Authorization Inquiry JSON-to-EDI API Contents

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").

Inquiry 278 Request

Identification Header

Requestor Detail

Subscriber Header

Dependent

Patient Event Detail

Patient Event Provider Name

Patient Event Service Level

Patient Event Service Level Provider Name

Inquiry 278 Response

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)

Inquiry API JSON-to-EDI mapping

Inquiry 278 Request

Identification Header (Request)

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 If umClearingHouseId is empty, this value will also be used to populate ISA08 GS03	R 2/80

Requestor Detail (Request)

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

Subscriber (Request)

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

Dependent (Request)

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

Patient Event Detail (Request)

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

Patient Event Provider Name (Request)

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

Patient Event Service Level (Request)

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

Patient Event Service Level Provider Name (Request)

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

Inquiry 278 Response

Identification Header (Response)

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

Request Validation (Response)

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

UM Request Validation (Response)

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

Requester Request Validation (Response)

Name	Element	Loop	Constraints
responseCode	AAA01	2010B	R 1/1
rejectReasonCode	AAA03	2010B	R 2/2
followupActionCode	AAA04	2010B	R 1/1

Requester (Response)

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

Subscriber (Response)

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

Dependent (Response)

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

Patient Event Detail (Response)

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

Patient Event Provider Name (Response)

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

Patient Event Service Level (Response)

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

Patient Event Service Level Provider (Response)

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

Updated 5 days ago