Submission JSON-to-EDI Contents
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
For an overview about JSON-to-EDI mapping, see Understanding JSON-to-EDI API Mapping.
Submission 278 Request
Identification Header (Request)
| Name | Required/Commonly Used | Hint | Element Loop | Code | EDI Mapping Notes | Constraint |
|---|---|---|---|---|---|---|
| Header Section (Request) | Required | |||||
senderId | Required | ISA06/GS02 N/A | Interchange Sender ID | 15/15 | ||
submitterTransactionIdentifier | Required | BHT03 N/A | Submitter Transaction Identifier | 1/50 | ||
payerId | Required | NM109 2010A | NM101=PR NM102=2 If umClearingHouseId is empty, this value will also be used to populate ISA08 GS03 | 2/80 | ||
payerName | Required | NM103 2010A | 1/60 | |||
umClearingHouseId | Required | N/A | If not empty, populate ISA08 GS03 |
Requestor Detail (Request)
| Name | Required/Commonly Used | Hint | Element Loop | Code | EDI Mapping Notes | Constraint |
|---|---|---|---|---|---|---|
| Request Information Section | Required | |||||
requesterType | Required | Default to 1P | NM101 2010B | 1P (Provider) 2B (Third-Party Administrator) 36 (Employer) FA (Facility) PR (Payer) | 2/3 | |
Requester Name (if Requester is an individual, provide lastName and firstName, otherwise provide organizationName) | Required | |||||
organizationName | Commonly Used | NM103 2010B | NM102=2 | 1/60 | ||
lastName | NM103 2010B | 1/60 | ||||
firstName | NM104 2010B | NM102=1 | 1/35 | |||
| Requester Address Information | ||||||
address1 | Commonly Used | N301 2010B | 1/55 | |||
address2 | Commonly Used | N302 2010B | 1/55 | |||
city | Commonly Used | N401 2010B | 2/30 | |||
state | Commonly Used | N402 2010B | 2/2 | |||
postalCode | Commonly Used | N403 2010B | 3/15 | |||
countryCode | N404 2010B | 2/3 | ||||
countrySubDivisionCode | N407 2010B | 1/3 | ||||
| Identification Code (Provide one of the following) | ||||||
npi | NM109 2010B | NM108=XX | 2/80 | |||
ssn | NM109 2010B | NM108=34 | 2/80 | |||
servicesPlanID | NM109 2010B | NM108=XV | 2/80 | |||
employersId | NM109 2010B | NM108=24 | 2/80 | |||
etin | NM109 2010B | NM108=46 | 2/80 | |||
| Requester Contact Information | ||||||
contactName | PER02 2010B | PER01=IC | 1/60 | |||
contactElectronicMail | PER04 PER06 PER08 2010B | PER03=EM PER05=EM PER07=EM | 1/256 | |||
contactFacsimile | PER04 PER06 PER08 2010B | PER03=FX PER05=FX PER07=FX | 1/256 | |||
contactTelephone | Commonly Used | PER04 PER06 PER08 2010B | PER03=TE PER05=TE PER07=TE | 1/256 | ||
contactTelephoneExtension | PER06 PER08 2010B | PER05=EX PER07=EX | 1/256 | |||
providerCode | PRV01 2010B | AD (Admitting) AS (Assistant Surgeon) AT (Attending) CO (Consulting) CV (Covering) OP (Operating) OR (Ordering) OT (Other Physician) PC (Primary Care Physician) PE (Performing) RF (Referring) | PRV02=PXC | 1/3 | ||
referenceIdentification | PRV03 2010B | 1/50 | ||||
| Requester Identification (Provide any of the following if available) | ||||||
providerUpinNumber | REF02 2010B | REF01=1G | 1/50 | |||
facilityIdNumber | REF02 2010B | REF01=1J | 1/50 | |||
employerIdentificationNumber | REF02 2010B | REF01=EI | 1/50 | |||
| providerSiteNumber | REF02 2010B | REF01=G5 | 1/50 | |||
| providerPlanNetworkIdNumber | REF02 2010B | REF01=N5 | 1/50 | |||
facilityNetworkIdNumber | REF02 2010B | REF01=N7 | 1/50 | |||
socialSecurityNumber | REF02 2010B | REF01=SY | 1/50 | |||
carrierAssignedReferenceNumber | REF02 2010B | REF01=ZH | 1/50 |
Subscriber (Request)
| Name | Required/Commonly Used | Hint | Element Loop | Code | EDI Mapping Notes | Constraint |
|---|---|---|---|---|---|---|
| Subscriber Section | ||||||
lastName | Required | While not required by guide, widely used by payers | NM103 2010C | NM101=IL NM102=1 | 1/60 | |
firstName | Required | While not required by guide, widely used by payers | NM104 2010C | 1/35 | ||
middleName | NM105 2010C | 1/25 | ||||
suffix | NM107 2010C | 1/10 | ||||
memberId | Required | NM109 2010C | NM108=MI | 2/80 | ||
dateOfBirth | Required | While not required by guide, widely used by payers | DMG02 2010C | DMG01=D8 YYYYMMDD | 1/35 | |
genderCode | DMG03 2010C | F (Female) M (Male) U (Unknown) | 1/1 | |||
| Address Information | ||||||
address1 | N301 2010C | 1/55 | ||||
address2 | N302 2010C | 1/55 | ||||
city | N401 2010C | 2/30 | ||||
state | N402 2010C | 2/2 | ||||
postalCode | N403 2010C | 3/15 | ||||
countryCode | N404 2010C | 2/3 | ||||
countrySubDivisionCode | N407 2010C | 1/3 | ||||
insuredIndicator | INS01 2010C | Y (Yes) N (No) | 1/1 | |||
militaryRelationship | INS08 2010C | AO (Active Military - Overseas) AU (Active Military - USA) DI (Deceased) PV (Previous) RU (Retired Military - USA) | 2/2 | |||
supplementalIdentification (Object) | ||||||
| Subscriber Supplemental Identification (provide any of the following if available) | ||||||
policyNumber | REF02 2010C | REF01=1L | 1/50 | |||
branchIdentifier | REF02 2010C | REF01=3L | 1/50 | |||
groupNumber | Commonly Used | REF02 2010C | REF01=6P | 1/50 | ||
departmentNumber | REF02 2010C | REF01=DP | 1/50 | |||
patientAccountNumber | REF02 2010C | REF01=EJ | 1/50 | |||
healthInsuranceClaimNumber | REF02 2010C | REF01=F6 | 1/50 | |||
idCard | REF02 2010C | REF01=HJ | 1/50 | |||
insurancePolicyNumber | REF02 2010C | REF01=IG | 1/50 | |||
planNetworkIdentificationNumber | REF02 2010C | REF01=N6 | 1/50 | |||
medicaidRecipientIdentificationNumber | REF02 2010C | REF01=NQ | 1/50 | |||
ssn | Commonly Used | REF02 2010C | REF01=SY | 1/50 |
Dependent (Request)
| Name | Required/Commonly Used | Hint | Element Loop | Code | EDI Mapping Notes | Constraint |
|---|---|---|---|---|---|---|
| Dependent Section (Required if Patient is a dependent of the Insured Individual) | 1/60 | |||||
lastName | Required | While not required by guide, widely used by payers | NM103 2010D | NM101=QC NM102=1 | ||
firstName | Required | While not required by guide, widely used by payers | NM104 2010D | 1/35 | ||
middleName | NM105 2010D | 1/25 | ||||
suffix | NM107 2010D | 1/10 | ||||
dateOfBirth | Required | While not required by guide, widely used by payers | DMG02 2010D | DMG01=D8 YYYYMMDD | 1/35 | |
genderCode | DMG03 2010D | F (Female) M (Male) U (Unknown) | 1/1 | |||
| Address Information | ||||||
address1 | N301 2010D | 1/55 | ||||
address2 | N302 2010D | 1/55 | ||||
city | N401 2010D | 2/30 | ||||
state | N402 2010D | 2/2 | ||||
postalCode | N403 2010D | 3/15 | ||||
countryCode | N404 2010D | 2/3 | ||||
countrySubDivisionCode | N407 2010D | 1/3 | ||||
insuredIndicator | INS01 2010D | Y (Yes) N (No) | 1/1 | |||
relationshipToInsuredCode | INS02 2010D | 01 (Spouse) 19 (Child) G8 (Other Relationship) | 2/2 | |||
birthSequenceNumber | INS17 2010D | 1/9 | ||||
| Dependent Supplemental Identification (Provide any of the following if available) | ||||||
patientAccountNumber | REF02 2010D | REF01=EJ | 1/50 | |||
ssn | Commonly Used | REF02 2010D | REF01=SY | 1/50 |
Patient Event Detail (Request)
| Name | Required/Commonly Used | Hint | Element | Code | EDI Mapping Notes | Constraint |
|---|---|---|---|---|---|---|
| Patient Event Details Section | Required | 1/2 | ||||
requestCategoryCode | Commonly Used | UM01 2000E | requestCategoryCode====================== AR Admission Review HS Health Services Review IN Individual SC Specialty Care Review | 1/2 | ||
certificationTypeCode | UM02 2000E | 1 (Appeal - Immediate) 2 (Appeal - Standard) 3 (Cancel) 4 (Extension) I (Initial) N (Reconsideration) R Renewal) S (Revised) | 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) | 1/2 | |||
facilityTypeCode | UM04_1 2000E | 01 (Pharmacy) 02 (TelehealthProvidedOtherthaninPatient’sHome) 03 (School) 04 (HomelessShelter) 05 (IndianHealthServiceFreestandingFacility) 06 (IndianHealthServiceProviderbasedFacility) 07 (Tribal638FreestandingFacility) 08 (Tribal638ProviderbasedFacility) 09 (Prison/CorrectionalFacility) 10 (TelehealthProvidedinPatient’sHome) 11 (Office) 12 (Home) 13 (AssistedLivingFacility) 14 (GroupHome) 15 (MobileUnit) 16 (TemporaryLodging) 17 (WalkinRetailHealthClinic) 18 (PlaceofEmploymentWorksite) 19 (OffCampusOutpatientHospital) 20 (UrgentCareFacility) 21 (InpatientHospital) 22 (OnCampusOutpatientHospital) 23 (EmergencyRoom–Hospital) 24 (AmbulatorySurgicalCenter) 25 (BirthingCenter) 26 (MilitaryTreatmentFacility) 27 (OutreachSite/Street) 28-30 (Unassigned) 31 (SkilledNursingFacility) 32 (NursingFacility) 33 (CustodialCareFacility) 34 (Hospice) 35-40 (Unassigned) 41 (AmbulanceLand) 42 (Ambulance–AirorWater) 43-48 (Unassigned) 49 (IndependentClinic) 50 (FederallyQualifiedHealthCenter) 51 (InpatientPsychiatricFacility) 52 (PsychiatricFacilityPartialHospitalization) 53 (CommunityMentalHealthCenter) 54( IntermediateCareFacility/IndividualswithIntellectualDisabilities)55 (ResidentialSubstanceAbuseTreatmentFacility) 56 (PsychiatricResidentialTreatmentCenter) 57 (NonresidentialSubstanceAbuseTreatmentFacility) 58 (NonresidentialOpioidTreatmentFacility) 59 (Unassigned) 60 (MassImmunizationCenter) 61 (ComprehensiveInpatientRehabilitationFacility) 62 (ComprehensiveOutpatientRehabilitationFacility) 63-64 (Unassigned) 65 (EndStageRenalDiseaseTreatmentFacility) 66 (ProgramsofAllInclusiveCarefortheElderly(PACE)Center*) 67-70 (Unassigned) 71 (PublicHealthClinic) 72 (RuralHealthClinic) 73-80 (Unassigned) 81 (IndependentLaboratory) 82-98 (Unassigned) 99 (OtherPlaceofService) | 1/2 | |||
facilityCodeQualifier | UM04_2 2000E | A (Uniform Billing Claim Form Bill Type) B (Place of Service Codes for Professional or Dental Services) | 1/2 | |||
relatedCausesCode1 | UM05_1 2000E | AA (Uto Accident) AP (Another Party Responsible) EM (Employment) | 2/3 | |||
relatedCausesCode2 | UM05_2 2000E | AP (Another Party Responsible) EM (Employment) | 2/3 | |||
relatedCausesCode3 | UM05_3 2000E | AP (Another Party Responsible) | 2/3 | |||
stateCode | UM05_4 2000E | 2/2 | ||||
countryCode | UM05_5 2000E | 2/3 | ||||
levelOfServiceCode | UM06 2000E | 03 (Emergency) E (Elective) U (Urgent) | 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) | 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) | 1/1 | |||
releaseOfInformationCode | UM09 2000E | M (Limited or Restricted) Y (Permitted) | 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) | 1/2 | |||
previousReviewAuthorizationNumber | REF02 2000E | REF01=BB | 1/50 | |||
previousAdministrativeReferenceNumber | REF02 2000E | REF01=NT | 1/50 | |||
accidentDate | DTP03 2000E | DTP01=439 DTP02=D8 YYYYMMDD | 1/35 | |||
lastMenstrualPeriodDate | DTP03 2000E | DTP01=484 DTP02=D8 YYYYMMDD | 1/35 | |||
estimatedDateOfBirth | DTP03 2000E | DTP01=ABC DTP02=D8 YYYYMMDD | 1/35 | |||
onsetDate | DTP03 2000E | DTP01=431 DTP02=D8 YYYYMMDD | 1/35 | |||
eventDateBegin | DTP03 2000E | DTP01=AAH DTP02=D8 YYYYMMDD | 1/35 | |||
eventDateEnd | EventDateBegin must exist | DTP03 2000E | DTP01=AAH DTP02=RD8 YYYYMMDD | 1/35 | ||
admissionDateBegin | DTP03 2000E | DTP01=435 DTP02=D8 YYYYMMDD | 1/35 | |||
admissionDateEnd | AdmissionDateBegin must exist | DTP03 2000E | DTP01=435 DTP02=RD8 YYYYMMDD | 1/35 | ||
dischargeDate | DTP03 2000E | DTP01=096 DTP02=D8 YYYYMMDD | 1/35 | |||
| Diagnosis Information | ||||||
diagnosisTypeCode1 | HI01_1 2000E | ABF (Diagnosis) ABJ (Admitting Diagnosis) ABK (Principal Diagnosis) APR (Patient’s Reason for Visit) DR (Diagnosis Related Group (DRG)) | 1/3 | |||
DiagnosisCode1 | HI01_2 2000E | 1/30 | ||||
DiagnosisDate1 | HI01_4 2000E | HI01_3=D8 YYYYMMDD | 1/35 | |||
diagnosisTypeCode2 | HI02_1 2000E | ABF (Diagnosis) ABJ (Admitting Diagnosis) APR (Patient’s Reason for Visit) DR (Diagnosis Related Group (DRG)) | 1/3 | |||
DiagnosisCode2 | HI02_2 2000E | 1/30 | ||||
DiagnosisDate2 | HI02_4 2000E | HI02_3=D8 YYYYMMDD | 1/35 | |||
diagnosisTypeCode3 | HI03_1 2000E | ABF (Diagnosis) APR (Patient’s Reason for Visit) DR (Diagnosis Related Group (DRG)) | 1/3 | |||
DiagnosisCode3 | HI03_2 2000E | 1/30 | ||||
DiagnosisDate3 | HI03_4 2000E | HI03_3=D8 YYYYMMDD | 1/35 | |||
diagnosisTypeCode4 | HI04_1 2000E | ABF (Diagnosis) APR (Patient’s Reason for Visit) DR (Diagnosis Related Group (DRG)) | 1/3 | |||
DiagnosisCode4 | HI04_2 2000E | 1/30 | ||||
DiagnosisDate4 | HI04_4 2000E | HI04_3=D8 YYYYMMDD | 1/35 | |||
diagnosisTypeCode5 | HI05_1 2000E | ABF (Diagnosis) APR (Patient’s Reason for Visit) DR (Diagnosis Related Group (DRG)) | 1/3 | |||
DiagnosisCode5 | HI05_2 2000E | 1/30 | ||||
DiagnosisDate5 | HI05_4 2000E | HI05_3=D8 YYYYMMDD | 1/35 | |||
diagnosisTypeCode6 | HI06_1 2000E | ABF (Diagnosis) APR (Patient’s Reason for Visit) DR (Diagnosis Related Group (DRG)) | 1/3 | |||
DiagnosisCode6 | HI06_2 2000E | 1/30 | ||||
DiagnosisDate6 | HI06_4 2000E | HI06_3=D8 YYYYMMDD | 1/35 | |||
diagnosisTypeCode7 | HI07_1 2000E | ABF (Diagnosis) APR (Patient’s Reason for Visit) DR (Diagnosis Related Group (DRG)) | 1/3 | |||
DiagnosisCode7 | HI07_2 2000E | 1/30 | ||||
DiagnosisDate7 | HI07_4 2000E | HI07_3=D8 YYYYMMDD | 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 | 1/30 | ||||
DiagnosisDate8 | HI08_4 2000E | HI08_3=D8 YYYYMMDD | 1/35 | |||
diagnosisTypeCode9 | HI09_1 2000E | ABF (Diagnosis) APR (Patient’s Reason for Visit) DR (Diagnosis Related Group (DRG)) | 1/3 | |||
DiagnosisCode9 | HI09_2 2000E | 1/30 | ||||
DiagnosisDate9 | HI09_4 2000E | HI09_3=D8 YYYYMMDD | 1/35 | |||
diagnosisTypeCode10 | HI010_1 2000E | ABF (Diagnosis) APR (Patient’s Reason for Visit) DR (Diagnosis Related Group (DRG)) | 1/3 | |||
DiagnosisCode10 | HI010_2 2000E | 1/30 | ||||
DiagnosisDate10 | HI010_4 2000E | HI010_3=D8 YYYYMMDD | 1/35 | |||
diagnosisTypeCode11 | HI011_1 2000E | ABF (Diagnosis) APR (Patient’s Reason for Visit) DR (Diagnosis Related Group (DRG)) | 1/3 | |||
DiagnosisCode11 | HI011_2 2000E | 1/30 | ||||
DiagnosisDate11 | HI011_4 2000E | HI011_3=D8 YYYYMMDD | 1/35 | |||
diagnosisTypeCode12 | HI012_1 2000E | ABF (Diagnosis) APR (Patient’s Reason for Visit) DR (Diagnosis Related Group (DRG)) | 1/3 | |||
DiagnosisCode12 | HI012_2 2000E | 1/30 | ||||
DiagnosisDate12 | HI012_4 2000E | HI012_3=D8 YYYYMMDD | 1/35 | |||
quantityQualifier | HSD01 2000E | DY (Days) FL (Units) HS (Hours) MN (Month) VS (Visits) | 2/2 | |||
serviceUnitCount | HSD02 2000E | 1/15 | ||||
unitOrBasisForMeasurementCode | HSD03 2000E | DA (Days) MO (Months) WK (Week) | 2/2 | |||
sampleSelectionModulus | HSD04 2000E | 1/6 | ||||
timePeriodQualifier | HSD05 2000E | 6 (Hour) 7 (Day) 21 (Years) 26 (Episode) 27 (Visit) 29 (Remaining) 34 (Month) 35 (Week) | 1/2 | |||
periodCount | HSD06 2000E | 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) | 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) | 1/1 | |||
ambulanceCertificationConditionIndicator | CRC02 2000E | N (No) Y (Yes) | CRC01=07 | 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) | 2/3 | |||
ambulanceCertificationConditionCode2 | Use codes listed in CRC03 | CRC04 2000E | 2/3 | |||
ambulanceCertificationConditionCode3 | Use codes listed in CRC03 | CRC05 2000E | 2/3 | |||
ambulanceCertificationConditionCode4 | Use codes listed in CRC03 | CRC06 2000E | 2/3 | |||
ambulanceCertificationConditionCode5 | Use codes listed in CRC03 | CRC07 2000E | 2/3 | |||
chiropracticCertificationConditionIndicator | CRC02 2000E | N (No) Y (Yes) | CRC01=08 | 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) | 2/3 | |||
chiropracticCertificationConditionCode2 | Use codes listed in CRC03 | CRC04 2000E | 2/3 | |||
chiropracticCertificationConditionCode3 | Use codes listed in CRC03 | CRC05 2000E | 2/3 | |||
chiropracticCertificationConditionCode4 | Use codes listed in CRC03 | CRC06 2000E | 2/3 | |||
chiropracticCertificationConditionCode5 | Use codes listed in CRC03 | CRC07 2000E | 2/3 | |||
durableMedicalEquipmentCertificationConditionIndicator | CRC02 2000E | N (No) Y (Yes) | CRC01=09 | 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) | 2/3 | |||
durableMedicalEquipmentCertificationConditionCode2 | Use codes listed in CRC03 | CRC04 2000E | 2/3 | |||
durableMedicalEquipmentCertificationConditionCode3 | Use codes listed in CRC03 | CRC05 2000E | 2/3 | |||
durableMedicalEquipmentCertificationConditionCode4 | Use codes listed in CRC03 | CRC06 2000E | 2/3 | |||
durableMedicalEquipmentCertificationConditionCode5 | Use codes listed in CRC03 | CRC07 2000E | 2/3 | |||
oxygenTherapyCertificationConditionIndicator | CRC02 2000E | N (No) Y (Yes) | CRC01=11 | 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) | 2/3 | |||
oxygenTherapyCertificationConditionCode2 | Use codes listed in CRC03 | CRC04 2000E | 2/3 | |||
oxygenTherapyCertificationConditionCode3 | Use codes listed in CRC03 | CRC05 2000E | 2/3 | |||
oxygenTherapyCertificationConditionCode5 | Use codes listed in CRC03 | CRC07v 2000E | 2/3 | |||
oxygenTherapyCertificationConditionCode4 | Use codes listed in CRC03 | CRC06 2000E | 2/3 | |||
functionalLimitationsCertificationConditionIndicator | CRC02 2000E | N (No) Y (Yes) | CRC01=75 | 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) | 2/3 | |||
functionalLimitationsCertificationConditionCode2 | Use codes listed in CRC03 | CRC04 2000E | 2/3 | |||
functionalLimitationsCertificationConditionCode3 | Use codes listed in CRC03 | CRC05 2000E | 2/3 | |||
functionalLimitationsCertificationConditionCode4 | Use codes listed in CRC03 | CRC06 2000E | 2/3 | |||
functionalLimitationsCertificationConditionCode5 | Use codes listed in CRC03 | CRC07 2000E | 2/3 | |||
activitiesPermittedCertificationConditionIndicator | CRC02 2000E | N (No) Y (Yes) | CRC01=76 | 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) | 2/3 | |||
activitiesPermittedCertificationConditionCode2 | Use codes listed in CRC03 | CRC04 2000E | 2/3 | |||
activitiesPermittedCertificationConditionCode3 | Use codes listed in CRC03 | CRC05 2000E | 2/3 | |||
activitiesPermittedCertificationConditionCode4 | Use codes listed in CRC03 | CRC06 2000E | 2/3 | |||
activitiesPermittedCertificationConditionCode5 | Use codes listed in CRC03 | CRC07 2000E | 2/3 | |||
mentalStatusCertificationConditionIndicator | CRC02 2000E | N (No) Y (Yes) | CRC01=77 | 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) | 2/3 | |||
mentalStatusCertificationConditionCode2 | Use codes listed in CRC03 | CRC04 2000E | 2/3 | |||
mentalStatusCertificationConditionCode3 | Use codes listed in CRC03 | CRC05 2000E | 2/3 | |||
mentalStatusCertificationConditionCode4 | Use codes listed in CRC03 | CRC06 2000E | 2/3 | |||
mentalStatusCertificationConditionCode5 | Use codes listed in CRC03 | CRC07 2000E | 2/3 | |||
freeFormMessageText | MSG01 2000E | 1/264 | ||||
admissionToFacility (Object) | ||||||
admissionTypeCode | CL101 2000E | 1/1 | ||||
admissionSourceCode | CL102 2000E | 1/1 | ||||
patientStatusCode | CL103 2000E | 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) | 1/1 | |||
| ambulanceTransport (Object) | ||||||
patientWeight | CR102 2000E | CR101=LB | 1/10 | |||
transportCode | CR103 2000E | I (Initial Trip) R (Return Trip) T (Transfer Trip) X (Round Trip) | 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) | 1/1 | |||
transportDistance | CR106 2000E | CR105=DH | 1/15 | |||
roundTripPurposeDescription | CR109 2000E | 1/80 | ||||
stretcherPurposeDescription | CR110 2000E | 1/80 | ||||
| spinalManipulation (Object) | ||||||
treatmentSeriesNumber | CR201 2000E | 1/9 | ||||
treatmentCount | CR202 2000E | 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) | 2/3 | |||
subluxationEndLevelCode | Use codes listed in CR203 | CR204 2000E | 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) | 1/1 | |||
complicationIndicator | CR209 2000E | N (No) Y (Yes) | 1/1 | |||
patientConditionDescription1 | CR210 2000E | 1/80 | ||||
patientConditionDescription2 | CR211 2000E | 1/80 | ||||
xrayAvailabilityIndicator | CR212 2000E | N (No) Y (Yes) | 1/1 | |||
| homeOxygenTherapyInformation (Object) | ||||||
equipmentTypeCode1 | CR503 2000E | A (Concentrator) B (Liquid Stationary) C (Gaseous Stationary) D (Liquid Portable) E (Gaseous Portable) O (Other) | 1/1 | |||
equipmentTypeCode2 | Use codes listed in CR503 | CR504 2000E | 1/1 | |||
equipmentTypeCode3 | Use codes listed in CR503 | CR518 2000E | 1/1 | |||
equipmentReasonDescription | CR505 2000E | 1/80 | ||||
flowRate | CR506 2000E | 1/15 | ||||
dailyUseCount | CR507 2000E | 1/15 | ||||
usePeriodHourCount | CR508 2000E | 1/15 | ||||
respiratoryTherapistOrderText | CR509 2000E | 1/80 | ||||
arterialBloodGasQuantity | CR510 2000E | 1/15 | ||||
saturationQuantity | CR511 2000E | 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) | 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) | 1/1 | |||
testFindingsCode2 | Use codes listed in CR513 | CR514 2000E | 1/1 | |||
testFindingsCode3 | Use codes listed in CR513 | CR515 2000E | 1/1 | |||
portableSystemFlowRate | CR516 2000E | 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) | 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) | 1/1 | |||
startDate | CR602 2000E | 8/8 | ||||
certificationPeriodStartDate | CR604 2000E | 1/35 | ||||
certificationPeriodEndDate | CR604 2000E | CR603=RD8 | 1/35 | |||
medicareCoverageIndicator | CR607 2000E | 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.) | 1/1 | |||
surgeryDate | CR609 2000E | 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) | 2/2 | |||
surgicalProcedureCode | CR611 2000E | 1/15 | ||||
physicalOrderDate | CR612 2000E | 8/8 | ||||
lastVisitDate | CR613 2000E | 8/8 | ||||
physicianContactDate | CR614 2000E | 8/8 | ||||
lastAdmissionPeriodStartDate | CR616 2000E | 1/35 | ||||
lastAdmissionPeriodEndDate | CR616 2000E | CR615=RD8 | 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) | 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 | Required/Commonly Used | Hint | Element Loop | Code | Constraint |
|---|---|---|---|---|---|
| Attachment (Object) | |||||
reportTypeCode | Required | 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) | 2/2 | |
transmissionCode | Required | PWK02 2000E/F | AA (Available on Request at Provider Site) BM (By Mail) EL (Electronically Only) EM (E-Mail) FX (By Fax) VO (Voice) | 1/2 | |
controlNumber | PWK06 2000E/F | PWK05=AC | S 2/80 | ||
description | PWK07 2000E/F | S 1/80 |
Patient Event Provider Name (Request)
| Name | Required/Commonly Used | Hint | Element Loop | Code | EDI Mapping Notes | Constraint |
|---|---|---|---|---|---|---|
| Patient Event Provider Name Section (can contain multiple instances) | ||||||
entityIdentifierCode | Commonly Used | 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) | 2/3 | ||
Provider Name (if Provider is an individual, provide lastName and firstName, otherwise provide organizationName) | ||||||
organizationName | NM103 2010EA | NM102=2 | 1/60 | |||
lastName | Commonly Used | NM103 2010EA | 1/60 | |||
firstName | Commonly Used | NM104 2010EA | NM102=1 | 1/35 | ||
middleName | NM105 2010EA | 1/25 | ||||
namePrefix | NM106 2010EA | 1/10 | ||||
nameSuffix | NM107 2010EA | 1/10 | ||||
identificationCodeQualifier | Commonly Used | 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)) | 1/2 | ||
identifier | Commonly Used | NM109 2010EA | 2/80 | |||
| Patient Event Provider Address Information | ||||||
address1 | N301 2010EA | 1/55 | ||||
address2 | N302 2010EA | 1/55 | ||||
city | N401 2010EA | 2/30 | ||||
state | N402 2010EA | 2/2 | ||||
postalCode | N403 2010EA | 3/15 | ||||
countryCode | N404 2010EA | 2/3 | ||||
countrySubDivisionCode | N407 2010EA | 1/3 | ||||
| Requestor Contact Information | ||||||
contactName | PER02 2010EA | PER01=IC | 1/60 | |||
contactElectronicMail | PER04 PER06 PER08 | PER03=EM PER05=EM PER07=EM | 1/256 | |||
contactFacsimile | PER04 PER06 PER08 | PER03=FX PER05=FX PER07=FX | 1/256 | |||
ContactTelephone | Commonly Used | PER04 PER06 PER08 | PER03=TE PER05=TE PER07=TE | 1/256 | ||
ContactTelephoneExtension | PER06 PER08 | PER05=EX PER07=EX | 1/256 | |||
| Provider Supplemental Information (provide any of the following if available) | ||||||
stateLicenseNumber | REF02 2010EA | REF01=0B | 1/50 | |||
licenseNumberStateCode | Required if StateLicenseNumber is entered | REF03 2010EA | 1/50 | |||
providerUpinNumber | REF02 2010EA | REF01=1G | 1/50 | |||
facilityIdNumber | REF02 2010EA | REF01=1J | 1/50 | |||
employersIdentificationNumber | REF02 2010EA | REF01=EI | 1/50 | |||
providerPlanNetworkIdentificationNumber | REF02 2010EA | REF01=N5 | 1/50 | |||
facilityNetworkIdentificationNumber | REF02 2010EA | REF01=N7 | 1/50 | |||
ssn | REF02 2010EA | REF01=SY | 1/50 | |||
carrierAssignedReferenceNumber | REF02 2010EA | REF01=ZH | 1/50 | |||
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) | 1/3 | |||
providerTaxonomyCode | PRV03 2010EA | 1/50 |
Patient Event Transport Information (Request)
| Name | Required/Commonly Used | Element Loop | Code | EDI Mapping Notes | Constraint |
|---|---|---|---|---|---|
patientEventTransportInformation (Object) | |||||
entityIdentifierCode | Required | NM101 2010EB | 45 (Drop-off Location) FS (Final Scheduled Destination) ND (Next Destination) PW (Pickup Address) R3 (Next Scheduled Destination) | 2/3 | |
transportLocationName | Required | NM103 2010EB | NM102=2 | 1/60 | |
address1 | Required | N301 2010EB | 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 | Required/Commonly Used | Element Loop | Code | EDI Mapping Notes | Constraints |
|---|---|---|---|---|---|
patientEventOtherUmoName (Object) | |||||
entityIdentifierCode | Required | NM101 2010EC | 00 (Alternate Insurer) CA (Carrier) GG (Intermediary) | 2/3 | |
otherUmoName | NM103 2010EC | NM102=2 | S 1/60 | ||
otherUmoDenialReason1 | REF02 2010EC | REF01=ZZ | 1/50 | ||
otherUmoDenialReason2 | REF04_2 2010EC | REF04_1=ZZ | 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 | 1/35 |
Patient Event Service Level (Request)
| Name | Required/Commonly Used | Hint | Element Loop | Description | EDI Mapping Notes | Constraints |
|---|---|---|---|---|---|---|
| Service Level Section (one instance per procedure code) | Required | |||||
| Health Care Services Review Information | ||||||
requestCategoryCode | Commonly Used | UM01 2000F | HS (Health Services Review) SC (Specialty Care Review) | 1/2 | ||
certificationTypeCode | UM02 2000F | 1 (Appeal - Immediate) 2 (Appeal - Standard) 3 (Cancel) 4 (Extension) I (Initial) N (Reconsideration) R (Renewal) S (Revised) | 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) | 1/2 | |||
facilityTypeCode | Commonly Used | UM04_1 2000F | 01 (Pharmacy) 02 (TelehealthProvidedOtherthaninPatient’sHome) 03 (School) 04 (HomelessShelter) 05 (IndianHealthServiceFreestandingFacility) 06 (IndianHealthServiceProviderbasedFacility) 07 (Tribal638FreestandingFacility) 08 (Tribal638ProviderbasedFacility) 09 (Prison/CorrectionalFacility) 10 (TelehealthProvidedinPatient’sHome) 11 (Office) 12 (Home) 13 (AssistedLivingFacility) 14 (GroupHome) 15 (MobileUnit) 16 (TemporaryLodging) 17 (WalkinRetailHealthClinic) 18 (PlaceofEmploymentWorksite) 19 (OffCampusOutpatientHospital) 20 (UrgentCareFacility) 21 (InpatientHospital) 22 (OnCampusOutpatientHospital) 23 (EmergencyRoom–Hospital) 24 (AmbulatorySurgicalCenter) 25 (BirthingCenter) 26 (MilitaryTreatmentFacility) 27 (OutreachSite/Street) 28-30 (Unassigned) 31 (SkilledNursingFacility) 32 (NursingFacility) 33 (CustodialCareFacility) 34 (Hospice) 35-40 (Unassigned) 41 (AmbulanceLand) 42 (Ambulance–AirorWater) 43-48 (Unassigned) 49 (IndependentClinic) 50 (FederallyQualifiedHealthCenter) 51 (InpatientPsychiatricFacility) 52 (PsychiatricFacilityPartialHospitalization) 53 (CommunityMentalHealthCenter) 54 (IntermediateCareFacility/IndividualswithIntellectualDisabilities) 55 (ResidentialSubstanceAbuseTreatmentFacility) 56 (PsychiatricResidentialTreatmentCenter) 57 (NonresidentialSubstanceAbuseTreatmentFacility) 58 (NonresidentialOpioidTreatmentFacility) 59 (Unassigned) 60 (MassImmunizationCenter) 61 (ComprehensiveInpatientRehabilitationFacility) 62 (ComprehensiveOutpatientRehabilitationFacility) 63-64 (Unassigned) 65 (EndStageRenalDiseaseTreatmentFacility) 66 (ProgramsofAllInclusiveCarefortheElderly(PACE)Center*) 67-70 (Unassigned) 71 (PublicHealthClinic) 72 (RuralHealthClinic) 73-80 (Unassigned) 81 (IndependentLaboratory) 82-98 (Unassigned) 99 (OtherPlaceofService) | 1/2 | ||
facilityCodeQualifier | Commonly Used | UM04_2 2000F | A (Uniform Billing Claim Form Bill Type) B (Place of Service Codes for Professional or Dental Services) | 1/2 | ||
previousReviewAuthorizationNumber | REF02 2000F | REF01=BB | 1/50 | |||
previousAdministrativeReferenceNumber | REF02 2000F | REF01=NT | 1/50 | |||
serviceDateBegin | Commonly Used | Usually same as 2000E Event Date | DTP03 2000F | DTP01=472 DTP02=D8 YYYYMMDD | 1/35 | |
serviceDateEnd | DTP03 2000F | DTP01=472 DTP02=RD8 YYYYMMDD ServiceDateBegin must exist | 1/35 | |||
freeFormMessageText | MSG01 2000F | 1/264 | ||||
| One of the follow Service Sections is Required | ||||||
| Professional Service Information | ||||||
productOrServiceIDQualifier | Commonly Used | SV101_1 2000F | HC (HCPCS) N4 (National Drug Code) | 2/2 | ||
procedureCode | While not required strongly recommended as procedure code required by some payers if not sending previousReviewAuthorizationNumber or previousAdministrativeReferenceNumber | SV101_2 2000F | 1/48 | |||
procedureModifier1 | SV101_3 2000F | 2/2 | ||||
procedureModifier2 | SV101_4 2000F | 2/2 | ||||
procedureModifier3 | SV101_5 2000F | 2/2 | ||||
procedureModifier4 | SV101_6 2000F | 2/2 | ||||
procedureCodeDescription | SV101_7 2000F | 1/80 | ||||
procedureCode2 | SV101_8 2000F | 1/48 | ||||
serviceLineAmount | SV102 2000F | 1/18 | ||||
unitOrBasisForMeasurementCode | SV103 2000F | F2 (International Unit) MJ (Minutes) UN (Unit) | 2/2 | |||
serviceUnitCount | SV104 2000F | 1/15 | ||||
| Diagnosis | ||||||
diagnosisCodePointer1 | SV107_1 2000F | 1/2 | ||||
diagnosisCodePointer2 | SV107_2 2000F | 1/2 | ||||
diagnosisCodePointer3 | SV107_3 2000F | 1/2 | ||||
diagnosisCodePointer4 | SV107_4 2000F | 1/2 | ||||
epsdtIndicator | SV111 2000F | 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) | 1/1 | |||
| One of the follow Service Sections is Required | ||||||
| Institutional Service Information | ||||||
serviceLineRevenueCode | SV201 2000F | HC (HCPCS or CPT) N4 (National Drug Code) ZZ (ICD-10) | 1/48 | |||
productOrServiceIDQualifier | SV202_1 2000F | 2/2 | ||||
procedureCode | SV202_2 2000F | 1/48 | ||||
procedureModifier1 | SV202_3 2000F | 2/2 | ||||
procedureModifier2 | SV202_4 2000F | 2/2 | ||||
procedureModifier3 | SV202_5 2000F | 2/2 | ||||
procedureModifier4 | SV202_6 2000F | 2/2 | ||||
procedureCodeDescription | SV202_7 2000F | 1/80 | ||||
procedureCode2 | SV202_8 2000F | 1/48 | ||||
serviceLineAmount | SV203 2000F | 1/18 | ||||
unitOrBasisForMeasurementCode | SV204 2000F | DA (Days) F2 (International Unit) UN (Unit) | 2/2 | |||
serviceUnitCount | SV205 2000F | 1/15 | ||||
serviceLineRate | SV206 2000F | 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)) | 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) | 1/1 | |||
| Dental Service Information | ||||||
procedureCode | SV301_2 2000F | SV301_1=AD | 1/48 | |||
procedureModifier1 | SV301_3 2000F | 2/2 | ||||
procedureModifier2 | SV301_4 2000F | 2/2 | ||||
procedureModifier3 | SV301_5 2000F | 2/2 | ||||
procedureModifier4 | SV301_6 2000F | 2/2 | ||||
procedureCodeDescription | SV301_7 2000F | 1/80 | ||||
procedureCode2 | SV301_8 2000F | 1/48 | ||||
serviceLineAmount | SV302 2000F | 1/18 | ||||
oralCavityDesignationCode | SV304_1 2000F | 1/3 | ||||
oralCavityDesignationCode2 | SV304_2 2000F | 1/3 | ||||
oralCavityDesignationCode3 | SV304_3 2000F | 1/3 | ||||
oralCavityDesignationCode4 | SV304_4 2000F | 1/3 | ||||
oralCavityDesignationCode5 | SV304_5 2000F | 1/3 | ||||
prosthesisCrownOrInlayCode | SV305 2000F | I (Initial Placement) R (Replacement) | 1/1 | |||
serviceUnitCount | SV306 2000F | 1/15 | ||||
description | SV307 2000F | 1/80 | ||||
| Tooth Information | ||||||
toothCode | TOO02 2000F | TOO01=JP | 1/30 | |||
toothSurfaceCode1 | TOO03_1 2000F | B (Buccal) D (Distal) F (Facial) I (Incisal) L (Lingual) M (Mesial) O (Occlusal) | 1/2 | |||
toothSurfaceCode2 | Use codes listed in TOO03_1 | TOO03_2 2000F | 1/2 | |||
toothSurfaceCode3 | Use codes listed in TOO03_1 | TOO03_3 2000F | 1/2 | |||
toothSurfaceCode4 | Use codes listed in TOO03_1 | TOO03_4 2000F | 1/2 | |||
toothSurfaceCode5 | Use codes listed in TOO03_1 | TOO03_5 2000F | 1/2 | |||
| healthCareServiceDelivery (Object) | ||||||
quantityQualifier | HSD01 2000F | DY (Days) FL (Units) HS (Hours) MN (Month) VS (Visits) | 2/2 | |||
serviceQuantity | HSD02 2000F | 1/15 | ||||
unitOrBasisForMeasurementCode | HSD03 2000F | DA (Days) MO (Months) WK (Week) | 2/2 | |||
sampleSelectionModulus | HSD04 2000F | 1/6 | ||||
timePeriodQualifier | HSD05 2000F | 6 (Hour) 7 (Day) 21 (Years) 26 (Episode) 27 (Visit) 29 (Remaining) 34 (Month) 35 (Week) | 1/2 | |||
periodCount | HSD06 2000F | 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) | 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) | 1/1 | |||
| attachments (Array of objects) | ||||||
| serviceProviderName (Array of objects) |
Patient Event Service Level Provider Name (Request)
| Name | Required/Commonly Used | Hint | Element Loop | Code | EDI Mapping Notes | Constraint |
|---|---|---|---|---|---|---|
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) | 2/3 | |||
Provider Name (if Provider is an individual, provide lastName and firstName, otherwise provide organizationName) | ||||||
organizationName | NM103 2010F | NM102=2 | 1/60 | |||
lastName | Commonly Used | NM103 2010F | 1/60 | |||
firstName | Commonly Used | NM104 2010F | NM102=1 | 1/35 | ||
middleName | NM105 2010F | 1/25 | ||||
namePrefix | NM106 2010F | 1/10 | ||||
nameSuffix | NM107 2010F | 1/10 | ||||
identificationCodeQualifier | Commonly Used | 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)) | 1/2 | ||
identifier | Commonly Used | NM109 2010F | 2/80 | |||
| Service Level Provider Address Information | ||||||
address1 | N301 2010F | 1/55 | ||||
address2 | N302 2010F | 1/55 | ||||
city | N401 2010F | 2/30 | ||||
state | N402 2010F | 2/2 | ||||
postalCode | N403 2010F | 3/15 | ||||
countryCode | N404 2010F | 2/3 | ||||
countrySubDivisionCode | N407 2010F | 1/3 | ||||
contactName | PER02 2010F | PER01=IC | 1/60 | |||
contactElectronicMail | PER04 PER06 PER08 | PER03=EM PER05=EM PER07=EM | 1/256 | |||
contactFacsimile | PER04 PER06 PER08 | PER03=FX PER05=FX PER07=FX | 1/256 | |||
contactTelephone | PER04 PER06 PER08 2010F | PER03=TE PER05=TE PER07=TE | 1/256 | |||
| Provider Supplemental Information (provide any of the following if available) | ||||||
stateLicenseNumber | REF02 2010F | REF01=0B | 1/50 | |||
licenseNumberStateCode | Required if StateLicenseNumber is entered | REF03 2010F | 1/80 | |||
providerUpinNumber | REF02 2010F | REF01=1G | 1/50 | |||
facilityIdNumber | REF02 2010F | REF01=1J | 1/50 | |||
employersIdentificationNumber | REF02 2010F | REF01=EI | 1/50 | |||
providerPlanNetworkIdentificationNumber | REF02 2010F | REF01=N5 | 1/50 | |||
facilityNetworkIdentificationNumber | REF02 2010F | REF01=N7 | 1/50 | |||
ssn | REF02 2010F | REF01=SY | 1/50 | |||
carrierAssignedReferenceNumber | REF02 2010F | REF01=ZH | 1/50 | |||
providerCode | PRV01 2010F | AS (Assistant Surgeon) OP (Operating) OR (Ordering) OT (Other Physician) PC (Primary Care Physician) PE (Performing) | PRV02=PXC | 1/3 | ||
providerTaxonomyCode | PRV03 2010F | 1/50 |
Submission 278 Response
Identification Header (Response)
| Name | Required/Commonly Used | Element Loop | EDI Mapping Notes | Constraint |
|---|---|---|---|---|
| Header Section | ||||
submitterTransactionIdentifier | Required | BHT03 N/A | 1/50 | |
payerId | NM109 2010A | 2/80 | ||
payerName | NM103 2010A | 1/60 | ||
umClearingHouseId | GS03 N/A | 2/15 | ||
| Address Information | ||||
contactName | PER02 | 1/60 | ||
contactElectronicMail | PER04 PER06 PER08 2010A | PER03=EM PER05=EM PER07=EM | 1/256 | |
contactFacsimile | PER04 PER06 PER08 2010A | PER03=FX PER05=FX PER07=FX | 1/256 | |
contactTelephone | Commonly Used | PER04 PER06 PER08 2010A | PER03=TE PER05=TE PER07=TE | 1/256 |
contactTelephoneExtension | PER06 PER08 2010A | PER05=EX PER07=EX | 1/256 | |
contactUrl | PER04 PER06 PER08 2010A | PER03=UM PER05=UM PER07=UM | 1/256 | |
requestValidation (Array of objects) | ||||
umRequestValidation (Array of objects) |
Request Validation (Response)
| Name | Element Loop | Description | Constraint |
|---|---|---|---|
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 | Constraint |
|---|---|---|---|
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 | Required/Commonly Used | Hint | Element Loop | Code | EDI Mapping Notes | Constraint |
|---|---|---|---|---|---|---|
| Requester Information Section | Required | |||||
requesterType | Required | Default=1P | NM101 2010B | 1P Provider 2A Federal, State, County or City Facility 2B Third-Party Administrator 36 Employer FA Facility PR Payer X3 Utilization Management Organization | 2/3 | |
Requester Name (if Requester is an individual, provide lastName and firstName, otherwise provide organizationName) | ||||||
organizationName | Commonly Used | NM103 2010B | NM102=2 | 1/60 | ||
lastName | NM103 2010B | NM102=1 | 1/60 | |||
firstName | NM104 2010B | NM102=1 | 1/35 | |||
| Identification Code (Provide one of the following) | Required | |||||
npi | Commonly Used | NM109 2010B | NM108=XX | 2/80 | ||
ssn | NM109 2010B | NM108=34 | 2/80 | |||
employersId | NM109 2010B | NM108=24 | 2/80 | |||
etin | NM109 2010B | NM108=46 | 2/80 | |||
providerCode | PRV01 2010B | AD (Admitting) AS (Assistant Surgeon) AT (Attending) CO (Consulting) CV (Covering) OP (Operating) OR (Ordering) OT (Other Physician) PC (Primary Care Physician) PE (Performing) RF (Referring) | PRV02=PXC | 1/3 | ||
referenceIdentification | PRV03 2010B | 1/50 | ||||
| Requester Identification (Provide any of the following if available) | ||||||
providerUpinNumber | REF02 2010B | REF01=1G | 1/50 | |||
facilityIdNumber | REF02 2010B | REF01=1J | 1/50 | |||
employerIdentificationNumber | REF02 2010B | REF01=EI | 1/50 | |||
providerSiteNumber | REF02 2010B | REF01=G5 | 1/50 | |||
providerPlanNetworkIdNumber | REF02 2010B | REF01=N5 | 1/50 | |||
facilityNetworkIdNumber | REF02 2010B | REF01=N7 | 1/50 | |||
socialSecurityNumber | REF02 2010B | REF01=SY | 1/50 | |||
carrierAssignedReferenceNumber | REF02 2010B | REF01=ZH | 1/50 | |||
requesterRequestValidation (Array of objects) | ||||||
responseCode | AAA01 2010B | N (No) Y (Yes) | 1/1 | |||
rejectReasonCode | AAA03 2010B | 2/2 | ||||
followupActionCode | AAA04 2010B | 1/1 |
Subscriber (Response)
| Name | Required/Commonly Used | Hint | Element Loop | Code | EDI Mapping Notes | Constraint |
|---|---|---|---|---|---|---|
| Subscriber Section | Required | |||||
lastName | Required | While not required by guide, widely used by payers | NM103 2010C | NM101=IL NM102=1 | 1/60 | |
firstName | Required | While not required by guide, widely used by payers | NM104 2010C | 1/35 | ||
middleName | NM105 2010C | 1/25 | ||||
prefix | NM106 2010C | 1/10 | ||||
suffix | NM107 2010C | 1/10 | ||||
memberId | Required | NM109 2010C | NM108=MI | 2/80 | ||
dateOfBirth | Required | While not required by guide, widely used by payers | DMG02 2010C | DMG01=D8 YYYYMMDD | 1/35 | |
genderCode | DMG03 2010C | F (Female) M (Male) U (Unknown) | 1/1 | |||
| Requester Address Information | ||||||
address1 | Commonly Used | N301 2010C | 1/55 | |||
address2 | Commonly Used | N302 2010C | 1/55 | |||
city | Commonly Used | N401 2010C | 2/30 | |||
state | Commonly Used | N402 2010C | 2/2 | |||
postalCode | Commonly Used | N403 2010C | 3/15 | |||
countryCode | N404 2010C | 2/3 | ||||
countrySubDivisionCode | N407 2010C | 1/3 | ||||
insuredIndicator | INS01 2010C | Y (Yes) N (No) | 1/1 | |||
militaryRelationship | INS08 2010C | AO (Active Military - Overseas) AU (Active Military - USA) DI (Deceased) PV (Previous) RU (Retired Military - USA) | 2/2 | |||
| Subscriber Supplemental Identification (Provide any of the following if available) | ||||||
policyNumber | REF02 2010C | REF01=1L | 1/50 | |||
branchIdentifier | REF02 2010C | REF01=3L | 1/50 | |||
groupNumber | Commonly Used | REF02 2010C | REF01=6P | 1/50 | ||
departmentNumber | REF02 2010C | REF01=DP | 1/50 | |||
patientAccountNumber | REF02 2010C | REF01=EJ | 1/50 | |||
healthInsuranceClaimNumber | REF02 2010C | REF01=F6 | 1/50 | |||
idCard | REF02 2010C | REF01=HJ | 1/50 | |||
insurancePolicyNumber | REF02 2010C | REF01=IG | 1/50 | |||
planNetworkIdentificationNumber | REF02 2010C | REF01=N6 | 1/50 | |||
medicaidRecipientIdentificationNumber | REF02 2010C | REF01=NQ | 1/50 | |||
ssn | Commonly Used | REF02 2010C | REF01=SY | 1/50 | ||
| subscriberRequestValidation (Array of objects) | ||||||
responseCode | AAA01 2010C | N (No) Y (Yes) | 1/1 | |||
rejectReasonCode | AAA03 2010C | 2/2 | ||||
followupActionCode | AAA04 2010C | 1/1 |
Dependent (Response)
| Name | Required/Commonly Used | Element Loop | Code | EDI Mapping Notes | Constraint |
|---|---|---|---|---|---|
| Dependent Section (Required if Patient is a dependent of the Insured Individual) | |||||
lastName | Required | NM103 2010D | NM101=QC NM102=1 | 1/60 | |
firstName | Required | NM104 2010D | 1/35 | ||
middleName | NM105 2010D | 1/25 | |||
suffix | NM107 2010D | 1/10 | |||
memberId | NM109 2010D | NM108=MI | 2/80 | ||
dateOfBirth | Required | DMG02 2010D | DMG01=D8 YYYYMMDD | 1/35 | |
genderCode | DMG03 2010D | F (Female) M (Male) U (Unknown) | 1/1 | ||
address1 | Required | N301 2010D | 1/55 | ||
address2 | Required | N302 2010D | 1/55 | ||
city | Required | N401 2010D | 2/30 | ||
state | Required | N402 2010D | 2/2 | ||
postalCode | Required | N403 2010D | 3/15 | ||
countryCode | N404 2010D | 2/3 | |||
countrySubDivisionCode | N407 2010D | 1/3 | |||
insuredIndicator | INS01 2010D | Y (Yes) N (No) | 1/1 | ||
relationshipToInsuredCode | INS02 2010D | 01 (Spouse) 19 (Child) G8 (Other Relationship) | 2/2 | ||
birthSequenceNumber | INS17 2010D | Y (Yes) N (No) | 1/9 | ||
| Dependent Supplemental Identification (Provide any of the following if available) | |||||
patientAccountNumber | REF02 2010D | REF01=EJ | 1/50 | ||
ssn | Commonly Used | REF02 2010D | REF01=SY | 1/50 | |
dependentRequestValidation (Array of objects) | |||||
responseCode | AAA01 2010D | N (No) Y (Yes) | 1/1 | ||
rejectReasonCode | AAA03 2010D | 2/2 | |||
followupActionCode | AAA04 2010D | 1/1 |
Patient Event Detail (Response)
| Name | Required/Commonly Used | Hint | Element Loop | Code | EDI Mapping Notes | Constraint |
|---|---|---|---|---|---|---|
| Patient Event Detail Section | Required | |||||
| Health Care Services Review Information | ||||||
requestCategoryCode | Commonly Used | UM01 2000E | AR (Admission Review) HS (Health Services Review) IN (Individual) SC (Specialty Care Review) | 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 | 01 (Pharmacy) 02 (TelehealthProvidedOtherthaninPatient’sHome) 03 (School) 04 (HomelessShelter) 05 (IndianHealthServiceFreestandingFacility) 06 (IndianHealthServiceProviderbasedFacility) 07 (Tribal638FreestandingFacility) 08 (Tribal638ProviderbasedFacility) 09 (Prison/CorrectionalFacility) 10 (TelehealthProvidedinPatient’sHome) 11 (Office) 12 (Home) 13 (AssistedLivingFacility) 14 (GroupHome) 15 (MobileUnit) 16 (TemporaryLodging) 17 (WalkinRetailHealthClinic) 18 (PlaceofEmploymentWorksite) 19 (OffCampusOutpatientHospital) 20 (UrgentCareFacility) 21 (InpatientHospital) 22 (OnCampusOutpatientHospital) 23 (EmergencyRoom–Hospital) 24 (AmbulatorySurgicalCenter) 25 (BirthingCenter) 26 (MilitaryTreatmentFacility) 27 (OutreachSite/Street) 28-30 (Unassigned) 31 (SkilledNursingFacility) 32 (NursingFacility) 33 (CustodialCareFacility) 34 (Hospice) 35-40 (Unassigned) 41 (AmbulanceLand) 42 (Ambulance–AirorWater) 43-48 (Unassigned) 49 (IndependentClinic) 50 (FederallyQualifiedHealthCenter) 51 (InpatientPsychiatricFacility) 52 (PsychiatricFacilityPartialHospitalization) 53 (CommunityMentalHealthCenter) 54 (IntermediateCareFacility/IndividualswithIntellectualDisabilities) 55 (ResidentialSubstanceAbuseTreatmentFacility) 56 (PsychiatricResidentialTreatmentCenter) 57 (NonresidentialSubstanceAbuseTreatmentFacility) 58 (NonresidentialOpioidTreatmentFacility) 59 (Unassigned) 60 (MassImmunizationCenter) 61 (ComprehensiveInpatientRehabilitationFacility) 62 (ComprehensiveOutpatientRehabilitationFacility) 63-64 (Unassigned) 65 (EndStageRenalDiseaseTreatmentFacility) 66 (ProgramsofAllInclusiveCarefortheElderly(PACE)Center*) 67-70 (Unassigned) 71 (PublicHealthClinic) 72 (RuralHealthClinic) 73-80 (Unassigned) 81 (IndependentLaboratory) 82-98 (Unassigned) 99 (OtherPlaceofService) | 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 | Should be sent if known by submitter | REF02 2000E | REF01=NT | R 1/50 | ||
previousReviewAuthorizationNumber | Commonly Used | Should be sent if known by submitter | REF02 2000E | REF01=BB | 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 | Commonly Used | Send if related to Health Services Review (UM01 = HS) or Referrals (UM01 = SC) | DTP03 2000E | DTP01=AAH DTP02=D8 YYYYMMDD | 1/35 | |
eventDateEnd | DTP03 2000E | DTP01=AAH DTP02=RD8 YYYYMMDD EventDateBegin must exist | R 1/35 | |||
admissionDateBegin | Send if related to Admission Review (UM01 = AR) | 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 | |||
| Diagnosis | ||||||
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 | Required/Commonly Used | Hint | Element | Code | EDI Mapping Notes | Constraint |
|---|---|---|---|---|---|---|
| Patient Event Provider Name Section (Can contain multiple instances) | ||||||
entityIdentifierCode | Commonly Used | 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) | 2/3 | ||
Mark> Provider Name (If Provider is an individual, provide lastName and firstName, otherwise provide organizationName) | ||||||
organizationName | NM103 2010EA | NM102=2 | 1/60 | |||
lastName | Commonly Used | NM103 2010EA | NM102=1 | 1/60 | ||
firstName | Commonly Used | NM104 2010EA | NM102=1 | 1/35 | ||
middleName | NM105 2010EA | 1/25 | ||||
namePrefix | NM106 2010EA | 1/10 | ||||
nameSuffix | NM107 2010EA | 1/10 | ||||
identificationCodeQualifier | Commonly Used | 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)) | 1/2 | ||
identifier | Commonly Used | NM109 2010EA | 2/80 | |||
| Patient Event Provider Address Information | ||||||
address1 | N301 2010EA | 1/55 | ||||
address2 | N302 2010EA | 1/55 | ||||
city | N401 2010EA | 2/30 | ||||
state | N402 2010EA | 2/2 | ||||
postalCode | N403 2010EA | 3/15 | ||||
countryCode | N404 2010EA | 2/3 | ||||
countrySubDivisionCode | N407 2010EA | 1/3 | ||||
contactName | PER02 2010EA | 1/60 | ||||
contactElectronicMail | PER04 PER06 PER08 2010EA | PER03=EM PER05=EM PER07=EM | 1/256 | |||
contactFacsimile | PER04 PER06 PER08 2010EA | PER03=FX PER05=FX PER07=FX | 1/256 | |||
contactTelephone | Commonly Used | PER04 PER06 PER08 2010EA | PER03=TE PER05=TE PER07=TE | 1/256 | ||
contactUrl | PER04 PER06 PER08 2010EA | PER03=UM PER05=UM PER07=UM | 1/256 | |||
providerCode | PRV01 2010EA | AD (Admitting) AS (Assistant Surgeon) AT (Attending) OP (Operating) OR (Ordering) OT (Other Physician) PC (Primary Care Physician) PE (Performing) RF (Referring) | PRV02=PXC | 1/3 | ||
providerTaxonomyCode | PRV03 2010EA | 1/50 | ||||
| Provider Supplemental Information (Provide any of the following if available) | ||||||
stateLicenseNumber | REF02 2010EA | REF01=0B | 1/50 | |||
licenseNumberStateCode | Required if StateLicenseNumber is entered | REF03 2010EA | 1/80 | |||
providerUpinNumber | REF02 2010EA | REF01=1G | 1/50 | |||
facilityIdNumber | REF02 2010EA | REF01=1J | 1/50 | |||
employersIdentificationNumber | REF02 2010EA | REF01=EI | 1/50 | |||
providerPlanNetworkIdentificationNumber | REF02 2010EA | REF01=N5 | 1/50 | |||
facilityNetworkIdentificationNumber | REF02 2010EA | REF01=N7 | 1/50 | |||
ssn | REF02 2010EA | REF01=SY | 1/50 | |||
carrierAssignedReferenceNumber | REF02 2010EA | REF01=ZH | 1/50 | |||
patientEventProviderRequestValidation (Array of objects) | - | |||||
responseCode | AAA01 2010EA | 1/1 | ||||
rejectReasonCode | AAA03 2010EA | 2/2 | ||||
followupActionCode | AAA04 2010EA | 1/1 |
Patient Event Additional Patient Information Contact Name (Response)
| Name | Element Loop | Code | Constraint |
|---|---|---|---|
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 | Code | EDI Mapping Notes | Constraint |
|---|---|---|---|---|
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 2010EC | N (No) Y (Yes) | R 1/1 | |
rejectReasonCode | AAA03 2010EC | R 2/2 | ||
followupActionCode | AAA04 2010EC | R 1/1 |
Patient Event Service Level (Response)
| Name | Required/Commonly Used | Hint | Element | Code | EDI Mapping Notes | Constraint |
|---|---|---|---|---|---|---|
| Service Level Section (One instance per procedure code) | Required | R 1/2 | ||||
| Health Care Services Review Information | ||||||
requestCategoryCode | Commonly Used | 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 | Commonly Used | UM04_1 2000F | 01 (Pharmacy) 02 (TelehealthProvidedOtherthaninPatient’sHome) 03 (School) 04 (HomelessShelter) 05 (IndianHealthServiceFreestandingFacility) 06 (IndianHealthServiceProviderbasedFacility) 07 (Tribal638FreestandingFacility) 08 (Tribal638ProviderbasedFacility) 09 (Prison/CorrectionalFacility) 10 (TelehealthProvidedinPatient’sHome) 11 (Office) 12 (Home) 13 (AssistedLivingFacility) 14 (GroupHome) 15 (MobileUnit) 16 (TemporaryLodging) 17 (WalkinRetailHealthClinic) 18 (PlaceofEmploymentWorksite) 19 (OffCampusOutpatientHospital) 20 (UrgentCareFacility) 21 (InpatientHospital) 22 (OnCampusOutpatientHospital) 23 (EmergencyRoom–Hospital) 24 (AmbulatorySurgicalCenter) 25 (BirthingCenter) 26 (MilitaryTreatmentFacility) 27 (OutreachSite/Street) 28-30 (Unassigned) 31 (SkilledNursingFacility) 32 (NursingFacility) 33 (CustodialCareFacility) 34 (Hospice) 35-40 (Unassigned) 41 (AmbulanceLand) 42 (Ambulance–AirorWater) 43-48 (Unassigned) 49 (IndependentClinic) 50 (FederallyQualifiedHealthCenter) 51 (InpatientPsychiatricFacility) 52 (PsychiatricFacilityPartialHospitalization) 53 (CommunityMentalHealthCenter) 54 (IntermediateCareFacility/IndividualswithIntellectualDisabilities) 55 (ResidentialSubstanceAbuseTreatmentFacility) 56 (PsychiatricResidentialTreatmentCenter) 57 (NonresidentialSubstanceAbuseTreatmentFacility) 58 (NonresidentialOpioidTreatmentFacility) 59 (Unassigned) 60 (MassImmunizationCenter) 61 (ComprehensiveInpatientRehabilitationFacility) 62 (ComprehensiveOutpatientRehabilitationFacility) 63-64 (Unassigned) 65 (EndStageRenalDiseaseTreatmentFacility) 66 (ProgramsofAllInclusiveCarefortheElderly(PACE)Center*) 67-70 (Unassigned) 71 (PublicHealthClinic) 72 (RuralHealthClinic) 73-80 (Unassigned) 81 (IndependentLaboratory) 82-98 (Unassigned) 99 (OtherPlaceofService) | R 1/2 | ||
facilityCodeQualifier | Commonly Used | 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 | Commonly Used | Usually same as 2000E Event Date | 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 | ||||
| One of the follow Service Sections is Required | Required | |||||
| Professional Service Information | ||||||
productOrServiceIDQualifier | Commonly Used | SV101_1 2000F | HC (HCPCS) N4 (National Drug Code) | R 2/2 | ||
procedureCode | Commonly Used | While not required strongly recommended as procedure code required by some payers if not sending previousReviewAuthorizationNumber or previousAdministrativeReferenceNumber | 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 Information | ||||||
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 | |||
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 | ||||
| Dental Service Information | ||||||
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 | ||||
| Tooth Information | ||||||
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 | Required/Commonly Used | Element Loop | Code | EDI Mapping Notes | Constraint |
|---|---|---|---|---|---|
| Service Level Provider Name Section (Can contain multiple instances) | |||||
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 | ||
Provider Name (If Provider is an individual, provide lastName and firstName, otherwise provide organizationName) | |||||
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 | |||
| Service Level Provider Address Information | |||||
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 | 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 | AS (Assistant Surgeon) OP (Operating) OR (Ordering) OT (Other Physician) PC (Primary Care Physician) PE (Performing) | PRV02=PXC | R 1/3 | |
providerTaxonomyCode | PRV03 2010FA | R 1/50 | |||
| Provider Supplemental Information (Provide any of the following if available) | |||||
providerSupplementalInformation(Object) | |||||
stateLicenseNumber | REF02 2010FA | REF01=0B | R 1/50 | ||
licenseNumberStateCode | Required if StateLicenseNumber is entered | REF03 2010FA | 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 | Code | EDI Mapping Notes | 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 | ||
| Service Level Provider Address Information | ||||
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 | ||
| Contact Information | ||||
contactName | PER02 2010FB | PER01 = IC | S 1/60 | |
contactElectronicMail | PER04 PER06 PER08 2010FB 2010FB | PER03=EM PER05=EM PER07=EM | S 1/256 | |
contactFacsimile | PER04 PER06 PER08 2010FB 2010FB | PER03=FX PER05=FX PER07=FX | S 1/256 | |
contactTelephone | PER04 PER06 PER08 2010FB 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 16 hours ago