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.

See JSON-to-EDI API Mapping.

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.

Transaction Header(Request)

Submitter (1000A)

Receiver (1000B)

Subscriber

Subscriber Hierarchical Level (2000B)

Subscriber Information (2010BA)

Payer Information (2010BB)

Other Subscriber Information (2320)

Other Subscriber Name (2330A)

Dependent (2010CA)

Patient Hierarchical Level (2000C)

Patient Name (2010CA)

Property and Casualty (2010CA)

Providers

Provider ID

Provider Contact Information – 2010AA

Pay-To Address Name – 2010AB

Pay-To Plan Name – 2010AC

Claims

Claim Information (2300)

Claim Information (CLM)

Claim Date Information (DTP)

Claim Supplemental (PWK)*

Contract Information (CN)

Patient Amount Paid*

File Information (K3)*

Claim Note (NTE)

Ambulance Transport Information (CR)

Spinal Manipulation Service Information (CR)

Ambulance Certification (CRC)

Patient Vision Information (CRC)

Homebound Indicator (CRC)

EPSDT Referral (CRC)

Health Care Code Information (HI)

Anesthesia Related Procedure (HI)

Condition Information (HI)

Claim Pricing Information (HCP)

Ambulance Pick Up Location (2310E)

Ambulance Drop Off Location (2310F)

Service Facility Location (2310C)

Other Payers (2330B-G)

Other Payer (2330B)

Other Payer Referring Provider (2330C)

Other Payer Rendering Provider (2330D)

Other Payer Service Facility Location (2330E)

Other Payer Supervising Provider (2330F)

Other Payer Billing Provider (2330G)

Service Lines (2400)

LX - 1

DTP – 8 Service

REF Provider Control - 10

AMT Sales Tax - 11

AMT Postage - 12

K3 File Information 13

NTE Third Party 14

QTY Ambulance 15

QTY Obstetric Anesthesia - 9

CRC Hospice - 6

CRC Durable - 7

SV - 2

PWK - 3

CR102 & CR301 (Ambulance) - 4

CR301 - 5

DTP 8

REF 10 – MISC Number References

HCP 18

Durable Medical Equipment (DME) Service

Drug Identification (2410)

Line Adjudication (2430)

Line Adjudication Information

Line Adjustment Information

Form Identification (2440)

Form Identification Code

Supporting Documentation

Other Providers (2420A-2420F)

Ambulance Pick Up Location (2420G)

Ambulance Drop Off Location (2420H)

Professional Claims v3 API JSON-to-EDI mapping

Transaction Header (Request)

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 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

Submitter (1000A)

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

Receiver (1000B)

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

Subscriber

Subscriber Information (SBR) (2000B)

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

Subscriber Information (2010BA)

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

Payer Information (2010BB)

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

Other Subscriber Information (2320)

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

Other Subscriber Name (2330A)

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

Dependent (2010CA)

📘
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

Patient Hierarchical Level (2000C)

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

Patient Name (2010CA)

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

Property and Casualty (2010CA)

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

Providers

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

Provider ID

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)

Provider Contact Information (2010AA)

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

Pay-To Address Name (2010AB)

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

Pay-To Plan Name (2010AC)

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

Claims

Claim Information (2300)

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

Claim Information (CLM)

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

Claim Date Information (DTP)

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

Claim Supplemental (PWK)

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

Contract Information (CN1)

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

Patient Amount Paid

Name	Element	Loop	Description	Constraints
`patientAmountPaid`	AMT02	2300	Amount paid by the patient. AMT01=F5	1/18

File Information (K3)

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

Ambulance Transport Information (CR)

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

Spinal Manipulation Service Information (CR)

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

Ambulance Certification (CRC)

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.

Patient Vision Information (CRC)

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.

Homebound Indicator (CRC)

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

EPSDT Referral (CRC)

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

Health Care Code Information (HI)

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

Anesthesia Related Procedure (HI)

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

Condition Information (HI)

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

Claim Pricing Information (HCP)

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

Ambulance Pick Up Location (2310E)

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

Ambulance Drop Off Location (2310F)

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

Service Facility Location (2310C)

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

Other Payers (2330B-G)

Other Payer (2330B)

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

Other Payer Referring Provider (2330C)

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

Other Payer Rendering Provider (2330D)

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

Other Payer Service Facility Location (2330E)

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

Other Payer Supervising Provider (2330F)

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

Other Payer Billing Provider (2330G)

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

Service Lines (2400)

📘
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).

LX — 1

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

DTP — 8 Service

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

REF Provider Control — 10

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

AMT Sales Tax — 11

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

AMT Postage — 12

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

K3 File Information

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

NTE Third Party — 14

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

QTY Ambulance 15

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

QTY Obstetric Anesthesia - 9

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

CRC Hospice - 6

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

CRC Durable - 7

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

SV — 2

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

PWK - 3

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

CR102 & CR301 (Ambulance) — 4

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

CR301 - 5

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

DTP 8

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

REF 10 – MISC Number References

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

HCP 18 — Line Pricing/Repricing

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

Durable Medical Equipment (DME) Service

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

Drug Identification (2410)

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

Line Adjudication (2430)

Line Adjudication Information (SVD)

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

Line Adjustment Information

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

Form Identification (2440)

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.

Form Identification Code

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

Supporting Documentation

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

Other Providers (2420A-2420F)

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

Ambulance Pick Up Location (2420G)

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

Ambulance Drop Off Location (2420H)

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

📘
NOTE
While we make every effort to keep all information up to date and accurate, Optum makes no warranties, express or implied, about completeness, accuracy, reliability, or availability regarding the content, images, services or hyperlinks in our documentation. We provide this information as a service to our customers; your use of this information is your responsibility.

Related Topic

JSON-to-EDI API Mapping

Updated about 2 months ago

📘NOTE

📘NOTE

Professional Claims v3 API JSON-to-EDI mapping

📘NOTE

📘NOTE

📘NOTE

📘
NOTE

📘
NOTE

📘
NOTE

📘
NOTE

📘
NOTE