JSON Fields versus X12 EDI Loop Associated with a Field in 275 in an Attachments Request
```json
{
"controlNumber": "controlNumber",
"tradingPartnerId": "tradingPartnerId",
"tradingPartnerServiceId": "LOOP 1000A; NM109",
"tradingPartnerName": "LOOP 1000A NM103",
"payerFaxNumber": "fax number of the payer",
"payerAddress": {
"address1": "",
"address2": "",
"city": "",
"state": "",
"postalCode": ""
},
"submitter":
{
"organizationName": "LOOP 1000B NM103",
"firstName": "LOOP 1000B NM104",
"lastName": "LOOP 1000B NM103",
"etin": "LOOP 1000B NM109; "
},
"provider":
{
"organizationName": "LOOP 1000C NM103",
"lastName": "LOOP 1000C NM103",
"firstName": "LOOP 1000C NM104",
"middleName": "LOOP 1000C NM105",
"suffix": "LOOP 1000C NM107",
"npi": "LOOP 1000C NM109",
"taxonomyCode": "LOOP 1000C PRV03",
"providerCommercialNumber": "Loops to 1000C; Maps to REF02; REF01=G2",
"locationNumber": "Loops to 1000C; Maps to REF02; REF01=LU",
"stateLicenseNumber": "Loops to 1000C; Maps to REF02; REF01=0B",
"providerUpinNumber": "Loops to 1000C; Maps to REF02; REF01=1G",
"address":
{
"address1": "LOOP 1100C",
"address2": "LOOP 1100C; maps N302",
"city": "LOOP 1100C; N401",
"state": "LOOP 1100C; N402",
"postalCode": "LOOP 1100C; N403"
},
"phoneNumber": "Used in fax cover sheet",
"faxNumber": "Used in fax cover sheet"
},
"subscriber":
{
"memberId": "LOOP 1000D NM segment; NM108=MI",
"firstName" : "LOOP 1000D NM segment; NM104",
"lastName" : "LOOP 1000D NM segment; NM103"
},
"claimInformation":
{
"patientControlNumber": "LOOP 1000D REF=EJ segment",
"billingTypeIdentifier": "LOOP 1000D REF=BLT",
"medicalRecordIdentifier": "LOOP 1000D REF=EA",
"claimNumber": "LOOP 1000D REF=D9",
"beginClaimServiceDate": "LOOP 1000D DTP segment; DTP01=472; DTP02=RD8",
"endClaimServiceDate": "LOOP 1000D DTP segment; DTP01=472; DTP02=RD8",
"claimServiceDate": "LOOP 1000D DTP segment; DTP01=472; DTP02=D8",
"serviceLines":[ //Note: for each serviceLine, we will add LX segment and keep incrementing LX01
{
"payerClaimControlNumber": "LOOP 2000A; TRNO1=2; Payer Claim Control Number is the value from the TRN segment loop 2200D of the 277 when in response to a solicited request",
"providerAttachmentControlNumber" : "LOOP 2000A TRN01=1; For the unsolicited 275, the Attachment Control Number is the value from PWK06 loop 2300 of the 837. This is the main matching criteria and must be unique on a per attachment basis.",
"claimStatus": [
{
"claimStatusCategoryCode": "LOOP 2000A; STC01-1",
"additionalInformationRequestCode": "LOOP 2000A; STC01-2"
}],
"providerControlNumber": "LOOP 2000A; REF01=6R",
"lineItemControlNumber": "LOOP 2000A; REF01=FJ",
"procedureOrRevenueDetails":
{
"procedureOrRevenueCode": "LOOP 2000A; REF01; valid values: CPT, F8, FO, PRT,RB, VP, YJ, ZZ",
"procedureOrRevenueValue": "value of the code provided in REF01; this would be REF02",
"revenueCode": "LOOP 2000A; REF04-02"
},
"procedureCodeModifier":
{
"serviceChangeNumber": "LOOP 2000A; REF01=SK; REF02",
"objectCode" : "LOOP 2000A; REF04-1=XX4; REF04-2",
"systemNumber": "LOOP 2000A; REF04-3=06; REF04-4",
"specialPaymentReferenceNumber": "LOOP 2000A; REF04-5=4N; REF04-6"
},
"serviceLineDateInformation":
{
"serviceDate": "LOOP 2100A; DTP01=472; DTP03=value; DTP02=D8",
"beginServiceDate": "LOOP 2100A; DTP01=472; DTP03=value ; DTP02=RD8",
"endServiceDate": "LOOP 2100A; DTP01=472; DTP03=value ; DTP02=RD8",
"submissionDate": "LOOP 2100B; DTP01=472; DTP03=value; DTP02=D8"
},
"attachmentDetails":
{
"name": "Should match a file name sent with Form-Data files, Used to complete LOOP 2110B; BIN02 and LOOP 2110B; BIN01"
}
}
]
}
}
```
Updated 9 months ago