300,"DTP","DTP03","Date Time Period","R","M",1,"AN",1,35,null,"R","n/a"]
[2300,"DN1","","Orthodontic Total Months of Treatment","S","O",1,{"$nulls":4},"S"]
[2300,"DN1","DN101","Quantity","S","O",1,"R",1,15,null,"S","n/a"]
[2300,"DN1","DN102","Quantity","S","O",1,"R",1,15,null,"S","n/a"]
[2300,"DN1","DN104","Description","S","O",1,"AN",1,80,null,"S","n/a"]
[2300,"DN2","","Tooth Status","S","O",35,{"$nulls":4},"S"]
[2300,"DN2","DN201","Reference Identification","R","M",1,"AN",1,50,null,"R","n/a"]
[2300,"DN2","DN202","Tooth Status Code","R","O",1,"ID",1,2,"E To Be Extracted\nM Missing","R","n/a"]
[2300,"DN2","DN206","Code List Qualifier Code","R","M",1,"ID",1,3,"JP Universal National Tooth Designation System","R","n/a"]
[2300,"PWK","","Claim Supplemental Information","S","O",10,{"$nulls":4},"S"]
[2300,"PWK","PWK01","Report Type Code","R","M",1,"ID",2,2,"B4 Referral Form\nDA Dental Models\nDG Diagnostic Report\nEB Explanation of Benefits (Coordination of Benefits or\nMedicare Secondary Payor)\nOZ Support Data for Claim\nP6 Periodontal Charts\nRB Radiology Films\nRR Radiology Reports","R","n/a"]
[2300,"PWK","PWK02","Report Transmission Code","R","O",1,"ID",1,2,"AA Available on Request at Provider Site\nBM By Mail\nEL Electronically Only\nEM E-Mail\nFT File Transfer\nFX By Fax","R","n/a"]
[2300,"PWK","PWK05","Identification Code Qualifier","S","X",1,"ID",1,2,"AC Attachment Control Number","S","n/a"]
[2300,"PWK","PWK06","Identification Code","S","X",1,"AN",2,80,null,"S","n/a"]
[2300,"CN1","","Contract Information","S","O",1,{"$nulls":4},"S"]
[2300,"CN1","CN101","Contract Type Code","R","M",1,"ID",2,2,"02 Per Diem\n03 Variable Per Diem\n04 Flat\n05 Capitated\n06 Percent\n09 Other","R","n/a"]
[2300,"CN1","CN102","Monetary Amount","S","O",1,"R",1,18,null,"S","n/a"]
[2300,"CN1","CN103","Percent, Decimal Format","S","O",1,"R",1,6,null,"S","n/a"]
[2300,"CN1","CN104","Reference Identification","S","O",1,"AN",1,50,null,"S","n/a"]
[2300,"CN1","CN105","Terms Discount Percent","S","O",1,"R",1,6,null,"S","n/a"]
[2300,"CN1","CN106","Version Identifier","S","O",1,"AN",1,30,null,"S","n/a"]
[2300,"AMT","","Patient Amount Paid","S","O",1,{"$nulls":4},"S"]
[2300,"AMT","AMT01","Amount Qualifier Code","R","M",1,"ID",1,3,"F5 Patient Amount Paid","RNS","n/a"]
[2300,"AMT","AMT02","Monetary Amount","R","M",1,"R",1,18,null,"R","n/a"]
[2300,"REF","","Predetermination Identification","S","O",1,{"$nulls":4},"S"]
[2300,"REF","REF01","Reference Identification Qualifier","R","M",1,"ID",2,3,"G3 Predetermination of Benefits Identification Number","RNS","n/a"]
[2300,"REF","REF02","Reference Identification","R","X",1,"AN",1,50,null,"S","n/a"]
[2300,"REF","","Service Authorization Exception Code","S","O",1,{"$nulls":4},"S"]
[2300,"REF","REF01","Reference Identification Qualifier","R","M",1,"ID",2,3,"4N Special Payment Reference Number","RNS","n/a"]
[2300,"REF","REF02","Reference Identification","R","X",1,"AN",1,50,"1 Immediate/Urgent Care\n2 Services Rendered in a Retroactive Period\n3 Emergency Care\n4 Client has Temporary Medicaid\n5 Request from County for Second Opinion to Determine\nif Recipient Can Work\n6 Request for Override Pending\n7 Special Handling","R","n/a"]
[2300,"REF","","Payer Claim Control Number","S","O",1,{"$nulls":4},"S"]
[2300,"REF","REF01","Reference Identification Qualifier","R","M",1,"ID",2,3,"F8 Original Reference Number","RNS","n/a"]
[2300,"REF","REF02","Reference Identification","R","X",1,"AN",1,50,null,"R","n/a"]
[2300,"REF","","Referral Number","S","O",1,{"$nulls":4},"S"]
[2300,"REF","REF01","Reference Identification Qualifier","R","M",1,"ID",2,3,"9F Referral Number","RNS","n/a"]
[2300,"REF","REF02","Reference Identification","R","X",1,"AN",1,50,null,"R","n/a"]
[2300,"REF","","Prior Authorization","S","O",1,{"$nulls":4},"S"]
[2300,"REF","REF01","Reference Identification Qualifier","R","M",1,"ID",2,3,"G1 Prior Authorization Number","RNS","n/a"]
[2300,"REF","REF02","Reference Identification","R","X",1,"AN",1,50,null,"R","n/a"]
[2300,"REF","","Repriced Claim Number","S","O",1,{"$nulls":4},"S"]
[2300,"REF","REF01","Reference Identification Qualifier","R","M",1,"ID",2,3,"9A Repriced Claim Reference Number","RNS","n/a"]
[2300,"REF","REF02","Reference Identification","R","X",1,"AN",1,50,null,"R","n/a"]
[2300,"REF","","Adjusted Repriced Claim Number","S","O",1,{"$nulls":4},"S"]
[2300,"REF","REF01","Reference Identification Qualifier","R","M",1,"ID",2,3,"9C Adjusted Repriced Claim Reference Number","RNS","n/a"]
[2300,"REF","REF02","Reference Identification","R","X",1,"AN",1,50,null,"R","n/a"]
[2300,"REF","","Claim Identifier For Transmission Intermediaries","S","O",1,{"$nulls":4},"S"]
[2300,"REF","REF01","Reference Identification Qualifier","R","M",1,"ID",2,3,"D9 Claim Number","RNS","n/a"]
[2300,"REF","REF02","Reference Identification","R","X",1,"AN",1,50,null,"R","n/a"]
[2300,"K3","","File Information","S","O",10,{"$nulls":4},"S"]
[2300,"K3","K301","Fixed Format Information","R","M",1,"AN",1,80,null,"R","n/a"]
[2300,"NTE","","Claim Note","S","O",5,{"$nulls":4},"S"]
[2300,"NTE","NTE01","Note Reference Code","R","O",1,"ID",3,3,"ADD Additional Information","R","n/a"]
[2300,"NTE","NTE02","Description","R","M",1,"AN",1,80,null,"R","n/a"]
[2300,"HI","","Health Care Diagnosis Code","S","O",1,{"$nulls":4},"S"]
[2300,"HI","HI01","Health Care Code Information","R","M",1,{"$nulls":4},"R"]
[2300,"HI","HI01 - 1","Code List Qualifier Code","R","M",1,"ID",1,3,"ABK International Classification of Diseases Clinical Modification (ICD-10-CM) Principal Diagnosis\nBK International Classification of Diseases Clinical Modification (ICD-9-CM) Principal Diagnosis\nTQ Systemized Nomenclature of Dentistry (SNODENT)","RNS","n/a"]
[2300,"HI","HI01 - 2","Industry Code","R","M",1,"AN",1,30,null,"R","n/a"]
[2300,"HI","HI02","Health Care Code Information","S","O",1,{"$nulls":4},"S"]
[2300,"HI","HI02 - 1","Code List Qualifier Code","R","M",1,"ID",1,3,"ABF International Classification of Diseases Clinical Modification (ICD-10-CM) Diagnosis\nBF International Classification of Diseases Clinical Modification (ICD-9-CM) Diagnosis\nTQ Systemized Nomenclature of Dentistry (SNODENT)","RNS","n/a"]
[2300,"HI","HI02 - 2","Industry Code","R","M",1,"AN",1,30,null,"R","n/a"]
[2300,"HI","HI03","Health Care Code Information","S","O",1,{"$nulls":4},"S"]
[2300,"HI","HI03 - 1","Code List Qualifier Code","R","M",1,"ID",1,3,"ABF International Classification of Diseases Clinical Modification (ICD-10-CM) Diagnosis\nBF International Classification of Diseases Clinical Modification (ICD-9-CM) Diagnosis\nTQ Systemized Nomenclature of Dentistry (SNODENT)","RNS","n/a"]
[2300,"HI","HI03 - 2","Industry Code","R","M",1,"AN",1,30,null,"R","n/a"]
[2300,"HI","HI04","Health Care Code Information","S","O",1,{"$nulls":4},"S"]
[2300,"HI","HI04 - 1","Code List Qualifier Code","R","M",1,"ID",1,3,"ABF International Classification of Diseases Clinical\nModification (ICD-10-CM) Diagnosis\nBF International Classification of Diseases Clinical\nModification (ICD-9-CM) Diagnosis\nTQ Systemized Nomenclature of Dentistry (SNODENT)","RNS","n/a"]
[2300,"HI","HI04 - 2","Industry Code","R","M",1,"AN",1,30,null,"R","n/a"]
[2300,"HCP","","Claim Pricing/Repricing Information","S","O",1,{"$nulls":4},"S"]
[2300,"HCP","HCP01","Pricing Methodology","R","X",1,"ID",2,2,"00 Zero Pricing (Not Covered Under Contract)\n01 Priced as Billed at 100%\n02 Priced at the Standard Fee Schedule\n03 Priced at a Contractual Percentage\n04 Bundled Pricing\n05 Peer Review Pricing\n07 Flat Rate Pricing\n08 Combination Pricing\n09 Maternity Pricing\n10 Other Pricing\n11 Lower of Cost\n12 Ratio of Cost\n13 Cost Reimbursed\n14 Adjustment Pricing","R","\"00/02\""]
[2300,"HCP","HCP02","Monetary Amount","R","O",1,"R",1,18,null,"R","n/a"]
[2300,"HCP","HCP03","Monetary Amount","S","O",1,"R",1,18,null,"S","n/a"]
[2300,"HCP","HCP04","Reference Identification","S","O",1,"AN",1,50,null,"S","n/a"]
[2300,"HCP","HCP05","Rate","S","O",1,"R",1,9,null,"S","n/a"]
[2300,"HCP","HCP06","Reference Identification","S","O",1,"AN",1,50,null,"S","n/a"]
[2300,"HCP","HCP13","Reject Reason Code","S","X",1,"ID",2,2,"T1 Cannot Identify Provider as TPO (Third Party\nOrganization) Participant\nT2 Cannot Identify Payer as TPO (Third Party\nOrganization) Participant\nT3 Cannot Identify Insured as TPO (Third Party\nOrganization) Participant\nT4 Payer Name or Identifier Missing\nT5 Certification Information Missing\nT6 Claim does not contain enough information for repricing","S","n/a"]
[2300,"HCP","HCP14","Policy Compliance Code","S","O",1,"ID",1,2,"1 Procedure Followed (Compliance)\n2 Not Followed - Call Not Made (Non-Compliance Call\nNot Made)\n3 Not Medically Necessary (Non-Compliance Non-\nMedically Necessary)\n4 Not Followed Other (Non-Compliance Other)\n5 Emergency Admit to Non-Network Hospital","S","n/a"]
[2300,"HCP","HCP15","Exception Code","S","O",1,"ID",1,2,"1 Non-Network Professional Provider in Network\nHospital\n2 Emergency Care\n3 Services or Specialist not in Network\n4 Out-of-Service Area\n5 State Mandates\n6 Other","S","n/a"]
["2310A",null,"","Referring Provider Name","S","O",2,{"$nulls":4},"S"]
["2310A","NM1","","Referring Provider Name","S","O",1,{"$nulls":4},"S"]
["2310A","NM1","NM101","Entity Identifier Code","R","M",1,"ID",2,3,"DN Referring Provider\nP3 Primary Care Provider","RNS","n/a"]
["2310A","NM1","NM102","Entity Type Qualifier","R","M",1,"ID",1,1,"1 Person","RNS","n/a"]
["2310A","NM1","NM103","Name Last or Organization Name","R","X",1,"AN",1,60,null,"R","n/a"]
["2310A","NM1","NM104","Name First","S","O",1,"AN",1,35,null,"S","n/a"]
["2310A","NM1","NM105","Name Middle","S","O",1,"AN",1,25,null,"S","n/a"]
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["2330D","NM1","NM102","Entity Type Qualifier","R","M",1,"ID",1,1,"1 Person","RNS","n/a"]
["2330D","REF","","Other Payer Rendering Provider Secondary Identification","R","O",3,{"$nulls":4},"R"]
["2330D","REF","REF01","Reference Identification Qualifier","R","M",1,"ID",2,3,"0B State License Number\n1G Provider UPIN Number\nG2 Provider Commercial Number\nLU Location Number","R","n/a"]
["2330D","REF","REF02","Reference Identification","R","O",1,"AN",1,50,null,"R","n/a"]
["2330E",null,"","Other Payer Supervising Provider","S","O",1,{"$nulls":4},"S"]
["2330E","NM1","","Other Payer Supervising Provider","S","O",1,{"$nulls":4},"S"]
["2330E","NM1","NM101","Entity Identifier Code","R","M",1,"ID",2,3,"DQ Supervising Physician","RNS","n/a"]
["2330E","NM1","NM102","Entity Type Qualifier","R","M",1,"ID",1,1,"1 Person","RNS","n/a"]
["2330E","REF","","Other Payer Supervising Provider Identification","R","O",3,{"$nulls":4},"R"]
["2330E","REF","REF01","Reference Identification Qualifier","R","M",1,"ID",2,3,"0B State License Number\n1G Provider UPIN Number\nG2 Provider Commercial Number\nLU Location Number","R","n/a"]
["2330E","REF","REF02","Reference Identification","R","X",1,"AN",1,50,null,"R","n/a"]
["2330F",null,"","Other Payer Billing Provider","S","O",1,{"$nulls":4},"S"]
["2330F","NM1","","Other Payer Billing Provider","S","O",1,{"$nulls":4},"S"]
["2330F","NM1","NM101","Entity Identifier Code","R","M",1,"ID",2,3,"85 Billing Provider","RNS","n/a"]
["2330F","NM1","NM102","Entity Type Qualifier","R","M",1,"ID",1,1,"1 Person\n2 Non-Person Entity","RNS","n/a"]
["2330F","REF","","Other Payer Billing Provider Secondary Identification","R","O",2,{"$nulls":4},"R"]
["2330F","REF","REF01","Reference Identification Qualifier","R","M",1,"ID",2,3,"G2 Provider Commercial Number, \nLU Location Number","R","n/a"]
["2330F","REF","REF02","Reference Identification","R","X",1,"AN",1,50,null,"R","n/a"]
["2330G",null,"","Other Payer Service Facility Location","S","O",1,{"$nulls":4},"S"]
["2330G","NM1","","Other Payer Service Facility Location","S","O",1,{"$nulls":4},"S"]
["2330G","NM1","NM101","Entity Identifier Code","R","M",1,"ID",2,3,"77 Service Location","RNS","n/a"]
["2330G","NM1","NM102","Entity Type Qualifier","R","M",1,"ID",1,1,"2 Non-Person Entity","RNS","n/a"]
["2330G","REF","","Other Payer Service Facility Location Secondary Identification","R","O",3,{"$nulls":4},"R"]
["2330G","REF","REF01","Reference Identification Qualifier","R","M",1,"ID",2,3,"0B State License Number\nG2 Provider Commercial Number\nLU Location Number","R","n/a"]
["2330G","REF","REF02","Reference Identification","R","X",1,"AN",1,50,null,"R","n/a"]
["2330H","REF","","Other Payer Assistant Surgeon","S","O",1,{"$nulls":4},"S"]
["2330H","NM1","","Other Payer Assistant Surgeon","S","O",1,{"$nulls":4},"S"]
["2330H","NM1","NM101","Entity Identifier Code","R","M",1,"ID",2,3,"DD Assistant Surgeon","RNS","n/a"]
["2330H","NM1","NM102","Entity Type Qualifier","R","M",1,"ID",1,1,"1 Person\n2 Non-Person Entity","RNS","n/a"]
["2330H","REF","","Other Payer Assistant Surgeon Secondary Identifier","R","O",3,{"$nulls":4},"R"]
["2330H","REF","REF01","Reference Identification Qualifier","R","M",1,"ID",2,3,"0B State License Number\n1G Provider UPIN Number\nG2 Provider Commercial Number\nLU Location Number","R","n/a"]
["2330H","REF","REF02","Reference Identification","R","X",1,"AN",1,50,null,"R","n/a"]
[2400,null,"","Service Line Counter","R","O",50,{"$nulls":4},"R"]
[2400,"LX","","Service Line Counter","R","O",1,{"$nulls":4},"R"]
[2400,"LX","LX01","Assigned Number","R","M",1,"N0",1,6,null,"R","n/a"]
[2400,"SV3","","Dental Service","R","O",1,{"$nulls":4},"R"]
[2400,"SV3","SV301","Composite Medical Procedure Identifier","R","M",1,{"$nulls":4},"R"]
[2400,"SV3","SV301 - 1","Product/Service ID Qualifier","R","M",1,"ID",2,2,"AD American Dental Association Codes","R","n/a"]
[2400,"SV3","SV301 - 2","Product/Service ID","R","M",1,"AN",1,48,null,"R","n/a"]
[2400,"SV3","SV301 - 3","Procedure Modifier","S","O",1,"AN",2,2,null,"S","n/a"]
[2400,"SV3","SV301 - 4","Procedure Modifier","S","O",1,"AN",2,2,null,"S","n/a"]
[2400,"SV3","SV301 - 5","Procedure Modifier","S","O",1,"AN",2,2,null,"S","n/a"]
[2400,"SV3","SV301 - 6","Procedure Modifier","S","O",1,"AN",2,2,null,"S","n/a"]
[2400,"SV3","SV301 - 7","Description","S","O",1,"AN",1,80,null,"S","n/a"]
[2400,"SV3","SV302","Monetary Amount","R","O",1,"R",1,18,null,"R","n/a"]
[2400,"SV3","SV303","Facility Code Value","S","O",1,"AN",1,2,null,"S","n/a"]
[2400,"SV3","SV304","Oral Cavity Designation","S","O",1,{"$nulls":4},"S"]
[2400,"SV3","SV304 - 1","Oral Cavity Designation Code","R","M",1,"ID",1,3,null,"R","n/a"]
[2400,"SV3","SV304 - 2","Oral Cavity Designation Code","S","O",1,"ID",1,3,null,"S","n/a"]
[2400,"SV3","SV304 - 3","Oral Cavity Designation Code","S","O",1,"ID",1,3,null,"S","n/a"]
[2400,"SV3","SV304 - 4","Oral Cavity Designation Code","S","O",1,"ID",1,3,null,"S","n/a"]
[2400,"SV3","SV304 - 5","Oral Cavity Designation Code","S","O",1,"ID",1,3,null,"S","n/a"]
[2400,"SV3","SV305","Prosthesis, Crown or Inlay Code","S","O",1,"ID",1,1,"I Initial Placement\nR Replacement","S","n/a"]
[2400,"SV3","SV306","Quantity","S","O",1,"R",1,15,null,"S","n/a"]
[2400,"SV3","SV311","Composite Diagnosis Code Pointer","S","O",1,{"$nulls":4},"S"]
[2400,"SV3","SV311 - 1","Diagnosis Code Pointer","R","M",1,"N0",1,2,null,"R","n/a"]
[2400,"SV3","SV311 - 2","Diagnosis Code Pointer","S","O",1,"N0",1,2,null,"S","n/a"]
[2400,"SV3","SV311 - 3","Diagnosis Code Pointer","S","O",1,"N0",1,2,null,"S","n/a"]
[2400,"SV3","SV311 - 4","Diagnosis Code Pointer","S","O",1,"N0",1,2,null,"S","n/a"]
[2400,"TOO","","Tooth Information","S","O",32,{"$nulls":4},"S"]
[2400,"TOO","TOO01","Code List Qualifier Code","R","X",1,"ID",1,3,"JP Universal National Tooth Designation System","RNS","n/a"]
[2400,"TOO","TOO02","Industry Code","R","X",1,"AN",1,30,null,"R","n/a"]
[2400,"TOO","TOO03","Tooth Surface","S","O",1,{"$nulls":4},"S"]
[2400,"TOO","TOO03 - 1","Tooth Surface Code","R","M",1,"ID",1,2,"B Buccal\nD Distal\nF Facial\nI Incisal\nL Lingual\nM Mesial\nO Occlusal","R","n/a"]
[2400,"TOO","TOO03 - 2","Tooth Surface Code","S","O",1,"ID",1,2,"B Buccal\nD Distal\nF Facial\nI Incisal\nL Lingual\nM Mesial\nO Occlusal","S","n/a"]
[2400,"TOO","TOO03 - 3","Tooth Surface Code","S","O",1,"ID",1,2,"B Buccal\nD Distal\nF Facial\nI Incisal\nL Lingual\nM Mesial\nO Occlusal","S","n/a"]
[2400,"TOO","TOO03 - 4","Tooth Surface Code","S","O",1,"ID",1,2,"B Buccal\nD Distal\nF Facial\nI Incisal\nL Lingual\nM Mesial\nO Occlusal","S","n/a"]
[2400,"TOO","TOO03 - 5","Tooth Surface Code","S","O",1,"ID",1,2,"B Buccal\nD Distal\nF Facial\nI Incisal\nL Lingual\nM Mesial\nO Occlusal","S","n/a"]
[2400,"DTP","","Date - Service Date","S","O",1,{"$nulls":4},"S"]
[2400,"DTP","DTP01","Date/Time Qualifier","R","M",1,"ID",3,3,"472 Service","R","n/a"]
[2400,"DTP","DTP02","Date Time Period Format Qualifier","R","M",1,"ID",2,3,"D8 Date Expressed in Format CCYYMMDD","R","n/a"]
[2400,"DTP","DTP03","Date Time Period","R","M",1,"AN",1,35,null,"R","n/a"]
[2400,"DTP","","Date - Prior Placement","S","O",1,{"$nulls":4},"S"]
[2400,"DTP","DTP01","Date/Time Qualifier","R","M",1,"ID",3,3,"139 Estimated\n441 Prior Placement","R","n/a"]
[2400,"DTP","DTP02","Date Time Period Format Qualifier","R","M",1,"ID",2,3,"D8 Date Expressed in Format CCYYMMDD","RNS","n/a"]
[2400,"DTP","DTP03","Date Time Period","R","M",1,"AN",1,35,null,"R","n/a"]
[2400,"DTP","","Date - Appliance Placement","S","O",1,{"$nulls":4},"S"]
[2400,"DTP","DTP01","Date/Time Qualifier","R","M",1,"ID",3,3,"452 Appliance Placement","RNS","n/a"]
[2400,"DTP","DTP02","Date Time Period Format Qualifier","R","M",1,"ID",2,3,"D8 Date Expressed in Format CCYYMMDD","RNS","n/a"]
[2400,"DTP","DTP03","Date Time Period","R","M",1,"AN",1,35,null,"R","n/a"]
[2400,"DTP","","Date - Replacement","S","O",1,{"$nulls":4},"S"]
[2400,"DTP","DTP01","Date/Time Qualifier","R","M",1,"ID",3,3,"446 Replacement","RNS","n/a"]
[2400,"DTP","DTP02","Date Time Period Format Qualifier","R","M",1,"ID",2,3,"D8 Date Expressed in Format CCYYMMDD","RNS","n/a"]
[2400,"DTP","DTP03","Date Time Period","R","M",1,"AN",1,35,null,"R","n/a"]
[2400,"DTP","","Date - Treatment Start","S","O",1,{"$nulls":4},"S"]
[2400,"DTP","DTP01","Date/Time Qualifier","R","M",1,"ID",3,3,"196 Start","RNS","n/a"]
[2400,"DTP","DTP02","Date Time Period Format Qualifier","R","M",1,"ID",2,3,"D8 Date Expressed in Format CCYYMMDD","RNS","n/a"]
[2400,"DTP","DTP03","Date Time Period","R","M",1,"AN",1,35,null,"R","n/a"]
[2400,"DTP","","Date - Treatment Completion","S","O",1,{"$nulls":4},"S"]
[2400,"DTP","DTP01","Date/Time Qualifier","R","M",1,"ID",3,3,"198 Completion","RNS","n/a"]
[2400,"DTP","DTP02","Date Time Period Format Qualifier","R","M",1,"ID",2,3,"D8 Date Expressed in Format CCYYMMDD","RNS","n/a"]
[2400,"DTP","DTP03","Date Time Period","R","M",1,"AN",1,35,null,"R","n/a"]
[2400,"CN1","","Contract Information","S","O",1,{"$nulls":4},"S"]
[2400,"CN1","CN101","Contract Type Code","R","M",1,"ID",2,2,"02 Per Diem\n03 Variable Per Diem\n04 Flat\n05 Capitated\n06 Percent\n09 Other","R","n/a"]
[2400,"CN1","CN102","Monetary Amount","S","O",1,"R",1,18,null,"S","n/a"]
[2400,"CN1","CN103","Percent, Decimal Format","S","O",1,"R",1,6,null,"S","n/a"]
[2400,"CN1","CN104","Reference Identification","S","O",1,"AN",1,50,null,"S","n/a"]
[2400,"CN1","CN105","Terms Discount Percent","S","O",1,"R",1,6,null,"S","n/a"]
[2400,"CN1","CN106","Version Identifier","S","O",1,"AN",1,30,null,"S","n/a"]
[2400,"REF","","Service Predetermination Identification","S","O",5,{"$nulls":4},"S"]
[2400,"REF","REF01","Reference Identification Qualifier","R","M",1,"ID",2,3,"G3 Predetermination of Benefits Identification Number","RNS","n/a"]
[2400,"REF","REF02","Reference Identification","R","X",1,"AN",1,50,null,"S","n/a"]
[2400,"REF","REF04","Reference Identifier","S","O",1,{"$nulls":4},"S"]
[2400,"REF","REF04 - 1","Reference Identification Qualifier","R","M",1,"ID",2,3,"2U Payer Identification Number","R","n/a"]
[2400,"REF","REF04 - 2","Reference Identification","R","M",1,"AN",1,50,null,"R","n/a"]
[2400,"REF","","Prior Authorization","S","O",5,{"$nulls":4},"S"]
[2400,"REF","REF01","Reference Identification Qualifier","R","M",1,"ID",2,3,"G1 Prior Authorization Number","RNS","n/a"]
[2400,"REF","REF02","Reference Identification","R","X",1,"AN",1,50,null,"R","n/a"]
[2400,"REF","REF04","Reference Identifier","S","O",1,{"$nulls":4},"S"]
[2400,"REF","REF04 - 1","Reference Identification Qualifier","R","M",1,"ID",2,3,"2U Payer Identification Number","R","n/a"]
[2400,"REF","REF04 - 2","Reference Identification","R","M",1,"AN",1,50,null,"R","n/a"]
[2400,"REF","","Line Item Control Number","S","O",1,{"$nulls":4},"S"]
[2400,"REF","REF01","Reference Identification Qualifier","R","M",1,"ID",2,3,"6R Provider Control Number","RNS","n/a"]
[2400,"REF","REF02","Reference Identification","R","X",1,"AN",1,50,null,"R","n/a"]
[2400,"REF","","Repriced Claim Number","S","O",1,{"$nulls":4},"S"]
[2400,"REF","REF01","Reference Identification Qualifier","R","M",1,"ID",2,3,"9A Repriced Claim Reference Number","RNS","n/a"]
[2400,"REF","REF02","Reference Identification","R","X",1,"AN",1,50,null,"R","n/a"]
[2400,"REF","","Adjusted Repriced Claim Number","S","O",1,{"$nulls":4},"S"]
[2400,"REF","REF01","Reference Identification Qualifier","R","M",1,"ID",2,3,"9C Adjusted Repriced Claim Reference Number","RNS","n/a"]
[2400,"REF","REF02","Reference Identification","R","X",1,"AN",1,50,null,"R","n/a"]
[2400,"REF","","Referral Number","S","O",5,{"$nulls":4},"S"]
[2400,"REF","REF01","Reference Identification Qualifier","R","M",1,"ID",2,3,"9F Referral Number","RNS","n/a"]
[2400,"REF","REF02","Reference Identification","R","X",1,"AN",1,50,null,"R","n/a"]
[2400,"REF","REF04","Reference Identifier","S","O",1,{"$nulls":4},"S"]
[2400,"REF","REF04 - 1","Reference Identification Qualifier","R","M",1,"ID",2,3,"2U Payer Identification Number","R","n/a"]
[2400,"REF","REF04 - 2","Reference Identification","R","M",1,"AN",1,50,null,"R","n/a"]
[2400,"AMT","","Sales Tax Amount","S","O",1,{"$nulls":4},"S"]
[2400,"AMT","AMT01","Amount Qualifier Code","R","M",1,"ID",1,3,"T Tax","RNS","n/a"]
[2400,"AMT","AMT02","Monetary Amount","R","M",1,"R",1,18,null,"R","n/a"]
[2400,"K3","","File Information","S","O",10,{"$nulls":4},"S"]
[2400,"K3","K301","Fixed Format Information","R","M",1,"AN",1,80,null,"R","n/a"]
[2400,"HCP","","Line Pricing/Repricing Information","S","O",1,{"$nulls":4},"S"]
[2400,"HCP","HCP01","Pricing Methodology","R","X",1,"ID",2,2,"00 Zero Pricing (Not Covered Under Contract)\n01 Priced as Billed at 100%\n02 Priced at the Standard Fee Schedule\n03 Priced at a Contractual Percentage\n04 Bundled Pricing\n05 Peer Review Pricing\n06 Per Diem Pricing\n07 Flat Rate Pricing\n08 Combination Pricing\n09 Maternity Pricing\n10 Other Pricing\n11 Lower of Cost\n12 Ratio of Cost\n13 Cost Reimbursed\n14 Adjustment Pricing","R","\"00/02\""]
[2400,"HCP","HCP02","Monetary Amount","R","O",1,"R",1,18,null,"R","n/a"]
[2400,"HCP","HCP03","Monetary Amount","S","O",1,"R",1,18,null,"S","n/a"]
[2400,"HCP","HCP04","Reference Identification","S","O",1,"AN",1,50,null,"S","n/a"]
[2400,"HCP","HCP05","Rate","S","O",1,"R",1,9,null,"S","n/a"]
[2400,"HCP","HCP09","Product/Service ID Qualifier","S","X",1,"ID",2,2,"AD American Dental Association Codes","S","n/a"]
[2400,"HCP","HCP10","Product/Service ID","S","X",1,"AN",1,48,null,"S","n/a"]
[2400,"HCP","HCP11","Unit or Basis for Measurement Code","S","X",1,"ID",2,2,"UN Unit","S","n/a"]
[2400,"HCP","HCP12","Quantity","S","X",1,"R",1,15,null,"S","n/a"]
[2400,"HCP","HCP13","Reject Reason Code","S","X",1,"ID",2,2,"T1 Cannot Identify Provider as TPO (Third Party\nOrganization) Participant\nT2 Cannot Identify Payer as TPO (Third Party\nOrganization) Participant\nT3 Cannot Identify Insured as TPO (Third Party\nOrganization) Participant\nT4 Payer Name or Identifier Missing\nT5 Certification Information Missing\nT6 Claim does not contain enough information for repricing","S","n/a"]
[2400,"HCP","HCP14","Policy Compliance Code","S","O",1,"ID",1,2,"1 Procedure Followed (Compliance)\n2 Not Followed - Call Not Made (Non-Compliance Call\nNot Made)\n3 Not Medically Necessary (Non-Compliance Non-\nMedically Necessary)\n4 Not Followed Other (Non-Compliance Other)\n5 Emergency Admit to Non-Network Hospital","S","n/a"]
[2400,"HCP","HCP15","Exception Code","S","O",1,"ID",1,2,"1 Non-Network Professional Provider in Network\nHospital\n2 Emergency Care\n3 Services or Specialist not in Network\n4 Out-of-Service Area\n5 State Mandates\n6 Other","S","n/a"]
["2420A",null,"","Rendering Provider Name",null,"O",1]
["2420A","NM1","","Rendering Provider Name","S","O",1,{"$nulls":4},"S"]
["2420A","NM1","NM101","Entity Identifier Code","R","M",1,"ID",2,3,"82 Rendering Provider","RNS","n/a"]
["2420A","NM1","NM102","Entity Type Qualifier","R","M",1,"ID",1,1,"1 Person\n2 Non-Person Entity","RNS","n/a"]
["2420A","NM1","NM103","Name Last or Organization Name","R","X",1,"AN",1,60,null,"R","n/a"]
["2420A","NM1","NM104","Name First","S","O",1,"AN",1,35,null,"S","n/a"]
["2420A","NM1","NM105","Name Middle","S","O",1,"AN",1,25,null,"S","n/a"]
["2420A","NM1","NM107","Name Suffix","S","O",1,"AN",1,10,null,"S","n/a"]
["2420A","NM1","NM108","Identification Code Qualifier","S","X",1,"ID",1,2,"XX Centers for Medicare and Medicaid Services National Provider Identifier","S","n/a"]
["2420A","NM1","NM109","Identification Code","S","X",1,"AN",2,80,null,"S","n/a"]
["2420A","PRV","","Rendering Provider Specialty Information","R","O",1,{"$nulls":4},"R"]
["2420A","PRV","PRV01","Provider Code","R","M",1,"ID",1,3,"PE Performing","RNS","n/a"]
["2420A","PRV","PRV02","Reference Identification Qualifier","R","X",1,"ID",2,3,"PXC Health Care Provider Taxonomy Code","RNS","n/a"]
["2420A","PRV","PRV03","Reference Identification","R","X",1,"AN",1,50,null,"R","n/a"]
["2420A","REF","","Rendering Provider Secondary Identification","S","O",20,{"$nulls":4},"S"]
["2420A","REF","REF01","Reference Identification Qualifier","R","M",1,"ID",2,3,"0B State License Number\n1G Provider UPIN Number\nG2 Provider Commercial Number\nLU Location Number","R","n/a"]
["2420A","REF","REF02","Reference Identification","R","X",1,"AN",1,50,null,"R","n/a"]
["2420A","REF","REF04","Reference Identifier","S","O",1,{"$nulls":4},"S"]
["2420A","REF","REF04 - 1","Reference Identification Qualifier","R","M",1,"ID",2,3,"2U Payer Identification Number","R","n/a"]
["2420A","REF","REF04 - 2","Reference Identification","R","M",1,"AN",1,50,null,"R","n/a"]
["2420B",null,"","Assistant Surgeon Name",null,"O",1]
["2420B","NM1","","Assistant Surgeon Name","S","O",1,{"$nulls":4},"S"]
["2420B","NM1","NM101","Entity Identifier Code","R","M",1,"ID",2,3,"DD Assistant Surgeon","RNS","n/a"]
["2420B","NM1","NM102","Entity Type Qualifier","R","M",1,"ID",1,1,"1 Person","RNS","n/a"]
["2420B","NM1","NM103","Name Last or Organization Name","R","X",1,"AN",1,60,null,"R","n/a"]
["2420B","NM1","NM104","Name First","S","O",1,"AN",1,35,null,"S","n/a"]
["2420B","NM1","NM105","Name Middle","S","O",1,"AN",1,25,null,"S","n/a"]
["2420B","NM1","NM107","Name Suffix","S","O",1,"AN",1,10,null,"S","n/a"]
["2420B","NM1","NM108","Identification Code Qualifier","S","X",1,"ID",1,2,"XX Centers for Medicare and Medicaid Services\nNational Provider Identifier","S","n/a"]
["2420B","NM1","NM109","Identification Code","S","X",1,"AN",2,80,null,"S","n/a"]
["2420B","PRV","","Assistant Surgeon Specialty Information","S","O",1,{"$nulls":4},"S"]
["2420B","PRV","PRV01","Provider Code","R","M",1,"ID",1,3,"AS Assistant Surgeon","RNS","n/a"]
["2420B","PRV","PRV02","Reference Identification Qualifier","R","X",1,"ID",2,3,"PXC Health Care Provider Taxonomy Code","RNS","n/a"]
["2420B","PRV","PRV03","Reference Identification","R","X",1,"AN",1,50,null,"R","n/a"]
["2420B","REF","","Assistant Surgeon Secondary Identification","S","O",20,{"$nulls":4},"S"]
["2420B","REF","REF01","Reference Identification Qualifier","R","M",1,"ID",2,3,"0B State License Number\n1G Provider UPIN Number\nG2 Provider Commercial Number\nLU Location Number","R","n/a"]
["2420B","REF","REF02","Reference Identification","R","X",1,"AN",1,50,null,"R","n/a"]
["2420B","REF","REF04","Reference Identifier","S","O",1,{"$nulls":4},"S"]
["2420B","REF","REF04 - 1","Reference Identification Qualifier","R","M",1,"ID",2,3,"2U Payer Identification Number","R","n/a"]
["2420B","REF","REF04 - 2","Reference Identification","R","M",1,"AN",1,50,null,"R","n/a"]
["2420C",null,"","Supervising Provider Name","S","O",1,{"$nulls":4},"S"]
["2420C","NM1","","Supervising Provider Name","S","O",1,{"$nulls":4},"S"]
["2420C","NM1","NM101","Entity Identifier Code","R","M",1,"ID",2,3,"DQ Supervising Physician","R","n/a"]
["2420C","NM1","NM102","Entity Type Qualifier","R","M",1,"ID",1,1,"1 Person","R","n/a"]
["2420C","NM1","NM103","Name Last or Organization Name","R","X",1,"AN",1,60,null,"R","n/a"]
["2420C","NM1","NM104","Name First","S","O",1,"AN",1,35,null,"S","n/a"]
["2420C","NM1","NM105","Name Middle","S","O",1,"AN",1,25,null,"S","n/a"]
["2420C","NM1","NM107","Name Suffix","S","O",1,"AN",1,10,null,"S","n/a"]
["2420C","NM1","NM108","Identification Code Qualifier","S","X",1,"ID",1,2,"XX Centers for Medicare and Medicaid Services\nNational Provider Identifier","S","n/a"]
["2420C","NM1","NM109","Identification Code","S","X",1,"AN",2,80,null,"S","n/a"]
["2420C","REF","","Supervising Provider Secondary Identification","S","O",20,{"$nulls":4},"S"]
["2420C","REF","REF01","Reference Identification Qualifier","R","M",1,"ID",2,3,"0B State License Number\n1G Provider UPIN Number\nG2 Provider Commercial Number\nLU Location Number","R","n/a"]
["2420C","REF","REF02","Reference Identification","R","X",1,"AN",1,50,null,"R","n/a"]
["2420C","REF","REF04","Reference Identifier","S","O",1,{"$nulls":4},"S"]
["2420C","REF","REF04 - 1","Reference Identification Qualifier","R","M",1,"ID",2,3,"2U Payer Identification Number","R","n/a"]
["2420C","REF","REF04 - 2","Reference Identification","R","M",1,"AN",1,50,null,"R","n/a"]
["2420D",null,"","Service Facility Location Name","S","O",1,{"$nulls":4},"S"]
["2420D","NM1","","Service Facility Location Name","S","O",1,{"$nulls":4},"S"]
["2420D","NM1","NM101","Entity Identifier Code","R","M",1,"ID",2,3,"77 Service Location","R","n/a"]
["2420D","NM1","NM102","Entity Type Qualifier","R","M",1,"ID",1,1,"2 Non-Person Entity","R","n/a"]
["2420D","NM1","NM103","Name Last or Organization Name","R","X",1,"AN",1,60,null,"R","n/a"]
["2420D","NM1","NM108","Identification Code Qualifier","S","X",1,"ID",1,2,"XX Centers for Medicare and Medicaid Services National Provider Identifier","S","n/a"]
["2420D","NM1","NM109","Identification Code","S","X",1,"AN",2,80,null,"S","n/a"]
["2420D","N3","","Service Facility Location Address","R","O",1,{"$nulls":4},"R"]
["2420D","N3","N301","Address Information","R","M",1,"AN",1,55,null,"R","n/a"]
["2420D","N3","N302","Address Information","S","O",1,"AN",1,55,null,"S","n/a"]
["2420D","N4","","Service Facility Location City, State, ZIP Code","R","O",1,{"$nulls":4},"R"]
["2420D","N4","N401","City Name","R","O",1,"AN",2,30,null,"R","n/a"]
["2420D","N4","N402","State or Province Code","S","X",1,"ID",2,2,null,"S","n/a"]
["2420D","N4","N403","Postal Code","S","O",1,"ID",3,15,null,"S","n/a"]
["2420D","N4","N404","Country Code","S","X",1,"ID",2,3,null,"S","n/a"]
["2420D","N4","N407","Country Subdivision Code","S","X",1,"ID",1,3,null,"SNS","n/a"]
["2420D","REF","","Service Facility Location Secondary Identification","S","O",20,{"$nulls":4},"S"]
["2420D","REF","REF01","Reference Identification Qualifier","R","M",1,"ID",2,3,"1G Provider UPIN Number\nG2 Provider Commercial Number\nLU Location Number","R","n/a"]
["2420D","REF","REF02","Reference Identification","R","X",1,"AN",1,50,null,"R","n/a"]
["2420D","REF","REF04","Reference Identifier","S","O",1,{"$nulls":4},"S"]
["2420D","REF","REF04 - 1","Reference Identification Qualifier","R","M",1,"ID",2,3,"2U Payer Identification Number","R","n/a"]
["2420D","REF","REF04 - 2","Reference Identification","R","M",1,"AN",1,50,null,"R","n/a"]
[2430,null,"","Line Adjudication Information",null,"O",15]
[2430,"SVD","","Line Adjudication Information","S","O",1,{"$nulls":4},"S"]
[2430,"SVD","SVD01","Identification Code","R","M",1,"AN",2,80,null,"R","n/a"]
[2430,"SVD","SVD02","Monetary Amount","R","M",1,"R",1,18,null,"R","n/a"]
[2430,"SVD","SVD03","Composite Medical Procedure Identifier","R","O",1,{"$nulls":4},"R"]
[2430,"SVD","SVD03 - 1","Product/Service ID Qualifier","R","M",1,"ID",2,2,"AD American Dental Association Codes ER Jurisdiction Specific Procedure and Supply Codes","R","n/a"]
[2430,"SVD","SVD03 - 2","Product/Service ID","R","M",1,"AN",1,48,null,"R","n/a"]
[2430,"SVD","SVD03 - 3","Procedure Modifier","S","O",1,"AN",2,2,null,"S","n/a"]
[2430,"SVD","SVD03 - 4","Procedure Modifier","S","O",1,"AN",2,2,null,"S","n/a"]
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[2430,"CAS","CAS02","Claim Adjustment Reason Code","R","M",1,"ID",1,5,null,"R","n/a"]
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[2430,"CAS","CAS08","Claim Adjustment Reason Code","S","X",1,"ID",1,5,null,"S","n/a"]
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[2430,"CAS","CAS10","Quantity","S","X",1,"R",1,15,null,"S","n/a"]
[2430,"CAS","CAS11","Claim Adjustment Reason Code","S","X",1,"ID",1,5,null,"S","n/a"]
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[2430,"CAS","CAS13","Quantity","S","X",1,"R",1,15,null,"S","n/a"]
[2430,"CAS","CAS14","Claim Adjustment Reason Code","S","X",1,"ID",1,5,null,"S","n/a"]
[2430,"CAS","CAS15","Monetary Amount","S","X",1,"R",1,18,null,"S","n/a"]
[2430,"CAS","CAS16","Quantity","S","X",1,"R",1,15,null,"S","n/a"]
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[2430,"CAS","CAS19","Quantity","S","X",1,"R",1,15,null,"S","n/a"]
[2430,"DTP","","Line Check or Remittance Date","R","O",1,{"$nulls":4},"R"]
[2430,"DTP","DTP01","Date/Time Qualifier","R","M",1,"ID",3,3,"573 Date Claim Paid","RNS","n/a"]
[2430,"DTP","DTP02","Date Time Period Format Qualifier","R","M",1,"ID",2,3,"D8 Date Expressed in Format CCYYMMDD","RNS","n/a"]
[2430,"DTP","DTP03","Date Time Period","R","M",1,"AN",1,35,null,"R","n/a"]
[2430,"AMT","","Remaining Patient Liability","S","O",1,{"$nulls":4},"S"]
[2430,"AMT","AMT01","Amount Qualifier Code","R","M",1,"ID",1,3,"EAF Amount Owed","RNS","n/a"]
[2430,"AMT","AMT02","Monetary Amount","R","M",1,"R",1,18,null,"R","n/a"]
[2430,"SE","","Transaction Set Trailer","R","M",1,{"$nulls":4},"R"]
[2430,"SE","SE01","Number of Included Segments","R","M",1,"N0",1,10,null,"R","n/a"]
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[null,"GE","","FUNCTIONAL GROUP TRAILER","R","M",1,null,"","",null,"R"]
[null,"GE","GE01","Number of Transaction Sets Included","R","M",1,"N0",1,6,null,"R","n/a"]
[null,"GE","GE02","Group Control Number","R","M",1,"N0",1,9,null,"R","n/a"]
[null,"IEA","","INTERCHANGE CONTROL TRAILER","R","M",1,null,"","",null,"R"]
[null,"IEA","IEA01","Number of Included Functional Groups","R","M",1,"N0",1,5,null,"R","n/a"]
[null,"IEA","IEA02","Interchange Control Number","R","M",1,"N0",9,9,null,"R","n/a"]

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{"sheet":"837 FAQ","index":7,"n_rows":13,"n_cols":2,"rows_kept":13}
["Question","Answer"]
["How do I submit an 837 test file?","Please see the Companion Guide for information about Testing with Medicaid.  "]
["How do I ensure my 837 file will not be rejected as a duplicate?","837 files must have a unique ISA13, GS06 and BHT03 for each TPN to be accepted into PRISM."]
["Do professional clinic encounters need an admit date?","Any professional encounter with an inpatient Place of Service must include an admit date."]
["What is the claim processing start date in PRISM?","PRISM will accept claims and encounters with a start date after 01/01/2019."]
["What SNIP levels will PRISM edit at?","PRISM will edit at SNIP level: 1 - EDI Syntax , 2 - HIPAA Syntax, 3 - Balancing, and 7 - Partner Specific (UT AT)"]
["How should plans report themselves on the 837?","Plans must report Provider Location ID in SBR03 and 'MC' in SBR09 of Loop 2320 and then their PRISM Location ID in NM109 of Loop 2330B. EX: SBR*P*18*123456789******MC in Loop 2320 and NM1*PR*2*EXAMPLE PLAN**{}PI*123456789{*} in Loop 2330B"]
["What is the MCO Plan?  And the Other Plan?","The MCO Plan is the contracted MCO acting as Medicaid.  MCOs should consider themselves Utah Medicaid on the 837.  \"Other Plans\" are all additional plans a member is covered by.  The MCO Plan and any Other Plans must be reported on the 837 in Loop 2320.  "]
["When is a referring provider needed?","You must submit a referring/ordering provider for Home Health, Durable Medical Equipment, Hospice, Lab and Xray. The provider must be known and enrolled in Medicaid on the date of service. Report the Referring/Ordering Provider in REF*DK on 837P files and REF*DN on 837I files."]
["When is a rendering provider needed?","If the billing provider is a group than a rendering provider is required.  Even on an institutional encounter that includes an attending provider.  PRISM determines provider types by how the provider was enrolled.  Please consult the 1101 Provider File for clarification on provider types."]
["PRISM will not accept NTE segments.  Where should we report data previously in the NTE?","Please use:\nDTP*050 of Loop 2300 for Claim Entry Date\nDTP*573 of Loop 2330B for Claim Paid/Adjudicated Date\nHCP*02 of loop 2300 for Payment Amount"]
["How should denial reasons be reported?","Plans must report denial reasons at the header and service line levels using the corresponding CAS segments."]
["Who should I contact if I have additional questions about 837 transactions?","Please contact mhc-edi@utah.gov.  To ensure a timely response the plan must provide the Interchange Control Number associated with the file the encounter was submitted on.  "]

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[null,"Segment Id","Element Pos","Loop/Segment/Element Name","Usage","Repeat","Condition Designator","Data Type","Minimum","Maximum","Implementation Guide Code list",null,"PRISM Values"]
[null,"ISA",null,"Interchange Control Header","R",1,"M",{"$nulls":4},"R"]
[null,"ISA","ISA01","Authorization Information Qualifier","R",1,"M","ID",2,2,"00 No Authorization Information Present (No Meaningful Information in I02)\n03 Additional Data Identification","R","\"00\""]
[null,"ISA","ISA02","Authorization Information","R",1,"M","AN",10,10,null,"R","\"          \""]
[null,"ISA","ISA03","Security Information Qualifier","R",1,"M","ID",2,2,"00 No Security Information Present (No Meaningful Information in I04)\n01 Password","R","\"00\""]
[null,"ISA","ISA04","Security Information","R",1,"M","AN",10,10,null,"R","\"          \""]
[null,"ISA","ISA05","Interchange ID Qualifier","R",1,"M","ID",2,2,"01 Duns (Dun & Bradstreet)\n14 Duns Plus Suffix\n20 Health Industry Number (HIN)\n27 Carrier Identification Number as assigned by Health Care Financing Administration (HCFA)\n28 Fiscal Intermediary Identification Number as assigned by Health Care Financing Administration (HCFA)\n29 Medicare Provider and Supplier Identification Number as assigned by Health Care Financing Administration (HCFA)\n30 U.S. Federal Tax Identification Number\n33 National Association of Insurance Commissioners Company Code (NAIC)\nZZ Mutually Defined","R","\"ZZ\""]
[null,"ISA","ISA06","Interchange Sender ID","R",1,"M","AN",15,15,null,"R","n/a"]
[null,"ISA","ISA07","Interchange ID Qualifier","R",1,"M","ID",2,2,"01 Duns (Dun & Bradstreet)\n14 Duns Plus Suffix\n20 Health Industry Number (HIN)\n27 Carrier Identification Number as assigned by Health Care Financing Administration (HCFA)\n28 Fiscal Intermediary Identification Number as assigned by Health Care Financing Administration (HCFA)\n29 Medicare Provider and Supplier Identification Number as assigned by Health Care Financing Administration (HCFA)\n30 U.S. Federal Tax Identification Number\n33 National Association of Insurance Commissioners Company Code (NAIC)\nZZ Mutually Defined","R","\"ZZ\""]
[null,"ISA","ISA08","Interchange Receiver ID","R",1,"M","AN",15,15,null,"R","n/a"]
[null,"ISA","ISA09","Interchange Date","R",1,"M","DT",6,6,null,"R","SYSDATE\nFormat: YYMMDD"]
[null,"ISA","ISA10","Interchange Time","R",1,"M","TM",4,4,null,"R","SYSDATE\nFormat: HHMM"]
[null,"ISA","ISA11","Repetition Separator","R",1,"M",null,1,1,null,"R","\"^\""]
[null,"ISA","ISA12","Interchange Control Version Number","R",1,"M","ID",5,5,"00501 Standards Approved for Publication by ASC X12 Procedures Review Board through October 2003","R","\"00501\""]
[null,"ISA","ISA13","Interchange Control Number","R",1,"M","N0",9,9,null,"R","n/a"]
[null,"ISA","ISA14","Acknowledgment Requested","R",1,"M","ID",1,1,"0 No Interchange Acknowledgment Requested\n1 Interchange Acknowledgment Requested (TA1)","R","\"0\""]
[null,"ISA","ISA15","Usage Indicator","R",1,"M","ID",1,1,"P Production Data\nT Test Data","R","\"P/T\""]
[null,"ISA","ISA16","Component Element Separator","R",1,"M","AN",1,1,null,"R","\":\""]
[null,"GS",null,"Functional Group Header","R",1,"M",{"$nulls":4},"R"]
[null,"GS","GS01","Functional Identifier Code","R",1,"M","ID",2,2,"HN Health Care Information Status Notification (277)","R","\"HN\""]
[null,"GS","GS02","Application Sender's Code","R",1,"M","AN",2,15,null,"R","n/a"]
[null,"GS","GS03","Application Receiver's Code","R",1,"M","AN",2,15,null,"R","n/a"]
[null,"GS","GS04","Date","R",1,"M","DT",8,8,null,"R","SYSDATE\nFormat: YYYYMMDD"]
[null,"GS","GS05","Time","R",1,"M","TM",4,8,null,"R","SYSDATE\nFormat: HHMM"]
[null,"GS","GS06","Group Control Number","R",1,"M","N0",1,9,null,"R","n/a"]
[null,"GS","GS07","Responsible Agency Code","R",1,"M","ID",1,2,"X Accredited Standards Committee X12","R","\"X\""]
[null,"GS","GS08","Version / Release / Industry Identifier Code","R",1,"M","AN",1,12,"005010X214 Standards Approved for Publication by ASC X12 Procedures Review Board through October 2003","R","\"005010X214\""]
[null,"ST",null,"Transaction Set Header","R",1,"M",{"$nulls":4},"R"]
[null,"ST","ST01","Transaction Set Identifier Code","R",1,"M","ID",3,3,"277 Standards Approved for Publication by ASC X12 Procedures Review Board through October 2003","R","\"277\""]
[null,"ST","ST02","Transaction Set Control Number","R",1,"M","AN",4,9,null,"R","n/a"]
[null,"ST","ST03","Implementation Convention Reference","R",1,"O","AN",1,35,null,"R","\"005010X214\""]
[null,"BHT",null,"Beginning of Hierarchical Transaction","R",1,"M",{"$nulls":4},"R"]
[null,"BHT","BHT01","Hierarchical Structure Code","R",1,"M","ID",4,4,"0085 Information Source, Information Receiver, Provider of Service, Patient","R","\"0085\""]
[null,"BHT","BHT02","Transaction Set Purpose Code","R",1,"M","ID",2,2,"08 Status","R","\"08\""]
[null,"BHT","BHT03","Reference Identification","R",1,"O","AN",1,50,null,"R","n/a"]
[null,"BHT","BHT04","Date","R",1,"O","DT",8,8,null,"R","SYSDATE\nFormat: YYYYMMDD"]
[null,"BHT","BHT05","Time","R",1,"O","TM",4,8,null,"R","SYSDATE\nFormat: HHMM"]
[null,"BHT","BHT06","Transaction Type Code","R",1,"O","ID",2,2,"TH Information Source, Information Receiver, Provider of Service, Patient","R","\"TH\""]
["2000A",null,null,"Information Source Level","R",1,"M",{"$nulls":4},"R"]
["2000A","HL",null,"Information Source Level","R",1,"M",{"$nulls":4},"R"]
["2000A","HL","HL01","Hierarchical ID Number","R",1,"M","AN",1,12,null,"R","n/a"]
["2000A","HL","HL03","Hierarchical Level Code","R",1,"M","ID",1,2,"20 Information Source","R","\"20\""]
["2000A","HL","HL04","Hierarchical Child Code","R",1,"O","ID",1,1,"1 Additional Subordinate HL Data Segment in This Hierarchical Structure.","R","\"1\""]
["2100A",null,null,"Information Source Name","R",1,"O",{"$nulls":4},"R"]
["2100A","NM1",null,"Information Source Name","R",1,"O",{"$nulls":4},"R"]
["2100A","NM1","NM101","Entity Identifier Code","R",1,"M","ID",2,3,"AY Clearing House\nPR Payer","R","\"PR\""]
["2100A","NM1","NM102","Entity Type Qualifier","R",1,"M","ID",1,1,"2 Non-Person Entity","R","\"2\""]
["2100A","NM1","NM103","Organization Name","R",1,"R","AN",1,60,null,"R","\"Utah Medicaid\""]
["2100A","NM1","NM108","Identification Code Qualifier","R",1,"R","ID",1,2,"46 Electronic Transmitter Identification Number (ETIN)\nFI Federal Taxpayer’s Identification Number\nPI Payor Identification\nXV Centers for Medicare and Medicaid Services PlanID","R","\"46\""]
["2100A","NM1","NM109","Identifier Code","R",1,"R","AN",2,80,null,"R","n/a"]
["2200A",null,null,"Transmission Receipt Control Identifier","R",1,"O",{"$nulls":4},"R"]
["2200A","TRN","TRN","Transmission Receipt Control Identifier","R",1,"O",{"$nulls":4},"R"]
["2200A","TRN","TRN01","Trace Type Code","R",1,"M","ID",1,2,"1 Current Transaction Trace Numbers","R","\"1\""]
["2200A","TRN","TRN02","Reference Identification","R",1,"M","AN",1,50,null,"R","n/a"]
["2200A","DTP","DTP","Information Source Receipt Date","R",1,"O",{"$nulls":4},"R"]
["2200A","DTP","DTP01","Date/Time Qualifier","R",1,"M","ID",3,3,"050 Received","R","\"050\""]
["2200A","DTP","DTP02","Date Time Period Format Qualifier","R",1,"M","ID",2,3,"D8 Date Expressed in Format CCYYMMDD","R","\"D8\""]
["2200A","DTP","DTP03","Date Time Period","R",1,"M","AN",1,35,null,"R","n/a"]
["2200A","DTP","DTP","Information Source Process Date","R",1,"O",{"$nulls":4},"R"]
["2200A","DTP","DTP01","Date/Time Qualifier","R",1,"M","ID",3,3,"009 Process","R","\"009\""]
["2200A","DTP","DTP02","Date Time Period Format Qualifier","R",1,"M","ID",2,3,"D8 Date Expressed in Format CCYYMMDD","R","\"D8\""]
["2200A","DTP","DTP03","Date Time Period","R",1,"M","AN",1,35,null,"R","n/a"]
["2000B",null,null,"Information Receiver Level","R",1,"M",{"$nulls":4},"R"]
["2000B","HL",null,"Information Receiver Level","R",1,"M",{"$nulls":4},"R"]
["2000B","HL","HL01","Hierarchical ID Number","R",1,"M","AN",1,12,null,"R","n/a"]
["2000B","HL","HL02","Hierarchical Parent ID Number","R",1,"O","AN",1,12,null,"R","n/a"]
["2000B","HL","HL03","Hierarchical Level Code","R",1,"M","ID",1,2,"21 Information Receiver","R","\"21\""]
["2000B","HL","HL04","Hierarchical Child Code","R",1,"O","ID",1,1,"0 No Subordinate HL Segment in This Hierarchical Structure.\n1 Additional Subordinate HL Data Segment in This Hierarchical Structure.","R","n/a"]
["2100B",null,null,"Information Receiver Name","R",1,"O",{"$nulls":4},"R"]
["2100B","NM1",null,"Information Receiver Name","R",1,"O",{"$nulls":4},"R"]
["2100B","NM1","NM101","Entity Identifier Code","R",1,"M","ID",2,3,"41 Submitter","R","\"41\""]
["2100B","NM1","NM102","Entity Type Qualifier","R",1,"M","ID",1,1,"1 Person\n2 Non-Person Entity","R","n/a"]
["2100B","NM1","NM103","Organization Name","R",1,"R","AN",1,60,null,"R","n/a"]
["2100B","NM1","NM104","Name First","S",1,"O","AN",1,35,null,"S","n/a"]
["2100B","NM1","NM105","Name Middle","S",1,"O","AN",1,25,null,"S","n/a"]
["2100B","NM1","NM108","Identification Code Qualifier","R",1,"R","ID",1,2,"46 Electronic Transmitter Identification Number (ETIN)","R","\"46\""]
["2100B","NM1","NM109","Identifier Code","R",1,"R","AN",2,80,null,"R","n/a"]
["2200B",null,null,"Information Receiver Application Trace Identifier","R",1,"O",{"$nulls":4},"R"]
["2200B","TRN",null,"Information Receiver Application Trace Identifier","R",1,"O",{"$nulls":4},"R"]
["2200B","TRN","TRN01","Trace Type Code","R",1,"M","ID",1,2,"2 Referenced Transaction Trace Numbers","R","\"2\""]
["2200B","TRN","TRN02","Reference Identification","R",1,"M","AN",1,50,null,"R","n/a"]
["2200B","STC",null,"Information Receiver Status Information","R",">1","O",{"$nulls":4},"R"]
["2200B","STC","STC01","Health Care Claim Status","R",1,"M",{"$nulls":4},"R"]
["2200B","STC","STC01 - 1","Industry Code","R",1,"M","AN",1,30,null,"R","n/a"]
["2200B","STC","STC01 - 2","Industry Code","R",1,"M","AN",1,30,null,"R","n/a"]
["2200B","STC","STC01 - 3","Entity Identifier Code","S",1,"O","ID",2,3,"36 Employer\n40 Receiver\n41 Submitter\nAY Clearinghouse\nPR Payer","S","n/a"]
["2200B","STC","STC02","Date","R",1,"O","DT",8,8,null,"R","n/a"]
["2200B","STC","STC03","Action Code","R",1,"O","ID",1,2,"U Reject\nWQ Accept","R","n/a"]
["2200B","STC","STC04","Monetary Amount","R",1,"O","R",1,18,null,"R","n/a"]
["2200B","STC","STC10","Health Care Claim Status","S",1,"O",{"$nulls":4},"S"]
["2200B","STC","STC10 - 1","Industry Code","R",1,"M","AN",1,30,null,"R","n/a"]
["2200B","STC","STC10 - 2","Industry Code","R",1,"M","AN",1,30,null,"R","n/a"]
["2200B","STC","STC10 - 3","Entity Identifier Code","S",1,"O","ID",2,3,"36 Employer\n40 Receiver\n41 Submitter\nAY Clearinghouse\nPR Payer","S","n/a"]
["2200B","STC","STC11","Health Care Claim Status","S",1,"O",{"$nulls":4},"S"]
["2200B","STC","STC11 - 1","Industry Code","R",1,"M","AN",1,30,null,"R","n/a"]
["2200B","STC","STC11 - 2","Industry Code","R",1,"M","AN",1,30,null,"R","n/a"]
["2200B","STC","STC11 - 3","Entity Identifier Code","S",1,"O","ID",2,3,"36 Employer\n40 Receiver\n41 Submitter\nAY Clearinghouse\nPR Payer","S","n/a"]
["2200B","QTY",null,"Total Accepted Quantity","S",1,"O",{"$nulls":4},"S"]
["2200B","QTY","QTY01","Quantity Qualifier","R",1,"M","ID",2,2,"90 Acknowledged Quantity","R","\"90\""]
["2200B","QTY","QTY02","Quantity","R",1,"R","R",1,15,null,"R","n/a"]
["2200B","QTY",null,"Total Rejected Quantity","S",1,"O",{"$nulls":4},"S"]
["2200B","QTY","QTY01","Quantity Qualifier","R",1,"M","ID",2,2,"AA Unacknowledged Quantity","R","\"AA\""]
["2200B","QTY","QTY02","Quantity","R",1,"R","R",1,15,null,"R","n/a"]
["2200B","AMT",null,"Total Accepted Amount","S",1,"O",{"$nulls":4},"S"]
["2200B","AMT","AMT01","Amount Qualifier Code","R",1,"M","ID",1,3,"YU In Process","R","\"YU\""]
["2200B","AMT","AMT02","Monetary Amount","R",1,"M","R",1,18,null,"R","n/a"]
["2200B","AMT",null,"Total Rejected Amount","S",1,"O",{"$nulls":4},"S"]
["2200B","AMT","AMT01","Amount Qualifier Code","R",1,"M","ID",1,3,"YY Returned","R","\"YY\""]
["2200B","AMT","AMT02","Monetary Amount","R",1,"M","R",1,18,null,"R","n/a"]
["2000C",null,null,"Billing Provider of Service Level","S",">1","O",{"$nulls":4},"S"]
["2000C","HL",null,"Billing Provider of Service Level","S",1,"O",{"$nulls":4},"S"]
["2000C","HL","HL01","Hierarchical ID Number","R",1,"M","AN",1,12,null,"R","n/a"]
["2000C","HL","HL02","Hierarchical Parent ID Number","R",1,"O","AN",1,12,null,"R","n/a"]
["2000C","HL","HL03","Hierarchical Level Code","R",1,"M","ID",1,2,"19 Provider of Service","R","\"19\""]
["2000C","HL","HL04","Hierarchical Child Code","R",1,"O","ID",1,1,"0 No Subordinate HL Segment in This Hierarchical Structure\n1 Additional Subordinate HL Data Segment in This Hierarchical Structure.","R","n/a"]
["2100C",null,null,"Billing Provider Name","R",1,"O",{"$nulls":4},"R"]
["2100C","NM1",null,"Billing Provider Name","R",1,"O",{"$nulls":4},"R"]
["2100C","NM1","NM101","Entity Identifier Code","R",1,"M","ID",2,3,"85 Billing Provider","R","\"85\""]
["2100C","NM1","NM102","Entity Type Qualifier","R",1,"M","ID",1,1,"1 Person\n2 Non-Person Entity","R","n/a"]
["2100C","NM1","NM103","Organization Name","R",1,"R","AN",1,60,null,"R","n/a"]
["2100C","NM1","NM104","Name First","S",1,"O","AN",1,35,null,"S","n/a"]
["2100C","NM1","NM105","Name Middle","S",1,"O","AN",1,25,null,"S","n/a"]
["2100C","NM1","NM107","Name Suffix","S",1,"O","AN",1,10,null,"S","n/a"]
["2100C","NM1","NM108","Identification Code Qualifier","R",1,"R","ID",1,2,"FI Federal Taxpayer’s Identification Number\nXX Centers for Medicare and Medicaid Services National Provider Identifier","R","\"XX/FI\""]
["2100C","NM1","NM109","Identifier Code","R",1,"R","AN",2,80,null,"R","n/a"]
["2200C",null,null,"Provider of Service Information Trace Identifier","S",1,"O",{"$nulls":4},"S"]
["2200C","TRN",null,"Provider of Service Information Trace Identifier","S",1,"O",{"$nulls":4},"S"]
["2200C","TRN","TRN01","Trace Type Code","R",1,"M","ID",1,2,"1 Current Transaction Trace Numbers","R","\"1\""]
["2200C","TRN","TRN02","Reference Identification","R",1,"M","AN",1,50,null,"R","\"0\""]
["2200C","STC",null,"Billing Provider Status Information","S",">1","O",{"$nulls":4},"S"]
["2200C","STC","STC01","Health Care Claim Status","R",1,"M",{"$nulls":4},"R"]
["2200C","STC","STC01 - 1","Industry Code","R",1,"M","AN",1,30,null,"R","n/a"]
["2200C","STC","STC01 - 2","Industry Code","R",1,"M","AN",1,30,null,"R","n/a"]
["2200C","STC","STC01 - 3","Entity Identifier Code","S",1,"O","ID",2,3,"36 Employer\n40 Receiver\n41 Submitter\n77 Service Location\n82 Rendering Provider\n85 Billing Provider\n87 Pay-to Provider\nAY Clearinghouse\nPR Payer","S","\"85\""]
["2200C","STC","STC03","Action Code","R",1,"O","ID",1,2,"U Reject\nWQ Accept","R","n/a"]
["2200C","STC","STC04","Monetary Amount","R",1,"O","R",1,18,null,"R","n/a"]
["2200C","STC","STC10","Health Care Claim Status","S",1,"O",{"$nulls":4},"S"]
["2200C","STC","STC10 - 1","Industry Code","R",1,"M","AN",1,30,null,"R","n/a"]
["2200C","STC","STC10 - 2","Industry Code","R",1,"M","AN",1,30,null,"R","n/a"]
["2200C","STC","STC10 - 3","Entity Identifier Code","S",1,"O","ID",2,3,"36 Employer\n40 Receiver\n41 Submitter\n77 Service Location\n82 Rendering Provider\n85 Billing Provider\n87 Pay-to Provider\nAY Clearinghouse\nPR Payer","S","n/a"]
["2200C","STC","STC11","Health Care Claim Status","S",1,"O",{"$nulls":4},"S"]
["2200C","STC","STC11 - 1","Industry Code","R",1,"M","AN",1,30,null,"R","n/a"]
["2200C","STC","STC11 - 2","Industry Code","R",1,"M","AN",1,30,null,"R","n/a"]
["2200C","STC","STC11 - 3","Entity Identifier Code","S",1,"O","ID",2,3,"36 Employer\n40 Receiver\n41 Submitter\n77 Service Location\n82 Rendering Provider\n85 Billing Provider\n87 Pay-to Provider\nAY Clearinghouse\nPR Payer","S","n/a"]
["2200C","REF",null,"Provider Secondary Identifier","S",3,"O",{"$nulls":4},"S"]
["2200C","REF","REF01","Reference Identification Qualifier","R",1,"M","ID",2,3,"0B State License Number\n1G Provider UPIN Number\nG2 Provider Commercial Number\nLU Location Number\nSY Social Security Number\nTJ Federal Taxpayer’s Identification Number","R","\"G2\""]
["2200C","REF","REF02","Reference Identification","R",1,"R","AN",1,50,null,"R","n/a"]
["2200C","QTY",null,"Total Accepted Quantity","S",1,"O",{"$nulls":4},"S"]
["2200C","QTY","QTY01","Quantity Qualifier","R",1,"M","ID",2,2,"QA Quantity Approved","R","\"QA\""]
["2200C","QTY","QTY02","Quantity","R",1,"R","R",1,15,null,"R","n/a"]
["2200C","QTY",null,"Total Rejected Quantity","S",1,"O",{"$nulls":4},"S"]
["2200C","QTY","QTY01","Quantity Qualifier","R",1,"M","ID",2,2,"QC Quantity Disapproved","R","\"QC\""]
["2200C","QTY","QTY02","Quantity","R",1,"R","R",1,15,null,"R","n/a"]
["2200C","AMT",null,"Total Accepted Amount","S",1,"O",{"$nulls":4},"S"]
["2200C","AMT","AMT01","Amount Qualifier Code","R",1,"M","ID",1,3,"YU In Process","R","\"YU\""]
["2200C","AMT","AMT02","Monetary Amount","R",1,"M","R",1,18,null,"R","n/a"]
["2200C","AMT",null,"Total Rejected Amount","S",1,"O",{"$nulls":4},"S"]
["2200C","AMT","AMT01","Amount Qualifier Code","R",1,"M","ID",1,3,"YY Returned","R","\"YY\""]
["2200C","AMT","AMT02","Monetary Amount","R",1,"M","R",1,18,null,"R","n/a"]
["2000D",null,null,"Patient Level","S",">1","O",{"$nulls":4},"S"]
["2000D","HL",null,"Patient Level","S",1,"O",{"$nulls":4},"S"]
["2000D","HL","HL01","Hierarchical ID Number","R",1,"M","AN",1,12,null,"R","n/a"]
["2000D","HL","HL02","Hierarchical Parent ID Number","R",1,"O","AN",1,12,null,"R","n/a"]
["2000D","HL","HL03","Hierarchical Level Code","R",1,"M","ID",1,2,"PT Patient","R","n/a"]
["2100D",null,null,"Patient Name","R",1,"O",{"$nulls":4},"R"]
["2100D","NM1",null,"Patient Name","R",1,"O",{"$nulls":4},"R"]
["2100D","NM1","NM101","Entity Identifier Code","R",1,"M","ID",2,3,"QC Patient","R","\"QC\""]
["2100D","NM1","NM102","Entity Type Qualifier","R",1,"M","ID",1,1,"1 Person","R","\"1\""]
["2100D","NM1","NM103","Last Name","R",1,"R","AN",1,60,null,"R","n/a"]
["2100D","NM1","NM104","Name First","S",1,"O","AN",1,35,null,"S","n/a"]
["2100D","NM1","NM105","Name Middle","S",1,"O","AN",1,25,null,"S","n/a"]
["2100D","NM1","NM107","Name Suffix","S",1,"O","AN",1,10,null,"S","n/a"]
["2100D","NM1","NM108","Identification Code Qualifier","R",1,"R","ID",1,2,"II Standard Unique Health Identifier for each Individual in the United States\nMI Member Identification Number","R","\"MI\""]
["2100D","NM1","NM109","Identifier Code","R",1,"R","AN",2,80,null,"R","n/a"]
["2200D",null,null,"Claim Status Tracking Number","R",">1","O",{"$nulls":4},"R"]
["2200D","TRN",null,"Claim Status Tracking Number","R",1,"O",{"$nulls":4},"R"]
["2200D","TRN","TRN01","Trace Type Code","R",1,"M","ID",1,2,"2 Referenced Transaction Trace Numbers","R","\"2\""]
["2200D","TRN","TRN02","Reference Identification","R",1,"M","AN",1,50,null,"R","n/a"]
["2200D","STC",null,"Claim Level Status Information","R",">1","O",{"$nulls":4},"R"]
["2200D","STC","STC01","Health Care Claim Status","R",1,"M",{"$nulls":4},"R"]
["2200D","STC","STC01 - 1","Industry Code","R",1,"M","AN",1,30,null,"R","n/a"]
["2200D","STC","STC01 - 2","Industry Code","R",1,"M","AN",1,30,null,"R","n/a"]
["2200D","STC","STC01 - 3","Entity Identifier Code","S",1,"O","ID",2,3,"03 Dependent\n1P Provider\n1Z Home Health Care\n40 Receiver\n41 Submitter\n71 Attending Physician\n72 Operating Physician\n73 Other Physician\n77 Service Location\n82 Rendering Provider\n85 Billing Provider\n87 Pay-to Provider\nDK Ordering Physician\nDN Referring Provider\nDQ Supervising Physician\nFA Facility\nGB Other Insured\nHK Subscriber\nIL Insured or Subscriber\nLI Independent Lab\nMSC Mammography Screening Center\nPR Payer\nPRP Primary Payer\nQB Purchase Service Provider\nQC Patient\nQD Responsible Party\nSEP Secondary Payer\nTL Testing Laboratory\nTTP Tertiary Payer\nTU Third Party Repricing Organization (TPO)","S","n/a"]
["2200D","STC","STC02","Date","R",1,"O","DT",8,8,null,"R","n/a"]
["2200D","STC","STC03","Action Code","R",1,"O","ID",1,2,"U Reject\nWQ Accept","R","n/a"]
["2200D","STC","STC04","Monetary Amount","R",1,"O","R",1,18,null,"R","n/a"]
["2200D","STC","STC10","Health Care Claim Status","S",1,"O",{"$nulls":4},"S"]
["2200D","STC","STC10 - 1","Industry Code","R",1,"M","AN",1,30,null,"R","n/a"]
["2200D","STC","STC10 - 2","Industry Code","R",1,"M","AN",1,30,null,"R","n/a"]
["2200D","STC","STC10 - 3","Entity Identifier Code","S",1,"O","ID",2,3,"03 Dependent\n1P Provider\n1Z Home Health Care\n40 Receiver\n41 Submitter\n71 Attending Physician\n72 Operating Physician\n73 Other Physician\n77 Service Location\n82 Rendering Provider\n85 Billing Provider\n87 Pay-to Provider\nDK Ordering Physician\nDN Referring Provider\nDQ Supervising Physician\nFA Facility\nGB Other Insured\nHK Subscriber\nIL Insured or Subscriber\nLI Independent Lab\nMSC Mammography Screening Center\nPR Payer\nPRP Primary Payer\nQB Purchase Service Provider\nQC Patient\nQD Responsible Party\nSEP Secondary Payer\nTL Testing Laboratory\nTTP Tertiary Payer\nTU Third Party Repricing Organization (TPO)","S","n/a"]
["2200D","STC","STC11","Health Care Claim Status","S",1,"O",{"$nulls":4},"S"]
["2200D","STC","STC11 - 1","Industry Code","R",1,"M","AN",1,30,null,"R","n/a"]
["2200D","STC","STC11 - 2","Industry Code","R",1,"M","AN",1,30,null,"R","n/a"]
["2200D","STC","STC11 - 3","Entity Identifier Code","S",1,"O","ID",2,3,"03 Dependent\n1P Provider\n1Z Home Health Care\n40 Receiver\n41 Submitter\n71 Attending Physician\n72 Operating Physician\n73 Other Physician\n77 Service Location\n82 Rendering Provider\n85 Billing Provider\n87 Pay-to Provider\nDK Ordering Physician\nDN Referring Provider\nDQ Supervising Physician\nFA Facility\nGB Other Insured\nHK Subscriber\nIL Insured or Subscriber\nLI Independent Lab\nMSC Mammography Screening Center\nPR Payer\nPRP Primary Payer\nQB Purchase Service Provider\nQC Patient\nQD Responsible Party\nSEP Secondary Payer\nTL Testing Laboratory\nTTP Tertiary Payer\nTU Third Party Repricing Organization (TPO)","S","n/a"]
["2200D","STC","STC12","Free-form Message Text","S",1,"O","AN",1,264,null,"S","n/a"]
["2200D","REF",null,"Payer Claim Control Number","S",1,"O",{"$nulls":4},"S"]
["2200D","REF","REF01","Reference Identification Qualifier","R",1,"M","ID",2,3,"1K Payor’s Claim Number","R","\"1K\""]
["2200D","REF","REF02","Reference Identification","R",1,"R","AN",1,50,null,"R","n/a"]
["2200D","REF",null,"Claim Identification Number For Clearinghouses and Other Transmission Intermediaries","S",1,"O",{"$nulls":4},"S"]
["2200D","REF","REF01","Reference Identification Qualifier","R",1,"M","ID",2,3,"D9 Claim Number","R","\"D9\""]
["2200D","REF","REF02","Reference Identification","R",1,"R","AN",1,50,null,"R","n/a"]
["2200D","REF",null,"Institutional Bill Type Identification","S",1,"O",{"$nulls":4},"S"]
["2200D","REF","REF01","Reference Identification Qualifier","R",1,"M","ID",2,3,"BLT Billing Type","R","\"BLT\""]
["2200D","REF","REF02","Reference Identification","R",1,"R","AN",1,50,null,"R","n/a"]
["2200D","DTP",null,"Claim Level Service Date","R",1,"O",{"$nulls":4},"R"]
["2200D","DTP","DTP01","Date/Time Qualifier","R",1,"M","ID",3,3,"472 Service","R","\"472\""]
["2200D","DTP","DTP02","Date Time Period Format Qualifier","R",1,"M","ID",2,3,"D8 Date Expressed in Format CCYYMMDD\nRD8 Range of Dates Expressed in Format CCYYMMDDCCYYMMDD","R","n/a"]
["2200D","DTP","DTP03","Date Time Period","R",1,"M","AN",1,35,null,"R","n/a"]
["2220D",null,null,"Service Line Information","S",">1","O",{"$nulls":4},"S"]
["2220D","SVC",null,"Service Line Information","S",1,"O",{"$nulls":4},"S"]
["2220D","SVC","SVC01","Composite Medical Procedure Identifier","R",1,"M",{"$nulls":4},"R"]
["2220D","SVC","SVC01 - 1","Product/Service ID Qualifier","R",1,"M","ID",2,2,"AD American Dental Association Codes\nER Jurisdiction Specific Procedure and Supply Codes\nHC Health Care Financing Administration Common Procedural Coding System (HCPCS) Codes\nHP Health Insurance Prospective Payment System(HIPPS) Skilled Nursing Facility Rate Code\nIV Home Infusion EDI Coalition (HIEC) Product/Service Code\nNU National Uniform Billing Committee (NUBC) UB92 Codes\nWK Advanced Billing Concepts (ABC) Codes","R","n/a"]
["2220D","SVC","SVC01 - 2","Product/Service ID","R",1,"M","AN",1,48,null,"R","n/a"]
["2220D","SVC","SVC01 - 3","Procedure Modifier","S",1,"O","AN",2,2,null,"S","n/a"]
["2220D","SVC","SVC01 - 4","Procedure Modifier","S",1,"O","AN",2,2,null,"S","n/a"]
["2220D","SVC","SVC01 - 5","Procedure Modifier","S",1,"O","AN",2,2,null,"S","n/a"]
["2220D","SVC","SVC01 - 6","Procedure Modifier","S",1,"O","AN",2,2,null,"S","n/a"]
["2220D","SVC","SVC02","Monetary Amount","R",1,"M","R",1,18,null,"R","n/a"]
["2220D","SVC","SVC04","Product/Service ID","S",1,"O","AN",1,48,null,"S","n/a"]
["2220D","SVC","SVC07","Quantity","S",1,"O","R",1,15,null,"S","n/a"]
["2220D","STC",null,"Service Line Level Status Information","R",">1","O",{"$nulls":4},"R"]
["2220D","STC","STC01","Health Care Claim Status","R",1,"M",{"$nulls":4},"R"]
["2220D","STC","STC01 - 1","Industry Code","R",1,"M","AN",1,30,null,"R","n/a"]
["2220D","STC","STC01 - 2","Industry Code","R",1,"M","AN",1,30,null,"R","n/a"]
["2220D","STC","STC01 - 3","Entity Identifier Code","S",1,"O","ID",2,3,"03 Dependent\n1P Provider\n1Z Home Health Care\n40 Receiver\n41 Submitter\n71 Attending Physician\n72 Operating Physician\n73 Other Physician\n77 Service Location\n82 Rendering Provider\n85 Billing Provider\n87 Pay-to Provider\nDK Ordering Physician\nDN Referring Provider\nDQ Supervising Physician\nFA Facility\nGB Other Insured\nHK Subscriber\nIL Insured or Subscriber\nLI Independent Lab\nPR Payer\nQB Purchase Service Provider\nQC Patient\nQD Responsible Party\nTL Testing Laboratory\nTU Third Party Repricing Organization (TPO)\nMSC Mammography Screening Center\nPRP Primary Payer\nSEP Secondary Payer\nTTP Tertiary Payer","S","n/a"]
["2220D","STC","STC03","Action Code","R",1,"O","ID",1,2,"U Reject","R","\"U\""]
["2220D","STC","STC10","Health Care Claim Status","S",1,"O",{"$nulls":4},"S"]
["2220D","STC","STC10 - 1","Industry Code","R",1,"M","AN",1,30,null,"R","n/a"]
["2220D","STC","STC10 - 2","Industry Code","R",1,"M","AN",1,30,null,"R","n/a"]
["2220D","STC","STC10 - 3","Entity Identifier Code","S",1,"O","ID",2,3,"03 Dependent\n1P Provider\n1Z Home Health Care\n40 Receiver\n41 Submitter\n71 Attending Physician\n72 Operating Physician\n73 Other Physician\n77 Service Location\n82 Rendering Provider\n85 Billing Provider\n87 Pay-to Provider\nDK Ordering Physician\nDN Referring Provider\nDQ Supervising Physician\nFA Facility\nGB Other Insured\nHK Subscriber\nIL Insured or Subscriber\nLI Independent Lab\nPR Payer\nQB Purchase Service Provider\nQC Patient\nQD Responsible Party\nTL Testing Laboratory\nTU Third Party Repricing Organization (TPO)\nMSC Mammography Screening Center\nPRP Primary Payer\nSEP Secondary Payer\nTTP Tertiary Payer","S","n/a"]
["2220D","STC","STC11","Health Care Claim Status","S",1,"O",{"$nulls":4},"S"]
["2220D","STC","STC11 - 1","Industry Code","R",1,"M","AN",1,30,null,"R","n/a"]
["2220D","STC","STC11 - 2","Industry Code","R",1,"M","AN",1,30,null,"R","n/a"]
["2220D","STC","STC11 - 3","Entity Identifier Code","S",1,"O","ID",2,3,"03 Dependent\n1P Provider\n1Z Home Health Care\n40 Receiver\n41 Submitter\n71 Attending Physician\n72 Operating Physician\n73 Other Physician\n77 Service Location\n82 Rendering Provider\n85 Billing Provider\n87 Pay-to Provider\nDK Ordering Physician\nDN Referring Provider\nDQ Supervising Physician\nFA Facility\nGB Other Insured\nHK Subscriber\nIL Insured or Subscriber\nLI Independent Lab\nPR Payer\nQB Purchase Service Provider\nQC Patient\nQD Responsible Party\nTL Testing Laboratory\nTU Third Party Repricing Organization (TPO)\nMSC Mammography Screening Center\nPRP Primary Payer\nSEP Secondary Payer\nTTP Tertiary Payer","S","n/a"]
["2220D","STC","STC12","Free-form Message Text","S",1,"O","AN",1,264,null,"S","n/a"]
["2220D","REF",null,"Service Line Item Identification","R",1,"O",{"$nulls":4},"R"]
["2220D","REF","REF01","Reference Identification Qualifier","R",1,"M","ID",2,3,"FJ Line Item Control Number","R","\"FJ\""]
["2220D","REF","REF02","Reference Identification","R",1,"R","AN",1,50,null,"R","n/a"]
["2220D","REF",null,"Pharmacy Prescription Number","S",1,"O",{"$nulls":4},"S"]
["2220D","REF","REF01","Reference Identification Qualifier","R",1,"M","ID",2,3,"XZ Pharmacy Prescription Number","R","\"XZ\""]
["2220D","REF","REF02","Reference Identification","R",1,"R","AN",1,50,null,"R","n/a"]
["2220D","DTP",null,"Service Line Date","S",1,"O",{"$nulls":4},"S"]
["2220D","DTP","DTP01","Date/Time Qualifier","R",1,"M","ID",3,3,"472 Service","R","\"472\""]
["2220D","DTP","DTP02","Date Time Period Format Qualifier","R",1,"M","ID",2,3,"D8 Date Expressed in Format CCYYMMDD\nRD8 Range of Dates Expressed in Format CCYYMMDDCCYYMMDD","R","\"RD8\""]
["2220D","DTP","DTP03","Date Time Period","R",1,"M","AN",1,35,null,"R","n/a"]
[null,"SE",null,"Transaction Set Trailer","R",1,"M",{"$nulls":4},"R"]
[null,"SE","SE01","Number of Included Segments","R",1,"M","N0",1,10,null,"R","n/a"]
[null,"SE","SE02","Transaction Set Control Number","R",1,"M","AN",4,9,null,"R","n/a"]
[null,"GE",null,"Functional Group Trailer","R",1,"M",{"$nulls":4},"R"]
[null,"GE","GE01","Number of Transaction Sets Included","R",1,"M","N0",1,6,null,"R","n/a"]
[null,"GE","GE02","Group Control Number","R",1,"M","N0",1,9,null,"R","n/a"]
[null,"IEA",null,"Interchange Control Trailer","R",1,"M",{"$nulls":4},"R"]
[null,"IEA","IEA01","Number of Included Functional Groups","R",1,"M","N0",1,5,null,"R","n/a"]
[null,"IEA","IEA02","Interchange Control Number","R",1,"M","N0",9,9,null,"R","n/a"]

{"sheet":"277CA CG ","index":9,"n_rows":0,"n_cols":0,"rows_kept":0}

{"sheet":"Edits","index":10,"n_rows":205,"n_cols":9,"rows_kept":205}
["ERROR CODE","Invoice Type","Long Description","Default Disposition","277CA_Category Status Code (Encounter-Reject)","277CA _Claim Status Code (Encounter-Reject)","277CA Entity Code (Encounter-Reject)","Edit Logic","Lifecycle"]
[1014,"P/I/D","Original TCN has already been replaced","J-Reject","A3",35,"n/a","If Claim Frequency is Adjustment (or) Void and \nIf Parent Claim is already adjusted then post edit for header","N"]
[2023,"I","Missing ICD Surgical code. There is an Operating physician listed on the claim.","J-Reject","A6",666,"n/a","If the claim type is R - Inpatient. Surgery procedure code is empty AND Operating physician NPI is not empty then post the edit.","N"]
[2024,"P/I/D","Member is not eligible for all dates of service","J-Reject","A7",88,"PR",null,"N"]
[2025,"I","For Nursing Facility, ICF/ID,Inpatient, Outpatient, or Dialysis Center claims the Admission Source Invalid \n","J-Reject","A6",229,"n/a","If Loading Edit 1026 posted and Claim Type is T - Nursing Facility, A - ICF/ID, R - Inpatient, or F - Outpatient OPPS post the edit .","N"]
[2026,"D","A tooth surface is reported on the claim but the tooth number is missing","J-Reject","A6",242,"n/a","If there is a tooth surface submitted on the claim but there is no tooth number present on the claim then post the edit.","N"]
[2027,"I","Invalid National discharge status.","J-Reject","A7",234,"n/a","If the claim type is T - Nursing Facility, A - ICF/ID, or R - Inpatient and the patient discharge status is not one of the valid discharge statues values per HIPAA X12 Implementation Guides then post the edit. \n","N"]
[2028,"P/I/D","Unable to determine the Benefit Plan due to claim type restriction.","J-Reject","A3",276,"n/a","If Benefit Plan at the header has as Claim Type Restriction for the claim type stamped on the claim then post the edit for Header.","N"]
[2029,"P/I/D","Recipient ID not on file","J-Reject","A7",26,"IL","If Claim Header Member ID is not present Then post the edit for header.","Y"]
[2048,"I/D/P","From date after submit date","J-Reject","A3",187,"n/a","System raises an exception. Statement from/to date cannot be greater than Julian date in TCN","N"]
[2049,"P/I/D","Through date after submit date","J-Reject","A7",188,"n/a","Statement from/to date submitted on a file is compared with the Julian date in TCN and the error is raised if it is greater than the Julian date in TCN","N"]
[2054,"I","Discharge Hour Missing","J-Reject","A6",233,"n/a","If claim type is R - Inpatient post if Discharge Hour is missing","N"]
[2059,"D","The procedure has an Oral Cavity Required Indicator of Y and an Oral Cavity was not submitted on the claim.","J-Reject","A6",245,"PR","Dental Invoice - If Procedure Oral Cavity Required Indicator is 'Y' and Oral Cavity Designation is Empty then post the edit at line","N"]
[2060,"D","The procedure has a Tooth Surface Required Indicator of Y and a Tooth Surface was not submitted on the claim.","J-Reject","A6",244,"PR","Dental Invoice - If Tooth Surface Required Indicator is \"Y\" and if the Tooth surface is either empty or 0 then post edit for Line. \nBypass: ​Claim frequency is Void","N"]
[2072,"I","Invalid claim frequency code","J-Reject","A7",122,"n/a",null,"N"]
[2073,"P/I/D","Invalid Billing Provider NPI","J-Reject","A6",153,85,"Billing Provider Primary Id at header does not match with the database","Y"]
[2075,"D","Invalid Quadrant/Arch","J-Reject","A7",245,"n/a","For Invoice Type Dental: Oral Cavity Code Identifying the area of the oral cavity in which service is rendered, '00', '01', '02', '09', '10', '20', '30', '40' (applies to all 5 occurrences of the oral cavity designation code).\nOral cavity designation is validated against database. Error is raised for invalid value.","N"]
[2076,"P/I/D","Payer ID invalid","J-Reject","A7",480,"PR","Other Payer primary id at header do not match with the database.\nCall the Pr_Prvdrvalidationforloading procedure with the Other Payer id and qualifier as '7' MMIS Id. Other Payer id will always be the MMIS id.","N"]
[2079,"P/I/D","No match found on history for replacement - Replacement Claim TCN not included.","J-Reject","A4",35,"n/a","Map to multiple Cloud edits \n2655 - If ERN is not submitted in the Encounter Claim, system will post this edit\n2656 - If claim Frequency Code is 7 or 8 and there isn’t any matching claim found with the Parent ERN and Health Plan Id combination, system will post this edit. \n2658 - If claim Frequency Code is 7 or 8 and the parent claim is not available in the accepted & ETRR generated status (131, 83) and edit 9074 is not posted then system will post this edit.","N"]
[2080,"P/I/D","Original TCN has already been voided","J-Reject","A3",35,"n/a","1409/1407 \n\n1409 - For any claim which is Adjustment or Void, copy the Original TCN of the Original Claim to Parent TCN of the Adjustment Claim. For example: \n\nClaim Frequency Code TCN Original TCN Parent TCN \n\n1 1 1 NULL \n7 2 2 1 \n\n1407 - If claim Frequency Code is 7 or 8 and former TCN is invalid then system raises an error. Loading puts # in the Parent TCN in Erroneous Data field.","N"]
[2081,"P/I/D","Other payer amount missing/invalid","J-Reject","A6",183,"PR","Cloud Error Code: 1621/1622/1607/1013/1611\n1621 - The Other Payer Paid Amount is not numeric. Amount edits should accept zero and negative values as valid values and not post any edit.\n1622 - The Other Payer Paid Amount is not numeric. Amount edits should accept zero and negative values as valid values and not post any edit.\n1607 - If a file is submitted with Other Payer Service Line Paid Amount Missing, an error will be raised\n1013 - Institutional Invoice - \nIf Claim Header Total Non Covered Amount is less than zero or not a valid number, post edit at header.\n1611 - The Patient Responsibility Amount is not numeric. Amount edits should accept zero and negative values as valid values and not post any edit.","N"]
[2082,"P/D","Place of service invalid.","J-Reject","A7",249,"n/a","• Professional or Dental Invoices and \n• Claim Line Medicare Indicator is ‘N’ \n• If Procedure Code submitted on the claim is on the Procedure x POS cross-walk in reference, and the POS submitted for the line is not associated to the Procedure Code for the Claim Type in the cross-walk for the DOS \nOR \nCloud Edit Logic - 1403/1363 \n1403 - The error is raised when the Place of Service at header on data file is validated with the database and no match found OR the Place of Service at the header is not valid for the DOS on the claim \nOR \n1363 - The error is raised when the Place of Service at Line on data file is validated with the database and no match found OR the Place of Service at the line is not valid for the DOS on the claim line \nOR \nIf Claim Type is F-Outpatient, and OCE Editor returns 0053, 0055, post the edit.","N"]
[2088,"P/I","Modifier (Position 1) is not found in the database.","J-Reject","A7",453,"n/a","For Invoice Type Professional and Institutional: \nIf occurrence of Modifier (Position 1) is invalid against database then error is raised.","N"]
[2089,"P/I","Modifier (Position 2) is not found in the database.","J-Reject","A7",453,"n/a","For Invoice Type Professional or Institutional:\nIf occurrence of Modifier (Position 2) is invalid against database then error is raised.","N"]
[2090,"P/I","Modifier (Position 3) is not found in the database.","J-Reject","A7",453,"n/a","For Invoice Type Professional or Institutional:\nIf occurrence of Modifier (Position 3) is invalid against database then error is raised.","N"]
[2091,"P/I","Modifier (Position 4) is not found in the database.","J-Reject","A7",453,"n/a","For Invoice Type Professional or Institutional: \nIf occurrence of Modifier (Position 4) is invalid against database then error is raised.","N"]
[2092,"P/I/D","Based on the claim type determination logic, the system is unable to derive a claim type.","J-Reject","A7",481,"n/a","Based on the claim type determination logic described in Appendix-G , the claim type is derived. If based on the logic, it is unable to derive the claim type, edit 1008 is posted on header.","N"]
[2093,"I","Admit source missing","J-Reject","A6",229,"n/a","If Loading Error 1660 posted and claim type is T - Nursing Facility, A - ICF/ID, R - Inpatient, or F - Outpatient OPPS Post the edit.","N"]
[2094,"P/I/D","When pricing the claim/line the system is programmed to use a Charge Mode and a Charge Mode Rate is not present, the error will post.","A-Accept","n/a","n/a","n/a","System parameters are replaced with charge mode rate in Cloud. If the charge mode rate is not found, then post the edit","N"]
[2095,"P/I/D","Based on date of service, no rate is found in rate setting for the service.","A-Accept","n/a","n/a","n/a","For all invoices \nIf Rate value is not available in Rate Setting then post the edit\nBypass:\n​If Line manual price is not null\nOR\nService Code Manual Price Indicator is set to YES\nOR\nIf Line is priced at $0 based on UT-G Logic then bypass edit","N"]
[5128,"I","DRG code invalid","J-Reject","A7",256,"n/a","For Claim Type R - Inpatient: \nUse the DRG submitted on the claim to check whether the DRG is in the DRG Rate Table the Percentage of Charge for the DRG is DRG = 1 (Invalid DRG) or 4 (End dated) then post edit 5128.","N"]
[5167,"P","Missing/Invalid Ordering Provider for Lab and X-ray claim","J-Reject","A6",153,"DK","If the claim type is X - Laboratory , then confirm the Ordering provider NPI exists  and is valid.","N"]
[5371,"P","Date of service on the claim does not fall within the enrollment dates for the ordering provider on the provider record.","J-Reject","A6",153,"n/a","For Invoice Type of Professional: Post the edit if following is true. \n1.If the date of service on the claim does not fall within the enrollment dates for the ordering provider on the provider record, post edit.","N"]
[5372,"P/I/D","Date of service on the claim does not fall within the enrollment dates for the servicing provider on the provider record","J-Reject","A7",91,"PR","Post the edit if following is true. \n1.If the date of service on the claim does not fall within a Provider record with a status of \"Open\" for the enrollment dates for the servicing provider, post edit. Post for FFS, encounters and crossovers in this case. \nBYPASS: \nIf claim type is I - Ambulance or O - Indian Health Services","N"]
[5373,"I","Only one interim bill allowed per admission. Two claims have been submitted by the same Billing Provider with Frequency Code 2 or 3 with dates of service within 10 days of one another.","J-Reject","A7",781,"PR","Current Claim Type is R - Inpatient (frequency is '2' or '3') vs \nHistory Claim Type is R - Inpatient (frequency is '2' or '3') \n- Member is Same. \n- Billing Provider NPIs are equal. \n- Header Dates of Service of the history claim are within 10 days of Current Claim \nPost the Edit. ","N"]
[5378,"P/I/D","Referring Provider NPI Invalid","A-Accept","n/a","n/a","n/a","The error is raised if the Referring Provider Id at header on data file is validated with the database and no match found","N"]
[5379,"P/I/D","Provider ineligible on date of service. Billing Provider Location Status is not Active for the specified header service begin date and end date","J-Reject","A7",88,"PR","All Invoice Types -Institutional & Professional & Dental \nIf Billing Provider is present and if the billing provider's Base Location Status is not (Active for the specified header service begin date and end date) then post edit for header","N"]
[5381,"I","Attending physician ID missing or invalid","J-Reject","A6",26,71,"For claim types R - Inpatient, A - ICF/ID or T - Nursing Facility if the Attending Provider ID: \nis not found in the database \nOR \nis not active for the from date of service \nOR \nAttending provider does not contain a PAC of 033 or 068 in provider enrollment. \nOR \nIf Header Attending provider ID is empty \nthen post edit. \nOR \n1481 - Attending Provider Id at header on data file is validated with the database. If not found, error is raised \nBypass: \nMedicare Indicator is set to \"Y\" (crossover)","N"]
[5382,"I","Operating Provider Primary Id at header/line does not match with an active record provider record in the system for the date of service.","J-Reject","A7",88,"PR","Invoice type Institutional. \n1557 - Operating Provider Primary Id at header do not match with the database \n1558 - Operating Provider Primary Id at line do not match with the database in adjudication check that Operating Provider is active on from date of service at header and/or at line. If not active post edit. \nBypass if Medicare Indicator is set to \"Y\" (crossover)","N"]
[5475,"P","Missing Ordering Provider for Med-Vendor claim","J-Reject","A6",153,"n/a","If the claim type is Med Supplies/DME/P&O Contractors, then confirm ordering/referring provider NPI exists and is valid","N"]
[5477,"P/I","Missing/Invalid Ordering Provider for Home Health claim","J-Reject","A6",153,"n/a","If the claim type is Home Health or PDN/PDN Home Health, then confirm ordering/referring provider NPI exists and is valid","N"]
[5548,"P/I/D","Procedure to sex mismatch\n","J-Reject","A3",474,"n/a","If Procedure code is not valid for the member gender for the time of service dates then post edit 1146 for Line. \nBypass if Medicare Indicator is set to \"Y\" (crossover)","N"]
[5549,"I","Other procedure code not on file","J-Reject","A6",490,"n/a","For Invoice Type of Institutional:\nThe Surgical Procedure codes should be valid and available in Database. The Data if valid should be loaded into the database and not post any edit","N"]
[20110,"I","Admit date after statement covers begin date","J-Reject","A7",189,"n/a","If the claim type is R - Inpatient and admit date is more than 3 days after the from service date then post the edit at the header. \nThis Edit will be Applicable for Cross Overs.","N"]
[20112,"P/I/D","Group Billing Provider has Missing/Invalid Rendering Provider","J-Reject","A6",153,82,null,"N"]
[20114,"P/I/D","Recipient name does not match file name\n","J-Reject","A7",125,"IL","If the first 5 chars of first or last name on the claim don’t match the member record \nPost the edit.","N"]
[20115,"P/I/D","MCO's Entry Date Missing","J-Reject","A6",122,"n/a","Repricer Received Date (MCO Entry Date) is missing","N"]
[20116,"P/I/D","MCO's Paid Date is a future date","J-Reject","A6",122,"n/a","If claim form type is institutional, and Plan Paid Date (Loop 2330B DTP segment with qualifier 573) is a future date at the header level, then post the edit. \nIf claim form type is professional or dental, and Plan Paid Date (Loop 2430 DTP segment with qualifier 573) is  a future date missing at the line level, then post the edit.","N"]
[20117,"P","MCO not responsible for payment","J-Reject","A3",97,"n/a","If the Invoice type is professional and the place of service is 21, 61 or 51 and the member is not enrolled in managed care at the time of admission, post edit.","N"]
[20119,"P/I/D","Mental Health SPMI indicator invalid/missing","A-Accept","n/a","n/a","n/a",null,"N"]
[20120,"I","Client has Foster Care Eligibility for MH/SUD outpatient encounter","J-Reject","A3",88,"IL",null,"N"]
[20121,"P/I/D","Recipient enrolled with another plan during service Period\n","J-Reject","A3",97,"PR","If Claim Type is not R - Inpatient or Place of Service is not 21, 61 or 51 and \nthe Member has eligibility for the From DOS on the Encounter and \nIf the system is not able to Derive the Benefit Plan for the MCO submitted on the claim based on From DOS, \nPost the edit. \nNote : \nStep 1: Use the Location Id(MCO Location ID) submitted on the claim and get the Program to which the Provider Location is associated with. Once the Program is derived, go to the Benefit Plan cross walk to derive the Benefit Plan. \nStep 2: For the derived benefit plan, make sure the member is enrolled in the Benefit Plan for the From_Dates of service submitted on the claim.","N"]
[20122,"P/I/D","Recipient enrolled with another plan on admission date\n","J-Reject","A3",97,"PR","This exception will post on a submitted Encounter claim if: \nFor Claim Type R - Inpatient\nAdmit date is not blank or invalid \nAND \nFor the Admit Date, the System is not able to derive the Member's benefit plan for the MCO submitted \nFor Claim Type R - Inpatient Admit date is not blank and the place of service is 21, 61 or 51\nFor the Admit Date, the System is not able to derive the Member's benefit plan for the MCO submitted \nBypass for the program type \"PMHP\" {This will be handled through Disposition configuration}","N"]
[20123,"P/I/D","Plan Paid Amount missing","J-Reject","A6",183,"PR","If claim form type is institutional, and Plan Paid Amount (HCP02) is missing on the claim and is not present at the header or line level, then post the edit. \nIf claim form type is professional or dental, and Plan Paid Amount (HCP02) is missing at the line level, then post the edit.","N"]
[20124,"I","Procedure date not between 3 days prior to the admit date and statement through date","J-Reject","A3",187,"n/a","If Claim Type is R-Inpatient \nAND \nLine service date not between 3 days prior to the admit date and statement through date then post the edit","N"]
[20125,"P/I","Drug Procedure Code must have a valid NDC Code","J-Reject","A7",287,"n/a","If the Invoice Type is Professional OR Claim Type is F - Outpatient OPPS\nAND \nif HCPCS Code \"Claim Line Procedure IID\" is in the NDC to Procedure Crosswalk \nAND \nNDC doesn’t exists on the claim line or is invalid \nBypass: \nIf the claim type is F - Outpatient OPPS and revenue code on the claim line is 0459 or 0450, then bypass the edit.","N"]
[20126,"I","Admitting diagnosis code missing","J-Reject","A6",232,"n/a","If the Claim type is from group R - Inpatient\nAdmitting diagnosis is spaces then post the edit.","N"]
[20128,"P/I/D","Must contain at least one service line not plan denied.\n","J-Reject","A3",247,"n/a","If the MCO Paid Amount is not zero and all lines are marked denied (HCP01 - \"00\" at the line level loop 2400).","N"]
[20129,"P/I","Primary Diagnosis Code for Substance Abuse","J-Reject","A7",254,"n/a","For Invoice Type Professional and Institutional: Post edit when the Mental Health PRISM Location ID is submitted on a claim with a substance use primary diagnosis code.","N"]
[20130,"P/I","Primary Diagnosis Code is for Mental Health","J-Reject","A7",254,"n/a","For Invoice Type Professional or Institutional: Post edit when the Substance Use PRISM Location ID is submitted on a claim with a mental health primary diagnosis code.","N"]
[20131,"I","Procedure code must exist for this Revenue Code.","J-Reject","A3",455,"n/a","If the claim type F - Outpatient OPPS, \nThe indicator on the reference file \"HCPCS Required\" is Yes for a revenue code and there is no HCPCS code submitted then post the edit. ","N"]
[20133,"P/I/D","MCO paid amount equal Other Payer's TPL amount (and both amounts are not zero)","J-Reject","A3",286,"n/a",null,"N"]
[20136,"I","Missing covered days for Inpatient claim. Covered days are reported as Value code 80","J-Reject","A7",456,"n/a","If the claim type is A - ICF/ID, R - Inpatient or T - Nursing Facility and The covered days is missing then post the edit.","N"]
[20140,"P/I","Admit date missing","J-Reject","A3",189,"n/a",null,"N"]
[20142,"P/I/D","Recipient DOB Month and year does not match file month and year\n","J-Reject","A7",158,"IL","If Member Birth Date (In Member Details table) is not present or if Member Claim Date of Birth (Submitted In file) is not present Then post the edit for header. \nIf Month of Member Claim DOB is not Month of Member DOB or if Year of Member Claim DOB is not Year of Member DOB or if Day of Member Claim DOB is not Day of Member DOB \nThen post the edit for header.","N"]
[20143,"P/I/D","From date of service missing","J-Reject","A6",187,"n/a","For invoice type institutional check the from service date at the header. \nFor invoice types Professional and Dental check the from service date at the line . If it is missing post the edit at header or line correspondingly. \nOn a Claim Type F - Outpatient OPPS if header date of service spans more than one date and the line date of service is blank then post the edit.","Y"]
[20144,"P/I/D","First date of service greater than last date of service.","J-Reject","A3",188,"n/a","If either To Date of Service is Invalid or To Date of Service is earlier than From Date of Service then post edit at line.","N"]
[20145,"I","Discharge Hour Invalid","J-Reject","A7",233,"n/a",null,"N"]
[20146,"I","Revenue code missing","J-Reject","A6",455,"n/a","Institutional Invoice - If Revenue code without modifier is not present or it is zero then post edit at header.","N"]
[20147,"P/I/D","Encounter is greater than 12 months From End Date Of Service.","A-Accept","n/a","n/a","n/a","For Institutional invoices, \nIf Days between Claim Header \"To Date of service\" and \"TCN Load Date\" is greater than 365 days, then set 1217 at header \nFor professional and dental invoices, \nIf Days between Claim Line “From Date of service” and \"TCN Load Date\" is greater than 365 days, then set 1217 at line \nIf the claim Medicare Indicator is set to \"Y\" (crossover) and the claim source is not \"66\" or \"77\" \nIf the difference between the claim To date of service and the TCN Date is greater than 365 days AND if the difference between Medicare paid date and TCN date is greater than 180 days then post the edit. For encounters, use the date the claim was submitted to the MCO instead of the TCN date.","N"]
[20148,"P/I","Invalid procedure code / NDC combination","J-Reject","A7",448,"n/a","For Invoice Type Professional or Claim Type F - Outpatient OPPS: \nIf Claim Line Procedure is not \"Empty\" \nAND \nif HCPCS Code \"Claim Line Procedure IID\" is in the NDC to Procedure Crosswalk \nAND \nif NDC is not empty and is not Valid for \"Procedure\" for the from date of service \nthen post 20148 edit for Line.","N"]
[20149,"I","Diagnosis code not on file.","J-Reject","A3",255,"n/a","For Invoice Type Institutional:\nOther Diagnosis Code at header is not found on diagnosis table and the Diagnosis code is not blank.\nOR\nIF OCE Editor returns 3102, post the edit.","N"]
[20150,"I","Admitting diagnosis code invalid for an Inpatient claim.","J-Reject","A7",232,"n/a","If Claim Type is R - Inpatient and Admitting Diagnosis Code at header is not found on diagnosis table and the Diagnosis code is not blank.","N"]
[20151,"I","E-code is invalid","J-Reject","A3",255,"n/a","For Invoice Type Institutional:\nE-code Diagnosis Code at header is not found on diagnosis table and the Diagnosis code is not blank","N"]
[20152,"I","Revenue code invalid.","J-Reject","A7",455,"n/a","For Invoice Type of Institutional:\nRevenue Code on data file is validated against database. If not found, error is raised. ","N"]
[20153,"P/I/D","Procedure code invalid.","J-Reject","A7",454,"n/a","If Claim Header Last Run Error Number is zero and if edit 1652 is already posted for Line in Previous Run then Post edit for Line. \n","N"]
[20154,"D","Tooth number invalid or tooth number is invalid for the procedure code.","J-Reject","A7",244,"n/a","Dental Invoice - \nIf Procedure Tooth Number Required Indicator is \"\"Y\"\" and Tooth Number is invalid for the procedure code then post error for Line. \n**Procedure Code and Tooth Number combination check** \nIf Edit 1019 is not Posted AND If Procedure Tooth Number Required Indicator is \"\"Y\"\" and Tooth Number is invalid for the Procedure Code, then post error for Line.","N"]
[20155,"P/I/D","Gender on the diagnosis code is not matching with the member's gender.","J-Reject","A7",86,"n/a","The gender on the diagnosis code is not matching with the member gender then post the edit. State will configure the gender for diagnosis codes in the reference file. \n","N"]
[20156,"D","Tooth number missing","J-Reject","A6",244,"n/a","Dental Invoice - \nIf Procedure Tooth Number Required Indicator is \"Y\" and Tooth Number is Empty then post error for Line.","N"]
[20166,"P/I/D","Procedure code is not valid for the From and To date of service.\n","J-Reject","A6",454,"n/a","If the procedure code is not valid for the from date of service or not valid for the to date of service then post the edit.","N"]
[20168,"D","A Dental Hygienist is not eligible to be reimbursed for services in this place of service. Services must be performed in a public health setting.","J-Reject","A7","n/a","n/a","For Dental Invoice Type: \nIf the billing/servicing provider PT/SP/SSP is A030/B159/C999 and the place of service is not 03, 05, 07, 12, 13, 14, 15, 32, 33, 34 or 50, post the edit.","N"]
[20169,"P/D","Accident date is greater than the To Date of Service at the claim level.","J-Reject","A7",727,"n/a","If invoice type Professional or Dental and If there is an Accident Date at the header which is greater than To Date of Service then post edit at header. \nOR \nFor Invoice type Institutional, If the Occurrence Code is 01, 02, 04, then the Occurrence Date must not be after the Statement From Date. Occurrence Code 03 and 05, must not be after the Statement To Date","N"]
[20173,"I/P/D","Plan reported the claim/line as denied. Encounter is \"Accepted\" and no other system edit or checks were applied. Claim/line was shadow priced at $0","A-Accept","n/a","n/a","n/a","If the MCO Plan denied an encounter at the header, then PRISM will update the header and all lines with status = Accepted and the paid amount will be set to $0 and post edit at header and lines. (disposition status = Accepted) \nIf the MCO Plan denied an encounter at lines, then PRISM will mark update all the denied lines with status = Accepted and the paid amount will be set to $0 and post edit at the corresponding lines. (disposition status = Accepted) \nNote: \n1. If edit was posted at Line, then remove all Reject edits at Line. \n2. If edit was posted at Header, then remove all Reject edits at Header and Line.","N"]
[20174,"I","Incorrect billing of Rev Code with HCPCS","J-Reject","A7",454,"n/a",null,"N"]
[20179,"I","Admit type is not 1, 2, 3, 4, 5 or 9 on an Inpatient claim.","J-Reject","A6",231,"n/a","If claim type is R-Inpatient \nand if the admission type code is not '1', '2', '3', '4', '5' or ‘9’ then post edit at header.","N"]
[20300,"I","Principle procedure code not on file","J-Reject","A6",465,"n/a",null,"N"]
[20703,"P/I/D","Original TCN was rejected","J-Reject","A3",122,"n/a",null,"N"]
[20900,"P/I/D","Missing or Invalid original TCN","J-Reject","A7",122,"n/a","Claim Frequency Type is void or adjustment and [Parent Claim Header TCN is empty or Parent Claim Header TCN is not found] then post edit for header.","Y"]
[20902,"P/I/D","Duplicate encounter","J-Reject","A3",54,"n/a",null,"N"]
[]
[]
[]
["Loading Edits","Invoice Type","Long Description","Default Disposition","277CA_Category Status Code (Encounter-Reject)","277CA _Claim Status Code (Encounter-Reject)","277CA Entity Code (Encounter-Reject)",null,"Recommend correction"]
[1002,"P/I/D","Invalid service line from date","Information","n/a","n/a","n/a",null,"Y"]
[1003,"P/I/D","Invalid service line to date","Information","n/a","n/a","n/a",null,"Y"]
[1012,"I","Derive discharge date from occurrence code 42","Information","n/a","n/a","n/a",null,"Y"]
[1013,"I","Invalid total non-covered amount","Information","n/a","n/a","n/a",null,"Y"]
[1015,"I","Invalid admission type","Information","n/a","n/a","n/a",null,"Y"]
[1016,"I","Invalid occurrence code","Information","n/a","n/a","n/a",null,"Y"]
[1017,"I","Invalid occurrence span code","Information","n/a","n/a","n/a",null,"Y"]
[1018,"I","Invalid value code","Information","n/a","n/a","n/a",null,"Y"]
[1019,"D","Tooth number invalid","Information","n/a","n/a","n/a",null,"Y"]
[1020,"P/I/D","Invalid accident date","Information","n/a","n/a","n/a",null,"Y"]
[1026,"I","Admission source invalid","Information","n/a","n/a","n/a",null,"Y"]
[1040,"P/I","The National Uniform Billing Committee (NUBC) Code on the claim header does not match the database","Information","n/a","n/a","n/a",null,"Y"]
[1042,"I","Invalid patient status code","Information","n/a","n/a","n/a",null,"Y"]
[1070,"I","Duplicate value code","Information","n/a","n/a","n/a",null,"Y"]
[1095,"P/I/D","Subscriber gender code is missing","Information","n/a","n/a","n/a",null,"Y"]
[1097,"P/I/D","Subscriber birth date missing","Information","n/a","n/a","n/a",null,"Y"]
[1098,"P/I/D","Invalid subscriber primary ID","Information","n/a","n/a","n/a",null,"Y"]
[1111,"I","Invalid occurrence span from date","Information","n/a","n/a","n/a",null,"Y"]
[1112,"I","Invalid occurrence span to date","Information","n/a","n/a","n/a",null,"Y"]
[1136,"P/D","Missing accident date","Information","n/a","n/a","n/a",null,"Y"]
[1147,"P/D","Duplicate referring provider ID","Information","n/a","n/a","n/a",null,"Y"]
[1219,"P/I/D","Invalid subscriber name","Information","n/a","n/a","n/a",null,"Y"]
[1234,"P/I/D","Invalid MCO Adjudication Date","Information","n/a","n/a","n/a",null,"Y"]
[1363,"P/D","Invalid place of service","Information","n/a","n/a","n/a",null,"Y"]
[1403,"P/D","Invalid place of service","Information","n/a","n/a","n/a",null,"Y"]
[1405,"P/D","Auto accident state or province code missing","Information","n/a","n/a","n/a",null,"Y"]
[1407,"P/I/D","TCN exists and adjustment already in progress","Information","n/a","n/a","n/a",null,"N"]
[1408,"P/I/D","Parent TCN/ERN/Claim not found at header","Information","n/a","n/a","n/a",null,"Y"]
[1421,"P/I/D","Invalid other diagnosis code","Information","n/a","n/a","n/a",null,"Y"]
[1428,"P/I/D","Invalid Billing Provider NPI","Information","n/a","n/a","n/a",null,"Y"]
[1444,"P/I/D","Referring Provider NPI Invalid","Information","n/a","n/a","n/a",null,"Y"]
[1445,"P/I","Missing referring provider ID and ID type","Information","n/a","n/a","n/a",null,"Y"]
[1452,"P/I/D","Invalid Servicing/Rendering Provider NPI","Information","n/a","n/a","n/a",null,"Y"]
[1453,"I","Servicing/Rendering provider not on file","Information","n/a","n/a","n/a",null,"Y"]
[1454,"P/D","Servicing/Rendering provider taxonomy at header does not match with database","Information","n/a","n/a","n/a",null,"N"]
[1455,"P/D","Invalid servicing/rendering provider taxonomy code","Information","n/a","n/a","n/a",null,"N"]
[1457,"P/I/D","Invalid adjustment reason code","Information","n/a","n/a","n/a",null,"Y"]
[1462,"P/I","Invalid National Drug Code","Information","n/a","n/a","n/a",null,"Y"]
[1468,"P/I/D","Invalid billing date at header","Information","n/a","n/a","n/a",null,"Y"]
[1470,"P/I","Invalid primary diagnosis code","Information","n/a","n/a","n/a",null,"Y"]
[1471,"I","Invalid admitting diagnosis code","Information","n/a","n/a","n/a",null,"Y"]
[1472,"I","Invalid patient reason for visit diagnosis code","Information","n/a","n/a","n/a",null,"N"]
[1473,"I","Invalid external causes of injury diagnosis code","Information","n/a","n/a","n/a",null,"Y"]
[1474,"I","Invalid value amount","Information","n/a","n/a","n/a",null,"Y"]
[1475,"I","Invalid covered days amount","Information","n/a","n/a","n/a",null,"Y"]
[1476,"I","Invalid co-insurance days amount","Information","n/a","n/a","n/a",null,"Y"]
[1477,"I","Invalid life time reserve days amount","Information","n/a","n/a","n/a",null,"Y"]
[1481,"I","Attending provider ID not enrolled","Information","n/a","n/a","n/a",null,"Y"]
[1485,"I","Invalid attending provider taxonomy code","Information","n/a","n/a","n/a",null,"N"]
[1493,"P/I/D","Statement from and to date submitted is greater than TCN date","Information","n/a","n/a","n/a",null,"Y"]
[1494,"I","Invalid revenue code","Information","n/a","n/a","n/a",null,"Y"]
[1495,"I","Invalid submit facility","Information","n/a","n/a","n/a",null,"Y"]
[1496,"I","Invalid bill classification","Information","n/a","n/a","n/a",null,"Y"]
[1517,"P","Invalid Ordering Provider NPI","Information","n/a","n/a","n/a",null,"Y"]
[1541,"I","Other provider ID at header not enrolled","Information","n/a","n/a","n/a",null,"Y"]
[1542,"I","Other provider ID at line not enrolled","Information","n/a","n/a","n/a",null,"Y"]
[1550,"D","Assistant Surgeon at header not enrolled ","Information","n/a","n/a","n/a",null,"Y"]
[1551,"D","Assistant Surgeon at line not enrolled","Information","n/a","n/a","n/a",null,"Y"]
[1554,"D","Invalid Assistant Surgeon taxonomy at header","Information","n/a","n/a","n/a",null,"N"]
[1555,"I","Invalid Assistant Surgeon taxonomy at line ","Information","n/a","n/a","n/a",null,"N"]
[1557,"I","Operating provider ID at header not enrolled","Information","n/a","n/a","n/a",null,"Y"]
[1558,"I","Operating provider ID at line not enrolled","Information","n/a","n/a","n/a",null,"Y"]
[1564,"D","Invalid referring provider taxonomy code","Information","n/a","n/a","n/a",null,"N"]
[1606,"P/I/D","Missing Billing Provider Taxonomy","Information","n/a","n/a","n/a",null,"N"]
[1609,"I","Servicing/rendering provider ID on file","Information","n/a","n/a","n/a",null,"Y"]
[1611,"I","Invalid patient responsibility amount format","Information","n/a","n/a","n/a",null,"Y"]
[1621,"P/I/D","Other payer paid amount at header is not numeric or is negative ","Information","n/a","n/a","n/a",null,"Y"]
[1622,"P/I/D","Other payer paid amount at line is not numeric or is negative ","Information","n/a","n/a","n/a",null,"Y"]
[1627,"P/I","Invalid National Drug Unit count","Information","n/a","n/a","n/a",null,"Y"]
[1647,"P/I/D","1st procedure modifier invalid","Information","n/a","n/a","n/a",null,"Y"]
[1648,"P/I/D","2nd procedure modifier invalid","Information","n/a","n/a","n/a",null,"Y"]
[1649,"P/I/D","3rd procedure modifier invalid","Information","n/a","n/a","n/a",null,"Y"]
[1650,"P/I/D","4th procedure modifier invalid","Information","n/a","n/a","n/a",null,"Y"]
[1652,"P/I/D","Procedure code not known","Information","n/a","n/a","n/a",null,"Y"]
[1660,"I","Admission Source missing","Information","n/a","n/a","n/a",null,"Y"]
[1661,"P/D","Accident state on the claim does not match database","Information","n/a","n/a","n/a",null,"Y"]
[1662,"P/I/D","Invalid claim frequency code","Information","n/a","n/a","n/a",null,"Y"]
[1668,"D","Invalid 1st oral cavity designation","Information","n/a","n/a","n/a",null,"Y"]
[1669,"D","Invalid 2nd oral cavity designation","Information","n/a","n/a","n/a",null,"Y"]
[1670,"D","Invalid 3rd oral cavity designation","Information","n/a","n/a","n/a",null,"Y"]
[1671,"D","Invalid 4th oral cavity designation","Information","n/a","n/a","n/a",null,"Y"]
[1672,"D","Invalid 5th oral cavity designation","Information","n/a","n/a","n/a",null,"Y"]
[2645,"P/I/D","Payer ID invalid","Information","n/a","n/a","n/a",null,"Y"]
[2647,"P/I/D","Other Payer plan type at header failed","Information","n/a","n/a","n/a",null,"Y"]
[2650,"P/I/D","Missing Adjudication Date","Information","n/a","n/a","n/a",null,"Y"]
[2653,"P/I/D","Invalid Health Plan or Program Code combination at header","Information","n/a","n/a","n/a",null,"Y"]
[2655,"P/I/D","ERN missing at header","Information","n/a","n/a","n/a",null,"Y"]
[2656,"P/I/D","Parent ERN and health plan not found at header","Information","n/a","n/a","n/a",null,"Y"]
[2658,"P/I/D","Invalid parent TCN/ERN/Claim at header","Information","n/a","n/a","n/a",null,"Y"]
[2659,"P/I/D","ERN and Health Plan already exists at header","Information","n/a","n/a","n/a",null,"Y"]
[5003,"P","Anesthesia related surgical code does not match with the database","Information","n/a","n/a","n/a",null,"Y"]
[5014,"P/I/D","Referring Provider NPI Invalid","Information","n/a","n/a","n/a",null,"Y"]
[5015,"P","Missing referring primary care provider ID and ID type","Information","n/a","n/a","n/a",null,"Y"]
[5031,"P/D","Duplicate referring primary care provider ID","Information","n/a","n/a","n/a",null,"Y"]
[5500,"I","Invalid principal procedure code","Information","n/a","n/a","n/a",null,"Y"]
[5502,"I","Invalid surgical code","Information","n/a","n/a","n/a",null,"Y"]
[9012,"P/I/D","The repriced allowed amount at header is negative","Information","n/a","n/a","n/a",null,"Y"]
[9013,"P/I","Servicing Facility ID missing","Information","n/a","n/a","n/a",null,"N"]
[9014,"P/I/D","Service Facility Location ID not on file header","Information","n/a","n/a","n/a",null,"N"]
[9015,"P/D","Service Facility location not enrolled","Information","n/a","n/a","n/a",null,"N"]
[9021,"P/I/D","Invalid adjustment quantity","Information","n/a","n/a","n/a",null,"Y"]
[9022,"P","Invalid patient weight","Information","n/a","n/a","n/a",null,"Y"]
[9023,"P","Invalid transportation distance","Information","n/a","n/a","n/a",null,"Y"]
[9024,"P/I/D","Invalid repriced allowed amount","Information","n/a","n/a","n/a",null,"Y"]
[9025,"P/I/D","Invalid remaining patient liability amount","Information","n/a","n/a","n/a",null,"Y"]
[9026,"P/D","Service Facility Location ID missing","Information","n/a","n/a","n/a",null,"N"]
[9030,"P/I/D","Invalid MCO Claim Entry Date","Information","n/a","n/a","n/a",null,"Y"]
[9032,"P/I/D","Derive MCO SPMI Indicator","Information","n/a","n/a","n/a",null,"N"]
[9045,"P/I/D","Invalid remark code","Information","n/a","n/a","n/a",null,"N"]
[9070,"D","Invalid referring primary care provider taxonomy code","Information","n/a","n/a","n/a",null,"N"]
[9074,"P/I/D","Parent TCN/ERN already adjusted or void at header","Information","n/a","n/a","n/a",null,"Y"]
[9075,"P","Invalid patient weight at header","Information","n/a","n/a","n/a",null,"Y"]

{"sheet":"421 Mapping","index":11,"n_rows":26,"n_cols":10,"rows_kept":26}
["Record Type","Data Element Name","Required","Data Type","Length","Start Position","End Position","Delimited line Position (starts at 0)","Sample Format","Data Description"]
["99999","SUBMITTER-ID","Y","String","4",1,4,"n/a","00AH","First four characters of the submitter id (Identifier of the organization that physically transmits the data)\n"]
["99999","CAPITATED-PLAN-ID","Y","String","20",{"$f":"G2+1","v":5},{"$f":"F3+E3-1","v":24},"n/a","7059407","Also called “Health Plan ID” or “Payer Primary ID”, this is the ID of the Qualified Health Plan, Community Mental Health Services Provider or Coordinating Agency, etc.\nUse PRISM Assigned Plan ID, right padded with spaces\nThis is same as Location ID."]
["99999","FILLER","N","String","20",{"$f":"G3+1","v":25},{"$f":"F4+E4-1","v":44},"n/a","BLANK SPACES","Fixed String (Blank Spaces)"]
["99999","SUBMISSION-NUMBER","Y","String","30",45,74,"n/a","6765294","Number identifying a batch - may not be reused by the same capitated health plan.\nThis is the batch number that the capitated health plan submits to be returned on the ETRR.\nRight padded with spaces."]
["99999","REJECTED_RECORD_COUNT","Y","String","10",75,84,"n/a","0000000005","The no.of records available in PRISM in rejected status for this combination of submitter-id, capitated plan and submission number columns.\nThe count will be zero padded. For example, if the no.of records rejected during adjudication is 5, this element would contain 0000000005, if there are no rejected records, the value will be 0000000000.\nA value of zero in this element would effectively mean that the batch from this submitter and capitated plan is processed completely.\n"]
["99999","FILLER","Y","String","20",85,104,"n/a","BLANK SPACES","Fixed String (Blank Spaces)"]
["99999","FILLER","Y","String","3",105,107,"n/a","BLANK SPACES","Fixed String (Blank Spaces)"]
["99999","FILLER","Y","String","1",108,108,"n/a","BLANK SPACES","Fixed String (Blank Spaces)"]
["99999","FILLER","Y","String","1",109,109,"n/a","BLANK SPACES","Fixed String (Blank Spaces)"]
["99999","ERROR-NUMBER","Y","String","5",110,114,"n/a","99999","Fixed String “99999”"]
["99999","ERROR-SEVERITY","Y","String","2",115,116,"n/a","IO","Fixed String “IO”"]
["99999","FILLER","Y","String","20",117,136,"n/a","BLANK SPACES","Fixed String (Blank Spaces)"]
["99999","FILLER","Y","String","18",137,154,"n/a","BLANK SPACES","Fixed String (Blank Spaces)"]
["00","SUBMITTER-ID","Y","String","4","1","4","n/a","00AH","Identifier of the organization that physically transmits the data.\nFirst four characters of the submitter id. "]
["00","CAPITATED-PLAN-ID","Y","String","20",{"$f":"G15+1","v":5},{"$f":"F16+E16-1","v":24},"n/a","7059407","Also called “Health Plan ID” or “Payer Primary ID”, this is the ID of the Qualified Health Plan, Community Mental Health Services Provider or Coordinating Agency, etc.\nUse PRISM Assigned Plan ID, right padded with spaces.\nThis is same as Location ID."]
["00","RELATED-PLAN-ID","N","String","20",{"$f":"G16+1","v":25},{"$f":"F17+E17-1","v":44},"n/a","7059407","This will be the same as CAPITATED-PLAN-ID\nUse PRISM Assigned Plan ID, right padded with spaces.\nThis is same as Location ID."]
["00","SUBMISSION-NUMBER","Y","String","30",{"$f":"G17+1","v":45},{"$f":"F18+E18-1","v":74},"n/a","6765294","Number identifying a batch - may not be reused by the same capitated health plan.\nThis is the batch number that the capitated health plan submits to be returned on the ETRR.\nRight padded with spaces."]
["00","ENCOUNTER-REFERENCE-NUMBER","N","String","30",75,104,"n/a","02837E14120553","The Encounter Reference Number assigned by the capitated health plan. This is a number assigned by the capitated health plan to be returned on the ETRR.\nRight padded with spaces."]
["00","ENCOUNTER-LINE-NUMBER","N","String","3",105,107,"n/a","000","See \"Appendix UT-I - CE Live Edits\" for the list of Encounter specific edits.\nThe Encounter Line Number assigned by the capitated health plan. This is a number assigned by the capitated health plan to be returned on the ETRR.\nThis section will be ZERO FILL for the Accepted Encounter which does not have ETRR flagged=’Y’ edits on both its header and line. "]
["00","RECORD-TYPE","N","String","1",{"$f":"G20+1","v":108},{"$f":"F21+E21-1","v":108},"n/a","1","Send the Claim Frequency Type Code from the inbound encounter.\n1 - Original Claim\n7 - Adjustment Claim\n8 - Void"]
["00","RECORD-CATEGORY","N","String","1",{"$f":"G21+1","v":109},{"$f":"F22+E22-1","v":109},"n/a","P","Invoice Type value from the inbound encounter.\nValues are:\n“P” = Professional\n“I” = Institutional\n“D” = Dental"]
["00","ERROR-NUMBER","Y","String","5",110,114,"n/a","1429","See \"Appendix UT-I - CE Live Edits\" for the list of Encounter specific edits.\nThis section will be ZERO FILL for the Accepted Encounter which does not have ETRR flagged=’Y’ edits on both its header and line.\nRight padded with spaces"]
["00","ERROR-SEVERITY","Y","String","2",115,116,"n/a","RL","See \"Appendix UT-I - CE Live Edits\" for the list of Encounter specific edits.\nValues are:\n“RB” = Reject Batch\n“RE” = Reject Encounter\n“RL” = Reject Line\n“IO” = Information Only\nThis section will be ZERO FILL for the Accepted Encounter which does not have ETRR flagged=’Y’ edits on both its header and line."]
["00","ERROR-FIELD","N","String","20",117,136,"n/a","|~| |~| LEQAWEE DEPA","First 20 positions of erroneous field"]
["00","TCN","Y","String","18",137,154,"n/a","331604110187820000","PRISM TCN"]

{"sheet":"276 Mapping","index":12,"n_rows":250,"n_cols":13,"rows_kept":250,"hidden":true}
[null,"Loop Id","Segment Id","Element Pos","Data Element #","Loop/Segment/Element Name","Condition Designator","Usage","Repeat","Data Type","Minimum","Maximum","Implementation Guide Code list"]
[null,null,"ISA",null,"CNSI","Interchange Control Header","M","R",1]
[null,null,"ISA","ISA01","I01","Authorization Information Qualifier","M","R",1,"ID",2,2,"00,03"]
[null,null,"ISA","ISA02","I02","Authorization Information","M","R",1,"AN",10,10]
[null,null,"ISA","ISA03","I03","Security Information Qualifier","M","R",1,"ID",2,2,"00,01,"]
[null,null,"ISA","ISA04","I04","Security Information","M","R",1,"AN",10,10]
[null,null,"ISA","ISA05","I05","Interchange ID Qualifier","M","R",1,"ID",2,2,"01,14,20,27,28,29,30,33,ZZ"]
[null,null,"ISA","ISA06","I06","Interchange Sender ID","M","R",1,"AN",15,15]
[null,null,"ISA","ISA07","I05","Interchange ID Qualifier","M","R",1,"ID",2,2,"01,14,20,27,28,29,30,33,ZZ"]
[null,null,"ISA","ISA08","I07","Interchange Receiver ID","M","R",1,"AN",15,15]
[null,null,"ISA","ISA09","I08","Interchange Date","M","R",1,"DT",6,6]
[null,null,"ISA","ISA10","I09","Interchange Time","M","R",1,"TM",4,4]
[null,null,"ISA","ISA11","I65","Repetition Separator","M","R",1,null,1,1]
[null,null,"ISA","ISA12","I11","Interchange Control Version Number","M","R",1,"ID",5,5,501]
[null,null,"ISA","ISA13","I12","Interchange Control Number","M","R",1,"N0",9,9]
[null,null,"ISA","ISA14","I13","Acknowledgment Requested","M","R",1,"ID",1,1,"0,1,"]
[null,null,"ISA","ISA15","I14","Interchange Usage Indicator","M","R",1,"ID",1,1,"P,T"]
[null,null,"ISA","ISA16","I15","Component Element Separator","M","R",1,null,1,1]
[null,null,"GS",null,null,"Functional Group Header","M","R",1]
[null,null,"GS","GS01",479,"Functional Identifier Code","M","R",1,"ID",2,2,"HR"]
[null,null,"GS","GS02",142,"Application Sender's Code","M","R",1,"AN",2,15]
[null,null,"GS","GS03",124,"Application Receiver's Code","M","R",1,"AN",2,15]
[null,null,"GS","GS04",373,"Date","M","R",1,"DT",8,8]
[null,null,"GS","GS05",337,"Time","M","R",1,"TM",4,8]
[null,null,"GS","GS06",28,"Group Control Number","M","R",1,"N0",1,9]
[null,null,"GS","GS07",455,"Responsible Agency Code","M","R",1,"ID",1,2,"X"]
[null,null,"GS","GS08",480,"Version / Release / Industry Identifier Code","M","R",1,"AN",1,12,"005010X212"]
[null,null,"ST",null,null,"Transaction Set Header","M","R",1]
[null,null,"ST","ST01",143,"Transaction Set Identifier Code","M","R",1,"ID",3,3,276]
[null,null,"ST","ST02",329,"Transaction Set Control Number","M","R",1,"AN",4,9]
["A",null,null,3,1705,"Implementation Convention Reference","O","R",1,"AN",1,35]
[null,null,"BHT",null,null,"Beginning of Hierarchical Transaction"]
[null,null,"BHT","BHT01",1005,"Hierarchical Structure Code","M","R",1,"ID",4,4,10]
[null,null,"BHT","BHT02",353,"Transaction Set Purpose Code","M","R",1,"ID",2,2,13]
["A",null,"BHT",null,127,"Reference Identification","O","R",1,"AN",1,50]
[null,null,"BHT","BHT04",373,"Date","O","R",1,"DT",8,8]
["A",null,"BHT","BHT05",337,"Time","O","R",1,"TM",4,8]
[null,"2000A",{"$nulls":3},"Information Source Level","M","R",">1"]
[null,"2000A","HL",null,null,"Information Source Level","M","R",1]
[null,"2000A","HL","HL01",628,"Hierarchical ID Number","M","R",1,"AN",1,12]
[null,"2000A","HL","HL03",735,"Hierarchical Level Code","M","R",1,"ID",1,2,20]
[null,"2000A","HL","HL04",736,"Hierarchical Child Code","O","R",1,"ID",1,1,1]
[null,"2100A",{"$nulls":3},"Payer Name","O","R",1]
[null,"2100A","NM1",null,null,"Payer Name","O","R",1]
[null,"2100A","NM1","NM101",98,"Entity Identifier Code","M","R",1,"ID",2,3,"PR"]
[null,"2100A","NM1","NM102",1065,"Entity Type Qualifier","M","R",1,"ID",1,1,2]
[null,"2100A","NM1","NM103",1035,"Name Last or Organization Name","X","R",1,"AN",1,60]
[null,"2100A","NM1","NM108",66,"Identification Code Qualifier","X","R",1,"ID",1,2,"PI,XV"]
[null,"2100A","NM1","NM109",67,"Identification Code","X","R",1,"AN",2,80]
["D"]
["D"]
["D"]
["D"]
["D"]
["D"]
["D"]
["D"]
["D"]
[null,"2000B",{"$nulls":3},"Information Receiver Level","M","R",">1"]
[null,"2000B","HL",null,null,"Information Receiver Level","M","R",1]
[null,"2000B","HL","HL01",628,"Hierarchical ID Number","M","R",1,"AN",1,12]
[null,"2000B","HL","HL02",734,"Hierarchical Parent ID Number","O","R",1,"AN",1,12]
[null,"2000B","HL","HL03",735,"Hierarchical Level Code","M","R",1,"ID",1,2,21]
[null,"2000B","HL","HL04",736,"Hierarchical Child Code","O","R",1,"ID",1,1,1]
[null,"2100B",{"$nulls":3},"Information Receiver Name","O","R",1]
[null,"2100B","NM1",null,null,"Information Receiver Name","O","R",1]
[null,"2100B","NM1","NM101",98,"Entity Identifier Code","M","R",1,"ID",2,3,41]
[null,"2100B","NM1","NM102",1065,"Entity Type Qualifier","M","R",1,"ID",1,1,"1,2"]
[null,"2100B","NM1","NM103",1035,"Name Last or Organization Name","X","S",1,"AN",1,60]
[null,"2100B","NM1","NM104",1036,"Name First","O","S",1,"AN",1,35]
[null,"2100B","NM1","NM105",1037,"Name Middle","O","S",1,"AN",1,25]
["D"]
[null,"2100B","NM1","NM108",66,"Identification Code Qualifier","X","R",1,"ID",1,2,46]
[null,"2100B","NM1","NM109",67,"Identification Code","X","R",1,"AN",2,80]
[null,"2000C",{"$nulls":3},"Service Provider Level","M","R",">1"]
[null,"2000C","HL",null,null,"Service Provider Level","M","R",1]
[null,"2000C","HL","HL01",628,"Hierarchical ID Number","M","R",1,"AN",1,12]
[null,"2000C","HL","HL02",734,"Hierarchical Parent ID Number","O","R",1,"AN",1,12]
[null,"2000C","HL","HL03",735,"Hierarchical Level Code","M","R",1,"ID",1,2,19]
[null,"2000C","HL","HL04",736,"Hierarchical Child Code","O","R",1,"ID",1,1,1]
[null,"2100C",{"$nulls":3},"Provider Name","O","R",2]
[null,"2100C","NM1",null,null,"Provider Name","O","R",1]
[null,"2100C","NM1","NM101",98,"Entity Identifier Code","M","R",1,"ID",2,3,"1P"]
[null,"2100C","NM1","NM102",1065,"Entity Type Qualifier","M","R",1,"ID",1,1,"1,2"]
[null,"2100C","NM1","NM103",1035,"Name Last or Organization Name","X","S",1,"AN",1,60]
[null,"2100C","NM1","NM104",1036,"Name First","O","S",1,"AN",1,35]
[null,"2100C","NM1","NM105",1037,"Name Middle","O","S",1,"AN",1,25]
["D"]
[null,"2100C","NM1","NM107",1039,"Name Suffix","O","S",1,"AN",1,10]
[null,"2100C","NM1","NM108",66,"Identification Code Qualifier","X","R",1,"ID",1,2,"FI,SV,XX"]
[null,"2100C","NM1","NM109",67,"Identification Code","X","R",1,"AN",2,80]
[null,"2000D",{"$nulls":3},"Subscriber Level","M","R",">1"]
[null,"2000D","HL",null,null,"Subscriber Level","M","R",1]
[null,"2000D","HL","HL01",628,"Hierarchical ID Number","M","R",1,"AN",1,12]
[null,"2000D","HL","HL02",734,"Hierarchical Parent ID Number","O","R",1,"AN",1,12]
[null,"2000D","HL","HL03",735,"Hierarchical Level Code","M","R",1,"ID",1,2,22]
[null,"2000D","HL","HL04",736,"Hierarchical Child Code","O","R",1,"ID",1,1,"0,1"]
[null,"2000D","DMG",null,null,"Subscriber Demographic Information","O","S",1]
[null,"2000D","DMG","DMG01",1250,"Date Time Period Format Qualifier","X","R",1,"ID",2,3,"D8"]
[null,"2000D","DMG","DMG02",1251,"Date Time Period","X","R",1,"AN",1,35]
[null,"2000D","DMG","DMG03",1068,"Gender Code","O","S",1,"ID",1,1,"F,M"]
[null,"2100D",{"$nulls":3},"Subscriber Name","O","R",1]
[null,"2100D","NM1",null,null,"Subscriber Name","O","R",1]
[null,"2100D","NM1","NM101",98,"Entity Identifier Code","M","R",1,"ID",2,3,"IL"]
[null,"2100D","NM1","NM102",1065,"Entity Type Qualifier","M","R",1,"ID",1,1,"1,2"]
[null,"2100D","NM1","NM103",1035,"Name Last or Organization Name","X","R",1,"AN",1,60]
[null,"2100D","NM1","NM104",1036,"Name First","O","S",1,"AN",1,35]
[null,"2100D","NM1","NM105",1037,"Name Middle","O","S",1,"AN",1,25]
["D"]
[null,"2100D","NM1","NM107",1039,"Name Suffix","O","S",1,"AN",1,10]
[null,"2100D","NM1","NM108",66,"Identification Code Qualifier","X","R",1,"ID",1,2,"24,II,MI"]
[null,"2100D","NM1","NM109",67,"Identification Code","X","R",1,"AN",2,80]
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[null,"2100C","NM1","NM105",1037,"Name Middle","O","S",1,"AN",1,25]
[null,"2100C","NM1","NM106",1039,"Name Suffix","O","S",1,"AN",1,10]
["D",{"$nulls":12},"Element Deleted/not used"]
[null,"2100C","NM1","NM108",66,"Identification Code Qualifier","X","R",1,"ID",1,2,"FI,SV,XX"]
[null,"2100C","NM1","NM109",67,"Identification Code","X","R",1,"AN",2,80]
["A","2200C",{"$nulls":3},"Provider of Service Trace Identifier","O","S",1,{"$nulls":4},"Loop Added"]
["A","2200C","TRN",null,null,"Provider of Service Trace Identifier","O","S",1,{"$nulls":4},"Segment Added"]
["A","2200C","TRN","TRN01",481,"Trace Type Code","M","R",1,"ID",1,2,1]
["A","2200C","TRN","TRN02",127,"Reference Identification","M","R",1,"AN",1,50]
["A","2200C","STC",null,null,"Provider Status Information","O","R",">1",{"$nulls":4},"Segment Added"]
["A","2200C","STC","STC01","C043","Health Care Claim Status","M","R",1]
["A","2200C","STC","STC01-1",1271,"Industry Code","M","R",1,"AN",1,30]
["A","2200C","STC","STC01-2",1271,"Industry Code","M","R",1,"AN",1,30]
["A","2200C","STC","STC01-3",98,"Entity Identifier Code","O","S",1,"ID",2,3,"1P"]
["A","2200C","STC","STC02",373,"Date","O","R",1,"DT",8,8]
["A","2200C","STC","STC10","C043","Health Care Claim Status","O","S",1]
["A","2200C","STC","STC10-1",1271,"Industry Code","M","R",1,"AN",1,30]
["A","2200C","STC","STC10-2",1271,"Industry Code","M","R",1,"AN",1,30]
["A","2200C","STC","STC10-3",98,"Entity Identifier Code","O","S",1,"ID",2,3,"1P"]
["A","2200C","STC","STC11","C043","Health Care Claim Status","O","S",1]
["A","2200C","STC","STC11-1",1271,"Industry Code","M","R",1,"AN",1,30]
["A","2200C","STC","STC11-2",1271,"Industry Code","M","R",1,"AN",1,30]
["A","2200C","STC","STC11-3",98,"Entity Identifier Code","O","S",1,"ID",2,3,"1P"]
[null,"2000D",{"$nulls":3},"Subscriber Level","O","S",">1"]
[null,"2000D","HL",null,null,"Subscriber Level","O","S",1]
[null,"2000D","HL","HL01",628,"Hierarchical ID Number","M","R",1,"AN",1,12]
[null,"2000D","HL","HL02",734,"Hierarchical Parent ID Number","O","R",1,"AN",1,12]
[null,"2000D","HL","HL03",735,"Hierarchical Level Code","M","R",1,"ID",1,2,22]
[null,"2000D","HL","HL04",736,"Hierarchical Child Code","O","R",1,"ID",1,1,"0,1"]
["D",{"$nulls":12},"Segment Deleted"]
["D"]
["D"]
["D"]
[null,"2100D",{"$nulls":3},"Subscriber Name","O","R",1]
[null,"2100D","NM1",null,null,"Subscriber Name","O","R",1]
[null,"2100D","NM1","NM101",98,"Entity Identifier Code","M","R",1,"ID",2,3,"IL","Code Change"]
[null,"2100D","NM1","NM102",1065,"Entity Type Qualifier","M","R",1,"ID",1,1,"1,2"]
[null,"2100D","NM1","NM103",1035,"Name Last or Organization Name","X","R",1,"AN",1,60,null,"Length Change"]
[null,"2100D","NM1","NM104",1036,"Name First","O","S",1,"AN",1,35,null,"Length Change"]
[null,"2100D","NM1","NM105",1037,"Name Middle","O","S",1,"AN",1,25]
["D",{"$nulls":12},"Element Deleted/not used"]
[null,"2100D","NM1","NM107",1039,"Name Suffix","O","S",1,"AN",1,10]
[null,"2100D","NM1","NM108",66,"Identification Code Qualifier","X","R",1,"ID",1,2,"24,II,MI","Code Change"]
[null,"2100D","NM1","NM109",67,"Identification Code","X","R",1,"AN",2,80]
[null,"2200D",{"$nulls":3},"Claim Status Tracking Number","O","S",">1",{"$nulls":4},"Name Change"]
[null,"2200D","TRN",null,null,"Claim Status Tracking Number","O","S",1,{"$nulls":4},"Name Change"]
[null,"2200D","TRN","TRN01",481,"Trace Type Code","M","R",1,"ID",1,2,2]
[null,"2200D","TRN","TRN02",127,"Reference Identification","M","R",1,"AN",1,50,null,"Length Change"]
[null,"2200D","STC",null,null,"Claim Level Status Information","O","R",">1"]
[null,"2200D","STC","STC01","C043","Health Care Claim Status","M","R",1]
[null,"2200D","STC","STC01 - 1",1271,"Industry Code","M","R",1,"AN",1,30]
[null,"2200D","STC","STC01 - 2",1271,"Industry Code","M","R",1,"AN",1,30]
[null,"2200D","STC","STC01 - 3",98,"Entity Identifier Code","O","S",1,"ID",2,3,"03,13,17,1E,1G,1H,1I,1O,1P,1Q,1R,1S,1T,1U,1V,1W,1X,1Y,1Z,28,2A,2B,2D,2E,2I,2K,2P,2Q,2S,2Z,30,36,3A,3C,3D,3E,3F,3G,3H,3I,3J,3K,3L,3M,3N,3O,3P,3Q,3R,3S,3T,3U,3V,3W,3X,3Y,3Z,40,43,44,4A,4B,4C,4D,4E,4F,4G,4H,4I,4J,4L,4M,4N,4O,4P,4Q,4R,4S,4U,4V,4W,4X,4Y,4Z,5A,5B,5C,5D,5E,5F,5G,5H,5I,5J,5K,5L,5M,5N,5O,5P,5Q,5R,5S,5T,5U,5V,5W,5X,5Y,5Z,61,6A,6B,6C,6D,6E,6F,6G,6H,6I,6J,6K,6L,6M,6N,6O,6P,6Q,6R,6S,6U,6V,6W,6X,6Y,71,72,73,74,77,7C,80,82,84,85,87,95,CK,CZ,D2,DD,DJ,DK,DN,DO,DQ,E1,E2,E7,E9,FA,FD,FE,G0,G3,GB,GD,GI,GJ,GK,GM,GY,HF,HH,I3,IJ,IL,IN,LI,LR,MR,OB,OD,OX,P0,P2,P3,P4,P6,P7,PT,PV,PW,QA,QB,QC,QD,QE,QH,QK,QL,QN,QO,QS,QV,QY,RC,RW,S4,SJ,SU,T4,TL,TQ,TT,TU,UH,X3,X4,X5,ZZ,MSC,PRP,SEP,TTP","Code Change"]
["A","2200D","STC","STC11-4",1270,"Code List Qualifier Code","O","S",1,"ID",1,3,"RX","Element added"]
[null,"2200D","STC","STC02",373,"Date","O","R",1,"DT",8,8]
[null,"2200D","STC","STC04",782,"Monetary Amount","O","S",1,"R",1,18]
[null,"2200D","STC","STC05",782,"Monetary Amount","O","S",1,"R",1,18]
[null,"2200D","STC","STC06",373,"Date","O","S",1,"DT",8,8]
["D",{"$nulls":12},"Element Deleted"]
[null,"2200D","STC","STC08",373,"Date","O","S",1,"DT",8,8]
[null,"2200D","STC","STC09",429,"Check Number","O","S",1,"AN",1,16]
[null,"2200D","STC","STC10","C043","Health Care Claim Status","O","S",1]
[null,"2200D","STC","STC10 - 1",1271,"Industry Code","M","R",1,"AN",1,30]
[null,"2200D","STC","STC10 - 2",1271,"Industry Code","M","R",1,"AN",1,30]
[null,"2200D","STC","STC10 - 3",98,"Entity Identifier Code","O","S",1,"ID",2,3,"03,13,17,1E,1G,1H,1I,1O,1P,1Q,1R,1S,1T,1U,1V,1W,1X,1Y,1Z,28,2A,2B,2D,2E,2I,2K,2P,2Q,2S,2Z,30,36,3A,3C,3D,3E,3F,3G,3H,3I,3J,3K,3L,3M,3N,3O,3P,3Q,3R,3S,3T,3U,3V,3W,3X,3Y,3Z,40,43,44,4A,4B,4C,4D,4E,4F,4G,4H,4I,4J,4L,4M,4N,4O,4P,4Q,4R,4S,4U,4V,4W,4X,4Y,4Z,5A,5B,5C,5D,5E,5F,5G,5H,5I,5J,5K,5L,5M,5N,5O,5P,5Q,5R,5S,5T,5U,5V,5W,5X,5Y,5Z,61,6A,6B,6C,6D,6E,6F,6G,6H,6I,6J,6K,6L,6M,6N,6O,6P,6Q,6R,6S,6U,6V,6W,6X,6Y,71,72,73,74,77,7C,80,82,84,85,87,95,CK,CZ,D2,DD,DJ,DK,DN,DO,DQ,E1,E2,E7,E9,FA,FD,FE,G0,G3,GB,GD,GI,GJ,GK,GM,GY,HF,HH,I3,IJ,IL,IN,LI,LR,MR,OB,OD,OX,P0,P2,P3,P4,P6,P7,PT,PV,PW,QA,QB,QC,QD,QE,QH,QK,QL,QN,QO,QS,QV,QY,RC,RW,S4,SJ,SU,T4,TL,TQ,TT,TU,UH,X3,X4,X5,ZZ,MSC,PRP,SEP,TTP","Code Change"]
["A","2200D","STC","STC10-4",1270,"Code List Qualifier Code","O","S",1,"ID",1,3,"RX","Element Added"]
[null,"2200D","STC","STC11","C043","Health Care Claim Status","O","S",1]
[null,"2200D","STC","STC11 - 1",1271,"Industry Code","M","R",1,"AN",1,30]
[null,"2200D","STC","STC11 - 2",1271,"Industry Code","M","R",1,"AN",1,30]
[null,"2200D","STC","STC11 - 3",98,"Entity Identifier Code","O","S",1,"ID",2,3,"03,13,17,1E,1G,1H,1I,1O,1P,1Q,1R,1S,1T,1U,1V,1W,1X,1Y,1Z,28,2A,2B,2D,2E,2I,2K,2P,2Q,2S,2Z,30,36,3A,3C,3D,3E,3F,3G,3H,3I,3J,3K,3L,3M,3N,3O,3P,3Q,3R,3S,3T,3U,3V,3W,3X,3Y,3Z,40,43,44,4A,4B,4C,4D,4E,4F,4G,4H,4I,4J,4L,4M,4N,4O,4P,4Q,4R,4S,4U,4V,4W,4X,4Y,4Z,5A,5B,5C,5D,5E,5F,5G,5H,5I,5J,5K,5L,5M,5N,5O,5P,5Q,5R,5S,5T,5U,5V,5W,5X,5Y,5Z,61,6A,6B,6C,6D,6E,6F,6G,6H,6I,6J,6K,6L,6M,6N,6O,6P,6Q,6R,6S,6U,6V,6W,6X,6Y,71,72,73,74,77,7C,80,82,84,85,87,95,CK,CZ,D2,DD,DJ,DK,DN,DO,DQ,E1,E2,E7,E9,FA,FD,FE,G0,G3,GB,GD,GI,GJ,GK,GM,GY,HF,HH,I3,IJ,IL,IN,LI,LR,MR,OB,OD,OX,P0,P2,P3,P4,P6,P7,PT,PV,PW,QA,QB,QC,QD,QE,QH,QK,QL,QN,QO,QS,QV,QY,RC,RW,S4,SJ,SU,T4,TL,TQ,TT,TU,UH,X3,X4,X5,ZZ,MSC,PRP,SEP,TTP","Code Change"]
["A","2200D","STC","STC11-4",1270,"Code List Qualifier Code","O","S",1,"ID",1,3,"RX","Element Added"]
[null,"2200D","REF",null,null,"Payer Claim Control Number","O","S",1,{"$nulls":4},"Loop and Segment name change"]
[null,"2200D","REF",null,128,"Reference Identification Qualifier","M","R",1,"ID",2,3,"1K"]
[null,"2200D","REF",null,127,"Reference Identification","X","R",1,"AN",1,50,null,"Length Change"]
[null,"2200D","REF",null,null,"Institutional Bill Type Identification","O","S",1]
[null,"2200D","REF",null,128,"Reference Identification Qualifier","M","R",1,"ID",2,3,"BLT"]
[null,"2200D","REF",null,127,"Reference Identification","X","R",1,"AN",1,50,null,"Length Change"]
["A","2200D","REF",null,null,"Patient Control Number","O","S",1,{"$nulls":4},"Segment Added"]
["A","2200D","REF","REF01",128,"Reference Identification Qualifier","M","R",1,"ID",2,3,"EJ"]
["A","2200D","REF","REF02",127,"Reference Identification","X","R",1,"AN",1,50]
["A","2200D","REF",null,null,"Pharmacy Prescription Number","O","S",1,{"$nulls":4},"Segment Added"]
["A","2200D","REF","REF01",128,"Reference Identification Qualifier","M","R",1,"ID",2,3,"XZ"]
["A","2200D","REF","REF02",127,"Reference Identification","X","R",1,"AN",1,50]
["A","2200D","REF",null,null,"Voucher Identifier","O","S",1,{"$nulls":4},"Segment Added"]
["A","2200D","REF","REF01",128,"Reference Identification Qualifier","M","R",1,"ID",2,3,"VV"]
["A","2200D","REF","REF02",127,"Reference Identification","X","R",1,"AN",1,50]
["A","2200D","REF",null,null,"Claim Identification Number For Clearinghouses and Other Transmission Intermediaries","O","S",1,{"$nulls":4},"Segment Added"]
["A","2200D","REF","REF01",128,"Reference Identification Qualifier","M","R",1,"ID",2,3,"D9"," "]
["A","2200D","REF","REF02",127,"Reference Identification","X","R",1,"AN",1,50]
["D",{"$nulls":12},"Segment Deleted"]
["D"]
["D"]
[" ","2200D","DTP",null,null,"Claim Service Date","O","S",1]
[null,"2200D","DTP","DTP01",374,"Date/Time Qualifier","M","R",1,"ID",3,3,472,"Code Change"]
[null,"2200D","DTP","DTP02",1250,"Date Time Period Format Qualifier","M","R",1,"ID",2,3,"D8,RD8","Code Change"]
[null,"2200D","DTP","DTP03",1251,"Date Time Period","M","R",1,"AN",1,35,"CCYYMMDD, CCYYMMDD-CCYYMMDD","New format allowed"]
[null,"2220D",{"$nulls":3},"Service Line Information","O","S",">1"]
[null,"2220D","SVC",null,null,"Service Line Information","O","S",1]
[null,"2220D","SVC","SVC01","C003","Composite Medical Procedure Identifier","M","R",1]
[null,"2220D","SVC","SVC01 - 1",235,"Product/Service ID Qualifier","M","R",1,"ID",2,2,"AD,ER,HC,HP,IV,N4,NU,WK","Code Change"]
[null,"2220D","SVC","SVC01 - 2",234,"Product/Service ID","M","R",1,"AN",1,48]
[null,"2220D","SVC","SVC01 - 3",1339,"Procedure Modifier","O","S",1,"AN",2,2]
[null,"2220D","SVC","SVC01 - 4",1339,"Procedure Modifier","O","S",1,"AN",2,2]
[null,"2220D","SVC","SVC01 - 5",1339,"Procedure Modifier","O","S",1,"AN",2,2]
[null,"2220D","SVC","SVC01 - 6",1339,"Procedure Modifier","O","S",1,"AN",2,2]
[null,"2220D","SVC","SVC02",782,"Monetary Amount","M","R",1,"R",1,18]
[null,"2220D","SVC","SVC03",782,"Monetary Amount","O","R",1,"R",1,18]
[null,"2220D","SVC","SVC04",234,"Product/Service ID","O","S",1,"AN",1,48]
[null,"2220D","SVC","SVC07",380,"Quantity","O","R",1,"R",1,15,null,"Usage Change"]
[null,"2220D","STC",null,null,"Service Line Status Information","O","R",">1",{"$nulls":4},"Usage change, repeat change"]
[null,"2220D","STC","STC01","C043","Health Care Claim Status","M","R",1]
[null,"2220D","STC","STC01 - 1",1271,"Industry Code","M","R",1,"AN",1,30]
[null,"2220D","STC","STC01 - 2",1271,"Industry Code","M","R",1,"AN",1,30]
[null,"2220D","STC","STC01 - 3",98,"Entity Identifier Code","O","S",1,"ID",2,3,"03,13,17,1E,1G,1H,1I,1O,1P,1Q,1R,1S,1T,1U,1V,1W,1X,1Y,1Z,28,2A,2B,2D,2E,2I,2K,2P,2Q,2S,2Z,30,36,3A,3C,3D,3E,3F,3G,3H,3I,3J,3K,3L,3M,3N,3O,3P,3Q,3R,3S,3T,3U,3V,3W,3X,3Y,3Z,40,43,44,4A,4B,4C,4D,4E,4F,4G,4H,4I,4J,4L,4M,4N,4O,4P,4Q,4R,4S,4U,4V,4W,4X,4Y,4Z,5A,5B,5C,5D,5E,5F,5G,5H,5I,5J,5K,5L,5M,5N,5O,5P,5Q,5R,5S,5T,5U,5V,5W,5X,5Y,5Z,61,6A,6B,6C,6D,6E,6F,6G,6H,6I,6J,6K,6L,6M,6N,6O,6P,6Q,6R,6S,6U,6V,6W,6X,6Y,71,72,73,74,77,7C,80,82,84,85,87,95,CK,CZ,D2,DD,DJ,DK,DN,DO,DQ,E1,E2,E7,E9,FA,FD,FE,G0,G3,GB,GD,GI,GJ,GK,GM,GY,HF,HH,I3,IJ,IL,IN,LI,LR,MR,OB,OD,OX,P0,P2,P3,P4,P6,P7,PT,PV,PW,QA,QB,QC,QD,QE,QH,QK,QL,QN,QO,QS,QV,QY,RC,RW,S4,SJ,SU,T4,TL,TQ,TT,TU,UH,X3,X4,X5,ZZ,MSC,PRP,SEP,TTP","Code Change"]
["A","2220D","STC","STC01-4",1270,"Code List Qualifier Code","O","S",1,"ID",1,3,"RX","Element Added"]
[null,"2220D","STC","STC02",373,"Date","O","R",1,"DT",8,8]
[null,"2220D","STC","STC04",null,"Monetary Amount",{"$nulls":7},"Element Deleted"]
[null,"2220D","STC","STC05",null,"Monetary Amount",{"$nulls":7},"Element Deleted"]
[null,"2220D","STC","STC06",null,"Date"]
[null,"2220D","STC","STC08",null,"Date"]
[null,"2220D","STC","STC09",null,"Check Number"]
[null,"2220D","STC","STC10","C043","Health Care Claim Status","O","S",1]
[null,"2220D","STC","STC10 - 1",1271,"Industry Code","M","R",1,"AN",1,30]
[null,"2220D","STC","STC10 - 2",1271,"Industry Code","M","R",1,"AN",1,30]
[null,"2220D","STC","STC10 - 3",98,"Entity Identifier Code","O","S",1,"ID",2,3,"03,13,17,1E,1G,1H,1I,1O,1P,1Q,1R,1S,1T,1U,1V,1W,1X,1Y,1Z,28,2A,2B,2D,2E,2I,2K,2P,2Q,2S,2Z,30,36,3A,3C,3D,3E,3F,3G,3H,3I,3J,3K,3L,3M,3N,3O,3P,3Q,3R,3S,3T,3U,3V,3W,3X,3Y,3Z,40,43,44,4A,4B,4C,4D,4E,4F,4G,4H,4I,4J,4L,4M,4N,4O,4P,4Q,4R,4S,4U,4V,4W,4X,4Y,4Z,5A,5B,5C,5D,5E,5F,5G,5H,5I,5J,5K,5L,5M,5N,5O,5P,5Q,5R,5S,5T,5U,5V,5W,5X,5Y,5Z,61,6A,6B,6C,6D,6E,6F,6G,6H,6I,6J,6K,6L,6M,6N,6O,6P,6Q,6R,6S,6U,6V,6W,6X,6Y,71,72,73,74,77,7C,80,82,84,85,87,95,CK,CZ,D2,DD,DJ,DK,DN,DO,DQ,E1,E2,E7,E9,FA,FD,FE,G0,G3,GB,GD,GI,GJ,GK,GM,GY,HF,HH,I3,IJ,IL,IN,LI,LR,MR,OB,OD,OX,P0,P2,P3,P4,P6,P7,PT,PV,PW,QA,QB,QC,QD,QE,QH,QK,QL,QN,QO,QS,QV,QY,RC,RW,S4,SJ,SU,T4,TL,TQ,TT,TU,UH,X3,X4,X5,ZZ,MSC,PRP,SEP,TTP","Code Change"]
["A","2220D","STC","STC10-4",1270,"Code List Qualifier Code","O","S",1,"ID",1,3,"RX","Element Added"]
[null,"2220D","STC","STC11","C043","Health Care Claim Status","O","S",1]
[null,"2220D","STC","STC11 - 1",1271,"Industry Code","M","R",1,"AN",1,30]
[null,"2220D","STC","STC11 - 2",1271,"Industry Code","M","R",1,"AN",1,30]
[null,"2220D","STC","STC11 - 3",98,"Entity Identifier Code","O","S",1,"ID",2,3,"03,13,17,1E,1G,1H,1I,1O,1P,1Q,1R,1S,1T,1U,1V,1W,1X,1Y,1Z,28,2A,2B,2D,2E,2I,2K,2P,2Q,2S,2Z,30,36,3A,3C,3D,3E,3F,3G,3H,3I,3J,3K,3L,3M,3N,3O,3P,3Q,3R,3S,3T,3U,3V,3W,3X,3Y,3Z,40,43,44,4A,4B,4C,4D,4E,4F,4G,4H,4I,4J,4L,4M,4N,4O,4P,4Q,4R,4S,4U,4V,4W,4X,4Y,4Z,5A,5B,5C,5D,5E,5F,5G,5H,5I,5J,5K,5L,5M,5N,5O,5P,5Q,5R,5S,5T,5U,5V,5W,5X,5Y,5Z,61,6A,6B,6C,6D,6E,6F,6G,6H,6I,6J,6K,6L,6M,6N,6O,6P,6Q,6R,6S,6U,6V,6W,6X,6Y,71,72,73,74,77,7C,80,82,84,85,87,95,CK,CZ,D2,DD,DJ,DK,DN,DO,DQ,E1,E2,E7,E9,FA,FD,FE,G0,G3,GB,GD,GI,GJ,GK,GM,GY,HF,HH,I3,IJ,IL,IN,LI,LR,MR,OB,OD,OX,P0,P2,P3,P4,P6,P7,PT,PV,PW,QA,QB,QC,QD,QE,QH,QK,QL,QN,QO,QS,QV,QY,RC,RW,S4,SJ,SU,T4,TL,TQ,TT,TU,UH,X3,X4,X5,ZZ,MSC,PRP,SEP,TTP","Code Change"]
["A","2220D","STC","STC11-4",1270,"Code List Qualifier Code","O","S",1,"ID",1,3,"RX","Element Added"]
[null,"2220D","REF",null,null,"REF","O","S",1]
[null,"2220D","REF","REF01",128,"Reference Identification Qualifier","M","R",1,"ID",2,3,"FJ"]
[null,"2220D","REF","REF02",127,"Reference Identification","X","R",1,"AN",1,50,null,"Length Change"]
[null,"2220D","DTP",null,null,"Service Line Date","O","R",1]
[null,"2220D","DTP","DTP01",374,"Date/Time Qualifier","M","R",1,"ID",3,3,472]
[null,"2220D","DTP","DTP02",1250,"Date Time Period Format Qualifier","M","R",1,"ID",2,3,"D8,RD8","Code Change"]
[null,"2220D","DTP","DTP03",1251,"Date Time Period","M","R",1,"AN",1,35,"CCYYMMDD, CCYYMMDD-CCYYMMDD","New format allowed"]
[null,"2000E",{"$nulls":3},"Dependent Level","O","S",">1"]
[null,"2000E","HL",null,null,"Dependent Level","O","S",1]
[null,"2000E","HL","HL01",628,"Hierarchical ID Number","M","R",1,"AN",1,12]
[null,"2000E","HL","HL02",734,"Hierarchical Parent ID Number","O","R",1,"AN",1,12]
[null,"2000E","HL","HL03",735,"Hierarchical Level Code","M","R",1,"ID",1,2,23]
[{"$nulls":13},"Segment deleted"]
[]
[]
[]
[null,"2100E",{"$nulls":3},"Dependent Name","O","R",1]
[null,"2100E","NM1",null,null,"Dependent Name","O","R",1]
[null,"2100E","NM1","NM101",98,"Entity Identifier Code","M","R",1,"ID",2,3,"QC"]
[null,"2100E","NM1","NM102",1065,"Entity Type Qualifier","M","R",1,"ID",1,1,1]
[null,"2100E","NM1","NM103",1035,"Name Last or Organization Name","X","R",1,"AN",1,60,null,"Length Change"]
[null,"2100E","NM1","NM104",1036,"Name First","O","S",1,"AN",1,35,null,"Length Change"]
[null,"2100E","NM1","NM105",1037,"Name Middle","O","S",1,"AN",1,25]
["D",{"$nulls":12},"Element Deleted"]
[null,"2100E","NM1","NM107",1039,"Name Suffix","O","S",1,"AN",1,10]
["D",{"$nulls":12},"Element Deleted"]
["D",{"$nulls":12},"Element Deleted"]
[null,"2200E",{"$nulls":3},"Claim Status Tracking Number","O","R",">1"]
[null,"2200E","TRN",null,null,"Claim Status Tracking Number","O","R",1,{"$nulls":4},"Name Change"]
[null,"2200E","TRN","TRN01",481,"Trace Type Code","M","R",1,"ID",1,2,2]
[null,"2200E","TRN","TRN02",127,"Reference Identification","M","R",1,"AN",1,50,null,"Length Change"]
[null,"2200E","STC",null,null,"Claim Level Status Information","O","R",">1"]
[null,"2200E","STC","STC01","C043","Health Care Claim Status","M","R",1]
[null,"2200E","STC","STC01 - 1",1271,"Industry Code","M","R",1,"AN",1,30]
[null,"2200E","STC","STC01 - 2",1271,"Industry Code","M","R",1,"AN",1,30]
[null,"2200E","STC","STC01 - 3",98,"Entity Identifier Code","O","S",1,"ID",2,3,"03,13,17,1E,1G,1H,1I,1O,1P,1Q,1R,1S,1T,1U,1V,1W,1X,1Y,1Z,28,2A,2B,2D,2E,2I,2K,2P,2Q,2S,2Z,30,36,3A,3C,3D,3E,3F,3G,3H,3I,3J,3K,3L,3M,3N,3O,3P,3Q,3R,3S,3T,3U,3V,3W,3X,3Y,3Z,40,43,44,4A,4B,4C,4D,4E,4F,4G,4H,4I,4J,4L,4M,4N,4O,4P,4Q,4R,4S,4U,4V,4W,4X,4Y,4Z,5A,5B,5C,5D,5E,5F,5G,5H,5I,5J,5K,5L,5M,5N,5O,5P,5Q,5R,5S,5T,5U,5V,5W,5X,5Y,5Z,61,6A,6B,6C,6D,6E,6F,6G,6H,6I,6J,6K,6L,6M,6N,6O,6P,6Q,6R,6S,6U,6V,6W,6X,6Y,71,72,73,74,77,7C,80,82,84,85,87,95,CK,CZ,D2,DD,DJ,DK,DN,DO,DQ,E1,E2,E7,E9,FA,FD,FE,G0,G3,GB,GD,GI,GJ,GK,GM,GY,HF,HH,I3,IJ,IL,IN,LI,LR,MR,OB,OD,OX,P0,P2,P3,P4,P6,P7,PT,PV,PW,QA,QB,QC,QD,QE,QH,QK,QL,QN,QO,QS,QV,QY,RC,RW,S4,SJ,SU,T4,TL,TQ,TT,TU,UH,X3,X4,X5,ZZ,MSC,PRP,SEP,TTP","Code Change"]
["A","2200E","STC","STC01-4",1270,"Code List Qualifier Code","O","S",1,"ID",1,3,"RX","Element Added"]
[null,"2200E","STC","STC02",373,"Date","O","R",1,"DT",8,8]
[null,"2200E","STC","STC04",782,"Monetary Amount","O","S",1,"R",1,18]
[null,"2200E","STC","STC05",782,"Monetary Amount","O","S",1,"R",1,18]
[null,"2200E","STC","STC06",373,"Date","O","S",1,"DT",8,8]
["D",{"$nulls":12},"Element Deleted"]
[null,"2200E","STC","STC08",373,"Date","O","S",1,"DT",8,8]
[null,"2200E","STC","STC09",429,"Check Number","O","S",1,"AN",1,16]
[null,"2200E","STC","STC10","C043","Health Care Claim Status","O","S",1]
[null,"2200E","STC","STC10 - 1",1271,"Industry Code","M","R",1,"AN",1,30]
[null,"2200E","STC","STC10 - 2",1271,"Industry Code","M","R",1,"AN",1,30]
[null,"2200E","STC","STC10 - 3",98,"Entity Identifier Code","O","S",1,"ID",2,3,"03,13,17,1E,1G,1H,1I,1O,1P,1Q,1R,1S,1T,1U,1V,1W,1X,1Y,1Z,28,2A,2B,2D,2E,2I,2K,2P,2Q,2S,2Z,30,36,3A,3C,3D,3E,3F,3G,3H,3I,3J,3K,3L,3M,3N,3O,3P,3Q,3R,3S,3T,3U,3V,3W,3X,3Y,3Z,40,43,44,4A,4B,4C,4D,4E,4F,4G,4H,4I,4J,4L,4M,4N,4O,4P,4Q,4R,4S,4U,4V,4W,4X,4Y,4Z,5A,5B,5C,5D,5E,5F,5G,5H,5I,5J,5K,5L,5M,5N,5O,5P,5Q,5R,5S,5T,5U,5V,5W,5X,5Y,5Z,61,6A,6B,6C,6D,6E,6F,6G,6H,6I,6J,6K,6L,6M,6N,6O,6P,6Q,6R,6S,6U,6V,6W,6X,6Y,71,72,73,74,77,7C,80,82,84,85,87,95,CK,CZ,D2,DD,DJ,DK,DN,DO,DQ,E1,E2,E7,E9,FA,FD,FE,G0,G3,GB,GD,GI,GJ,GK,GM,GY,HF,HH,I3,IJ,IL,IN,LI,LR,MR,OB,OD,OX,P0,P2,P3,P4,P6,P7,PT,PV,PW,QA,QB,QC,QD,QE,QH,QK,QL,QN,QO,QS,QV,QY,RC,RW,S4,SJ,SU,T4,TL,TQ,TT,TU,UH,X3,X4,X5,ZZ,MSC,PRP,SEP,TTP","Code Change"]
["A","2200E","STC","STC10-4",1270,"Code List Qualifier Code","O","S",1,"ID",1,3,"RX","Element Added"]
[null,"2200E","STC","STC11","C043","Health Care Claim Status","O","S",1]
[null,"2200E","STC","STC11 - 1",1271,"Industry Code","M","R",1,"AN",1,30]
[null,"2200E","STC","STC11 - 2",1271,"Industry Code","M","R",1,"AN",1,30]
[null,"2200E","STC","STC11 - 3",98,"Entity Identifier Code","O","S",1,"ID",2,3,"03,13,17,1E,1G,1H,1I,1O,1P,1Q,1R,1S,1T,1U,1V,1W,1X,1Y,1Z,28,2A,2B,2D,2E,2I,2K,2P,2Q,2S,2Z,30,36,3A,3C,3D,3E,3F,3G,3H,3I,3J,3K,3L,3M,3N,3O,3P,3Q,3R,3S,3T,3U,3V,3W,3X,3Y,3Z,40,43,44,4A,4B,4C,4D,4E,4F,4G,4H,4I,4J,4L,4M,4N,4O,4P,4Q,4R,4S,4U,4V,4W,4X,4Y,4Z,5A,5B,5C,5D,5E,5F,5G,5H,5I,5J,5K,5L,5M,5N,5O,5P,5Q,5R,5S,5T,5U,5V,5W,5X,5Y,5Z,61,6A,6B,6C,6D,6E,6F,6G,6H,6I,6J,6K,6L,6M,6N,6O,6P,6Q,6R,6S,6U,6V,6W,6X,6Y,71,72,73,74,77,7C,80,82,84,85,87,95,CK,CZ,D2,DD,DJ,DK,DN,DO,DQ,E1,E2,E7,E9,FA,FD,FE,G0,G3,GB,GD,GI,GJ,GK,GM,GY,HF,HH,I3,IJ,IL,IN,LI,LR,MR,OB,OD,OX,P0,P2,P3,P4,P6,P7,PT,PV,PW,QA,QB,QC,QD,QE,QH,QK,QL,QN,QO,QS,QV,QY,RC,RW,S4,SJ,SU,T4,TL,TQ,TT,TU,UH,X3,X4,X5,ZZ,MSC,PRP,SEP,TTP","Code Change"]
[null,"2200E","STC","STC11-4",1270,"Code List Qualifier Code","O","S",1,"ID",1,3,"RX","Element Added"]
[null,"2200E","REF",null,null,"Payer Claim Control Number","O","S",1,{"$nulls":4},"Name Change"]
[null,"2200E","REF","REF01",128,"Reference Identification Qualifier","M","R",1,"ID",2,3,"1K"]
[null,"2200E","REF","REF02",127,"Reference Identification","X","R",1,"AN",1,50,null,"Length Change"]
[null,"2200E","REF",null,null,"Institutional Bill Type Identification","O","S",1]
[null,"2200E","REF","REF01",128,"Reference Identification Qualifier","M","R",1,"ID",2,3,"BLT"]
[null,"2200E","REF","REF02",127,"Reference Identification","X","R",1,"AN",1,50,null,"Length Change"]
["D",{"$nulls":12},"Segment deleted"]
["D"]
["D"]
["A","2200E","REF",null,null,"Patient Control Number","O","S",1,{"$nulls":4},"Segment Added"]
["A","2200E","REF","REF01",128,"Reference Identification Qualifier","M","R",1,"ID",2,3,"EJ"]
["A","2200E","REF","REF02",127,"Reference Identification","X","R",1,"AN",1,50]
["A","2200E","REF",null,null,"Pharmacy Prescription Number","O","S",1,{"$nulls":4},"Segment Added"]
["A","2200E","REF","REF01",128,"Reference Identification Qualifier","M","R",1,"ID",2,3,"XZ"]
["A","2200E","REF","REF02",127,"Reference Identification","X","R",1,"AN",1,50]
["A","2200E","REF",null,null,"Voucher Identifier","O","S",1,{"$nulls":4},"Segment Added"]
["A","2200E","REF","REF01",128,"Reference Identification Qualifier","M","R",1,"ID",2,3,"VV"]
["A","2200E","REF","REF02",127,"Reference Identification","X","R",1,"AN",1,50]
["A","2200E","REF",null,null,"Claim Identification Number For Clearinghouses and Other Transmisson Intermediaries","O","S",1,{"$nulls":4},"Segment Added"]
["A","2200E","REF","REF01",128,"Reference Identification Qualifier","M","R",1,"ID",2,3,"D9"]
["A","2200E","REF","REF02",127,"Reference Identification","X","R",1,"AN",1,50]
[null,"2200E","DTP",null,null,"Claim Service Date","O","S",1]
[null,"2200E","DTP","DTP01",374,"Date/Time Qualifier","M","R",1,"ID",3,3,472,"Code Change"]
[null,"2200E","DTP","DTP02",1250,"Date Time Period Format Qualifier","M","R",1,"ID",2,3,"D8,RD8","Code Change"]
[null,"2200E","DTP","DTP03",1251,"Date Time Period","M","R",1,"AN",1,35,"CCYYMMDD, CCYYMMDD-CCYYMMDD","New format allowed"]
[null,"2220E",{"$nulls":3},"Service Line Information","O","S",">1"]
[null,"2220E","SVC",null,null,"Service Line Information","O","S",1]
[null,"2220E","SVC","SVC01","C003","Composite Medical Procedure Identifier","M","R",1]
[null,"2220E","SVC","SVC01 - 1",235,"Product/Service ID Qualifier","M","R",1,"ID",2,2,"AD,ER,HC,HP,IV,N4,NU,WK","Code Change"]
[null,"2220E","SVC","SVC01 - 2",234,"Product/Service ID","M","R",1,"AN",1,48]
[null,"2220E","SVC","SVC01 - 3",1339,"Procedure Modifier","O","S",1,"AN",2,2]
[null,"2220E","SVC","SVC01 - 4",1339,"Procedure Modifier","O","S",1,"AN",2,2]
[null,"2220E","SVC","SVC01 - 5",1339,"Procedure Modifier","O","S",1,"AN",2,2]
[null,"2220E","SVC","SVC01 - 6",1339,"Procedure Modifier","O","S",1,"AN",2,2]
[null,"2220E","SVC","SVC02",782,"Monetary Amount","M","R",1,"R",1,18]
["A","2220E","SVC","SVC03",782,"Monetary Amount","O","R",1,"R",1,18,null,"Element Added"]
[null,"2220E","SVC","SVC04",234,"Product/Service ID","O","S",1,"AN",1,48]
[null,"2220E","SVC","SVC07",380,"Quantity","O","R",1,"R",1,15,null,"Usage Change"]
[null,"2220E","STC",null,null,"Service Line Status Information","O","R",">1",{"$nulls":4},"Repeat and usage change"]
[null,"2220E","STC","STC01","C043","Health Care Claim Status","M","R",1]
[null,"2220E","STC","STC01 - 1",1271,"Industry Code","M","R",1,"AN",1,30]
[null,"2220E","STC","STC01 - 2",1271,"Industry Code","M","R",1,"AN",1,30]
[null,"2220E","STC","STC01 - 3",98,"Entity Identifier Code","O","S",1,"ID",2,3,"03,13,17,1E,1G,1H,1I,1O,1P,1Q,1R,1S,1T,1U,1V,1W,1X,1Y,1Z,28,2A,2B,2D,2E,2I,2K,2P,2Q,2S,2Z,30,36,3A,3C,3D,3E,3F,3G,3H,3I,3J,3K,3L,3M,3N,3O,3P,3Q,3R,3S,3T,3U,3V,3W,3X,3Y,3Z,40,43,44,4A,4B,4C,4D,4E,4F,4G,4H,4I,4J,4L,4M,4N,4O,4P,4Q,4R,4S,4U,4V,4W,4X,4Y,4Z,5A,5B,5C,5D,5E,5F,5G,5H,5I,5J,5K,5L,5M,5N,5O,5P,5Q,5R,5S,5T,5U,5V,5W,5X,5Y,5Z,61,6A,6B,6C,6D,6E,6F,6G,6H,6I,6J,6K,6L,6M,6N,6O,6P,6Q,6R,6S,6U,6V,6W,6X,6Y,71,72,73,74,77,7C,80,82,84,85,87,95,CK,CZ,D2,DD,DJ,DK,DN,DO,DQ,E1,E2,E7,E9,FA,FD,FE,G0,G3,GB,GD,GI,GJ,GK,GM,GY,HF,HH,I3,IJ,IL,IN,LI,LR,MR,OB,OD,OX,P0,P2,P3,P4,P6,P7,PT,PV,PW,QA,QB,QC,QD,QE,QH,QK,QL,QN,QO,QS,QV,QY,RC,RW,S4,SJ,SU,T4,TL,TQ,TT,TU,UH,X3,X4,X5,ZZ,MSC,PRP,SEP,TTP","Code Change"]
["A","2220E","STC","STC01-4",1270,"Code List Qualifier Code","O","S",1,"ID",1,3,"RX","Element Added"]
[null,"2220E","STC","STC02",373,"Date","O","R",1,"DT",8,8]
["D",{"$nulls":12},"Element Deleted"]
["D",{"$nulls":12},"Element Deleted"]
["D",{"$nulls":12},"Element Deleted"]
["D",{"$nulls":12},"Element Deleted"]
["D",{"$nulls":12},"Element Deleted"]
["D",{"$nulls":12},"Element Deleted"]
[null,"2220E","STC","STC10","C043","Health Care Claim Status","O","S",1]
[null,"2220E","STC","STC10 - 1",1271,"Industry Code","M","R",1,"AN",1,30]
[null,"2220E","STC","STC10 - 2",1271,"Industry Code","M","R",1,"AN",1,30]
[null,"2220E","STC","STC10 - 3",98,"Entity Identifier Code","O","S",1,"ID",2,3,"03,13,17,1E,1G,1H,1I,1O,1P,1Q,1R,1S,1T,1U,1V,1W,1X,1Y,1Z,28,2A,2B,2D,2E,2I,2K,2P,2Q,2S,2Z,30,36,3A,3C,3D,3E,3F,3G,3H,3I,3J,3K,3L,3M,3N,3O,3P,3Q,3R,3S,3T,3U,3V,3W,3X,3Y,3Z,40,43,44,4A,4B,4C,4D,4E,4F,4G,4H,4I,4J,4L,4M,4N,4O,4P,4Q,4R,4S,4U,4V,4W,4X,4Y,4Z,5A,5B,5C,5D,5E,5F,5G,5H,5I,5J,5K,5L,5M,5N,5O,5P,5Q,5R,5S,5T,5U,5V,5W,5X,5Y,5Z,61,6A,6B,6C,6D,6E,6F,6G,6H,6I,6J,6K,6L,6M,6N,6O,6P,6Q,6R,6S,6U,6V,6W,6X,6Y,71,72,73,74,77,7C,80,82,84,85,87,95,CK,CZ,D2,DD,DJ,DK,DN,DO,DQ,E1,E2,E7,E9,FA,FD,FE,G0,G3,GB,GD,GI,GJ,GK,GM,GY,HF,HH,I3,IJ,IL,IN,LI,LR,MR,OB,OD,OX,P0,P2,P3,P4,P6,P7,PT,PV,PW,QA,QB,QC,QD,QE,QH,QK,QL,QN,QO,QS,QV,QY,RC,RW,S4,SJ,SU,T4,TL,TQ,TT,TU,UH,X3,X4,X5,ZZ,MSC,PRP,SEP,TTP","Code Change"]
["A","2220E","STC","STC10-4",1270,"Code List Qualifier Code","O","S",1,"ID",1,3,"RX","Element Added"]
[null,"2220E","STC","STC11","C043","Health Care Claim Status","O","S",1]
[null,"2220E","STC","STC11 - 1",1271,"Industry Code","M","R",1,"AN",1,30]
[null,"2220E","STC","STC11 - 2",1271,"Industry Code","M","R",1,"AN",1,30]
[null,"2220E","STC","STC11 - 3",98,"Entity Identifier Code","O","S",1,"ID",2,3,"03,13,17,1E,1G,1H,1I,1O,1P,1Q,1R,1S,1T,1U,1V,1W,1X,1Y,1Z,28,2A,2B,2D,2E,2I,2K,2P,2Q,2S,2Z,30,36,3A,3C,3D,3E,3F,3G,3H,3I,3J,3K,3L,3M,3N,3O,3P,3Q,3R,3S,3T,3U,3V,3W,3X,3Y,3Z,40,43,44,4A,4B,4C,4D,4E,4F,4G,4H,4I,4J,4L,4M,4N,4O,4P,4Q,4R,4S,4U,4V,4W,4X,4Y,4Z,5A,5B,5C,5D,5E,5F,5G,5H,5I,5J,5K,5L,5M,5N,5O,5P,5Q,5R,5S,5T,5U,5V,5W,5X,5Y,5Z,61,6A,6B,6C,6D,6E,6F,6G,6H,6I,6J,6K,6L,6M,6N,6O,6P,6Q,6R,6S,6U,6V,6W,6X,6Y,71,72,73,74,77,7C,80,82,84,85,87,95,CK,CZ,D2,DD,DJ,DK,DN,DO,DQ,E1,E2,E7,E9,FA,FD,FE,G0,G3,GB,GD,GI,GJ,GK,GM,GY,HF,HH,I3,IJ,IL,IN,LI,LR,MR,OB,OD,OX,P0,P2,P3,P4,P6,P7,PT,PV,PW,QA,QB,QC,QD,QE,QH,QK,QL,QN,QO,QS,QV,QY,RC,RW,S4,SJ,SU,T4,TL,TQ,TT,TU,UH,X3,X4,X5,ZZ,MSC,PRP,SEP,TTP","Code Change"]
["A","2220E","STC","STC11-4",1270,"Code List Qualifier Code","O","S",1,"ID",1,3,"RX","Element Added"]
[null,"2220E","REF",null,null,"Service Line Item Identification","O","S",1]
[null,"2220E","REF","REF01",128,"Reference Identification Qualifier","M","R",1,"ID",2,3,"FJ"]
[null,"2220E","REF","REF02",127,"Reference Identification","X","R",1,"AN",1,50,null,"Length Change"]
[null,"2220E","DTP",null,null,"Service Line Date","O","R",1]
[null,"2220E","DTP","DTP01",374,"Date/Time Qualifier","M","R",1,"ID",3,3,472]
[null,"2220E","DTP","DTP02",1250,"Date Time Period Format Qualifier","M","R",1,"ID",2,3,"D8,RD8","Code Change"]
[null,"2220E","DTP","DTP03",1251,"Date Time Period","M","R",1,"AN",1,35,"CCYYMMDD,  CCYYMMDD-CCYYMMDD","New format allowed"]
[null,"2220E","SE",null,null,"Transaction Set Trailer","M","R",1]
[null,"2220E","SE","SE01",96,"Number of Included Segments","M","R",1,"N0",1,10]
[null,"2220E","SE","SE02",329,"Transaction Set Control Number","M","R",1,"AN",4,9]
[null,"2220E","GE",null,null,"Functional Group Trailer","M","R",1]
[null,"2220E","GE","GE01",97,"Number of Transaction Sets Included","M","R",1,"N0",1,6]
[null,"2220E","GE","GE02",28,"Group Control Number","M","R",1,"N0",1,9]
[null,"2220E","IEA",null,null,"Interchange Control Trailer","M","R",1]
[null,"2220E","IEA","IEA01","I16","Number of Included Functional Groups","M","R",1,"N0",1,5]
[null,"2220E","IEA","IEA02","I12","Interchange Control Number","M","R",1,"N0",9,9]

{"sheet":"276 and 277 CG","index":14,"n_rows":0,"n_cols":0,"rows_kept":0,"hidden":true}

{"sheet":"Response File FAQ","index":15,"n_rows":17,"n_cols":2,"rows_kept":17}
["Question","Answer"]
["How long will it take to see my response files?","Please allow six hours for the processing of the 277CA.  The 421/ETRR report will be available at 6am the day after encounters are adjudicated.  "]
["Why did the encounter accept at header if lines were rejected?","PRISM will edit at the service line level as well as the claim header level. If any line on the encounter was accepted, the entire encounter will accept. Plans will need to look closely at each service line to determine if the service was accepted or rejected. Any service reported as Plan Denied will be accepted."]
["How can I view my response files in PRISM?","In the EDI Analyst role go to the My Inbox drop down on the top left of the screen.  Go to Retrieve Acknowledgment/Response under HIPAA.  The easiest way to search for your response files is to select \"Transaction Type\" from the drop down and \"837%\" in the note field.  \"%\" is the wildcard in PRISM and often helps before and after a value you are searching for (such as part of a filename, etc).  "]
["Why can't we find the 277CA in the HIPPA Retrieve Acknowledgement Screen?","Plans can only access files associated to their Provider ID in PRISM. To ensure access to the 277CA, plans must report Provider Location ID in SBR03 and 'MC' in SBR09 of Loop 2320 and then their PRISM Location ID in NM109 of Loop 2330B. All instances of SBR03 and NM109 of the loops referenced must all have the same first 7 numbers to ensure access to the 277CA."]
["What is the HTML Error Report?","Plans may find the html Error Report helpful as well.  This report details all errors including warning errors for files that have passed validation.  Specific element and loop location data is provided for plan convenience.  These are EDI Translator Reports that provide additional information about 999 and TA1 issues.  You can download them from the PRISM Retrieve/Acknowledgement Response screen."]
["Where is the 421?","The 421 is a flat file available in the SFTP.  The file name starts with 4950_DOH such as: 4950_DOH[YOUR TPN]_10647652_20230126.txt"]
["Why are some of my encounters missing from the 277CA?","Encounters with an invalid billing provider NPI will not return on the 277CA.  You will receive a notice that the billing provider NPI is invalid and should apply that status to all encounters with that billing provider NPI.  \n\nFurthermore, any encounters that are unable to fully process the day the file is submitted will not be on the 277CA.  These encounters will show up on subsequent 421 Files the day after they are processed.  "]
["How can I check claim status in PRISM?","Plans will not have access to the Claims screens in PRISM.  Plans must submit 276 files to request claims status.  A 277 response file will be returned with claim status."]
["My 277CA returned a value of 'DK' but 'DK' is not valid per the 837I Institutional Guide.","This is a known error related to changes requiring Ordering/Referring providers on Home Health, Durable Medical Equipment, Hospice, Lab and X-Ray. 'DK' is the correct value for 837P 277CAs but 'DN' should be returned on 277CAs for 837I encounters. If your scenario does not meet the above conditions please contact the encounter team for clarification."]
["Why is my encounter rejecting for \"Missing/Invalid MCO Id?\" ","When a member is not enrolled with the plan submitting the encounter the Originator Plan ID is not stamped on the TCN and the edit 2076/2645 \"Payer ID invalid\" \"Missing/Invalid MCOid\" is posted along with 2024 \"Member is not eligible on the date of service\".  This also occurs when the Plan has not reported themselves correctly on the 837 in loops 2320 and 2330B."]
["I already corrected and resubmitted this encounter, why was it rejected again?","There are certain critical header-level errors PRISM identifies in the adjudication process that stops further adjudication of the claim.  In this case, you may be informed of a critical error but additional rejection errors are not discovered.  This may result in multiple submission attempts to fully correct an encounter."]
["When submitting a corrected encounter that was previously rejected do I need to submit a replacement (Claim Frequency 7) encounter?","Encounters that were rejected in PRISM do not need to be resubmitted as a replacement (Claim Frequency 7).  A rejected encounter that has been corrected can be resubmitted as an original.  "]
["Why is a service denying for valid gender?","If the procedure code is not valid at the date of service, edit 5548 will post. The procedure code and gender must be valid at the date of service or this edit will post."]
["Why is a service denying for Group Billing Provider has Missing/Invalid Rendering Provider? ","PRISM will consider the billing provider the rendering provider if the rendering provider is absent on the 837.  However, a rendering provider cannot be a group provider.  Please confirm the Billing Provider is not registered in PRISM as a group provider or Ambulatory Health Care Facility.  If so, please provide a valid rendering provider."]
["I am getting an error that says \"\tERN missing or no matching ERN found on history for replacement/void\" but my encounter was an original.  How do I resolve this? ","PRISM requires a Payer Claim Control Number in the REF Payer Claim Control Number segment of Loop 2300.  If you are submitting a replacement (7) or void (8), please provide the original ERN of the previously adjudicated claim.  If you are submitting an original claim, please use the same ERN reported in CLM01."]
["Who should I contact if I have additional questions about response files?","Please contact mhc-edi@utah.gov.  To ensure a timely response the plan must provide the Interchange Control Number associated with the file the encounter was submitted on.  "]

{"sheet":"Revision History","index":16,"n_rows":8,"n_cols":2,"rows_kept":8}
["Date","Changes"]
["2023-01-10","Created"]
["2023-01-20","January 2023 Companion Guides added"]
["2023-01-26","OMH Data Team Staff reviewed FAQs"]
["2023-02-01","Edits added"]
["2023-02-10","276 and 277 file resources hidden "]
["2023-02-27","Ignore Only Edits added to Edits Tab"]
["2023-03-02","OMH Data Team Staff reviewed updated FAQs"]