NoA JSON-to-EDI Contents

NoA 278 Request

Identification Header

Information Source Details

Subscriber Header

Dependent Details

Patient Event Detail

Provider Details

Provider Supplemental Information

Additional Patient Information Contact Name

Patient Event Transport Information

Patient Event Other UMO Name

Service Level Section

Health Care Service Review Information

Professional Service Information

Institutional Service Information

Dental Service Information

Tooth Information

Health Care Service Delivery

Attachments

Service Level Provider Name

Provider Name

Provider Supplemental Information

NoA 278 Response

Submitter Response
Notification Validation
Submitter Transaction Identifier Response

Source Response
Source Notification Validation

Subscriber Response

Dependent Response

Patient Event Detail Response

Patient Event Provider Name Response

Service Level Response

Service Provider Information

JSON-to-EDI mapping

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

NoA 278 Request

Identification Header (Request)

Name	Required/Commonly Used	Element Loop	EDI Mapping Notes	Character Count (Min/Max)
Header Section (Request)	Required
`senderId`	Required	201985AAS	Interchange Sender ID	15/15
`submitterTransactionIdentifier`	Required	BHT03	Submitter Transaction Identifier	1/50
`payerId`	Required	2010B/NM109	NM101=PR NM102=2 If UMClearingHouseID is empty populate also ISA08 GS03	2/80
`payerName`	Required	2010B/NM103		1/60
`umClearingHouseId`	Required		If not empty, populate ISA08 GS03	15/15

Information Source Details

Name	Required/Commonly Used	Element Loop	Code	EDI Mapping Notes	Character Count (Min/Max)
Information Source Details	Required
`sourceType`	Required	2010A NM101 Default 1P	`sourceType` ========= 1P Provider 2B Third-Party Administrator FA Facility PR Payer X3 Utilization Management Organization		2/3
Sourcer Name (if Requester is an individual, provide `lastName` and `firstName`, otherwise provide `organizationName`)	Required
`organizationName`	Commonly Used	2010A/NM103		NM102=2	1/60
`lastName`		2010A/NM103			1/60
`firstName`		2010A/NM104		NM102=1	1/35
`middleName`		2010A/NM105			1/25
`suffixName`		2010A/NM107			1/10
Source Identification (Provide any of the following if available)
`providerUpinNumber`		2010A/REF02		REF01=1G	1/50
`facilityIdNumber`		2010A/REF02		REF01=1J	1/50
`employerIdentificationNumber`		2010A/REF02		REF01=EI	1/50
`providerSiteNumber`		2010A/REF02		REF01=G5	1/50
`providerPlanNetworkIdNumber`		2010A/REF02		REF01=N5	1/50
`facilityNetworkIdNumber`		2010A/REF02		REF01=N7	1/50
`socialSecurityNumber`		2010A/REF02		REF01=SY	1/50
`carrierAssignedReferenceNumber`		2010A/REF02		REF01=ZH	1/50
Source Address Information
`address1`	Commonly Used	2010A/N301			1/55
`address2`		2010A/N302			1/55
`city`	Commonly Used	2010A/N401			2/30
`state`	Commonly Used	2010A/N402			2/2
`postalCode`	Commonly Used	2010A/N403			3/15
`countryCode`		2010A/N404			2/3
`countrySubDivisionCode`		2010A/N407			1/3
Source Identification Code (Provide one of the following)	Required
`npi`	Commonly Used	2010A/NM109		NM108=XX	2/80
`payorId`		2010A/NM109		NM108=PI	2/80
`ssn`		2010A/NM109		NM108=34	2/80
`servicesPlanID`		2010A/NM109		NM108=XV	2/80
`employersId`		2010A/NM109		NM108=24	2/80
`etin`		2010A/NM109		NM108=46	2/80
Source Contact Information
`contactName`		2010A/PER02		PER01=IC	1/60
`contactElectronicMail`		2010A/PER04		PER03=EM or PER06 PER05=EM or PER08 PER07=EM	1/256
`contactFacsimile`		2010A/PER04		PER03=FX or PER06 PER05=FX or PER08 PER07=FX	1/256
`contactTelephone`	Commonly Used	2010A/PER04		PER03=TE or PER06 PER05=TE or PER08 PER07=TE	1/256
Source Provider Information
`providerCode`		2010A/PRV01	`providerCode` ========== AD Admitting AS Assistant Surgeon AT Attending CO Consulting CV Covering OP Operating OR Ordering OT Other Physician PC Primary Care Physician PE Performing RF Referring	PRV02=PXC	2/2
`referenceIdentification`		2010A/PRV03			1/50

Subscriber Section (Request)

Name	Required/Commonly Used	Element Loop	Code	EDI Mapping Notes	Character Count (Min/Max)
Subscriber Section	Required
`lastName`	Required	2010C/NM103		NM101=IL/NM102=1	1/60
`firstName`	Required	2010C/NM104			1/35
`middleName`		2010C/NM105			1/25
`suffix`		2010C/NM107			1/10
`memberId`	Required	2010C/NM109		NM108=MI	2/80
Subscriber Supplemental Identification (Provide any of the following if available)
`policyNumber`		2010C/REF02		REF01=1L	1/50
`groupNumber`	Commonly Used	2010C/REF02		REF01=6P	1/50
`patientAccountNumber`		2010C/REF02		REF01=EJ	1/50
`healthInsuranceClaimNumber`		2010C/REF02		REF01=F6	1/50
`idCard`		2010C/REF02		REF01=HJ	1/50
`insurancePolicyNumber`		2010C/REF02		REF01=IG	1/50
`planNetworkIdentificationNumber`		2010C/REF02		REF01=N6	1/50
`medicaidRecipientIdentificationNumber`		2010C/REF02		REF01=NQ	1/50
`ssn`	Commonly Used	2010C/REF02		REF01=SY	1/50
Subscriber Address
`address1`		2010C/N301			1/55
`address2`		2010C/N302			1/55
`city`		2010C/N401			2/30
`state`		2010C/N402			2/2
`postalCode`		2010C/N403			3/15
`countryCode`		2010C/N404			2/3
`countrySubDivisionCode`		2010C/N407			1/3
Subscriber Demographic
`dateOfBirth`	Commonly Used	2010C/ DMG02		DMG01=D8 YYYYMMDD	8/8
`genderCode`		2010C/DMG03	`genderCode` ========= F Female M Male U Unknown		1/1
`militaryRelationship`		2010C/INS08	`militaryRelationship` =========== AO Active Military - Overseas AU Active Military - USA DI Deceased PV Previous RU Retired Military - USA		2/2

Dependent Section (Request)

Name	Required/Commonly Used	Element Loop	Code	EDI Mapping Notes	Character Count (Min/Max)
Dependent Section (Required if Patient is a dependent of the Insured Individual)
`lastName`	Required	2010D/NM103		NM101=QC NM102=1	1/60
`firstName`	Required	2010D/NM104			1/35
`middleName`		2010D/NM105			1/25
`suffix`		2010D/NM107			1/10
`dateOfBirth`	Commonly Used	2010D/DMG02		DMG01=D8 YYYYMMDD	8/8
`genderCode`	Commonly Used	2010D/DMG03	`genderCode` ========== F Female M Male U Unknown		1/1
Dependent Supplemental Identification (Provide any of the following if available)
`patientAccountNumber`		2010D/REF02		REF01=EJ	1/50
`ssn`		2010D/REF02		REF01=SY	1/50
Dependent Address
`address1`		2010D/N301			1/55
`address2`		2010D/N302			1/55
`city`		2010D/N401			2/30
`state`		2010D/N402			2/2
`postalCode`		2010D/N403			3/15
`countryCode`		2010D/N404			2/3
`countrySubDivisionCode`		2010D/N407			1/3
Dependent Demographic
`relationshipToInsuredCode`		2010D/INS02	`relationshipToInsuredCode` ========= 01 Spouse 19 Child G8 Other Relationship	INS01=N	2/2
`birthSequenceNumber`		2010D/INS17			1/9
`supplementalIdentification` (Object)
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

Patient Event Detail (Request)

Name	Required/Commonly Used	Hint	Element	Code	EDI Mapping Notes	Character Count (Min/Max)
Patient Event Details Section	Required					1/2
Health Care Services Review Information
`requestCategoryCode`	Required		2000E/UM01	`requestCategoryCode` ============ AR Admission Review HS Health Services Review SC Specialty Care Review		1/2
`certificationTypeCode`	Required		2000E/UM02	`certificationTypeCode` ============ 1 Appeal - Immediate 2 Appeal - Standard 3 Cancel 4 Extension 5 Notification I Initial N Reconsideration R Renewal S Revised		1/1
`serviceTypeCode`	Required		2000E/UM03			1/2
`facilityTypeCode`	Required		2000E/UM04_1			1/2
`facilityCodeQualifier`	Required		2000E/UM04_2	`facilityCodeQualifier` =========== A Uniform Billing Claim Form Bill Type B Place of Service Codes for Professional or Dental Services		1/2
`levelOfServiceCode`			2000E/UM06	`levelOfServiceCode` ============ 03 Emergency E Elective U Urgent		1/3
`CertificationActionCode`			2000E/HCR01	`certificationActionCode` ========== A1 Certified in total A3 Not Certified A4 Pended A6 Modified C Canceled CT Contact Payer NA No Action Required		1/2
`prognosisCode`			2000E/HCR02			1/50
`releaseOfInformationCode`			2000E/HCR03			1/30
`delayReasonCode`			2000E/HCR04	`secondSurgicalOpinionIndicator` ======== N No Y Yes		1/1
`previousReviewAuthorizationNumber`			2000E REF02		REF01=BB	1/50
`previousAdministrativeReferenceNumber`			2000E/REF02		REF01=NT	1/50
`accidentDate`			2000E/DTP03		DTP01=439 DTP02=D8 YYYYMMDD	1/35
`lastMenstrualPeriodDate`			2000E/DTP03		DTP01=484 DTP02=D8 YYYYMMDD	1/35
`estimatedDateOfBirth`			2000E/DTP03		DTP01=ABC DTP02=D8 YYYYMMDD	1/35
`onsetDate`			2000E/DTP03		DTP01=431 DTP02=D8 YYYYMMDD	1/35
`eventDateBegin`			2000E/DTP03		DTP01=AAH DTP02=D8 YYYYMMDD	1/35
`eventDateEnd`		`EventDateBegin` must exist	2000E/DTP03		DTP01=AAH DTP02=RD8 YYYYMMDD `EventDateBegin` must exist	1/35
`admissionDateBegin`			2000E/DTP03		DTP01=435 DTP02=D8 YYYYMMDD	1/35
`admissionDateEnd`		`AdmissionDateBegin` must exist	2000E/DTP03		DTP01=435 DTP02=RD8 YYYYMMDD `AdmissionDateBegin` must exist	1/35
`dischargeDate`			2000E/DTP03		DTP01=096 DTP02=D8 YYYYMMDD	1/35
`certificationIssueDateBegin`
`certificationIssueDateEnd`			2000E DTP03		DTP01=102 DTP02=D8 YYYYMMDD	1/35
`certificationExpirationDateBegin`			2000E DTP03		DTP01=102 DTP02=RD8 YYYYMMDD `CertificationIssueDateBegin must exist`	1/35
`certificationExpirationDateEnd`			2000E DTP03		DTP01=036 DTP02=RD8 YYYYMMDD `CertificationExpirationDateBegin must exist`	1/35
`certificationEffectiveDateBegin`			2000E DTP03		DTP01=007 DTP02=D8 YYYYMMDD	1/35
`certificationEffectiveDateEnd`			2000E DTP03		DTP01=007 DTP02=RD8 YYYYMMDD `CertificationEffectiveDateBegin must exist`	1/35
Diagnosis Information
`diagnosisTypeCode1`	Commonly Used		200E/HI01_1	`diagnosisTypeCode1` ============== ABF Diagnosis ABJ Admitting Diagnosis ABK Principal Diagnosis APR Patient’s Reason for Visit DR Diagnosis Related Group (DRG)		1/3
`diagnosisCode1`	Commonly Used		2000E/HI01_2			1/30
`diagnosisDate1`			2000E/HI01_4		HI01_3=D8 YYYYMMDD	1/35
`diagnosisTypeCode2`			2000E/HI02_1	`diagnosisTypeCode2` ============== ABF Diagnosis ABJ Admitting Diagnosis APR Patient’s Reason for Visit DR Diagnosis Related Group (DRG)		1/3
`DiagnosisCode2`			2000E/HI02_2			1/30
`DiagnosisDate2`			2000E/HI02_4		HI02_3=D8 YYYYMMDD	1/35
`diagnosisTypeCode3`			2000E/HI03_1	`diagnosisTypeCode3` ============= ABF Diagnosis APR Patient’s Reason for Visit DR Diagnosis Related Group (DRG)		1/3
`DiagnosisCode3`			2000E/HI03_2			1/30
`DiagnosisDate3`			2000E/HI03_4		HI03_3=D8 YYYYMMDD	1/35
`diagnosisTypeCode4`			2000E/HI04_1	`diagnosisTypeCode4` ============= ABF Diagnosis APR Patient’s Reason for Visit DR Diagnosis Related Group (DRG)		1/3
`DiagnosisCode4`			2000E/HI04_2			1/30
`DiagnosisDate4`			2000E/HI04_4		HI04_3=D8 YYYYMMDD	1/35
`diagnosisTypeCode5`			2000E/HI05_1	`diagnosisTypeCode5` ============== ABF Diagnosis APR Patient’s Reason for Visit DR Diagnosis Related Group (DRG)		1/3
`diagnosisCode5`			2000E/HI05_2			1/30
`diagnosisDate5`			2000E/HI05_4		HI05_3=D8 YYYYMMDD	1/35
`diagnosisTypeCode6`			2000E/HI06_1	`diagnosisTypeCode6` ============== ABF Diagnosis APR Patient’s Reason for Visit DR Diagnosis Related Group (DRG)		1/3
`diagnosisCode6`			2000E/HI06_2			1/30
`diagnosisDate6`			2000E/HI06_4		HI06_3=D8 YYYYMMDD	1/35
`diagnosisTypeCode7`			2000E/HI07_1	`diagnosisTypeCode7` ============= ABF Diagnosis APR Patient’s Reason for Visit DR Diagnosis Related Group (DRG)		1/3
`diagnosisCode7`			2000E/HI07_2			1/30
`diagnosisDate7`			2000E/HI07_4		HI07_3=D8 YYYYMMDD	1/35
`diagnosisTypeCode8`			2000E/HI08_1	`diagnosisTypeCode8` =============== ABF Diagnosis APR Patient’s Reason for Visit DR Diagnosis Related Group (DRG)		R 1/3
`diagnosisCode8`			2000E/HI08_2			1/30
`diagnosisDate8`			2000E/HI08_4		HI08_3=D8 YYYYMMDD	1/35
`diagnosisTypeCode9`			2000E/HI09_1	`diagnosisTypeCode9` ============== ABF Diagnosis APR Patient’s Reason for Visit DR Diagnosis Related Group (DRG)		1/3
`diagnosisCode9`			2000E/HI09_2			1/30
`diagnosisDate9`			2000E/HI09_4		HI09_3=D8 YYYYMMDD	1/35
`diagnosisTypeCode10`			2000E/HI010_1	`diagnosisTypeCode10` ============= ABF Diagnosis APR Patient’s Reason for Visit DR Diagnosis Related Group (DRG)		1/3
`diagnosisCode10`			2000E/HI010_2			1/30
`diagnosisDate10`			2000E/HI010_4		HI010_3=D8 YYYYMMDD	1/35
`diagnosisTypeCode11`			2000E/HI011_1	`diagnosisTypeCode11` ============== ABF Diagnosis APR Patient’s Reason for Visit DR Diagnosis Related Group (DRG)		1/3
`diagnosisCode11`			2000E/HI011_2			1/30
`diagnosisDate11`			2000E/HI011_4		HI011_3=D8 YYYYMMDD	1/35
`diagnosisTypeCode12`			2000E/HI012_1	`diagnosisTypeCode12` ============= ABF Diagnosis APR Patient’s Reason for Visit DR Diagnosis Related Group (DRG)		1/3
`diagnosisCode12`			2000E/HI012_2			1/30
`diagnosisDate12`			2000E/HI012_4		HI012_3=D8 YYYYMMDD	1/35
Health Care Services Delivery
`quantityQualifier`			2000E/HSD01			2/2
`serviceUnitCount`			2000E/HSD02			1/15
`unitOrBasisForMeasurementCode`			2000E/HSD03			2/2
`sampleSelectionModulus`			2000E/HSD04			1/6
`timePeriodQualifier`			2000E/HSD05			1/2
`periodCount`			2000E/HSD06			1/3
`deliveryFrequencyCode`			2000E/HSD07			1/2
`deliveryPatternTimeCode`			2000E/HSD08			1/1
Claim Codes
`admissionTypeCode`	Commonly Used		2000E/CL101			1/1
`admissionSourceCode`			2000E/CL102			1/1
`patientStatusCode`			2000E/CL103			1/2
Ambulance Transport Information
`transportCode`			2000E/CR103			1/1
`transportDistance`			2000E/CR106		CR105=DH	1/15
Spinal Manipulation Service Information
`treatmentSeriesNumber`			2000E/CR201			1/9
`treatmentCount`			2000E/CR202			1/15
`subluxationBeginningLevelCode`			2000E/CR203			2/3
`subluxationEndLevelCode`		Use codes listed in CR203	2000E/CR204			2/3
Home Oxygen Therapy Information (Object)
`equipmentTypeCode1`			2000E/CR503			1/1
`equipmentTypeCode2`		Use codes listed in CR503	2000E/CR504			1/1
`equipmentTypeCode3`		Use codes listed in CR503	2000E/CR518			1/1
`flowRate`			2000E/CR506			1/15
`dailyUseCount`			2000E/CR507			1/15
`usePeriodHourCount`			2000E/CR508			1/15
`respiratoryTherapistOrderText`			2000E/CR509			1/80
`portableSystemFlowRate`			2000E/CR516			1/15
`deliverySystemCode`			2000E/CR517			1/1
Home Health Care Information
`prognosisCode`			2000E/CR601			1/1
`startDate`			2000E/CR602			8/8
`certificationPeriodStartDate`			2000E/CR604			1/35
`certificationPeriodEndDate`			2000E/CR604		CR603=RD8	1/35
`medicareCoverageIndicator`			2000E/CR607			1/1
`certificationTypeCode`			2000E/CR608			1/1
Additional Patient Information (Can contain multiple instances)
`reportTypeCode`			2000E/PWK01			2/2
`transmissionCode`			2000E/PWK02			1/2
`controlNumber`			2000E/PWK06		PWK05=AC	2/80
`description`			2000E/PWK07			1/80
`freeFormMessageText`			2000E/MSG01			1/264
Patient Event Provider Name Section (Can contain multiple instances)
`entityIdentifierCode`			2010EA/NM101	`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

Provider Details

Name	Element Loop	EDI Mapping Notes	Character Count (Min/Max)
Provider Name (If Provider is an individual, provide `lastName` and `firstName`, or provide `organizationName`)
`organizationName`	2010EA/NM103	NM102=2	1/60
`lastName`	2010EA/NM103		1/60
`firstName`	2010EA/NM104	NM102=1	1/35
`middleName`	2010EA/NM105		1/25
`namePrefix`	2010EA/NM106		1/10
`nameSuffix`	2010EA/NM107		1/10
`identificationCodeQualifier`	2010EA/NM108		1/2
`identifier`	2010EA/NM109		2/80
`address1`	2010EA/N301		1/55
`address2`	2010EA/N302		1/55
`city`	2010EA/N401		2/30
`state`	2010EA/N402		2/2
`postalCode`	2010EA/N403		3/15
`countryCode`	2010EA/N404		2/3
`countrySubDivisionCode`	2010EA/N407		1/3

Provider Supplemental Information (Request)

Name	Hint	Element Loop	EDI Mapping Notes	Character Count (Min/Max)
Provider Supplemental Information (provide any of the following if available)
`stateLicenseNumber`		2010EA/REF02	REF01=0B	1/50
`licenseNumberStateCode`	Required if `StateLicenseNumber` is entered	2010EA/REF03		1/50
`providerUpinNumber`		2010EA/REF02	REF01=1G	1/50
`facilityIdNumber`		2010EA/REF02	REF01=1J	1/50
`employersIdentificationNumber`		2010EA/REF02	REF01=EI	1/50
`providerPlanNetworkIdentificationNumber`		2010EA/REF02	REF01=N5	1/50
`facilityNetworkIdentificationNumber`		2010EA/REF02	REF01=N7	1/50
`ssn`		2010EA/REF02	REF01=SY	1/50
`carrierAssignedReferenceNumber`		2010EA/REF02	REF01=ZH	1/50
`contactName`		2010EA/PER02	PER01=IC	1/60
`contactElectronicMail`		2010EA/PER04	PER03=EM or PER06 PER05=EM or PER08 PER07=EM	1/256
`contactFacsimile`		2010EA/PER04	PER03=FX or PER06 PER05=FX or PER08 PER07=FX	1/256
`contactTelephone`		2010EA/PER04	PER03=TE or PER06 PER05=TE or PER08 PER07=TE	1/256
`providerCode`		2010EA PRV01	PRV02=PXC	1/3
`providerTaxonomyCode`		2010EA/PRV03		1/50

Additional Patient Information Contact Name (Request)

Name	Element Loop	EDI Mapping Notes	Character Count (Min/Max)
Additional Patient Information Contact Name (Can contain multiple instances)
`entityIdentifierCode`	2010EB	NM101=L5	2/3
`organizationName`	2010EB/NM103	NM102=2	1/60
`lastName`	2010EB/NM103		1/60
`firstName`	2010EB/NM104	NM102=1	1/35
`middleName`	2010EB/NM105		1/25
`nameSuffix`	2010EB/NM107		1/10
`identificationCodeQualifier`	2010EB/NM108		1/2
`identifier`	2010EB/NM109		2/80
`address1`	2010EB/N301		1/55
`address2`	2010EB/N302		1/55
`city`	2010EB/N401		2/30
`state`	2010EB/N402		2/2
`postalCode`	2010EB/N403		3/15
`countryCode`	2010EB/N404		2/3
`countrySubDivisionCode`	2010EB/N407		1/3
`contactName`	2010EB/PER02	PER01=IC	1/60
`contactElectronicMail`	2010EA/PER04	PER03=EM or PER06 PER05=EM or PER08 PER07=EM	1/256
`contactFacsimile`	2010EA/PER04	PER03=FX or PER06 PER05=FX or PER08 PER07=FX	1/256
`contactTelephone`	2010EA/PER04	PER03=TE or PER06 PER05=TE or PER08 PER07=TE	1/256

Patient Event Transport Information

Name	Element Loop	EDI Mapping Notes	Character Count (Min/Max)
Patient Event Transport Information (Can contain multiple instances)
`entityIdentifierCode`	2010EC/NM101		2/3
`transportLocationName`	2010EC NM103	NM102=2	1/60
`address1`	2010EC/N301		1/55
`address2`	2010EC/N302		1/55
`city`	2010EC/N401		2/30
`state`	2010EC/N402		2/2
`postCode`	2010EC/N403		3/15

Patient Event Other UMO Name

Name	Element Loop	EDI Mapping Notes	Character Count (Min/Max)
Patient Event Other UMO Name (Can contain multiple instances)
`entityIdentifierCode`	2010ED/NM101		2/3
`otherUmoName`	2010ED NM103	NM102=2	1/60
`otherUmoDenialReason1`	2010ED/REF02	REF01=ZZ	1/50
`otherUmoDenialReason2`	2010ED REF04_2	REF04_1=ZZ	1/50
`otherUmoDenialReason3`	2010ED REF04_4	REF04_3=ZZ	1/50
`otherUmoDenialReason4`	2010ED REF04_6	REF04_5=ZZ	1/50
`postCode`	2010ED/DTP03	YYYYMMDD DTP01=598 DTP02=D8	1/35

Service Level Section

Health Care Services Review Information

Name	Hint	Element Loop	Code	EDI Mapping Notes	Character Count (Min/Max)
Service Level Section (One instance per procedure code)
Health Care Services Review Information
`requestCategoryCode`		2000F/UM01	`requestCategoryCode` ===================== HS Health Services Review SC Specialty Care Review		1/2
`certificationTypeCode`		2000F/UM02	`certificationTypeCode` ===================== 1 Appeal - Immediate 2 Appeal - Standard 3 Cancel 4 Extension 5 Notification I Initial N Reconsideration R Renewal S Revised		1/1
`serviceTypeCode`		2000F/UM03			1/2
`facilityTypeCode`		2000F/UM04_1			1/2
`facilityCodeQualifier`		2000F/UM04_2			1/2
`certificationActionCode`		2000F/HCR01			1/2
`reviewIdentificationNumber`		2000F/HCR02			1/50
`reviewDecisionReasonCode`		2000F/HCR03			1/30
`secondSurgicalOpinionIndicator`		2000F/HCR04			1/1
`previousReviewAuthorizationNumber`		2000F/REF02		REF01=BB	1/50
`previousAdministrativeReferenceNumber`		2000F/REF02		REF01=NT	1/50
`serviceDateBegin`		2000F/DTP03		DTP01=472 DTP02=D8 YYYYMMDD	1/35
`serviceDateEnd`	`ServiceDateBegin` must exist	2000F/DTP03		DTP01=472 DTP02=RD8 YYYYMMDD	1/35
`certificationIssueDate`		2000F/DTP03		DTP01=102 DTP02=D8 YYYYMMDD	1/35
`certificationExpirationDate`		2000F/DTP03		DTP01=036 DTP02=D8 YYYYMMDD	1/35
`certificationEffectiveDateBegin`		2000F/DTP03		DTP01=007 DTP02=D8 YYYYMMDD	1/35
`certificationEffectiveDateEnd`	`CertificationEffectiveDateBegin` must exist	2000F/DTP03		DTP01=007 DTP02=RD8 YYYYMMDD	1/35

Professional Service Information

Name	Element Loop	Character Count (Min/Max)
Professional Service Information
`productOrServiceIDQualifier`	2000F/SV101_1	2/2
`procedureCode`	2000F/SV101_2	1/48
`procedureModifier1`	2000F/SV101_3	2/2
`procedureModifier2`	2000F/SV101_4	2/2
`procedureModifier3`	2000F/SV101_5	2/2
`procedureModifier4`	2000F/SV101_6	2/2
`procedureCodeDescription`	2000F/SV101_7	1/80
`procedureCode2`	2000F/SV101_8	1/48
`serviceLineAmount`	2000F/SV102	1/18
`unitOrBasisForMeasurementCode`	2000F/SV103	2/2
`serviceUnitCount`	2000F/SV104	1/15
`diagnosisCodePointer1`	2000F/SV107_1	1/2
`diagnosisCodePointer2`	2000F/SV107_2	1/2
`diagnosisCodePointer3`	2000F/SV107_3	1/2
`diagnosisCodePointer4`	2000F/SV107_4	1/2
`epsdtIndicator`	2000F/SV111	1/1
`nursingHomeLevelOfCare`	2000F/SV120	1/1

Institutional Service Information

Name	Element Loop	Character Count (Min/Max)
Institutional Service Information
`serviceLineRevenueCode`	2000F/SV201	1/48
`productOrServiceIDQualifier`	2000F/SV202_1	2/2
`procedureCode`	2000F/SV202_2	1/48
`procedureModifier1`	2000F/SV202_3	2/2
`procedureModifier2`	2000F/SV202_4	2/2
`procedureModifier3`	2000F/SV202_5	2/2
`procedureModifier4`	2000F/SV202_6	2/2
`procedureCodeDescription`	2000F/SV202_7	1/80
`procedureCode2`	2000F/SV202_8	1/48
`serviceLineAmount`	2000F/SV203	1/18
`unitOrBasisForMeasurementCode`	2000F/SV204	2/2
`serviceUnitCount`	2000F/SV205	1/15
`serviceLineRate`	2000F/SV206	1/10
`nursingHomeResidentialStatusCode`	2000F/SV209	1/1
`nursingHomeLevelOfCare`	2000F/SV210	1/1

Dental Service Information

Name	Element Loop	EDI Mapping Notes	Character Count (Min/Max)
Institutional Service Information
`procedureCode`	2000F/SV301_2	SV301_1=AD	1/48
`procedureModifier1`	2000F/SV301_3		2/2
`procedureModifier2`	2000F/SV301_4		2/2
`procedureModifier3`	2000F/SV301_5		2/2
`procedureModifier4`	2000F/SV301_6		2/2
`procedureCodeDescription`	2000F/SV301_7		1/80
`procedureCode2`	2000F/SV301_8		1/48
`serviceLineAmount`	2000F/SV302		1/18
`oralCavityDesignationCode`	2000F/SV304_1		1/3
`oralCavityDesignationCode2`	2000F/SV304_2		1/3
`oralCavityDesignationCode3`	2000F/SV304_3		1/3
`oralCavityDesignationCode4`	2000F/SV304_4		1/3
`oralCavityDesignationCode5`	2000F/SV304_5		1/3
`prosthesisCrownOrInlayCode`	2000F/SV305		1/1
`serviceUnitCount`	2000F/SV306		1/15
`description`	2000F/SV307		1/80

Tooth Information

Name	Element Loop	EDI Mapping Notes	Character Count (Min/Max)
Tooth Information
`toothCode`	2000F/TOO02	TOO01=JP	1/30
`toothSurfaceCode1`	2000F/TOO03_1		1/2
`toothSurfaceCode2`	2000F/TOO03_2		1/2
`toothSurfaceCode3`	2000F/TOO03_3		1/2
`toothSurfaceCode4`	2000F/TOO03_4		1/2
`toothSurfaceCode5`	2000F/TOO03_5		1/2

Health Care Service Delivery

Name	Element Loop	Character Count (Min/Max)
Health Care Service
`quantityQualifier`	2000F/HSD01	2/2
`serviceQuantity`	2000F/HSD02	1/15
`unitOrBasisForMeasurementCode`	2000F/HSD03	2/2
`sampleSelectionModulus`	2000F/HSD04	1/6
`timePeriodQualifier`	2000F/HSD05	1/2
`periodCount`	2000F/HSD06	1/3
`deliveryFrequencyCode`	2000F/HSD07	1/2
`deliveryPatternTimeCode`	2000F/HSD08	1/1

Attachments

Name	Element Loop	EDI Mapping Notes	Character Count (Min/Max)
Attachments
`reportTypeCode`	2000F/PWK01		2/2
`transmissionCode`	2000F/PWK02		1/2
`controlNumber`	2000F/PWK06	PWK05=AC	2/80
`description`	2000F/PWK07		1/80
`freeFormMessageText`	2000F/MSG01		1/264

Service Level Provider Name Section

Name	Required/Commonly Used	Hint	Element Loop	Code	EDI Mapping Notes	Character Count (Min/Max)
Service Level Provider Name Section (Can contain multiple instances)
`entityIdentifierCode`			2010F/NM101			2/3

Provider Name

Name	Element Loop	EDI Mapping Notes	Character Count (Min/Max)
Provider Name (If Provider is an individual, provide `lastName` and `firstName`, otherwise provide `organizationName`)
`organizationName`	2010F/NM103	NM102=2	1/60
`lastName`	2010F/NM103		1/60
`firstName`	2010F/NM104	NM102=1	1/35
`middleName`	2010F/NM105		1/25
`namePrefix`	2010F/NM106		1/10
`nameSuffix`	2010F/NM107		1/10
`identificationCodeQualifier`	2010F/NM108		1/2
`identifier`	2010F/NM109		2/80
`address1`	2010F/N301		1/55
`address2`	2010F/N302		1/55
`city`	2010F/N401		2/30
`state`	2010F/N402		2/2
`postalCode`	2010F/N403		3/15
`countryCode`	2010F/N404		2/3
`countrySubDivisionCode`	2010F/N407		1/3

Provider Supplemental Information

Name	Hint	Element Loop	EDI Mapping Notes	Character Count (Min/Max)
Provider Supplemental Information (Provide any of the following if available)
`stateLicenseNumber`		2010F/REF02	REF01=08	1/50
`licenseNumberStateCode`	Required if `StateLicenseNumber` is entered	2010F REF03		1/80
`providerUpinNumber`		2010F/REF02	REF01=1G	1/50
`facilityIdNumber`		2010F/REF02	REF01=1J	1/50
`employersIdentificationNumber`		2010F/REF02	REF01=EI	1/50
`providerSiteNumber`		2010F/REF02	REF01=G5	1/50
`providerPlanNetworkIdentificationNumber`		2010F/REF02	REF01=N5	1/50
`facilityNetworkIdentificationNumber`		2010F/REF02	REF01=N7	1/50
`ssn`		2010F/REF02	REF01=SY	1/50
`carrierAssignedReferenceNumber`		2010F/REF02	REF01=ZH	1/50
`contactName`		2010F/PER02	PER01=IC	1/60
`contactElectronicMail`		2010F/PER04	PER03=EM or PER06 PER05=EM or PER08 PER07=EM	1/256
`contactFacsimile`		2010F/PER04	PER03=FX or PER06 PER05=FX or PER08 PER07=FX	1/256
`contactTelephone`		2010F/PER04	PER03=TE or PER06 PER05=TE or PER08 PER07=TE	1/256
`providerCode`		2010F/PRV01	PRV02=PXC	1/3
`providerTaxonomyCode`		2010F/PRV03		1/50

NoA 278 Response

Submitter (Response)

Notification Validation (Response)

Name	Element Loop	Code	Character Count (Min/Max)
notificationValidation
`responseCode`	2000A/AAA01	N (No) Y (Yes)	2/2
`rejectReasonCode`	2000A/AAA03		1/2
`followupActionCode`	2000A/AAA04		2/80

Submitter Transaction Identifier (Response)

Name	Required/Commonly Used	Hint	Element Loop	Code	EDI Mapping Notes	Character Count (Min/Max)
Submitter Transaction Identifier
`submitterTransactionIdentifier`			BTH03
`payerId`			2010B/NM109
`payerName`			2010B/NM103
`umClearingHouseId`			GS03
`contactName`			2010B/PER02
`contactElectronicMail`			2010B/PER08
`contactTelephone`			2010B/PER04
`contactTelephoneExtension`			2010B/PER06

Source (Response)

Source Notification Validation

Name	Required/Commonly Used	Hint	Element Loop	Code	EDI Mapping Notes
Source Notification Validation	Required
`sourceType`	Required	Default 1P	2010A NM101	`sourceType` ========= 1P Provider 2B Third-Party Administrator FA Facility PR Payer X3 Utilization Management Organization
Sourcer Name (if Requester is an individual, provide `lastName` and `firstName`, otherwise provide `organizationName`)	Required
`organizationName`	Commonly Used		2010A/NM103
`lastName`			2010A/NM103
`firstName`			2010A/NM104
`middleName`			2010A/NM105
`suffixName`			2010A/NM107
Source Identification (Provide any of the following if available)
`providerUpinNumber`			2010A/REF02		REF01=1G
`facilityIdNumber`			2010A/REF02		REF01=1J
`employerIdentificationNumber`			2010A/REF02		REF01=EI
`providerSiteNumber`			2010A/REF02		REF01=G5
`providerPlanNetworkIdNumber`			2010A/REF02		REF01=N5
`facilityNetworkIdNumber`			2010A/REF02		REF01=N7
`socialSecurityNumber`			2010A/REF02		REF01=SY
`carrierAssignedReferenceNumber`			2010A/REF02		REF01=ZH
Source Identification Code (Provide one of the following)
`npi`			2010A/NM109
Source Provider Information
`providerCode`			2010A/PRV01
`referenceIdentification`			2010A/PRV03

Subscriber (Response)

Name	Element Loop	EDI Mapping Notes
traceNumbers
`traceTypeCode`	2000C/TRN01
`trackingNumber`	2000C/TRN02
`traceAssigningEntityIdentifier`	2000C/TRN03
`traceAssigningEntityAdditionalIdentifier`	2000C/TRN04
Subscriber Level Validation
`receiptNumber`	2010C/REF02
Subscriber Notification Validation
`lastName`	2000C/NM103
`firstName`	2010C/NM104
`middleName`	2010C/NM105
`prefix`	2010C/NM106
`suffix`	2010C/NM107
`memberId`	2010C/NM109
`dateOfBirth`	2010C/DMG02
`genderCode`	2010C/DMG03
Supplemental Identification
`policyNumber`	2010C/REF02	REF01=1L
`groupNumber`	2010C/REF02	REF01=6P
`patientAccountNumber`	2010C/REF02	REF01=EJ
`healthInsuranceClaimNumber`	2010C/REF02	REF01=F6
`idCard`	2010C/REF02	REF01=HJ
`insurancePolicyNumber`	2010C/REF02	REF01=IG
`planNetworkIdentificationNumber`	2010C/REF02	REF01=N6
`medicaidRecipientIdentificationNumber`	2010C/REF02	REF01=NQ
`ssn`	2010C/REF02	REF01=SY
`insuredIndicator`	2010C/INS01
`militaryRelationship`	2010C/INS08

Dependent (Response)

Name	Required/Commonly Used	Element Loop	EDI Mapping Notes
Dependent	Required
`receiptNumber`		2000C/REF02
traceNumbers
`traceTypeCode`		2000D/TRN01
`trackingNumber`		2000D/TRN02
`traceAssigningEntityIdentifier`		2000D/TRN03
`traceAssigningEntityAdditionalIdentifier`		2000D/TRN04
Dependent Level Validation
`responseCode`		2000D/AAA01
`rejectReasonCode`		2000D/AAA03
`followupActionCode`		2000D/AAA04
Dependent Notification Validation
`responseCode`		2010D/AAA01
`rejectReasonCode`		2010D/AAA03
`followupActionCode`		2010D/AAA04
Dependent Level Information
`lastName`		2010D/NM103
`firstName`		2010D/NM104
`middleName`		2010D/NM105
`suffix`		2010D/NM107
`dateOfBirth`		2010D/DMG02
`genderCode`		2010D/DMG03
Supplemental Identification
`patientAccountNumber`		2010D/REF02	REF01=EJ
`ssn`		2010D/REF02	REF01=SY
`insuredIdenticator`		2010D/INS01
`relationshipToInsuredCode`		2010D/INS02
`birthSequenceNumber`		2010D/INS17

Patient Event Detail (Response)

Name	Element Loop	EDI Mapping Notes
Trace Numbers
`traceTypeCode`	2000E/TRN01
`trackingNumber`	2000E/TRN02
`traceAssigningEntityIdentifier`	2000E/TRN03
`traceAssigningEntityAdditionalIdentifier`	2000E/TRN04
Patient Event Notification Validation
`responseCode`	2000D/AAA01
`rejectReasonCode`	2000D/AAA03
`followupActionCode`	2000D/AAA04
Patient Event Information
`requestCategoryCode`	2000E/UM01
`certificationTypeCode`	2000E/UM02
`serviceTypeCode`	2000E/UM03
`facilityTypeCode`	2000E/UM041
`facilityCodeQualifier`	2000E/UM042
`levelOfServiceCode`	2000E/UM06
`certificationActionCode`	2000E/HCR01
`reviewIdentificationNumber`	2000E/HCR02
`reviewDecisionReasonCode`	2000E/HCR03
`secondSurgicalOpinionIndicator`	2000E/HCR04
`administrativeReferenceNumber`	2000E/REF02	REF01=NT
`previousReviewAuthorizationNumber`	2000E/REF02	REF01-BB
`eventDateBegin`	2000E/DTP03	DTP01=AAH
`eventDateEnd`	2000E/DTP03	DTP01=AAH
`admissionDateBegin`	2000E/DTP03	DTP01=435
`dischargeDate`	2000E/DTP03	DTP01=096
`certificationIssueDate`	2000E/DTP03	DTP01=102
`certificationExpirationDate`	2000E/DTP03	DTP01=036
`certificationEffectiveDateBegin`	2000E/DTP03	DTP01=007
`certificationEffectiveDateEnd`	2000E/DTP03	DTP01=007
`diagnosisTypeCode1`	2000E/HI01_1
`diagnosisCode1`	2000E/HI01_2
`diagnosisDate1`	2000E/HI01_4	HI01_3=D8
`diagnosisTypeCode2`	2000E/HI02_1
`diagnosisCode2`	2000E/HI02_2
`diagnosisDate2`	2000E/HI02_4	HI02_3=D8
`diagnosisTypeCode3`	2000E/HI03_1
`diagnosisCode3`	2000E/HI03_2
`diagnosisDate3`	2000E/HI03_4	HI03_3=D8
`diagnosisTypeCode4`	2000E/HI04_1
`diagnosisCode4`	2000E/HI04_2
`diagnosisDate4`	2000E/HI04_4	HI03_3=D8
`diagnosisTypeCode5`	2000E/HI05_1
`diagnosisCode5`	2000E/HI05_2
`diagnosisDate5`	2000E/HI05_4	HI05_3=D8
`diagnosisTypeCode6`	2000E/HI06_1
`diagnosisCode6`	2000E/HI06_2
`diagnosisDate6`	2000E/HI06_4	HI06_3=D8
`diagnosisTypeCode7`	2000E/HI07_1
`diagnosisCode7`	2000E/HI07_2
`diagnosisDate7`	2000E/HI07_4	HI07_3=D8
`diagnosisTypeCode8`	2000E/HI08_1
`diagnosisCode8`	2000E/HI08_2
`diagnosisDate8`	2000E/HI08_4	HI08_3=D8
`diagnosisTypeCode9`	2000E/HI09_1
`diagnosisCode9`	2000E/HI09_2
`diagnosisDate9`	2000E/HI09_4	HI09_3=D8
`diagnosisTypeCode10`	2000E/HI10_1
`diagnosisCode10`	2000E/HI10_2
`diagnosisDate10`	2000E/HI10_4	HI10_3=D8
`diagnosisTypeCode11`	2000E/HI11_1
`diagnosisCode11`	2000E/HI11_4	HI11_3=D8
`diagnosisDate11`	2000E/HI11_4	HI11_3=D8
`diagnosisTypeCode12`	2000E/HI12_1
`diagnosisCode12`	2000E/HI12_2
`diagnosisDate12`	2000E/HI12_4	HI12_3=D8

Patient Event Provider Name

Name	Hint	Element	EDI Mapping Notes	Character Count (Min/Max)
Patient Event Provider Request Validation)
`entityIdentifierCode`		2010EA/NM101
`lastName`		2010EA/NM103		1/60
`firstName`		2010EA/NM104		1/35
`middleName`		2010EA/NM105		1/25
`namePrefix`		2010EA/NM106		1/10
`nameSuffix`		2010EA/NM107		1/10
`identificationCodeQualifier`		2010EA/NM108		1/2
`identifier`		2010EA/NM109		2/80
Provider Supplemental Information (Provide any of the following if available)
`stateLicenseNumber`		2010EA/REF02	REF01=0B	1/50
`licenseNumberStateCode`	Required if `StateLicenseNumber` is entered	2010EA/REF03		1/80
`providerUpinNumber`		2010EA/REF02	REF01=1G	1/50
`facilityIdNumber`		2010EA/REF02	REF01=1J	1/50
`employersIdentificationNumber`		2010EA/REF02	REF01=EI	1/50
`providerPlanNetworkIdentificationNumber`		2010EA/REF02	REF01=N5	1/50
`facilityNetworkIdentificationNumber`		2010EA/REF02	REF01=N7	1/50
`ssn`		2010EA/REF02	REF01=SY	1/50
`carrierAssignedReferenceNumber`		2010EA/REF02	REF01=ZH	1/50
`provideCode`		2010EA/PRV01
`providerTaxonomyCode`		2010EA/PRV03
`patientEventProviderRequestValidation` (Array of objects)		-
`responseCode`		2010EA/AAA01		1/1
`rejectReasonCode`		2010EA/AAA03		2/2
`followupActionCode`		2010EA/AAA04		1/1

Service Level (Response)

Name	Required/Commonly Used	Hint	Element	EDI Mapping Notes	Character Count (Min/Max)
Service Level Section (One instance per procedure code)	Required
Trace Numbers
`traceTypeCode`			2000E/TRN01		1/1
`trackingNumber`			2000E/TRN02		2/2
`traceAssigningEntityIdentifier`			2000E/TRN03		1/1
`traceAssigningEntityAdditionalIdentifier`	Commonly Used		2000E/TRN04		1/2
Service Notification Validation
`requestCategoryCode`			2000F/UM01
`certificationTypeCode`			2000F/UM02		1/1
`serviceTypeCode`			2000F/UM03		1/2
`facilityTypeCode`	Commonly Used		2000F/UM041		1/2
`facilityCodeQualifier`	Commonly Used		2000F/UM042		1/2
`certificationActionCode`			2000F/HCR01		1/2
`reviewIdentificationNumber`			2000F/HCR02		1/50
`reviewDecisionReasonCode`			2000F/HCR03		1/30
`secondSurgicalOpinionIndicator`			2000F/HCR04		1/1
`administrativeReferenceNumber`			2000F/REF02	REF01=BB	1/50
`previousReviewAuthorizationNumber`			2000F/REF02	REF01=NT	1/50
`serviceDateBegin`	Commonly Used	Usually same as 2000E Event Date	2000F/DTP03	DTP01=472	1/35
`serviceDateEnd`			2000F/DTP03	DTP01=472	1/35_
`certificationIssueDate`			2000F/DTP03	DTP01=102	1/35
`certificationExpirationDate`			2000F/DTP03	DTP01=036	1/35
`certificationEffectiveDateBegin`			2000F/DTP03	DTP01=007	1/35
`certificationEffectiveDateEnd`			2000F/DTP03	DTP01=007	1/35
One of the follow Service Sections is Required	Required
Professional Service Information
`productOrServiceIDQualifier`	Commonly Used		2000F/SV1011		2/2
`procedureCode`	Commonly Used	While not required strongly recommended as procedure code required by some payers if not sending `previousReviewAuthorizationNumber` or `previousAdministrativeReferenceNumber`	2000F/SV1012		1/48
`procedureModifier`			2000F/SV1013		2/2
`procedureModifier2`			2000F/SV1014		2/2
`procedureModifier3`			2000F/SV1015		2/2
`procedureModifier4`			2000F/SV1016		2/2
`procedureCode2`			2000F/SV1018		1/48
`serviceLineAmount`			2000F/SV102		1/18
`unitOrBasisForMeasurementCode`			2000F/SV103		2/2
`serviceUnitCount`			2000F/SV104		1/15
`epsdtIndicator`			2000F/SV111		1/1
`nursingHomeLevelOfCareCode`			2000F/SV120		1/1
InstitutionalService Information
`serviceLineRevenueCode`			2000F/SV201		1/48
`productOrServiceIDQualifier`			2000F/SV2021		2/2
`procedureCode`			2000F/SV2022		1/48
`procedureModifier`			2000F/SV2023		2/2
`procedureModifier2`			2000F/SV2024		2/2
`procedureModifier3`			2000F/SV202_5		2/2
`procedureModifier4`			2000F/SV2026		2/2
`procedureCodeDescription`			2000F/SV2027		1/80
`procedureCode2`			2000F/SV2028		1/48
`serviceLineAmount`			2000F/SV203		1/18
`unitOrBasisForMeasurementCode`			2000F/SV204		2/2
`serviceUnitCount`			2000F/SV205		1/15
`serviceLineRate`			2000F/SV206		1/10
`nursingHomeLevelOfCare`			2000F/SV210		1/1
Dental Service Information
`procedureCode`			2000F/SV3012		1/48
`procedureModifier`			2000F/SV3013		2/2
`procedureModifier2`			2000F/SV3014		2/2
`procedureModifier3`			2000F/SV3015		2/2
`procedureModifier4`			2000F/SV3016		2/2
`procedureCode2`			2000F/SV3018		1/48
`serviceLineAmount`			2000F/SV302		1/18
`americanDentalAssociationCodes`			2000F/SV3041		1/3
`americanDentalAssociationCodes2`			2000F/SV3042		1/3
`americanDentalAssociationCodes3`			2000F/SV3043		1/3
`americanDentalAssociationCodes4`			2000F/SV3044		1/3
`americanDentalAssociationCodes5`			2000F/SV3045		1/3
`prosthesisCrownOrInlayCode`			2000F/SV305		1/1
`serviceUnitCount`			2000F/SV306		1/15
Tooth Information
`toothCode`			2000F/TOO02		1/30
`toothSurfaceCode`			2000F/TOO031		1/2
`toothSurfaceCode2`			2000F/TOO032		1/2
`toothSurfaceCode3`			2000F/TOO033		1/2
`toothSurfaceCode4`			2000F/TOO034		1/2
`toothSurfaceCode5`			2000F/TOO035		1/2
Free Form Message Text
`freeFormMessageText`			2000F/MSG01
`serviceProviderRequestValidation` (Array of object)
`responseCode`			2010F/AAA01		1/1
`rejectReasonCode`			2010F/AAA03		2/2
`followupActionCode`			2010F/AAA04		1/1

Service Provider Information (Response)

Name	Hint	Element Loop	Code	EDI Mapping Notes	Character Count (Min/Max)
Service Level Provider Name Section (Can contain multiple instances)
`entityIdentifierCode`		2010F/NM101			2/3
Provider Name (If Provider is an individual, provide `lastName` and `firstName`, otherwise provide `organizationName`)
`lastName`		2010F/NM103		NM102=1	1/60
`firstName`		2010F/NM104		NM102=1	1/35
`middleName`		2010F/NM105			1/25
`namePrefix`		2010F/NM106			1/10
`nameSuffix`		2010F/NM107			1/10
`identificationCodeQualifier`		2010F/NM108	24 (Employer’s Identification Number) 34 (Social Security Number) 46 (Electronic Transmitter Identification Number (ETIN)) XX (Centers for Medicare and Medicaid Services National Provider Identifier (NPI))		1/2
`identifier`		2010F/NM109			2/80
Provider Supplemental Information (Provide any of the following if available)
`stateLicenseNumber`		2010F/REF02		REF01=0B	1/50
`licenseNumberStateCode`	Required if `StateLicenseNumber` is entered	2010F/REF03			1/80
`providerUpinNumber`		2010F/REF02		REF01=1G	1/50
`facilityIdNumber`		2010F/REF02		REF01=1J	1/50
`employersIdentificationNumber`		2010F/REF02		REF01=EI	1/50
`providerSiteNumber`		2010F/REF02		REF01=G5	1/50
`providerPlanNetworkIdentificationNumber`		2010F/REF02		REF01=N5	1/50
`facilityNetworkIdentificationNumber`		2010F/REF02		REF01=N7	1/50
`ssn`		2010F/REF02		REF01=SY	1/50
`carrierAssignedReferenceNumber`		2010F/REF02		REF01=ZH	1/50
`providerCode`		2010F/PRV01		PRV02=PXC	1/3
`providerTaxonomyCode`		2010F/PRV03			1/50
`serviceProviderRequestValidation` (Array of objects)
`responseCode`		2010F/AAA01	N (No) Y (Yes)		1/1
`rejectReasonCode`		2010F/AAA03			2/2
`followupActionCode`		2010F/AAA04			1/1