Submission JSON-to-EDI API 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
IFa 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
IFa 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.
Submission 278 Request
Identification Header
Requestor Detail
Subscriber Header
Dependent
Patient Event Detail
Attachment 2000E and 2000F PWK (Request and Response)
patient Event Transport Information (Request)
Patient Event Other UMO Name (Request)
Patient Event Provider Name
Patient Event Service Level
Patient Event Service Level Provider Name
Submission 278 Response
Identification Header
Request Validation
UM Request Validation
Requester
Subscriber (Response)
Dependent (Response)
Patient Event Detail (Response)
Attachment 2000E and 2000F PWK (Request and Response)
Patient Event Additional Patient Information Contact Name (Response)
Patient Event Transport Information (Response)
Patient Event Provider Name (Response)
Patient Event Service Level
Patient Event Service Level Provider (Response)
Service Detail Additional Service Information Contact Name (Response)
Submission API JSON-to-EDI mapping
Submission 278 Request
Identification Header (Request)
| Field | Element | Loop | Description | Constraints |
|---|---|---|---|---|
| senderId | ISA06/GS02 | N/A | Interchange Sender ID | R 15/15 |
| submitterTransactionIdentifier | BHT03 | N/A | Submitter Transaction Identifier | R 1/50 |
| payerId | NM109 | 2010A | NM101=PR NM102=2 If umClearingHouseId is empty, this value will also be used to populate ISA08 GS03 | R 2/80 |
| payerName | NM103 | 2010A | S 1/60 | |
| umClearingHouseId | N/A | N/A | if not empty populate ISA08 GS03 | |
| portalUsername | N/A | N/A | ||
| portalPassword | N/A | N/A |
Requestor Detail (Request)
| Name | Element | Loop | Description | Constraints |
|---|---|---|---|---|
| requesterType | NM101 | 2010B | Default to 1P 1P (Provider) 2B (Third-Party Administrator) 36 (Employer) FA (Facility) PR (Payer) | R 2/3 |
| organizationName | NM103 | 2010B | NM102=2 | S 1/60 |
| lastName | NM103 | 2010B | S 1/60 | |
| firstName | NM104 | 2010B | NM102=1 | S 1/35 |
| address1 | N301 | 2010B | R 1/55 | |
| address2 | N302 | 2010B | S 1/55 | |
| city | N401 | 2010B | R 2/30 | |
| state | N402 | 2010B | S 2/2 | |
| postalCode | N403 | 2010B | S 3/15 | |
| countryCode | N404 | 2010B | S 2/3 | |
| countrySubDivisionCode | N407 | 2010B | S 1/3 | |
| npi | NM109 | 2010B | NM108=XX | R 2/80 |
| ssn | NM109 | 2010B | NM108=34 | R 2/80 |
| servicesPlanID | NM109 | 2010B | NM108=XV | R 2/80 |
| employersId | NM109 | 2010B | NM108=24 | R 2/80 |
| etin | NM109 | 2010B | NM108=46 | R 2/80 |
| contactName | PER02 | 2010B | PER01=IC | S 1/60 |
| contactElectronicMail | PER04 PER06 PER08 | 2010B | PER03=EM PER05=EM PER07=EM | S 1/256 |
| contactFacsimile | PER04 PER06 PER08 | 2010B | PER03=FX PER05=FX PER07=FX | S 1/256 |
| contactTelephone | PER04 PER06 PER08 | 2010B | PER03=TE PER05=TE PER07=TE | S 1/256 |
| contactTelephoneExtension | PER06 PER08 | 2010B | PER05=EX PER07=EX | S 1/256 |
| providerCode | PRV01 | 2010B | PRV02=PXC AD (Admitting) AS (Assistant Surgeon) AT (Attending) CO (Consulting) CV (Covering) OP (Operating) OR (Ordering) OT (Other Physician) PC (Primary Care Physician) PE (Performing) RF (Referring) | R 1/3 |
| referenceIdentification | PRV03 | 2010B | S 1/50 | |
| requestorIdentification (Object) | — | — | ||
| providerUpinNumber | REF02 | 2010B | REF01=1G | R 1/50 |
| facilityIdNumber | REF02 | 2010B | REF01=1J | R 1/50 |
| employerIdentificationNumber | REF02 | 2010B | REF01=EI | R 1/50 |
| providerSiteNumber | REF02 | 2010B | REF01=G5 | R 1/50 |
| providerPlanNetworkIdNumber | REF02 | 2010B | REF01=N5 | R 1/50 |
| facilityNetworkIdNumber | REF02 | 2010B | REF01=N7 | R 1/50 |
| socialSecurityNumber | REF02 | 2010B | REF01=SY | R 1/50 |
| carrierAssignedReferenceNumber | REF02 | 2010B | REF01=ZH | R 1/50 |
Subscriber (Request)
| Name | Element | Loop | Description | Constraints |
|---|---|---|---|---|
| lastName | NM103 | 2010C | NM101=IL NM102=1 | S 1/60 |
| firstName | NM104 | 2010C | S 1/35 | |
| middleName | NM105 | 2010C | S 1/25 | |
| suffix | NM107 | 2010C | S 1/10 | |
| memberId | NM109 | 2010C | NM108=MI | R 2/80 |
| dateOfBirth | DMG02 | 2010C | DMG01=D8 YYYYMMDD | R 1/35 |
| genderCode | DMG03 | 2010C | F (Female) M (Male) U (Unknown) | S 1/1 |
| address1 | N301 | 2010C | R 1/55 | |
| address2 | N302 | 2010C | S 1/55 | |
| city | N401 | 2010C | R 2/30 | |
| state | N402 | 2010C | S 2/2 | |
| postalCode | N403 | 2010C | S 3/15 | |
| countryCode | N404 | 2010C | S 2/3 | |
| countrySubDivisionCode | N407 | 2010C | S 1/3 | |
| insuredIndicator | INS01 | 2010C | Y (Yes) N (No) | R 1/1 |
| militaryRelationship | INS08 | 2010C | AO (Active Military - Overseas) AU (Active Military - USA) DI (Deceased) PV (Previous) RU (Retired Military - USA) | R 2/2 |
| supplementalIdentification (Object) | — | — | ||
| policyNumber | REF02 | 2010C | REF01=1L | R 1/50 |
| branchIdentifier | REF02 | 2010C | REF01=3L | R 1/50 |
| groupNumber | REF02 | 2010C | REF01=6P | R 1/50 |
| departmentNumber | REF02 | 2010C | REF01=DP | R 1/50 |
| patientAccountNumber | REF02 | 2010C | REF01=EJ | R 1/50 |
| healthInsuranceClaimNumber | REF02 | 2010C | REF01=F6 | R 1/50 |
| idCard | REF02 | 2010C | REF01=HJ | R 1/50 |
| insurancePolicyNumber | REF02 | 2010C | REF01=IG | R 1/50 |
| planNetworkIdentificationNumber | REF02 | 2010C | REF01=N6 | R 1/50 |
| medicaidRecipientIdentificationNumber | REF02 | 2010C | REF01=NQ | R 1/50 |
| ssn | REF02 | 2010C | REF01=SY | R 1/50 |
Dependent (Request)
| Name | Element | Loop | Description | Constraints |
|---|---|---|---|---|
| lastName | NM103 | 2010D | NM101=QC NM102=1 | S 1/60 |
| firstName | NM104 | 2010D | S 1/35 | |
| middleName | NM105 | 2010D | S 1/25 | |
| suffix | NM107 | 2010D | S 1/10 | |
| dateOfBirth | DMG02 | 2010D | DMG01=D8 YYYYMMDD | R 1/35 |
| genderCode | DMG03 | 2010D | F (Female) M (Male) U (Unknown) | S 1/1 |
| address1 | N301 | 2010D | R 1/55 | |
| address2 | N302 | 2010D | S 1/55 | |
| city | N401 | 2010D | R 2/30 | |
| state | N402 | 2010D | S 2/2 | |
| postalCode | N403 | 2010D | S 3/15 | |
| countryCode | N404 | 2010D | S 2/3 | |
| countrySubDivisionCode | N407 | 2010D | S 1/3 | |
| insuredIndicator | INS01 | 2010D | Y (Yes) N (No) | R 1/1 |
| relationshipToInsuredCode | INS02 | 2010D | 01 (Spouse) 19 (Child) G8 (Other Relationship) | R 2/2 |
| birthSequenceNumber | INS17 | 2010D | S 1/9 | |
| supplementalIdentification (Object) | - | - | ||
| patientAccountNumber | REF02 | 2010D | REF01=EJ | R 1/50 |
| ssn | REF02 | 2010D | REF01=SY | R 1/50 |
Patient Event Detail (Request)
| Name | Element | Loop | Description | Constraints |
|---|---|---|---|---|
| requestCategoryCode | UM01 | 2000E | AR (Admission Review) HS (Health Services Review) IN (Individual) SC (Specialty Care Review) | R 1/2 |
| certificationTypeCode | UM02 | 2000E | 1 (Appeal - Immediate) 2 (Appeal - Standard) 3 (Cancel) 4 (Extension) I (Initial) N (Reconsideration) R Renewal) S (Revised) | R 1/1 |
| serviceTypeCode | UM03 | 2000E | 1 (Medical Care) 2 (Surgical) 3 (Consultation) 4 (Diagnostic X-Ray) 5 (Diagnostic Lab) 6 (Radiation Therapy) 7 (Anesthesia) 8 (Surgical Assistance) 11 (Used Durable Medical Equipment) 12 (Durable Medical Equipment Purchase) 14 (Renal Supplies in the Home) 15 (Alternate Method Dialysis) 16 (Chronic Renal Disease (CRD) Equipment) 17 (Pre-Admission Testing) 18 (Durable Medical Equipment Rental) 20 (Second Surgical Opinion) 21 (Third Surgical Opinion) 23 (Diagnostic Dental) 24 (Periodontics) 25 (Restorative) 26 (Endodontics) 27 (Maxillofacial Prosthetics) 28 (Adjunctive Dental Services) 33 (Chiropractic) 35 (Dental Care) 36 (Dental Crowns) 37 (Dental Accident) 38 (Orthodontics) 39 (Prosthodontics) 40 (Oral Surgery) 42 (Home Health Care) 44 (Home Health Visits) 45 (Hospice) 46 (Respite Care) 54 (Long Term Care) 56 (Medically Related Transportation) 61 (In-vitro Fertilization) 62 (MRI/CAT Scan) 63 (Donor Procedures) 64 (Acupuncture) 65 (Newborn Care) 66 (Pathology) 67 (Smoking Cessation) 68 (Well Baby Care) 69 (Maternity) 70 (Transplants) 71 (Audiology Exam) 72 (Inhalation Therapy) 73 (Diagnostic Medical) 74 (Private Duty Nursing) 75 (Prosthetic Device) 76 (Dialysis) 77 (Otological Exam) 78 (Chemotherapy) 79 (Allergy Testing) 80 (Immunizations) 82 (Family Planning) 83 (Infertility) 84 (Abortion) 85 (AIDS) 86 (Emergency Services) 87 (Cancer) 88 (Pharmacy) 93 (Podiatry) A4 (Psychiatric) A6 (Psychotherapy) A9 (Rehabilitation) AD (Occupational Therapy) AE (Physical Medicine) AF (Speech Therapy) AG (Skilled Nursing Care) AI (Substance Abuse) AJ (Alcoholism) AK (Drug Addiction) AL (Vision (Optometry)) AR (Experimental Drug Therapy) B1 (Burn Care) BB (Partial Hospitalization (Psychiatric)) BC (Day Care (Psychiatric)) BD (Cognitive Therapy) BE (Massage Therapy) BF (Pulmonary Rehabilitation) BG (Cardiac Rehabilitation) BL (Cardiac) BN (Gastrointestinal) BP (Endocrine) BQ (Neurology) BS (Invasive Procedures) BY (Physician Visit - Office: Sick) BZ (Physician Visit - Office: Well) C1 (Coronary Care) CQ (Case Management) GY (Allergy) IC (Intensive Care) MH (Mental Health) NI (Neonatal Intensive Care) ON (Oncology) PT (Physical Therapy) PU (Pulmonary) RN (Renal) RT (Residential Psychiatric Treatment) TC (Transitional Care) TN (Transitional Nursery Care) | S 1/2 |
| facilityTypeCode | UM04_1 | 2000E | R 1/2 | |
| facilityCodeQualifier | UM04_2 | 2000E | A (Uniform Billing Claim Form Bill Type) B (Place of Service Codes for Professional or Dental Services) | R 1/2 |
| relatedCausesCode1 | UM05_1 | 2000E | AA (Uto Accident) AP (Another Party Responsible) EM (Employment) | R 2/3 |
| relatedCausesCode2 | UM05_2 | 2000E | AP (Another Party Responsible) EM (Employment) | S 2/3 |
| relatedCausesCode3 | UM05_3 | 2000E | AP (Another Party Responsible) | S 2/3 |
| stateCode | UM05_4 | 2000E | S 2/2 | |
| countryCode | UM05_5 | 2000E | S 2/3 | |
| levelOfServiceCode | UM06 | 2000E | 03 (Emergency) E (Elective) U (Urgent) | S 1/3 |
| currentHealthConditionCode | UM07 | 2000E | 1 (Acute) 2 (Stable) 3 (Chronic) 4 (Systemic) 5 (Localized) 6 (Mild Disease) 7 (Normal Healthy) 8 (Severe Systemic Disease) 9 (Severe Systemic Disease Threat to Life) E (Excellent) F (Fair) G (Good) P (Poor) | S 1/1 |
| prognosisCode | UM08 | 2000E | 1 (Poor) 2 (Guarded) 3 (Fair) 4 (Good) 5 (Very Good) 6 (Excellent) 7 (Less than 6 Months to Live) 8 (Terminal) | S 1/1 |
| releaseOfInformationCode | UM09 | 2000E | M (Limited or Restricted) Y (Permitted) | S 1/1 |
| delayReasonCode | UM10 | 2000E | 1 (Proof of Eligibility Unknown or Unavailable) 2 (Litigation) 3 (Authorization Delays) 4 (Delay in Certifying Provider) 7 (Third Party Processing Delay) 8 (Delay in Eligibility Determination) 10 (Administration Delay in the Prior Approval Process) 11 (Other) 15 (Natural Disaster) 16 (Lack of Information) 17 (No response to initial request) | S 1/2 |
| previousReviewAuthorizationNumber | REF02 | 2000E | REF01=BB | R 1/50 |
| previousAdministrativeReferenceNumber | REF02 | 2000E | REF01=NT | R 1/50 |
| accidentDate | DTP03 | 2000E | DTP01=439 DTP02=D8 YYYYMMDD | R 1/35 |
| lastMenstrualPeriodDate | DTP03 | 2000E | DTP01=484 DTP02=D8 YYYYMMDD | R 1/35 |
| estimatedDateOfBirth | DTP03 | 2000E | DTP01=ABC DTP02=D8 YYYYMMDD | R 1/35 |
| onsetDate | DTP03 | 2000E | DTP01=431 DTP02=D8 YYYYMMDD | R 1/35 |
| eventDateBegin | DTP03 | 2000E | DTP01=AAH DTP02=D8 YYYYMMDD | R 1/35 |
| eventDateEnd | DTP03 | 2000E | DTP01=AAH DTP02=RD8 YYYYMMDD EventDateBegin must exist | R 1/35 |
| admissionDateBegin | DTP03 | 2000E | DTP01=435 DTP02=D8 YYYYMMDD | R 1/35 |
| admissionDateEnd | DTP03 | 2000E | DTP01=435 DTP02=RD8 YYYYMMDD AdmissionDateBegin must exist | R 1/35 |
| dischargeDate | DTP03 | 2000E | DTP01=096 DTP02=D8 YYYYMMDD | R 1/35 |
| diagnosisTypeCode1 | HI01_1 | 2000E | ABF (Diagnosis) ABJ (Admitting Diagnosis) ABK (Principal Diagnosis) APR (Patient’s Reason for Visit) DR (Diagnosis Related Group (DRG)) | R 1/3 |
| DiagnosisCode1 | HI01_2 | 2000E | R 1/30 | |
| DiagnosisDate1 | HI01_4 | 2000E | HI01_3=D8 YYYYMMDD | S 1/35 |
| diagnosisTypeCode2 | HI02_1 | 2000E | ABF (Diagnosis) ABJ (Admitting Diagnosis) APR (Patient’s Reason for Visit) DR (Diagnosis Related Group (DRG)) | R 1/3 |
| DiagnosisCode2 | HI02_2 | 2000E | R 1/30 | |
| DiagnosisDate2 | HI02_4 | 2000E | HI02_3=D8 YYYYMMDD | S 1/35 |
| diagnosisTypeCode3 | HI03_1 | 2000E | ABF (Diagnosis) APR (Patient’s Reason for Visit) DR (Diagnosis Related Group (DRG)) | R 1/3 |
| DiagnosisCode3 | HI03_2 | 2000E | R 1/30 | |
| DiagnosisDate3 | HI03_4 | 2000E | HI03_3=D8 YYYYMMDD | S 1/35 |
| diagnosisTypeCode4 | HI04_1 | 2000E | ABF (Diagnosis) APR (Patient’s Reason for Visit) DR (Diagnosis Related Group (DRG)) | R 1/3 |
| DiagnosisCode4 | HI04_2 | 2000E | R 1/30 | |
| DiagnosisDate4 | HI04_4 | 2000E | HI04_3=D8 YYYYMMDD | S 1/35 |
| diagnosisTypeCode5 | HI05_1 | 2000E | ABF (Diagnosis) APR (Patient’s Reason for Visit) DR (Diagnosis Related Group (DRG)) | R 1/3 |
| DiagnosisCode5 | HI05_2 | 2000E | R 1/30 | |
| DiagnosisDate5 | HI05_4 | 2000E | HI05_3=D8 YYYYMMDD | S 1/35 |
| diagnosisTypeCode6 | HI06_1 | 2000E | ABF (Diagnosis) APR (Patient’s Reason for Visit) DR (Diagnosis Related Group (DRG)) | R 1/3 |
| DiagnosisCode6 | HI06_2 | 2000E | R 1/30 | |
| DiagnosisDate6 | HI06_4 | 2000E | HI06_3=D8 YYYYMMDD | S 1/35 |
| diagnosisTypeCode7 | HI07_1 | 2000E | ABF (Diagnosis) APR (Patient’s Reason for Visit) DR (Diagnosis Related Group (DRG)) | R 1/3 |
| DiagnosisCode7 | HI07_2 | 2000E | R 1/30 | |
| DiagnosisDate7 | HI07_4 | 2000E | HI07_3=D8 YYYYMMDD | S 1/35 |
| diagnosisTypeCode8 | HI08_1 | 2000E | ABF (Diagnosis) APR (Patient’s Reason for Visit) DR (Diagnosis Related Group (DRG)) | R 1/3 |
| DiagnosisCode8 | HI08_2 | 2000E | R 1/30 | |
| DiagnosisDate8 | HI08_4 | 2000E | HI08_3=D8 YYYYMMDD | S 1/35 |
| diagnosisTypeCode9 | HI09_1 | 2000E | ABF (Diagnosis) APR (Patient’s Reason for Visit) DR (Diagnosis Related Group (DRG)) | R 1/3 |
| DiagnosisCode9 | HI09_2 | 2000E | R 1/30 | |
| DiagnosisDate9 | HI09_4 | 2000E | HI09_3=D8 YYYYMMDD | S 1/35 |
| diagnosisTypeCode10 | HI010_1 | 2000E | ABF (Diagnosis) APR (Patient’s Reason for Visit) DR (Diagnosis Related Group (DRG)) | R 1/3 |
| DiagnosisCode10 | HI010_2 | 2000E | R 1/30 | |
| DiagnosisDate10 | HI010_4 | 2000E | HI010_3=D8 YYYYMMDD | S 1/35 |
| diagnosisTypeCode11 | HI011_1 | 2000E | ABF (Diagnosis) APR (Patient’s Reason for Visit) DR (Diagnosis Related Group (DRG)) | R 1/3 |
| DiagnosisCode11 | HI011_2 | 2000E | R 1/30 | |
| DiagnosisDate11 | HI011_4 | 2000E | HI011_3=D8 YYYYMMDD | S 1/35 |
| diagnosisTypeCode12 | HI012_1 | 2000E | ABF (Diagnosis) APR (Patient’s Reason for Visit) DR (Diagnosis Related Group (DRG)) | R 1/3 |
| DiagnosisCode12 | HI012_2 | 2000E | R 1/30 | |
| DiagnosisDate12 | HI012_4 | 2000E | HI012_3=D8 YYYYMMDD | S 1/35 |
| quantityQualifier | HSD01 | 2000E | DY (Days) FL (Units) HS (Hours) MN (Month) VS (Visits) | S 2/2 |
| serviceUnitCount | HSD02 | 2000E | S 1/15 | |
| unitOrBasisForMeasurementCode | HSD03 | 2000E | DA (Days) MO (Months) WK (Week) | S 2/2 |
| sampleSelectionModulus | HSD04 | 2000E | S 1/6 | |
| timePeriodQualifier | HSD05 | 2000E | 6 (Hour) 7 (Day) 21 (Years) 26 (Episode) 27 (Visit) 29 (Remaining) 34 (Month) 35 (Week) | S 1/2 |
| periodCount | HSD06 | 2000E | S 1/3 | |
| deliveryFrequencyCode | HSD07 | 2000E | 1 (1st Week of the Month) 2 (2nd Week of the Month) 3 (3rd Week of the Month) 4 (4th Week of the Month) 5 (5th Week of the Month) 6 (1st & 3rd Weeks of the Month) 7 (2nd & 4th Weeks of the Month) 8 (1st Working Day of Period) 9 (Last Working Day of Period) A (Monday through Friday) B (Monday through Saturday) C (Monday through Sunday) D (Monday) E (Tuesday) F (Wednesday) G (Thursday) H (Friday) J (Saturday) K (Sunday) L (Monday through Thursday) M (Immediately) N (As Directed) O (Daily Mon. through Fri.) P (1/2 Mon. & 1/2 Thurs.) Q (1/2 Tues. & 1/2 Thurs.) R (1/2 Wed. & 1/2 Fri.) S (Once Anytime Mon. through Fri.) SA (Sunday, Monday, Thursday, Friday, Saturday) SB (Tuesday through Saturday) SC (Sunday, Wednesday, Thursday, Friday, Saturday) SD (Monday, Wednesday, Thursday, Friday, Saturday) SG (Tuesday through Friday) SL (Monday, Tuesday and Thursday) SP (Monday, Tuesday and Friday) SX (Wednesday and Thursday) SY (Monday, Wednesday and Thursday) SZ (Tuesday, Thursday and Friday) T (1/2 Tue. & 1/2 Fri.) U (1/2 Mon. & 1/2 Wed.) V (1/3 Mon., 1/3 Wed., 1/3 Fri.) W (Whenever Necessary) WE (Weekend) X (1/2 By Wed., Bal. By Fri.) Y (None) | S 1/2 |
| deliveryPatternTimeCode | HSD08 | 2000E | A (1st Shift (Normal Working Hours)) B (2nd Shift) C (3rd Shift) D (A.M.) E (P.M.) F (As Directed) G (Any Shift) Y (None) | S 1/1 |
| ambulanceCertificationConditionIndicator | CRC02 | 2000E | CRC01=07 N (No) Y (Yes) | R 1/1 |
| ambulanceCertificationConditionCode1 | CRC03 | 2000E | 01 (Patient was admitted to a hospital) 02 (Patient was bed confined before the ambulance service) 03 (Patient was bed confined after the ambulance service) 04 (Patient was moved by stretcher) 05 (Patient was unconscious or in shock) 06 (Patient was transported in an emergency situation) 07 (Patient had to be physically restrained) 08 (Patient had visible hemorrhaging) 09 (Ambulance service was medically necessary) 41 (Patient or Caregiver is Unable to Propel or Lift a Standard Weight Wheelchair) 43 (Patient Weight or Usage Needs Necessitate a Heavy Duty Wheelchair) 5A (Treatment is rendered related to the terminal illness) 60 (Transportation Was To the Nearest Facility) 9D (Lack of Appropriate Facility within Reasonable Distance to Treat Patient in the Event of Complications) | R 2/3 |
| ambulanceCertificationConditionCode2 | CRC04 | 2000E | Use codes listed in CRC03 | S 2/3 |
| ambulanceCertificationConditionCode3 | CRC05 | 2000E | Use codes listed in CRC03 | S 2/3 |
| ambulanceCertificationConditionCode4 | CRC06 | 2000E | Use codes listed in CRC03 | S 2/3 |
| ambulanceCertificationConditionCode5 | CRC07 | 2000E | Use codes listed in CRC03 | S 2/3 |
| chiropracticCertificationConditionIndicator | CRC02 | 2000E | CRC01=08 N (No) Y (Yes) | R 1/1 |
| chiropracticCertificationConditionCode1 | CRC03 | 2000E | 11 (Ambulance is impaired and Walking Aid is Used for Therapy or Mobility) 12 (Patient is confined to a bed or chair) 14 (Ambulation is impaired and Walking Aid is Used for Mobility) 24 (Patient has an orthopedic impairment requiring traction equipment) 25 (Item has been prescribed as part of a planned regimen of treatment in patient home) 27 (Patient or a caregiver has been instructed in use of equipment) 30 (Without the equipment, the patient would require surgery) | R 2/3 |
| chiropracticCertificationConditionCode2 | CRC04 | 2000E | Use codes listed in CRC03 | S 2/3 |
| chiropracticCertificationConditionCode3 | CRC05 | 2000E | Use codes listed in CRC03 | S 2/3 |
| chiropracticCertificationConditionCode4 | CRC06 | 2000E | Use codes listed in CRC03 | S 2/3 |
| chiropracticCertificationConditionCode5 | CRC07 | 2000E | Use codes listed in CRC03 | S 2/3 |
| durableMedicalEquipmentCertificationConditionIndicator | CRC02 | 2000E | CRC01=09 N (No) Y (Yes) | R 1/1 |
| durableMedicalEquipmentCertificationConditionCode1 | CRC03 | 2000E | 01 (Patient was admitted to a hospital) 02 (Patient was bed confined before the ambulance service) 03 (Patient was bed confined after the ambulance service) 04 (Patient was moved by stretcher) 05 (Patient was unconscious or in shock) 06 (Patient was transported in an emergency situation) 07 (Patient had to be physically restrained) 08 (Patient had visible hemorrhaging) 09 (Ambulance service was medically necessary) 10 (Patient is ambulatory) 11 (Ambulation is Impaired and Walking Aid is Used for Therapy or Mobility) 12 (Patient is confined to a bed or chair) 13 (Patient is Confined to a Room or an Area Without Bathroom Facilities) 14 (Ambulation is Impaired and Walking Aid is Used for Mobility) 15 (Patient Condition Requires Positioning of the Body or Attachments Which Would Not be Feasible With the Use of an Ordinary Bed) 16 (Patient needs a trapeze bar to sit up due to respiratory condition or change body positions for other medical reasons) 17 (Patient’s Ability to Breathe is Severely Impaired) 18 (Patient condition requires frequent and/or immediate changes in body positions) 19 (Patient can operate controls) 20 (Siderails Are to be Attached to a Hospital Bed Owned by the Beneficiary) 21 (Patient owns equipment) 22 (Mattress or Siderails are Being Used with Prescribed Medically Necessary Hospital Bed Owned by the Beneficiary) 23 (Patient Needs Lift to Get In or Out of Bed or to Assist in Transfer from Bed to Wheelchair) 24 (Patient has an orthopedic impairment requiring traction equipment which prevents ambulation during period of use) 25 (Item has been prescribed as part of a planned regimen of treatment in patient home) 26 (Patient is highly susceptible to decubitus ulcers) 27 (Patient or a care-giver has been instructed in use of equipment) 29 (A 6-7 hour nocturnal study documents 30 episodes of apnea each lasting more than 10 seconds) 30 (Without the equipment, the patient would require surgery) 31 (Patient has had a total knee replacement) 32 (Patient has intractable lymphedema of the extremities) 33 (Patient is in a nursing home) 35 (This Feeding is the Only Form of Nutritional Intake for This Patient) 37 (Oxygen delivery equipment is stationary) 38 (Certification signed by the physician is on file at the supplier’s office) 40 (Patient or Caregiver is Capable of Using the Equipment Without Technical or Professional Supervision) 41 (Patient or Caregiver is Unable to Propel or Lift a Standard Weight Wheelchair) 42 (Patient Requires Leg Elevation for Edema or Body Alignment) 43 (Patient Weight or Usage Needs Necessitate a Heavy Duty Wheelchair) 44 (Patient Requires Reclining Function of a Wheelchair) 45 (Patient is Unable to Operate a Wheelchair Manually) 46 (Patient or Caregiver Requires Side Transfer into Wheelchair, Commode or Other) 58 (Durable Medical Equipment (DME) Purchased New) 59 (Durable Medical Equipment (DME) Is Under Warranty) 60 (Transportation Was To the Nearest Facility) 9D (Lack of Appropriate Facility within Reasonable Distance to Treat Patient in the Event of Complications) 9H (Patient Requires Intensive) 9J (Patient Requires Protective Isolation) 9K (Patient Requires Frequent Monitoring) IH (Independent at Home) LB (Legally Blind) SL (Speech Limitations) | R 2/3 |
| durableMedicalEquipmentCertificationConditionCode2 | CRC04 | 2000E | Use codes listed in CRC03 | S 2/3 |
| durableMedicalEquipmentCertificationConditionCode3 | CRC05 | 2000E | Use codes listed in CRC03 | S 2/3 |
| durableMedicalEquipmentCertificationConditionCode4 | CRC06 | 2000E | Use codes listed in CRC03 | S 2/3 |
| durableMedicalEquipmentCertificationConditionCode5 | CRC07 | 2000E | Use codes listed in CRC03 | S 2/3 |
| oxygenTherapyCertificationConditionIndicator | CRC02 | 2000E | CRC01=11 N (No) Y (Yes) | R 1/1 |
| oxygenTherapyCertificationConditionCode1 | CRC03 | 2000E | 06 (Patient was transported in an emergency situation) 16 (Patient needs a trapeze bar to sit up due to respiratory condition or change body positions for other medical reasons) 17 (Patient's Ability to Breathe is Severely Impaired) 25 (Item has been prescribed as part of a planned regimen of treatment in patient home) 33 (Patient is in a nursing home) 37 (Oxygen delivery equipment is stationary) 39 (Patient Has Mobilizing Respiratory Tract Secretions) 5A (Treatment is rendered related to the terminal illness) 9J (Patient Requires Protective Isolation) 9K (Patient Requires Frequent Monitoring) DY (Dyspnea with Minimal Exertion) | R 2/3 |
| oxygenTherapyCertificationConditionCode2 | CRC04 | 2000E | Use codes listed in CRC03 | S 2/3 |
| oxygenTherapyCertificationConditionCode3 | CRC05 | 2000E | Use codes listed in CRC03 | S 2/3 |
| oxygenTherapyCertificationConditionCode4 | CRC06 | 2000E | Use codes listed in CRC03 | S 2/3 |
| oxygenTherapyCertificationConditionCode5 | CRC07 | 2000E | Use codes listed in CRC03 | S 2/3 |
| functionalLimitationsCertificationConditionIndicator | CRC02 | 2000E | CRC01=75 N (No) Y (Yes) | R 1/1 |
| functionalLimitationsCertificationConditionCode1 | CRC03 | 2000E | 02 (Patient was bed confined before the ambulance service) 03 (Patient was bed confined after the ambulance service) 04 (Patient was moved by stretcher) 05 (Patient was unconscious or in shock) 06 (Patient was transported in an emergency situation) 11 (Ambulation is Impaired and Walking Aid is Used for Therapy or Mobility) 12 (Patient is confined to a bed or chair) 14 (Ambulation is Impaired and Walking Aid is Used for Mobility) 15 (Patient Condition Requires Positioning of the Body or Attachments Which Would Not be Feasible With the Use of an Ordinary Bed) 16 (Patient needs a trapeze bar to sit up due to respiratory condition or change body positions for other medical reasons) 17 (Patient’s Ability to Breathe is Severely Impaired) 18 (Patient condition requires frequent and/or immediate changes in body positions) 19 (Patient can operate controls) 20 (Siderails Are to be Attached to a Hospital Bed Owned by the Beneficiary) 21 (Patient owns equipment) 22 (Mattress or Siderails are Being Used with Prescribed Medically Necessary Hospital Bed Owned by the Beneficiary) 23 (Patient Needs Lift to Get In or Out of Bed or to Assist in Transfer from Bed to Wheelchair) 24 (Patient has an orthopedic impairment requiring traction equipment which prevents ambulation during period of use) 25 (Item has been prescribed as part of a planned regimen of treatment in patient home) 26 (Patient is highly susceptible to decubitus ulcers) 27 (Patient or a care-giver has been instructed in use of equipment) 28 (Patient has poor diabetic control) 30 (Without the equipment, the patient would require surgery) 31 (Patient has had a total knee replacement) 32 (Patient has intractable lymphedema of the extremities) 35 (This Feeding is the Only Form of Nutritional Intake for This Patient) 37 (Oxygen delivery equipment is stationary) 39 (Patient Has Mobilizing Respiratory Tract Secretions) 40 (Patient or Caregiver is Capable of Using the Equipment Without Technical or Professional Supervision) 41 (Patient or Caregiver is Unable to Propel or Lift a Standard Weight Wheelchair) 42 (Patient Requires Leg Elevation for Edema or Body Alignment) 43 (Patient Weight or Usage Needs Necessitate a Heavy Duty Wheelchair) 44 (Patient Requires Reclining Function of a Wheelchair) 45 (Patient is Unable to Operate a Wheelchair Manually) 46 (Patient or Caregiver Requires Side Transfer into Wheelchair, Commode or Other) 5A (Treatment is rendered related to the terminal illness) 68 (Severe) 69 (Moderate) 9E (Sudden Onset of Disorientation) 9F (Sudden Onset of Severe, Incapacitating Pain) 9H (Patient Requires Intensive) AA (Amputation) AL (Ambulation Limitations) BL (Bowel Limitations, Bladder Limitations, or both (Incontinence) B) BPD (Beneficiary is Partially Dependent B) BTD (Beneficiary is Totally Dependent) CA (Cane Required) CB (Complete Bedrest C) CNJ (Cumulative Injury) CO (Contracture) DY (Dyspnea with Minimal Exertion) EL (Endurance Limitations) EP (Exercises Prescribed) HL (Hearing Limitations) LB (Legally Blind) LE (Lethargic) OL (Other Limitation) PA (Paralysis) PW (Partial Weight Bearing) SL (Speech Limitations T) TNJ (Traumatic Injury) WA (Walker Required) WR (Wheelchair Required) | R 2/3 |
| functionalLimitationsCertificationConditionCode2 | CRC04 | 2000E | Use codes listed in CRC03 | S 2/3 |
| functionalLimitationsCertificationConditionCode3 | CRC05 | 2000E | Use codes listed in CRC03 | S 2/3 |
| functionalLimitationsCertificationConditionCode4 | CRC06 | 2000E | Use codes listed in CRC03 | S 2/3 |
| functionalLimitationsCertificationConditionCode5 | CRC07 | 2000E | Use codes listed in CRC03 | S 2/3 |
| activitiesPermittedCertificationConditionIndicator | CRC02 | 2000E | CRC01=76 N (No) Y (Yes) | R 1/1 |
| activitiesPermittedCertificationConditionCode1 | CRC03 | 2000E | 10 (Patient is ambulatory) 13 (Patient is Confined to a Room or an Area Without Bathroom Facilities) 19 (Patient can operate controls) 21 (Patient owns equipment) 22 (Mattress or Siderails are Being Used with Prescribed Medically Necessary Hospital Bed Owned by the Beneficiary) 27 (Patient or a care-giver has been instructed in use of equipment) 31 (Patient has had a total knee replacement) 40 (Patient or Caregiver is Capable of Using the Equipment Without Technical or Professional Supervision) BR (Bedrest BRP (Bathroom Privileges)) CA (Cane Required) CB (Complete Bedrest) CR (Crutches Required) EL (Endurance Limitations) EP (Exercises Prescribed) IH (Independent at Home) NR (No Restrictions) PA (Paralysis) PW (Partial Weight Bearing) TR (Transfer to Bed, or Chair, or Both) UT (Up as Tolerated) WA (Walker Required) WR (Wheelchair Required) | R 2/3 |
| activitiesPermittedCertificationConditionCode2 | CRC04 | 2000E | Use codes listed in CRC03 | S 2/3 |
| activitiesPermittedCertificationConditionCode3 | CRC05 | 2000E | Use codes listed in CRC03 | S 2/3 |
| activitiesPermittedCertificationConditionCode4 | CRC06 | 2000E | Use codes listed in CRC03 | S 2/3 |
| activitiesPermittedCertificationConditionCode5 | CRC07 | 2000E | Use codes listed in CRC03 | S 2/3 |
| mentalStatusCertificationConditionIndicator | CRC02 | 2000E | CRC01=77 N (No) Y (Yes) | R 1/1 |
| mentalStatusCertificationConditionCode1 | CRC03 | 2000E | 01 (Patient was admitted to a hospital) 05 (Patient was unconscious or in shock) 07 (Patient had to be physically restrained) 13 (Patient is Confined to a Room or an Area Without Bathroom Facilities) 20 (Siderails Are to be Attached to a Hospital Bed Owned by the Beneficiary) 22 (Mattress or Siderails are Being Used with Prescribed Medically Necessary Hospital Bed Owned by the Beneficiary) 23 (Patient Needs Lift to Get In or Out of Bed or to Assist in Transfer from Bed to Wheelchair) 26 (Patient is highly susceptible to decubitus ulcers) 33 (Patient is in a nursing home) 34 (Patient is conscious) 5A (Treatment is rendered related to the terminal illness) 68 (Severe) 69 (Moderate) 9E (Sudden Onset of Disorientation) 9F (Sudden Onset of Severe, Incapacitating Pain) 9J (Patient Requires Protective Isolation) 9K (Patient Requires Frequent Monitoring) AG (Agitated) BPD (Beneficiary is Partially Dependent) BTD (Beneficiary is Totally Dependent) CB (Complete Bedrest) CM (Comatose) DI (Disoriented) DP (Depressed) FO (Forgetful) HO (Hostile) LE (Lethargic) MC (Other Mental Condition) OT (Oriented) UN (Uncooperative) | R 2/3 |
| mentalStatusCertificationConditionCode2 | CRC04 | 2000E | Use codes listed in CRC03 | S 2/3 |
| mentalStatusCertificationConditionCode3 | CRC05 | 2000E | Use codes listed in CRC03 | S 2/3 |
| mentalStatusCertificationConditionCode4 | CRC06 | 2000E | Use codes listed in CRC03 | S 2/3 |
| mentalStatusCertificationConditionCode5 | CRC07 | 2000E | Use codes listed in CRC03 | S 2/3 |
| freeFormMessageText | MSG01 | 2000E | R 1/264 | |
| admissionToFacility (Object) | - | - | ||
| admissionTypeCode | CL101 | 2000E | S 1/1 | |
| admissionSourceCode | CL102 | 2000E | S 1/1 | |
| patientStatusCode | CL103 | 2000E | S 1/2 | |
| nursingHomeResidentialStatusCode | CL104 | 2000E | 1 (Transferred to Intermediate Care Facility - Mentally Retarded (ICF-MR)) 2 (Newly Admitted) 3 (Newly Eligible) 4 (No Longer Eligible) 5 (Still a Resident) 6 (Temporary Absence - Hospital) 7 (Temporary Absence - Other) 8 (Transferred to Intermediate Care Facility - Level II (ICF II)) 9 (Other) | S 1/1 |
| ambulanceTransport (Object) | - | - | ||
| patientWeight | CR102 | 2000E | CR101=LB | S 1/10 |
| transportCode | CR103 | 2000E | I (Initial Trip) R (Return Trip) T (Transfer Trip) X (Round Trip) | R 1/1 |
| transportReasonCode | CR104 | 2000E | A (Patient was transported to nearest facility for care of symptoms, complaints, or both) B (Patient was transported for the benefit of a preferred physician) C (Patient was transported for the nearness of family members) D (Patient was transported for the care of a specialist or for availability of specialized equipment) E (Patient Transferred to Rehabilitation Facility) F (Patient Transferred to Residential Facility) | S 1/1 |
| transportDistance | CR106 | 2000E | CR105=DH | S 1/15 |
| roundTripPurposeDescription | CR109 | 2000E | S 1/80 | |
| stretcherPurposeDescription | CR110 | 2000E | S 1/80 | |
| spinalManipulation (Object) | - | - | ||
| treatmentSeriesNumber | CR201 | 2000E | S 1/9 | |
| treatmentCount | CR202 | 2000E | S 1/15 | |
| subluxationBeginningLevelCode | CR203 | 2000E | C1 (Cervical 1) C2 (Cervical 2) C3 (Cervical 3) C4 (Cervical 4) C5 (Cervical 5) C6 (Cervical 6) C7 (Cervical 7) CO (Coccyx) IL (Ilium) L1 (Lumbar 1) L2 (Lumbar 2) L3 (Lumbar 3) L4 (Lumbar 4) L5 (Lumbar 5) OC (Occiput) SA (Sacrum) T1 (Thoracic 1) T2 (Thoracic 2) T3 (Thoracic 3) T4 (Thoracic 4) T5 (Thoracic 5) T6 (Thoracic 6) T7 (Thoracic 7) T8 (Thoracic 8) T9 (Thoracic 9) T10 (Thoracic 10) T11 (Thoracic 11) T12 (Thoracic 12) | S 2/3 |
| subluxationEndLevelCode | CR204 | 2000E | Use codes listed in CR203 | S 2/3 |
| patientConditionCode | CR208 | 2000E | A (Acute Condition) C (Chronic Condition) D (Non-acute) E (Non-Life Threatening) F (Routine) G (Symptomatic) M (Acute Manifestation of a Chronic Condition) | R 1/1 |
| complicationIndicator | CR209 | 2000E | N (No) Y (Yes) | R 1/1 |
| patientConditionDescription1 | CR210 | 2000E | S 1/80 | |
| patientConditionDescription2 | CR211 | 2000E | S 1/80 | |
| xrayAvailabilityIndicator | CR212 | 2000E | N (No) Y (Yes) | S 1/1 |
| homeOxygenTherapyInformation (Object) | - | - | ||
| equipmentTypeCode1 | CR503 | 2000E | A (Concentrator) B (Liquid Stationary) C (Gaseous Stationary) D (Liquid Portable) E (Gaseous Portable) O (Other) | R 1/1 |
| equipmentTypeCode2 | CR504 | 2000E | Use codes listed in CR503 | S 1/1 |
| equipmentTypeCode3 | CR518 | 2000E | Use codes listed in CR503 | S 1/1 |
| equipmentReasonDescription | CR505 | 2000E | S 1/80 | |
| flowRate | CR506 | 2000E | R 1/15 | |
| dailyUseCount | CR507 | 2000E | S 1/15 | |
| usePeriodHourCount | CR508 | 2000E | S 1/15 | |
| respiratoryTherapistOrderText | CR509 | 2000E | S 1/80 | |
| arterialBloodGasQuantity | CR510 | 2000E | S 1/15 | |
| saturationQuantity | CR511 | 2000E | S 1/15 | |
| testConditionCode | CR512 | 2000E | E (Exercising) N (No special conditions for test) O (On oxygen) R (At rest on room air) S (Sleeping) W (Walking) X (Other) | S 1/1 |
| testFindingsCode1 | CR513 | 2000E | 1 (Dependent edema suggesting congestive heart failure) 2 (“P” Pulmonale on Electrocardiogram (EKG)) 3 (Erythrocythemia with a hematocrit greater than 56 percent) | S 1/1 |
| testFindingsCode2 | CR514 | 2000E | Use codes listed in CR513 | S 1/1 |
| testFindingsCode3 | CR515 | 2000E | Use codes listed in CR513 | S 1/1 |
| portableSystemFlowRate | CR516 | 2000E | S 1/15 | |
| deliverySystemCode | CR517 | 2000E | A (Nasal Cannula) B (Oxygen Conserving Device) C (Oxygen Conserving Device with Oxygen Pulse System) D (Oxygen Conserving Device with Reservoir System) E (Transtracheal Catheter) | R 1/1 |
| homeHealth (Object) | - | - | ||
| prognosisCode | CR601 | 2000E | 1 (Poor) 2 (Guarded) 3 (Fair) 4 (Good) 5 (Very Good) 6 (Excellent) 7 (Less than 6 Months to Live) 8 (Terminal) | R 1/1 |
| startDate | CR602 | 2000E | R 8/8 | |
| certificationPeriodStartDate | CR604 | 2000E | S 1/35 | |
| certificationPeriodEndDate | CR604 | 2000E | CR603=RD8 | S 1/35 |
| medicareCoverageIndicator | CR607 | 2000E | R 1/1 | |
| certificationTypeCode | CR608 | 2000E | 1 (Appeal - Immediate Use this value only for appeals of review decisions where the level of service required is emergency or urgent.) 2 (Appeal - Standard 1327 Use this value for appeals of review decisions where the level of service required is not emergency or urgent.) 3 (Cancel) 4 (Extension Indicates that this is an extension request to a prior approved service.) 6 (Verification This code is used to request the UMO to reconsider a previously denied referral or certification request.) I (Initial) R (Renewal Indicates that this is a request to renew a prior approved service.) S (Revised Use if the requester is revising the specifics of a certification for which services have not been rendered.) | R 1/1 |
| surgeryDate | CR609 | 2000E | S 8/8 | |
| productOrServiceQualifier | CR610 | 2000E | HC (Health Care Financing Administration Common Procedural Coding System (HCPCS) Codes) ID (International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM) - Procedure) | S 2/2 |
| surgicalProcedureCode | CR611 | 2000E | S 1/15 | |
| physicalOrderDate | CR612 | 2000E | S 8/8 | |
| lastVisitDate | CR613 | 2000E | S 8/8 | |
| physicianContactDate | CR614 | 2000E | S 8/8 | |
| lastAdmissionPeriodStartDate | CR616 | 2000E | S 1/35 | |
| lastAdmissionPeriodEndDate | CR616 | 2000E | CR615=RD8 | S 1/35 |
| patientLocationCode | CR617 | 2000E | A (Acute Care Facility) B (Boarding Home) C (Hospice) D (Intermediate Care Facility) E (Long-term or Extended Care Facility) F (Not Specified) G (Nursing Home) H (Sub-acute Care Facility) L (Other Location) M (Rehabilitation Facility) O (Outpatient Facility) P (Private Home) R (Residential Treatment Facility) S (Skilled Nursing Home) T (Rest Home) | S 1/1 |
| attachments (Array of objects) | - | - | Can repeat up to 10 times | |
| patientEventProviderName (Array of objects) | - | - | ||
| patientEventTransportInformation (Array of objects) | - | - | ||
| patientEventOtherUmoName (Array of objects) | - | - | ||
| serviceLevel (Array of objects) | - | - |
Attachment 2000E and 2000F PWK (Request and Response)
| Name | Element | Loop | Description | Constraints |
|---|---|---|---|---|
| attachment (Object) | - | - | ||
| reportTypeCode | PWK01 | 2000E/F | 03 (Report Justifying Treatment Beyond Utilization Guidelines) 04 (Drugs Administered) 05 (Treatment Diagnosis) 06 (Initial Assessment) 07 (Functional Goals (Expected outcomes of rehabilitative services)) 08 (Plan of Treatment) 09 (Progress Report) 10 (Continued Treatment) 11 (Chemical Analysis) 13 (Certified Test Report) 15 (Justification for Admission) 21 (Recovery Plan) 48 (Social Security Benefit Letter) 55 (Rental Agreement (Use for medical or dental equipment rental)) 59 (Benefit Letter) 77 (Support Data for Verification) A3 (Allergies/Sensitivities Document) A4 (Autopsy Report) AM (Ambulance Certification (Information to support necessity of ambulance trip)) AS (Admission Summary (A brief patient summary; it lists the patient’s chief complaints and the reasons for admitting the patient to the hospital)) AT (Purchase Order Attachment (Use for purchase of medical or dental equipment)) B2 (Prescription) B3 (Physician Order) BR (Benchmark Testing Results) BS (Baseline) BT (Blanket Test Results) CB (Chiropractic Justification (Lists the reasons chiropractic is just and appropriate treatment)) CK (Consent Form(s)) D2 (Drug Profile Document) DA (Dental Models) DB (Durable Medical Equipment Prescription) DG (Diagnostic Report) DJ (Discharge Monitoring Report) DS (Discharge Summary) FM (Family Medical History Document) HC (Health Certificate) HR (Health Clinic Records) I5 (Immunization Record) IR (State School Immunization Records) LA (Laboratory Results) M1 (Medical Record Attachment) NN (Nursing Notes) OB (Operative Note) OC (Oxygen Content Averaging Report) OD (Orders and Treatments Document) OE (Objective Physical Examination (including vital signs) Document) OX (Oxygen Therapy Certification) P4 (Pathology Report) P5 (Patient Medical History Document) P6 (Periodontal Charts (Required when using the PWK segment to provide missing teeth information)) P7 (Periodontal Reports) PE (Parenteral or Enteral Certification) PN (Physical Therapy Notes) PO (Prosthetics or Orthotic Certification) PQ (Paramedical Results) PY (Physician’s Report) PZ (Physical Therapy Certification) QC (Cause and Corrective Action Report) QR (Quality Report) RB (Radiology Films) RR (Radiology Reports) RT (Report of Tests and Analysis Report) RX (Renewable Oxygen Content Averaging Report) SG (Symptoms Document) V5 (Death Notification) XP (Photographs) | R 2/2 |
| transmissionCode | PWK02 | 2000E/F | AA (Available on Request at Provider Site) BM (By Mail) EL (Electronically Only) EM (E-Mail) FX (By Fax) VO (Voice) | R 1/2 |
| controlNumber | PWK06 | 2000E/F | PWK05=AC | S 2/80 |
| description | PWK07 | 2000E/F | S 1/80 |
Patient Event Provider Name (Request)
| Name | Element | Loop | Description | Constraints |
|---|---|---|---|---|
| patientEventProviderName (Object) | - | - | ||
| entityIdentifierCode | NM101 | 2010EA | 71 (Attending Physician) 72 (Operating Physician) 73 (Other Physician) 77 (Service Location) AAJ (Admitting Services) DD (Assistant Surgeon) DK (Ordering Physician) DN (Referring Provider) FA (Facility) G3 (Clinic) P3 (Primary Care Provider) QB (Purchase Service Provider) QV (Group Practice) SJ (Service Provider) | R 2/3 |
| organizationName | NM103 | 2010EA | NM102=2 | S 1/60 |
| lastName | NM103 | 2010EA | S 1/60 | |
| firstName | NM104 | 2010EA | NM102=1 | S 1/35 |
| middleName | NM105 | 2010EA | S 1/25 | |
| namePrefix | NM106 | 2010EA | S 1/10 | |
| nameSuffix | NM107 | 2010EA | S 1/10 | |
| identificationCodeQualifier | NM108 | 2010EA | 24 (Employer’s Identification Number) 34 (Social Security Number) 46 (Electronic Transmitter Identification Number (ETIN)) XX (Centers for Medicare and Medicaid Services National Provider Identifier (NPI)) | S 1/2 |
| identifier | NM109 | 2010EA | S 2/80 | |
| address1 | N301 | 2010EA | R 1/55 | |
| address2 | N302 | 2010EA | S 1/55 | |
| city | N401 | 2010EA | R 2/30 | |
| state | N402 | 2010EA | S 2/2 | |
| postalCode | N403 | 2010EA | S 3/15 | |
| countryCode | N404 | 2010EA | S 2/3 | |
| countrySubDivisionCode | N407 | 2010EA | S 1/3 | |
| providerCode | PRV01 | 2010EA | PRV02=PXC AD (Admitting) AS (Assistant Surgeon) AT (Attending) OP (Operating) OR (Ordering) OT (Other Physician) PC (Primary Care Physician) PE (Performing) RF (Referring) | R 1/3 |
| providerTaxonomyCode | PRV03 | 2010EA | R 1/50 | |
| contactName | PER02 | 2010EA | PER01=IC | S 1/60 |
| contactElectronicMail | PER04 PER06 PER08 | 2010EA | PER03=EM PER05=EM PER07=EM | S 1/256 |
| contactFacsimile | PER04 PER06 PER08 | 2010EA | PER03=FX PER05=FX PER07=FX | S 1/256 |
| ContactTelephone | PER04 PER06 PER08 | 2010EA | PER03=TE PER05=TE PER07=TE | S 1/256 |
| ContactTelephoneExtension | PER06 PER08 | 2010EA | PER05=EX PER07=EX | S 1/256 |
| providerSupplementalInformation (Object) | - | - | ||
| stateLicenseNumber | REF02 | 2010EA | REF01=0B | R 1/50 |
| licenseNumberStateCode | REF03 | 2010EA | Required if StateLicenseNumber is entered | R 1/50 |
| providerUpinNumber | REF02 | 2010EA | REF01=1G | R 1/50 |
| facilityIdNumber | REF02 | 2010EA | REF01=1J | R 1/50 |
| employersIdentificationNumber | REF02 | 2010EA | REF01=EI | R 1/50 |
| providerPlanNetworkIdentificationNumber | REF02 | 2010EA | REF01=N5 | R 1/50 |
| facilityNetworkIdentificationNumber | REF02 | 2010EA | REF01=N7 | R 1/50 |
| ssn | REF02 | 2010EA | REF01=SY | R 1/50 |
| carrierAssignedReferenceNumber | REF02 | 2010EA | REF01=ZH | R 1/50 |
patient Event Transport Information (Request)
| Name | Element | Loop | Description | Constraints |
|---|---|---|---|---|
| patientEventTransportInformation (Object) | - | - | ||
| entityIdentifierCode | NM101 | 2010EB | 45 (Drop-off Location) FS (Final Scheduled Destination) ND (Next Destination) PW (Pickup Address) R3 (Next Scheduled Destination) | R 2/3 |
| transportLocationName | NM103 | 2010EB | NM102=2 | S 1/60 |
| address1 | N301 | 2010EB | R 1/55 | |
| address2 | N302 | 2010EB | S 1/55 | |
| city | N401 | 2010EB | S 2/30 | |
| state | N402 | 2010EB | S 2/2 | |
| postalCode | N403 | 2010EB | S 3/15 |
Patient Event Other UMO Name (Request)
| Name | Element | Loop | Description | Constraints |
|---|---|---|---|---|
| patientEventOtherUmoName (Object) | - | - | ||
| entityIdentifierCode | NM101 | 2010EC | 00 (Alternate Insurer) CA (Carrier) GG (Intermediary) | R 2/3 |
| otherUmoName | NM103 | 2010EC | NM102=2 | S 1/60 |
| otherUmoDenialReason1 | REF02 | 2010EC | REF01=ZZ | R 1/50 |
| otherUmoDenialReason2 | REF04_2 | 2010EC | REF04_1=ZZ | R 1/50 |
| otherUmoDenialReason3 | REF04_4 | 2010EC | REF04_3=ZZ | S 1/50 |
| otherUmoDenialReason4 | REF04_6 | 2010EC | REF04_5=ZZ | S 1/50 |
| otherUmoDenialDate | DTP03 | 2010EC | YYYYMMDD DTP01=598 DTP02=D8 | R 1/35 |
Patient Event Service Level (Request)
| Name | Element | Loop | Description | Constraints |
|---|---|---|---|---|
| serviceLevel (Object) | - | - | ||
| requestCategoryCode | UM01 | 2000F | HS (Health Services Review) SC (Specialty Care Review) | R 1/2 |
| certificationTypeCode | UM02 | 2000F | 1 (Appeal - Immediate) 2 (Appeal - Standard) 3 (Cancel) 4 (Extension) I (Initial) N (Reconsideration) R (Renewal) S (Revised) | S 1/1 |
| serviceTypeCode | UM03 | 2000F | 1 (Medical Care) 2 (Surgical) 3 (Consultation) 4 (Diagnostic X-Ray) 5 (Diagnostic Lab) 6 (Radiation Therapy) 7 (Anesthesia) 8 (Surgical Assistance) 11 (Used Durable Medical Equipment) 12 (Durable Medical Equipment Purchase) 14 (Renal Supplies in the Home) 15 (Alternate Method Dialysis) 16 (Chronic Renal Disease (CRD) Equipment) 17 (Pre-Admission Testing) 18 (Durable Medical Equipment Rental) 20 (Second Surgical Opinion) 21 (Third Surgical Opinion) 23 (Diagnostic Dental) 24 (Periodontics) 25 (Restorative) 26 (Endodontics) 27 (Maxillofacial Prosthetics) 28 (Adjunctive Dental Services) 33 (Chiropractic) 35 (Dental Care) 36 (Dental Crowns) 37 (Dental Accident) 38 (Orthodontics) 39 (Prosthodontics) 40 (Oral Surgery) 42 (Home Health Care) 44 (Home Health Visits) 45 (Hospice) 46 (Respite Care) 54 (Long Term Care) 56 (Medically Related Transportation) 61 (In-vitro Fertilization) 62 (MRI/CAT Scan) 63 (Donor Procedures) 64 (Acupuncture) 65 (Newborn Care) 66 (Pathology) 67 (Smoking Cessation) 68 (Well Baby Care) 69 (Maternity) 70 (Transplants) 71 (Audiology Exam) 72 (Inhalation Therapy) 73 (Diagnostic Medical) 74 (Private Duty Nursing) 75 (Prosthetic Device) 76 (Dialysis) 77 (Otological Exam) 78 (Chemotherapy) 79 (Allergy Testing) 80 (Immunizations) 82 (Family Planning) 83 (Infertility) 84 (Abortion) 85 (AIDS) 86 (Emergency Services) 87 (Cancer) 88 (Pharmacy) 93 (Podiatry) A4 (Psychiatric) A6 (Psychotherapy) A9 (Rehabilitation) AD (Occupational Therapy) AE (Physical Medicine) AF (Speech Therapy) AG (Skilled Nursing Care) AI (Substance Abuse) AJ (Alcoholism) AK (Drug Addiction) AL (Vision (Optometry)) AR (Experimental Drug Therapy) B1 (Burn Care) BB (Partial Hospitalization (Psychiatric)) BC (Day Care (Psychiatric)) BD (Cognitive Therapy) BE (Massage Therapy) BF (Pulmonary Rehabilitation) BG (Cardiac Rehabilitation) BL (Cardiac) BN (Gastrointestinal) BP (Endocrine) BQ (Neurology) BS (Invasive Procedures) BY (Physician Visit - Office: Sick) BZ (Physician Visit - Office: Well) C1 (Coronary Care) GY (Allergy) IC (Intensive Care) MH (Mental Health) NI (Neonatal Intensive Care) ON (Oncology) PT (Physical Therapy) PU (Pulmonary) RN (Renal) RT (Residential Psychiatric Treatment) TC (Transitional Care) TN (Transitional Nursery Care) | S 1/2 |
| facilityTypeCode | UM04_1 | 2000F | R 1/2 | |
| facilityCodeQualifier | UM04_2 | 2000F | A (Uniform Billing Claim Form Bill Type) B (Place of Service Codes for Professional or Dental Services) | R 1/2 |
| previousReviewAuthorizationNumber | REF02 | 2000F | REF01=BB | R 1/50 |
| previousAdministrativeReferenceNumber | REF02 | 2000F | REF01=NT | R 1/50 |
| serviceDateBegin | DTP03 | 2000F | DTP01=472 DTP02=D8 YYYYMMDD | R 1/35 |
| serviceDateEnd | DTP03 | 2000F | DTP01=472 DTP02=RD8 YYYYMMDD ServiceDateBegin must exist | R 1/35 |
| freeFormMessageText | MSG01 | 2000F | R 1/264 | |
| professionalService (Object) | - | - | ||
| productOrServiceIDQualifier | SV101_1 | 2000F | HC (HCPCS) N4 (National Drug Code) | R 2/2 |
| procedureCode | SV101_2 | 2000F | R 1/48 | |
| procedureModifier1 | SV101_3 | 2000F | S 2/2 | |
| procedureModifier2 | SV101_4 | 2000F | S 2/2 | |
| procedureModifier3 | SV101_5 | 2000F | S 2/2 | |
| procedureModifier4 | SV101_6 | 2000F | S 2/2 | |
| procedureCodeDescription | SV101_7 | 2000F | S 1/80 | |
| procedureCode2 | SV101_8 | 2000F | S 1/48 | |
| serviceLineAmount | SV102 | 2000F | S 1/18 | |
| unitOrBasisForMeasurementCode | SV103 | 2000F | F2 (International Unit) MJ (Minutes) UN (Unit) | S 2/2 |
| serviceUnitCount | SV104 | 2000F | S 1/15 | |
| diagnosisCodePointer1 | SV107_1 | 2000F | R 1/2 | |
| diagnosisCodePointer2 | SV107_2 | 2000F | S 1/2 | |
| diagnosisCodePointer3 | SV107_3 | 2000F | S 1/2 | |
| diagnosisCodePointer4 | SV107_4 | 2000F | S 1/2 | |
| epsdtIndicator | SV111 | 2000F | S 1/1 | |
| nursingHomeLevelOfCare | SV120 | 2000F | 1 (Skilled Nursing Facility (SNF)) 2 (Intermediate Care Facility (ICF)) 3 (Intermediate Care Facility - Mentally Retarded (ICF-MR)) 4 (Chronic Disease Hospital (CD)) 5 (Intermediate Care Facility (ICF) Level II) 6 (Special Skilled Nursing Facility (SNF)) 7 (Nursing Facility (NF)) 8 (Hospice) | S 1/1 |
| institutionalService (Object) | - | - | ||
| serviceLineRevenueCode | SV201 | 2000F | S 1/48 | |
| productOrServiceIDQualifier | SV202_1 | 2000F | HC (HCPCS or CPT) N4 (National Drug Code) ZZ (ICD-10) | R 2/2 |
| procedureCode | SV202_2 | 2000F | R 1/48 | |
| procedureModifier1 | SV202_3 | 2000F | S 2/2 | |
| procedureModifier2 | SV202_4 | 2000F | S 2/2 | |
| procedureModifier3 | SV202_5 | 2000F | S 2/2 | |
| procedureModifier4 | SV202_6 | 2000F | S 2/2 | |
| procedureCodeDescription | SV202_7 | 2000F | S 1/80 | |
| procedureCode2 | SV202_8 | 2000F | S 1/48 | |
| serviceLineAmount | SV203 | 2000F | S 1/18 | |
| unitOrBasisForMeasurementCode | SV204 | 2000F | DA (Days) F2 (International Unit) UN (Unit) | S 2/2 |
| serviceUnitCount | SV205 | 2000F | S 1/15 | |
| serviceLineRate | SV206 | 2000F | S 1/10 | |
| nursingHomeResidentialStatusCode | SV209 | 2000F | 1 (Transferred to Intermediate Care Facility - Mentally Retarded (ICF-MR)) 2 (Newly Admitted) 3 (Newly Eligible) 4 (No Longer Eligible) 5 (Still a Resident) 6 (Temporary Absence - Hospital) 7 (Temporary Absence - Other) 8 (Transferred to Intermediate Care Facility - Level II (ICF II)) | S 1/1 |
| nursingHomeLevelOfCare | SV210 | 2000F | 1 (Skilled Nursing Facility (SNF)) 2 (Intermediate Care Facility (ICF)) 3 (Intermediate Care Facility - Mentally Retarded (ICF-MR)) 4 (Chronic Disease Hospital (CD)) 5 (Intermediate Care Facility (ICF) Level II) 6 (Special Skilled Nursing Facility (SNF)) 7 (Nursing Facility (NF)) 8 (Hospice) | S 1/1 |
| dentalService (Object) | - | - | ||
| procedureCode | SV301_2 | 2000F | SV301_1=AD | R 1/48 |
| procedureModifier1 | SV301_3 | 2000F | S 2/2 | |
| procedureModifier2 | SV301_4 | 2000F | S 2/2 | |
| procedureModifier3 | SV301_5 | 2000F | S 2/2 | |
| procedureModifier4 | SV301_6 | 2000F | S 2/2 | |
| procedureCodeDescription | SV301_7 | 2000F | S 1/80 | |
| procedureCode2 | SV301_8 | 2000F | S 1/48 | |
| serviceLineAmount | SV302 | 2000F | S 1/18 | |
| oralCavityDesignationCode | SV304_1 | 2000F | R 1/3 | |
| oralCavityDesignationCode2 | SV304_2 | 2000F | S 1/3 | |
| oralCavityDesignationCode3 | SV304_3 | 2000F | S 1/3 | |
| oralCavityDesignationCode4 | SV304_4 | 2000F | S 1/3 | |
| oralCavityDesignationCode5 | SV304_5 | 2000F | S 1/3 | |
| prosthesisCrownOrInlayCode | SV305 | 2000F | I (Initial Placement) R (Replacement) | S 1/1 |
| serviceUnitCount | SV306 | 2000F | R 1/15 | |
| description | SV307 | 2000F | S 1/80 | |
| toothInformation (Object) | - | - | ||
| toothCode | TOO02 | 2000F | TOO01=JP | R 1/30 |
| toothSurfaceCode1 | TOO03_1 | 2000F | B (Buccal) D (Distal) F (Facial) I (Incisal) L (Lingual) M (Mesial) O (Occlusal) | R 1/2 |
| toothSurfaceCode2 | TOO03_2 | 2000F | Use codes listed in TOO03_1 | S 1/2 |
| toothSurfaceCode3 | TOO03_3 | 2000F | Use codes listed in TOO03_1 | S 1/2 |
| toothSurfaceCode4 | TOO03_4 | 2000F | Use codes listed in TOO03_1 | S 1/2 |
| toothSurfaceCode5 | TOO03_5 | 2000F | Use codes listed in TOO03_1 | S 1/2 |
| healthCareServiceDelivery (Object) | - | - | ||
| quantityQualifier | HSD01 | 2000F | DY (Days) FL (Units) HS (Hours) MN (Month) VS (Visits) | S 2/2 |
| serviceQuantity | HSD02 | 2000F | S 1/15 | |
| unitOrBasisForMeasurementCode | HSD03 | 2000F | DA (Days) MO (Months) WK (Week) | S 2/2 |
| sampleSelectionModulus | HSD04 | 2000F | S 1/6 | |
| timePeriodQualifier | HSD05 | 2000F | 6 (Hour) 7 (Day) 21 (Years) 26 (Episode) 27 (Visit) 29 (Remaining) 34 (Month) 35 (Week) | S 1/2 |
| periodCount | HSD06 | 2000F | S 1/3 | |
| deliveryFrequencyCode | HSD07 | 2000F | 1 (1st Week of the Month) 2 (2nd Week of the Month) 3 (3rd Week of the Month) 4 (4th Week of the Month) 5 (5th Week of the Month) 6 (1st & 3rd Weeks of the Month) 7 (2nd & 4th Weeks of the Month) 8 (1st Working Day of Period) 9 (Last Working Day of Period) A (Monday through Friday) B (Monday through Saturday) C (Monday through Sunday) D (Monday) E (Tuesday) F (Wednesday) G (Thursday) H (Friday) J (Saturday) K (Sunday) L (Monday through Thursday) M (Immediately) N (As Directed) O (Daily Mon. through Fri.) P (1/2 Mon. & 1/2 Thurs.) Q (1/2 Tues. & 1/2 Thurs.) R (1/2 Wed. & 1/2 Fri.) S (Once Anytime Mon. through Fri.) SA (Sunday, Monday, Thursday, Friday, Saturday) SB (Tuesday through Saturday) SC (Sunday, Wednesday, Thursday, Friday, Saturday) SD (Monday, Wednesday, Thursday, Friday, Saturday) SG (Tuesday through Friday) SL (Monday, Tuesday and Thursday) SP (Monday, Tuesday and Friday) SX (Wednesday and Thursday) SY (Monday, Wednesday and Thursday) SZ (Tuesday, Thursday and Friday) T (1/2 Tue. & 1/2 Fri.) U (1/2 Mon. & 1/2 Wed.) V (1/3 Mon., 1/3 Wed., 1/3 Fri.) W (Whenever Necessary) X (1/2 By Wed., Bal. By Fri.) Y (None) | S 1/2 |
| deliveryPatternTimeCode | HSD08 | 2000F | A (1st Shift (Normal Working Hours)) B (2nd Shift) C (3rd Shift) D (A.M.) E (P.M.) F (As Directed) G (Any Shift) Y (None) | S 1/1 |
| attachments (Array of objects) | - | - | ||
| serviceProviderName (Array of objects) | - | - |
Patient Event Service Level Provider Name (Request)
| Name | Element | Loop | Description | Constraints |
|---|---|---|---|---|
| serviceProviderName (Object) | - | - | ||
| entityIdentifierCode | NM101 | 2010F | 1T (Physician, Clinic or Group Practice) 72 (Operating Physician) 73 (Other Physician) 77 (Service Location) DD (Assistant Surgeon) DK (Ordering Physician) DQ (Supervising Physician) FA (Facility) G3 (Clinic) P3 (Primary Care Provider) QB (Purchase Service Provider) QV (Group Practice) SJ (Service Provider) | R 2/3 |
| organizationName | NM103 | 2010F | NM102=2 | S 1/60 |
| lastName | NM103 | 2010F | S 1/60 | |
| firstName | NM104 | 2010F | NM102=1 | S 1/35 |
| middleName | NM105 | 2010F | S 1/25 | |
| namePrefix | NM106 | 2010F | S 1/10 | |
| nameSuffix | NM107 | 2010F | S 1/10 | |
| identificationCodeQualifier | NM108 | 2010F | 24 (Employer’s Identification Number) 34 (Social Security Number) 46 (Electronic Transmitter Identification Number (ETIN)) XX (Centers for Medicare and Medicaid Services National Provider Identifier (NPI)) | S 1/2 |
| identifier | NM109 | 2010F | S 2/80 | |
| address1 | N301 | 2010F | R 1/55 | |
| address2 | N302 | 2010F | S 1/55 | |
| city | N401 | 2010F | R 2/30 | |
| state | N402 | 2010F | S 2/2 | |
| postalCode | N403 | 2010F | S 3/15 | |
| countryCode | N404 | 2010F | S 2/3 | |
| countrySubDivisionCode | N407 | 2010F | S 1/3 | |
| contactName | PER02 | 2010F | PER01=IC | S 1/60 |
| contactElectronicMail | PER04 PER06 PER08 | 2010F | PER03=EM PER05=EM PER07=EM | S 1/256 |
| contactFacsimile | PER04 PER06 PER08 | 2010F | PER03=FX PER05=FX PER07=FX | S 1/256 |
| contactTelephone | PER04 PER06 PER08 | 2010F | PER03=TE PER05=TE PER07=TE | S 1/256 |
| providerCode | PRV01 | 2010F | PRV02=PXC AS (Assistant Surgeon) OP (Operating) OR (Ordering) OT (Other Physician) PC (Primary Care Physician) PE (Performing) | R 1/3 |
| providerTaxonomyCode | PRV03 | 2010F | R 1/50 | |
| providerSupplementalInformation (Object) | - | - | ||
| stateLicenseNumber | REF02 | 2010F | REF01=0B | R 1/50 |
| licenseNumberStateCode | REF03 | 2010F | Required if StateLicenseNumber is entered | S 1/80 |
| providerUpinNumber | REF02 | 2010F | REF01=1G | R 1/50 |
| facilityIdNumber | REF02 | 2010F | REF01=1J | R 1/50 |
| employersIdentificationNumber | REF02 | 2010F | REF01=EI | R 1/50 |
| providerPlanNetworkIdentificationNumber | REF02 | 2010F | REF01=N5 | R 1/50 |
| facilityNetworkIdentificationNumber | REF02 | 2010F | REF01=N7 | R 1/50 |
| ssn | REF02 | 2010F | REF01=SY | R 1/50 |
| carrierAssignedReferenceNumber | REF02 | 2010F | REF01=ZH | R 1/50 |
Submission 278 Response
Identification Header (Response)
| Name | Element | Loop | Description | Constraints |
|---|---|---|---|---|
| submitterTransactionIdentifier | BHT03 | N/A | R 1/50 | |
| payerId | NM109 | 2010A | R 2/80 | |
| payerName | NM103 | 2010A | S 1/60 | |
| umClearingHouseId | GS03 | N/A | R 2/15 | |
| contactName | PER02 | 2010A | S 1/60 | |
| contactElectronicMail | PER04 PER06 PER08 | 2010A | PER03=EM PER05=EM PER07=EM | S 1/256 |
| contactFacsimile | PER04 PER06 PER08 | 2010A | PER03=FX PER05=FX PER07=FX | S 1/256 |
| contactTelephone | PER04 PER06 PER08 | 2010A | PER03=TE PER05=TE PER07=TE | S 1/256 |
| contactTelephoneExtension | PER06 PER08 | 2010A | PER05=EX PER07=EX | S 1/256 |
| contactUrl | PER04 PER06 PER08 | 2010A | PER03=UM PER05=UM PER07=UM | S 1/256 |
| requestValidation (Array of objects) | - | - | ||
| umRequestValidation (Array of objects) | - | - |
Request Validation (Response)
| Name | Element | Loop | Description | Constraints |
|---|---|---|---|---|
| responseCode | AAA01 | 2000A | N (No) Y (Yes) | R 1/1 |
| rejectReasonCode | AAA03 | 2000A | R 2/2 | |
| followupActionCode | AAA04 | 2000A | R 1/1 |
UM Request Validation (Response)
| Name | Element | Loop | Description | Constraints |
|---|---|---|---|---|
| responseCode | AAA01 | 2010A | N (No) Y (Yes) | R 1/1 |
| rejectReasonCode | AAA03 | 2010A | R 2/2 | |
| followupActionCode | AAA04 | 2010A | R 1/1 |
Requester (Response)
| Name | Element | Loop | Description | Constraints |
|---|---|---|---|---|
| requesterType | NM101 | 2010B | Default 1P 1P (Provider) FA (Facility) | R 2/3 |
| organizationName | NM103 | 2010B | NM102=2 | S 1/60 |
| lastName | NM103 | 2010B | NM102=1 | S 1/60 |
| firstName | NM104 | 2010B | NM102=1 | S 1/35 |
| npi | NM109 | 2010B | NM108=XX | R 2/80 |
| ssn | NM109 | 2010B | NM108=34 | R 2/80 |
| employersId | NM109 | 2010B | NM108=24 | R 2/80 |
| etin | NM109 | 2010B | NM108=46 | R 2/80 |
| providerCode | PRV01 | 2010B | PRV02=PXC AD (Admitting) AS (Assistant Surgeon) AT (Attending) CO (Consulting) CV (Covering) OP (Operating) OR (Ordering) OT (Other Physician) PC (Primary Care Physician) PE (Performing) RF (Referring) | R 1/3 |
| referenceIdentification | PRV03 | 2010B | S 1/50 | |
| requesterIdentification (Object) | - | - | ||
| providerUpinNumber | REF02 | 2010B | REF01=1G | R 1/50 |
| facilityIdNumber | REF02 | 2010B | REF01=1J | R 1/50 |
| employerIdentificationNumber | REF02 | 2010B | REF01=EI | R 1/50 |
| providerSiteNumber | REF02 | 2010B | REF01=G5 | R 1/50 |
| providerPlanNetworkIdNumber | REF02 | 2010B | REF01=N5 | R 1/50 |
| facilityNetworkIdNumber | REF02 | 2010B | REF01=N7 | R 1/50 |
| socialSecurityNumber | REF02 | 2010B | REF01=SY | R 1/50 |
| carrierAssignedReferenceNumber | REF02 | 2010B | REF01=ZH | R 1/50 |
| requesterRequestValidation (Array of objects) | - | - | ||
| responseCode | AAA01 | 2010B | N (No) Y (Yes) | R 1/1 |
| rejectReasonCode | AAA03 | 2010B | R 2/2 | |
| followupActionCode | AAA04 | 2010B | R 1/1 |
Subscriber (Response)
| Name | Element | Loop | Description | Constraints |
|---|---|---|---|---|
| lastName | NM103 | 2010C | NM101=IL NM102=1 | S 1/60 |
| firstName | NM104 | 2010C | S 1/35 | |
| middleName | NM105 | 2010C | S 1/25 | |
| prefix | NM106 | 2010C | S 1/10 | |
| suffix | NM107 | 2010C | S 1/10 | |
| memberId | NM109 | 2010C | NM108=MI | R 2/80 |
| dateOfBirth | DMG02 | 2010C | DMG01=D8 YYYYMMDD | R 1/35 |
| genderCode | DMG03 | 2010C | F (Female) M (Male) U (Unknown) | S 1/1 |
| address1 | N301 | 2010C | R 1/55 | |
| address2 | N302 | 2010C | S 1/55 | |
| city | N401 | 2010C | R 2/30 | |
| state | N402 | 2010C | S 2/2 | |
| postalCode | N403 | 2010C | S 3/15 | |
| countryCode | N404 | 2010C | S 2/3 | |
| countrySubDivisionCode | N407 | 2010C | S 1/3 | |
| insuredIndicator | INS01 | 2010C | Y (Yes) N (No) | R 1/1 |
| militaryRelationship | INS08 | 2010C | AO (Active Military - Overseas) AU (Active Military - USA) DI (Deceased) PV (Previous) RU (Retired Military - USA) | R 2/2 |
| supplementalIdentification (Object) | - | - | ||
| policyNumber | REF02 | 2010C | REF01=1L | R 1/50 |
| branchIdentifier | REF02 | 2010C | REF01=3L | R 1/50 |
| groupNumber | REF02 | 2010C | REF01=6P | R 1/50 |
| departmentNumber | REF02 | 2010C | REF01=DP | R 1/50 |
| patientAccountNumber | REF02 | 2010C | REF01=EJ | R 1/50 |
| healthInsuranceClaimNumber | REF02 | 2010C | REF01=F6 | R 1/50 |
| idCard | REF02 | 2010C | REF01=HJ | R 1/50 |
| insurancePolicyNumber | REF02 | 2010C | REF01=IG | R 1/50 |
| planNetworkIdentificationNumber | REF02 | 2010C | REF01=N6 | R 1/50 |
| medicaidRecipientIdentificationNumber | REF02 | 2010C | REF01=NQ | R 1/50 |
| ssn | REF02 | 2010C | REF01=SY | R 1/50 |
| subscriberRequestValidation (Array of objects) | - | - | ||
| responseCode | AAA01 | 2010C | N (No) Y (Yes) | R 1/1 |
| rejectReasonCode | AAA03 | 2010C | R 2/2 | |
| followupActionCode | AAA04 | 2010C | R 1/1 |
Dependent (Response)
| Name | Element | Loop | Description | Constraints |
|---|---|---|---|---|
| lastName | NM103 | 2010D | NM101=QC NM102=1 | S 1/60 |
| firstName | NM104 | 2010D | S 1/35 | |
| middleName | NM105 | 2010D | S 1/25 | |
| suffix | NM107 | 2010D | S 1/10 | |
| memberId | NM109 | 2010D | NM108=MI | S 2/80 |
| dateOfBirth | DMG02 | 2010D | DMG01=D8 YYYYMMDD | R 1/35 |
| genderCode | DMG03 | 2010D | F (Female) M (Male) U (Unknown) | S 1/1 |
| address1 | N301 | 2010D | R 1/55 | |
| address2 | N302 | 2010D | S 1/55 | |
| city | N401 | 2010D | R 2/30 | |
| state | N402 | 2010D | S 2/2 | |
| postalCode | N403 | 2010D | S 3/15 | |
| countryCode | N404 | 2010D | S 2/3 | |
| countrySubDivisionCode | N407 | 2010D | S 1/3 | |
| insuredIndicator | INS01 | 2010D | Y (Yes) N (No) | R 1/1 |
| relationshipToInsuredCode | INS02 | 2010D | 01 (Spouse) 19 (Child) G8 (Other Relationship) | R 2/2 |
| birthSequenceNumber | INS17 | 2010D | Y (Yes) N (No) | S 1/9 |
| supplementalIdentification (Object) | - | - | ||
| patientAccountNumber | REF02 | 2010D | REF01=EJ | R 1/50 |
| ssn | REF02 | 2010D | REF01=SY | R 1/50 |
| dependentRequestValidation (Array of objects) | - | - | ||
| responseCode | AAA01 | 2010D | N (No) Y (Yes) | R 1/1 |
| rejectReasonCode | AAA03 | 2010D | R 2/2 | |
| followupActionCode | AAA04 | 2010D | R 1/1 |
Patient Event Detail (Response)
| Name | Element | Loop | Description | Constraints |
|---|---|---|---|---|
| requestCategoryCode | UM01 | 2000E | AR (Admission Review) HS (Health Services Review) IN (Individual) SC (Specialty Care Review) | R 1/2 |
| certificationTypeCode | UM02 | 2000E | 1 (Appeal - Immediate) 2 (Appeal - Standard) 3 (Cancel) 4 (Extension) I (Initial) N (Reconsideration) R (Renewal) S (Revised) | R 1/1 |
| serviceTypeCode | UM03 | 2000E | 1 (Medical Care) 2 (Surgical) 3 (Consultation) 4 (Diagnostic X-Ray) 5 (Diagnostic Lab) 6 (Radiation Therapy) 7 (Anesthesia) 8 (Surgical Assistance) 11 (Used Durable Medical Equipment) 12 (Durable Medical Equipment Purchase) 14 (Renal Supplies in the Home) 15 (Alternate Method Dialysis) 16 (Chronic Renal Disease (CRD) Equipment) 17 (Pre-Admission Testing) 18 (Durable Medical Equipment Rental) 20 (Second Surgical Opinion) 21 (Third Surgical Opinion) 23 (Diagnostic Dental) 24 (Periodontics) 25 (Restorative) 26 (Endodontics) 27 (Maxillofacial Prosthetics) 28 (Adjunctive Dental Services) 33 (Chiropractic) 35 (Dental Care) 36 (Dental Crowns) 37 (Dental Accident) 38 (Orthodontics) 39 (Prosthodontics) 40 (Oral Surgery) 42 (Home Health Care) 44 (Home Health Visits) 45 (Hospice) 46 (Respite Care) 54 (Long Term Care) 56 (Medically Related Transportation) 61 (In-vitro Fertilization) 62 (MRI/CAT Scan) 63 (Donor Procedures) 64 (Acupuncture) 65 (Newborn Care) 66 (Pathology) 67 (Smoking Cessation) 68 (Well Baby Care) 69 (Maternity) 70 (Transplants) 71 (Audiology Exam) 72 (Inhalation Therapy) 73 (Diagnostic Medical) 74 (Private Duty Nursing) 75 (Prosthetic Device) 76 (Dialysis) 77 (Otological Exam) 78 (Chemotherapy) 79 (Allergy Testing) 80 (Immunizations) 82 (Family Planning) 83 (Infertility) 84 (Abortion) 85 (AIDS) 86 (Emergency Services) 87 (Cancer) 88 (Pharmacy) 93 (Podiatry) A4 (Psychiatric) A6 (Psychotherapy) A9 (Rehabilitation) AD (Occupational Therapy) AE (Physical Medicine) AF (Speech Therapy) AG (Skilled Nursing Care) AH (Skilled Nursing Care - Room and Board) AI (Substance Abuse) AJ (Alcoholism) AK (Drug Addiction) AL (Vision (Optometry)) AR (Experimental Drug Therapy) B1 (Burn Care) BB (Partial Hospitalization (Psychiatric)) BC (Day Care (Psychiatric)) BD (Cognitive Therapy) BE (Massage Therapy) BF (Pulmonary Rehabilitation) BG (Cardiac Rehabilitation) BL (Cardiac) BN (Gastrointestinal) BP (Endocrine) BQ (Neurology) BS (Invasive Procedures) BY (Physician Visit - Office: Sick) BZ (Physician Visit - Office: Well) C1 (Coronary Care) CQ (Case Management) GY (Allergy) IC (Intensive Care) MH (Mental Health) NI (Neonatal Intensive Care) ON (Oncology) PT (Physical Therapy) PU (Pulmonary) RN (Renal) RT (Residential Psychiatric Treatment) TC (Transitional Care) TN (Transitional Nursery Care) | S 1/2 |
| facilityTypeCode | UM04_1 | 2000E | R 1/2 | |
| facilityCodeQualifier | UM04_2 | 2000E | A (Uniform Billing Claim Form Bill Type) B (Place of Service Codes for Professional or Dental Services) | R 1/2 |
| levelOfServiceCode | UM06 | 2000E | 03 (Emergency) E (Elective) U (Urgent) | S 1/3 |
| certificationActionCode | HCR01 | 2000E | A1 (Certified in total) A2 (Certified - partial) A3 (Not Certified) A4 (Pended) A6 (Modified) C (Canceled) CT (Contact Payer) NA (No Action Required) | R 1/2 |
| reviewIdentificationNumber | HCR02 | 2000E | S 1/50 | |
| reviewDecisionReasonCode | HCR03 | 2000E | S 1/30 | |
| secondSurgicalOpinionIndicator | HCR04 | 2000E | S 1/1 | |
| administrativeReferenceNumber | REF02 | 2000E | REF01=NT | R 1/50 |
| previousReviewAuthorizationNumber | REF02 | 2000E | REF01=BB | R 1/50 |
| accidentDate | DTP03 | 2000E | DTP01=439 DTP02=D8 YYYYMMDD | R 1/35 |
| lastMenstrualPeriodDate | DTP03 | 2000E | DTP01=484 DTP02=D8 YYYYMMDD | R 1/35 |
| estimatedDateOfBirth | DTP03 | 2000E | DTP01=ABC DTP02=D8 YYYYMMDD | R 1/35 |
| onsetOfCurrentSymptomsOrIllnessDate | DTP03 | 2000E | DTP01=431 DTP02=D8 YYYYMMDD | R 1/35 |
| eventDateBegin | DTP03 | 2000E | DTP01=AAH DTP02=D8 YYYYMMDD | R 1/35 |
| eventDateEnd | DTP03 | 2000E | DTP01=AAH DTP02=RD8 YYYYMMDD EventDateBegin must exist | R 1/35 |
| admissionDateBegin | DTP03 | 2000E | DTP01=435 DTP02=D8 YYYYMMDD | R 1/35 |
| admissionDateEnd | DTP03 | 2000E | DTP01=435 DTP02=RD8 YYYYMMDD AdmissionDateBegin must exist | R 1/35 |
| dischargeDate | DTP03 | 2000E | DTP01=096 DTP02=D8 YYYYMMDD | R 1/35 |
| certificationIssueDate | DTP03 | 2000E | DTP01=102 DTP02=D8 YYYYMMDD | R 1/35 |
| certificationExpirationDate | DTP03 | 2000E | DTP01=036 DTP02=D8 YYYYMMDD | R 1/35 |
| certificationEffectiveDateBegin | DTP03 | 2000E | DTP01=007 DTP02=D8 YYYYMMDD | R 1/35 |
| certificationEffectiveDateEnd | DTP03 | 2000E | DTP01=007 DTP02=RD8 YYYYMMDD CertificationEffectiveDateBegin must exist | R 1/35 |
| diagnosisTypeCode1 | HI01_1 | 2000E | ABF (Diagnosis) ABJ (Admitting Diagnosis) ABK (Principal Diagnosis) APR (Patient’s Reason for Visit) DR (Diagnosis Related Group (DRG)) | R 1/3 |
| DiagnosisCode1 | HI01_2 | 2000E | R 1/30 | |
| DiagnosisDate1 | HI01_4 | 2000E | HI01_3=D8 YYYYMMDD | S 1/35 |
| diagnosisTypeCode2 | HI02_1 | 2000E | ABF (Diagnosis) ABJ (Admitting Diagnosis) APR (Patient’s Reason for Visit) DR (Diagnosis Related Group (DRG)) | R 1/3 |
| DiagnosisCode2 | HI02_2 | 2000E | R 1/30 | |
| DiagnosisDate2 | HI02_4 | 2000E | HI02_3=D8 YYYYMMDD | S 1/35 |
| diagnosisTypeCode3 | HI03_1 | 2000E | ABF (Diagnosis) APR (Patient’s Reason for Visit) DR (Diagnosis Related Group (DRG)) | R 1/3 |
| DiagnosisCode3 | HI03_2 | 2000E | R 1/30 | |
| DiagnosisDate3 | HI03_4 | 2000E | HI03_3=D8 YYYYMMDD | S 1/35 |
| diagnosisTypeCode4 | HI04_1 | 2000E | ABF (Diagnosis) APR (Patient’s Reason for Visit) DR (Diagnosis Related Group (DRG)) | R 1/3 |
| DiagnosisCode4 | HI04_2 | 2000E | R 1/30 | |
| DiagnosisDate4 | HI04_4 | 2000E | HI04_3=D8 YYYYMMDD | S 1/35 |
| diagnosisTypeCode5 | HI05_1 | 2000E | ABF (Diagnosis) APR (Patient’s Reason for Visit) DR (Diagnosis Related Group (DRG)) | R 1/3 |
| DiagnosisCode5 | HI05_2 | 2000E | R 1/30 | |
| DiagnosisDate5 | HI05_4 | 2000E | HI05_3=D8 YYYYMMDD | S 1/35 |
| diagnosisTypeCode6 | HI06_1 | 2000E | ABF (Diagnosis) APR (Patient’s Reason for Visit) DR (Diagnosis Related Group (DRG)) | R 1/3 |
| DiagnosisCode6 | HI06_2 | 2000E | R 1/30 | |
| DiagnosisDate6 | HI06_4 | 2000E | HI06_3=D8 YYYYMMDD | S 1/35 |
| diagnosisTypeCode7 | HI07_1 | 2000E | ABF (Diagnosis) APR (Patient’s Reason for Visit) DR (Diagnosis Related Group (DRG)) | R 1/3 |
| DiagnosisCode7 | HI07_2 | 2000E | R 1/30 | |
| DiagnosisDate7 | HI07_4 | 2000E | HI07_3=D8 YYYYMMDD | S 1/35 |
| diagnosisTypeCode8 | HI08_1 | 2000E | ABF (Diagnosis) APR (Patient’s Reason for Visit) DR (Diagnosis Related Group (DRG)) | R 1/3 |
| DiagnosisCode8 | HI08_2 | 2000E | R 1/30 | |
| DiagnosisDate8 | HI08_4 | 2000E | HI08_3=D8 YYYYMMDD | S 1/35 |
| diagnosisTypeCode9 | HI09_1 | 2000E | ABF (Diagnosis) APR (Patient’s Reason for Visit) DR (Diagnosis Related Group (DRG)) | R 1/3 |
| DiagnosisCode9 | HI09_2 | 2000E | R 1/30 | |
| DiagnosisDate9 | HI09_4 | 2000E | HI09_3=D8 YYYYMMDD | S 1/35 |
| diagnosisTypeCode10 | HI010_1 | 2000E | ABF (Diagnosis) APR (Patient’s Reason for Visit) DR (Diagnosis Related Group (DRG)) | R 1/3 |
| DiagnosisCode10 | HI010_2 | 2000E | R 1/30 | |
| DiagnosisDate10 | HI010_4 | 2000E | HI010_3=D8 YYYYMMDD | S 1/35 |
| diagnosisTypeCode11 | HI011_1 | 2000E | ABF (Diagnosis) APR (Patient’s Reason for Visit) DR (Diagnosis Related Group (DRG)) | R 1/3 |
| DiagnosisCode11 | HI011_2 | 2000E | R 1/30 | |
| DiagnosisDate11 | HI011_4 | 2000E | HI011_3=D8 YYYYMMDD | S 1/35 |
| diagnosisTypeCode12 | HI012_1 | 2000E | ABF (Diagnosis) APR (Patient’s Reason for Visit) DR (Diagnosis Related Group (DRG)) | R 1/3 |
| DiagnosisCode12 | HI012_2 | 2000E | R 1/30 | |
| DiagnosisDate12 | HI012_4 | 2000E | HI012_3=D8 YYYYMMDD | S 1/35 |
| quantityQualifier | HSD01 | 2000E | DY (Days) FL (Units) HS (Hours) MN (Month) VS (Visits) | S 2/2 |
| serviceUnitCount | HSD02 | 2000E | S 1/15 | |
| unitOrBasisForMeasurementCode | HSD03 | 2000E | DA (Days) MO (Months) WK (Week) | S 2/2 |
| sampleSelectionModulus | HSD04 | 2000E | S 1/6 | |
| timePeriodQualifier | HSD05 | 2000E | 6 (Hour) 7 (Day) 21 (Years) 26 (Episode) 27 (Visit) 29 (Remaining) 34 (Month) 35 (Week) | S 1/2 |
| periodCount | HSD06 | 2000E | S 1/3 | |
| deliveryFrequencyCode | HSD07 | 2000E | 1 (1st Week of the Month) 2 (2nd Week of the Month) 3 (3rd Week of the Month) 4 (4th Week of the Month) 5 (5th Week of the Month) 6 (1st & 3rd Weeks of the Month) 7 (2nd & 4th Weeks of the Month) 8 (1st Working Day of Period) 9 (Last Working Day of Period) A (Monday through Friday) B (Monday through Saturday) C (Monday through Sunday) D (Monday) E (Tuesday) F (Wednesday) G (Thursday) H (Friday) J (Saturday) K (Sunday) L (Monday through Thursday) M (Immediately) N (As Directed) O (Daily Mon. through Fri.) P (1/2 Mon. & 1/2 Thurs.) Q (1/2 Tues. & 1/2 Thurs.) R (1/2 Wed. & 1/2 Fri.) S (Once Anytime Mon. through Fri.) SA (Sunday, Monday, Thursday, Friday, Saturday) SB (Tuesday through Saturday) SC (Sunday, Wednesday, Thursday, Friday, Saturday) SD (Monday, Wednesday, Thursday, Friday, Saturday) SG (Tuesday through Friday) SL (Monday, Tuesday and Thursday) SP (Monday, Tuesday and Friday) SX (Wednesday and Thursday) SY (Monday, Wednesday and Thursday) SZ (Tuesday, Thursday and Friday) T (1/2 Tue. & 1/2 Fri.) U (1/2 Mon. & 1/2 Wed.) V (1/3 Mon., 1/3 Wed., 1/3 Fri.) W (Whenever Necessary) WE (Weekend) X (1/2 By Wed., Bal. By Fri.) Y (None) | S 1/2 |
| deliveryPatternTimeCode | HSD08 | 2000E | A (1st Shift (Normal Working Hours)) B (2nd Shift) C (3rd Shift) D (A.M.) E (P.M.) F (As Directed) G (Any Shift) Y (None) | S 1/1 |
| institutionalAdmissionTypeCode | CL101 | 2000E | S 1/1 | |
| institutionalAdmissionSourceCode | CL102 | 2000E | S 1/1 | |
| institutionalPatientStatusCode | CL103 | 2000E | S 1/2 | |
| ambulanceTransportCode | CR103 | 2000E | I (Initial Trip) R (Return Trip) T (Transfer Trip) X (Round Trip) | R 1/1 |
| ambulanceUnitOrBasisForMeasurementCode | CR105 | 2000E | DH (Miles) DK (Kilometers) | S 2/2 |
| ambulanceTransportDistance | CR106 | 2000E | S 1/15 | |
| spinalManipulationTreatmentSeriesNumber | CR201 | 2000E | S 1/9 | |
| spinalManipulationTreatmentCount | CR202 | 2000E | S 1/15 | |
| spinalManipulationSubluxationLevelCode | CR203 | 2000E | C1 (Cervical 1) C2 (Cervical 2) C3 (Cervical 3) C4 (Cervical 4) C5 (Cervical 5) C6 (Cervical 6) C7 (Cervical 7) CO (Coccyx) IL (Ilium) L1 (Lumbar 1) L2 (Lumbar 2) L3 (Lumbar 3) L4 (Lumbar 4) L5 (Lumbar 5) OC (Occiput) SA (Sacrum) T1 (Thoracic 1) T10 (Thoracic 10) T11 (Thoracic 11) T12 (Thoracic 12) T2 (Thoracic 2) T3 (Thoracic 3) T4 (Thoracic 4) T5 (Thoracic 5) T6 (Thoracic 6) T7 (Thoracic 7) T8 (Thoracic 8) T9 (Thoracic 9) | S 2/3 |
| spinalManipulationSubluxationLevelCode2 | CR204 | 2000E | Use codes listed in CR203 | S 2/3 |
| oxygenEquipmentTypeCode | CR503 | 2000E | A (Concentrator) B (Liquid Stationary) C (Gaseous Stationary) D (Liquid Portable) E (Gaseous Portable) O (Other) | S 1/1 |
| oxygenEquipmentTypeCode2 | CR504 | 2000E | Use codes listed in CR503 | S 1/1 |
| oxygenFlowRate | CR506 | 2000E | R 1/15 | |
| dailyOxygenUseCount | CR507 | 2000E | S 1/15 | |
| oxygenUsePeriodHourCount | CR508 | 2000E | S 1/15 | |
| respiratoryTherapistOrderText | CR509 | 2000E | S 1/80 | |
| portableOxygenSystemFlowRate | CR516 | 2000E | S 1/15 | |
| oxygenDeliverySystemCode | CR517 | 2000E | A (Nasal Cannula) B (Oxygen Conserving Device) C (Oxygen Conserving Device with Oxygen Pulse System) D (Oxygen Conserving Device with Reservoir System) E (Transtracheal Catheter | R 1/1 |
| oxygenSystemTypeCode | CR518 | 2000E | A (Concentrator) B (Liquid Stationary) C (Gaseous Stationary) D (Liquid Portable) E (Gaseous Portable) O (Other) | S 1/1 |
| homeHealthPrognosisCode | CR601 | 2000E | 1 (Poor) 2 (Guarded) 3 (Fair) 4 (Good) 5 (Very Good) 6 (Excellent) 7 (Less than) 6 (Months to Live) 8 (Terminal) | R 1/1 |
| homeHealthStartDate | CR602 | 2000E | R 8/8 | |
| homeHealthCertificationPeriodStartDate | CR604 | 2000E | S 1/35 | |
| homeHealthCertificationPeriodEndDate | CR604 | 2000E | CR603=RD8 | S 1/35 |
| homeHealthMedicareCoverageIndicator | CR607 | 2000E | R 1/1 | |
| homeHealthCertificationTypeCode | CR608 | 2000E | 1 (Appeal - Immediate) 2 (Appeal - Standard) 3 (Cancel) 4 (Extension) 5 (Notification) 6 (Verification) I (Initial) R (Renewal) S (Revised) | R 1/1 |
| freeFormMessageText | MSG01 | 2000E | R 1/264 | |
| patientEventRequestValidation (Array of objects) | - | - | ||
| responseCode | AAA01 | 2000E | N (No) Y (Yes) | R 1/1 |
| rejectReasonCode | AAA03 | 2000E | R 2/2 | |
| followupActionCode | AAA04 | 2000E | R 1/1 | |
| attachments (Array of objects) | - | - | Can repeat up to 10 times | |
| patientEventProviderName (Array of objects) | - | - | ||
| patientEventAdditionalPatientInformationContactName (Array of objects) | - | - | ||
| patientEventTransportInformation (Array of objects) | - | - | ||
| serviceLevel (Array of objects) | - | - |
Patient Event Provider Name (Response)
| Name | Element | Loop | Description | Constraints |
|---|---|---|---|---|
| entityIdentifierCode | NM101 | 2010EA | 71 (Attending Physician) 72 (Operating Physician) 73 (Other Physician) 77 (Service Location) AAJ (Admitting Services) DD (Assistant Surgeon) DK (Ordering Physician) DN (Referring Provider) FA (Facility) G3 (Clinic) P3 (Primary Care Provider) QB (Purchase Service Provider) QV (Group Practice) SJ (Service Provider) | R 2/3 |
| organizationName | NM103 | 2010EA | NM102=2 | S 1/60 |
| lastName | NM103 | 2010EA | NM102=1 | S 1/60 |
| firstName | NM104 | 2010EA | NM102=1 | S 1/35 |
| middleName | NM105 | 2010EA | S 1/25 | |
| namePrefix | NM106 | 2010EA | S 1/10 | |
| nameSuffix | NM107 | 2010EA | S 1/10 | |
| identificationCodeQualifier | NM108 | 2010EA | 24 (Employer’s Identification Number) 34 (Social Security Number) 46 (Electronic Transmitter Identification Number (ETIN)) XX (Centers for Medicare and Medicaid Services National Provider Identifier (NPI)) | S 1/2 |
| identifier | NM109 | 2010EA | S 2/80 | |
| address1 | N301 | 2010EA | R 1/55 | |
| address2 | N302 | 2010EA | S 1/55 | |
| city | N401 | 2010EA | R 2/30 | |
| state | N402 | 2010EA | S 2/2 | |
| postalCode | N403 | 2010EA | S 3/15 | |
| countryCode | N404 | 2010EA | S 2/3 | |
| countrySubDivisionCode | N407 | 2010EA | S 1/3 | |
| contactName | PER02 | 2010EA | S 1/60 | |
| contactElectronicMail | PER04 PER06 PER08 | 2010EA | PER03=EM PER05=EM PER07=EM | S 1/256 |
| contactFacsimile | PER04 PER06 PER08 | 2010EA | PER03=FX PER05=FX PER07=FX | S 1/256 |
| contactTelephone | PER04 PER06 PER08 | 2010EA | PER03=TE PER05=TE PER07=TE | S 1/256 |
| contactUrl | PER04 PER06 PER08 | 2010EA | PER03=UM PER05=UM PER07=UM | S 1/256 |
| providerCode | PRV01 | 2010EA | PRV02=PXC AD (Admitting) AS (Assistant Surgeon) AT (Attending) OP (Operating) OR (Ordering) OT (Other Physician) PC (Primary Care Physician) PE (Performing) RF (Referring) | R 1/3 |
| providerTaxonomyCode | PRV03 | 2010EA | R 1/50 | |
| providerSupplementalInformation (Object) | - | - | ||
| stateLicenseNumber | REF02 | 2010EA | REF01=0B | R 1/50 |
| licenseNumberStateCode | REF03 | 2010EA | Required if StateLicenseNumber is entered | S 1/80 |
| providerUpinNumber | REF02 | 2010EA | REF01=1G | R 1/50 |
| facilityIdNumber | REF02 | 2010EA | REF01=1J | R 1/50 |
| employersIdentificationNumber | REF02 | 2010EA | REF01=EI | R 1/50 |
| providerPlanNetworkIdentificationNumber | REF02 | 2010EA | REF01=N5 | R 1/50 |
| facilityNetworkIdentificationNumber | REF02 | 2010EA | REF01=N7 | R 1/50 |
| ssn | REF02 | 2010EA | REF01=SY | R 1/50 |
| carrierAssignedReferenceNumber | REF02 | 2010EA | REF01=ZH | R 1/50 |
| patientEventProviderRequestValidation (Array of objects) | - | - | ||
| responseCode | AAA01 | 2000EA | R 1/1 | |
| rejectReasonCode | AAA03 | 2000EA | R 2/2 | |
| followupActionCode | AAA04 | 2000EA | R 1/1 |
Patient Event Additional Patient Information Contact Name (Response)
| Name | Element | Loop | Description | Constraints |
|---|---|---|---|---|
| organizationName | NM103 | 2010EB | NM102=2 NM101=L5 | S 1/60 |
| lastName | NM103 | 2010EB | S 1/60 | |
| firstName | NM104 | 2010EB | NM102=1 NM101=L5 | S 1/35 |
| middleName | NM105 | 2010EB | S 1/25 | |
| nameSuffix | NM107 | 2010EB | S 1/10 | |
| identificationCodeQualifier | NM108 | 2010EB | 24 (Employer’s Identification Number) 34 (Social Security Number) 46 (Electronic Transmitter Identification Number (ETIN)) PI (Payor Identification) XV (Centers for Medicare and Medicaid Services PlanID) XX (Centers for Medicare and Medicaid Services National Provider Identifier (NPI)) | S 1/2 |
| identifier | NM109 | 2010EB | S 2/80 | |
| address1 | N301 | 2010EB | R 1/55 | |
| address2 | N302 | 2010EB | S 1/55 | |
| city | N401 | 2010EB | R 2/30 | |
| state | N402 | 2010EB | S 2/2 | |
| postalCode | N403 | 2010EB | S 3/15 | |
| countryCode | N404 | 2010EB | S 2/3 | |
| countrySubDivisionCode | N407 | 2010EB | S 1/3 | |
| contactName | PER02 | 2010EB | S 1/60 | |
| contactElectronicMail | PER04 PER06 PER08 | 2010EB | PER03=EM PER05=EM PER07=EM | S 1/256 |
| contactFacsimile | PER04 PER06 PER08 | 2010EB | PER03=FX PER05=FX PER07=FX | S 1/256 |
| contactTelephone | PER04 PER06 PER08 | 2010EB | PER03=TE PER05=TE PER07=TE | S 1/256 |
| contactUrl | PER04 PER06 PER08 | 2010EB | PER03=UR PER05=UR PER07=UR | S 1/256 |
Patient Event Transport Information (Response)
| Name | Element | Loop | Description | Constraints |
|---|---|---|---|---|
| entityIdentifierCode | NM101 | 2010EC | 45 (Drop-off Location) FS (Final Scheduled Destination) ND (Next Destination) PW (Pickup Address) R3 (Next Scheduled Destination) | R 2/3 |
| transportLocationName | NM103 | 2010EC | NM102=2 | R 1/60 |
| address1 | N301 | 2010EC | R 1/55 | |
| address2 | N302 | 2010EC | S 1/55 | |
| city | N401 | 2010EC | S 2/30 | |
| state | N402 | 2010EC | S 2/2 | |
| postalCode | N403 | 2010EC | S 3/15 | |
| patientEventTransportInformationValidation (Array of objects) | - | - | ||
| responseCode | AAA01 | 2000EC | N (No) Y (Yes) | R 1/1 |
| rejectReasonCode | AAA03 | 2000EC | R 2/2 | |
| followupActionCode | AAA04 | 2000EC | R 1/1 |
Patient Event Service Level (Response)
| Name | Element | Loop | Description | Constraints |
|---|---|---|---|---|
| requestCategoryCode | UM01 | 2000F | HS (Health Services Review) SC (Specialty Care Review) | R 1/2 |
| certificationTypeCode | UM02 | 2000F | 1 (Appeal - Immediate) 2 (Appeal - Standard) 3 (Cancel) 4 (Extension) I (Initial) N (Reconsideration) R (Renewal) S (Revised) | S 1/1 |
| serviceTypeCode | UM03 | 2000F | 1 (Medical Care) 2 (Surgical) 3 (Consultation) 4 (Diagnostic X-Ray) 5 (Diagnostic Lab) 6 (Radiation Therapy) 7 (Anesthesia) 8 (Surgical Assistance) 11 (Used Durable Medical Equipment) 12 (Durable Medical Equipment Purchase) 14 (Renal Supplies in the Home) 15 (Alternate Method Dialysis) 16 (Chronic Renal Disease (CRD) Equipment) 17 (Pre-Admission Testing) 18 (Durable Medical Equipment Rental) 20 (Second Surgical Opinion) 21 (Third Surgical Opinion) 23 (Diagnostic Dental) 24 (Periodontics) 25 (Restorative) 26 (Endodontics) 27 (Maxillofacial Prosthetics) 28 (Adjunctive Dental Services) 33 (Chiropractic) 35 (Dental Care) 36 (Dental Crowns) 37 (Dental Accident) 38 (Orthodontics) 39 (Prosthodontics) 40 (Oral Surgery) 42 (Home Health Care) 44 (Home Health Visits) 45 (Hospice) 46 (Respite Care) 54 (Long Term Care) 56 (Medically Related Transportation) 61 (In-vitro Fertilization) 62 (MRI/CAT Scan) 63 (Donor Procedures) 64 (Acupuncture) 65 (Newborn Care) 66 (Pathology) 67 (Smoking Cessation) 68 (Well Baby Care) 69 (Maternity) 70 (Transplants) 71 (Audiology Exam) 72 (Inhalation Therapy) 73 (Diagnostic Medical) 74 (Private Duty Nursing) 75 (Prosthetic Device) 76 (Dialysis) 77 (Otological Exam) 78 (Chemotherapy) 79 (Allergy Testing) 80 (Immunizations) 82 (Family Planning) 83 (Infertility) 84 (Abortion) 85 (AIDS) 86 (Emergency Services) 87 (Cancer) 88 (Pharmacy) 93 (Podiatry) A4 (Psychiatric) A6 (Psychotherapy) A9 (Rehabilitation) AD (Occupational Therapy) AE (Physical Medicine) AF (Speech Therapy) AG (Skilled Nursing Care) AI (Substance Abuse) AJ (Alcoholism) AK (Drug Addiction) AL (Vision (Optometry)) AR (Experimental Drug Therapy) B1 (Burn Care) BB (Partial Hospitalization (Psychiatric)) BC (Day Care (Psychiatric)) BD (Cognitive Therapy) BE (Massage Therapy) BF (Pulmonary Rehabilitation) BG (Cardiac Rehabilitation) BL (Cardiac) BN (Gastrointestinal) BP (Endocrine) BQ (Neurology) BS (Invasive Procedures) BY (Physician Visit - Office: Sick) BZ (Physician Visit - Office: Well) C1 (Coronary Care) GY (Allergy) IC (Intensive Care) MH (Mental Health) NI (Neonatal Intensive Care) ON (Oncology) PT (Physical Therapy) PU (Pulmonary) RN (Renal) RT (Residential Psychiatric Treatment) TC (Transitional Care) TN (Transitional Nursery Care) | S 1/2 |
| facilityTypeCode | UM04_1 | 2000F | R 1/2 | |
| facilityCodeQualifier | UM04_2 | 2000F | A (Uniform Billing Claim Form Bill Type) B (Place of Service Codes for Professional or Dental Services) | R 1/2 |
| certificationActionCode | HCR01 | 2000F | A1 (Certified in total) A3 (Not Certified) A4 (Pended) A6 (Modified) C (Canceled) CT (Contact Payer) NA (No Action Required) | R 1/2 |
| reviewIdentificationNumber | HCR02 | 2000F | S 1/50 | |
| reviewDecisionReasonCode | HCR03 | 2000F | S 1/30 | |
| secondSurgicalOpinionIndicator | HCR04 | 2000F | S 1/1 | |
| administrativeReferenceNumber | REF02 | 2000F | REF01=NT | R 1/50 |
| previousReviewAuthorizationNumber | REF02 | 2000F | REF01=BB | R 1/50 |
| serviceDateBegin | DTP03 | 2000F | DTP01=472 DTP02=D8 YYYYMMDD | R 1/35 |
| serviceDateEnd | DTP03 | 2000F | DTP01=472 DTP02=RD8 YYYYMMDD ServiceDateBegin must exist | R 1/35 |
| certificationIssueDate | DTP03 | 2000F | DTP01=102 DTP02=D8 YYYYMMDD | R 1/35 |
| certificationExpirationDate | DTP03 | 2000F | DTP01=036 DTP02=D8 YYYYMMDD | R 1/35 |
| certificationEffectiveDateBegin | DTP03 | 2000F | DTP01=007 DTP02=D8 YYYYMMDD | R 1/35 |
| certificationEffectiveDateEnd | DTP03 | 2000F | DTP01=007 DTP02=RD8 YYYYMMDD CertificationEffectiveDateBegin must exist | R 1/35 |
| quantityQualifier | HSD01 | 2000F | DY (Days) FL (Units) HS (Hours) MN (Month) VS (Visits) | S 2/2 |
| serviceUnitCount | HSD02 | 2000F | S 1/15 | |
| unitOrBasisForMeasurementCode | HSD03 | 2000F | DA (Days) MO (Months) WK (Week) | S 2/2 |
| sampleSelectionModulus | HSD04 | 2000F | S 1/6 | |
| timePeriodQualifier | HSD05 | 2000F | 6 (Hour) 7 (Day) 21 (Years) 26 (Episode) 27 (Visit) 29 (Remaining) 34 (Month) 35 (Week) | S 1/2 |
| periodCount | HSD06 | 2000F | S 1/3 | |
| deliveryFrequencyCode | HSD07 | 2000F | 1 (1st Week of the Month) 2 (2nd Week of the Month) 3 (3rd Week of the Month) 4 (4th Week of the Month) 5 (5th Week of the Month) 6 (1st & 3rd Weeks of the Month) 7 (2nd & 4th Weeks of the Month) 8 (1st Working Day of Period) 9 (Last Working Day of Period) A (Monday through Friday) B (Monday through Saturday) C (Monday through Sunday) D (Monday) E (Tuesday) F (Wednesday) G (Thursday) H (Friday) J (Saturday) K (Sunday) L (Monday through Thursday) M (Immediately) N (As Directed) O (Daily Mon. through Fri.) P (1/2 Mon. & 1/2 Thurs.) Q (1/2 Tues. & 1/2 Thurs.) R (1/2 Wed. & 1/2 Fri.) S (Once Anytime Mon. through Fri.) SA (Sunday, Monday, Thursday, Friday, Saturday) SB (Tuesday through Saturday) SC (Sunday, Wednesday, Thursday, Friday, Saturday) SD (Monday, Wednesday, Thursday, Friday, Saturday) SG (Tuesday through Friday) SL (Monday, Tuesday and Thursday) SP (Monday, Tuesday and Friday) SX (Wednesday and Thursday) SY (Monday, Wednesday and Thursday) SZ (Tuesday, Thursday and Friday) T (1/2 Tue. & 1/2 Fri.) U (1/2 Mon. & 1/2 Wed.) V (1/3 Mon., 1/3 Wed., 1/3 Fri.) W (Whenever Necessary) X (1/2 By Wed., Bal. By Fri.) Y (None) | S 1/2 |
| deliveryPatternTimeCode | HSD08 | 2000F | A (1st Shift (Normal Working Hours)) B (2nd Shift) C (3rd Shift) D (A.M.) E (P.M.) F (As Directed) G (Any Shift) Y (None) | S 1/1 |
| freeFormMessageText | MSG01 | 2000F | R 1/264 | |
| professionalService (Object) | - | - | ||
| productOrServiceIDQualifier | SV101_1 | 2000F | HC (HCPCS) N4 (National Drug Code) | R 2/2 |
| procedureCode | SV101_2 | 2000F | R 1/48 | |
| procedureModifier | SV101_3 | 2000F | S 2/2 | |
| procedureModifier2 | SV101_4 | 2000F | S 2/2 | |
| procedureModifier3 | SV101_5 | 2000F | S 2/2 | |
| procedureModifier4 | SV101_6 | 2000F | S 2/2 | |
| procedureCodeDescription | SV101_7 | 2000F | S 1/80 | |
| procedureCode2 | SV101_8 | 2000F | S 1/48 | |
| serviceLineAmount | SV102 | 2000F | S 1/18 | |
| unitOrBasisForMeasurementCode | SV103 | 2000F | F2 (International Unit) MJ (Minutes) UN (Unit) | S 2/2 |
| serviceUnitCount | SV104 | 2000F | S 1/15 | |
| epsdtIndicator | SV111 | 2000F | S 1/1 | |
| nursingHomeLevelOfCareCode | SV120 | 2000F | 1 (Skilled Nursing Facility (SNF)) 2 (Intermediate Care Facility (ICF)) 3 (Intermediate Care Facility - Mentally Retarded (ICF-MR)) 4 (Chronic Disease Hospital (CD)) 5 (Intermediate Care Facility (ICF) Level II) 6 (Special Skilled Nursing Facility (SNF)) 7 (Nursing Facility (NF)) 8 (Hospice) | S 1/1 |
| institutionalService (Object) | - | - | ||
| serviceLineRevenueCode | SV201 | 2000F | S 1/48 | |
| productOrServiceIDQualifier | SV202_1 | 2000F | HC (HCPCS or CPT) N4 (National Drug Code) ZZ (ICD-10) | R 2/2 |
| procedureCode | SV202_2 | 2000F | R 1/48 | |
| procedureModifier | SV202_3 | 2000F | S 2/2 | |
| procedureModifier2 | SV202_4 | 2000F | S 2/2 | |
| procedureModifier3 | SV202_5 | 2000F | S 2/2 | |
| procedureModifier4 | SV202_6 | 2000F | S 2/2 | |
| procedureCodeDescription | SV202_7 | 2000F | S 1/80 | |
| procedureCode2 | SV202_8 | 2000F | S 1/48 | |
| serviceLineAmount | SV203 | 2000F | S 1/18 | |
| unitOrBasisForMeasurementCode | SV204 | 2000F | S 2/2 | |
| serviceUnitCount | SV205 | 2000F | S 1/15 | |
| serviceLineRate | SV206 | 2000F | S 1/10 | |
| nursingHomeLevelOfCareCode | SV210 | 2000F | 1 (Skilled Nursing Facility (SNF)) 2 (Intermediate Care Facility (ICF)) 3 (Intermediate Care Facility - Mentally Retarded (ICF-MR)) 4 (Chronic Disease Hospital (CD)) 5 (Intermediate Care Facility (ICF) Level II) 6 (Special Skilled Nursing Facility (SNF)) 7 (Nursing Facility (NF)) 8 (Hospice) | S 1/1 |
| dentalService (Object) | - | - | ||
| procedureCode | SV301_2 | 2000F | SV301_1=AD | R 1/48 |
| procedureModifier | SV301_3 | 2000F | S 2/2 | |
| procedureModifier2 | SV301_4 | 2000F | S 2/2 | |
| procedureModifier3 | SV301_5 | 2000F | S 2/2 | |
| procedureModifier4 | SV301_6 | 2000F | S 2/2 | |
| procedureCodeDescription | SV301_7 | 2000F | S 1/80 | |
| procedureCode2 | SV301_8 | 2000F | S 1/48 | |
| serviceLineAmount | SV302 | 2000F | S 1/18 | |
| americanDentalAssociationCodes | SV304_1 | 2000F | R 1/3 | |
| americanDentalAssociationCodes2 | SV304_2 | 2000F | S 1/3 | |
| americanDentalAssociationCodes3 | SV304_3 | 2000F | S 1/3 | |
| americanDentalAssociationCodes4 | SV304_4 | 2000F | S 1/3 | |
| americanDentalAssociationCodes5 | SV304_5 | 2000F | S 1/3 | |
| prosthesisCrownOrInlayCode | SV305 | 2000F | I (Initial Placement) R (Replacement) | S 1/1 |
| serviceUnitCount | SV306 | 2000F | R 1/15 | |
| toothInformation (Object) | - | - | ||
| toothCode | TOO02 | 2000F | TOO01=JP | R 1/30 |
| toothSurfaceCode | TOO03_1 | 2000F | B (Buccal) D (Distal) F (Facial) I (Incisal) L (Lingual) M (Mesial) O (Occlusal) | R 1/2 |
| toothSurfaceCode2 | TOO03_2 | 2000F | S 1/2 | |
| toothSurfaceCode3 | TOO03_3 | 2000F | S 1/2 | |
| toothSurfaceCode4 | TOO03_4 | 2000F | S 1/2 | |
| toothSurfaceCode5 | TOO03_5 | 2000F | S 1/2 | |
| serviceRequestValidation (Array of object) | - | - | ||
| responseCode | AAA01 | 2000F | R 1/1 | |
| rejectReasonCode | AAA03 | 2000F | R 2/2 | |
| followupActionCode | AAA04 | 2000F | R 1/1 | |
| attachments (Array of objects) | - | - | Can repeat up to 10 times | |
| serviceProviderName (Array of objects) | - | - | ||
| serviceDetailAdditionalServiceInformationContactName (Array of objects) | - | - |
Patient Event Service Level Provider (Response)
| Name | Element | Loop | Description | Constraints |
|---|---|---|---|---|
| entityIdentifierCode | NM101 | 2010FA | 72 (Operating Physician) 73 (Other Physician) 77 (Service Location) DD (Assistant Surgeon) DK (Ordering Physician) DQ (Supervising Physician) FA (Facility) G3 (Clinic) P3 (Primary Care Provider) QB (Purchase Service Provider) QV (Group Practice) SJ (Service Provider) | R 2/3 |
| organizationName | NM103 | 2010FA | NM102=2 | S 1/60 |
| lastName | NM103 | 2010FA | NM102=1 | S 1/60 |
| firstName | NM104 | 2010FA | NM102=1 | S 1/35 |
| middleName | NM105 | 2010FA | S 1/25 | |
| namePrefix | NM106 | 2010FA | S 1/10 | |
| nameSuffix | NM107 | 2010FA | S 1/10 | |
| identificationCodeQualifier | NM108 | 2010FA | 24 (Employer’s Identification Number) 34 (Social Security Number) 46 (Electronic Transmitter Identification Number (ETIN)) XX (Centers for Medicare and Medicaid Services National Provider Identifier (NPI)) | S 1/2 |
| identifier | NM109 | 2010FA | S 2/80 | |
| address1 | N301 | 2010FA | R 1/55 | |
| address2 | N302 | 2010FA | S 1/55 | |
| city | N401 | 2010FA | R 2/30 | |
| state | N402 | 2010FA | S 2/2 | |
| postalCode | N403 | 2010FA | S 3/15 | |
| countryCode | N404 | 2010FA | S 2/3 | |
| countrySubDivisionCode | N407 | 2010FA | S 1/3 | |
| contactName | PER02 | 2010FA | PER01 = IC | S 1/60 |
| contactElectronicMail | PER04 PER06 PER08 | 2010FA | PER03=EM PER05=EM PER07=EM | S 1/256 |
| contactFacsimile | PER04 PER06 PER08 | 2010FA | PER03=FX PER05=FX PER07=FX | S 1/256 |
| contactTelephone | PER04 PER06 PER08 | 2010FA | PER03=TE PER05=TE PER07=TE | S 1/256 |
| contactUrl | PER04 PER06 PER08 | 2010FA | PER03=UR PER05=UR PER07=UR | S 1/256 |
| providerCode | PRV01 | 2010FA | PRV02=PXC AS (Assistant Surgeon) OP (Operating) OR (Ordering) OT (Other Physician) PC (Primary Care Physician) PE (Performing) | R 1/3 |
| providerTaxonomyCode | PRV03 | 2010FA | R 1/50 | |
| providerSupplementalInformation (Object) | - | - | ||
| stateLicenseNumber | REF02 | 2010FA | REF01=0B | R 1/50 |
| licenseNumberStateCode | REF03 | 2010FA | Required if StateLicenseNumber is entered | S 1/80 |
| providerUpinNumber | REF02 | 2010FA | REF01=1G | R 1/50 |
| facilityIdNumber | REF02 | 2010FA | REF01=1J | R 1/50 |
| employersIdentificationNumber | REF02 | 2010FA | REF01=EI | R 1/50 |
| providerSiteNumber | REF02 | 2010FA | REF01=G5 | R 1/50 |
| providerPlanNetworkIdentificationNumber | REF02 | 2010FA | REF01=N5 | R 1/50 |
| facilityNetworkIdentificationNumber | REF02 | 2010FA | REF01=N7 | R 1/50 |
| ssn | REF02 | 2010FA | REF01=SY | R 1/50 |
| carrierAssignedReferenceNumber | REF02 | 2010FA | REF01=ZH | R 1/50 |
| serviceProviderRequestValidation (Array of objects) | - | - | ||
| responseCode | AAA01 | 2010FA | N (No) Y (Yes) | R 1/1 |
| rejectReasonCode | AAA03 | 2010FA | R 2/2 | |
| followupActionCode | AAA04 | 2010FA | R 1/1 |
Service Detail Additional Service Information Contact Name (Response)
| Name | Element | Loop | Description | Constraints |
|---|---|---|---|---|
| organizationName | NM103 | 2010FB | NM102=2 NM101=L5 | S 1/60 |
| lastName | NM103 | 2010FB | S 1/60 | |
| firstName | NM104 | 2010FB | NM102=1 NM101=L5 | S 1/35 |
| middleName | NM105 | 2010FB | S 1/25 | |
| nameSuffix | NM107 | 2010FB | S 1/10 | |
| identificationCodeQualifier | NM108 | 2010FB | 24 (Employer’s Identification Number) 34 (Social Security Number) 46 (Electronic Transmitter Identification Number (ETIN)) PI (Payor Identification) XV (Centers for Medicare and Medicaid Services PlanID) XX (Centers for Medicare and Medicaid Services National Provider Identifier (NPI)) | S 1/2 |
| identifier | NM109 | 2010FB | S 2/80 | |
| address1 | N301 | 2010FB | R 1/55 | |
| address2 | N302 | 2010FB | S 1/55 | |
| city | N401 | 2010FB | R 2/30 | |
| state | N402 | 2010FB | S 2/2 | |
| postalCode | N403 | 2010FB | S 3/15 | |
| countryCode | N404 | 2010FB | S 2/3 | |
| countrySubDivisionCode | N407 | 2010FB | S 1/3 | |
| contactName | PER02 | 2010FB | PER01 = IC | S 1/60 |
| contactElectronicMail | PER04 PER06 PER08 | 2010FB | PER03=EM PER05=EM PER07=EM | S 1/256 |
| contactFacsimile | PER04 PER06 PER08 | 2010FB | PER03=FX PER05=FX PER07=FX | S 1/256 |
| contactTelephone | PER04 PER06 PER08 | 2010FB | PER03=TE PER05=TE PER07=TE | S 1/256 |
| contactUrl | PER04 PER06 PER08 | 2010FB | PER03=UR PER05=UR PER07=UR | S 1/256 |
Updated about 15 hours ago