Integrated Rules Institutional Claims JSON-to-EDI 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").

📘
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.

See JSON-to-EDI API Mapping.

The Consolidated 837i Implementation Guide page 53 discusses this in further detail.

📘
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.

Institutional Claims Request JSON-to-EDI mapping

Transaction Header (Request)

Submitter

Receiver

Subscriber

Other Subscriber Information (2320)

Dependent

Providers

Provider Contact Information

Billing Provider Pay to Plan Name

Billing Provider Address

Operating Physician

Other Operating Physician

Other Payer (2330B)

Other Payer Referring Provider (2330H)

Other Payer Rendering Provider (2330G)

Claim Information

Claim Notes

EPSDT Referral

Claim Date Information

Claim Code Information

Claim Contract Information

Claim Supplemental/Report Information (Paperwork)

Claim Supplemental/Reference Information

Condition Codes

Principal Diagnosis

Admitting Diagnosis

Patient’s Reason for Visit

External Cause of Injury

Diagnosis Related Group Information

Other Diagnosis Information List

Principal Procedure Information

Other Procedure Information List

Occurrence Span Information List

Occurrence Information List

Value Information List

Treatment Code Information List

Claim Pricing Information

Service Facility Location

Institutional Service Lines

Drug Identification (2410)

Line Adjudication (2430)

Claim Line Adjustment (2430)

Integrated Rules Institutional Claims JSON-to-EDI mapping

Transaction Header (Request)

Field	Description	C/R
`controlNumber`	Transaction Set Control Number. This is provided by the submitter. Unique ID used to trace the request. Value goes in ISA13 (no loop).	R 9/9
`tradingPartnerServiceId`	ID used by the clearinghouse for the trading partner. Loop 2100A, NM109. You can use the ConnectCenter CPID value as the `tradingPartnerServiceId` from the searchable Optum Payer List.	2/80 R

Submitter

Name	Element	Loop	Description	C/R
`submitter` (Object)			Identification of the provider, including information, such as the organizationName.
`organizationName`	NM103	1000A	Organization name for the submitter. Can use organization or last name.	1/60 R
`taxId`	NM108	1000A	Electronic Transmitter Identification Number (ETIN) 46.	1/2 R
`contactInformation`				R
`name`	PER02	1000A	Submitter name.	1/60 R
`phoneNumber`	PER04	1000A	Phone number of the submitter. PER03 = TE	1/256 R
`faxNumber`	PER04	1000A	Fax number of the submitter. PER03 = FX	1/256 S
`email`	PER04	1000A	Email address of the submitter. PER03 = EM	1/256 S

Receiver

Name	Element	Loop	Description	C/R
`receiver` (Object)				R
`organizationName`	NM103	1000B	Organization name for the holder of the insurance policy.	1/60 R
`taxId`	NM108	1000B	Electronic Transmitter Identification Number (ETIN) 46.	1/2 S

Subscriber

Contains the information about the person holding the insurance policy.

Name	Element	Loop	Description	C/R
`subscriber` (Object)			Medical insurance subscriber; includes the patient's insurance member ID and insurance policyNumber.	R
`lastName`	NM103	2010BA	The subscriber’s last name as shown on their policy.	1/60 R
`firstName`	NM104	2010BA	The subscriber’s first name as shown on their policy.	1/35 S
`middleName`	NM105	2010BA	Subscribers middle name.	1/25 S
`memberId`	NM109	2010BA	The subscriber’s insurance member ID. NM108 = MI (Standard Unique Health Identifier for each Individual in the United States)	2/80 R
`ssn`	REF02	2010BA	Subscriber’s social security number. REF01 = SY	1/50 S
`standardHealthId`	NM109	2010BA	Standard health Identifier. NM108 = II (Standard Unique Health Identifier for each U.S. Individual) 📝 Only sent if Member ID is not assigned by payer.	2/80 S
`paymentResponsibilityLevelCode`	SBR01	2320	Code identifying the payer's level of responsibility for payment of claim. Example: P = Primary	1/1 R
`dateOfBirth`	DMG02	2010BA	The subscriber’s birth date listed on their policy. Required when the subscriber is the patient.	1/35 S
`gender`	DMG03	2010BA	The subscriber’s gender as shown on their policy. F = Female; M = Male; U = Unknown Required when the subscriber is the patient.	1/1 S
`address` (Object)
`address1`	N301	2010BA	Subscriber’s address line 1. Required when the subscriber is the patient.	1/35 S
`address2`	N302	2010BA	Subscriber’s address line 2.	1/35 S
`city`	N401	2010BA	Subscriber’s city. Required when the subscriber is the patient.	2/30 S
`state`	N402	2010BA	Subscriber’s state. Required when the subscriber is the patient and when the claim is inside US or CA.	2/2 S
`postalCode`	N403	2010BA	Subscriber’s postal code. Required when the subscriber is the patient and when the claim is inside US or CA.	3/15 S
`countryCode`	N404	2010BA	Pay-to country code.	1/35 S
`countrySubDivisionCode`	N404	2010BA	Pay-to country code.	1/35 S

Other Subscriber Information (2320)

Name	Element	Loop	Description	C/R
`otherSubscriberInformation` (Object)			The insurance policy holder.	S
`individualRelationshipCode`	SBR02	2320	Code indicating the relationship between two individuals or entities. Example: 01 = Spouse Required when patient is the subscriber.	2/2
`policyNumber`	SBR03	2320	Deprecated The subscriber’s policy number as shown on their policy.	1/50
`groupNumber`	SBR03	2320	The subscriber’s group number as shown on their policy.	1/50 S
`otherInsuredGroupName`	SBR04	2320	Plan name.	1/60 S
`claimFilingIndicatorCode`	SBR09	2320	Code identifying the claim type. Example: 13 = Point of Service	1/2 R

Dependent

📘
NOTE
When the dependent is the patient, elements marked with “R” in the C/R column are required.

Name	Element	Loop	Description	C/R
`dependent` (Object)			Dependent of the policy holder (information about the insurance policy holder's dependent who received the medical services.	S
`lastName`	NM103	2010CA	Dependent’s last name. Required if patient is a dependent of subscriber and cannot be uniquely identified.	1/60 S
`firstName`	NM104	2010CA	Dependent’s first name.	1/35 R
`middleName`	NM105	2010CA	Dependent’s middle name.	1/25 S
`dateOfBirth`	DMG02	2010CA	Dependent’s birth date. Required if patient is a dependent of subscriber and cannot be uniquely identified.	1/35 S
`gender`	DMG03	2010CA	Dependent’s gender code. Options: F or M Required if patient is a dependent of subscriber and cannot be uniquely identified.	1/1 S
`ssn`	REF02	2010CA	Dependent social security number. REF01 = SY	1/50 S
`relationshipToSubscriberCode`	PAT01	2000C	Patient’s relationship to insured. Example: 01 = Spouse Required if patient is a dependent of subscriber and cannot be uniquely identified.	2/2 R

Providers

📘
NOTE
Another way to set billing, referring, rendering and attending provider information. If used, it will overwrite anything you send in billing, referring, rendering, and attending.
Loop: 2000A, 2310F, 2310D, 2310A.

Name	Element	Loop	Description	C/R
`providers` (Array of Objects)			The providers involved with the medical claim.	R
`providerType`	NM101	As noted.	Code for provider type. 85 = Billing Provider 2010BB 82 = Rendering Provider 2310D DN = Referring Provider 2310F	2/3 R
`npi`	NM109	As noted.	National Provider Identification value. NM108 = XX Billing Provider 2010AA Rendering 2310D Referring 2310F	2/80 S
`ssn`	REF02	2010AA	Provider’s social security number. REF01 = SY	S
`employerId`	REF02	2010AA	Provider tax ID number. REF01 = EI	1/50 R
Obsolete/Deprecated REF02 values for this segment/object include the following:
`commercialNumber` `locationNumber` `stateLicenseNumber` `providerUpinNumber`			See `otherPayerRenderingProvider` and `otherPayerReferringProvider` for current values.

Provider Contact Information

Name	Element	Loop	Description	C/R
`contactInformation` (Object)			Each provider's contact information
`organizationName`	NM103	2010AA	Provider’s organization name, you can use organization or last name.	1/60 R
`lastName`	NM103	2010AA	Provider last name, you can use organization or last name.	1/60 R
`firstName`	NM104	2010AA	Provider first name.	1/35 S
`middleName`	NM105	2010AA	Middle initial.	1/25 S
`address` (Object)
`address1`	N301	2010AA	Provider’s address line 1.	1/35 R
`address2`	N302	2010AA	Provider’s address line 2.	1/35 S
`city`	N401	2010AA	Provider’s city.	1/60 R
`state`	N402	2010AA	Provider’s state. Required for claims inside the US/CA.	1/35 S
`postalCode`	N403	2010AA	Provider’s postal code. All claims inside the US/CA require a 9-digit zip code.	3/15 S
`countryCode`	N404	2010AA	Pay-to country code.	1/35 S
`countrySubDivisionCode`	N404	2010AA	Pay-to country code.	1/35 S
`contactInformation` (Object)
`name`	PER02	2010AA	Provider contact name.	1/60 R
`faxNumber`	PER04	2010AA	Provider fax number. PER03 = FX	1/256 S
`phoneNumber`	PER04	2010AA	Provider contact phone number. PER03 = TE	1/256 R

Billing Provider Pay to Plan Name (Loop 2010AC — Sub-loop of Loop 2000A)

Name	Element	Loop	Description	C/R
`billingPayToPlanName` (Object)	NM1		Provide full name and identification of an individual or entity	S
`organizationName`	NM103	2010AC	NM103 where, NM102 = 2	1/60 R
`identificationCodeQualifier`	NM108	2010AC	Identification Code Qualifier. If this value is present, NM108 is required.	1/2 R
`identificationCode`	NM109	2010AC	If this value is present, NM108 is required.	2/80 R
`payerIdentificationNumber`	REF02	2010AC	REF02 where, REF01 = 2U	1/50 S
`claimOfficeNumber`	REF02	2010AC	Electronic Transmitter ID Number (ETIN) 46. REF02 where, REF01 = FY	1/2 S
`taxId`	REF02	2010AC	REF02 where, REF01 = EI	9/9 S
`naic`	REF02	2010AC	REF02 where, REF01 = NF. Employer's Identification Number.	6/6 S
`address` (Object)				R
`address1`	N301	2010AC	Provider’s address line 1.	1/35 R
`address2`	N302	2010AC	Provider’s address line 2.	1/35 S
`city`	N401	2010AC	Provider’s city.	1/60 R
`state`	N402	2010AC	Provider’s state or province code. Required for claims in US/CA.	1/35 S
`postalCode`	N403	2010AC	Provider’s postal code. All claims inside the US/CA require a 9-digit zip code.	3/15 R
`countryCode`	N404	2010AC	Pay-to country code.	1/35 S
`countrySubDivisionCode`	N404	2010AC	Pay-to country code.	1/35 S

Billing Provider Address (Loop 2010AB — Sub-loop of Loop 2000A)

Name	Element	Loop	Description	C/R
`billingPayToAddressName` (Object)			Billing provider location record.
`entityTypeQualifier`	NM102	2010AB	Billing Provider Qualifier 1 = Person 2 = Non-Person Entity	1/1 R
`address` (Object)				R
`address1`	N301	2010AB	Billing Provider’s address line 1.	1/35 R
`address2`	N302	2010AB	Billing Provider’s address line 2.	1/35 S
`city`	N401	2010AB	Billing Provider’s city.	1/60 R
`state`	N402	2010AB	Billing Provider’s state/province. Required for claims in US/CA).	1/35 R
`postalCode`	N403	2010AB	Billing Provider’s postal code. All claims inside the US/CA require a 9-digit zip code.	3/15 R
`countryCode`	N404	2010AB	Billing Pay-to country code.	1/35 S
`countrySubDivisionCode`	N404	2010AB	Billing Pay-to country code.	1/35 S

Operating Physician (Loop 2010AA — Sub-loop of Loop 2000A)

Name	Element	Loop	Description	C/R
`operatingPhysician` (Object)			Doctor's information.
`organizationName`	NM103	2010AA	Provider’s organization name, you can use organization or last name.	1/60 R
`lastName`	NM103	2010AA	Provider last name, you can use organization or last name).	1/60 R
`firstName`	NM104	2010AA	Provider first name.	1/35 S
`middleName`	NM105	2010AA	Middle initial.	1/25 S
Obsolete/Deprecated REF02 values for this segment/object include the following:
`commercialNumber` `locationNumber` `stateLicenseNumber` `providerUpinNumber`			See `otherPayerRenderingProvider` and `otherPayerReferringProvider` for current values.

Other Operating Physician

Name	Element	Loop	Description	C/R
`otherOperatingPhysician` (Object)			Records for any other physicians involved in the claim.	S
`organizationName`	NM103	2010AA	Provider’s organization name. Can use organization or last name.	1/60 R
`lastName`	NM103	2010AA	Provider last name , you can use organization or last name.	1/60 R
`firstName`	NM104	2010AA	Provider first name.	1/35 S
`middleName`	NM105	2010AA	Middle initial.	1/25 S
Obsolete/Deprecated REF02 values for this segment/object include the following:
`commercialNumber` `locationNumber` `stateLicenseNumber` `providerUpinNumber`			See `otherPayerRenderingProvider` and `otherPayerReferringProvider` for current values.

Other Payer (2330B)

Name	Element	Loop	Description	C/R
`otherPayerName` (Object)			The other organization that pays for the insurance policy.	R
`otherPayerOrganizationName`	NM103	2330B	The Payer’s name as specified on their policy.	1/60 R
`otherPayerIdentifierTypeCode`	NM108	2330B	Type of identification. Example: PI = Payer ID Number	1/2
`otherPayerIdentifier`	NM109	2330B	Code identifying a party or other code.	2/80 R
`otherPayerAddress` (Object)				S
`address1`	N301	2330B	Payer’s address line 1. Required when other payer is payer for the patient.	1/35 S
`address2`	N302	2330B	Payer’s address line 2.	1/35 S
`city`	N401	2330B	Payer’s city. Required when other is payer for the patient.	1/60 S
`state`	N402	2330B	Payer’s state of residence Required when other payer is payer for the patient.	1/35 S
`postalCode`	N403	2330B	Payer’s postal code. Required when other payer is the payer for the patient.	3/15 S
`countryCode`	N404	2330B	Country Code.	1/35 S
`countrySubDivisionCode`	N404	2330B	Country Sub Division Code.	1/35
`otherPayerAdjudicationOrPaymentDate`	DTP03	2330B	Expression of a date. DTP01 = 573 (Date Claim Paid) DTP02 = D8	1/35
`otherPayerSecondaryIdentifier`				R
`qualifier`	REF01	2330B	Other payer secondary identifier . REF01 = 2U/EI/FY/NF	2/3
`identifier`	REF02	2330B	Value of the ID.	1/50
`otherPayerClaimAdjustmentIndicator`	REF02	2330B	Used for payer-to-payer Coordination of Benefits. Required if REF01 = T4 (Signal Code).	1/50 S
`otherPayerClaimControlNumber`	REF02	2330B	Used to assist payer-to-payer Coordination of Benefits actions. REF01 = F8	1/50 S

Other Payer Referring Provider (2330H)

Name	Element	Loop	Description	C/R
`otherPayerReferringProvider` (Object)		2330H	NM101=DN (Referring Provider) NM102=1 (Person) Array[Other Payer Referring Provider] Note: be sure to review the OpenAPI to understand this object	S
`otherPayerReferringProviderIdentifier`		2330H	NM101 = P3 (Primary Care Provider) NM102=1 (Person) Array[ReferenceIdentification]	R
`referenceIdentification` (Object)		2330H		R
`qualifier`	REF01	2330H	Type of ID. REF01=0B/1G/G2 OB - State License Number 1G - Provider UPIN Number G2 - Provider Commercial Number	2/3 S
`identifier`	REF02	2330H	REF01 ID/number.	1/50 S

Other Payer Rendering Provider (2330G)

Name	Element	Loop	Description	C/R
`otherPayerRenderingProvider` (Object)		2330G	Supplies the full name of an individual or organization.	S
`entityTypeQualifier`	2330G	NM102	NM101=82 (Rendering Provider) NM102 = 1 (Person) or 2 (Non-Person Entity)
`otherPayerRenderingProviderIdentifier`	REF01	2330G	Provider who provided medical care	1/1 R
`referenceIdentification` (Object)	2330G	REF02	Reference ID as specified by the transaction set or by the REF01 `qualifier`	1/50 R
`qualifier`	REF01	2330G	Type of ID. REF01=0B/1G/G2: OB - State License Number 1G: Provider UPIN Number G2: Provider Commercial Number LU: Location Number	2/3 R
`identifier`	REF02	2330G	REF01 ID/number.	1/50 R

See Page 146 of the Consolidated 837 TR3 for more details. Note that the claimChargeAmount field in this object is the sum total of all service lines' individual lineItemChargeAmountvalues. The amount in the claimChargeAmount MUST equal the sum of all service line charge amounts.

Name	Element	Loop	Description	C/R
`claimInformation` (Object)			A key block of medical coding information that defines the actual procedures and services rendered for the medical encounter. It contains other JSON blocks including the serviceLines objects that contain the professionalService line item charges and diagnosis information.
`claimFilingCode`	SBR09	2000B	Subscriber claim filing code. Example: 12 = PPO	1/2R
`propertyCasualtyClaimNumber`	REF02	2010CA	Patient property and casualty claim number. REF01=Y4	1/50
`patientWeight`	PAT08	Deprecated Patient weight.	1/10
`patientControlNumber`	CLM01	2300	Identifier to track a claim from creation by the provider through payment.	1/38 R
`claimChargeAmount`	CLM02	2300	Total claim charge amount. This value must equal the sum total of all service line charge amounts (reported in Loop 2400 SV203 for each service line)	1/18 R
`placeOfServiceCode`	CLM05 -01	2300	Code identifying where services were or may be performed.	1/2 R
`claimFrequencyCode`	CLM05 -03	2300	Code defining claim frequency.	1/1 R
`signatureIndicator`	CLM06	2300	Provider signature is on file indicator. Yes = Y, No = N	1/1 R
`signatureIndicator`	CLM06	2300	Provider signature is on file indicator. Yes = Y, No = N	1/1 R
`planParticipationCode`	CLM07	2300	Code indicating whether the provider accepts assignment. A = Assigned B = Assignment accepted only on clinical lab services C = Not Assigned	1/1 R
`benefitsAssignmentCertificationIndicator`	CLM08	2300	Code indicating the insured or authorized person authorizes benefits to be assigned to the provider. Yes = Y, No = N	1/1 R
`releaseInformationCode`	CLM09	2300	Code indicating whether the provider has on file a patient's signed statement authorizing release of medical data to other organizations. Informed = I, Yes = Y	1/1 R
`delayReasonCode`	CLM20	2300	R for late-submitted claims. If not required, do not send.	S
`patientEstimatedAmountDue`	AMT02	2300	Patient responsibility amount. AMT01=F3	1/18 S
`fileInformation`	K301	2300	Array. Data in fixed format agreed upon by the sender and the receiver	1/80
`billingNote`	NTE02	2300	Billing comments or special instructions. NTE01=ADD	1/80

Claim Notes

Name	Element	Loop	Description	C/R
`claimNote` (Object)			Information providing informational context for the claim	S
`allergies`	NTE02	2300	Allergies information. NTE01=ALGClaims	1/80 S
`goalRehabOrDischargePlans`	NTE02	2300	Description goals, rehabilitation potential, or discharge plans. NTE01=DCP	1/80 S
`diagnosisDescription`	NTE02	2300	Diagnosis description. NTE01=DGN	1/80 S
`dme`	NTE02	2300	Durable Medical Equipment (DME) and Supplies. NTE01=DME Claims	1/80 S
`medications`	NTE02	2300	Medications notes. NTE01=MEDClaims	1/80 S
`nutritionalRequirements`	NTE02	2300	Nutritional Requirements NTE01=NTRClaims	1/80 S
`ordersForDisciplinesAndTreatments`	NTE02	2300	Orders for Disciplines and Treatments NTE01=ODTClaims	1/80 S
`functionalLimitsOrReasonHomebound`	NTE02	2300	Functional Limitations, Reason Homebound, or Both NTE01=RHBClaims	1/80 S
`reasonsPatientLeavesHome`	NTE02	2300	Reasons Patient Leaves Home NTE01=RLHClaims *	1/80 S
`timesAndReasonsPatientNotAtHome`	NTE02	2300	Times and Reasons Patient Not at Home SET NTE01=RNHClaims	1/80 S
`unusualHomeOrSocialEnv`	NTE02	2300	Unusual Home, Social Environment, or Both NTE01=SETClaims	1/80 S
`safetyMeasures`	NTE02	2300	Safety Measures NTE01=SFMClaims	1/80 S
`supplementalPlanOfTreatment`	NTE02	2300	Supplementary Plan of Treatment NTE01=SPTClaims	1/80 S
`updatedInformation`	NTE02	2300	Updated Information. NTE01=UPIClaims	1/80 S

EPSDT Referral

Name	Element	Loop	Description	C/R
`epsdtReferral` (Object)			Early & Periodic Screening, Diagnosis, and Treatment (EPSDT)	S
`responseCode`	CRC02	2300	Response to the question: Was an EPSDT referral given to patient? Y = indicates the condition codes in CRC03 to CRC07 apply N = indicates the condition codes in CRC03 to CRC07 do not apply CRC01=ZZ	1/1 R
`conditionIndicators`	CRC03 CRC04 CRC05	2300	Condition indicator. Ex: ST = New Services Requested. Use CRC04 and CRC05 if a second code is necessary.	2/3 R

Claim Date Information

DTP = Date or Time or Period

Name	Element	Loop	Description	C/R
`claimDateInformation` (Object)			Date Format: YYYYMMDD	R
`statementBeginDate`	DTP03	2300	DTP01=434	1/35 R
`statementEndDate`	DTP03	2300	DTP01=434	1/35 R
`dischargeHour`	DTP03	2300	Time of discharge. DTP01=096, DTP02=TM Format: CCYYMMDDHHMM	1/35 R
`repricerReceivedDate`	DTP03	2300	Date when the repricer forwarded the claim to the payer DTP01=050	1/35 S
`admissionDateAndHour`	DTP03	2300	Start of Care date. DTP02=DT; Format CCYYMMDDHHMM.	1/35 S

Claim Code Information

Institutional Claim Code in the TR3.

Name	Element	Loop	Description	C/R
`claimCodeInformation` (Object)			Some of the medical coding for the claim	R
`admissionTypeCode<br><br>`	CL101	2300	Priority of the admission or visit	1/1 R
`admissionSourceCode`	CL102	2300	Code indicating the source of the admission.	1/1 S
`patientStatusCode`	CL103	2300	Code indicating patient status as of “statement covers through" date.	1/2 R

Claim Contract Information

Name	Element	Loop	Description	C/R
`claimContractInformation` (Object)			R for the claim submission when the submitter is contractually bound to supply this data on adjudicated claims. Use the CN1 segment for claims not meeting HIPAA use. See the 837i X12 Implementation Guide page 160 for more information.	S
`contractTypeCode`	CN101	2300	Code identifying a contract type. Example: 02 = Per Diem	2/2 R
`contractAmount`	CN102	2300	Contract amount.	1/18 S
`contractPercentage`	CN103	2300	Allowance or charge percent.	1/6 S
`contractCode`	CN104	2300	Contract code.	1/50 S
`termsDiscountPercentage`	CN105	2300	Terms discount percentage, stated as %, available to purchaser if an invoice is paid on or before the terms discount due date.	1/6 S
`contractVersionIdentifier`	CN106	2300	Additional identifying number for the contract.	1/30 S

Report Information (Paperwork)

Name	Element	Loop	Description	C/R
`claimSupplementalInformation` (Object)			Provides references to all attachment documents for the claim	S
`reportInformation` (Object)
`attachmentReportTypeCode`	PWK01	2300	Code indicating document title or contents, report, or supporting item. Example: 08 = Plan of Treatment	2/2 R
`attachmentTransmissionCode`	PWK02	2300	Code defining timing, transmission method or format by which reports are to be sent. Example: BM = By mail.	1/2 R
`attachmentControlNumber`	PWK06	2300	Code identifying a party or other code. R when PWK02 = BM, EL, EM, FX or FT	2/80 S

Claim Supplemental/Reference Information

UMO = Utilization Management Organization

Name	Element	Loop	Description	C/R
`claimSupplementalInformation` (Object)			Additional claim information. REF01 selection is R.	S
`priorAuthorizationNumber`	REF02	2300	Pre-auth number assigned by payer or UMO to authorize a service before it is performed. REF01=G1	1/50 S
`referralNumber`	REF02	2300	Number assigned by the payer or UMO. REF01=9F	1/50 S
`claimControlNumber`	REF02	2300	The number assigned by the payer to identify a claim. The number is usually referred to as: an Internal Control Number (ICN), Claim Control Number (CCN), or a Document Control Number (DCN). REF01=F8	1/50 S
`cliaNumber`	REF02	2300	Clinical Laboratory Improvement Amendment (CLIA) number. REF01=X4	1/50 S
`repricedClaimNumber`	REF02	2300	Repriced claim number completed by the repricer. REF01=9A	1/50 S
`adjustedRepricedClaimRefNumber`	REF02	2300	Adjusted repriced claim reference number from the repricer. REF01=9C	1/50 S
`investigationalDeviceExemptionNumber`	REF02	2300	FDA investigational device exemption (ID) number. REF01=LX	1/50 S
`claimNumber`	REF02	2300	Clearinghouse Claim ID number REF01=D9	1/50 S
`mammographyCertificationNumber`	REF02	2300	Mammography certification number. REF01=EW	1/50 S
`medicalRecordNumber`	REF02	2300	Patient's medical record number. REF01=EA	1/50 S
`demoProjectIdentifier`	REF02	2300	Identify atypical claims in content, purpose, or payment, demonstration or special project, or clinical trial. REF01=P4	1/50 S
`carePlanOversightNumber`	REF02	2300	Phone of home health agency/hospice providing Medicare patient services for the service period. REF01=1J	1/50 S
`medicareCrossoverReferenceId`	REF02	2300	Medicare crossover ID. REF01=F5	1/50 S
`serviceAuthorizationExceptionCode`	REF02	2300	Service authorization exception code. REF01=4N	1/50 S
`autoAccidentState`	REF02	2300	Auto accident state or province code. REF01=LU	1/50 S
`peerReviewAuthorizationNumber`	REF02	2300	Preauth. number assigned by the payer or UMO to authorize services. REF01=G4	1/50 S

Condition Codes

HI – Health Care Information Codes. Used to supply information related to the delivery of health care. This is an array of up to 12 records, that ties the claim to one or more sets of industry code lists that set the standards by which information is reported for the claim.

Name	Element	Loop	Description	C/R
`conditionCodesList`			Array size is 2
`conditionCodes`		2300	Array of 12 Value of the National Uniform Billing Committee (NUBC) code.	R
	HI01-02 to HI12-02	2300	Value of the condition code. Min 1, max 12 HI01-01=BG to HI12-01=BG	1/30

Principal Diagnosis

Name	Element	Loop	Description	C/R
`principalDiagnosis` (Object)		2300	Principal diagnosis	R
`qualifierCode`	HI01-01	2300	Principal diagnosis code.	1/3 R
`principalDiagnosisCode`	HI01-02	2300	Value of the diagnosis code.	1/30 R
`presentOnAdmissionIndicator`	HI01-09	2300	Identifies the diagnosis onset as it relates to the reported diagnosis. U = Unknown W = Not Applicable Y = Yes	1/1 S

Admitting Diagnosis

Name	Element	Loop	Description	C/R
`admittingDiagnosis` (Object)		2300	Admitting diagnosis when the claim includes inpatient admission	S
`qualifierCode`	HI01-01	2300	Admitting diagnosis code.	1/3 R
`admittingDiagnosisCode`	HI01-02	2300	Value of the admitting diagnosis code.	1/30 R

Patient’s Reason for Visit

Required when a claim involves outpatient visits.

Name	Element	Loop	Description	C/R
`patientReasonForVisit` (Object)		2300	Patient’s reason for the visit.	S
`qualifierCode`	HI01-01 HI02-01 HI03-01	2300	Identifies an Industry code list. APR = International Classification of Diseases Clinical Modification (ICD-10-CM) Patient’s Reason for Visit PR = International Classification of Diseases Clinical Modification (ICD-9-CM) Patient’s Reason for Visit	1/3 R
`patientReasonForVisitCode`	HI01-02 HI02-02 HI03-02	2300	Reason for visit code.	1/30 R

External Cause of Injury

Name	Element	Loop	Description	C/R
`externalCauseOfInjury` (Object)			External Cause of Injury	S
`qualifierCode`	HI01-01 to HI0012-01	2300	Industry code. 12 segments	1/3
`externalCauseOfInjury`	HI01-02 to HI012-02	2300	External cause of injury value. 12 segments	1/30
`presentOnAdmissionIndicator`	HI01-09 to HI012-09	2300	Present on admission indicator. 12 segments Y = onset before hospital admission N = onset did NOT occur prior to admission to the hospital U = Unknown if onset occurred before or after hospital admission.	1/1 S

Diagnosis Related Group Information

Name	Element	Loop	Description	C/R
`diagnosisRelatedGroupInformation` (Object)			Diagnosis Related Group (DRG)	S
`drugRelatedGroupCode`	HI01-02	2300	Related drug group code.	1/30

Other Diagnosis Information List

Name	Element	Loop	Description	C/R
`otherDiagnosisInformationList` (Object)			Other Diagnosis Information segment repeat 2 times	S
`otherDiagnosisInformation` (Array)		2300	Array size up to 12
`qualifierCode`	HI01-1 to HI012-1	2300	Industry code.	1/3 R
`otherDiagnosisCode`	HI01-2 to HI012-2	2300	Other diagnosis code value.	1/30 R
`presentOnAdmissionIndicator`	HI01-9 to HI012-9	2300	Present on admission indicator. 12 segments Y = onset before hospital admission N = onset NOT before hospital admission U = Unknown if onset occurred before or after hospital admission	1/1 S

Principal Procedure Information

Name	Element	Loop	Description	C/R
`principalProcedureInformation` (Object)			Principal Procedure Information When a procedure is performed for an inpatient claim.	S
`qualifierCode`	HI01-01	2300	Industry code. BR = International classification of diseases, clinical modification (ICD-9-CM) CAH = Advanced Billing Concepts (ABC)	1/3
`principalProcedureCode`	HI01-02	2300	Value of the industry Code.	1/30 R
`principalProcedureDateTime`	HI01-03	2300	Principal procedure performed date and time qualifier. D8 = MMDDYYCC	2/3 R
`principalProcedureDate`	HI01-04	2300	Date the principal procedure was performed. Format: MMDDYYCC	1/38 R

Other Procedure Information List

Name	Element	Loop	Description	C/R
`otherProcedureInformationList` (Object)			Segment repeat: 2	S
`otherProcedureInformation`			Array size up to 12 R
`qualifierCode`	HI01-01 to HI012-01	2300	Industry Code BQ = International classification of diseases clinical modification (ICD-9-CM), other procedure codes	1/3 R
`procedureCode`	HI01-02 to HI012-02	2300	Industry Code value.	1/30 R
`procedureDateTime`	HI01-03 to HI012-3	2300	Principal procedure performed date and time qualifier. D8 = MMDDYYCC	2/3 R
`procedureDate`	HI01-04 to HI012-04	2300	Date the principal procedure was performed. Format: MMDDYYCC	1/38 R

Occurrence Span Information List

Name	Element	Loop	Description	C/R
`occurrenceSpanInformationList` (Object)		2300	Segment repeat: 2	S
`occurrenceSpanInformation`		2300	Occurrence Span Information Array size up to 12	R
`occurrenceSpanCode`	HI01-02 to HI012-02	2300	Industry Code. BI = Occurrence Span	1/3 R
`occurrenceSpanCodeStartDate`	HI01-04 to HI012-04	2300	Date Time Period Format Qualifier Format: MMDDYYCC	2/3 R
`occurrenceSpanCodeEndDate`	HI01-04 to HI012-04	2300	Date Time Period Format Qualifier Format: MMDDYYCC	1/35 R

Occurrence Information List

Name	Element	Loop	Description	C/R
`occurrenceInformationList` (Object)			Segment repeat: 2	S
`occurrenceInformation`			Occurrence Information Array size up to 12	R
`occurrenceSpanCode`	HI01-02 to HI012-02	2300	Industry Code. BI = Occurrence Span	1/3 R
`occurrenceSpanCodeStartDate`	HI01-04 to HI012-04	2300	Date Time Period Format Qualifier	2/3 R
`occurrenceSpanCodeEndDate`	HI01-04 to HI012-04	2300	Occurrence span code date Format: MMDDYYCC	1/35 R

Value Information List

Required when a Value Code applies to the claim.

Name	Element	Loop	Description	C/R
`valueInformationList` (Object)			Segment repeat: 2	S
`valueInformation`			Value Information Array up to 12	R
`valueCode`	HI01-02 to HI012-02	2300	Industry Code.	1/30 R
`valueCodeAmount`	HI01-05 to HI012-05	2300	Monetary Amount.	1/18 R

Treatment Code Information List

Required when Home Health Agencies need to report Plan of Treatment information
under various payer contracts.

Name	Element	Loop	Description	C/R
`treatmentCodeInformationList` (Object)			Segment repeat: 2	S
`treatmentCodeInformation`			Array up to 12
`treatmentCode`	HI01-02 to HI12-02	2300	Value of the treatment code.	1/30 R

Claim Pricing Information (Completed by repricer)

Name	Element	Loop	Description	C/R
`claimPricingInformation` (Object)			Pricing/repricing information about a health care claim or line item from the repricer. Specific to Payer in loop 2010BB.	S
`pricingMethodologyCode`	HCP01	2300	Pricing Methodology. Code for pricing methodology used to price or reprice the claim or line item.	2/2 R
`repricedAllowedAmount`	HCP02	2300	Monetary Amount. Repriced Allowed Amount	1/18 R
`repricedSavingAmount`	HCP03	2300	Monetary Savings amount. Completed by the repricer only. Specific to Payer in loop 2010-BB.	1/18 S
`repricedOrgIdentifier`	HCP04	2300	Reference Identification. Repricing organization identification number.	1/50 S
`repricedPerDiem`	HCP05	2300	Pricing rate associated with per diem or flat rate repricing.	1/9 S
`repricedApprovedDRGCode`	HCP06	2300	Reference information for a transaction set, or by the Reference Identification Qualifier.	1/50 S
`repricedApprovedAmount`	HCP07	2300	Monetary Amount Approved DRG amount.	1/18 S
`repricedApprovedRevenueCode`	HCP08	2300	Completed only by repricer. Revenue Code Approved revenue code.	1/48 S
`repricedApprovedServiceUnitCode`	HCP11	2300	Unit or Basis for Measurement Code. Specifies the value units or method of taking a measurement.	2/2 S
`repricedApprovedServiceUnitCount`	HCP12	2300	# of service units or inpatient days.	1/50 S
`rejectReasonCode`	HCP13	2300	Reject Reason Code assigned by issuer. Identifies the reason for rejection. Example: T4 Payer Name or Identifier Missing.	2/2 S
`policyComplianceCode`	HCP14	2300	Policy Compliance Code specifying policy compliance. Example: 1 = Procedure Followed (Compliance)	1/2 S
`exceptionCode`	HCP15	2300	Code specifying the exception reason for consideration of out-of-network health care services. Example: 2 = Emergency Care	1/2 S

Service Facility Location

Name	Element	Loop	Description	C/R
`serviceFacilityLocation` (Object)				S
`organizationName`	NM103	2310E	Service facility organization name or individual last name	1/60 R
`facilityPrimaryIdentifier`	NM109	2310C	Lab or Facility primary identifier. R when the service location to be identified has an NPI and is not a component/subcomponent of the Billing Provider entity. NM108 = XX	2/80 S
`address` (Object)				S
`address1`	N301	2310E	First line of facility address information.	1/55 R
`address2`	N302	2310E	Second line of facility address information.	1/55 S
`city`	N401	2310E	City in which the facility is located.	2/30 R
`state`	N402	2310E	State in which the facility is located. R in US/CA	2/2 R
`postalCode`	N403	2310E	Displays the postal code. R in US/CA	3/15 R
`countryCode`	N404	2310E	Pay-to countryCode	1/35 S
`countrySubDivisionCode`	N404	2310E	Pay-to countryCode	1/35 S

Institutional Service Lines

At least one of SV201 or SV202 is required. This object also is required when a tax or surcharge applies to the reported service; the submitter must report that information to the receiver. All service lines in the claim provide a lineItemChargeAmount attribute (SV203). The sum of all service lines' lineItemChargeAmount values must equal the claimChargeAmount in the Claim Information object.

Name	Element	Loop	Description	C/R
`serviceLines` (Object)				R
`assignedNumber`	LX01	2400	Service Line Number. The number assigned for differentiation within a transaction set.	1/6 R
`serviceTaxAmount`	AMT02	2400	Service Tax Amount AMT01=GT	1/18 S
`facilityTaxAmount`	AMT02	2400	Facility Tax Amount AMT01=N8	1/18 S
`thirdPartyOrganizationNotes`	NTE02	2400	Third Party Organization Notes. Required when the repricer sends more information to the payer. NTE01=TPO	1/80 S
`institutionalService` (Object)			SV2 - Institutional Service Line	R
`serviceLineRevenueCode`	SV201	2400	National Uniform Billing Committee (NUBC) revenue code identifying a medical product or service.	1/48 R
`compositeMedicalProcedureIdentifier` (Object)			Required for outpatient claims if a procedure code exists for this line item; or for an inpatient claim if an HCPCS or HIPPS code exists for the item.	S
`procedureIdentifier`	SV202 -01	2400	Code identifying the type/source of the descriptive number used in product/service ID. Example: HC = Health Care Financing Administration Common Procedural Coding System (HCPCS) codes.	2/2 R
`procedureCode`	SV202 -02	2400	Identifying number for the product/service.	2/2 R
`procedureModifiers`	SV202 -03 SV202 -04 SV202 -05 SV202 -06	2400	Identifies special circumstances related to service performance, defined by trading partners. Array up to 4 values.	2/2 S
`description`	SV202 -07	2400	Description of the procedure. Required if SV202-02 value is a non-specific procedure code.	1/80 S
`lineItemChargeAmount`	SV203	2400	Submitted service line item amount. The total charge amount for the service line. All service line charge amounts in this field must equal the total claim charge amount in Loop 2300 CLM02.	1/18 R
`serviceUnitCount`	SV205	2400	Service unit count. If a decimal, the fractional digits limit is 3.	1/8 R
`lineItemDeniedChargeAmount`	SV207	2400	Non-covered service amount.	1/18 S
`serviceLineSupplementalInformation` (Object)			Line Supplemental Information in TR3	S
`attachmentReportTypeCode`	PWK01	2400	Code indicating the doc type, report or supporting item. Example: 06 = Initial Assessment	2/2 R
`attachmentTransmissionCode`	PWK02	2400	Code defining timing, transmission method or format for sending reports. Example: BM = By Mail	1/2 R
`attachmentControlNumber`	PWK06	2400	Attachment Control Number. Identifies attached electronic documentation. PWK05=AC	2/50 S
`serviceLineDateInformation` (Object)			Service Date	S
`serviceDate`	DTP03	2400	Date, time, or range of dates, times, or dates and times. DTP01=472 Service DTP02=D8 Date	1/35 S
`beginServiceDate`	DTP03	2400	Date, time, or range of dates, times, or dates and times. DTP01=472 DTP02=RD8	1/35 S
`endServiceDate`	DTP03	2400	Date, time, or range of dates, times, or dates and times. DTP01=472 and DTP02=RD8	1/35 S
`serviceLineReferenceInformation` (Object)			Reference Information	S
`providerControlNumber`	REF02	2400	Provider control number. REF01=6R (Provider Control number)	1/50 R
`repricedLineItemRefNumber`	REF02	2400	Repriced line item reference number REF01=9B	1/50 R
`adjustedRepricedLineItemRefNumber`	REF02	2400	Adjusted Repriced Line Item Reference Number REF01=9D	1/50 S
`linePricingInformation` (Object)			Health Care Line Pricing/Repricing Information	S
`pricingMethodologyCode`	HCP01	2400	Pricing Methodology Code. The pricing/repricing method for the claim/line item.	2/2 R
`repricedAllowedAmount`	HCP02	2400	Monetary Amount Allowed amount.	1/18 R
`repricedSavingAmount`	HCP03	2400	Monetary Amount Savings amount.	1/18 S
`repricedOrganizationIdentifier`	HCP04	2400	Reference Identification. Repricing organization ID number.	1/50 S
`flatRateAmount`	HCP05	2400	Pricing rate associated with per diem/flat rate repricing.	1/9 S
`apgCode`	HCP06	2400	Reference Identification Approved DRG code.	1/50 S
`apgAmount`	HCP07	2400	Monetary Amount Approved DRG amount.	1/18 S
`serviceIdQualifier`	HCP09	2400	Product/Service ID Qualifier Code. It identifies the type/source of the number used in the Product/Service ID (234). Ex: ER = Jurisdiction Specific Procedure and Supply Codes	2/2 S
`repricedApprovedHCPCSCode`	HCP10	2400	Product/Service ID Approved procedure code.	1/48 S
`measurementUnitCode`	HCP11	2400	Unit/Basis Measurement Code DA = Days UN = Unit	2/2 S
`repricedApprovedServiceUnitCount`	HCP12	2400	Quantity Approved service units or inpatient days.	1/15 S
`rejectReasonCode`	HCP13	2400	Reject Reason Code rejection message, returned from the third-party organization.	2/2 S
`policyComplianceCode`	HCP14	2400	Policy Compliance Code. Specifies policy compliance.	1/2 S
`exceptionCode`	HCP15	2400	Exception Code showing the reason for consideration of out-of-network health care services. Example: 2 = Emergency Care	1/2 S

Drug Identification (2410)

Loop 2410 contains compound drug components, quantities and prices.

Name	Element	Loop	Description	C/R
`drugIdentification` (Object)			Drug Identification (LIN)	S
`serviceIdQualifier`	LIN02	2410	Product/Service ID Qualifier Code defining the Product/Service ID value.	2/2 R
`nationalDrugCode`	LIN03	2410	Product/Service ID. Identifying number for a product or service	1/48 R
`nationalDrugUnitCount`	CTP04	2410	Numeric value of quantity.	1/15 R
`measurementUnitCode`	CTP05 -01	2410	Composite Unit of Measure. A code specifying the units representing a value, or a measurement. Example: ME = Milligram	2/2 R
Prescription or Compound Drug Association Number (Ref)
`linkSequenceNumber`	REF02	2410	Reference Identification Link sequence number. A provider-assigned value, unique to the claim. It enables the receiver to assemble a drug compound. REF01=VY (Link Sequence Number)	1/50 S
`pharmacyPrescriptionNumber`	REF02	2410	Reference Identification. Pharmacy prescription number. REF01=XZ	1/50 R

Line Adjudication (2430)

Name	Element	Loop	Description	C/R
`lineAdjustmentInformation` (Object)			Line Adjudication Information	S
`otherPayerPrimaryIdentifier`	SVD01	2430	Payer identification code.	2/80 R
`serviceLinePaidAmount`	SVD02	2430	Service line paid amount. This value is the final line-level payment, minus payer adjustments.	1/18 R
`serviceIdQualifier`	SVD03-01	2430	Product/Service ID Qualifier Code. It identifies the descriptive number type/source used in the Product/Service ID (234).	2/2 R
`procedureCode`	SVD03-02	2430	Product/Service ID Number for a product or service.	1/48 R
`procedureModifiers`	SVD03-03 to SVD03-06	2430	Procedure Modifier. Identifies special circumstances about service performance, as defined by trading partners	2/2 S
`procedureCodeDescription`	SVD03-07	2430	Procedure description.	1/80 S
`paidServiceUnitCount`	SVD05	2430	Paid service unit count. Number of paid units from the remittance advice. When paid units are not present, use the original billed units.	1/15 R
`bundledOrUnbundledLineNumber`	SVD06	2430	Bundled Line Number. Used for service line bundling. It references the LX Assigned Number of the service line where the service line was bundled.	1/6 S
`remainingPatientLiability`	AMT02	2430	Amount of remaining patient liability. AMT01=EAF (Amount Owed)	1/18 S
`claimPaidDate`	DTP03	2430	Adjudication or payment date. DT01=573 (Date Claim Paid) DTP02=D8 (Date as CCYYMMDD) Dubbed Remittance Date in TR3.	1/35 R

Claim Line Adjustment (2430)

Name	Element	Loop	Description	C/R
`claimAdjustmentInformation` (Array)			Repeats 5 times	S
`adjustmentGroupCode`	CAS01	2430	Claim Adjustment Group Code. It identifies the general category of payment adjustment. Example: CO = Contractual Obligations	1/2 R
`adjustmentdetails` (Array)			Repeats 6 times
`adjustmentReasonCode`	S	2430	Claim Adjustment Reason Code. Describes the reason for the adjustment. CAS02/CAS05/CAS08/CAS11/CAS14	1/5 S
`adjustmentAmount`	S	2430	Monetary amount of the adjustment. CAS03/CAS06/CAS09/CAS12/CAS15	1/18 R
`adjustmentQuantity`	S	2430	Quantity of units of service being adjusted. CAS04/CAS07/CAS10/CAS13/CAS16	1/15 S

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