Professional 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.
The Consolidated 837p Implementation Guide pages 53 and 54, 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.
Subscriber Hierarchical Level (2000B)
Subscriber Information (2010BA)
Ambulance Transport Information (CR)
Spinal Manipulation Service Information (CR)
Patient Vision Information (CRC)
Health Care Code Information (HI)
Anesthesia Related Procedure (HI)
Claim Pricing Information (HCP)
Ambulance Pick Up Location (2310E)
Other Payer Referring Provider (2330C)
Other Payer Rendering Provider (2330D)
Other Payer Service Facility Location (2330E)
REF 10 – MISC Number References
Professional Claims v3 API JSON-to-EDI mapping
Field | Description | Constraints |
---|---|---|
controlNumber | Transaction Set Control Number. This is provided by the submitter. Unique ID used to trace the request. Value goes in ISA13 (no loop). | 9/9 R |
tradingPartnerServiceId | ID used by the Change Healthcare clearinghouse for the trading partner. Loop 2100A, NM109. You can use the ConnectCenter CPID value as the tradingPartnerServiceId from the searchable Optum Payer list npd or cap. | 2/80 R |
Name | Element | Loop | Description | Constraints |
---|---|---|---|---|
submitter (Object) | Identification of the provider, including information, such as the organizationName. | R | ||
organizationName | NM103 | 1000A | Organization name for the submitter. Can use organization or last name. NM102 = 02 (Non-Person Entity) | 1/60 R |
lastName | NM103 | 1000A | Last name for the submitter. Can use organization or last name. NM102 = 01(Person) | 1/60 R |
firstName | NM104 | 1000A | Submitter first name. NM102 = 01(Person) | 1/35 |
middleName | NM105 | 1000A | Submitter middle name or initial. NM102 = 01(Person) | 1/25 |
suffix | NM107 | 1000A | Use when needed to identify submitter. | 1/10 |
taxId | NM108 | 1000A | Electronic Transmitter Identification Number (ETIN) 46 | 1/2 R |
contactInformation (Object) | ||||
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 |
Name | Element | Loop | Description | Constraints |
---|---|---|---|---|
receiver (Object) | The insurance company that underwrites the insurance policy. | R | ||
organizationName | NM103 | 1000B | Organization name for the entity underwriting the insurance policy. | 1/60 R |
See the 837p Implementation Guide page 116 and the OpenAPI Spec for more information.
Name | Element | Loop | Description | Constraints |
---|---|---|---|---|
paymentResponsibilityLevelCode | SBR01 | 2000B | Code that identifies payer's level of responsibility for payment of claim. Example: P = Primary S = Secondary | 1/1 R |
groupNumber | SBR03 | 2000B | The subscriber’s group number as specified on their policy. | 1/50 S |
subscriberGroupName | SBR04 | 2000B | The subscriber group name is the plan name. | 1/60 S |
insuranceTypeCode | SBR05 | 2000B | Code that identifies the type of insurance policy in a specific insurance program. Information is specific only to Medicare plans. Refer to the ASC X12 Consolidated 270/271 Guide bottom of page 117. | 1/3 S |
pregnancyIndicator | PAT09 | See Desc. | Subscriber 2000B or Patient 2000C. | 1/10 S |
See the 837p Implementation Guide page 116 to 127 and the OpenAPI Spec for more information.
Name | Element | Loop | Description | Constraints |
---|---|---|---|---|
subscriber (Object) | The person who has the insurance policy; includes the patient's insurance member ID and insurance policyNumber. | R | ||
memberId | NM109 | 2010BA | The subscriber’s insurance member ID. | 2/80 R |
ssn | REF02 | 2010BA | Subscriber’s social security number. REF01=SY | 1/50 |
firstName | NM104 | 2010BA | The subscriber’s first name as specified on their policy. | 1/35 |
middleName | NM105 | 2010BA | Subscribers middle name. | 1/25 |
suffix | NM107 | 2010BA | Use to identify the individual. | 1/10 |
dateOfBirth | DMG02 | 2010BA | The subscriber’s birth date as specified on their policy. Format: YYYYMMDD Required when subscriber is the patient. | 1/35 S |
gender | DMG03 | 2010BA | The subscriber’s gender as specified on their policy. Required when subscriber is the patient. | 1/1 S |
address (Object) | ||||
address1 | N301 | 2010BA | Subscriber’s address line 1. Required when subscriber is the patient. | 1/35 S |
address2 | N302 | 2010BA | Subscriber’s address line 2. | 1/35 |
city | N401 | 2010BA | Subscriber’s city. Required when subscriber is the patient. | 1/60 S |
state | N402 | 2010BA | Subscriber’s state. Required when subscriber is the patient. | 1/35 S |
postalCode | N403 | 2010BA | Subscriber’s postal code. Required when subscriber is the patient. | 3/15 S |
countryCode | N404 | 2010AB | Country code. | 1/35 |
countrySubDivisionCode | N404 | 2010AB | Country Sub Division code. | 1/35 |
Destination Payer's information for the claim. See the 837p Implementation Guide page 133, and the OpenAPI spec for more information.
Name | Element | Loop | Description | Constraints |
---|---|---|---|---|
tradingPartnerName | NM103 | 2010BB | Organization Name. NM101=PR (Payer) MN102=2 (Non-Person Entity) | 1/60 R |
tradingPartnerServiceId | NM109 | 2010BB | Code that identifies party or other code. NM108=PI (Payer Identification) | 2/80 |
payerAddress (Object) | ||||
address1 | N301 | 2010BB | Address Information. | 1/55 |
address2 | N302 | 2010BB | Additional Address Information. | 1/55 |
city | N401 | 2010BB | City Name. | 2/30 |
state | N402 | 2010BB | State Name. | 2/2 |
postalCode | N403 | 2010BB | Payer Postal Zone or Zip Code. | 3/15 |
countryCode | N404 | 2010BB | Country Code. | 1/35 |
countrySubDivisionCode | N404 | 2010BB | Country sub division Code. | 1/35 |
See the 837p Implementation Guide page 116 through 18 and page 297 and the OpenAPI spec for more information.
Name | Element | Loop | Description | Constraints |
---|---|---|---|---|
otherSubscriberInformation (Array of objects) | The person who has the insurance policy. | S | ||
paymentResponsibilityLevelCode | SBR01 | 2320 | Code that identifies payer's level of responsibility for claim payment. Example: P = Primary | 1/1 R |
individualRelationshipCode | SBR02 | 2320 | Code that describes the relationship between two individuals or entities. Example: 01 = Spouse | 2/2 R |
insuranceGroupOrPolicyNumber | SBR03 | 2320 | The subscriber’s policy number as specified on their policy. | 1/50 S |
otherInsuredGroupName | SBR04 | 2320 | Plan name. | 1/60 |
insuranceTypeCode | SBR05 | 2320 | Code that identifies the insurance policy type within a specific insurance program. See annotation in OpenAPI Spec. | 1/3 |
claimFilingIndicatorCode | SBR09 | 2320 | Identifies the claim type. Example: 13 = Point of Service See annotation in OpenAPI Spec. | 1/2 R |
claimLevelAdjustments (Array) | S | |||
adjustmentGroupCode | CAS01 | 2320 | Identifies the category of payment adjustment. Example: CO = Contractual Obligations | 1/2 |
adjustmentdetails (Array) | ||||
adjustmentReasonCode | See Desc. | 2320 | Describes the detailed reason for the adjustment. CAS02, CAS05, CAS08, CAS11, CAS14, CAS17 | 1/5 |
adjustmentAmount | See Desc. | 2320 | Amount of the adjustment. CAS03, CAS06, CAS09, CAS12, CAS15, CAS18 | 1/18 |
adjustmentQuantity | See Desc. | 2320 | Units of service adjusted. CAS04, CAS07, CAS10, CAS13, CAS16, CAS19 | 1/15 |
AMT — Patient Amount Paid | ||||
payerPaidAmount | AMT02 | 2320 | Coordination of Benefits (COB) Payer Paid amount. It is the amount that Medicaid actually paid. | 1/18 |
nonCoveredChargeAmount | AMT02 | 2320 | Monetary Amount — COB Non-Covered Amount. | 1/18 |
remainingPatientLiability | AMT02 | 2320 | Monetary Amount — Remaining Patient Liability. Check the Consolidated 837 Guide for further details and requirements. Use the search term "remaining patient liability" for Loop 2320. | 1/18 S |
OI — Other Insurance Coverage Information | ||||
benefitsAssignmentCertificationIndicator | OI03 | 2320 | This element answers the question of whether the insured authorized remitting payment directly to the provider. | 1/1 |
patientSignatureGeneratedForPatient | OI04 | 2320 | R when a signature is executed on the patient’s behalf under state/federal law. Example: P = Signature generated by provider because the patient was not physically present for services. | 1/1 |
releaseOfInformationCode | OI06 | 2320 | Code that shows that the provider has on file a signed statement by the patient authorizing release of medical data to other organizations. | 1/1 |
MOA — Medicare Outpatient Adjudication | ||||
reimbursementRate | MOA01 | 2320 | Percentage expressed as a decimal. | 1/10 |
hcpcsPayableAmount | MOA02 | 2320 | The claim's Health Care Financing Administration Common Procedural Coding System (HCPCS) payable amount. | 1/18 |
claimPaymentRemarkCode | MOA03 MOA04 MOA05 MOA06 MOA07 | 2320 | Reference information for a Transaction Set or specified by the Reference Identification Qualifier. | 1/50 |
endStageRenalDiseasePaymentAmount | MOA08 | 2320 | End Stage Renal Disease (ESRD) payment amount. | 1/18 |
nonPayableProfessionalComponentBilledAmount | MOA09 | 2320 | The professional component amount billed but not payable. | 1/18 |
Name | Element | Loop | Description | Constraints |
---|---|---|---|---|
otherSubscriberName (Object) | The insurance policy subscriber. | R | ||
otherInsuredQualifier | NM102 | 2330A | Entity type. Example: 1 = Person, 2 = Non-Person Entity | 1/1 |
otherInsuredLastName | NM103 | 2330A | The subscriber’s last name as specified on their policy. | 1/60 R |
otherInsuredFirstName | NM104 | 2330A | The subscriber’s first name as specified on their policy. | 1/35R |
otherInsuredMiddleName | NM105 | 2330A | Subscribers middle name. | 1/25 S |
otherInsuredNameSuffix | NM107 | 2330A | Use to identify the individual. | 1/10 S |
otherInsuredIdentifierTypeCode | NM108 | 2330A | Type of identification. Example: MI = Member Identification Number | 1/2 R |
otherInsuredIdentifier | NM109 | 2330A | Code that identifies a party or other code. | 2/80 S |
otherInsuredAddress (Object) | ||||
address1 | N301 | 2330A | Subscriber’s address Line 1. Required when the subscriber is the patient. | 1/35 S |
address2 | N302 | 2330A | Subscriber’s address line 2. | 1/35 S |
city | N401 | 2330A | Subscriber’s city. Required when the subscriber is the patient. | 1/60 S |
state | N402 | 2330A | Subscriber’s state. Required when the subscriber is the patient. | 1/35 S |
postalCode | N403 | 2330A | Subscriber’s postal code. Required when the subscriber is the patient. | 3/15 S |
countryCode | N404 | 2330A | Country code. | 1/35 S |
countrySubDivisionCode | N404 | 2330A | Country Sub Division code. | 1/35 S |
otherInsuredAdditionalIdentifier | REF02 | 2330A | Social Security Number. REF01=SY | 1/50 S |
NOTE
When the dependent is the patient, elements marked with “R” in the Constraints column are required.
Name | Element | Loop | Description | Constraints |
---|---|---|---|---|
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 See Desc. |
firstName | NM104 | 2010CA | Dependent’s first name. | 1/35 R |
middleName | NM105 | 2010CA | Dependent’s middle name. | 1/25 R |
suffix | NM107 | 2010CA | Use to identify the individual. | 1/10 R |
dateOfBirth | DMG02 | 2010CA | Dependent’s birth date. R when the dependent is the patient. Required if patient is a dependent of subscriber and cannot be uniquely identified. | 1/35 See Desc. |
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 See Desc. |
ssn | REF02 | 2010CA | Dependent social security number. REF01=SY | 1/50 |
relationshipToSubscriberCode | PAT01 | 2000C | Patient’s relation to the insured person. Example: 01 = Spouse Required if patient is a dependent of subscriber and cannot be uniquely identified. | 2/2 R |
Name | Element | Loop | Description | Constraints |
---|---|---|---|---|
relationshipToSubscriberCode | PAT01 | 2000C | Patient’s relation to the insured person. Value of PAT01. Example: 01 = Spouse Required if patient is a dependent of subscriber and cannot be uniquely identified. | 1/50 See Desc |
pregnancyIndicator | PAT09 | See Desc. | Subscriber 2000B or Patient 2000C | 1/10 |
Name | Element | Loop | Description | Constraints |
---|---|---|---|---|
dependent (Object) | S | |||
lastName | NM103 | 2010CA | Dependent’s last name. Required if patient is a dependent of subscriber and cannot be uniquely identified. | 1/60 See Desc. |
firstName | NM104 | 2010CA | Dependent’s first name. | 1/35 |
middleName | NM105 | 2010CA | Dependent’s middle name. | 1/25 |
suffix | NM107 | 2010CA | Use to identify the individual. | 1/10 R |
dateOfBirth | DMG02 | 2010CA | Dependent’s birth date. Format: YYYYMMDD Required if patient is a dependent of subscriber and cannot be uniquely identified. | 1/35 See Desc |
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 See Desc. |
ssn | REF02 | 2010CA | Dependent social security number. REF01=SY | 1/50 |
contactInformation (Object) | Property and Casualty Patient Contact Information. | S | ||
name | PER02 | 2010CA | Provider contact name. | 1/60 S |
phoneNumber | PER04 | 2010CA | Provider contact phone number. PER03=TE | 1/256 S |
Name | Element | Loop | Description | Constraints |
---|---|---|---|---|
contactInformation (Object) | 2010CA | Property and Casualty Patient Contact Information. | S | |
name | PER02 | 2010CA | Provider contact name. | 1/60 |
phoneNumber | PER04 | 2010CA | Provider contact phone number. PER03=TE | 1/256 R |
faxNumber | PER04 | 2010CA | Provider fax number. PER03=FX | 1/256 S |
email | PER04 | 2010CA | Submitter email address. PER03 = EM | 1/256 S |
validContact | PER04 | 2010CA | Boolean. | S |
Name | Element | Loop | Description | Constraints |
---|---|---|---|---|
providers (Object) | The providers involved with the medical claim. | R | ||
providerType | NM101 | See Desc | Provider type, send what is in quotes: “BillingProvider” (Loop 2010AA), “ReferringProvider” (Loop 2310A), “RenderingProvider” (Loop 2310B), “OrderingProvider” (Loop 2420E) or “SupervisingProvider” (Loop 2310D) | R |
npi | NM109 | relative | National Provider Identification value. NM108 = XX | 2/80 S |
Name | Element | Loop | Description | Constraints |
---|---|---|---|---|
Billing Provider Tax ID | ||||
ssn | REF02 | 2010AC | Provider's Social Security Number. REF01 = SY (Social Security Number) If provider listed does not have a Tax ID send SSN. | 1/50 See Desc. |
employerId | REF02 | 2010AC | Provider tax identification number. REF01 = EI (Employer ID) | 1/50 R |
Billing Provider Secondary ID | ||||
commercialNumber | REF02 | 2010A | Provider Commercial Number. REF01=G2 | 1/50 |
locationNumber | REF02 | 2010AC | Provider location number. REF01 = LU | 1/50 |
payerIdentificationNumber | REF02 | 2010AC | Payer identification Number. REF01=2U | 1/50 |
employerIdentificationNumber | REF02 | 2010AC | Employer’s Identification Number. REF01=EI | 1/50 |
claimOfficeNumber | REF02 | 2010AC | Claim Office Number. | 1/50 |
naic | REF02 | 2010AC | National Association of Insurance Commissioners. (NAIC) code. REF01=NF | 1/50 |
Billing & Referring Provider UPIN/License | ||||
stateLicenseNumber | REF02 | 2010AC | See Desc. |State license number. REF01 = 0B Billing Provider (2010AA) Referring Provider (2310A) | 1/50 |
providerUpinNumber | REF02 | 2010AC | See Desc. | Provider UPIN number. REF01 = 1G Billing Provider (2010AA) Referring Provider (2310A) | 1/50 |
taxonomyCode | PRV03 | See Desc. | Health care provider taxonomy code. Referring Provider () Rendering Provider (2310B) |
Name | Element | Loop | Description | Constraints |
---|---|---|---|---|
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 |
suffix | NM107 | 2010AA | Use to identify the individual. | 1/10 |
address (Object) | ||||
address1 | N301 | 2010AA | Provider’s address line 1. | 1/35 R |
address2 | N302 | 2010AA | Provider’s address line 2. | 1/35 |
city | N401 | 2010AA | Provider’s city. | 1/60 R |
state | N402 | 2010AA | Provider’s state. | 1/35 S |
postalCode | N403 | 2010AA | Provider’s postal code. | 3/15 S |
countryCode | N404 | 2010AA | Country code. | 1/35 S |
countrySubDivisionCode | N404 | 2010AA | Country Sub Division code. | 1/35 S |
contactInformation (Object) | S | |||
name | PER02 | 2010AA | Provider contact name. | 1/60 S |
faxNumber | PER04 | 2010AA | Provider fax number. PER03=FX | 1/256 S |
phoneNumber | PER04 | 2010AA | Provider contact phone number. PER03=TE | 1/256 S |
Name | Element | Loop | Description | Constraints |
---|---|---|---|---|
payToAddress (Object) | S | |||
address1 | N301 | 2010AB | Pay-To address’s address line 1. | 1/35 R |
address2 | N302 | 2010AB | Pay-To address’s address line 2. | 1/35 S |
city | N401 | 2010AB | Pay-To address’s city. | 1/60 R |
state | N402 | 2010AB | Pay-To address’s state. | 1/35 S |
postalCode | N403 | 2010AB | Pay-To address’s postal code. | 3/15 S |
countryCode | N404 | 2010AB | Pay-To country code. | 1/35 S |
countrySubDivisionCode | N404 | 2010AB | Pay-To country code. | 1/35 S |
Name | Element | Loop | Description | Constraints |
---|---|---|---|---|
payToPlan (Object) | S | |||
organizationName | NM103 | 2010AC | Pay-To Plan organization name | 1/60 R |
primaryIdentifierTypeCode | NM108 | 2010AC | Pay-To Plan identification code qualifier. PI = Payer Identification XV = Centers for Medicare and Medicaid Service PlanID | 1/2 R |
primaryIdentifier | NM109 | 2010AC | Pay-To Plan Primary Identifier. | 2/80 R |
📝 REF01 and REF02 required for REF segment. | ||||
secondaryIdentifierTypeCode | REF01 | 2010AC | Pay-To Plan Reference Identification Qualifier. 2U = Payer Identification Number FY = Claim Office Number NF = NAIC code | 2/3 |
secondaryIdentifier | REF02 | 2010AC | Pay-To Plan Secondary Identifier. | 1/50 |
taxIdentificationNumber | REF02 | 2010AC | Pay-To Plan Tax Identification Number. REF01 = EI (Employer’s Identification Number) | 1/50 |
address (Object) | ||||
address1 | N301 | 2010AC | Pay-To Plan address line 1. | 1/35 R |
address2 | N302 | 2010AC | Pay-To Plan address line 2. | 1/35 S |
city | N401 | 2010AC | Pay-To Plan city. | 1/60 R |
state | N402 | 2010AC | Pay-To Plan state. | 1/35 S |
postalCode | N403 | 2010AC | Pay-To Plan postal code. | 3/15 S |
countryCode | N404 | 2010AC | Pay-To Country code. | 1/35 S |
countrySubDivisionCode | N404 | 2010AC | Pay-To Country code. | 1/35 S |
Name | Element | Loop | Description | Constraints |
---|---|---|---|---|
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. This section contains the standard charge entries that the provider(s) expect to receive for their services. | R | ||
claimFilingCode | SBR09 | 2000B | Subscriber claim filing code. Example: 12 = PPO | 1/2 R |
propertyCasualtyClaimNumber | REF02 | 2010CA | (Under Patient Name loop) Patient property and casualty claim number. REF01=Y4 (Agency Claim Number) | 1/50 S |
patientWeight | PAT08 | See Desc. | Patient weight. Subscriber 2300B or Patient 2000C | 1/10 |
patientControlNumber | CLM01 | 2300 | Identifier to track a claim from creation by provider through payment. | 1/38 R |
claimChargeAmount | CLM02 | 2300 | Total claim charge amount. | 1/18 R |
placeOfServiceCode | CLM05-01 | 2300 | Code identifying where services were, or may be performed. | 1/2 R |
claimFrequencyCode | CLM05-03 | 2300 | Code that defines the frequency of the claim. | 1/1 R |
signatureIndicator | CLM06 | 2300 | Provider signature is on file. Yes = Y, No = N | 1/1 R |
planParticipationCode | CLM07 | 2300 | Code that states if the provider accepted assignment. A = Assigned B = Assignment accepted only on clinical lab services C = Not Assigned | 1/1 R |
benefitsAssignmentCertificationIndicator | CLM08 | 2300 | Code that indicates the insured or authorized person, agrees benefits will be assigned to the provider. Yes = Y, No = N | 1/1 R |
releaseInformationCode | CLM09 | 2300 | Code that indicates if the provider has on file a signed statement by the patient authorizing the release of medical data to other organizations. Informed = I, Yes = Y | 1/1 R |
Name | Element | Loop | Description | Constraints |
---|---|---|---|---|
patientControlNumber | CLM01 | 2300 | Identifier used to track a claim from creation by the provider through payment. | 1/38 R |
claimChargeAmount | CLM02 | 2300 | Total claim charge amount. | 1/18 R |
placeOfServiceCode | CLM05-01 | 2300 | Code identifying where services were or may be performed. | 1/2 R |
claimFrequencyCode | CLM05-03 | 2300 | Code specifying the frequency of the claim. | 1/1 R |
signatureIndicator | CLM06 | 2300 | Provider signature is on file indicator. Yes = Y, No = N | 1/1 R |
planParticipationCode | CLM07 | 2300 | Code that indicates if the provider accepts the assignment. A = Assigned B = Assignment accepted on clinical lab services only C = Not Assigned | 1/1 R |
benefitsAssignmentCertificationIndicator | CLM08 | 2300 | Code that indicates the insured or authorized person authorizes benefits to be assigned to provider. Yes = Y, No = N | 1/1 R |
releaseInformationCode | CLM09 | 2300 | Code that indicates if the provider has on file a signed statement by the patient authorizing the release of medical data to other organizations. Informed = I, Yes = Y | 1/1 R |
patientSignatureSourceCode | CLM10 | 2300 | CLM10=P | Boolean |
relatedCausesCode | CLM11 | 2300 | CLM11 Allowed Values are: 'AA' Auto Accident 'EM' Employment 'OA' Other Accident | 2/3 |
patientAmountPaid | ATM02 | 2300 | ATM01=F5 | 1/18 |
autoAccidentStateCode | CLM11-04 | 2300 | Required when the CLM11-01 or CLM11-02 element contains the Auto Accident (AA) value, which identifies the state or province where the accident occurred. If not required, do not send. | 2/2 S |
autoAccidentCountryCode | CLM11-05 | 2300 | Required when the CLM11-01 or CLM11-02 element has the Auto Accident (AA) value and the accident happened in a country, other than in the US or Canada. | 2/3 S |
specialProgramCode | CLM12 | 2300 | Required if services are rendered under some circumstances in Medicaid. If not required, do not send. Codes are as follows: 02: Physically Handicapped Children's Program 03: Special Federal Funding 05: Disability 09: Second Opinion or Surgery. All listed codes apply only to Medicaid claims. | 2/3 S |
delayReasonCode | CLM20 | 2300 | Required if claim is submitted late, beyond contracted date of filing. If not required, do not send. See the Implementation Guide page 165. | 1/2 S |
homeBoundIndicator | CRC02 | 2300 | Required for Medicare claims when an independent lab provides an EKG tracing or obtains a specimen from a homebound or institutionalized patient. CRC01=75 CRC02=Y CRC03=IH | Boolean S |
fileInformation | K301 | 2300 | Consult the Consolidated 837 Guide before using this segment. Its requirements are significant and you should avoid it unless absolutely necessary. The K3 segment is used only to meet an unexpected data requirement of a legislative authority. | 1/80 S |
fileInformationList | K301 | 2300 | K301, use when there is more than one fileInformation. | List[String] S |
DTP = Date or Time or Period
Name | Element | Loop | Description | Constraints |
---|---|---|---|---|
Date Format: YYYYMMDD | ||||
symptomDate | DTP03 | 2300 | Date of first symptom. DTP01=431 | 1/35 |
initialTreatmentDate | DTP03 | 2300 | Date of initial treatment. DTP01=454 | 1/35 |
lastSeenDate | DTP03 | 2300 | Date of the last visit or consultation. DTP01=304 | 1/35 |
acuteManifestationDate | DTP03 | 2300 | Date of symptoms of a chronic condition. DTP01=453 | 1/35 |
accidentDate | DTP03 | 2300 | Date of the accident. DTP01=439 | 1/35 |
lastMenstrualPeriodDate | DTP03 | 2300 | Date of last menstruation. DTP01=484 | 1/35 |
lastXRayDate | DTP03 | 2300 | Date of last x-ray. DTP01=455 | 1/35 |
hearingAndVisionPrescriptionDate | DTP03 | 2300 | Hearing and vision prescription date. DTP01=471 | 1/35 |
disabilityBeginDate | DTP03 | 2300 | Initial disability start date. DTP01=360 | 1/35 |
disabilityEndDate | DTP03 | 2300 | End of disability date. DTP01=361 | 1/35 |
lastWorkedDate | DTP03 | 2300 | Date last worked. DTP01=297 | 1/35 |
authorizedReturnToWorkDate | DTP03 | 2300 | Date authorized to return to work. DTP01=296 | 1/35 |
admissionDate | DTP03 | 2300 | Date admitted to the hospital. DTP01=435 | 1/35 |
dischargeDate | DTP03 | 2300 | Date discharged from the hospital. DTP01=096 | 1/35 |
assumedAndRelinquishedCareBeginDate | DTP03 | 2300 | Date of assumed care. Used to indicate the date that the provider filing this claim assumed care from another provider for post-operative care. DTP01=090 | 1/35 |
assumedAndRelinquishedCareEndDate | DTP03 | 2300 | Relinquished care date. The date the provider for the claim assigned post-operative care to another provider. DTP01=091 | 1/35 |
repricerReceivedDate | DTP03 | 2300 | Date when a repricer passed the claim onto the payer. DTP01=050 | 1/35 |
firstContactDate | DTP03 | 2300 | Date the patient first consulted the provider for their condition. DTP01=444 | 1/35 |
See the 837p Consolidated Guide page 184 through 87 and the OpenAPI Spec for more details.
Name | Element | Loop | Description | Constraints |
---|---|---|---|---|
claimSupplementalInformation (Object) | S | |||
claimNumber | REF02 | 2300 | Claim ID number for clearinghouses. REF01=D9 | 1/50 R |
reportInformation (Object) | ||||
attachmentReportTypeCode | PWK01 | 2300 | Code that describes the attachment contents. Example: 08 = Plan of Treatment | 2/2 R |
attachmentTransmissionCode | PWK02 | 2300 | Code that describes how the attachment is sent. Example: EL = electronic only. | 1/2 R |
attachmentControlNumber | PWK06 | 2300 | Identifies an electronic attachment. The ACN appears in the 275's TRN02 field for an attachment. | 2/80 S |
REF | REF01 selection is required. | |||
referralNumber | REF02 | 2300 | Number assigned by the payer or Utilization Management Organization (UMO). REF01=9F | 1/50 |
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 |
cliaNumber | REF02 | 2300 | Clinical Laboratory Improvement Amendment (CLIA) number. REF01=X4 | 1/50 S |
repricedClaimNumber | REF02 | 2300 | The repriced claim number is completed by the repricer. REF01=9A | 1/50 S |
adjustedRepricedClaimNumber | REF02 | 2300 | Claim number for an adjusted repriced claim number. REF01=9C | 1/50 S |
investigationalDeviceExemptionNumber | REF02 | 2300 | FDA assigned investigational device exemption (ID). REF01=LX | 1/50 S |
mammographyCertificationNumber | REF02 | 2300 | Mammography certification number. REF01=EW | 1/50 S |
medicalRecordNumber | REF02 | 2300 | Medical record number of the patient. REF01=EA | 1/50 S |
demoProjectIdentifier | REF02 | 2300 | Claim identifier for atypical claims from content, purpose, and/or payment, for a demonstration or special project or clinical trial. REF01=P4 | 1/50 S |
carePlanOversightNumber | REF02 | 2300 | The number of the home health agency or hospice providing Medicare covered patient services for the period during which CPO services were furnished. 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 See annotation in OpenAPI Spec. | 1/50 S |
See the 837p Consolidated Guide page 188 and 89 and the OpenAPI Spec for more details.
Name | Element | Loop | Description | Constraints |
---|---|---|---|---|
claimContractInformation (Object) | ||||
contractTypeCode | CN101 | 2300 | Code that identifies 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, expressed as a percent, available to the purchaser if an invoice is paid on or before the terms discount due date. | 1/6 S |
contractVersionIdentifier | CN106 | 2300 | Additional identifier that identifies number for the contract. | 1/30 S |
Name | Element | Loop | Description | Constraints |
---|---|---|---|---|
patientAmountPaid | AMT02 | 2300 | Amount paid by the patient. AMT01=F5 | 1/18 |
Name | Element | Loop | Description | Constraints |
---|---|---|---|---|
fileInformation | K301 | 2300 | Data in fixed format agreed upon by the sender and receiver. Comma separated values. | 1/80 |
Some payers may require this information. Its form depends on the value stated in element NTE01. The object itself is Situational. Consult the 837p Consolidated Guide page 211 and the OpenAPI Spec for more details. Claim Notes may be overridden by additional claim notes in service lines; these take priority over top-level claim notes in this object.
Name | Element | Loop | Description | Constraints |
---|---|---|---|---|
claimNote (Object) | Claim Notes/Claim Information | S | ||
additionalInformation | NTE02 | 2300 | Description to clarify the related data elements and their content. NTE01=ADD | 1/80 |
certificationNarrative | NTE02 | 2300 | NTE01=CER Valid only for Professional Claims. | 1/80 |
goalRehabOrDischargePlans | NTE02 | 2300 | Description goals, rehabilitation potential or discharge plans. NTE01=DCP | 1/80 |
diagnosisDescription | NTE02 | 2300 | Diagnosis description. NTE01=DGN | 1/80 |
thirdPartOrgNotes | NTE02 | 2300 | Third-party organization notes. NTE01=TPO Valid only for Professional Claims. | 1/80 |
Name | Element | Loop | Description | Constraints |
---|---|---|---|---|
ambulanceTransportInformation (Object) | S | |||
patientWeightInPounds | CR102 | 2300 | Numeric value of weight. CR101=LB | 1/10 R |
ambulanceTransportReasonCode | CR104 | 2300 | Ambulance Transport Reason Code. | 1/1 R |
transportDistanceInMiles | CR106 | 2300 | Distance traveled during transport. CR105=DH (Miles) | 1/15 R |
roundTripPurposeDescription | CR109 | 2300 | The purpose of the round trip. | 1/80 S |
stretcherPurposeDescription | CR110 | 2300 | The purpose for the usage of a stretcher during the ambulance service. | 1/80 S |
Name | Element | Loop | Description | Constraints |
---|---|---|---|---|
spinalManipulationServiceInformation (Object) | S | |||
patientConditionCode | CR208 | 2300 | Code that provides the label describing patient’s condition. | 1/1 R |
patientConditionDescription1 | CR210 | 2300 | Description of the patient’s condition. | 1/80 S |
patientConditionDescription2 | CR211 | 2300 | Additional description of the patient’s condition. | 1/80 S |
Name | Element | Loop | Description | Constraints |
---|---|---|---|---|
ambulanceCertification (Array) | Required if two specific conditions exist: when the claim includes ambulance services, AND if the claim reports conditionCodes in one or more loop elements in CRC03-CRC07. If the transaction does not require this segment, do not send. | S | ||
certificationConditionIndicator | CRC02 | 2300 | Code that indicates a Yes or No condition or response. Y: indicates the condition codes in CRC03 to CRC07 apply. N: indicates the codes in CRC03 to CRC07 do not apply. CRC01=07 | 1/1 |
conditionCodes | CRC03 CRC04 CRC05 CRC06 CRC07 | 2300 | Code that labels a condition. First use CRC03, and then CRC04-07 as necessary. Ambulance condition code example: 01 = Patient admitted to hospital You can apply codes for CRC03 to CRC04-CRC07 as needed. | 2/3 |
sequenceOrder | 2300 | Provide each field to which it belongs. Example: 1 = CRC03 2 = CRC04 | ||
conditionCode | 2300 | Value of the condition code goes in this field. |
Name | Element | Loop | Description | Constraints |
---|---|---|---|---|
patientVisionInformation (Object) | ||||
codeCategory | CRC01 | 2300 | Qualifies CRC03 to CRC07. E1: Spectacle Lenses E2: Contact Lenses E3: Spectacle Frames | 2/2 |
certificationConditionIndicator | CRC02 | 2300 | Code that indicates a Yes or No condition or response. Y: indicates the condition code in CRC03 to CRC07 apply. N: indicates the conditional codes in CRC03 to CRC07 do not apply. CRC01=07 | 1/1 |
conditionCodes | CRC03 | 2300 | Code that indicates the reason for the replacement. First use CRC03, and then CRC04-07 as necessary. Condition Code Example: L2 = Replacement Due to Loss or Theft L3 = Replacement Due to Breakage or Damage | 2/3 |
sequenceOrder | 2300 | Provide which field it belongs to. Example: 1 = CRC03 2 = CRC04 and so on | ||
conditionCode | 2300 | Value of the condition code. |
Name | Element | Loop | Description | Constraints |
---|---|---|---|---|
homeBoundIndicator | CRC02 | 2300 | R for Medicare claims when an independent laboratory renders an EKG tracing or obtains a specimen from a homebound or institutionalized patient. Possible value: Y (Yes), or N (No). CRC01=75 (Functional Limitations) CRC03=IH (Independent at Home) | 1/1 |
Name | Element | Loop | Description | Constraints |
---|---|---|---|---|
epsdtReferral (Object) | Early & Periodic Screening, Diagnosis, and Treatment (EPSDT) | |||
responseCode | CRC02 | 2300 | Response to the question: Was an EPSDT referral given to the patient? Y = condition codes in CRC03 to CRC07 apply N = condition codes in CRC03 to CRC07 do not apply CRC01=ZZ | 1/1 |
conditionIndicators | CRC03 CRC04 CRC05 | 2300 | Condition indicator. Example: ST = New Services Requested Use CRC04 and CRC05 if more codes are necessary. | 2/3 |
Name | Element | Loop | Description | Constraints |
---|---|---|---|---|
healthCareCodeInformation (Object) | For sending health care codes with dates and quantities. | S | ||
sequenceOrder | 2300 | Use sequenceOrder for the values. | ||
diagnosisTypeCode | HI01-01 HI02-01 | 2300 | Health care diagnosis code qualifier. | 1/3 R |
diagnosisCode | HI01-02 HI02-02 | 2300 | Diagnosis code value. Maps to HealthCareDiagnosisCode HI02-02. | 1/30 R |
Name | Element | Loop | Description | Constraints |
---|---|---|---|---|
anesthesiaRelatedSurgicalProcedure (Array) | HI01-02 | 2300 | Procedure code value. HI01-01=BP HI02-01=BO Required for claims billing or reporting anesthesiology services, the provider knows the surgical code, and that claim adjudication relies on correct provision of the code. | 1/30 S |
Name | Element | Loop | Description | Constraints |
---|---|---|---|---|
conditionInformation (Array) | Array of conditionCodes . This can repeat. Needed when the claim includes patient's condition information. | S | ||
conditionCodes | HI02-02 | 2300 | Code that indicates a condition. First use CRC03, and then CRC04 to CRC07 as needed. Ambulance condition code. Example: 01 = Patient was admitted to a hospital | 2/3 R |
sequenceOrder | 2300 | Example: sequenceOrder = 1 for HI01-01 | 1/2 R | |
conditionCode | HI01-02 | 2300 | Value of the condition code. Example: HI01-01=BG (Condition) | 1/30 R |
See the 837p Implementation Guide page 254 and the OpenAPI Spec for more information.
Name | Element | Loop | Description | Constraints |
---|---|---|---|---|
claimPricingRepricingInformation (Object) | 2300 | Pricing/repricing information about a claim or a line item. Required when the repricer considers it necessary. Completed by the repricer. Providers do not complete this segment. | S | |
pricingMethodologyCode | HCP01 | 2300 | Pricing Methodology Code specifies the pricing method to price or reprice the claim. At least one instance of HCP01 or HCP13 is required. | 2/2 R |
repricedAllowedAmount | HCP02 | 2300 | Monetary Amount, Repriced Allowed Amount. Beyond the standard codes in the X12 TR3, your partner agreement defines code use. HCP02 is the allowed amount. | 1/18 R |
repricedSavingAmount | HCP03 | 2300 | Monetary Amount Savings. Completed by the repricer. | 1/18 S |
repricingOrganizationIdentifier | HCP04 | 2300 | Reference Identification Repricing organization identification number. | 1/50 S |
repricingPerDiemOrFlatRateAmong | HCP05 | 2300 | Pricing rate associated with per diem or flat rate repricing. | 1/9 S |
repricedApprovedAmbulatoryPatientGroupCode | HCP06 | 2300 | Reference Identification Approved DRG code. | 1/50 S |
repricedApprovedAmbulatoryPatientGroupAmount | HCP07 | 2300 | Monetary Amount Approved DRG amount. | 1/18 S |
rejectReasonCode | HCP13 | 2300 | Reject Reason Code Code is assigned by the issuer to identify the reason for the claim rejection. Example: T4 = Payer Name/Identifier Missing | 2/2 S |
policyComplianceCode | HCP14 | 2300 | Policy Compliance Code. It specifies policy compliance. Example: 1 = Procedure Followed (Compliance) | 1/2 S |
exceptionCode | HCP15 | 2300 | Code citing the exception reason for consideration of out-of-network services. Example: 2 = Emergency Care | 1/2 S |
Name | Element | Loop | Description | Constraints |
---|---|---|---|---|
ambulancePickUpLocation (Object) | Location. | S | ||
address1 | N301 | 2310E | First line of facility address information. | 1/55 |
address2 | N302 | 2310E | Second line of facility address information. | 1/55 |
city | N401 | 2310E | City in which the facility is located. | 2/30 |
state | N402 | 2310E | State in which the facility is located. | 2/2 |
postalCode | N403 | 2310E | Displays the postal code. | 3/15 |
countryCode | N404 | 2310E | Country code. | 1/35 |
countrySubDivisionCode | N404 | 2310E | Country Sub Division code. | 1/35 |
Name | Element | Loop | Description | Constraints |
---|---|---|---|---|
ambulanceDropOffLocation (Object) | S | |||
address1 | N301 | 2310F | First line of facility address information. | 1/55 |
address2 | N302 | 2310F | Second line of facility address information. | 1/55 |
city | N401 | 2310F | City in which the facility is located. | 2/30 |
state | N402 | 2310F | State in which the facility is located. | 2/2 |
postalCode | N403 | 2310F | Displays the postal code. | 3/15 |
countryCode | N404 | 2310F | Country code. | 1/35 |
countrySubDivisionCode | N404 | 2310F | Country Sub Division code. | 1/35 |
Name | Element | Loop | Description | Constraints |
---|---|---|---|---|
serviceFacilityLocation (Object) | Required when the service location is different from the billing provider's. | S | ||
organizationName | NM103 | 2310C | Service facility organization name or individual last name. | 1/60 R |
npi | NM109 | 2310C | Lab or Facility primary identifier. Required when the service location to be identified has an NPI and is not a component or subcomponent of the Billing Provider entity. NM108 = XX | 2/80 |
address (Object) | R | |||
address1 | N301 | 2310C | 1st line, facility address information. | 1/55 |
address2 | N302 | 2310C | 2nd line, facility address information. | 1/55 |
city | N401 | 2310C | City in which the facility is located. | 2/30 |
state | N402 | 2310C | State in which the facility is located. | 2/2 |
postalCode | N403 | 2310C | Displays the postal code. | 3/15 |
countryCode | N404 | 2310C | Country code. | 1/35 S |
countrySubDivisionCode | N404 | 2310C | Country Sub Division code. | 1/35 |
Name | Element | Loop | Description | Constraints |
---|---|---|---|---|
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 Identification Number | 1/2 |
otherPayerIdentifier | NM109 | 2330B | Code that identifies a party or other code. | 2/80 |
otherPayerAddress (Object) | ||||
address1 | N301 | 2330B | Payer’s address line 1. Required when other is payer for the patient. | 1/35 See Desc. |
address2 | N302 | 2330B | Payer’s address line 2. | 1/35 |
city | N401 | 2330B | Payer’s city. Required when other is payer for the patient. | 1/60 See Desc. |
state | N402 | 2330B | Payer’s state. Required when other is payer for the patient. | 1/35 See Desc. |
postalCode | N403 | 2330B | Payer’s postal code. Required when other is payer for the patient. | 3/15 S |
countryCode | N404 | 2330B | Country code. | 1/35 S |
countrySubDivisionCode | N404 | 2330B | Country Sub Division code. | 1/35 S |
otherPayerAdjudicationOrPaymentDate | DTP03 | 2330B | Expression of a date. DTP01=573 (Date Claim Paid) DTP02=D8 | 1/35 R |
otherPayerSecondaryIdentifier | REF02 | 2330B | 1/50 S | |
qualifier | REF01 | 2330B | Other payer secondary identifier. REF01=2U/EI/FY/NF | 2/3 R |
identifier | REF02 | 2330B | Value of the ID. | 1/50 R |
otherPayerClaimAdjustmentIndicator | REF02 | 2330B | Other Payer Claim Adjustment Indicator. REF01=T4 Signal Code | 1/50 S |
otherPayerClaimControlNumber | REF02 | 2330B | Other payer claims control number. REF01=F8 | 1/50 S |
See the 837p Implementation Guide page 334 and the OpenAPI Spec for more information.
Name | Element | Loop | Description | Constraints |
---|---|---|---|---|
otherPayerReferringProvider (Object) | 2330C | NM101=DN (Referring Provider) NM102=1 (Person) Array[Other Payer Referring Provider] | S | |
otherPayerReferringProviderIdentifier | 2330C | NM101 = P3 (Primary Care Provider) NM102=1 (Person) Array[ReferenceIdentification] | 1/50 R | |
ReferenceIdentification (Object) | 2330C | Reference ID as specified by the transaction set or by the Ref01 qualifier . | R | |
qualifier | REF01 | 2330C | Type of ID. REF01=0B/1G/G2: OB: State License Number 1G: Provider UPIN Number G2: Provider Commercial Number | 2/3 R |
identifier | REF02 | 2330C | REF01 ID/number. | 1/50 R |
See the 837p Implementation Guide page 338 and the OpenAPI Spec for more information.
Name | Element | Loop | Description | Constraints |
---|---|---|---|---|
otherPayerRenderingProvider (Object) | 2330D | Supplies the full name of an individual or organization. | S | |
entityTypeQualifier | 2330D | NM102 | NM101=82 (Rendering Provider) NM102= 1 (Person) or NM102 = 2 (Non-Person Entity) | R |
otherPayerRenderingProviderSecondary (Object) | REF01 | 2330D | R | |
otherPayerRenderingProviderSecondaryIdentifier | REF01 | 2330D | Array [ ReferenceIdentification ] | 1/1 R |
referenceIdentification | 2330D | REF02 | Reference ID as specified by the transaction set or by the Ref01 qualifier . | 1/50 R |
qualifier | REF01 | 2330D | Type of ID. REF01=0B/1G/G2: OB: State License Number 1G: Provider UPIN No G2: Provider Commercial Number LU: Location Number | 2/3 R |
identifier | REF02 | 2330D | REF01 ID/number. | 1/50 R |
See the 837p Implementation Guide page 342 and the OpenAPI Spec for more information.
Name | Element | Loop | Description | Constraints |
---|---|---|---|---|
otherPayerServiceFacilityLocation (Object) | 2330E | S | ||
otherPayerServiceFacilityLocationSecondaryIdentifier | Reference ID as specified by the transaction set or by the Reference Identification Qualifier. | 1/50 R | ||
qualifier | REF01 | 2330E | Type of ID. REF01=0B/G2/LU: OB: State License No G2: Provider Commercial No. LU: Location Number | 2/3 R |
identifier | REF02 | 2330E | REF01 ID/number. | 1/50 R |
See the 837p Implementation Guide page 345 for more information.
Name | Element | Loop | Description | Constraints |
---|---|---|---|---|
otherPayerSupervisingProvider (Object) | 2330F | NM101 = 98 | S | |
otherPayerSupervisingProviderIdentifier | REF02 | 2330F | Reference ID as specified by the transaction set or by the Reference Identification Qualifier. | 1/50 R |
qualifier | REF01 | 2330F | Type of ID. REF01=OB/1G/G2/LU: OB: State License Number 1G: Provider UPIN Number G2: Provider Commercial Number LU: Location Number | 2/3 R |
identifier | REF02 | 2330F | REF01 ID/number. | 1/50 R |
See the 837p Implementation Guide page 349 and the OpenAPI Spec for more information.
Name | Element | Loop | Description | Constraints |
---|---|---|---|---|
otherPayerBillingProvider (Object) | 2330G | NM101=85 (Billing Provider) NM102 = 1 (Person) or NM102 = 2 (Non-Person Entity) | S | |
entityTypeQualifier | NM102 | 2330G | Code qualifying the entity type. | R |
otherPayerBillingProvider | 2330G | R | ||
qualifier | REF01 | 2330G | Type of ID. REF01 = LU (Location Number) | 2/3 R |
identifier | REF02 | 2330G | REF01 ID/number. | 1/50 R |
NOTE
This section describes the line-level information reporting that may be required if it differs or adds further detail to information provided at the claim level. The general rule for all objects in this category is, If not required by this implementation guide, do not send in the 837P Implementation Guide. It does not rule out their use by the submitter. They also do not require or allow the receiver of the submission to reject it if this information is provided. Senders can use these data fields at their discretion. (Consolidated 837P 005010X222A2 page 46).
Name | Element | Loop | Description | Constraints |
---|---|---|---|---|
serviceLines (Array of objects) | SV101 | 2400 | Contains information that is supplementary to claim-level information. | S |
assignedNumber | LX01 | 2400 | Number assigned for differentiation within a transaction set. | 1/6 S |
Name | Element | Loop | Description | Constraints |
---|---|---|---|---|
serviceDate | DTP03 | 2400 | Service date or date range format YYYYMMDD. DateTimeQualifier always 472 DTP01 = 472 Service DTP02 = D8 Date expressed in format. | 1/35 R |
Name | Element | Loop | Description | Constraints |
---|---|---|---|---|
providerControlNumber | REF02 | 2400 | Reference information as defined for a transaction set or as noted by the reference indication qualifier. REF01=6R | 1/50 R |
Name | Element | Loop | Description | Constraints |
---|---|---|---|---|
salesTaxAmount | AMT02 | 2400 | Required when sales tax applies to the service line and the submitter reports that information to the receiver. If not required in the transaction, do not send. Value of AMT01=T Tax | 1/18 S |
Name | Element | Loop | Description | Constraints |
---|---|---|---|---|
postageClaimedAmount | AMT02 | 2400 | Postage Claimed Amount. When reporting this attribute (AMT02), the amount reported in lineItemChargeAmount (SV102) for the service line must include the amount reported in the postageClaimedAmount field.Also required when service line charge (SV102) includes a postage amount, which is claimed in this service line. If postage is not involved in the transaction, it is not required. Value of AMT01=F4 Postage Claimed | 1/18 S |
See the 837p Implementation Guide page 209 for more information.
Name | Element | Loop | Description | Constraints |
---|---|---|---|---|
fileInformation | K301 | 2300 | Data in fixed format agreed upon by the sender and receiver. Comma separated values. | 1/80 R |
Name | Element | Loop | Description | Constraints |
---|---|---|---|---|
thirdPartyOrganizationNotes | NTE02 | 2400 | Description to clarify data elements and content. NTE01=TPO | 1/80 R |
additionalNotes | NTE02 | 2400 | Additional description of related data elements and content. NTE01=ADD | 1/80 R |
goalRehabOrDischargePlans | NTE02 | 2400 | Description goals, rehabilitation potential, or discharge plans. NTE01=DCP | 1/80 R |
Name | Element | Loop | Description | Constraints |
---|---|---|---|---|
ambulancePatientCount | QTY02 | 2400 | Number of patients in the ambulance. Required when more than one patient is transported in the same vehicle. QTY01=PT Patients. If not required, do not send. | 1/15 S |
Name | Element | Loop | Description | Constraints |
---|---|---|---|---|
obstetricAnesthesiaAdditionalUnits | QTY02 | 2400 | The number of units reported by an anesthesia provider to reflect additional services complexity. QTY01=FL nits | 1/15 S |
Name | Element | Loop | Description | Constraints |
---|---|---|---|---|
hospiceEmployeeIndicator | CRC02 | 2400 | CRC02 is a Certification Condition Code Applies indicator. “Y” indicates the condition codes in CRC03 through CRC07 elements apply “N” indicates those codes do not apply CRC01 = 07 Hospice CRC03 = 65 Open | 1/1 S |
Name | Element | Loop | Description | Constraints |
---|---|---|---|---|
conditionIndicatorDurableMedicalEquipment (Object) | S | |||
certificationConditionIndicator | CRC02 | 2400 | CRC02 is a Certification Condition Code Applies indicator. “Y” indicates that the condition codes in CRC03 through CRC07 apply “N” indicates that those codes do not apply Value of CRC01 = 09 Durable Medical Equipment Certification. | 1/1 R |
conditionIndicator | CRC03 | 2400 | Code that states a condition. 01 = Patient admitted to hospital 12 = Patient confined to bed/chair | 2/3 R |
conditionIndicatorCode | CRC04 | 2400 | Second code, use CRC03 list. | 2/3 S |
Specifies details for each service line in the claim. See the 837p Implementation Guide pages 353 through 360 and the OpenAPI Spec for more information.
Name | Element | Loop | Description | Constraints |
---|---|---|---|---|
professionalService (Object) | Specify service line item details. | R | ||
compositeMedicalProcedureIdentifier | SV101 | 2400 | Identify a procedure by standard codes and modifiers. | 2/2 R |
procedureIdentifier | SV101-01 | 2400 | Code that identifies the type/source of the descriptive number used in the Product/Service ID. | 2/2 R |
procedureCode | SV101-02 | 2400 | The number for a product or service | 1/48 R |
procedureModifiers | SV101-03 to SV101-06 | 2400 | Improves the reporting accuracy of the associated procedure code. | 2/2 S |
description | SV101-07 | 2400 | Description to clarify related data elements and their content. | 1/80 S |
lineItemChargeAmount | SV102 | 2400 | The total charge amount for this service line. | 1/18 R |
measurementUnit | SV103 | 2400 | Unit or Basis for Measurement. It specifies the units for a reported value or for a taken measurement. Example: MJ = Minutes | 2/2 R |
serviceUnitCount | SV104 | 2400 | Number of units. Max length is eight digits excluding the decimal. Maximum three digits are allowed to the right of the decimal. | 1/8 R |
placeOfServiceCode | SV105 | 2400 | Code that states where service was performed or maybe performed. | 1/2 |
compositeDiagnosisCodePointers (Object) | ||||
diagnosisCodePointers | SV107 | 2400 | Diagnosis code for a service line. | 1/2 R |
emergencyIndicator | SV109 | 2400 | SV109 is the emergency-related indicator. “Y” indicates provided service was emergency related “N” indicates the service was not emergency related | 1/1 S |
epsdtIndicator | SV111 | 2400 | SV111 is early/ periodic screening for diagnosis and treatment of children with EPSDT involvement “Y” indicates EPSDT involvement “N” denotes no involvement | 1/1 S |
familyPlanningIndicator | SV112 | 2400 | SV112 is the family planning involvement indicator. “Y” indicates family planning services involvement “N” indicates no family planning services | 1/1 S |
copayStatusCode | SV115 | 2400 | Code stating if co-payment requirements were met on a line by line basis. 0 = Copay exempt | 1/1 S |
Claim supplemental information. See the 837p Implementation Guide page 184 and the OpenAPI Spec for further details.
Name | Element | Loop | Description | Constraints |
---|---|---|---|---|
serviceLineSupplementalInformation (Array) | S | |||
attachmentReportTypeCode | PWK01 | 2400 | Code for the title or contents of a document report or supporting document. CT = Certification | 2/2 R |
attachmentTransmissionCode | PWK02 | 2400 | Code value for the attachment delivery method. Example: BM = By mail. | 1/2 R |
attachmentControlNumber | PWK06 | 2400 | PWK06 describes the attached electronic documentation. The PWK06 value is held in the TRN of the electronic attachment. Requires: PWK05=AC (Attachment Control Number) | 2/50 S |
durableMedicalEquipmentCertificateOfMedicalNecessity (Object) | S | |||
attachmentTransmissionCode | PWK02 | 2400 | Code that defines the timing, transmission method or format by which reports are sent. PWK01 = CT | 1/2 R |
Name | Element | Loop | Description | Constraints |
---|---|---|---|---|
ambulanceTransportInformation (Object) | S | |||
patientWeightInPounds | CR102 | 2300 | Patient weight in pounds CR101 = LB | 1/10 S |
ambulanceTransportReasonCode | CR104 | 2300 | Code that shows the reason for ambulance transport. Example: E = Patient Transferred to Rehabilitation Facility | 1/1 R |
transportDistanceInMiles | CR106 | 2300 | Distance traveled during transport, in miles. CR105 = DH | 1/15 R |
roundTripPurposeDescription | CR109 | 2300 | The purpose for the round-trip ambulance service. | 1/80 S |
stretcherPurposeDescription | CR110 | 2300 | The purpose for usage of a stretcher during ambulance service. | 1/80 S |
Name | Element | Loop | Description | Constraints |
---|---|---|---|---|
durableMedicalEquipmentCertification (Object) | Provide information about a doctor's certification for durable medical equipment. | S | ||
certificationTypeCode | CR301 | 2400 | Code that indicates the certification type. I = Initial R = Renewal S = Revised | 1/1 R |
durableMedicalEquipmentDurationInMonths | CR303 | 2400 | Months used. CR302=MO | 1/15 R |
Service Line date information for various possible treatment elements. See the OpenAPI Spec for more information.
Name | Element | Loop | Description | Constraints |
---|---|---|---|---|
serviceLineDateInformation (Object) | Date format: YYYYMMDD DTP02 = D8 | S | ||
prescriptionDate | DTP03 | 2400 | Prescription date. DTP01 = 471 | 1/35 S |
certificationRevisionOrRecertificationDate | DTP03 | 2400 | Required when CR301 = R or S. DTP01 = 607 | 1/35 S |
beginTherapyDate | DTP03 | 2400 | Begin therapy date. Required when a Durable Medical Equipment Regional Carrier Certificate of Medical Necessity (DMERC CMN) DMERC Information Form (DIF) or Oxygen Therapy Certification is included on this service line DTP01 = 463 | 1/35 S |
lastCertificationDate | DTP03 | 2400 | The date the ordering physician signed the CMN or an Oxygen Therapy Certification or the date the supplier signed the DMERC Information Form (DIF). DTP01 = 461 | 1/35 S |
treatmentOrTherapyDate | DTP03 | 2400 | Date last seen. Required when a claim involves physician services, differs from the date listed at claim level, and will impact the payer’s adjudication process. DTP01 = 304 | 1/35 S |
hemoglobinTestDate | DTP03 | 2400 | Test date of the most recent Hemoglobin or Hematocrit tests or for both. Required on initial EPO claims service lines for dialysis patients when test results are billed or reported. DTP01 = 738 | 1/35 S |
serumCreatineTestDate | DTP03 | 2400 | Date of most recent serum creatine test. R on initial EPO claims service lines for dialysis patients when test results are billed or reported. DTP01 = 739 | 1/35 S |
shippedDate | DTP03 | 2400 | Shipped date. R when billing or reporting shipped products. DTP01 = 011 | 1/35 S |
lastXRayDate | DTP03 | 2400 | Date of the last x-ray. Required when claim involves spinal manipulation and an x-ray was taken, and differs from information at the claim level (Loop ID-2300). DTP01=455 | 1/35 S |
initialTreatmentDate | DTP03 | 2400 | Initial treatment date. Required when the Initial Treatment Date impacts adjudication for claims involving spinal manipulation, physical therapy, occupational therapy, or speech language pathology, and when it differs from the claim level report. DTP01=454 | 1/35 R |
Name | Element | Loop | Description | Constraints |
---|---|---|---|---|
serviceLineReferenceInformation (Object) | S | |||
repricedLineItemReferenceNumber | REF02 | 2400 | Repriced line item reference number. REF01 = 9B | 1/50 S |
adjustedRepricedLineItemReferenceNumber | REF02 | 2400 | Adjusted Repriced Line Item Reference Number. REF01 = 9D | 1/50 S |
payerIdentificationNumber | REF02 | 2400 | Payer Identification Number. | 1/50 S |
mammographyCertificationNumber | REF02 | 2400 | Mammography certification number. REF01 = EW | 1/50 S |
clinicalLaboratoryImprovementAmendmentNumber | REF02 | 2400 | Clinical Laboratory Improvement Amendment (CLIA) number. REF01 = X4 | 1/50 S |
referringCliaNumber | REF02 | 2400 | Referring CLIA Facility Certification Number. REF01 = F4 | 1/50 S |
immunizationBatchNumber | REF02 | 2400 | Immunization Batch Number. REF01 = BT | 1/50 S |
referralNumber | REF02 | 2400 | Number assigned by the payer or Utilization Management Organization (UMO). REF01 = 9F | 1/50 S |
See the 837p Implementation Guide page 254 and the OpenAPI Spec for further details.
Name | Element | Loop | Description | Constraints |
---|---|---|---|---|
linePricingRepricingInformation (Object) | Pricing or repricing information about a health care claim or line item. | S | ||
pricingMethodologyCode | HCP01 | 2400 | Pricing Methodology Code. It specifies the method by which a claim or line item is priced or repriced. | 2/2 R |
repricedAllowedAmount | HCP02 | 2400 | Monetary Amount Repriced Allowed Amount. Beyond the standard codes in the X12 TR3, your partner agreement defines code use. | 1/18 R |
repricedSavingAmount | HCP03 | 2400 | Monetary Amount Savings amount. Completed by the repricer only. | 1/18 S |
repricedOrganizationIdentifier | HCP04 | 2400 | Reference Identification Repricing organization identification number. | 1/50 |
flatRateAmount | HCP05 | 2400 | Pricing rate associated with per diem or 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 | Code denoting the type/source of the descriptive number used in Product/Service ID (234). Example: WK = Advanced Billing Concepts (ABC) Codes | 2/2 S |
repricedApprovedHCPCSCode | HCP10 | 2400 | Repriced Approved HCPCS Code. HCP10 is the approved procedure code. | 1/48 S |
measurementUnitCode | HCP11 | 2400 | Unit or Basis for Measurement Code. It specifies the units for a reported value or for a taken measurement. | 2/2 S |
repricedApprovedServiceUnitCount | HCP12 | 2400 | Quantity of service units or inpatient days. | 1/50 S |
rejectReasonCode | HCP13 | 2400 | Reject Reason Code. Code assigned by the issuer to describe the reason for rejection. Example: T4 Payer Name or Identifier Missing. | 2/2 S |
policyComplianceCode | HCP14 | 2400 | Policy Compliance Code. It specifies if policy compliance is followed. Example: 1 = Procedure Followed (Compliance) | 1/2 S |
exceptionCode | HCP15 | 2400 | Code specifying the reason for usage of out-of-network health care services. Example: 2 = Emergency Care | 1/2 S |
See the 837p Implementation Guide page 361 and the OpenAPI Spec for further details. Segment is situational, all fields are required if the object is in use for the claim.
Name | Element | Loop | Description | Constraints |
---|---|---|---|---|
durableMedicalEquipmentService (Object) | Required for reporting both rental and purchase costs of durable medical equipment such as a wheelchair. You won't use this if singly reporting only the purchase or rental price. | 2/2 S | ||
days | SV503 | 2400 | Describes the length of time the equipment will be needed. | 1/15 R |
rentalPrice | SV504 | 2400 | DME rental cost. | 1/18 R |
purchasePrice | SV505 | 2400 | DME purchase cost. | 1/18 R |
frequencyCode | SV506 | 2400 | Describes the billing interval for the equipment. 4 = Monthly | 1/1 R |
Required in a number of different situations. See the 837p Implementation Guide page 425, and the OpenAPI Spec for further details.
Name | Element | Loop | Description | Constraints |
---|---|---|---|---|
drugIdentification (Object) | Drug Identification | S | ||
serviceIdQualifier | LIN02 | 2410 | Code that identifies the type/source of the descriptive number in Product/Service ID. | 2/2 R |
nationalDrugCode | LIN03 | 2410 | Number that identifies a product or service. | 1/48 R |
CTP | Drug Quantity | |||
nationalDrugUnitCount | CTP04 | 2410 | Numeric value of quantity. | 1/15 R |
measurementUnitCode | CTP05-01 | 2410 | Code specifying a value's measurement units or how a measurement is taken. Example: GR(Gram) | 2/2 |
REF | Prescription or Compound Drug Association Number. | R | ||
linkSequenceNumber | REF01 | 2410 | Defined for a Transaction Set or as specified by the Reference Identification Qualifier. REF01 = VY (Link Sequence Number) Used when a drug is provided without a prescription. | 1/50 S |
pharmacyPrescriptionNumber | REF01 | 2410 | Defined for a Transaction Set or by the Reference Identification Qualifier. REF01 = XZ (Pharmacy Prescription Number) | 1/50 S |
See the 837p Implementation Guide page 483 and the OpenAPI Spec for further details.
Name | Element | Loop | Description | Constraints |
---|---|---|---|---|
lineAdjudicationInformation (Array of objects) | Line Adjudication Information. | S | ||
otherPayerPrimaryIdentifier | SVD01 | 2430 | Payer identification code. | 2/80 R |
serviceLinePaidAmount | SVD02 | 2430 | Service line paid amount. | 1/18 R |
serviceIdQualifier | SVD03-01 | 2430 | Product/Service ID Qualifier Code. Identifies the type/source of the descriptive number in 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 related to service performance, as defined by trading partners. | 2/2 S |
sequenceOrder | SVD03-03 to SVD03-06 | 2430 | Example: sequenceOrder =1 for SVD03-03 | |
procedureModifiers | SV101-03 to SV101-06 | 2430 | Improves reporting accuracy of an associated procedure code. Example: Loop 2430; SVD03-03 | 2/2 S |
procedureCodeDescription | SVD03-07 | 2430 | Description of the medical procedure. | 1/80 S |
paidServiceUnitCount | SVD05 | 2430 | Number of paid units in the remittance advice. When paid units are not in the remittance advice, use the original billed units. | 1/15 R |
bundledOrUnbundledLineNumber | SVD06 | 2430 | Bundled Line Number for bundling service lines. It references the LX Assigned Number of the service line where it was bundled. | 1/6 S |
adjudicationOrPaymentDate | DTP03 | 2430 | Expression of a date. DTP01 = 573 (Date Claim Paid) DTP02=D8 | 1/35 R |
remainingPatientLiability | AMT02 | 2430 | Amount of remaining patient liability after adjudication. This segment only used in provider-submitted claims. Required if the Other Payer (in Element SVD01 of the current loop) has adjudicated the claim with line-level content, and the provider can also do so. AMT01 = EAF (Amount Owed) | 1/18 S |
See the 837p Implementation Guide page 487 and the OpenAPI Spec for further details.
Name | Element | Loop | Description | Constraints |
---|---|---|---|---|
claimAdjustmentInformation (Array) | Repeats 5 times | S | ||
adjustmentGroupCode | CAS01 | 2430 | Claim Adjustment Group Code. It identifies the payment adjustment category. Example: CO = Contractual Obligations | 1/2 R |
adjustmentDetails (Array) | Repeats min=1, max=6 | R | ||
adjustmentReasonCode | See Desc. | 2430 | Claim Adjustment Reason Code. Identifies the reason for the adjustment. CAS02/CAS05/CAS08/CAS11/CAS14/CAS17 | 1/5 S |
adjustmentAmount | See Desc. | 2430 | Monetary Amount of the adjustment. CAS03/CAS06/CAS09/CAS12/CAS15/CAS18 | 1/18 R |
adjustmentQuantity | See Desc. | 2430 | Quantity - # of service units adjusted. CAS04/CAS07/CAS10/CAS13/CAS16/CAS19 | 1/15 S |
Loop ID-2440 allows providers to attach standardized supplemental information to the claim when required to do so by the payer. See the 837p Implementation Guide page 495 and the OpenAPI Spec for further details.
Name | Element | Loop | Description | Constraints |
---|---|---|---|---|
formIdentification (Array) | ||||
formTypeCode | LQ01 | 2440 | Correct values: AS = Form Type Code UT = Centers for Medicare and Medicaid Services (CMS) Durable Medical Equipment Regional Carrier (DMERC) Certificate of Medical Necessity (CMN) Forms | 1/3 |
formIdentifier | LQ02 | 2440 | Industry Code | 1/30 |
Use the FRM segment to answer specific questions on the form identified in the LQ segment. FRM01 indicates the question being answered. See the 837p Implementation Guide page 497, and the OpenAPI Spec for further details.
Answers can take one of 4 forms: FRM02 for Yes/No questions
FRM03 for text/uncodified answers
FRM04 for answers which use dates and FRM05 for answers in percentages. For each FRM01 (question) use a remaining FRM element, choosing the element with the appropriate format. Use one FRM segment for each question/answer pair.
Name | Element | Loop | Description | Constraints |
---|---|---|---|---|
supportingDocumentation (Array) | S | |||
questionNumber | FRM01 | 2440 | FRM01 is the question number on a questionnaire or codified form. | 1/20 S |
questionResponseCode | FRM02 | 2440 | Code that indicates a Yes or No condition or response. N = No W = Not Applicable; Y = Yes | 1/1 S |
questionResponse | FRM03 | 2440 | Text/uncodified answers. | 1/50 S |
questionResponseAsDate | FRM04 | 2440 | Answers that use dates. | 8/8 S |
questionResponseAsPercent | FRM05 | 2440 | Answers that are in percentage. Percentage is in decimal format. Example: 2% = 0.2 | 1/6 S |
For REF02, one of the stateLicenseNumber
(0B), providerUpinNumber
(1G), commercialNumber
(G2) or locationNumber
(LU) must be provided.
Name | Element | Loop | Description | Constraints |
---|---|---|---|---|
Other provider types include:renderingProvider purchaseServiceProvider supervisingProvider orderingProvider referringProvider | NM101 | See Desc. | Loops are: 82 = renderingProvider (2420A) QB = purchaseServiceProvider (2420B) DQ = supervisingProvider (2420D) DK = orderingProvider (2420E) DN = referringProvider (2420F) | 2/3 S |
organizationName | NM103 | 1000A | Provider’s organization name. Can use organization or last name. | 1/60 R |
lastName | NM103 | 1000A | Provider last name, you can use organization or last name. | 1/60 R |
firstName | NM104 | 1000A | Provider first name. | 1/35 S |
middleName | NM105 | 1000A | Middle initial. | 1/25 S |
npi | NM109 | National Provider Identification value. NM108 = XX | 2/80 S | |
taxonomyCode | PRV03 | See Desc. | Health care provider taxonomy code. Referring Provider (2310AA) Rendering Provider (2310B) | 1/50 R |
stateLicenseNumber | REF02 | See Desc. | State license number. REF01 = 0B Billing Provider (2010AA) Referring Provider (2310A) | 1/50 S |
providerUpinNumber | REF02 | See Desc. | Provider UPIN number. REF01 = 1G Billing Provider (2010AA) Referring Provider (2310A) | 1/50 S |
commercialNumber | REF02 | relative | Provider commercial number. REF01 = G2 (Provider Commercial Number) | 1/50 S |
locationNumber | REF02 | Provider location number. REF01 = LU | 1/50 S | |
otherIdentifier | REF04-02 | Payer identification number. Do not use with REF01=0B/1G or REF04-01=2U | 1/50 S |
This is required when the ambulance pick-up location for this service line differs from the ambulance pick-up location provided in Loop ID-2310E.
Name | Element | Loop | Description | Constraints |
---|---|---|---|---|
ambulancePickUpLocation (Object) | Location. | S | ||
address1 | N301 | 2420G | First line of facility address information. | 1/55 R |
address2 | N302 | 2420G | Second line of facility address information. | 1/55 S |
city | N401 | 2420G | City in which the facility is located. | 2/30 R |
state | N402 | 2420G | State in which the facility is located. | 2/2 S |
postalCode | N403 | 2420G | Displays the postal code. | 3/15 S |
countryCode | N404 | 2420G | Country code. | 1/35 S |
countrySubDivisionCode | N404 | 2420G | Country Sub Division code. | 1/35 S |
Name | Element | Loop | Description | Constraints |
---|---|---|---|---|
ambulanceDropOffLocation (Object) | S | |||
address1 | N301 | 2420H | First line of facility address information. | 1/55 R |
address2 | N302 | 2420H | Second line of facility address information. | 1/55 S |
city | N401 | 2420H | City in which the facility is located. | 2/30 R |
state | N402 | 2420H | State in which the facility is located. | 2/2 S |
postalCode | N403 | 2420H | Displays the postal code. | 3/15 S |
countryCode | N404 | 2420H | Country code. | 1/35 S |
countrySubDivisionCode | N404 | 2420H | Country Sub Division code. | 1/35 S |
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