Use our OpenAPI Spec JSON file as a reference for development. Notes on the data in the following sections include:
The Constraints column describes the minimum and maximum number of alphanumeric characters that a field entry can occupy: for example, 1/60 R is a Required field with a minimum of one and maximum of 60 characters.
If a field is required, the Constraints entry notes it.
For the Constraints column in each table, the following letters stand for specific meanings:
R = Required (must be used if/when the object is part of the transaction);
S = Situational (may be required depending on how the transaction content is structured).
Situational loops, segments, or elements can be Situational in two forms:
Required IF a condition is met, but can be used at the discretion of the sender if it is not required (for example, some descriptive notes can be added to a claim if necessary);
Required IF a condition is met, but if not, the sender must not use it in the request ("Do not send").
📘 NOTE
To obtain a license that also provides access to the full requirements for these transactions, visit https://x12.org/licensing . We make every effort to ensure consistency between our APIs and the X12 TR3. If there is a discrepancy, the X12 TR3 is the final authority.
Identification Header Requestor Detail Subscriber Header Dependent Patient Event Detail Patient Event Provider Name Patient Event Service Level Patient Event Service Level Provider Name
Identification Header Request Validation UM Request Validation Requester Request Validation Requester Subscriber (Response) Dependent (Response) Patient Event Detail (Response) Patient Event Provider Name (Response) Patient Event Service Level Patient Event Service Level Provider (Response)
Field Element Description Constraints senderId ISA06/GS02 Interchange Sender ID R 15/15 submitterTransactionIdentifier BHT03 Submitter Transaction Identifier R 1/50 payerId NM109 NM101=PR NM102=2 R 2/80
Name Element Loop Description Constraints requesterType NM101 2010B Default to 1P R 2/3 organizationName NM103 2010B NM102=2 S 1/60 lastName NM103 2010B S 1/60 firstName NM104 2010B NM102=1 S 1/35 address1 N301 2010B R 1/55 address2 N302 2010B S 1/55 city N401 2010B R 2/30 state N402 2010B S 2/2 postalCode N403 2010B S 3/15 countryCode N404 2010B S 2/3 countrySubDivisionCode N407 2010B S 1/3 npi NM109 2010B NM108=XX R 2/80 payorId NM109 2010B NM108=PI R 2/80 ssn NM109 2010B NM108=34 R 2/80 servicesPlanID NM109 2010B NM108=XV R 2/80 employersId NM109 2010B NM108=24 R 2/80 etin NM109 2010B NM108=46 R 2/80 contactElectronicMail PER04 2010B PER03=EM or PER06 PER05=EM or PER08 PER07=EM R 1/256 contactFacsimile PER04 2010B PER03=FX or PER06 PER05=FX or PER08 PER07=FX R 1/256 contactTelephone PER04 2010B PER03=TE or PER06 PER05=TE or PER08 PER07=TE R 1/256 contactTelephoneExtension PER06 2010B PER05=EX or PER08 PER07=EX S 1/256 providerCode PRV01 2010B PRV02=PXC R 1/3 referenceIdentification PRV03 2010B S 1/50 requestorIdentification (Object) — — providerUpinNumber REF02 2010B REF01=1G R 1/50 facilityIdNumber REF02 2010B REF01=1J R 1/50 employerIdentificationNumber REF02 2010B REF01=EI R 1/50 providerSiteNumber REF02 2010B REF01=G5 R 1/50 providerPlanNetworkIdNumber REF02 2010B REF01=N5 R 1/50 facilityNetworkIdNumber REF02 2010B REF01=N7 R 1/50 socialSecurityNumber REF02 2010B REF01=SY R 1/50 federalTaxpayerIdentificationNumber REF02 2010B REF01=TJ R 1/50 carrierAssignedReferenceNumber REF02 2010B REF01=ZH R 1/50
Name Element Loop Description Constraints lastName NM103 2010C NM101=98 NM102=1 S 1/60 firstName NM104 2010C S 1/35 middleName NM105 2010C S 1/25 suffix NM107 2010C S 1/10 memberId NM109 2010C NM108=MI R 2/80 dateOfBirth DMG02 2010C DMG01=D8 YYYYMMDD R 1/35 supplementalIdentification (Object) — — policyNumber REF02 2010C REF01=1L R 1/50 branchIdentifier REF02 2010C REF01=3L R 1/50 groupNumber REF02 2010C REF01=6P R 1/50 departmentNumber REF02 2010C REF01=DP R 1/50 patientAccountNumber REF02 2010C REF01=EJ R 1/50 healthInsuranceClaimNumber REF02 2010C REF01=F6 R 1/50 idCard REF02 2010C REF01=HJ R 1/50 insurancePolicyNumber REF02 2010C REF01=IG R 1/50 planNetworkIdentificationNumber REF02 2010C REF01=N6 R 1/50 medicaidRecipientIdentificationNumber REF02 2010C REF01=NQ R 1/50 ssn REF02 2010C REF01=SY R 1/50
Name Element Loop Description Constraints lastName NM103 2010D NM101=QC NM102=1 S 1/60 firstName NM104 2010D S 1/35 middleName NM105 2010D S 1/25 suffix NM107 2010D S 1/10 dateOfBirth DMG02 2010D DMG01=D8 YYYYMMDD R 1/35 supplementalIdentification (Object) - - employeeIdentificationNumber REF02 2010D REF01=28 R 1/50 patientAccountNumber REF02 2010D REF01=EJ R 1/50 ssn REF02 2010D REF01=SY R 1/50
Name Element Loop Description Constraints requestCategoryCode UM01 2000E R 1/2 certificationTypeCode UM02 2000E S 1/1 serviceTypeCode UM03 2000E S 1/2 facilityTypeCode UM04_1 2000E R 1/2 facilityCodeQualifier UM04_2 2000E R 1/2 certificationActionCode HCR01 2000E R 1/2 previousReviewAuthorizationNumber REF02 2000E REF01=BB R 1/50 previousAdministrativeReferenceNumber REF02 2000E REF01=NT R 1/50 accidentDate DTP03 2000E DTP01=374 DTP02=D8 YYYYMMDD R 1/35 eventDateBegin DTP03 2000E DTP01=AAH DTP02=D8 YYYYMMDD R 1/35 eventDateEnd DTP03 2000E DTP01=AAH DTP02=RD8 YYYYMMDD EventDateBegin must exist R 1/35 admissionDateBegin DTP03 2000E DTP01=374 DTP02=D8 YYYYMMDD R 1/35 admissionDateEnd DTP03 2000E DTP01=374 DTP02=RD8 YYYYMMDD AdmissionDateBegin must exist R 1/35 dischargeDate DTP03 2000E DTP01=096 DTP02=D8 YYYYMMDD R 1/35 certificationIssueDateBegin DTP03 2000E DTP01=102 DTP02=D8 YYYYMMDD R 1/35 certificationIssueDateEnd DTP03 2000E DTP01=102 DTP02=RD8 YYYYMMDD CertificationIssueDateBegin must exist R 1/35 certificationExpirationDateBegin DTP03 2000E DTP01=374 DTP02=D8 YYYYMMDD R 1/35 certificationExpirationDateEnd DTP03 2000E DTP01=374 DTP02=RD8 YYYYMMDD CertificationExpirationDateBegin must exist R 1/35 certificationEffectiveDateBegin DTP03 2000E DTP01=007 DTP02=D8 YYYYMMDD R 1/35 certificationEffectiveDateEnd DTP03 2000E DTP01=007 DTP02=RD8 YYYYMMDD CertificationEffectiveDateBegin must exist R 1/35 healthCareServicesReviewRequestDate DTP03 2000E DTP01=881 DTP02=D8 YYYYMMDD R 1/35 diagnosisTypeCode HI01_1 2000E R 1/3 diagnosisCode HI01_2 2000E R 1/30
Name Element Loop Description Constraints patientEventProviderName (Object) - - entityIdentifierCode NM101 2010EA R 2/3 organizationName NM103 2010EA NM102=2 S 1/30 lastName NM103 2010EA S 1/30 firstName NM104 2010EA NM102=1 S 1/35 middleName NM105 2010EA S 1/25 namePrefix NM106 2010EA S 1/10 nameSuffix NM107 2010EA S 1/10 identificationCodeQualifier NM108 2010EA S 1/2 identifier NM109 2010EA S 2/80 address1 N301 2010EA R 1/55 address2 N302 2010EA S 1/55 city N401 2010EA R 2/30 state N402 2010EA S 2/2 postalCode N403 2010EA S 3/15 countryCode N404 2010EA S 2/3 countrySubDivisionCode N407 2010EA S 1/3 providerCode PRV01 2010EA PRV02=PXC R 1/3 providerTaxonomyCode PRV03 2010EA R 1/50 providerSupplementalInformation (Object) - - stateLicenseNumber REF02 2010EA REF01=0B R 1/50 licenseNumberStateCode REF03 2010EA Required if StateLicenseNumber is entered S 1/80 providerUpinNumber REF02 2010EA REF01=1G R 1/50 facilityIdNumber REF02 2010EA REF01=1J R 1/50 employersIdentificationNumber REF02 2010EA REF01=EI R 1/50 providerPlanNetworkIdentificationNumber REF02 2010EA REF01=N5 R 1/50 facilityNetworkIdentificationNumber REF02 2010EA REF01=N7 R 1/50 ssn REF02 2010EA REF01=SY R 1/50 carrierAssignedReferenceNumber REF02 2010EA REF01=ZH R 1/50
Name Element Loop Description Constraints requestCategoryCode UM01 2000F R 1/2 certificationTypeCode UM02 2000F S 1/1 serviceTypeCode UM03 2000F S 1/2 facilityTypeCode UM04_1 2000F R 1/2 facilityCodeQualifier UM04_2 2000F R 1/2 certificationActionCode HCR01 2000F R 1/2 previousReviewAuthorizationNumber REF02 2000F REF01=BB R 1/50 previousAdministrativeReferenceNumber REF02 2000F REF01=NT R 1/50 serviceDateBegin DTP03 2000F DTP01=472 DTP02=D8 YYYYMMDD R 1/35 serviceDateEnd DTP03 2000F DTP01=472 DTP02=RD8 YYYYMMDD ServiceDateBegin must exist R 1/35 certificationIssueDateBegin DTP03 2000F DTP01=102 DTP02=D8 YYYYMMDD R 1/35 certificationIssueDateEnd DTP03 2000F DTP01=102 DTP02=RD8 YYYYMMDD CertificationIssueDateBegin must exist R 1/35 certificationExpirationDateBegin DTP03 2000F DTP01=374 DTP02=D8 YYYYMMDD R 1/35 certificationExpirationDateEnd DTP03 2000F DTP01=374 DTP02=RD8 YYYYMMDD CertificationExpirationDateBegin must exist R 1/35 certificationEffectiveDateBegin DTP03 2000F DTP01=007 DTP02=D8 YYYYMMDD R 1/35 certificationEffectiveDateEnd DTP03 2000F DTP01=007 DTP02=RD8 YYYYMMDD CertificationEffectiveDateBegin must exist R 1/35 professionalService (Object) - - productOrServiceIDQualifier SV101_1 2000F R 2/2 procedureCode SV101_2 2000F R 1/48 procedureCode2 SV101_8 2000F S 1/48 unitOrBasisForMeasurementCode SV103 2000F S 2/2 serviceUnitCount SV104 2000F S 1/15 institutionalService (Object) - - serviceLineRevenueCode SV201 2000F S 1/48 productOrServiceIDQualifier SV202_1 2000F R 2/2 procedureCode SV202_2 2000F R 2/2 procedureCode2 SV202_8 2000F S 1/48 unitOrBasisForMeasurementCode SV204 2000F S 2/2 serviceUnitCount SV205 2000F S 1/15 dentalService (Object) - - procedureCode SV301_2 2000F SV301_1=AD R 1/48 procedureCode2 SV301_8 2000F S 1/48 americanDentalAssociationCodes SV304_1 2000F R 1/3 prosthesisCrownOrInlayCode SV305 2000F S 1/1 serviceUnitCount SV306 2000F S 1/15 toothInformation (Object) - - toothCode TOO02 2000F TOO01=JP R 1/30 toothSurfaceCode TOO03_1 2000F R 1/2
Name Element Loop Description Constraints serviceProviderName (Object) - - entityIdentifierCode NM101 2010F R 2/3 organizationName NM103 2010F NM102=2 S 1/60 lastName NM103 2010F S 1/60 firstName NM104 2010F NM102=1 S 1/35 middleName NM105 2010F S 1/25 namePrefix NM106 2010F S 1/10 nameSuffix NM107 2010F S 1/10 identificationCodeQualifier NM108 2010F S 1/2 identifier NM109 2010F S 2/80 address1 N301 2010F R 1/55 address2 N302 2010F S 1/55 city N401 2010F R 2/30 state N402 2010F S 2/2 postalCode N403 2010F S 3/15 countryCode N404 2010F S 2/3 countrySubDivisionCode N407 2010F S 1/3 providerCode PRV01 2010F PRV02=PXC R 1/3 providerTaxonomyCode PRV03 2010F R 1/50 providerSupplementalInformation (Object) - - stateLicenseNumber REF02 2010F REF01=0B R 1/50 licenseNumberStateCode REF03 2010F Required if StateLicenseNumber is entered S 1/80 providerUpinNumber REF02 2010F REF01=1G R 1/50 facilityIdNumber REF02 2010F REF01=1J R 1/50 employersIdentificationNumber REF02 2010F REF01=EI R 1/50 providerSiteNumber REF02 2010F REF01=G5 R 1/50 providerPlanNetworkIdentificationNumber REF02 2010F REF01=N5 R 1/50 facilityNetworkIdentificationNumber REF02 2010F REF01=N7 R 1/50 ssn REF02 2010F REF01=SY R 1/50 carrierAssignedReferenceNumber REF02 2010F REF01=ZH R 1/50
Name Element Loop Description Constraints submitterTransactionIdentifier BHT03 N/A R 1/50 payerId NM109 2010A R 2/80 payerName NM103 2010A S 1/60 umClearingHouseId GS03 N/A R 2/15 contactName PER02 2010A S 1/60 contactElectronicMail PER04 2010A PER03=EM or PER06 PER05=EM or PER08 PER07=EM R 1/256 contactFacsimile PER04 2010A PER03=FX or PER06 PER05=FX or PER08 PER07=FX R 1/256 contactTelephone PER04 2010A PER03=TE or PER06 PER05=TE or PER08 PER07=TE R 1/256 contactTelephoneExtension PER06 2010A PER05=EX or PER08 PER07=EX S 1/256 contactUrl PER04 2010A PER03=UM or PER06 PER05=UM or PER08 PER07=UM R 1/256
Name Element Loop Description Constraints responseCode AAA01 2000A Yes/No Condition or Response Code R 1/1 rejectReasonCode AAA03 2000A R 2/2 followupActionCode AAA04 2000A R 2/2
Name Element Loop Description Constraints responseCode AAA01 2010A Yes/No Condition or Response Code R 1/1 rejectReasonCode AAA03 2010A R 2/2 followupActionCode AAA04 2010A S 1/1
Name Element Loop Description Constraints responseCode AAA01 2010B R 1/1 rejectReasonCode AAA03 2010B R 2/2 followupActionCode AAA04 2010B R 1/1
Name Element Loop Description Constraints requesterType NM101 2010B R 2/3 organizationName NM103 2010B NM102=2 S 1/60 lastName NM103 2010B NM102=1 S 1/60 firstName NM104 2010B NM102=1 S 1/35 npi NM109 2010B NM108=XX R 2/80 payorId NM109 2010B NM108=PI R 2/80 ssn NM109 2010B NM108=34 R 2/80 servicesPlanID NM109 2010B NM108=XV R 2/80 employersId NM109 2010B NM108=24 R 2/80 etin NM109 2010B NM108=46 R 2/80 providerCode PRV01 2010B PRV02=PXC R 1/3 referenceIdentification PRV03 2010B S 1/50 requesterIdentification (Object) - - providerUpinNumber REF02 2010B REF01=1G R 1/50 facilityIdNumber REF02 2010B REF01=1J R 1/50 employerIdentificationNumber REF02 2010B REF01=EI R 1/50 providerSiteNumber REF02 2010B REF01=G5 R 1/50 providerPlanNetworkIdNumber REF02 2010B REF01=N5 R 1/50 facilityNetworkIdNumber REF02 2010B REF01=N7 R 1/50 socialSecurityNumber REF02 2010B REF01=SY R 1/50 carrierAssignedReferenceNumber REF02 2010B REF01=ZH R 1/50
Name Element Loop Description Constraints lastName NM103 2010C NM101=IL NM102=1 S 1/60 firstName NM104 2010C S 1/35 middleName NM105 2010C S 1/25 suffix NM107 2010C S 1/10 memberId NM109 2010C NM108=MI R 2/80 dateOfBirth DMG02 2010C DMG01=D8 YYYYMMDD R 1/35 address1 N301 2010C R 1/55 address2 N302 2010C S 1/55 city N401 2010C R 2/30 state N402 2010C S 2/2 postalCode N403 2010C S 3/15 countryCode N404 2010C S 2/3 countrySubDivisionCode N407 2010C S 1/3 subscriberRequestValidation (Object) - - responseCode AAA01 2010C R 1/1 rejectReasonCode AAA03 2010C R 2/2 followupActionCode AAA04 2010C R 1/1 supplementalIdentification (Object) - - policyNumber REF02 2010C REF01=1L R 1/50 branchIdentifier REF02 2010C REF01=3L R 1/50 groupNumber REF02 2010C REF01=6P R 1/50 departmentNumber REF02 2010C REF01=DP R 1/50 patientAccountNumber REF02 2010C REF01=EJ R 1/50 healthInsuranceClaimNumber REF02 2010C REF01=F6 R 1/50 idCard REF02 2010C REF01=HJ R 1/50 insurancePolicyNumber REF02 2010C REF01=IG R 1/50 planNetworkIdentificationNumber REF02 2010C REF01=N6 R 1/50 medicaidRecipientIdentificationNumber REF02 2010C REF01=NQ R 1/50 ssn REF02 2010C REF01=SY R 1/50
Name Element Loop Description Constraints lastName NM103 2010D NM101=QC NM102=1 S 1/60 firstName NM104 2010D NM102=1 S 1/35 middleName NM105 2010D S 1/25 suffix NM107 2010D S 1/10 dateOfBirth DMG02 2010D DMG01=D8 YYYYMMDD R 1/35 address1 N301 2010D R 1/55 address2 N302 2010D S 1/55 city N401 2010D R 2/30 state N402 2010D S 2/2 postalCode N403 2010D S 3/15 countryCode N404 2010D S 2/3 countrySubDivisionCode N407 2010D S 1/3 dependentRequestValidation (Object) - - responseCode AAA01 2010D R 1/1 rejectReasonCode AAA03 2010D R 2/2 followupActionCode AAA04 2010D R 1/1 supplementalIdentification (Object) - - employeeIdentificationNumber REF02 2010D REF01=28 R 1/50 patientAccountNumber REF02 2010D REF01=EJ R 1/50 ssn REF02 2010D REF01=SY R 1/50
Name Element Loop Description Constraints requestCategoryCode UM01 2000E R 1/2 certificationTypeCode UM02 2000E S 1/1 serviceTypeCode UM03 2000E S 1/2 facilityTypeCode UM04_1 2000E R 1/2 facilityCodeQualifier UM04_2 2000E R 1/2 certificationActionCode HCR01 2000E R 1/2 reviewIdentificationNumber HCR02 2000E S 1/50 reviewDecisionReasonCode HCR03 2000E S 1/30 secondSurgicalOpinionIndicator HCR04 2000E S 1/1 previousReviewAuthorizationNumber REF02 2000E REF01=BB R 1/50 previousAdministrativeReferenceNumber REF02 2000E REF01=NT R 1/50 eventDateBegin DTP03 2000E DTP01=AAH DTP02=D8 YYYYMMDD R 1/35 eventDateEnd DTP03 2000E DTP01=AAH DTP02=RD8 YYYYMMDD EventDateBegin must exist R 1/35 admissionDateBegin DTP03 2000E DTP01=435 DTP02=D8 YYYYMMDD R 1/35 admissionDateEnd DTP03 2000E DTP01=435 DTP02=RD8 YYYYMMDD AdmissionDateBegin must exist R 1/35 dischargeDate DTP03 2000E DTP01=096 DTP02=D8 YYYYMMDD R 1/35 certificationIssueDate DTP03 2000E DTP01=102 DTP02=D8 YYYYMMDD R 1/35 certificationExpirationDate DTP03 2000E DTP01=036 DTP02=D8 YYYYMMDD R 1/35 certificationEffectiveDateBegin DTP03 2000E DTP01=007 DTP02=D8 YYYYMMDD R 1/35 certificationEffectiveDateEnd DTP03 2000E DTP01=007 DTP02=RD8 YYYYMMDD CertificationEffectiveDateBegin must exist R 1/35 healthCareServicesReviewRequestDateBegin DTP03 2000E DTP01=881 DTP02=D8 YYYYMMDD R 1/35 healthCareServicesReviewRequestDateEnd DTP03 2000E DTP01=881 DTP02=RD8 YYYYMMDD HealthCareServicesReviewRequestDateBegin must exist R 1/35 diagnosisTypeCode HI01_1 2000E R 1/3 diagnosisCode HI01_2 2000E R 1/30 quantityQualifier HSD01 2000E S 2/2 serviceUnitCount HSD02 2000E S 1/15 unitOrBasisForMeasurementCode HSD03 2000E S 2/2 sampleSelectionModulus HSD04 2000E S 1/6 timePeriodQualifier HSD05 2000E S 1/2 periodCount HSD06 2000E S 1/3 deliveryFrequencyCode HSD07 2000E S 1/2 deliveryPatternTimeCode HSD08 2000E S 1/1 institutionalAdmissionTypeCode CL101 2000E S 1/1 institutionalAdmissionSourceCode CL102 2000E S 1/1 institutionalPatientStatusCode CL103 2000E S 1/2 ambulanceTransportCode CR103 2000E S 1/2 ambulanceUnitOrBasisForMeasurementCode CR105 2000E S 2/2 ambulanceTransportDistance CR106 2000E S 1/15 spinalManipulationTreatmentSeriesNumber CR201 2000E S 1/9 spinalManipulationTreatmentCount CR202 2000E S 1/15 spinalManipulationSubluxationLevelCode CR203 2000E S 2/3 spinalManipulationSubluxationLevelCode2 CR204 2000E S 2/3 oxygenEquipmentTypeCode CR503 2000E S 1/1 oxygenEquipmentTypeCode2 CR504 2000E S 1/1 oxygenFlowRate CR506 2000E R 1/15 dailyOxygenUseCount CR507 2000E S 1/15 oxygenUsePeriodHourCount CR508 2000E S 1/15 respiratoryTherapistOrderText CR509 2000E S 1/80 portableOxygenSystemFlowRate CR516 2000E S 1/15 oxygenDeliverySystemCode CR517 2000E R 1/1 oxygenSystemTypeCode CR518 2000E S 1/1 homeHealthPrognosisCode CR601 2000E R 1/1 homeHealthStartDate CR602 2000E R 8/8 homeHealthCertificationPeriod CR604 2000E S 1/35 homeHealthMedicareCoverageIndicator CR607 2000E R 1/1 homeHealthCertificationTypeCode CR608 2000E R 1/1 freeFormMessageText MSG01 2000E R 1/264 dependentRequestValidation (Object) - - responseCode AAA01 2000E R 1/1 rejectReasonCode AAA03 2000E R 2/2 followupActionCode AAA04 2000E R 1/1 patientEventTransportInformation (Object) - - entityIdentifierCode NM101 2010EB R 2/3 organizationName NM103 2010EB R 1/60 identificationCodeQualifier NM108 2010EB ? 1/2 identifier NM109 2010EB ? 2/80 address1 N301 2010EB R 1/55 address2 N302 2010EB S 1/55 city N401 2010EB S 2/30 state N402 2010EB S 2/2 postalCode N403 2010EB S 3/15
Name Element Loop Description Constraints entityIdentifierCode NM101 2010EA R 2/3 organizationName NM103 2010EA NM102=2 S 1/60 lastName NM103 2010EA NM102=1 S 1/60 firstName NM104 2010EA NM102=1 S 1/35 middleName NM105 2010EA S 1/25 namePrefix NM106 2010EA S 1/10 nameSuffix NM107 2010EA S 1/10 identificationCodeQualifier NM108 2010EA S 1/2 identifier NM109 2010EA S 2/80 address1 N301 2010EA R 1/55 address2 N302 2010EA S 1/55 city N401 2010EA R 2/30 state N402 2010EA S 2/2 postalCode N403 2010EA S 3/15 countryCode N404 2010EA S 2/3 countrySubDivisionCode N407 2010EA S 1/3 contactName PER02 2010EA S 1/60 contactElectronicMail PER04 2010EA PER03=EM or PER06 PER05=EM or PER08 PER07=EM R 1/256 contactFacsimile PER04 2010EA PER03=FX or PER06 PER05=FX or PER08 PER07=FX R 1/256 contactTelephone PER04 2010EA PER03=TE or PER06 PER05=TE or PER08 PER07=TE R 1/256 contactTelephoneExtension PER06 2010EA PER05=EX or PER08 PER07=EX S 1/256 contactUrl PER04 2010EA PER03=UM or PER06 PER05=UM or PER08 PER07=UM R 1/256 providerCode PRV01 2010EA PRV02=PXC R 1/3 providerTaxonomyCode PRV03 2010EA R 1/50 patientEventProviderRequestValidation (Object) - - responseCode AAA01 2000EA R 1/1 rejectReasonCode AAA03 2000EA R 2/2 followupActionCode AAA04 2000EA R 1/1 providerSupplementalInformation (Object) - - stateLicenseNumber REF02 2010EA REF01=0B R 1/50 licenseNumberStateCode REF03 2010EA Required if StateLicenseNumber is entered S 1/80 providerUpinNumber REF02 2010EA REF01=1G R 1/50 facilityIdNumber REF02 2010EA REF01=1J R 1/50 employersIdentificationNumber REF02 2010EA REF01=EI R 1/50 providerPlanNetworkIdentificationNumber REF02 2010EA REF01=N5 R 1/50 facilityNetworkIdentificationNumber REF02 2010EA REF01=N7 R 1/50 ssn REF02 2010EA REF01=SY R 1/50 carrierAssignedReferenceNumber REF02 2010EA REF01=ZH R 1/50
Name Element Loop Description Constraints requestCategoryCode UM01 2000F R 1/2 certificationTypeCode UM02 2000F S 1/1 serviceTypeCode UM03 2000F S 1/2 facilityTypeCode UM04_1 2000F R 1/2 facilityCodeQualifier UM04_2 2000F R 1/2 certificationActionCode HCR01 2000F R 1/2 reviewIdentificationNumber HCR02 2000F S 1/50 reviewDecisionReasonCode HCR03 2000F S 1/30 secondSurgicalOpinionIndicator HCR04 2000F S 1/1 previousReviewAuthorizationNumber REF02 2000F REF01=BB R 1/50 previousAdministrativeReferenceNumber REF02 2000F REF01=NT R 1/50 serviceDateBegin DTP03 2000F DTP01=472 DTP02=D8 YYYYMMDD R 1/35 serviceDateEnd DTP03 2000F DTP01=472 DTP02=RD8 YYYYMMDD ServiceDateBegin must exist R 1/35 certificationIssueDate DTP03 2000F DTP01=102 DTP02=D8 YYYYMMDD R 1/35 certificationExpirationDate DTP03 2000F DTP01=036 DTP02=D8 YYYYMMDD R 1/35 certificationEffectiveDateBegin DTP03 2000F DTP01=007 DTP02=D8 YYYYMMDD R 1/35 certificationEffectiveDateEnd DTP03 2000F DTP01=007 DTP02=RD8 YYYYMMDD CertificationEffectiveDateBegin must exist R 1/35 quantityQualifier HSD01 2000F S 2/2 serviceUnitCount HSD02 2000F S 1/15 unitOrBasisForMeasurementCode HSD03 2000F S 2/2 sampleSelectionModulus HSD04 2000F S 1/6 timePeriodQualifier HSD05 2000F S 1/2 periodCount HSD06 2000F S 1/3 deliveryFrequencyCode HSD07 2000F S 1/2 deliveryPatternTimeCode HSD08 2000F S 1/1 freeFormMessageText MSG01 2000F R 1/264 serviceRequestValidation (Object) - - responseCode AAA01 2000F R 1/1 rejectReasonCode AAA03 2000F R 2/2 followupActionCode AAA04 2000F R 1/1 professionalService (Object) - - productOrServiceIDQualifier SV101_1 2000F R 2/2 procedureCode SV101_2 2000F R 1/48 procedureModifier SV101_3 2000F S 2/2 procedureModifier2 SV101_4 2000F S 2/2 procedureModifier3 SV101_5 2000F S 2/2 procedureModifier4 SV101_6 2000F S 2/2 procedureCodeDescription SV101_7 2000F S 1/80 procedureCode2 SV101_8 2000F S 1/48 serviceLineAmount SV101_8 2000F S 1/48 unitOrBasisForMeasurementCode SV103 2000F S 2/2 serviceUnitCount SV104 2000F S 1/15 epsdtIndicator SV111 2000F S 1/1 institutionalService (Object) - - serviceLineRevenueCode SV201 2000F S 1/48 productOrServiceIDQualifier SV202_1 2000F R 2/2 procedureCode SV202_2 2000F R 1/48 procedureModifier SV202_3 2000F S 2/2 procedureModifier2 SV202_4 2000F S 2/2 procedureModifier3 SV202_5 2000F S 2/2 procedureModifier4 SV202_6 2000F S 2/2 procedureCodeDescription SV202_7 2000F S 1/80 procedureCode2 SV202_8 2000F S 1/48 serviceLineAmount SV203 2000F S 1/18 unitOrBasisForMeasurementCode SV204 2000F S 2/2 serviceUnitCount SV205 2000F S 1/15 serviceLineRate SV206 2000F S 1/10 dentalService (Object) - - procedureCode SV301_2 2000F SV301_1=AD R 1/48 procedureModifier SV301_3 2000F S 2/2 procedureModifier2 SV301_4 2000F S 2/2 procedureModifier3 SV301_5 2000F S 2/2 procedureModifier4 SV301_6 2000F S 2/2 procedureCodeDescription SV301_7 2000F S 1/80 procedureCode2 SV301_8 2000F S 1/48 serviceLineAmount SV302 2000F S 1/18 americanDentalAssociationCodes SV304_1 2000F R 1/3 americanDentalAssociationCodes2 SV304_2 2000F S 1/3 americanDentalAssociationCodes3 SV304_3 2000F S 1/3 americanDentalAssociationCodes4 SV304_4 2000F S 1/3 americanDentalAssociationCodes5 SV304_5 2000F S 1/3 prosthesisCrownOrInlayCode SV305 2000F S 1/1 serviceUnitCount SV306 2000F R 1/15 toothInformation (Object) - - toothCode TOO02 2000F TOO01=JP R 1/30 toothSurfaceCode TOO03_1 2000F R 1/2 toothSurfaceCode2 TOO03_2 2000F S 1/2 toothSurfaceCode3 TOO03_3 2000F S 1/2 toothSurfaceCode4 TOO03_4 2000F S 1/2 toothSurfaceCode5 TOO03_5 2000F S 1/2
Name Element Loop Description Constraints entityIdentifierCode NM101 2010F R 2/3 organizationName NM103 2010F NM102=2 S 1/60 lastName NM103 2010F NM102=1 S 1/60 firstName NM104 2010F NM102=1 S 1/35 middleName NM105 2010F S 1/25 namePrefix NM106 2010F S 1/10 nameSuffix NM107 2010F S 1/10 identificationCodeQualifier NM108 2010F S 1/2 identifier NM109 2010F S 2/80 address1 N301 2010F R 1/55 address2 N302 2010F S 1/55 city N401 2010F R 2/30 state N402 2010F S 2/2 postalCode N403 2010F S 3/15 countryCode N404 2010F S 2/3 countrySubDivisionCode N407 2010F S 1/3 contactName PER02 2010F S 1/60 contactElectronicMail PER04 2010F PER03=EM or PER06 PER05=EM or PER08 PER07=EM R 1/256 contactFacsimile PER04 2010F PER03=FX or PER06 PER05=FX or PER08 PER07=FX R 1/256 contactTelephone PER04 2010F PER03=TE or PER06 PER05=TE or PER08 PER07=TE R 1/256 contactTelephoneExtension PER06 2010F PER05=EX or PER08 PER07=EX S 1/256 contactUrl PER04 2010F PER03=UM or PER06 PER05=UM or PER08 PER07=UM R 1/256 providerCode PRV01 2010F PRV02=PXC R 1/3 providerTaxonomyCode PRV03 2010F R 1/50 serviceProviderRequestValidation (Object) - - responseCode AAA01 2010F R 1/1 rejectReasonCode AAA03 2010F R 2/2 followupActionCode AAA04 2010F R 1/1 providerSupplementalInformation (Object) - - stateLicenseNumber REF02 2010F REF01=0B R 1/50 licenseNumberStateCode REF03 2010F Required if StateLicenseNumber is entered S 1/80 providerUpinNumber REF02 2010F REF01=1G R 1/50 facilityIdNumber REF02 2010F REF01=1J R 1/50 employersIdentificationNumber REF02 2010F REF01=EI R 1/50 providerSiteNumber REF02 2010F REF01=G5 R 1/50 providerPlanNetworkIdentificationNumber REF02 2010F REF01=N5 R 1/50 facilityNetworkIdentificationNumber REF02 2010F REF01=N7 R 1/50 ssn REF02 2010F REF01=SY R 1/50 carrierAssignedReferenceNumber REF02 2010F REF01=ZH R 1/50
