Inquiry JSON-to-EDI API Contents

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

For an overview about JSON-to-EDI mapping, see Understanding JSON-to-EDI API Mapping.

Inquiry 278 Request

Identification Header

Name	Required/Commonly Used	Element Loop	Constraint
Header Section (Request)	Required
`senderId`	Required	201985AAS	15/15
`submitterTransactionIdentifier`	Required	BHT03	1/50
`payerId`	Required	NM109 2010A	2/80
`payerName`	Required	NM103 2010A	1/60
`umClearingHouseId`	Required	GS03 ISA08	2/15

Requestor Detail

Name	Required/Commonly Used	Hint	Element, Loop	Code	Constraint
Request Information Section	Required
`requesterType`	Required	Default = IP	NM101 2010B	`requesterType` ============= 1P Provider 2A Federal, State, County, or City Facility 2B Third-Party Administrator 36 Employer FA Facility PR Payer X3 Utilization Management Organization	2/3

Name	Required/Commonly Used	Element Loop	Constraint
Requester Name (if requester is an individual, provide `lastName` and `firstName`, otherwise provide `organizationName`)	Required
`organizationName`	Commonly Used	NM103 2010B	1/60
`lastName`		NM103 2010B	1/60
`firstName`		NM104 2010B	1/60

Name	Element Loop	Constraint
Requester Identification (provide any of the following if available)
`providerUpinNumber`	REF02 2010B	1/50
`facilityIdNumber`	REF02 2010B	1/50
`employerIdentificationNumber`	REF02 2010B	1/50
`providerSiteNumber`	REF02 2010B	1/50
`providerPlanNetworkIdNumber`	REF02 2010B	1/50
`facilityNetworkIdNumber`	REF02 2010B	1/50
`socialSecurityNumber`	REF02 2010B	1/50
`federalTaxpayerIdentificationNumber`	REF02 2010B	1/50
`carrierAssignedReferenceNumber`	REF02 2010B	1/50

Name	Required/Commonly Used	Element Loop	Constraint
Requester Address Information
`address1`	Commonly Used	N301 2010B	1/55
`address2`	Commonly Used	N302 2010B	1/55
`city`	Commonly Used	N401 2010B	2/30
`state`	Commonly Used	N402 2010B	2/2
`postalCode`	Commonly Used	N403 2010B	3/15
`countryCode`		N404 2010B	2/3
`countrySubDivisionCode`		N407 2010B	1/3

Name	Required/Commonly Used	Element Loop	Constraint
Identification Code (Provide one of the following)	Required
`npi`	Commonly Used	NM109 2010B	2/80
`payorId`		NM109 2010B	2/80
`ssn`		NM109 2010B	2/80
`servicesPlanID`		NM109 2010B	2/80
`employersId`		NM109 2010B	2/80
`etin`		NM109 2010B	2/80

Name	Required/Commonly Used	Element	Constraint
Requestor Information
`contactName`		PER02 2010B	1/60
`contactFacsimile`		PER04 2010B	1/256
`contactTelephone`	Commonly Used	PER04 2010B	1/256
`contactTelephoneExtension`		PER04 2010B	1/256
`providerCode`		PRV01 2010B	1/3
`referenceIdentification`		PRV03 2010B	1/50

Subscriber (Request)

Name	Required/Commonly Used	Hint	Element	Constraint
Subscriber Section	Required
`lastName`	Required	While not required by guide, widely used by payers	NM103 2010C	1/60
`firstName`	Required	While not required by guide, widely used by payers	NM104 2010C	1/35
`middleName`			NM105 2010C	1/25
`suffix`			NM107 2010C	1/10
`memberId`	Required		NM109 2010C	2/80
`dateOfBirth`	Required	While not required by guide, widely used by payers	DMG02 2010C	1/35

Name	Required/Commonly Used	Element	Constraint
Subscriber Supplemental Identification (Provide any of the following if available)
`policyNumber`		REF02 2010C	1/50
`branchIdentifier`		REF02 2010C	1/50
`groupNumber`	Commonly Used	REF02 2010C	1/50
`departmentNumber`		REF02 2010C	1/50
`patientAccountNumber`		REF02 2010C	1/50
`healthInsuranceClaimNumber`		REF02 2010C	1/50
`idCard`		REF02 2010C	1/50
`insurancePolicyNumber`		REF02 2010C	1/50
`planNetworkIdentificationNumber`		REF02 2010C	1/50
`medicaidRecipientIdentificationNumber`		REF02 2010C	1/50
`ssn`	Commonly Used	REF02 2010C	1/50

Dependent (Request)

Name	Required/Commonly Used	Hint	Element	Constraint
Dependent Section (Required if Patient is a dependent of the Insured Individual)
`lastName`	Required	While not required by guide, widely used by payers	NM103 2010D	1/60
`firstName`	Required	While not required by guide, widely used by payers	NM104 2010D	1/35
`middleName`			NM105 2010D	1/25
`suffix`			NM107 2010D	1/10
`dateOfBirth`		While not required by guide, widely used by payers	DMG02 2010D	1/35
Dependent Section (required if patient is a dependent of the insured individual)
`employeeIdentificationNumber`			REF02 2010D	1/50
`patientAccountNumber`			REF02 2010D	1/50
`ssn`	Commonly Used		REF02 2010D	1/50

Patient Event Detail (Request)

Name	Required/Commonly Used	Hint	Element	Code	Constraint
Patient Event Detail Section	Required
Health Care Services Review Information
`requestCategoryCode`	Commonly Used		UM01 2000E	`requestCategoryCode` ===================== AR Admission Review HS Health Services Review IN Individual SC Specialty Care Review	1/2
`certificationTypeCode`			UM02 2000E	`certificationTypeCode` ======================== 1 Appeal -Immediate 2 Appeal -Standard 3 Cancel 4 Extension I Initial N Reconsideration R Renewal S Revised	1/1
`serviceTypeCode`			UM03 2000E		1/2
`facilityTypeCode`			UM04_1 2000E		1/2
`facilityCodeQualifier`			UM04_2 2000E		1/2
`certificationActionCode`			HCR01 2000E		1/2
`previousReviewAuthorizationNumber`	Commonly Used	Should be sent if known by submitter	REF02 2000E		1/2
`previousAdministrativeReferenceNumber`		Should be sent if known by submitter	REF02 2000E		1/50
`accidentDate`			DTP03 2000E		1/35
`eventDateBegin`	Commonly Used	Send if related to Health Services Review (UM01 = HS) or Referrals (UM01 = SC)	DTP03 2000E		1/35
`eventDateEnd`			DTP03 2000E		1/35
`admissionDateBegin`		Send if related to Admission Review (UM01 = AR)	DTP03 2000E		1/35
`admissionDateEnd`			DTP03 2000E		1/35
`dischargeDate`			DTP03 2000E		1/35
`certificationIssueDateBegin`			DTP03 2000E		1/35
`certificationIssueDateEnd`			DTP03 2000E		1/35
`certificationExpirationDateBegin`			DTP03 2000E		1/35
`certificationExpirationDateEnd`			DTP03 2000E		1/35
`certificationEffectiveDateBegin`			DTP03 2000E		1/35
`certificationEffectiveDateEnd`			DTP03 2000E		1/35
`healthCareServicesReviewRequestDate`			DTP03 2000E		1/35
Diagnosis
`diagnosisTypeCode`			HI01_1 2000E		1/3
`diagnosisCode`			HI01_2 2000E		1/30
Patient Event Provider Name Section (can contain multiple instances)
`entityIdentifierCode`	Commonly Used		NM101 2010EA	`entityIdentifierCode` ======================= 71 Attending Physician 72 Operating Physician 73 Other Physician 77 Service Location AAJ Admitting Services DD Assistant Surgeon DK Ordering Physician DN Referring Provider FA A Facility G3 Clinic P3 Primary Care Provider QB Purchase Service Provider QV Group Practice SJ Service Provider

Name	Required/Commonly Used	Element	Constraint
Provider Name (if Provider is an individual, provide `lastName` and `firstName`, otherwise provide `organizationName`)
`organizationName`		NM103 2010EA	1/30
`lastName`	Commonly Used	NM103 2010EA	1/30
`firstName`	Commonly Used	NM104 2010EA	1/35
`middleName`		NM105 2010EA	1/25
`namePrefix`		NM106 2010EA	1/10
`nameSuffix`		NM107 2010EA	1/10
`identificationCodeQualifier`	Commonly Used	NM108 2010EA	1/2
`identifier`	Commonly Used	NM109 2010EA	2/80
Patient Event Provider Address Information
`address1`		N301 2010EA	1/55
`address2`		N302 2010EA	1/55
`city`		N401 2010EA	2/30
`state`		N402 2010EA	2/2
`postalCode`		N403 2010EA	3/15
`countryCode`		N404 2010EA	2/3
`countrySubDivisionCode`		N407 2010EA	1/3
Provider Supplemental Information (provide any of the following if available)
`stateLicenseNumber`		REF02 2010EA	1/50
`licenseNumberStateCode`		REF03 2010EA	1/80
`providerUpinNumber`		REF02 2010EA	1/50
`facilityIdNumber`		REF02 2010EA	1/50
`employersIdentificationNumber`		REF02 2010EA	1/50
`providerPlanNetworkIdentificationNumber`		REF02 2010EA	1/50
`facilityNetworkIdentificationNumber`		REF02 2010EA	1/50
`ssn`		REF02 2010EA	1/50
`carrierAssignedReferenceNumber`		REF02 2010EA	1/50
`providerCode`		PRV01 2010EA	1/3
`providerTaxonomyCode`		PRV03 2010EA	1/50

Patient Event Service Level (Request)

Name	Required/Commonly Used	Hint	Element Loop	Code	Constraint
Service Level Section (one instance per procedure code)	Required
Health Care Services Review Information
`requestCategoryCode`	Commonly Used		UM01 2000F	`requestCategoryCode` ====================== HS Health Services Review SC Specialty Care Review	1/2
`certificationTypeCode`			UM02 2000F	`certificationTypeCode` ======================== 1 Appeal - Immediate 2 Appeal - Standard 3 Cancel 4 Extension I Initial N Reconsideration R Renewal S Revised	1/1
`serviceTypeCode`	Commonly Used		UM03 2000F		1/2
`facilityTypeCode`	Commonly Used		UM04_1 2000F		1/2
`facilityCodeQualifier`			UM04_2 2000F		1/2
`certificationActionCode`			HCR01 2000F		1/2
`previousReviewAuthorizationNumber`			REF02 2000F		1/50
`previousAdministrativeReferenceNumber`			REF02 2000F		1/50
`erviceDateBegin`	Commonly Used	Usually same as 2000E Event Date	DTP03 2000F		1/35
`serviceDateEnd`			DTP03 2000F		1/35
`certificationIssueDateBegin`			DTP03 2000F		1/35
`certificationIssueDateEnd`			DTP03 2000F		1/35
`certificationExpirationDateEnd`			DTP03 2000F		1/35
`certificationExpirationDateBegin`			DTP03 2000F		1/35
`certificationEffectiveDateBegin`			DTP03 2000F		1/35
`certificationEffectiveDateEnd`			DTP03 2000F		1/35
One of the following Service Sections is Required	Required
Professional Service Information
`productOrServiceIDQualifier`	Commonly Used		SV101_1 2000F	`productOrServiceIDQualifier` ============================== HC HCPCS N4 National Drug Code	2/2
`procedureCode`	Commonly Used	While not required strongly recommended as procedure code required by some payers if not sending `previousReviewAuthorizationNumber` or `previousAdministrativeReferenceNumber`	SV101_2 2000F		1/48
`procedureCode2`			SV101_8 2000F		1/48
`unitOrBasisForMeasurementCode`			SV103 2000F	`unitOrBasisForMeasurementCode` ================================ F2 International Unit MJ Minutes UN Unit	2/2
`serviceUnitCount`			SV104 2000F		1/15
Institutional Service Information
`serviceLineRevenueCode`			SV201 2000F	`ProductOrServiceIDQualifier` ============================== HC HCPCS or CPT N4 National Drug Code ZZ ICD-10	1/48
`productOrServiceIDQualifier`			SV202_1 2000F		2/2
`procedureCode`			SV202_2 2000F		2/2
`procedureCode2`			SV202_8 2000F		1/48
`unitOrBasisForMeasurementCode`			SV204 2000F		2/2
`serviceUnitCount`			SV205 2000F		1/15
Dental Service Information
`procedureCode`			SV301_2 2000F		1/48
`procedureCode2`			SV301_8 2000F		1/48
`americanDentalAssociationCodes`			SV304_1 2000F		1/3
`prosthesisCrownOrInlayCode`			SV305 2000F		1/1
`serviceUnitCount`			SV306 2000F		1/15
Tooth Information
`toothCode`			TOO02 2000F		1/30
`toothSurfaceCode`			TOO03_1 2000F		1/2

Patient Event Service Level Provider Name (Request)

Name	Element Loop	Code	Constraint
Service Level Provider Name Section (Can contain multiple instances)
`entityIdentifierCode`	NM101 2010F	`entityIdentifierCode` ======================= 72 Operating Physician 73 Other Physician 77 Service Location DD Assistant Surgeon DK Ordering Physician DQ Supervising Physician FA Facility G3 Clinic P3 Primary Care Provider QB Purchase Service Provider QV Group Practice SJ Service Provider	2/3
Provider Name (If Provider is an individual then provide lastName and firstName, otherwise provide organizationName)
`organizationName`	NM103 2010F		1/60
`lastName`	NM103 2010F		1/60
`firstName`	NM104 2010F		1/35
`middleName`	NM105 2010F		1/25
`namePrefix`	NM106 2010F		1/10
`nameSuffix`	NM107 2010F		1/10
`identificationCodeQualifier`	NM108 2010F	`IdentificationCodeQualifier` ============================== 24 Employer’s Identification Number 34 Social Security Number 46 Electronic Transmitter Identification Number (ETIN) XX (NPI)	1/2
`identifier`	NM109 2010F		2/80
Service Level Provider Address Information
`address1`	N301 2010F		1/55
`address2`	N302 2010F		1/55
`city`	N401 2010F		2/30
`state`	N402 2010F		2/2
`postalCode`	N403 2010F		3/15
`countryCode`	N404 2010F		2/3
`countrySubDivisionCode`	N407 2010F		1/3
Provider Supplemental Information (Provide any of the following if available)
`stateLicenseNumber`	REF02 2010F		1/50
`licenseNumberStateCode`	REF03 2010F		1/80
`providerUpinNumber`	REF02 2010F		1/50
`facilityIdNumber`	REF02 2010F		1/50
`employersIdentificationNumber`	REF02 2010F		1/50
`providerPlanNetworkIdentificationNumber`	REF02 2010F		1/50
`facilityNetworkIdentificationNumber`	REF02 2010F		1/50
`ssn`	REF02 2010F		1/50
`carrierAssignedReferenceNumber`	REF02 2010F		1/50
`providerCode`	PRV01 2010F		1/3
`providerTaxonomyCode`	PRV03 2010F		1/50

Inquiry 278 Response

Identification Header (Response)

Name	Required/Commonly Used	Element Loop	Constraint
Header Section (Response)	Required
`submitterTransactionIdentifier`	Required	N/A BHT03	1/50
`payerId`	Required	NM109 2010A	2/80
`payerName`	Required	NM103 2010A	1/60
`umClearingHouseId`	Required	GS03 NA	2/15

Requestor Detail (Response)

Name	Required/Commonly Used	Hint	Element Loop	Code	Constraint
Response) Information Section	Required
`requesterType`	Required	Default=IP	NM101 2010B	`requesterType` ============= 1P Provider 2A Federal, State, County, or City Facility 2B Third-Party Administrator 36 Employer FA Facility PR Payer X3 Utilization Management Organization	2/3

Name	Required/Commonly Used	Element Loop	EDI Mapping Notes	Constraint
	Required
`organizationName`	Commonly Used	NM103 2010B	NM102=2	1/60
`lastName`		NM103 2010B	NM102=1	1/60
`firstName`		NM104 2010B	NM102=1	1/60

Name	Element Loop	EDI Mapping Notes	Constraint
			2/3
`providerUpinNumber`	REF02 2010B	REF01=1G	1/50
`facilityIdNumber`	REF02 2010B	REF01=1J	1/50
`employerIdentificationNumber`	REF02 2010B	REF01=EI	1/50
`providerSiteNumber`	REF02 2010B	REF01=G5	1/50
`providerPlanNetworkIdNumber`	REF02 2010B	REF01=N5	1/50
`facilityNetworkIdNumber`	REF02 2010B	REF01=N7	1/50
`socialSecurityNumber`	REF02 2010B	REF01=SY	1/50
`carrierAssignedReferenceNumber`	REF02 2010B	REF01=ZH	1/50

Name	Required/Commonly Used	Element Loop	Constraint
Address Information
`address1`	Commonly Used	N301 2010F	1/55
`address2`	Commonly Used	N302 2010F	1/55
`city`	Commonly Used	N401 2010F	2/30
`state`	Commonly Used	N402 2010F	2/2
`postalCode`	Commonly Used	N403 2010F	3/15
`countryCode`		N404 2010F	2/3
`countrySubDivisionCode`		N407 2010F	1/3

Name	Required/Commonly Used	Element Loop	Constraint
Identification Code (Provide one of the following)	Required
`npi`	Commonly Used	NM109 2010B	2/80
`payorId`		NM109 2010B	2/80
`ssn`		NM109 2010B	2/80
`servicesPlanID`		NM109 2010B	2/80
`employersId`		NM109 2010B	2/80
`etin`		NM109 2010B	2/80

Name	Required/Commonly Used	Element Loop	EDI Mapping Notes	Constraint
Response) Contact Information
`contactName`		PER02 2010B	✍️If the PER segment itself is optional, even if some fields inside are marked as “Required,” they only become required when the segment is used.	1/60
`contactFacsimile`		PER04 2010B	PER03=FX or PER06 PER05=FX or PER08 PER07=FX	1/256
`contactTelephone`	Commonly Used	PER04 2010B	PER03=TE or PER06 PER05=TE or PER08 PER07=TE	1/256
`contactTelephoneExtension`		PER06 2010B	PER05=EX or PER08 PER07=EX	1/256
`providerCode`		PRV01 2010B	PER03=UM or PER06 PER05=UM or PER08 PER07=UM	1/3
`referenceIdentification`		PRV03 2010B		1/50

Request Validation (Response)

Name	Element Loop	EDI Mapping Notes	Constraint
`responseCode`	AAA01 2000A	Yes/No Condition or Response Code	1/1
`rejectReasonCode`	AAA03 2000A		2/2
`followupActionCode`	AAA04 2000A		2/2

UM Request Validation (Response)

Name	Element Loop	EDI Mapping Notes	Constraint
`responseCode`	AAA01 2010A	Yes/No Condition or Response Code	1/1
`rejectReasonCode`	AAA03 2010A		2/2
`followupActionCode`	AAA04 2010A		1/1

Requester Request Validation (Response)

Name	Element Loop	Constraint
`responseCode`	AAA01 2010B	1/1
`rejectReasonCode`	AAA03 2010B	2/2
`followupActionCode`	AAA04 2010B	1/1

Requester (Response)

Name	Required/Commonly Used	Hint	Element Loop	Code	Constraint
Response) Information Section	Required
`requesterType`	Required	Default=IP	NM101 2010B	`requesterType` ============= 1P Provider 2A Federal, State, County, or City Facility 2B Third-Party Administrator 36 Employer FA Facility PR Payer X3 Utilization Management Organization	2/3

Name	Required/Commonly Used	Element Loop	EDI Mapping Notes	Constraint
	Required
`organizationName`	Commonly Used	NM103 2010B	NM102=2	1/60
`lastName`		NM103 2010B	NM102=1	1/60
`firstName`		NM104 2010B	NM102=1	1/60

Name	Element Loop	EDI Mapping Notes	Constraint
Requestor Identification (provide any of the following if available)			2/3
`providerUpinNumber`	REF02 2010B	REF01=1G	1/50
`facilityIdNumber`	REF02 2010B	REF01=1J	1/50
`employerIdentificationNumber`	REF02 2010B	REF01=EI	1/50
`providerSiteNumber`	REF02 2010B	REF01=G5	1/50
`providerPlanNetworkIdNumber`	REF02 2010B	REF01=N5	1/50
`facilityNetworkIdNumber`	REF02 2010B	REF01=N7	1/50
`socialSecurityNumber`	REF02 2010B	REF01=SY	1/50
`carrierAssignedReferenceNumber`	REF02 2010B	REF01=ZH	1/50

Name	Required/Commonly Used	Element Loop	EDI Mapping Notes	Constraint
Response) Contact Information
`contactName`		PER02 2010B	✍️If the PER segment itself is optional, even if some fields inside are marked as “Required,” they only become required when the segment is used.	1/60
`contactFacsimile`		PER04 2010B	PER03=FX or PER06 PER05=FX or PER08 PER07=FX	1/256
`contactTelephone`	Commonly Used	PER04 2010B	PER03=TE or PER06 PER05=TE or PER08 PER07=TE	1/256
`contactTelephoneExtension`		PER06 2010B	PER05=EX or PER08 PER07=EX	1/256
`providerCode`		PRV01 2010B	PER03=UM or PER06 PER05=UM or PER08 PER07=UM	1/3
`referenceIdentification`		PRV03 2010B		1/50

Name	Required/Commonly Used	Element Loop	Code	Constraint
Identification Code (Provide one of the following)	Required
`npi`	Commonly Used	NM109 2010B		2/80
`payorId`		NM109 2010B		2/80
`ssn`		NM109 2010B		2/80
`servicesPlanID`		NM109 2010B		2/80
`employersId`		NM109 2010B		2/80
`etin`		NM109 2010B		2/80
`providerCode`		PRV01 2010B	PRV02=PXC	R 1/3
`referenceIdentification`		PRV03 2010B		S 1/50

Name	Element Loop	EDI Mapping Notes	Constraint
Requestor Identification (provide any of the following if available)			2/3
`providerUpinNumber`	REF02 2010B	REF01=1G	1/50
`facilityIdNumber`	REF02 2010B	REF01=1J	1/50
`employerIdentificationNumber`	REF02 2010B	REF01=EI	1/50
`providerSiteNumber`	REF02 2010B	REF01=G5	1/50
`providerPlanNetworkIdNumber`	REF02 2010B	REF01=N5	1/50
`facilityNetworkIdNumber`	REF02 2010B	REF01=N7	1/50
`socialSecurityNumber`	REF02 2010B	REF01=SY	1/50
`carrierAssignedReferenceNumber`	REF02 2010B	REF01=ZH	1/50

Name	Required/Commonly Used	Hint	Element Loop	EDI Mapping Notes	Constraint
Subscriber Section
`lastName`	Required	While not required by guide, widely used by payers	NM103 2010C	NM101=IL NM102=1	1/60
`firstName`	Required	While not required by guide, widely used by payers	NM104 2010C		1/35
`middleName`			NM105 2010C		1/25
`suffix`			NM107 2010C		1/10
`memberId`	Required		NM109 2010C	NM108=MI	2/80
`dateOfBirth`	Required	While not required by guide, widely used by payers	DMG02 2010C	DMG01=D8 YYYYMMDD	1/35
`address1`	Commonly Used		N301 2010C		1/55
`address2`	Commonly Used		N302 2010C		1/55
`city`	Commonly Used		N401 2010C		2/30
`state`	Commonly Used		N402 2010C		2/2
`postalCode`	Commonly Used		N403 2010C		3/15
`countryCode`			N404 2010C		2/3
`countrySubDivisionCode`			N407 2010C		1/3
`subscriberRequestValidation` (Object)
`responseCode`			AAA01 2010C		1/1
`rejectReasonCode`			AAA03 2010C		2/2
`followupActionCode`			AAA04 2010C		1/1
`Subscriber supplemental Identification` (provide any of the following if available)
`policyNumber`			REF02 2010C	REF01=1L	1/50
`branchIdentifier`			REF02 2010C	REF01=3L	1/50
`groupNumber`	Commonly Used		REF02 2010C	REF01=6P	1/50
`departmentNumber`			REF02 2010C	REF01=DP	1/50
`patientAccountNumber`			REF02 2010C	REF01=EJ	1/50
`healthInsuranceClaimNumber`			REF02 2010C	REF01=F6	1/50
`idCard`			REF02 2010C	REF01=HJ	1/50
`insurancePolicyNumber`			REF02 2010C	REF01=IG	1/50
`planNetworkIdentificationNumber`			REF02 2010C	REF01=N6	1/50
`medicaidRecipientIdentificationNumber`			REF02 2010C	REF01=NQ	1/50
`ssn`	Commonly Used		REF02 2010C	REF01=SY	1/50

Dependent (Response)

Name	Required/Commonly Used	Hint	Element Loop	EDI Mapping Notes	Constraint
Dependent Section (required if patient is a dependent of the Insured Individual)
`lastName`	Required	While not required by guide, widely used by payers	NM103 2010D	NM101=QC NM102=1	1/60
`firstName`	Required	While not required by guide, widely used by payers	NM104 2010D	NM102=1	1/35
`middleName`			NM105 2010D		1/25
`suffix`			NM107 2010D		1/10
`dateOfBirth`	Required	While not required by guide, widely used by payers	DMG02 2010D	DMG01=D8 YYYYMMDD	1/35
Requestor Address Information
`address1`	Commonly Used		N301 2010D		1/55
`address2`	Commonly Used		N302 2010D		1/55
`city`	Commonly Used		N401 2010D		2/30
`state`	Commonly Used		N402 2010D		2/2
`postalCode`	Commonly Used		N403 2010D		3/15
`countryCode`			N404 2010D		2/3
`countrySubDivisionCode`			N407 2010D		1/3
`dependentRequestValidation` (Object)
`responseCode`			AAA01 2010D		1/1
`rejectReasonCode`			AAA03 2010D		2/2
`followupActionCode`			AAA04 2010D		1/1
`supplementalIdentification` (Object)
Dependent Supplemental Identification (provide any of the following if available)
`employeeIdentificationNumber`			REF02 2010D	REF01=28	1/50
`patientAccountNumber`			REF02 2010D	REF01=EJ	1/50
`ssn`	Commonly Used		REF02 2010D	REF01=SY	1/50

Patient Event Detail (Response)

Name	Required/Commonly Used	Hint	Element Loop	Code	EDI Mapping Notes	Constraint
Health Care Services Review Information
`requestCategoryCode`	Commonly Used		UM01 2000E	`requestCategoryCode` ====================== AR Admission Review HS Health Services Review IN Individual SC Specialty Care Review		1/2
`certificationTypeCode`			UM02 2000E	`certificationTypeCode` ======================== 1 Appeal - Immediate 2 Appeal - Standard 3 Cancel 4 Extension I Initial N Reconsideration R Renewal S Revised		1/1
`serviceTypeCode`			UM03 2000E			1/2
`facilityTypeCode`			UM04_1 2000E			1/2
`facilityCodeQualifier`			UM04_2 2000E			1/2
`certificationActionCode`			HCR01 2000E			1/2
`reviewIdentificationNumber`			HCR02 2000E			1/50
`reviewDecisionReasonCode`			HCR03 2000E			1/30
`secondSurgicalOpinionIndicator`			HCR04 2000E			1/1
`previousReviewAuthorizationNumber`	Commonly Used	Should be sent if known by submitter	REF02 2000E		REF01=BB	1/50
`previousAdministrativeReferenceNumber`		Should be sent if known by submitter	REF02 2000E		REF01=NT	1/50
`eventDateBegin`	Commonly Used	Send if related to Health Services Review (UM01 = HS) or Referrals (UM01 = SC)	DTP03 2000E		DTP01=AAH DTP02=D8 YYYYMMDD	1/35
`eventDateEnd`			DTP03 2000E		DTP01=AAH DTP02=RD8 YYYYMMDD EventDateBegin must exist	1/35
`admissionDateBegin`		Send if related to Admission Review (UM01 = AR)	DTP03 2000E		DTP01=435 DTP02=D8 YYYYMMDD	1/35
`admissionDateEnd`			DTP03 2000E		DTP01=435 DTP02=RD8 YYYYMMDD AdmissionDateBegin must exist	1/35
`dischargeDate`			DTP03 2000E		DTP01=096 DTP02=D8 YYYYMMDD	1/35
`certificationIssueDate`			DTP03 2000E		DTP01=102 DTP02=D8 YYYYMMDD	1/35
`certificationExpirationDate`			DTP03 2000E		DTP01=036 DTP02=D8 YYYYMMDD	1/35
`certificationEffectiveDateBegin`			DTP03 2000E		DTP01=007 DTP02=D8 YYYYMMDD	1/35
`certificationEffectiveDateEnd`			DTP03 2000E		DTP01=007 DTP02=RD8 YYYYMMDD CertificationEffectiveDateBegin must exist	1/35
`healthCareServicesReviewRequestDateBegin`			DTP03 2000E		DTP01=881 DTP02=D8 YYYYMMDD	1/35
`healthCareServicesReviewRequestDateEnd`			DTP03 2000E		DTP01=881 DTP02=RD8 YYYYMMDD HealthCareServicesReviewRequestDateBegin must exist	1/35
Diagnosis
`diagnosisTypeCode`			HI01_1 2000E			1/3
`diagnosisCode`			HI01_2 2000E			1/30
`quantityQualifier`			HSD01 2000E			2/2
`serviceUnitCount`			HSD02 2000E			1/15
`unitOrBasisForMeasurementCode`			HSD03 2000E			2/2
`sampleSelectionModulus`			HSD04 2000E			1/6
`timePeriodQualifier`			HSD05 2000E			1/2
`periodCount`			HSD06 2000E			1/3
`deliveryFrequencyCode`			HSD07 2000E			1/2
`deliveryPatternTimeCode`			HSD08 2000E			1/1
`institutionalAdmissionTypeCode`			CL101 2000E			1/1
`institutionalAdmissionSourceCode`			CL102 2000E			1/1
`institutionalPatientStatusCode`			CL103 2000E			1/2
`ambulanceTransportCode`			CR103 2000E			1/2
`ambulanceUnitOrBasisForMeasurementCode`			CR105 2000E			2/2
`ambulanceTransportDistance`			CR106 2000E			1/15
`spinalManipulationTreatmentSeriesNumber`			CR201 2000E			1/9
`spinalManipulationTreatmentCount`			CR202 2000E			1/15
`spinalManipulationSubluxationLevelCode`			CR203 2000E			2/3
`spinalManipulationSubluxationLevelCode2`			CR204 2000E			2/3
`oxygenEquipmentTypeCode`			CR503 2000E			1/1
`oxygenEquipmentTypeCode2`			CR504 2000E			1/1
`oxygenFlowRate`			CR506 2000E			1/15
`dailyOxygenUseCount`			CR507 2000E			1/15
`oxygenUsePeriodHourCount`			CR508 2000E			1/15
`respiratoryTherapistOrderText`			CR509 2000E			1/80
`portableOxygenSystemFlowRate`			CR516 2000E			1/15
`oxygenDeliverySystemCode`			CR517 2000E			1/1
`oxygenSystemTypeCode`			CR518 2000E			1/1
`homeHealthPrognosisCode`			CR601 2000E			1/1
`homeHealthStartDate`			CR602 2000E			8/8
`homeHealthCertificationPeriod`			CR604 2000E			1/35
`homeHealthMedicareCoverageIndicator`			CR607 2000E			1/1
`homeHealthCertificationTypeCode`			CR608 2000E			1/1
`freeFormMessageText`			MSG01 2000E			1/264
`dependentRequestValidation` (Object)
`responseCode`			AAA01 2000E			1/1
`rejectReasonCode`			AAA03 2000E			2/2
`followupActionCode`			AAA04 2000E			1/1
`patientEventTransportInformation` (Object)
`entityIdentifierCode`	Commonly Used		NM101 2000EB	`entityIdentifierCode` ======================= 71 Attending Physician 72 Operating Physician 73 Other Physician 77 Service Location AAJ Admitting Services DD Assistant Surgeon DK Ordering Physician DN Referring Provider FA Facility G3 Clinic P3 Primary Care Provider QB Purchase Service Provider QV Group Practice SJ Service Provider		2/3
`organizationName`			NM103 2000EB			1/60
`identificationCodeQualifier`			NM108 2000EB			1/2
`identifier`			NM109 2000EB			2/80
`address1`			N301 2000EB			1/55
`address2`			N302 2000EB			1/55
`city`			N401 2000EB			2/30
`state`			N402 2000EB			2/2
`postalCode`			N403 2000EB			3/15

Patient Event Provider Name (Response)

Name	Required/Commonly Used	Element Loop	EDI Mapping Notes	Constraint
Patient Event Provider Name Section (Can contain multiple instances)
`entityIdentifierCode`		NM101 2010EA		2/3
Provider Name (if Provider is an individual, provide `lastName` and `firstName`, otherwise provide organizationName)
`organizationName`		NM103 2010EA	NM102=2	1/60
`lastName`	Commonly Used	NM103 2010EA	NM102=1	1/60
`firstName`	Commonly Used	NM104 2010EA	NM102=1	1/35
`middleName`		NM105 2010EA		1/25
`namePrefix`		NM106 2010EA		1/10
`nameSuffix`		NM107 2010EA		1/10
`identificationCodeQualifier`	Commonly Used	NM108 2010EA		1/2
`identifier`	Commonly Used	NM109 2010EA		2/80
Patient Event Provider Address Information
`address1`		N301 2010EA		1/55
`address2`		N302 2010EA		1/55
`city`		N401 2010EA		2/30
`state`		N402 2010EA		2/2
`postalCode`		N403 2010EA		3/15
`countryCode`		N404 2010EA		2/3
`countrySubDivisionCode`		N407 2010EA		1/3
`contactName`		PER02 2010EA		1/60
`contactElectronicMail`		PER04 2010EA	PER03=EM or PER06 PER05=EM or PER08 PER07=EM	1/256
`contactFacsimile`		PER04 2010EA	PER03=FX or PER06 PER05=FX or PER08 PER07=FX	1/256
`contactTelephone`		PER04 2010EA	PER03=TE or PER06 PER05=TE or PER08 PER07=TE	1/256
`contactTelephoneExtension`		PER06 2010EA	PER05=EX or PER08 PER07=EX	1/256
`contactUrl`		PER04 2010EA	PER03=UM or PER06 PER05=UM or PER08 PER07=UM	1/256
`providerCode`		PRV01 2010EA	PRV02=PXC	1/3
`providerTaxonomyCode`		PRV03 2010EA		1/50
`patientEventProviderRequestValidation` (Object)
responseCode		AAA01 2010EA		1/1
rejectReasonCode		AAA03 2010EA		2/2
followupActionCode		AAA04 2010EA		1/1
`providerSupplementalInformation` (Object)
`stateLicenseNumber`		REF02 2010EA	REF01=0B	1/50
`licenseNumberStateCode`		REF03 2010EA	Required if `StateLicenseNumber` is entered	1/80
`providerUpinNumber`		REF02 2010EA	REF01=1G	1/50
`facilityIdNumber`		REF02 2010EA	REF01=1J	1/50
`employersIdentificationNumber`		REF02 2010EA	REF01=EI	1/50
`providerPlanNetworkIdentificationNumber`		REF02 2010EA	REF01=N5	1/50
`facilityNetworkIdentificationNumber`		REF02 2010EA	REF01=N7	1/50
`ssn`		REF02 2010EA	REF01=SY	1/50
`carrierAssignedReferenceNumber`		REF02 2010EA	REF01=ZH	1/50

Patient Event Service Level (Response)

Name	Required/Commonly Used	Hint	Element Loop	Code	EDI Mapping Notes	Constraint
Service Level Section (One instance per procedure code)	Required
Health Care Services Review Information
`requestCategoryCode`	Commonly Used		UM01 2000F	`requestCategoryCode` ====================== HS Health Services Review SC Specialty Care Review		1/2
`certificationTypeCode`			UM02 2000F	`certificationTypeCode` ======================== 1 Appeal - Immediate 2 Appeal - Standard 3 Cancel 4 Extension I Initial N Reconsideration R Renewal S Revised		1/1
`serviceTypeCode`			UM03 2000F			1/2
`facilityTypeCode`	Commonly Used		UM04_1 2000F			1/2
`facilityCodeQualifier`	Commonly Used		UM04_2 2000F			1/2
`certificationActionCode`			HCR01 2000F			1/2
`reviewIdentificationNumber`			HCR02 2000F			1/50
`reviewDecisionReasonCode`			HCR03 2000F			1/30
`secondSurgicalOpinionIndicator`			HCR04 2000F			1/1
`previousReviewAuthorizationNumber`			REF02 2000F		REF01=BB	1/50
`previousAdministrativeReferenceNumber`			REF02 2000F		REF01=NT	1/50
`serviceDateBegin`	Commonly Used	Usually same as 2000E Event Date	DTP03 2000F		DTP01=472 DTP02=D8 YYYYMMDD	1/35
`serviceDateEnd`			DTP03 2000F		DTP01=472 DTP02=RD8 YYYYMMDD ServiceDateBegin must exist	1/35
`certificationIssueDate`			DTP03 2000F		DTP01=102 DTP02=D8 YYYYMMDD	1/35
`certificationExpirationDate`			DTP03 2000F		DTP01=036 DTP02=D8 YYYYMMDD	1/35
`certificationEffectiveDateBegin`			DTP03 2000F		DTP01=007 DTP02=D8 YYYYMMDD	1/35
`certificationEffectiveDateEnd`			DTP03 2000F		DTP01=007 DTP02=RD8 YYYYMMDD CertificationEffectiveDateBegin must exist	1/35
`quantityQualifier`			HSD01 2000F			2/2
`serviceUnitCount`			HSD02 2000F			1/15
`unitOrBasisForMeasurementCode`			HSD03 2000F			2/2
`sampleSelectionModulus`			HSD04 2000F			1/6
`timePeriodQualifier`			HSD05 2000F			1/2
`periodCount`			HSD06 2000F			1/3
`deliveryFrequencyCode`			HSD07 2000F			1/2
`deliveryPatternTimeCode`			HSD08 2000F			1/1
`freeFormMessageText`			MSG01 2000F			1/264
`serviceRequestValidation` (Object)
`responseCode`			AAA01 2000F			1/1
`rejectReasonCode`			AAA03 2000F			2/2
`followupActionCode`			AAA04 2000F			1/1
`professionalService` (Object)
One of the following Service Sections is Required	Required
Professional Service Information
`productOrServiceIDQualifier`	Commonly Used		SV101_1 2000F	`productOrServiceIDQualifier` ============================== HC HCPCS N4 National Drug Code		2/2
`procedureCode`	Commonly Used	While not required strongly recommended as procedure code required by some payers if not sending `previousReviewAuthorizationNumber` or `previousAdministrativeReferenceNumber`	SV101_2 2000F			1/48
`procedureModifier`			SV101_3 2000F			2/2
`procedureModifier2`			SV101_4 2000F			2/2
`procedureModifier3`			SV101_5 2000F			2/2
`procedureModifier4`			SV101_6 2000F			2/2
`procedureCodeDescription`			SV101_7 2000F			1/80
`procedureCode2`			SV101_8 2000F			1/48
`serviceLineAmount`			SV101_8 2000F			1/48
`unitOrBasisForMeasurementCode`			SV103 2000F	`unitOrBasisForMeasurementCode` ================================ F2 International Unit MJ Minutes UN Unit		2/2
`serviceUnitCount`			SV104 2000F			1/15
`epsdtIndicator`			SV111 2000F			1/1
`institutionalService` (Object)
`serviceLineRevenueCode`			SV201 2000F	`ProductOrServiceIDQualifier` ============================== HC HCPCS or CPT N4 National Drug Code ZZ ICD-10		1/48
`productOrServiceIDQualifier`			SV202_1 2000F			2/2
`procedureCode`			SV202_2 2000F			1/48
`procedureModifier`			SV202_3 2000F			2/2
`procedureModifier2`			SV202_4 2000F			2/2
`procedureModifier3`			SV202_5 2000F			2/2
`procedureModifier4`			SV202_6 2000F			2/2
`procedureCodeDescription`			SV202_7 2000F			1/80
`procedureCode2`			SV202_8 2000F			1/48
`serviceLineAmount`			SV203 2000F			1/18
`unitOrBasisForMeasurementCode`			SV204 2000F			2/2
`serviceUnitCount`			SV205 2000F			1/15
`serviceLineRate`			SV206 2000F			1/10
`dentalService` (Object)
`procedureModifier`			SV301_3 2000F			2/2
`procedureCode`			SV301_2 2000F		SV301_1=AD	1/48
`procedureModifier2`			SV301_4 2000F			2/2
`procedureModifier3`			SV301_5 2000F			2/2
`procedureModifier4`			SV301_6 2000F			2/2
`procedureCodeDescription`			SV301_7 2000F			1/80
`procedureCode2`			SV301_8 2000F			1/48
`serviceLineAmount`			SV302 2000F			1/18
`americanDentalAssociationCodes`			SV304_1 2000F			1/3
`americanDentalAssociationCodes2`			SV304_2 2000F			1/3
`americanDentalAssociationCodes3`			SV304_3 2000F			1/3
`americanDentalAssociationCodes4`			SV304_4 2000F			1/3
`americanDentalAssociationCodes5`			SV304_5 2000F			1/3
`prosthesisCrownOrInlayCode`			SV305 2000F			1/1
`serviceUnitCount`			SV306 2000F			1/15
`toothInformation` (Object)
`toothCode`			TOO02 2000F		TOO01=JP	1/30
`toothSurfaceCode`			TOO03_1 2000F			1/2
`toothSurfaceCode2`			TOO03_2 2000F			1/2
`toothSurfaceCode3`			TOO03_3 2000F			1/2
`toothSurfaceCode4`			TOO03_4 2000F			1/2
`toothSurfaceCode5`			TOO03_5 2000F			1/2

Patient Event Service Level Provider (Response)

Name	Required/Commonly Used	Element Loop	Code	EDI Mapping Notes	Constraint
Service Level Provider Name Section (can contain multiple instances)
`entityIdentifierCode`		NM101 2010F	`entityIdentifierCode` ======================= 72 Operating Physician 73 Other Physician 77 Service Location DD Assistant Surgeon DK Ordering Physician DQ Supervising Physician FA Facility G3 Clinic P3 Primary Care Provider QB Purchase Service Provider QV Group Practice SJ Service Provider		2/3
Provider Name (if Provider is an individual, provide `lastName` and `firstName`, otherwise provide `organizationName`)
`organizationName`		NM103 2010F		NM102=2	1/60
`lastName`		NM103 2010F		NM102=1	1/60
`firstName`		NM104 2010F		NM102=1	1/35
`middleName`		NM105 2010F			1/25
`namePrefix`		NM106 2010F			1/10
`nameSuffix`		NM107 2010F			1/10
`identificationCodeQualifier`		NM108 2010F	`IdentificationCodeQualifier` ============= 4 Employer’s Identification Number 34 Social Security Number 46 Electronic Transmitter Identification Number (ETIN) XX (NPI)		1/2
`identifier`		NM109 2010F			2/80
Service Level Provider Address Information
`address1`		N301 2010F			1/55
`address2`		N302 2010F			1/55
`city`		N401 2010F			2/30
`state`		N402 2010F			2/2
`postalCode`		N403 2010F			3/15
`countryCode`		N404 2010F			2/3
`countrySubDivisionCode`		N407 2010F			1/3
`contactName`		PER02 2010F			1/60
`contactElectronicMail`		PER04 2010F		PER03=EM or PER06 PER05=EM or PER08 PER07=EM	1/256
`contactFacsimile`		PER04 2010F		PER03=FX or PER06 PER05=FX or PER08 PER07=FX	1/256
`contactTelephone`		PER04 2010F		PER03=TE or PER06 PER05=TE or PER08 PER07=TE	1/256
`contactTelephoneExtension`		PER06 2010F		PER05=EX or PER08 PER07=EX	1/256
`contactUrl`		PER04 2010F		PER03=UM or PER06 PER05=UM or PER08 PER07=UM	1/256
`providerCode`		PRV01 2010F		PRV02=PXC	1/3
`providerTaxonomyCode`		PRV03 2010F			1/50
`serviceProviderRequestValidation` (Object)
`responseCode`		AAA01 2010F			1/1
`rejectReasonCode`		AAA03 2010F			2/2
`followupActionCode`		AAA04 2010F			1/1
`providerSupplementalInformation (Object)`
Provider Supplemental Information (provide any of the following if available)
`stateLicenseNumber`		REF02 2010F		REF01=0B	1/50
`licenseNumberStateCode`	Required if StateLicenseNumber is entered	REF03 2010F			1/80
`providerUpinNumber`		REF02 2010F		REF01=1G	1/50
`facilityIdNumber`		REF02 2010F		REF01=1J	1/50
`employersIdentificationNumber`		2010F REF02		REF01=EI	1/50
`providerSiteNumber`		REF02 2010F		REF01=G5	1/50
`providerPlanNetworkIdentificationNumber`		REF02 2010F		REF01=N5	1/50
`facilityNetworkIdentificationNumber`		REF02 2010F		REF01=N7	1/50
`ssn`		REF02 2010F		REF01=SY	1/50
`carrierAssignedReferenceNumber`		REF02 2010F		REF01=ZH	1/50