837 P 5010A1 Conversion Business Impacts · 837 P 5010A1 Conversion Business Impacts Title Business impacts in conversion of the 837P transaction to 5010A1 5010A1 Transaction Identifier

837 P 5010A1 Conversion Business Impacts

Title Business impacts in conversion of the 837P transaction to 5010A1

5010A1 Transaction Identifier 005010X222A1

Prepared By

Michael Stevens

Date February 1, 2010

Ingenix Confidential: Unauthorized access, copying, replication, and distribution is prohibited. This document must not be copied in whole or part by

any means, without the written authorization of Ingenix.

Page 2 of 140

Table of Contents Table of Contents ............................................................................................................................................2 Description......................................................................................................................................................4 General............................................................................................................................................................4 Conventions ....................................................................................................................................................4 Front Matter and Transaction Usage Changes ................................................................................................5 Coordination of Benefits Changes...............................................................................................................5 Provider Identification Changes..................................................................................................................5 Billing/Pay-to Provider Loop Changes .......................................................................................................5 Subscriber/Dependent Loop Usage Changes ..............................................................................................6 Loop and Segment changes from 4010A1 to 5010 .....................................................................................7 Loops deleted from the 4010A1 standard ...............................................................................................7 Loops added in the 5010 standard...........................................................................................................7 Loops moved in the 5010 Standard.........................................................................................................7 Segments deleted from the 4010A1 standard ..........................................................................................7 Segments added in the 5010 standard .....................................................................................................9

Data element changes with business impacts. ...............................................................................................10 Interchange Header Changes.....................................................................................................................10 Transaction Header ...................................................................................................................................10 Loop 1000A Submitter Name ...................................................................................................................11 Loop 1000B Receiver Name.....................................................................................................................12 Loop 2000A Billing/Pay-to Hierarchical Level ........................................................................................12 Loop 2010AA Billing Provider Name ......................................................................................................12 Loop 2010AB Pay-to Provider Name .......................................................................................................17 Loop 2010AC Pay-to Loop Name (New in 5010) ....................................................................................19 Loop 2000B Subscriber Information.........................................................................................................22 Loop 2010BA Subscriber Name ...............................................................................................................24 Loop 2010BB Payer Name .......................................................................................................................26 Loop 2010BC Responsible Party (Deleted in 5010) .................................................................................28 Loop 2010BD Credit/Debit Card Holder (Deleted in 5010).....................................................................29 Loop 2000C Patient Information...............................................................................................................30 Loop 2010CA Patient Name .....................................................................................................................32 Loop 2300 Claim Information...................................................................................................................34 Loop 2305 Home Health Care Plan Information (Loop Deleted in 5010) ................................................53 Loop 2310A Referring Provider Name .....................................................................................................54 Loop 2310B Rendering Provider Name....................................................................................................56

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Loop 2310C Purchased Service Provider (Deleted in 5010) ....................................................................60 Loop 2310C Service Facility Location .....................................................................................................61 Loop 2310D Supervising Provider Name Loop Changes .........................................................................65 Loop 2310E Ambulance Pick Up Location (New in 5010) ......................................................................67 Loop 2310F Ambulance Drop Off Location (New in 5010) .....................................................................68 Loop 2320 Other Subscriber Information .................................................................................................70 Loop 2330A Other Subscriber Name........................................................................................................81 Loop 2330B Other Payer Name................................................................................................................82 Loop 2330C Other Payer Name (Deleted in 5010) ...................................................................................84 Loop 2330C Other Payer Referring Provider............................................................................................85 Loop 2330D Other Payer Rendering Provider ..........................................................................................86 Loop 2330E Other Payer Service Facility Location..................................................................................87 Loop 2330F Other Payer Purchased Service Provider (Deleted in 5010) .................................................89 Loop 2330F Other Payer Supervising Provider ........................................................................................89 Loop 2330G Other Payer Billing Provider (New in 5010) .......................................................................91 Loop 2400 Service Line ............................................................................................................................93 Loop 2410 Drug Identification................................................................................................................109 Loop 2420A Rendering Provider ............................................................................................................111 Loop 2420B Purchased Service Provider ...............................................................................................114 Loop 2420C Service Facility Location ...................................................................................................116 Loop 2420D Supervising Provider Name ...............................................................................................119 Loop 2420E Ordering Provider Name ....................................................................................................122 Loop 2420F Referring Provider Name....................................................................................................125 Loop 2420G Other Payer Prior Authorization or Referral Number ........................................................128 Loop 2420G Ambulance Pick Up Location (New in 5010) ....................................................................129 Loop 2420H Ambulance Drop Off Location (New in 5010) ..................................................................131 Loop 2430 Line Adjudication Information Changes...............................................................................133 Loop 2440 Supporting Documentation ...................................................................................................134 Interchange Trailer Changes ...................................................................................................................135

Appendices..................................................................................................................................................136 Change Log .............................................................................................................................................136

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Description

This document provides an assessment of the business impacts of the conversion from the 4010A1 to 5010 standard of the 837P transaction set.

It looks at the Front Matter changes between the 4010A1 Implementation Guide and the 5010 Technical Report 3 (TR3) documents for the 837P.

It also looks at code, qualifier and usage changes within the 5010 837P transactions.

General The 5010 HIPAA implementation renames the 4010 implementation guides to ‘Technical Report 3’ documents. This document will refer to the 5010

implementation standards as TR3’s.

Conventions Loops, segments, and elements impacted by the conversion from 4010A1 to 5010 are presented in this document in table format.

The tables show loop, segment, and element usage changes specific to the 837P transaction, and details the changes between the 4010A1 and 5010 standards.

Text highlighted in yellow shows loops, segments, elements and values deleted from the 4010A1 to 5010 standard

Text highlighted in light blue shows loops, segments, elements and values added in the 5010 standard.

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Front Matter and Transaction Usage Changes There were significant changes to section 1 of the TR3 that change the business usage rules for the 837P transaction. (Section 1.3 of the 4010A1 IG, Section

1.4 of the 5010 TR3).

Coordination of Benefits Changes The 5010 implementation of the 837P significantly enhances handling of Coordination of Benefit claims. These changes are designed to minimize manual

intervention and the use of paper supporting documentation. Support for electronic COB is based on the coordinated use of the 837 and 835 transactions.

Section 1.4.1 of the TR3 for the 837P contains a detailed explanation of the COB changes to the transaction.

Provider Identification Changes In the 5010 standard, NPI is the only valid primary identifier for a provider. In provider loops, the provider identification qualifier (NM108) is restricted to the

value ‘XX’.

In order to support atypical providers, the NM108/NM109 elements are now, when used, situational elements in any provider loop. These elements will be

omitted for providers that do not qualify for an NPI.

The usage rule for NM108/NM109 elements in provider loops is as follows:

SITUATIONAL RULE: Required for providers on or after the mandated HIPAA National Provider Identifier (NPI) implementation date when the provider has received an NPI and the NPI is available to the submitter. OR Required for providers prior to the mandated HIPAA NPI implementation date when the provider has received an NPI and the submitter has the capability to send it. If not required by this implementation guide, do not send.

Billing/Pay-to Provider Loop Changes In the 5010 standard, Pay-to Provider no longer exists as an entity distinct from Billing Provider.

In the 5010 standard, the pay-to loop (Loop 2010AB) only contains a pay-to address when different from the billing provider address. It does not contain any

provider identification.

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Subscriber/Dependent Loop Usage Changes The rules for usage of the dependent/patient loop (2000C) have changed in the 5010 standard. The rules for identifying member and dependent are defined on

page 114 of the TR3 as follows:

1. If a patient can be uniquely identified to the destination payer in Loop ID-2010BB by a unique Member Identification Number, then the patient is the

subscriber or is considered to be the subscriber and is identified at this level, and the patient HL in Loop ID-2000C is not used.

2. If the patient is not the subscriber and cannot be identified to the destination payer by a unique Member Identification Number or it is not known to the

sender if the Member Identification number is unique, both this HL and the patient HL in Loop ID- 2000C are required.

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Loop and Segment changes from 4010A1 to 5010 This section provides an overview of the loop and segment changes between the 4010A1 and 5010 versions of the 837P. A detailed listing of segment/element

impacts for each of these changes is listed in the next section of this document.

Loops deleted from the 4010A1 standard

Loop Loop Name

2010BC Responsible Party

2010BD Credit/Debit Card Holder

2310C Purchased Service Provider

2330C Other Payer Patient Identification

2330F Other Payer Purchased Service Provider

2420G Other Payer Prior Authorization or Referral Number

Loops added in the 5010 standard

Loop Loop Name

2010AC Pay-to Plan

2310E Ambulance Pick Up Location

2310F Ambulance Drop Off Location

2330G Other Payer Billing Provider

2420G Ambulance Pick Up Location

2420H Ambulance Drop Off Location

Loops moved in the 5010 Standard

Loop Name 4010A1 Loop 5010 Loop

Service Facility Loop 2310D 2310C

Supervising Provider Name 2310E 2310D

Other Payer Referring Provider 2330D 2330C

Other Payer Rendering Provider 2330E 2330D

Other Payer Service Facility Location 2330G 2330E

Other Payer Supervising Provider 2330H 2330F

Segments deleted from the 4010A1 standard

This is a list of 4010A1 segments deleted from the 5010 standard where the loops these segments were used in were not deleted

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Loop Segment Segment Name

Transaction

Header

REF Transmission Type Identification

2010AA REF Credit/Debit Card Billing Information

2010AB REF Pay-to Provider Secondary Identification

2010CA REF Patient Secondary Identification Segment

2300 DTP Date – Similar Illness/Symptom Onset

2300 AMT Credit/Debit Card Maximum Amount

2300 AMT Total Purchased Service Amount

2300 REF Ambulatory Patient Group (APG)

2305 CR7 Home Health Care Plan Information

2305 HSD Health Care Services Delivery

2310A PRV Referring Provider Specialty Information

2320 AMT COB Approved Amount

2320 AMT COB Allowed Amount

2320 AMT COB Patient Responsibility Amount

2320 AMT COB Covered Amount

2320 AMT COB Discount Amount

2320 AMT COB Per Day Limit Amount

2320 AMT COB Patient Paid Amount

2320 AMT COB Tax Amount

2320 AMT COB Total Claim Before Taxes Amount

2320 DMG Subscriber Demographic Information

2330B PER Other Payer Contact Information

2400 CR2 Spinal Manipulation Service Information

2400 CR5 Home Oxygen Therapy Information

2400 DTP Date – Oxygen Saturation/Arterial Blood Gas Test

2400 DTP Date – Acute Manifestation


2400 REF Ambulatory Patient Group

2400 REF Oxygen Flow Rate

2400 REF Universal Product Number

2400 AMT Approved Amount

2400 HSD Health Care Services Delivery

2420F PRV Referring Provider Specialty Information

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Segments added in the 5010A1 standard

This is a list of segments added to existing loops in the 5010 standard.

Loop Segment Segment Name

2010AA REF Billing Provider UPIN/License Information

2010BA PER Property and Casualty Subscriber Contact information

2010BB REF Billing Provider Secondary Identification

2010CA REF Property and Casualty Patient Identifier

2010CA PER Property and Casualty Patient Contact information

2300 DTP Date – Property and Casualty Date of First Contact

2300 DTP Date – Repricer Received Date

2300 REF Care Plan Oversight

2300 HI Anesthesia Related Procedure

2300 HI Condition Information

2310C PER Service Facility Location Contact information

2320 AMT COB Total Non-Covered Amount

2320 AMT Remaining Patient Liability

2330B N3 Other Payer Address

2330B N4 Other Payer City/State/Zip Code

2330B REF Other Payer Claim Control Number

2400 PWK Line Supplemental Information

2400 QTY Ambulance Patient Count

2400 QTY Obstetric Anesthesia Additional Units

2400 REF Referral Number

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Data element changes with business impacts. This section lists all data elements that have changed, and analyzes business impacts for those changes.

Interchange Header Changes

Loop Segment /

Element Element Name

4010

Valid Values

and

Descriptions

5010

Valid Values

and

Descriptions

5010A1

Valid Values

and

Descriptions

Notes

N/A ISA Segment Repeat: Not specified

Segment Repeat: 1 Segment Repeat deleted

Change in Segment Repeat

N/A ISA11

4010: Interchange Control Version Number 5010 : Repetition Separator

U Defined between trading partners

This element is a delimiter in the 5010 standard, and must not occur in data.

N/A ISA12 Interchange Control Version Number 00401 00501

N/A GS Segment Repeat: Not specified



N/A GS08 Version Release / Industry Code Identifier

004010X098A1 005010X222 005010X222A1

Transaction Header

Loop Segment /


4010

Valid Values

and

Descriptions

5010

Valid Values

and

Descriptions

5010A1

Valid Values

and

Descriptions

Notes

N/A ST03 Implementation Convention Reference

005010X222 005010X222A1 New element in 5010

N/A BHT03 Reference Identification Length: 1 - 30 Length: 1 - 50 Maximum length increase from 30 - 50

N/A BHT06 Transaction Type Code

CH: Chargeable RP: Reporting

31: Subrogation Demand

CH: Chargeable RP: Reporting

TR3 usage rules for ‘31’ – Subrogation Demand:

The subrogation demand code is only for use by state

Medicaid agencies performing post payment recovery

claiming with willing trading partners.

NOTE: At the time of this writing, Subrogation Demand

is not a HIPAA mandated use of the 837 transaction.

N/A REF Transmission Type Identification Segment Deleted This segment is not used in the 5010 standard

N/A REF01 Transmission Type Identification Reference Identification Qualifier

Element Deleted 87:

N/A REF02 Transmission Type Identification Element Deleted

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Loop 1000A Submitter Name

Loop Segment /


4010

Valid Values

and

Descriptions

5010

Valid Values

and

Descriptions

5010A1

Valid Values

and

Descriptions

Notes

1000A NM103 Submitter Name Name Last or organization Name

Length: 1 - 35 Length: 1 - 60 Maximum length increase from 35 - 60

1000A NM104 Submitter Name Name First

Length: 1 - 25 Length: 1 - 35

Maximum length increase from 25 - 35 New TR3 rule:

SITUATIONAL RULE: Required when NM102 = 1 (person)

and the person has a first name. If not required by this

implementation guide, do not send.

Functionally, this element is no longer required when NM102 is ‘1’ – Person.

1000A PER03 Submitter EDI Contact Information Communications Number Qualifier

ED: Electronic Data Interchange Access Number

EM: Electronic Mail

FX: Facsimile TE: Telephone

EM: Electronic Mail FX: Facsimile TE: Telephone

Code Deleted

1000A PER05 PER07

Submitter EDI Contact Information Communications Number Qualifier

ED: Electronic Data Interchange Access Number

EM: Electronic Mail

EX: Telephone Extension

FX: Facsimile TE: Telephone

EM: Electronic Mail EX: Telephone

Extension FX: Facsimile TE: Telephone

Code Deleted

1000A PER04 PER06 PER08

Submitter EDI Contact Information Communication Number

Length: 1 - 80 Length: 1 - 256 Maximum length increase from 80 – 256

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Loop 1000B Receiver Name

Loop Segment /


4010

Valid Values

and

Descriptions

5010

Valid Values

and

Descriptions

5010A1

Valid Values

and

Descriptions

Notes

1000B NM103 Receiver Name Name Last or organization Name


Loop 2000A Billing/Pay-to Hierarchical Level

Loop Segment /


4010

Valid Values

and

Descriptions

5010

Valid Values

and

Descriptions

5010A1

Valid Values

and

Descriptions

Notes

2000A PRV01 Billing/Pay-to Specialty Information Provider Code

BI: Billing PT: Pay-To

BI: Billing Code Deleted

2000A PRV02 Billing/Pay-to Specialty Information Reference Identification Qualifier

ZZ: Mutually Defined

PXC: Health Care Provider Taxonomy Code

Qualifier change only, Usage intent to indicate Taxonomy code has not changed.

2000A PRV03 Billing/Pay-to Specialty Information Provider Taxonomy Code

Length: 1 - 30 Length: 1 - 50 Valid Taxonomy code is 10 bytes in length, this change should have no functional impact.

Loop 2010AA Billing Provider Name

Loop Segment /


4010

Valid Values

and

Descriptions

5010

Valid Values

and

Descriptions

5010A1

Valid Values

and

Descriptions

Notes

2010AA NM103 Billing Provider Name Name Last or organization Name


2010AA NM104 Billing Provider Name Name First


Maximum length increase from 25 – 35 New TR3 rule:

SITUATIONAL RULE: Required when NM102 = 1 (person) and

the person has a first name. If not required by this



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Loop Segment /


4010

Valid Values

and

Descriptions

5010

Valid Values

and

Descriptions

5010A1

Valid Values

and

Descriptions

Notes

2010AA NM108 Billing Provider Name Identification Code Qualifier

Usage: Required 24: Employer’s

Identification Number

34: Social Security Number

XX: Health Care Financing Administration National Provider Identifier

Usage: Situational XX: Health Care

Financing Administration National Provider Identifier

Usage changed from required to situational: TR3 rule:

SITUATIONAL RULE: Required for providers in the

United States or its territories on or after the mandated

HIPAA National Provider Identifier (NPI) implementation

date when the provider is eligible to receive an NPI.

OR

Required for providers not in the United States or its

territories on or after the mandated HIPAA National

Provider Identifier (NPI) implementation date when the

provider has received an NPI.

OR

Required for providers prior to the mandated NPI

implementation date when the provider has received an

NPI and the submitter has the capability to send it.

If not required by this implementation guide, do not

send.

With the 5010 implementation, this qualifier now supports only the identifier for NPI

2010AA NM109 Billing Provider Name Billing Provider Identifier

Usage: Required Usage: Situational



United States or its territories on or after the mandated

HIPAA National Provider Identifier (NPI) implementation

date when the provider is eligible to receive an NPI.

OR





OR





send. In 4010A1, could be Tax ID, SSN, or NPI. In 5010, must be NPI

Page 14 of 140

Loop Segment /


4010

Valid Values

and

Descriptions

5010

Valid Values

and

Descriptions

5010A1

Valid Values

and

Descriptions

Notes

2010AA N402 Billing Provider Address State or Province code


Segment N4 now supports international addresses. Changed from required to Situational TR3 Rule:

SITUATIONAL RULE: Required when address is in the United

States of America, including its territories, or Canada. If

not required by this implementation guide, do not send.

2010AA N403 Billing Provider Address Postal code


Changed from required to Situational TR3 Rule:

SITUATIONAL RULE: Required when the address is in the

United States of America, including its territories, or

Canada, or when a postal code exists for the country in

N404. If not required by this implementation guide, do

not send.

2010AA N407 Billing Provider Address Country Subdivision Code

New Element in 5010

Usage: Situational TR3 Rule:

SITUATIONAL RULE: Required when the address is not in the


Canada, and the country in N404 has administrative

subdivisions such as but not limited to states,

provinces, cantons, etc. If not required by this


2010AA REF Billing Provider Secondary Identification Segment

Usage: Situational

Usage: Required Name Change: BILLING PROVIDER TAX IDENTIFICATION

Usage change from situational to required Billing Provider Tax ID or SSN is now required in this segment REF Segment added in 5010 standard for Billing Provider UPIN/License information documented below

Page 15 of 140

Loop Segment /


4010

Valid Values

and

Descriptions

5010

Valid Values

and

Descriptions

5010A1

Valid Values

and

Descriptions

Notes

2010AA REF01 Billing Provider Tax Identification Reference Identification Qualifier

0B: State License Number

1A: Blue Cross Provider Number

1B: Blue Shield Provider Number

1C: Medicare Provider Number

1D: Medicaid Provider Number

1G: Provider UPIN Number

1H: CHAMPUS Identification Number

1J: Facility ID Number

B3: Preferred Provider Organization Number

BQ: Health Maintenance Organization Code Number

EI: Employer’s Identification Number

FH: Clinic Number

G2: Provider Commercial Number

G5: Provider Site Number

LU: Location Number

SY: Social Security Number

U3: Unique Supplier Identification Number (USIN)

X5: State Industrial Accident

EI: Employer’s


SY: Social Security

Number

Qualifier now restricted to only Tax ID or SSN

Page 16 of 140

Loop Segment /


4010

Valid Values

and

Descriptions

5010

Valid Values

and

Descriptions

5010A1

Valid Values

and

Descriptions

Notes

2010AA REF02 Billing Provider Tax Identification Length: 1 - 30 Length: 1 - 50

Length change from 30 to 50 In 5010, valid value restricted to Tax ID or SSN. Length change should have no business impact in this loop.

2010AA REF Billing Provider UPIN/License information

New Segment Usage: Situational Repeat: 2

TR3 usage rule:

Situational Rule: Required prior to the mandated HIPAA

National Provider Identifier (NPI) implementation date

when a UPIN and/or license number is necessary for the

receiver to identify the provider.

OR

Required on or after the mandated NPI implementation

date when NM109 of this loop is not used and a UPIN or

license number is necessary for the receiver to identify

the provider.


send.

TR3 Notes: 1. Payer specific secondary identifiers are

reported in the Loop ID-2010BB REF, Billing Provider

Secondary Identification. The functionality in this segment was a part of the 4010A1 ‘Billing Provider Secondary Identification’ segment.

2010AA REF01

Billing Provider UPIN/License information Reference Identification Qualifier

New Element 0B: State License

Number 1G: Provider UPIN

Number

Usage: Required

2010AA REF02

Billing Provider UPIN/License information Billing Provider UPIN and/or License information

New Element Length: 1 - 50

Usage: Required

2010AA REF Credit/Debit Card Billing Information Segment Deleted This segment is not used in the 5010 standard Credit/Debit card information is not included in any loop in the 5010 standard

2010AA REF01 Credit/Debit Card Billing Information Reference Identification Qualifier

Element Deleted

2010AA REF02 Credit/Debit Card Billing Information Element Deleted

Page 17 of 140

Loop Segment /


4010

Valid Values

and

Descriptions

5010

Valid Values

and

Descriptions

5010A1

Valid Values

and

Descriptions

Notes

2010AA PER02 Billing Provider Contact Information Name


Usage Change TR3 Rule:

SITUATIONAL RULE: Required in the first iteration of

the Billing Provider Contact Information segment. If not

required by this implementation guide, do not send.

2010AA PER04 PER06 PER08

Billing Provider Contact Information Communication Number


Loop 2010AB Pay-to Provider Name

Loop Segment /


4010

Valid Values

and

Descriptions

5010

Valid Values

and

Descriptions

5010A1

Valid Values

and

Descriptions

Notes

2010AB NM1 Pay-to Provider Name

Usage for the pay-to provider loop has changed significantly from 4010A1 to 5010. Pay-to provider no longer exists as an entity distinct from billing provider. In the 5010 standard, the pay-to loop only contains a pay-to address when different from the billing provider address. It does not contain any provider identification. TR3 rule:

Situational Rule: Required when the address for

payment is different than that of the Billing Provider. If


TR3 Notes: 1. The purpose of Loop ID-2010AB has

changed from previous versions. Loop ID-2010AB only

contains address information when different from the

Billing Provider Address. There are no applicable

identifiers for Pay-To Address information.

2010AB NM103 Pay-to Provider Name Last Name

Element Deleted

2010AB NM104 Pay-to Provider Name First Name

Element Deleted

2010AB NM105 Pay-to Provider Name Middle Name

Element Deleted

2010AB NM107 Pay-to Provider Name Name Suffix

Element Deleted

Page 18 of 140

Loop Segment /


4010

Valid Values

and

Descriptions

5010

Valid Values

and

Descriptions

5010A1

Valid Values

and

Descriptions

Notes

2010AB NM108 Pay-to Provider Name Identification Code Qualifier

Element Deleted

2010AB NM103 Pay-to Provider Name Identifier

Element Deleted

2010AB N402 Pay-to Provider Address State or Province code

Usage: Required

Usage: Situational Name change to Pay-to

Address – State or Provincial Code

Segment N4 now supports international addresses. Usage changed from required to situational TR3 Rule:




2010AB N403 Pay-to Provider Address Postal code

Usage: Required

Usage: Situational Name change to Pay-to Address – Postal

Code

Usage changed from required to situational TR3 Rule:





not send.

2010AB N407 Pay-to Provider Address Country Subdivision Code

New Element in 5010


SITUATIONAL RULE: Required when the address is not in

the United States of America, including its territories,

or Canada, and the country in N404 has administrative




2010AB REF Pay-to Provider Secondary Identification

Segment Deleted

This segment is not used in the 5010 standard Pay-to provider no longer exists as an entity distinct from billing provider. Pay-to provider loop contains pay-to address only.

2010AB REF01

Pay-to Provider Secondary Identification Reference Identification Qualifier

Element Deleted

2010AB REF02

Pay-to Provider Secondary Identification Pay-to Provider Secondary Identifier

Element Deleted

Page 19 of 140

Loop 2010AC Pay-to Loop Name (New in 5010)

Loop Segment /


4010

Valid Values

and

Descriptions

5010

Valid Values

and

Descriptions

5010A1

Valid Values

and

Descriptions

Notes

2010AC Pay-to Plan Name New Loop

TR3 Rule for loop usage:

Usage: SITUATIONAL

Situational Rule: Required when willing trading

partners agree to use this implementation for their

subrogation payment requests.

This loop may only be used when BHT06 = 31

2010AC NM1 Pay-to Plan Name New Segment Usage: Required when loop 2010AC is used

2010AC NM101 Pay-to Plan Name Entity Identifier Code

New Element PE: Payee

Usage: Required TR3 Rule:

PE is used to indicate the subrogated payee.

2010AC NM102 Pay-to Plan Name Entity Type Qualifier

New Element 2: Non-Person Entity

Usage: Required

2010AC NM103 Pay-to Plan Name Pay-to Plan Organization Name

New Element Usage: Required Length: 1 – 60

2010AC NM108 Pay-to Plan Name Identification Code Qualifier

New Element PI: Payor Identification XV: Centers for Medicare

and Medicaid Services PlanID

Usage: Required TR3 Rule:

On or after the mandated implementation date for the

HIPAA National Plan Identifier (National Plan ID), XV

must be sent. Prior to the mandated implementation

date and prior to any phasein period identified by

Federal regulation, PI must be sent. If a phase-in period

is designated, PI must be sent unless:

1. Both the sender and receiver agree to use the

National Plan ID,

2. The receiver has a National Plan ID, and

3. The sender has the capability to send the National

Plan ID.

If all of the above conditions are true, XV must be sent.

In this case the Payer Identification Number that would

have been sent using qualifier PI can be sent in the

corresponding REF segment using qualifier 2U.

2010AC NM109 Pay-to Plan Name Identification Code

New Element Usage: Required Length: 1 – 50

2010AC N3 Pay-to Plan Address New Segment Usage: Required when loop 2010AC is used

Page 20 of 140

Loop Segment /


4010

Valid Values

and

Descriptions

5010

Valid Values

and

Descriptions

5010A1

Valid Values

and

Descriptions

Notes

2010AC N301 Pay-to Plan Address Address Line 1

New Element Usage: Required Length: 1-55

2010AC N302 Pay-to Plan Address Address Line 2

New element Usage: Situational Length: 1-55

2010AC N4 Pay-to Plan City/State/Zip Code New Segment Usage: Required when loop 2010AC is used

2010AC N401 Pay-to Plan City New Element Usage: Required Length: 2-30

2010AC N402 Pay-to Plan Address State or Province code

New Element





2010AC N403 Pay-to Plan Address Postal code

New Element






not send.

2010AC N404 Pay-to Plan Address Country Code

New Element


SITUATIONAL RULE: Required when the address is outside

the United States of America. If not required by this


2010AC N407 Pay-to Plan Address Country Subdivision Code

New Element



the United States of America, including its territories, or





Page 21 of 140

Loop Segment /


4010

Valid Values

and

Descriptions

5010

Valid Values

and

Descriptions

5010A1

Valid Values

and

Descriptions

Notes

2010AC REF Pay-to Plan Secondary Identification

New Segment


Required prior to the mandated implementation date for

the HIPAA National Plan Identifier when an additional

identification number to that provided in the NM109 of

this loop is necessary for the claim processor to

identify the entity. If not required by this implementation

guide, do not send.

2010AC REF01 Pay-to Plan Secondary Identification Reference Identification Qualifier

New Element 2U: Payer Identification

Number FY: Claim Office Number NF: National Association

of Insurance Commissioners (NAIC) Code

Usage: Required TR3 rule for qualifier ‘2U’:

This code is only allowed when the National Plan

Identifier is reported in NM109 of this loop.

2010AC REF02 Pay-to Plan Secondary Identification Reference Identifier


Usage: Required

2010AC REF Pay-to Plan Tax identification

New Segment Usage: Required when loop 2010AC is used

2010AC REF01

Pay-to Plan Tax identification Reference Identification Qualifier

New Element EI: Employer’s


Usage: Required

2010AC REF02 Pay-to Plan Tax identification


Usage: Required

Page 22 of 140

Loop 2000B Subscriber Information

Loop Segment /


4010

Valid Values

and

Descriptions

5010

Valid Values

and

Descriptions

5010A1

Valid Values

and

Descriptions

Notes

2000B SBR01 Subscriber Information Payer Responsibility Sequence Number code

P: Primary S: Secondary T: Tertiary

A: Payer Responsibility Four

B: Payer Responsibility Five

C: Payer Responsibility Six

D: Payer Responsibility Seven

E: Payer Responsibility Eight

F: Payer Responsibility Nine

G: Payer Responsibility Ten

H: Payer Responsibility Eleven

P: Primary S: Secondary T: Tertiary U: Unknown

Codes Added

Page 23 of 140

Loop Segment /


4010

Valid Values

and

Descriptions

5010

Valid Values

and

Descriptions

5010A1

Valid Values

and

Descriptions

Notes

2000B SBR09 Subscriber Information Claim Filing Indicator code

09: Self-pay 10: Central

Certification 11: Other Non-

Federal Programs

12: Preferred Provider Organization (PPO)

13: Point of Service (POS)

14: Exclusive Provider Organization (EPO)

15: Indemnity Insurance

16: Health Maintenance Organization (HMO) Medicare Risk

AM: Automobile Medical

BL: Blue Cross/Blue Shield

CH: Champus CI: Commercial

Insurance Co.

DS: Disability HM: Health

Maintenance Organization

LI: Liability LM: Liability

Medical MB: Medicare

Part B MC: Medicaid OF: Other

Federal Program

TV: Title V VA: Veteran

Administrati

11: Other Non-Federal

Programs 12: Preferred Provider

Organization (PPO) 13: Point of Service

(POS) 14: Exclusive Provider

Organization (EPO) 15: Indemnity Insurance 16: Health Maintenance

Organization (HMO) Medicare Risk

AM: Automobile Medical BL: Blue Cross/Blue

Shield CH: Champus CI: Commercial

Insurance Co. DS: Disability FI: Federal Employees

Program HM: Health Maintenance

Organization LM: Liability Medical MA: Medicare Part A MB: Medicare Part B MC: Medicaid OF: Other Federal

Program TV: Title V VA: Veteran

Administration Plan WC: Workers’

Compensation

Codes Deleted Codes Added

Page 24 of 140

Loop 2010BA Subscriber Name

Loop Segment /


4010

Valid Values

and

Descriptions

5010

Valid Values

and

Descriptions

5010A1

Valid Values

and

Descriptions

Notes

2010BA NM103 Subscriber Name Name Last or organization Name

Length: 1 – 35 Length: 1 - 60 Maximum length increase from 35 – 60

2010BA NM104 Subscriber Name Name First

Length: 1 – 25 Length: 1 - 35






2010BA NM108 Subscriber Name Identification Code Qualifier

Usage: Situational

MI: Member

Identification

ZZ: Mutually Defined (HIPAA individual identifier)

Usage: Required MI: Member

Identification II: Standard Unique

Health Identifier for each Individual in the United States

Usage: Situational

Usage changed from required to situational in 5010A1. Situational Rule in 5010A1: Required when NM102 = 1 (person). If not, required by this implementation guide, do not send.

2010BA NM109 Subscriber Name Subscriber Primary Identifier

Usage: Situational


Usage changed from required to situational in 5010A1. Situational Rule in 5010A1: Required when NM102 = 1 (person). If not, required by this implementation guide, do not send.

2010BA N4 Subscriber City/State/Zip Code Usage: Required Usage: Situational

Usage changed from required to situational in 5010A1. Situational Rule in 5010A1: Required when the patient is the subscriber or considered to be the subscriber. if not required by this implementation guide, do not send.

2010BA N402 Subscriber City/State/Zip Code State or Province code

Required Situational





Page 25 of 140

Loop Segment /


4010

Valid Values

and

Descriptions

5010

Valid Values

and

Descriptions

5010A1

Valid Values

and

Descriptions

Notes

2010BA N403 Subscriber City/State/Zip Code Postal code

Required Situational






not send.

2010BA N407 Subscriber City/State/Zip Code Country Subdivision Code

Situational

New Element in 5010 TR3 Rule:







2010BA REF Subscriber Secondary Identification Segment Repeat:

4 Segment Repeat: 1 Segment repeat changed from 4 to 1

2010BA REF01 Subscriber Secondary Identification Reference Identification Qualifier

1W: Member Identification Number

23: Client Number

IG: Insurance Policy Number


SY: Social Security

Number

Codes Deleted

2010BA REF02 Subscriber Secondary Identification Subscriber Supplemental Identifier

Length: 1 - 30 Length: 1 - 50 Now restricted to SSN only

2010BA REF02 Property and Casualty Claim Number Length: 1 - 30 Length: 1 - 50 Maximum length change from 30 – 50

2010BA PER Property and Casualty Subscriber Contact information

New Segment

New Segment TR3 Rule:

Usage: SITUATIONAL

Situational Rule: Required for Property and Casualty

claims when this information is deemed necessary by

the submitter. If not required by this implementation

guide, do not send.

2010BA PER01

Property and Casualty Subscriber Contact information Contact Function Code

New Element IC: Information Contact

Usage: Required

Page 26 of 140

Loop Segment /


4010

Valid Values

and

Descriptions

5010

Valid Values

and

Descriptions

5010A1

Valid Values

and

Descriptions

Notes

2010BA PER02 Property and Casualty Subscriber Contact Name

New Element Length: 1-60

Usage: Situational TR3 Usage Rule:

SITUATIONAL RULE: Required when the Subscriber contact

is a person other than the person identified in the

Subscriber Name NM1 (Loop ID-2000BA). If not required

by this implementation guide, do not send.

2010BA PER03

Property and Casualty Subscriber Contact information Communications Number Qualifier

New Element TE: Telephone

Usage: Required

2010BA PER04

Property and Casualty Subscriber Contact information Communications Number

New Element Format must be AAABBBCCCC – numeric value

Usage: Required

2010BA PER05

Property and Casualty Subscriber Contact information Communications Number Qualifier

New Element EX: Telephone

Extension


SITUATIONAL RULE: Required when this information is

deemed necessary by the submitter. If not required by

this implementation guide, do not send.

2010BA PER06

Property and Casualty Subscriber Contact information Communications Number

New Element Telephone Extension





Loop 2010BB Payer Name

Loop Segment /


4010

Valid Values

and

Descriptions

5010

Valid Values

and

Descriptions

5010A1

Valid Values

and

Descriptions

Notes

2010BB NM103 Payer Name Organization Name


2010BB N4 Payer City/State/Zip Code Usage: Situational Usage: Required Usage: Situational

Situational Rule in 5010A1: Required when the patient is the subscriber or considered to be the subscriber. if not required by this implementation guide, do not send.

Page 27 of 140

Loop Segment /


4010

Valid Values

and

Descriptions

5010

Valid Values

and

Descriptions

5010A1

Valid Values

and

Descriptions

Notes

2010BB N402 Payer City/State/Zip Code State or Province code






2010BB N403 Payer City/State/Zip Code Postal code







not send.

2010BB N407 Payer City/State/Zip Code Country Subdivision Code

New Element in 5010








2010BB REF01 Payer Secondary Identification Reference Identification Qualifier

2U: Payer Identification Number

FY: Claim Office

Number NF: National

Association of Insurance Commissioners (NAIC) Code

TJ: Federal Taxpayer’s Identification Number



FY: Claim Office Number NF: National Association


Code Added Code Deleted

2010BB REF02 Payer Secondary Identification Payer Additional Identifier


Page 28 of 140

Loop Segment /


4010

Valid Values

and

Descriptions

5010

Valid Values

and

Descriptions

5010A1

Valid Values

and

Descriptions

Notes

2010BB REF Billing Provider Secondary Identification

New Segment

New Segment Usage: Situational TR3 Rule:

Situational Rule: Required prior to the mandated NPI

Implementation Date when an additional identification

number is necessary for the receiver to identify the

provider.

OR

Required on or after the mandated NPI Implementation

Date when NM109 in Loop 2010AA is not used and an

identification number other than the NPI is necessary

for the receiver to identify the provider. If not required


2010BB REF01 Billing Provider Secondary Identification Reference Identification Qualifier

New Element G2: Provider

Commercial Number LU: Location Number

Usage: Required TR3 Usage note for value ‘G2’

This code designates a proprietary provider number for

the destination payer identified in the Payer Name loop,

Loop ID-2010BB, associated with this claim. This is to

be used by all payers including: Medicare, Medicaid,

Blue Cross, etc.

2010BB REF02 Billing Provider Secondary Identifier


Usage: Required

Loop 2010BC Responsible Party (Deleted in 5010)

Loop Segment /


4010

Valid Values

and

Descriptions

5010

Valid Values

and

Descriptions

5010A1

Valid Values

and

Descriptions

Notes

2010BC Responsible Party Loop Deleted

2010BC NM1 Responsible Party Name Segment Deleted

2010BC NM101 Responsible Party Name Entity Identifier Code

Element Deleted

2010BC NM102 Responsible Party Name Entity Type Qualifier

Element Deleted

2010BC NM103 Responsible Party Name Last Name or Organization Name

Element Deleted

2010BC NM104 Responsible Party Name First Name

Element Deleted

2010BC NM105 Responsible Party Name Middle Name

Element Deleted

Page 29 of 140

Loop Segment /


4010

Valid Values

and

Descriptions

5010

Valid Values

and

Descriptions

5010A1

Valid Values

and

Descriptions

Notes

2010BC NM107 Responsible Party Name Name Suffix

Element Deleted

2010BC N3 Responsible Party Address Segment Deleted

2010BC N301 Responsible Party Address Address Line 1

Element Deleted

2010BC N302 Responsible Party Address Address Line 2

Element Deleted

2010BC N4 Responsible Party City/State/Zip Code

Segment Deleted

2010BC N401 Responsible Party City Element Deleted

2010BC N402 Responsible Party State Element Deleted

2010BC N403 Responsible Party Zip Code Element Deleted

2010BC N404 Responsible Party Country Code Element Deleted

Loop 2010BD Credit/Debit Card Holder (Deleted in 5010) Loop Segment

/ Element

Element Name 4010

Valid Values

and

Descriptions

5010

Valid Values

and

Descriptions

5010A1

Valid Values

and

Descriptions

Notes

2010BD Credit/Debit Card Holder Loop Deleted

2010BD NM1 Credit/Debit Card Holder Name Segment Deleted

2010BD NM101 Credit/Debit Card Holder Name Entity Identifier Code

Element Deleted

2010BD NM102 Credit/Debit Card Holder Name Entity Type Qualifier

Element Deleted

2010BD NM103 Credit/Debit Card Holder Name Last Name or Organization Name

Element Deleted

2010BD NM104 Credit/Debit Card Holder Name First Name

Element Deleted

2010BD NM105 Credit/Debit Card Holder Name Middle Name

Element Deleted

2010BD NM107 Credit/Debit Card Holder Name Name Suffix

Element Deleted

2010BD NM108 Credit/Debit Card Holder Name Identification Code Qualifier

Element Deleted

2010BD NM109 Credit/Debit Card Holder Name Credit or Debit Card Number

Element Deleted

2010BD REF Credit/Debit Card Information Element Deleted

Page 30 of 140

Loop Segment

/ Element

Element Name 4010

Valid Values

and

Descriptions

5010

Valid Values

and

Descriptions

5010A1

Valid Values

and

Descriptions

Notes

2010BD REF01 Credit/Debit Card Information Information Code Qualifier

Element Deleted

2010BD REF02 Credit/Debit Card Information Authorization Number

Element Deleted

Loop 2000C Patient Information

Loop Segment

/ Element Element Name

4010

Valid Values

and

Descriptions

5010

Valid Values

and

Descriptions

5010A1

Valid Values

and

Descriptions

Notes

Page 31 of 140

Loop Segment


4010

Valid Values

and

Descriptions

5010

Valid Values

and

Descriptions

5010A1

Valid Values

and

Descriptions

Notes

2000C PAT01 Patient Information Individual Relationship Code

01: Spouse 04: Grandfather

or Grandmother

05: Grandson or Granddaughter

07: Nephew or Niece

09: Adopted Child

10: Foster Child 15: Ward 17: Stepson or

Stepdaughter

19: Child 20: Employee 21: Unknown 22:

Handicapped Dependent

23: Sponsored Dependent

24: Dependent of a Minor Dependent

29: Significant Other

32: Mother 33: Father 34: Other Adult 36:

Emancipated Minor

39: Organ Donor

40: Cadaver Donor

41: Injured Plaintiff

43: Child Where Insured Has No Financial Responsibility

53: Life Partner G8: Other

Relationship

01: Spouse 19: Child 20: Employee 21: Unknown 39: Organ Donor 40: Cadaver Donor 53: Life Partner G8: Other Relationship

Codes Deleted

Page 32 of 140

Loop 2010CA Patient Name

Loop Segment /


4010

Valid Values

and

Descriptions

5010

Valid Values

and

Descriptions

5010A1

Valid Values

and

Descriptions

Notes

2010CA NM103 Patient Name Name Last or organization Name

Length: 1 – 35 Length: 1 - 60 Maximum length increase from 35 - 60

2010CA NM104 Patient Name Name First

Usage: Required Length: 1-25

Usage: Situational Length: 1 - 35

Usage Changed from required to Situational Maximum length increase from 25 - 35 New TR3 rule:





2010CA NM108 Patient Name Identification Code Qualifier

Element Deleted

2010CA NM109 Patient Name Patient Primary Identifier

Element Deleted

2010CA N402 Patient City/State/Zip Code State or Province code






2010CA N403 Patient City/State/Zip Code Postal code







not send.

2010CA N407 Patient City/State/Zip Code Country Subdivision Code

New Element in 5010








Page 33 of 140

Loop Segment /


4010

Valid Values

and

Descriptions

5010

Valid Values

and

Descriptions

5010A1

Valid Values

and

Descriptions

Notes

2010CA REF Patient Secondary Identification Segment

Segment Deleted

2010CA REF01 Patient Secondary Identification Reference Identification Qualifier

Element Deleted

2010CA REF02 Patient Secondary Identification Patient Secondary Identifier

Element Deleted

2010CA REF02 Property and Casualty Claim Number Reference Identification


2010CA REF Property and Casualty Claim Patient Information

New Segment

Usage: Situational Situational Rule in 5010A1: Required when an identification number is needed by the receiver to identify the patient for Property and Casualty claims. If not required by this implementation guide, do not send.

2010CA REF01 Property and Casualty Claim Patient Information Reference Identification Qualifier

New Element 1W: Member Identification Number SY: Social Security Number

Usage: Required

2010CA REF02 Property and Casualty Claim Patient Information Reference Identification

Length: 1 – 50 Usage: Required

2010CA PER Property and Casualty Patient Contact information

New Segment

New Segment TR3 Rule:

Situational Rule: Required for Property and Casualty

claims when this information is different than the

information provided in the Subscriber Contact

Information PER segment in Loop ID-2010BA and this

information is deemed necessary by the submitter. If


2010CA PER01

Property and Casualty Patient Contact information Contact Function Code


Usage: Required New Element

Page 34 of 140

Loop Segment /


4010

Valid Values

and

Descriptions

5010

Valid Values

and

Descriptions

5010A1

Valid Values

and

Descriptions

Notes

2010CA PER02 Billing Provider Contact Name New Element Length: 1 - 60


SITUATIONAL RULE: Required when the Patient contact is a

person other than the person identified in the Patient

Name NM1 (Loop ID-2010CA). If not required by this


2010CA PER03

Property and Casualty Patient Contact information Communications Number Qualifier


Usage: Required

2010CA PER04

Property and Casualty Patient Contact information Communications Number


Usage: Required

2010CA PER05

Property and Casualty Patient Contact information Communications Number Qualifier


Extension





2010CA PER06

Property and Casualty Patient Contact information Communications Number






Loop 2300 Claim Information

Loop Segment


4010

Valid Values

and

Descriptions

5010

Valid Values

and

Descriptions

5010A1

Valid Values

and

Descriptions

Notes

2300 CLM05-01

Claim Information Health Care Service Location Information

Place of Service Code


Code Source 235: The 4010A1 IG lists values for this element as a courtesy. Source of truth for valid values is “Place of Service Codes for Professional And Dental Claim’ listed at http://www.cms.hhs.gov/MedHCPCSGenInfo/Downloads/ Place_of_Service.pdf No functional differences in edit

Page 35 of 140

Loop Segment


4010

Valid Values

and

Descriptions

5010

Valid Values

and

Descriptions

5010A1

Valid Values

and

Descriptions

Notes

2300 CLM05-02 Claim Information Facility Code Qualifier

Usage: Not Used

New Element B: Place of Service Codes for Professional or Dental Services

Usage: Required Usage changed from not-used to required. Only valid value is ‘B’.

2300 CLM07 Claim Information Medicare Assignment Code

A: Assigned B: Assignment

Accepted on Clinical Lab Services Only

C: Not Assigned P: Patient

Refuses to Assign Benefits

A: Assigned B: Assignment

Accepted on Clinical Lab Services Only

C: Not Assigned

Code Deleted

2300 CLM08

Claim Information Benefits Assignment Certification Indicator

N: No Y: Yes

N: No W: Not Applicable Y: Yes

New Code TR3 usage notes for ‘W’

Use code ‘W’ when the patient refuses to assign

benefits.

Page 36 of 140

Loop Segment


4010

Valid Values

and

Descriptions

5010

Valid Values

and

Descriptions

5010A1

Valid Values

and

Descriptions

Notes

2300 CLM09 Claim Information Release of Information Code

A: Appropriate Release of Information on File at Health Care Service Provider or at Utilization Review Organization

I: Informed Consent to Release Medical Information for Conditions or Diagnoses Regulated by Federal Statutes

M: The Provider has Limited or Restricted Ability to Release Data Related to a Claim

N: No, Provider is Not Allowed to Release Data

O: On file at Payor or at Plan Sponsor

Y: Yes, Provider has a Signed Statement Permitting Release of Medical Billing Data Related to a Claim

I: Informed Consent to

Release Medical Information for Conditions or Diagnoses Regulated by Federal Statutes

Y: Yes, Provider has a

Signed Statement Permitting Release of Medical Billing Data Related to a Claim

Codes Deleted

Page 37 of 140

Loop Segment


4010

Valid Values

and

Descriptions

5010

Valid Values

and

Descriptions

5010A1

Valid Values

and

Descriptions

Notes

2300 CLM10 Claim Information Patient Signature Source Code

B: Signed signature authorization form or forms for both HCFA-1500 Claim Form block 12 and block 13 are on file

C: Signed HCFA-1500 Claim Form on file

M: Signed signature authorization form for HCFA-1500 Claim Form block 13 on file

P: Signature generated by provider because the patient was not physically present for services

S: Signed

signature authorization form for HCFA-1500 Claim Form block 12 on file

P: Signature generated

by provider because the patient was not physically present for services. Signature generated by an entity other than the patient according to State or Federal law.

Codes Deleted TR3 description of usage for value ‘P’ enhanced

2300 CLM11-01 Claim Information Related Causes Code

AA: Auto Accident AP: Another Party

Responsible EM: Employment OA: Other

Accident

AA: Auto Accident EM: Employment OA: Other Accident

Code Deleted

Page 38 of 140

Loop Segment


4010

Valid Values

and

Descriptions

5010

Valid Values

and

Descriptions

5010A1

Valid Values

and

Descriptions

Notes


AA: Auto Accident AP: Another Party

Responsible EM: Employment OA: Other

Accident

AA: Auto Accident EM: Employment OA: Other Accident

Code Deleted


Element Deleted

Page 39 of 140

Loop Segment


4010

Valid Values

and

Descriptions

5010

Valid Values

and

Descriptions

5010A1

Valid Values

and

Descriptions

Notes

2300 CLM12 Claim Information Special Program Indicator

01: Early & Periodic Screening, Diagnosis, and Treatment (EPSDT) or Child Health Assessment Program (CHAP)

02: Physically Handicapped Children’s Program

03: Special

Federal Funding. This code is used for Medicaid claims only.

05: Disability. This code is used for Medicaid claims only.

07: Induced Abortion - Danger to Life. This code is used for Medicaid claims only.

08: Induced Abortion - Rape or Incest. This code is used for Medicaid claims only.

09: Second Opinion or Surgery. This code is used for Medicaid claims only.

02: Physically

Handicapped Children’s Program. This code is used for Medicaid claims only.

03: Special Federal

Funding. This code is used for Medicaid claims only.

05: Disability. This code

is used for Medicaid claims only.

09: Second Opinion or

Surgery. This code is used for Medicaid claims only.

Codes Deleted TR3 Usage notes for value ‘02’ expanded

Page 40 of 140

Loop Segment


4010

Valid Values

and

Descriptions

5010

Valid Values

and

Descriptions

5010A1

Valid Values

and

Descriptions

Notes

2300 CLM16 Claim Information Participation Agreement

Element Deleted

2300 CLM20 Claim Information Delay Reason Code

1: Proof of Eligibility Unknown or Unavailable

2: Litigation 3: Authorization

Delays 4: Delay in

Certifying Provider

5: Delay in Supplying Billing Forms

6: Delay in Delivery of Custom-made Appliances

7: Third Party Processing Delay

8: Delay in Eligibility Determination

9: Original Claim Rejected or Denied Due to a Reason Unrelated to the Billing Limitation Rules

10: Administration Delay in the Prior Approval Process

11: Other

1: Proof of Eligibility Unknown or Unavailable

2: Litigation 3: Authorization Delays 4: Delay in Certifying

Provider 5: Delay in Supplying

Billing Forms 6: Delay in Delivery of

Custom-made Appliances

7: Third Party

Processing Delay 8: Delay in Eligibility

Determination 9: Original Claim

Rejected or Denied Due to a Reason Unrelated to the Billing Limitation Rules

10: Administration Delay

in the Prior Approval Process

11: Other 15: Natural Disaster

Code Added

2300 DTP Date – Acute Manifestation Segment Repeat: 5 Segment Repeat: 1 DTP01 qualifier 453 Segment repeat changed from 5 to 1


Segment Deleted

Page 41 of 140

Loop Segment


4010

Valid Values

and

Descriptions

5010

Valid Values

and

Descriptions

5010A1

Valid Values

and

Descriptions

Notes

2300 DTP01

Date – Similar Illness/Symptom Onset Date Time Qualifier

Element Deleted 438:

2300 DTP02


Element Deleted

2300 DTP03 Date – Similar Illness/Symptom Onset

Element Deleted

2300 DTP Date – Accident Repeat: 10 Repeat: 1 DTP01 qualifier 439 Segment repeat changed from 10 to 1

2300 DTP02 Date – Accident Date Time Qualifier

D8: Date Expressed in Format CCYYMMDD

DT: Date and Time Expressed in Format CCYYMMDDHHMM

D8: Date Expressed in Format CCYYMMDD

Code Deleted

2300 DTP03 Date – Accident CCYYMMDD or CCYYMMDDHHMM

CCYYMMDD Date time option removed. Date supported

Page 42 of 140

Loop Segment


4010

Valid Values

and

Descriptions

5010

Valid Values

and

Descriptions

5010A1

Valid Values

and

Descriptions

Notes

2300 DTP Date – Disability Begin

Repeat: 5 DTP01 Value 360: Disability

Begin

Repeat: 1 DTP01 Value 360: Disability Begin

The DTP segments for reporting Disability Start, End,

and date range have been consolidated into a single

segment in the 5010 standard. This segment should

only occur once in the 2300 loop

Use qualifier 360 in DTP01 if Disability Start date is

known, and Disability End date is not known.

Use qualifier 361 in DTP01 if Disability End date is

known, and Disability Start date is not know.

Use qualifier 314 in DTP01 if Disability Start and End

date are known. Segment Usage rule change: 4010A1 IG Rule:

Required on claims involving disability where, in the

opinion of the provider, the patient was or will be

unable to perform the duties normally associated with

his/her work.

5010 TR3 Rule:


judgment of the provider, the patient was or will be


his/her work.

360 Qualifier Note:

Use code 360 if patient is currently disabled and

disability end date is unknown.

Page 43 of 140

Loop Segment


4010

Valid Values

and

Descriptions

5010

Valid Values

and

Descriptions

5010A1

Valid Values

and

Descriptions

Notes

2300 DTP Date – Disability End

Repeat: 5 DTP01 Value 361: Disability End

Repeat: 1 DTP01 Value 361: Disability End

Segment Usage rule change: 4010A1 IG Rule:


opinion of the provider, the patient was or will be


his/her work.

5010 TR3 Rule:




his/her work.

361 Qualifier Note:

Use code 361 if patient is no longer disabled and the

start date is unknown.

2300 DTP New Segment Date – Disability

Repeat: 1

5010 TR3 Rule:




his/her work.

314 Qualifier Note:

Use code 314 when both disability start and end date

are being reported.

2300 DTP01 Date – Disability Date Time Qualifier

New Element Value 314: Disability

Usage: Required

2300 DTP02 Date – Disability Date Time Period Format Qualifier

RD8: Range of Dates Expressed in Format CCYYMMDDCCYYMMDD

Usage: Required

2300 DTP03 New Element Value Usage Required Disability Date Range in format CCYYMMDDCCYYMMDD

2300 DTP Date – Property and Casualty Date of First Contact

New Segment


Required for Property and Casualty claims when state

mandated. If not required by this implementation guide,

do not send.

Page 44 of 140

Loop Segment


4010

Valid Values

and

Descriptions

5010

Valid Values

and

Descriptions

5010A1

Valid Values

and

Descriptions

Notes

2300 DTP01

Date – Property and Casualty Date of First Contact Date Time Qualifier

New Element 444: First Visit or

Consultation

Usage: Required

2300 DTP02

Date – Property and Casualty Date of First Contact Date Time Period Format Qualifier

New Element D8: Date Expressed in

Format CCYYMMDD

Usage: Required

2300 DTP03 Date – Property and Casualty Date of First Contact

New Element Usage: Required Format: CCYYMMDD

2300 DTP Date – Repricer Received Date New Segment


Required when a repricer is passing the claim onto the

payer. If not required by this implementation guide, do

not send.

2300 DTP01 Date – Repricer Received Date Date Time Qualifier

New Element 050: Received

Usage: Required

2300 DTP02 Date – Repricer Received Date Date Time Period Format Qualifier


Format CCYYMMDD

Usage: Required

2300 DTP03 Date – Repricer Received Date New Element Usage: Required Format: CCYYMMDD

2300 PWK01 Attachment Report Type Code

03: Report Justifying Treatment Beyond Utilization Guidelines

04: Drugs Administered 05: Treatment Diagnosis 06: Initial Assessment 07: Functional Goals 08: Plan of Treatment 09: Progress Report 10: Continued

Treatment 11: Chemical Analysis 13: Certified Test Report 15: Justification for

Admission

Code Deleted Codes Added

Page 45 of 140

Loop Segment


4010

Valid Values

and

Descriptions

5010

Valid Values

and

Descriptions

5010A1

Valid Values

and

Descriptions

Notes

77: Support Data

for Verification

AS: Admission Summary

B2: Prescription B3: Physician

Order B4: Referral Form CT: Certification DA: Dental

Models DG: Diagnostic

Report DS: Discharge

Summary EB: Explanation

of Benefits (Coordination of Benefits or Medicare Secondary Payor)

21: Recovery Plan A3:

Allergies/Sensitivities Document

A4: Autopsy Report AM: Ambulance

Certification AS: Admission Summary B2: Prescription B3: Physician Order B4: Referral Form BR: Benchmark Testing

Results BS: Baseline BT: Blanket Test Results CB: Chiropractic

Justification CK: Consent Form(s) CT: Certification D2: Drug Profile

Document DA: Dental Models DB: Durable Medical

Equipment Prescription

DG: Diagnostic Report DJ: Discharge

Monitoring Report DS: Discharge Summary EB: Explanation of

Benefits (Coordination of Benefits or Medicare Secondary Payor)

HC: Health Certificate HR: Health Clinic

Records I5: Immunization

Record IR: State School

Immunization Records

LA: Laboratory Results

Page 46 of 140

Loop Segment


4010

Valid Values

and

Descriptions

5010

Valid Values

and

Descriptions

5010A1

Valid Values

and

Descriptions

Notes

MT: Models NN: Nursing

Notes OB: Operative

Note OZ: Support Data

for Claim PN: Physical

Therapy Notes

PO: Prosthetics or Orthotic Certification

PZ: Physical

Therapy Certification

RB: Radiology Films

RR: Radiology Reports

RT: Report of Tests and Analysis Report

M1: Medical Record Attachment

MT: Models 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

OZ: Support Data for Claim

P4: Pathology Report P5: Patient Medical

History Document 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 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

Page 47 of 140

Loop Segment


4010

Valid Values

and

Descriptions

5010

Valid Values

and

Descriptions

5010A1

Valid Values

and

Descriptions

Notes

2300 PWK02 Claim Supplemental Information Attachment Transmission Code

AA: Available on Request at Provider Site

BM: By Mail EL: Electronically

Only EM: E-Mail FX: By Fax

AA: Available on Request at Provider Site

BM: By Mail EL: Electronically Only EM: E-Mail FT: File Transfer FX: By Fax

Code Added

2300 CN101 Contract Information Contract Type Code

02: Per Diem 03: Variable Per

Diem 04: Flat 05: Capitated 06: Percent 09: Other

01: Diagnosis Related Group (DRG)

02: Per Diem 03: Variable Per Diem 04: Flat 05: Capitated 06: Percent 09: Other

Code Added

2300 CN104 Contract Information Contract Code


2300 AMT Credit/Debit Card Maximum Amount Segment Deleted

2300 AMT01 Credit/Debit Card Maximum Amount Amount Qualifier Code

Element Deleted MA: Maximum

Amount

2300 AMT02 Credit/Debit Card Maximum Amount Element Deleted

2300 AMT Total Purchased Service Amount Segment Deleted

2300 AMT01 Total Purchased Service Amount Amount Qualifier Code

Element Deleted NE: Net Billed

2300 AMT02 Total Purchased Service Amount Element Deleted

2300 REF02 Service Authorization Exception Code

Length: 1 - 30 Length: 1 - 50 (REF01 qualifier value ‘4N’) Maximum length increase from 30 – 50

2300 REF02 Mandatory Medicare (Section 4081) Crossover Indicator

Length: 1 - 30 Length: 1 - 50 (REF01 qualifier value ‘F5’) Maximum length increase from 30 – 50

2300 REF02 Mammography Certification Number Length: 1 - 30 Length: 1 - 50 (REF01 qualifier value ‘EW’) Maximum length increase from 30 – 50

2300 REF02 Referral Number Length: 1 - 30 Length: 1 - 50 (REF01 qualifier value ‘9F’) Maximum length increase from 30 – 50

2300 REF02 Prior Authorization Number Length: 1 - 30 Length: 1 - 50 (REF01 qualifier value ‘G1’) Maximum length increase from 30 – 50

Page 48 of 140

Loop Segment


4010

Valid Values

and

Descriptions

5010

Valid Values

and

Descriptions

5010A1

Valid Values

and

Descriptions

Notes

2300 REF02 Payer Claim control Number Length: 1 - 30 Length: 1 - 50

(REF01 qualifier value ‘F8’) Renamed from 4010A1 – ‘Original Reference Number (ICN/DCN)’ Maximum length increase from 30 – 50

2300 REF Clinical Laboratory Improvement Amendment (CLIA) Number

Segment Repeat: 3 Length: 1 - 30

Segment Repeat: 1 Length: 1 - 50

(REF01 qualifier value ‘F8’) Segment repeat changed from 3 t o1 Maximum length increase from 30 – 50

2300 REF02 Repriced Claim Number Length: 1 - 30 Length: 1 - 50 (REF01 qualifier value ‘9A’) Maximum length increase from 30 – 50

2300 REF02 Adjusted Repriced Claim Number Length: 1 - 30 Length: 1 - 50 (REF01 qualifier value ‘9C’) Maximum length increase from 30 – 50

2300 REF02 Investigational Device Exemption Number

Length: 1 - 30 Length: 1 - 50 (REF01 qualifier value ‘LX’) Maximum length increase from 30 – 50

2300 REF02 Claim Identifier for Transmission Intermediaries


(REF01 qualifier value ‘D9’) Renamed from 4010A1 – ‘Claim Identification Number for Clearinghouses and Other Transmission Intermediaries’’ Maximum length increase from 30 – 50

2300 REF Ambulatory Patient Group (APG) Segment Deleted

2300 REF01 Ambulatory Patient Group (APG) Reference Identification Qualifier

Element Deleted 1S: Ambulatory

Patient Group (APG) Number

2300 REF01 Ambulatory Patient Group Number Element Deleted

2300 REF02 Medical Record Number Length: 1 - 30 Length: 1 - 50 (REF01 qualifier value ‘EA’ Maximum length increase from 30 – 50

2300 REF02 Demonstration Project Identifier Length: 1 - 30 Length: 1 - 50 (REF01 qualifier value ‘P4 Maximum length increase from 30 – 50

2300 REF Care Plan Oversight New Segment


Required when the physician is billing Medicare for

Care Plan Oversight (CPO). If not required by this


2300 REF01 Care Plan Oversight Reference Identification Qualifier

New Element 1J: Facility ID Number

Usage: Required

Page 49 of 140

Loop Segment


4010

Valid Values

and

Descriptions

5010

Valid Values

and

Descriptions

5010A1

Valid Values

and

Descriptions

Notes

2300 REF02 Care Plan Oversight Number Length: 1 – 50 New Element

Usage: Required

2300 NTE01 Claim Note Note Reference Code

ADD: Additional Information

CER: Certification Narrative

DCP: Goals, Rehabilitation Potential, or Discharge Plans

DGN: Diagnosis Description

PMT: Payment TPO: Third Party

Organization Notes


CER: Certification

Narrative DCP: Goals, Rehabilitation

Potential, or Discharge Plans

DGN: Diagnosis

Description TPO: Third Party

Organization Notes

Code Deleted

2300 CR103 Ambulance Transport Information Ambulance Transport Code

Element Deleted in 5010

2300 CR212

Spinal Manipulation Service Information X-ray Availability Indicator

Element Deleted in 5010

Page 50 of 140

Loop Segment


4010

Valid Values

and

Descriptions

5010

Valid Values

and

Descriptions

5010A1

Valid Values

and

Descriptions

Notes

2300

CRC03 CRC04 CRC05 CRC06 CRC07

Ambulance Certification Condition Code

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

60:

Transportation Was To the Nearest Facility


04: Patient was moved

by stretcher 05: Patient was

unconscious or in shock


07: Patient had to be

physically restrained 08: Patient had visible

hemorrhaging 09: Ambulance service

was medically necessary

12: Patient is confined to a bed or chair

Codes Deleted Code Added

Page 51 of 140

Loop Segment


4010

Valid Values

and

Descriptions

5010

Valid Values

and

Descriptions

5010A1

Valid Values

and

Descriptions

Notes

2300

HI01-01 HI02-01 HI03-01 HI04-01 HI05-01 HI06-01 HI07-01 HI08-01

Healthcare Diagnosis Code Diagnosis Code Type

Usage: Situational BK: International

Classification of Diseases Clinical Modification (ICD-9-CM) Principal Diagnosis

Usage: Required BK: International


ABK: International Classification of Diseases Clinical Modification (ICD-10-CM) Principal Diagnosis

Usage changed from situational to required Code Added The HI Segment in the 5010 standard incorporates support for ICD-10

2300

HI09-01 HI10-01 HI11-01 HI12-01

Healthcare Diagnosis Code Diagnosis Code Type

New Elements BK: International


ABK: International Classification of Diseases Clinical Modification (ICD-10-CM) Principal Diagnosis

The 5010 HI segment increases the allowed occurrence of diagnosis codes from 8 to 12.

2300

HI09-02 HI10-02 HI11-02 HI12-02

Healthcare Diagnosis Code

New Element The 5010 HI segment increases the allowed occurrence of diagnosis codes from 8 to 12.

2300 HI Anesthesia Related Procedure

New Segment


Situational Rule: Required on claims where

anesthesiology services are being billed or reported

when the provider knows the surgical code and knows

the adjudication of the claim will depend on provision

of the surgical code. If not required by this


Page 52 of 140

Loop Segment


4010

Valid Values

and

Descriptions

5010

Valid Values

and

Descriptions

5010A1

Valid Values

and

Descriptions

Notes

2300 HI01-01 Anesthesia Related Procedure Code List Qualifier

New Element BP: Health Care

Financing Administration Common Procedural Coding System Principal Procedure

Usage: Required

2300 HI01-02

Anesthesia Related Procedure Anesthesia Related Surgical Procedure

HCPCS Code Usage: Required

2300 HI02-01 Anesthesia Related Procedure Code List Qualifier

New Element BO: Health Care

Financing Administration Common Procedural Coding System

Usage: Situational

2300 HI02-02

Anesthesia Related Procedure Anesthesia Related Surgical Procedure

HCPCS Code Usage: Situational

2300 HI Condition Information

New Segment


Required when condition information applies to the

claim. If not required by this implementation guide, do

not send.

2300 HI01-01 Condition Information Code List Qualifier

New Element BG: Condition

Usage: Required

2300 HI01-02 Condition Information Condition Code

New Element NUBC Code CODE SOURCE 132:

Usage: Required

Page 53 of 140

Loop Segment


4010

Valid Values

and

Descriptions

5010

Valid Values

and

Descriptions

5010A1

Valid Values

and

Descriptions

Notes

2300

HI02-01 HI03-01 HI04-01 HI05-01 HI06-01 HI07-01 HI08-01 HI09-01 HI10-01 HI11-01 HI12-01

Condition Information Code List Qualifier

New Element BG: Condition


SITUATIONAL RULE: Required when it is necessary to report

an additional condition code and the preceding HI data

elements have been used to report other condition

codes. If not required by this implementation guide, do

not send.

2300

HI02-02 HI03-02 HI04-02 HI05-02 HI06-02 HI07-02 HI08-02 HI09-02 HI10-02 HI11-02 HI12-02

Condition Information Condition Code

New Element NUBC Code CODE SOURCE 132:


SITUATIONAL RULE: Required when it is necessary to report

an additional condition code and the preceding HI data

elements have been used to report other condition

codes. If not required by this implementation guide, do

not send.

2300 HCP04 Claim Pricing/Repricing Information Length: 1 - 30 Length: 1 - 50 Maximum length increase from 30 – 50

2300 HCP06 Repriced Approved Ambulatory Patient Group Code


Loop 2305 Home Health Care Plan Information (Loop Deleted in 5010)

Loop Segment /


4010

Valid Values

and

Descriptions

5010

Valid Values

and

Descriptions

5010A1

Valid Values

and

Descriptions

Notes

2305 CR7 Home Health Care Plan Information Segment Deleted

2305 CR701 Home Health Care Plan Information Discipline Type Code

Element Deleted

2305 CR702 Home Health Care Plan Information Total Visits Required Count

Element Deleted

2305 CR703

Home Health Care Plan Information Certification Period Projected Visit Count

Element Deleted

Page 54 of 140

Loop Segment /


4010

Valid Values

and

Descriptions

5010

Valid Values

and

Descriptions

5010A1

Valid Values

and

Descriptions

Notes

2305 HSD Health Care Services Delivery Segment Deleted

2305 HSD01 Health Care Services Delivery Visits

Element Deleted

2305 HSD02 Health Care Services Delivery Number of Visits

Element Deleted

2305 HSD03 Health Care Services Delivery Frequency Period

Element Deleted

2305 HSD04 Health Care Services Delivery Frequency Count

Element Deleted

2305 HSD05 Health Care Services Delivery Duration of Visits Units

Element Deleted

2305 HSD06 Health Care Services Delivery Duration of Visits, Number of Units

Element Deleted

2305 HSD07

Health Care Services Delivery Ship. Delivery or Calendar Pattern Code

Element Deleted

2305 HSD08 Health Care Services Delivery Delivery Pattern Time Code

Element Deleted

Loop 2310A Referring Provider Name

Loop Segment


4010

Valid Values

and

Descriptions

5010

Valid Values

and

Descriptions

5010A1

Valid Values

and

Descriptions

Notes

2310A NM102 Referring Provider Name Entity Type Code

1: Person 2: Non-Person

Entity

1: Person Code Deleted

2310A NM103 Referring Provider Name Name Last or organization Name


Page 55 of 140

Loop Segment


4010

Valid Values

and

Descriptions

5010

Valid Values

and

Descriptions

5010A1

Valid Values

and

Descriptions

Notes

2310A NM104 Referring Provider Name Name First

Length: 1-25 Length: 1 - 35






2310A NM108 Referring Provider Name Identification Code Qualifier

24: Employer’s Identification Number



XX: Health Care


Codes Deleted

2310A NM109 Referring Provider Name Referring Provider Identifier

NPI is only valid identifier in this element in the 5010 standard.

2310A PRV Referring Provider Specialty Information

Segment Deleted

2310A PRV01

Referring Provider Specialty Information Provider Code

Element Deleted

2310A PRV02

Referring Provider Specialty Information Reference Identification Qualifier

Element Deleted

2310A PRV03

Referring Provider Specialty Information Provider Taxonomy Code

Element Deleted

2310A REF Referring Provider Secondary Identification

Max Occurrence: 5

Max Occurrence: 3 Change in maximum segment repeat

Page 56 of 140

Loop Segment


4010

Valid Values

and

Descriptions

5010

Valid Values

and

Descriptions

5010A1

Valid Values

and

Descriptions

Notes

2310A REF01

Referring Provider Secondary Identification Reference Identification Qualifier









LU: Location Number


TJ: Federal Taxpayers Identification Number


1G: Provider UPIN

Number G2: Provider

Commercial Number

Codes Deleted

2310A REF02 Referring Provider Secondary Identifier


Loop 2310B Rendering Provider Name

Loop Segment


4010

Valid Values

and

Descriptions

5010

Valid Values

and

Descriptions

5010A1

Valid Values

and

Descriptions

Notes

2310B NM103 Rendering Provider Name Name Last or organization Name


Page 57 of 140

Loop Segment


4010

Valid Values

and

Descriptions

5010

Valid Values

and

Descriptions

5010A1

Valid Values

and

Descriptions

Notes

2310B NM104 Rendering Provider Name Name First







2310B NM108 Rendering Provider Name Identification Code Qualifier







Usage changed from required to situational Codes Deleted TR3 Rule:

SITUATIONAL RULE: Required for providers in the United

States or its territories on or after the mandated HIPAA


when the provider is eligible to receive an NPI.

OR





OR





send.

Page 58 of 140

Loop Segment


4010

Valid Values

and

Descriptions

5010

Valid Values

and

Descriptions

5010A1

Valid Values

and

Descriptions

Notes

2310B NM109 Rendering Provider Name Rendering Provider Identifier

Usage Required Usage: Situational

NPI is only valid identifier in this element in the 5010 standard. TR3 Rule:

SITUATIONAL RULE: Required for providers in the United

States or its territories on or after the mandated HIPAA


when the provider is eligible to receive an NPI.

OR





OR





send.

2310B PRV02

Rendering Provider Specialty Information Reference Identification Qualifier



Qualifier code change only. No functional impact

2310B PRV03

Rendering Provider Specialty Information Reference Identification


2310B REF Rendering Provider Secondary Identification

Max Occurrence: 5


Page 59 of 140

Loop Segment


4010

Valid Values

and

Descriptions

5010

Valid Values

and

Descriptions

5010A1

Valid Values

and

Descriptions

Notes

2310B REF01

Rendering Provider Secondary Identification Reference Identification Qualifier









LU: Location Number

N5: Provider Plan Network Identification Number


X5: State Industrial Accident Provider Number


1G: Provider UPIN

Number G2: Provider


Codes Deleted

Page 60 of 140

Loop 2310C Purchased Service Provider (Deleted in 5010)

Loop Segment


4010

Valid Values

and

Descriptions

5010

Valid Values

and

Descriptions

5010A1

Valid Values

and

Descriptions

Notes

2310C Purchased Service Provider Loop Loop Deleted

4010A1 2310C Purchased Service Provider Loop

Deleted

Service Facility Loop moved from 4010A1 2310D loop to

5010 2310C loop

2310C NM1 Purchased Service Provider Purchased Service Provider Name

Segment Deleted

2310C NM101 Purchased Service Provider Entity Qualifier Code

Element Deleted

2310C NM102 Purchased Service Provider Entity Type Qualifier

Element Deleted

2310C NM103 Purchased Service Provider Last Name or Organization Name

Element Deleted

2310C NM104 Purchased Service Provider Name First

Element Deleted

2310C NM105 Purchased Service Provider Name Middle

Element Deleted

2310C NM108 Purchased Service Provider Identification Code Qualifier

Element Deleted

2310C NM109

Purchased Service Provider Purchased Service Provider Identification

Element Deleted

2310C REF Purchased Service Provider Secondary Identification

Segment Deleted

2310C REF01

Purchased Service Provider Secondary Identification Reference Identification Qualifier

Element Deleted

2310C REF02

Purchased Service Provider Secondary Identification Purchased Service Provider Secondary Identification

Element Deleted

Page 61 of 140

Loop 2310C Service Facility Location

Loop Segment


4010

Valid Values

and

Descriptions

5010

Valid Values

and

Descriptions

5010A1

Valid Values

and

Descriptions

Notes

2310C Service Facility Location Address Service Facility Loop moved from 4010A1 2310D loop to

5010 2310C loop

2310C NM101 Service Facility Location Entity Identifier Code

77: Service Location

FA: Facility LI: Independent

Lab TL: Testing

Laboratory


Codes Deleted

2310C NM103 Service Facility Location Name Last or organization Name


Usage: Required Length: 1 - 60

Usage changed from situational to required Maximum length increase from 35 – 60

2310C NM108 Service Facility Location Identification Code Qualifier




XX: Health Care


Codes Deleted

2310C NM109 Service Facility Location Service Facility Identifier


2310C N402 Service Facility Location State or Province code






2310C N403 Service Facility Location Postal code


Usage changed from required to situational TR3 Rule:





not send.

Page 62 of 140

Loop Segment


4010

Valid Values

and

Descriptions

5010

Valid Values

and

Descriptions

5010A1

Valid Values

and

Descriptions

Notes

2310C N407 Service Facility Location Country Subdivision Code

New Element in 5010








2310C REF Service Facility Location Secondary Identification

Max Occurrence: 5


Page 63 of 140

Loop Segment


4010

Valid Values

and

Descriptions

5010

Valid Values

and

Descriptions

5010A1

Valid Values

and

Descriptions

Notes

2310C REF01

Service Facility Location Secondary Identification Reference Identification Qualifier









LU: Location Number



X4: Clinical Laboratory Improvement Amendment Number



G2: Provider


Codes Deleted

Page 64 of 140

Loop Segment


4010

Valid Values

and

Descriptions

5010

Valid Values

and

Descriptions

5010A1

Valid Values

and

Descriptions

Notes

2310C REF02

Service Facility Location Secondary Identification Laboratory or Facility Secondary Identifier


2310C PER Service Facility Location Contact information

New Segment

TR3 Rule:

Usage: SITUATIONAL

Required for Property and Casualty claims when this

information is different than the information provided in

Loop ID-1000A Submitter EDI Contact Information PER

Segment, and Loop ID-2010AA Billing Provider

Contact Information PER segment and when deemed

necessary by the submitter.


send.

2310C PER01

Service Facility Location Contact information Contact Function Code


Usage: Required

2310C PER02 Service Facility Location Contact Name



SITUATIONAL RULE: Required when the name is different

than the name in the Loop ID-1000A Submitter EDI

Contact Information PER segment and in the Loop ID-

2010AA Billing Provider Contact Information PER. If not

required by this implementation guide, do not send.

2310C PER03

Service Facility Location Contact information Communications Number Qualifier


Usage: Required

2310C PER04

Service Facility Location Contact information Communications Number


Usage: Required

2310C PER05

Service Facility Location Contact information Communications Number Qualifier


Extension





Page 65 of 140

Loop Segment


4010

Valid Values

and

Descriptions

5010

Valid Values

and

Descriptions

5010A1

Valid Values

and

Descriptions

Notes

2310C PER06

Service Facility Location Contact information Communications Number






Loop 2310D Supervising Provider Name Loop Changes

Loop Segment /


4010

Valid Values

and

Descriptions

5010

Valid Values

and

Descriptions

5010A1

Valid Values

and

Descriptions

Notes

2310D Supervising Provider Name Supervising Provider Name moved from 4010A1 2310E

loop to 5010 2310D loop

2310D NM103 Supervising Provider Name Name Last or organization Name


2310D NM104 Supervising Provider Name Name First

Usage: Situational Length: 1-25


Usage changed from situational to required Maximum length increase from 25 - 35 New TR3 rule:





2310D NM108 Supervising Provider Name Identification Code Qualifier




XX: Health Care


Codes Deleted

2310D NM109 Supervising Provider Name Referring Provider Identifier


Page 66 of 140

Loop Segment /


4010

Valid Values

and

Descriptions

5010

Valid Values

and

Descriptions

5010A1

Valid Values

and

Descriptions

Notes

2310D REF01 Supervising Provider Name Secondary Identification

Segment Repeat: 5 Segment Repeat: 4 Segment Repeat changed from 5 to 4

2310D REF01

Supervising Provider Name Secondary Identification Reference Identification Qualifier









LU: Location Number





1G: Provider UPIN

Number G2: Provider


Codes Deleted

2310D REF02

Supervising Provider Name Secondary Identification Supervising Provider Secondary Identification


Page 67 of 140

Loop 2310E Ambulance Pick Up Location (New in 5010)

Loop Segment


4010

Valid Values

and

Descriptions

5010

Valid Values

and

Descriptions

5010A1

Valid Values

and

Descriptions

Notes

2310E Ambulance Pick Up Location New Loop

TR3 Usage Rules:

Usage: Situational

Required when billing for ambulance or non-

emergency transportation services. If not required by


2310E NM1 Ambulance Pick Up Location New Segment Usage: Required Required when 2310E Loop is present

2310E NM101 Ambulance Pick Up Location Entity Identifier Code

New Element PW: Pickup Address

Usage: Required

2310E NM102 Ambulance Pick Up Location Entity Type Qualifier


Usage: Required

2310E N3 Ambulance Pick Up Location Address

New Segment

Usage: Required Required when 2310E Loop is present TR3 Usage Rules:

If the ambulance pickup location is in an area where

there are no street addresses, enter a description of

where the service was rendered (for example,

“crossroad of State Road 34 and 45” or “Exit

near Mile marker 265 on Interstate 80”.)

2310E N301 Ambulance Pick Up Location Address Line


Usage: Required

2310E N302 Ambulance Pick Up Location Address Line


Usage: Situational TR3 Usage Rule

SITUATIONAL RULE: Required when there is a second

address line. If not required by this implementation

guide, do not send.

2310E N4 Ambulance Pick Up Location City/State/Zip Code

New Segment Usage: Required Required when 2310E Loop is present

2310E N401 Ambulance Pick Up Location City New Element Usage: Required Length: 2-30

Page 68 of 140

Loop Segment


4010

Valid Values

and

Descriptions

5010

Valid Values

and

Descriptions

5010A1

Valid Values

and

Descriptions

Notes

2310E N402 Ambulance Pick Up Location State or Province code

New Element


SITUATIONAL RULE: Required when address is in the


Canada. If not required by this implementation guide,

do not send.

2310E N403 Ambulance Pick Up Location Postal code

New Element






not send.

2310E N404 Ambulance Pick Up Location Country Code

New Element

Usage: Situational TR3 Rule




2310E N407 Ambulance Pick Up Location Country Subdivision Code

New Element








Loop 2310F Ambulance Drop Off Location (New in 5010)

Loop Segment


4010

Valid Values

and

Descriptions

5010

Valid Values

and

Descriptions

5010A1

Valid Values

and

Descriptions

Notes

2310F Ambulance Drop Off Location New Loop

TR3 Usage Rules:

Usage: Situational

Required when billing for ambulance or non-

emergency transportation services. If not required by


Page 69 of 140

Loop Segment


4010

Valid Values

and

Descriptions

5010

Valid Values

and

Descriptions

5010A1

Valid Values

and

Descriptions

Notes

2310F NM1 Ambulance Drop Off Location New Segment Usage: Required Required when 2310F Loop is present

2310F NM101 Ambulance Drop Off Location Entity Identifier Code

New Element 45: Pickup Address

Usage: Required

2310F NM102 Ambulance Drop Off Location Entity Type Qualifier


Usage: Required

2310F N3 Ambulance Drop Off Location Address

New Segment Usage: Required Required when 2310F Loop is present

2310F N301 Ambulance Drop Off Location Address Line


Usage: Required

2310F N302 Ambulance Drop Off Location Address Line





guide, do not send.

2310F N4 Ambulance Drop Off Location City/State/Zip Code

New Segment Usage: Required Required when 2310F Loop is present

2310F N401 Ambulance Drop Off Location City New Element Usage: Required Length: 2-30

2310F N402 Ambulance Drop Off Location State or Province code

New Element





do not send.

2310F N403 Ambulance Drop Off Location Postal code

New Element




Canada, or when a postal code exists for the country

in N404. If not required by this implementation guide,

do not send.

Page 70 of 140

Loop Segment


4010

Valid Values

and

Descriptions

5010

Valid Values

and

Descriptions

5010A1

Valid Values

and

Descriptions

Notes

2310F N404 Ambulance Drop Off Location Country Code

New Element





2310F N407 Ambulance Drop Off Location Country Subdivision Code

New Element








Loop 2320 Other Subscriber Information

Loop Segment


4010

Valid Values

and

Descriptions

5010

Valid Values

and

Descriptions

5010A1

Valid Values

and

Descriptions

Notes

2320 SBR01

Other Subscriber Information Payer Responsibility Sequence Number Code

P: Primary S: Secondary T: Tertiary

A :Payer Responsibility Four B: Payer Responsibility Five C: Payer Responsibility Six D: Payer Responsibility Seven E: Payer Responsibility Eight F: Payer Responsibility Nine G: Payer Responsibility Ten H: Payer Responsibility Eleven P: Primary S: Secondary T: Tertiary U: Unknown

Codes Added

Page 71 of 140

Loop Segment


4010

Valid Values

and

Descriptions

5010

Valid Values

and

Descriptions

5010A1

Valid Values

and

Descriptions

Notes

2320 SBR02 Other Subscriber Information Individual Relationship Code

01: Spouse 04: Grandfather

or Grandmother

05: Grandson or Granddaughter

07: Nephew or Niece

10: Foster Child 15: Ward 17: Stepson or

Stepdaughter

18: Self 19: Child 20: Employee 21: Unknown 22: Handicapped

Dependent 23: Sponsored

Dependent 24: Dependent

of a Minor Dependent

29: Significant Other

32: Mother 33: Father 34: Other Adult 36: Emancipated

Minor 39: Organ Donor 40: Cadaver

Donor 41: Injured

Plaintiff 43: Child Where

Insured Has No Financial Responsibility

53: Life Partner G8: Other

Relationship

01: Spouse 18: Self 19: Child 20: Employee 21: Unknown 39: Organ Donor 40: Cadaver Donor 53: Life Partner G8: Other Relationship

Codes Deleted

2320 SBR03 Other Subscriber Information Insured Group Or Policy Number


Page 72 of 140

Loop Segment


4010

Valid Values

and

Descriptions

5010

Valid Values

and

Descriptions

5010A1

Valid Values

and

Descriptions

Notes

2320 SBR05 Other Subscriber Information Insurance Type Code

Usage: Required AP: Auto

Insurance Policy

C1: Commercial CP: Medicare

Conditionally Primary

GP: Group Policy HM: Health

Maintenance

Usage: Situational 12: Medicare Secondary

Working Aged Beneficiary or Spouse with Employer Group Health Plan

13: Medicare Secondary End-Stage Renal Disease Beneficiary in the Mandated Coordination Period with an Employer’s Group Health Plan

14: Medicare Secondary, No-fault Insurance including Auto is Primary

15: Medicare Secondary Worker’s Compensation

16: Medicare Secondary Public Health Service (PHS)or Other Federal Agency

41: Medicare Secondary Black Lung

42: Medicare Secondary Veteran’s Administration

43: Medicare Secondary Disabled Beneficiary Under Age 65 with Large Group Health Plan (LGHP)

47: Medicare Secondary, Other Liability Insurance is Primary

Usage Changed from required to situational TR3 Rule:

SITUATIONAL RULE: Required when the payer identified in

Loop ID-2330B for this iteration of Loop ID-2320 is

Medicare and Medicare is not the primary payer (Loop

ID-2320 SBR01 is not P). If not required by this


Page 73 of 140

Loop Segment


4010

Valid Values

and

Descriptions

5010

Valid Values

and

Descriptions

5010A1

Valid Values

and

Descriptions

Notes

Organization (HMO)

IP: Individual Policy

LD: Long Term Policy

LT: Litigation MB: Medicare

Part B MC: Medicaid MI: Medigap Part

B MP: Medicare

Primary OT: Other PP: Personal

Payment (Cash - No Insurance)

SP: Supplemental Policy

Page 74 of 140

Loop Segment


4010

Valid Values

and

Descriptions

5010

Valid Values

and

Descriptions

5010A1

Valid Values

and

Descriptions

Notes

2320 SBR09 Other Subscriber Information Claim Filing Indicator code

09: Self-pay 10: Central

Certification 11: Other Non-

Federal Programs

12: Preferred Provider Organization (PPO)

13: Point of Service (POS)

14: Exclusive Provider Organization (EPO)

15: Indemnity Insurance

16: Health Maintenance Organization (HMO) Medicare Risk

AM: Automobile

Medical BL: Blue

Cross/Blue Shield

CH: Champus CI: Commercial

Insurance Co.

DS: Disability HM: Health

Maintenance Organization

LI: Liability LM: Liability

Medical MB: Medicare

Part B MC: Medicaid OF: Other

Federal Program

TV: Title V VA: Veteran

Administration Plan

11: Other Non-Federal

Programs 12: Preferred Provider

Organization (PPO) 13: Point of Service

(POS) 14: Exclusive Provider

Organization (EPO) 15: Indemnity Insurance 16: Health Maintenance

Organization (HMO) Medicare Risk

17: Dental Maintenance

Organization AM: Automobile Medical BL: Blue Cross/Blue

Shield CH Champus CI: Commercial

Insurance Co. DS: Disability FI: Federal Employees

Program HM: Health Maintenance

Organization LM: Liability Medical MA: Medicare Part A MB: Medicare Part B MC: Medicaid OF: Other Federal

Program TV: Title V VA: Veteran

Administration Plan WC: Workers’

Compensation Health Claim

Codes Deleted Codes Added

Page 75 of 140

Loop Segment


4010

Valid Values

and

Descriptions

5010

Valid Values

and

Descriptions

5010A1

Valid Values

and

Descriptions

Notes

2320 AMT COB Approved Amount Segment Deleted

2320 AMT01 COB Approved Amount Amount Qualifier Code

Element Deleted AAE: Approved

Amount

2320 AMT02 COB Approved Amount Approved Amount

Element Deleted

2320 AMT COB Total Non-Covered Amount New Segment


Required when the destination payer’s cost avoidance

policy allows providers to bypass claim submission to

the otherwise prior payer identified in Loop ID-2330B.


send.

763

TR3 Notes: 1. When this segment is used, the amount

reported in AMT02 must equal the total claim charge

amount reported in CLM02. Neither the prior payer

paid AMT, nor any CAS segments are used as this

claim has not been adjudicated by this payer.

2320 AMT01 COB Total Non-Covered Amount Amount Qualifier Code

New Element A8: Non-covered

Charges - Actual

Usage: Required

2320 AMT01 COB Total Non-Covered Amount Non-Covered Amount

New Element S9(7)V99

Usage: Required

2320 AMT COB Allowed Amount Segment Deleted

2320 AMT01 COB Allowed Amount Amount Qualifier Code

Element Deleted B6: Allowed -

Actual

2320 AMT02 COB Allowed Amount Approved Amount

Element Deleted

Page 76 of 140

Loop Segment


4010

Valid Values

and

Descriptions

5010

Valid Values

and

Descriptions

5010A1

Valid Values

and

Descriptions

Notes

2320 AMT Remaining Patient Liability New Segment


Required when the Other Payer identified in Loop ID-

2330B (of this iteration of Loop ID-2320) has

adjudicated this claim and provided claim level

information only.

OR

Required when the Other Payer identified in Loop ID-

2330B (of this iteration of Loop ID-2320) has

adjudicated this claim and the provider received a

paper remittance advice and the provider does not

have the ability to report line item information.


send.

TR3 Notes:

1. In the judgment of the provider, this is the

remaining amount to be paid after adjudication by the

Other Payer identified in Loop ID-2330B of this

iteration of Loop ID-2320.

2. This segment is only used in provider submitted

claims. It is not used in Payer-to-Payer Coordination of

Benefits (COB).

3. This segment is not used if the line level (Loop ID-

2430) Remaining Patient Liability AMT segment is

used for this Other Payer.

2320 AMT01 Remaining Patient Liability Amount Qualifier Code

New Element EAF: Amount Owed

Usage: Required

2320 AMT01 Remaining Patient Liability Remaining Patient Liability Amount

New Element S9(7)V99

Usage: Required

2320 AMT COB Patient Responsibility Amount Segment Deleted

2320 AMT01 COB Patient Responsibility Amount Amount Qualifier Code

Element Deleted F2: Patient

Responsibility - Actual

2320 AMT02

COB Patient Responsibility Amount Other Payer Patient Responsibility Amount

Element Deleted

2320 AMT COB Covered Amount Segment Deleted

Page 77 of 140

Loop Segment


4010

Valid Values

and

Descriptions

5010

Valid Values

and

Descriptions

5010A1

Valid Values

and

Descriptions

Notes

2320 AMT01 COB Covered Amount Amount Qualifier Code

Element Deleted AU: Coverage

Amount

2320 AMT02 COB Covered Amount Other Payer Covered Amount

Element Deleted

2320 AMT COB Discount Amount Segment Deleted

2320 AMT01 COB Discount Amount Amount Qualifier Code

Element Deleted D8: Discount

Amount

2320 AMT02 COB Discount Amount Other Payer Discount Amount

Element Deleted

2320 AMT COB Per Day Limit Amount Segment Deleted

2320 AMT01 COB Per Day Limit Amount Amount Qualifier Code

Element Deleted DY: Per Day

Limit

2320 AMT02 COB Per Day Limit Amount Other Payer Per Day Limit Amount

Element Deleted

2320 AMT COB Patient Paid Amount Segment Deleted

2320 AMT01 COB Patient Paid Amount Amount Qualifier Code

Element Deleted F5: Patient

Amount Paid

2320 AMT02 COB Patient Paid Amount Other Payer Patient Paid Amount

Element Deleted

2320 AMT COB Tax Amount Segment Deleted

2320 AMT01 COB Tax Amount Amount Qualifier Code

Element Deleted T: Tax

2320 AMT02 COB Tax Amount Other Payer Tax Amount

Element Deleted

2320 AMT COB Total Claim Before Taxes Amount

Segment Deleted

Page 78 of 140

Loop Segment


4010

Valid Values

and

Descriptions

5010

Valid Values

and

Descriptions

5010A1

Valid Values

and

Descriptions

Notes

2320 AMT01

COB Total Claim Before Taxes Amount Amount Qualifier Code

Element Deleted T2: Total Claim

Before Taxes

2320 AMT02

COB Total Claim Before Taxes Amount Other Payer Tax Amount

Element Deleted

2320 DMG Subscriber Demographic Information Segment Deleted

2320 DMG01 Subscriber Demographic Information Date Time Period Format Qualifier

Element Deleted

2320 DMG02 Subscriber Demographic Information Other Insured Birth Date

Element Deleted

2320 DMG03 Subscriber Demographic Information Other Insured Gender Code

Element Deleted

2320 OI03

Other Insured Coverage Information Benefits Assignment Certification Indicator

N: No Y: Yes

N: No W: Not Applicable Y: Yes

New Code TR3 usage notes for ‘W’

Use code ‘W’ when the patient refuses to assign

benefits.

Page 79 of 140

Loop Segment


4010

Valid Values

and

Descriptions

5010

Valid Values

and

Descriptions

5010A1

Valid Values

and

Descriptions

Notes

2320 OI04 Other Insured Coverage Information Patient Signature Source Code

B: Signed signature authorization form or forms for both HCFA-1500 Claim Form block 12 and block 13 are on file

C: Signed HCFA-1500 Claim Form on file

M: Signed signature authorization form for HCFA-1500 Claim Form block 13 on file

P: Signature generated by provider because the patient was not physically present for services

S: Signed

signature authorization form for HCFA-1500 Claim Form block 12 on file

P: Signature generated

by provider because the patient was not physically present for services. Signature generated by an entity other than the patient according to State or Federal law.

Codes Deleted TR3 description of usage for value ‘P’ enhanced

Page 80 of 140

Loop Segment


4010

Valid Values

and

Descriptions

5010

Valid Values

and

Descriptions

5010A1

Valid Values

and

Descriptions

Notes

2320 OI06 Other Insured Coverage Information Release of Information Code

A: Appropriate Release of Information on File at Health Care Service Provider or at Utilization Review Organization

I: Informed Consent to Release Medical Information for Conditions or Diagnoses Regulated by Federal Statutes

M: The Provider has Limited or Restricted Ability to Release Data Related to a Claim

N: No, Provider is Not Allowed to Release Data

O: On file at Payor or at Plan Sponsor

Y: Yes, Provider has a Signed Statement Permitting Release of Medical Billing Data Related to a Claim

I: Informed Consent to

Release Medical Information for Conditions or Diagnoses Regulated by Federal Statutes

Y: Yes, Provider has a

Signed Statement Permitting Release of Medical Billing Data Related to a Claim

Codes Deleted

Page 81 of 140

Loop 2330A Other Subscriber Name

Loop Segment /


4010

Valid Values

and

Descriptions

5010

Valid Values

and

Descriptions

5010A1

Valid Values

and

Descriptions

Notes

2330A NM103 Other Subscriber Name Name Last or organization Name


2330A NM104 Other Subscriber Name Name First




and the person has a first name. If not required by



2330A NM108 Other Subscriber Name Identification Code Qualifier

MI: Member Identification

ZZ: Mutually Defined (HIPAA individual identifier)

MI: Member Identification

II: Standard Unique

Health Identifier for each Individual in the United States

Should be no functional change. HHS has not adopted Unique Health Identifier standard. MI will be used as qualifier in the current environment for 5010 standard.

2330A N4 Other Subscriber City/State/ZIP Code

Usage: Situational Usage: Required Usage: Situational

Situational Rule in 5010A1: Required when the patient is the subscriber or considered to be the subscriber. if not required by this implementation guide, do not send.

2330A N407

Other Subscriber City/State/Zip Code Country Subdivision Code

New Element in 5010




or Canada, and the country in N404 has

administrative subdivisions such as but not limited to

states, provinces, cantons, etc. If not required by this


2330A REF Other Subscriber Secondary Identification

Max Occurrence: 3


Page 82 of 140

Loop Segment /


4010

Valid Values

and

Descriptions

5010

Valid Values

and

Descriptions

5010A1

Valid Values

and

Descriptions

Notes

2330A REF01

Other Subscriber Secondary Identification Reference Identification Qualifier

1W: Member Identification Number

23: Client Number

IG: Insurance Policy Number


SY: Social Security

Number

Codes Deleted

2330A REF02

Other Subscriber Secondary Identification Subscriber Supplemental Identifier

Length: 1 - 30 Length: 1 - 50 Now restricted to SSN only

Loop 2330B Other Payer Name

Loop Segment /


4010

Valid Values

and

Descriptions

5010

Valid Values

and

Descriptions

5010A1

Valid Values

and

Descriptions

Notes

2330B NM102 Other Payer Name Last Name or Organization Name


2330B N3 Other Payer Address New Segment


Required when the payer address is available and the

submitter intends for the claim to be printed on

paper at the next EDI location (for example, a

clearinghouse). If not required by this


2330B N301 Other Payer Address Address Line


Usage: Required

2330B N302 Other Payer Address Address Line





guide, do not send.

Page 83 of 140

Loop Segment /


4010

Valid Values

and

Descriptions

5010

Valid Values

and

Descriptions

5010A1

Valid Values

and

Descriptions

Notes

2330B N4 Other Payer City/State/Zip Code Usage: Required Usage: Situational

Situational Rule in 5010A1: Required when the payer address is available and the submitter intends for the claim to be printed on paper at the next EDI location (for example, a clearinghouse). if not required by this implementation guide, do not send.

2330B N401 Other Payer City New Element Usage: Required Length: 2-30

2330B N402 Other Payer State or Province code New Element





do not send.

2330B N403 Other Payer Postal code New Element






do not send.

2330B N404 Other Payer Country Code New Element


SITUATIONAL RULE: Required when the address is

outside the United States of America. If not required


2330B N407 Other Payer Country Subdivision Code

New Element





administrative subdivisions such as but not limited

to states, provinces, cantons, etc. If not required by


2330B PER Other Payer Contact Information Segment Deleted

2330B PER01 Other Payer Contact Information Contact Function Code

Element Deleted

2330B PER02 Other Payer Contact Information Other Payer Contact Name

Element Deleted

Page 84 of 140

Loop Segment /


4010

Valid Values

and

Descriptions

5010

Valid Values

and

Descriptions

5010A1

Valid Values

and

Descriptions

Notes

2330B PER03 Other Payer Contact Information Communication Number Qualifier

Element Deleted

2330B PER04 Other Payer Contact Information Communication Number

Element Deleted


Element Deleted


Element Deleted


Element Deleted


Element Deleted

2330B DTP

4010A1 :Claim Adjudication Date 5010: Claim Check or Remittance Date

Segment renamed in 5010 standard. No functional change in data.

2330B REF01

Other Payer Secondary Identification Reference Identification Qualifier


F8: Original Reference Number

FY: Claim Office

Number NF: National

Association of Insurance Commissioners (NAIC) Code



EI: Employer’s


FY: Claim Office Number NF: National Association


Code Added Codes Deleted

2330B REF02 Other Payer Additional Identifier Length: 1 - 30 Length: 1 - 50 Maximum length increase from 30 – 50

2330B REF02 Other Payer Prior Authorization Number

Length: 1 - 30 Length: 1 - 50 (REF01 qualifier value ‘G1’) Maximum length increase from 30 – 50

Page 85 of 140

Loop Segment /


4010

Valid Values

and

Descriptions

5010

Valid Values

and

Descriptions

5010A1

Valid Values

and

Descriptions

Notes

2330B REF02 Other Payer Referral Number Length: 1 - 30 Length: 1 - 50 (REF01 qualifier value ‘9F’) Maximum length increase from 30 – 50

2330B REF Other Payer Claim Adjustment Indicator

Segment Repeat: 2

Segment Repeat: 1 Change in maximum segment repeat

2330B REF Other Payer Claim Control Number New Segment


Required when it is necessary to identify the Other

Payer’s Claim Control Number in a payer-to-payer

COB situation.

OR

Required when the Other Payer’s Claim Control

Number is available.


send.

2330B REF01 Other Payer Claim Control Number Reference Identification Qualifier

New Element F8: Original Reference

Number

Usage: Required

2330B REF02 Other Payer Claim Control Number Length: 1 - 50 New Element

Usage: Required

Loop 2330C Other Payer Name (Deleted in 5010)

Loop Segment /


4010

Valid Values

and

Descriptions

5010

Valid Values

and

Descriptions

5010A1

Valid Values

and

Descriptions

Notes

2330C Other Payer Patient Identification Loop

Loop Deleted

4010A1 2310C Other Payer Patient Identification Loop

Deleted

Other Payer Referring Provider moved from 4010A1

2310D loop to 5010 2310C loop

2330C NM1 Other Payer Patient Name Other Payer Patient Name

Segment Deleted

2330C NM101 Other Payer Patient Name Entity Qualifier Code

Element Deleted

2330C NM102 Other Payer Patient Name Entity Type Qualifier

Element Deleted

Page 86 of 140

Loop Segment /


4010

Valid Values

and

Descriptions

5010

Valid Values

and

Descriptions

5010A1

Valid Values

and

Descriptions

Notes

2330C NM108 Other Payer Patient Name Identification Code Qualifier

Element Deleted

2330C NM109

Other Payer Patient Name Purchased Service Provider Identification

Element Deleted

2330C REF Other Payer Patient Identification Segment Deleted

2330C REF01 Other Payer Patient Identification Reference Identification Qualifier

Element Deleted

2330C REF02 Other Payer Patient Identification Secondary Identification

Element Deleted

Loop 2330C Other Payer Referring Provider

Loop Segment


4010

Valid Values

and

Descriptions

5010

Valid Values

and

Descriptions

5010A1

Valid Values

and

Descriptions

Notes

2330C Other Payer Referring Provider Loop Change Other Payer Referring Provider moved from 4010A1

2330D loop to 5010 2330C loop

2330C NM102

Other Payer Referring Provider Identification Entity Type Code

1: Person 2: Non-Person

Entity

1: Person

Code Deleted

Page 87 of 140

Loop Segment


4010

Valid Values

and

Descriptions

5010

Valid Values

and

Descriptions

5010A1

Valid Values

and

Descriptions

Notes

2330C REF01

Other Payer Referring Provider Secondary Identification Reference Identification Qualifier





EI: Employer’s



LU: Location Number



1G: Provider UPIN

Number G2: Provider

Commercial Number


2330C REF02 Other Payer Referring Provider Secondary Identifier


Loop 2330D Other Payer Rendering Provider

Loop Segment


4010

Valid Values

and

Descriptions

5010

Valid Values

and

Descriptions

5010A1

Valid Values

and

Descriptions

Notes

2330D Other Payer Rendering Provider Loop Change Other Payer Rendering Provider moved from 4010A1

2330E loop to 5010 2330D loop

Page 88 of 140

Loop Segment


4010

Valid Values

and

Descriptions

5010

Valid Values

and

Descriptions

5010A1

Valid Values

and

Descriptions

Notes

2330D REF01

Other Payer Rendering Provider Secondary Identification Reference Identification Qualifier

1B: Blue Shield

Provider Number



EI: Employer’s



LU: Location Number



1G: Provider UPIN

Number G2: Provider

Commercial Number

LU: Location Number

Codes Added Codes Deleted

2330D REF02

Other Payer Rendering Provider Secondary Identification Reference Identification


Loop 2330E Other Payer Service Facility Location

Loop Segment


4010 Valid Values

and Descriptions

5010 Valid Values and

Descriptions

5010A1

Valid Values

and

Descriptions

Notes

2330E Other Payer Service Facility Location

Loop Change Other Payer Service Facility Location moved from

4010A1 2330G loop to 5010 2330E loop

Page 89 of 140

Loop Segment


4010 Valid Values

and Descriptions

5010 Valid Values and

Descriptions

5010A1

Valid Values

and

Descriptions

Notes

2330E NM101

Other Payer Service Facility Location Entity Identifier Code



Lab TL: Testing

Laboratory


Codes Deleted

2330E REF01

Other Payer Service Facility Location Secondary Identification Reference Identification Qualifier

1A: Blue Cross

Provider Number





LU: Location Number



G2: Provider

Commercial Number

LU: Location Number


2330E REF02

Other Payer Service Facility Location Secondary Identification Reference Identification


Page 90 of 140

Loop 2330F Other Payer Purchased Service Provider (Deleted in 5010)

Loop Segment


4010

Valid Values

and

Descriptions

5010

Valid Values

and

Descriptions

5010A1

Valid Values

and

Descriptions

Notes

2330F Other Payer Purchased Service Provider

Loop Deleted

4010A1 2330F Other Payer Purchased Service

Provider Loop Deleted

Other Payer Supervising Provider moved from

4010A1 2330H loop to 5010 2330F loop

2330F NM1

Other Payer Purchased Service Provider Other Payer Patient Name

Segment Deleted

2330F NM101

Other Payer Purchased Service Provider Entity Qualifier Code

Element Deleted

2330F NM102

Other Payer Purchased Service Provider Entity Type Qualifier

Element Deleted

2330F REF Other Payer Purchased Service Provider Identification

Segment Deleted

2330F REF01

Other Payer Purchased Service Provider Identification Reference Identification Qualifier

Element Deleted

2330F REF02 Other Payer Purchased Service Provider Identifier

Element Deleted

Loop 2330F Other Payer Supervising Provider

Loop Segment


4010

Valid Values

and

Descriptions

5010

Valid Values

and

Descriptions

5010A1

Valid Values

and

Descriptions

Notes

2330F Other Payer Supervising Provider Loop Change Other Payer Supervising Provider moved from

4010A1 2330H loop to 5010 2330F loop

Page 91 of 140

Loop Segment


4010

Valid Values

and

Descriptions

5010

Valid Values

and

Descriptions

5010A1

Valid Values

and

Descriptions

Notes

2330F REF01

Other Payer Supervising Provider Secondary Identification Reference Identification Qualifier

1B: Blue Shield

Provider Number



EI: Employer’s



N5: Provider

Plan Network Identification Number


1G: Provider UPIN

Number G2: Provider

Commercial Number

LU: Location Number

Codes Added Codes Deleted

2330F REF02

Other Payer Supervising Provider Secondary Identification Reference Identification


Page 92 of 140

Loop 2330G Other Payer Billing Provider (New in 5010)

Loop Segment /


4010

Valid Values

and

Descriptions

5010

Valid Values

and

Descriptions

5010A1

Valid Values

and

Descriptions

Notes

2330G Other Payer Billing Provider New Loop

4010A1 Loop 2330G Other Payer Facility Location

moved to 5010 Loop 2330E

Other Payer Billing Provider (5010 Loop 2330G)

contains data new to the 5010 standard. TR3 Usage Rules:

Usage: Situational

Required prior to the mandated implementation of

the HIPAA National Provider Identifier (NPI) rule

when the provider in the corresponding Loop ID-

2310 is sent and one or more additional payer-

specific provider

identification numbers are required by this non-

destination payer (Loop ID-2330B) to identify the

provider.

OR

Required after the mandated implementation of the

NPI rule for providers who are not Health Care

Providers when the provider is sent in the

corresponding Loop ID-2310 and one or more

additional payer-specific provider identification

numbers are required by this non-destination payer

(Loop ID-2330B) to identify the provider.


send.

2330G NM1 Other Payer Billing Provider New Segment Usage: Required Required when 2330G Loop is present

2330G NM101 Other Payer Billing Provider Entity Identifier Code

New Element 85: Billing Provider


2330G NM102 Other Payer Billing Provider Entity Type Qualifier

New Element 1: Person 2: Non-Person Entity


2330G REF Other Payer Billing Provider Secondary Identification

New Segment Usage: Required Required when 2330G Loop is present

Page 93 of 140

Loop Segment /


4010

Valid Values

and

Descriptions

5010

Valid Values

and

Descriptions

5010A1

Valid Values

and

Descriptions

Notes

2330G REF01

Other Payer Billing Provider Secondary Identification Reference Identification Qualifier

New Element G2: Provider

Commercial Number

LU: Location Number

Usage: Required

2330G REF02 Other Payer Billing Provider Secondary Identifier


Usage: Required

Page 94 of 140

Loop 2400 Service Line

Loop Segment /


4010

Valid Values

and

Descriptions

5010

Valid Values

and

Descriptions

5010A1

Valid Values

and

Descriptions

Notes

2400 SV101-01 Professional Service Product or Service ID Qualifier

HC: Health Care

Financing Administration Common Procedural Coding System (HCPCS) Codes

IV: Home Infusion EDI Coalition (HIEC) Product/Service Code

ZZ: Mutually

Defined

ER: Jurisdiction Specific Procedure and Supply Codes

HC: Health Care Financing Administration Common Procedural Coding System (HCPCS) Codes

IV: Home Infusion EDI

Coalition (HIEC) Product/Service Code

WK: Advanced Billing

Concepts (ABC) Codes

Codes Added Code Deleted Value ‘’IV’ in both the 4010A1 and 5010 standard is defined as:

This code set is not allowed for use under HIPAA at

the time of this writing.

Value ‘’ER’ in the 5010 standard is defined as:


the time of this writing. Value ‘’WK’ in the 5010 standard is defined as:

At the time of this writing, this code set has been

approved by the Secretary of HHS as a pilot project

allowed under HIPAA law. The qualifier may only be

used in transactions covered under HIPAA; By

parties registered in the pilot project and their trading

partners,

OR

If a new rule names the Complementary, Alternative,

or Holistic Procedure Codes as an allowable code

set under HIPAA,

OR

For claims which are not covered under HIPAA.

Value ‘ZZ’ in the 4010A1 standard usage defined as:

Jurisdictionally Defined Procedure and Supply

Codes. (Used for Worker’s Compensation claims).

Contact your local (State) Jurisdiction for a list of

these codes.

2400 SV103

Professional Service Unit or Basis for Measurement Code

F2: International Unit

MJ: Minutes UN: Unit


Code Deleted

Page 95 of 140

Loop Segment /


4010

Valid Values

and

Descriptions

5010

Valid Values

and

Descriptions

5010A1

Valid Values

and

Descriptions

Notes

2400 SV105

Professional Service Health Care Service Location Information



Code Source 235: The 4010A1 IG lists values for this element as a courtesy. Source of truth for valid values is “Place of Service Codes for Professional And Dental Claim’ listed at http://www.cms.hhs.gov/MedHCPCSGenInfo/Downloads/ Place_of_Service.pdf No functional differences in edit

2400 SV107

Professional Service Composite Diagnosis Code Pointer

Usage: Situational Usage: Required Usage change from situational to required SV107-01 is now required.

2400 SV107-01 Diagnosis Code Pointer Usage: Situational Usage: Required Usage change from situational to required

2400 SV504

Durable Medical Equipment Service DME Rental Price

Usage: Situational Usage: Required Usage change from situational to required when segment SV5 is used

2400 SV505

Durable Medical Equipment Service DME Purchase Price


2400 SV506

Durable Medical Equipment Service Rental Unit Price Indicator


Page 96 of 140

Loop Segment /


4010

Valid Values

and

Descriptions

5010

Valid Values

and

Descriptions

5010A1

Valid Values

and

Descriptions

Notes

2400 PWK Line Supplemental Information New Segment

TR3 Rule:

Required when there is a paper attachment following

this claim.

OR

Required when attachments are sent electronically

(PWK02 = EL) but are transmitted in another

functional group (for example, 275) rather than by

paper. PWK06 is then used to identify the attached

electronic documentation. The number in PWK06 is

carried in the TRN of the electronic attachment.

OR

Required when the provider deems it necessary to

identify additional information that is being held at

the provider’s office and is available upon request by

the payer (or appropriate entity), but the information

is not being submitted with the claim. Use the value

of “AA” in PWK02 to convey this specific use of the

PWK segment.


send.

2400 PWK01 Line Supplemental Information Attachment Report Type Code

New Element 03: Report Justifying

Treatment Beyond Utilization Guidelines

04: Drugs Administered 05: Treatment

Diagnosis 06: Initial Assessment 07: Functional Goals 08: Plan of Treatment 09: Progress Report 10: Continued

Treatment 11: Chemical Analysis 13: Certified Test

Report 15: Justification for

Admission 21: Recovery Plan A3:

Allergies/Sensitivities Document

A4: Autopsy Report AM: Ambulance

New Element Usage Required

Page 97 of 140

Loop Segment /


4010

Valid Values

and

Descriptions

5010

Valid Values

and

Descriptions

5010A1

Valid Values

and

Descriptions

Notes

Certification AS: Admission

Summary B2: Prescription B3: Physician Order B4: Referral Form BR: Benchmark Testing

Results BS: Baseline BT: Blanket Test

Results CB: Chiropractic

Justification CK: Consent Form(s) CT: Certification D2: Drug Profile

Document DA: Dental Models DB: Durable Medical

Equipment Prescription

DG: Diagnostic Report DJ: Discharge

Monitoring Report DS: Discharge Summary EB: Explanation of

Benefits (Coordination of Benefits or Medicare Secondary Payor)

HC: Health Certificate HR: Health Clinic

Records I5: Immunization

Record IR: State School

Immunization Records

LA: Laboratory Results M1: Medical Record

Attachment MT: Models NN: Nursing Notes OB: Operative Note OC: Oxygen Content

Averaging Report OD: Orders and

Treatments

Page 98 of 140

Loop Segment /


4010

Valid Values

and

Descriptions

5010

Valid Values

and

Descriptions

5010A1

Valid Values

and

Descriptions

Notes

Document OE: Objective Physical

Examination (including vital signs) Document

OX: Oxygen Therapy Certification

OZ: Support Data for Claim

P4: Pathology Report P5: Patient Medical

History Document 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 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

2400 PWK02 Line Supplemental Information Attachment Transmission Code

New Element AA: Available on

Request at Provider Site

BM: By Mail EL: Electronically Only EM: E-Mail FT: File Transfer FX: By Fax

Usage Required

Page 99 of 140

Loop Segment /


4010

Valid Values

and

Descriptions

5010

Valid Values

and

Descriptions

5010A1

Valid Values

and

Descriptions

Notes

2400 PWK05 Line Supplemental Information Identification Code Qualifier

New Element AC: Attachment Control

Number

Usage Situational TR3 Rule:

SITUATIONAL RULE: Required when PWK02 = “BM”, “EL”,

“EM”, “FX” or “FT”. If not required by this


2400 PWK06 Line Supplemental Information Attachment Control Number

New Element

Usage Situational TR3 Rule:

SITUATIONAL RULE: Required when PWK02 = “BM”, “EL”,

“EM”, “FX” or “FT”. If not required by this


PWK06 is used to identify the attached electronic

documentation. The number in PWK06 is carried in

the TRN of the electronic attachment.

For the purpose of this implementation, the

maximum field length is 50.

2400 CR103 Ambulance Transport Information Ambulance Transport Code

Element Deleted

2400 CR2 Spinal Manipulation Service Information

Segment Deleted

2400 CR208

Spinal Manipulation Service Information Patient Condition Code

Element Deleted

2400 CR210

Spinal Manipulation Service Information Patient condition Description

Element Deleted

2400 CR211

Spinal Manipulation Service Information Patient Condition Description

Element Deleted

2400 CR212

Spinal Manipulation Service Information X-ray Availability Indicator

Element Deleted

2400 CR5 Home Oxygen Therapy Information

Segment Deleted

Page 100 of 140

Loop Segment /


4010

Valid Values

and

Descriptions

5010

Valid Values

and

Descriptions

5010A1

Valid Values

and

Descriptions

Notes

2400 CR501

Home Oxygen Therapy Information Certification Type Code

Element Deleted

2400 CR502

Home Oxygen Therapy Information Treatment Period Count

Element Deleted

2400 CR510

Home Oxygen Therapy Information Arterial Blood Gas Quantity

Element Deleted

2400 CR511

Home Oxygen Therapy Information Oxygen Saturation Quantity

Element Deleted

2400 CR512

Home Oxygen Therapy Information Oxygen Test Condition Code

Element Deleted

2400 CR513

Home Oxygen Therapy Information Oxygen Test Findings Code

Element Deleted

2400 CR514


Element Deleted

2400 CR515


Element Deleted

Page 101 of 140

Loop Segment /


4010

Valid Values

and

Descriptions

5010

Valid Values

and

Descriptions

5010A1

Valid Values

and

Descriptions

Notes

2400

CRC03 CRC04 CRC05 CRC06 CRC07

Ambulance Certification Condition Code


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


07: Patient had to be physically restrained

08: Patient had visible hemorrhaging

09: Ambulance service was medically necessary

60:

Transportation Was To the Nearest Facility


04: Patient was moved

by stretcher 05: Patient was

unconscious or in shock


07: Patient had to be

physically restrained 08: Patient had visible

hemorrhaging 09: Ambulance service

was medically necessary

12: Patient is confined

to a bed or chair

Codes Deleted Code Added

Page 102 of 140

Loop Segment /


4010

Valid Values

and

Descriptions

5010

Valid Values

and

Descriptions

5010A1

Valid Values

and

Descriptions

Notes

2400 CRC03 Hospice Employee Indicator Condition Indicator

Length: 2/2 Length: 3/3 Maximum length increase from 2/2 – 3/3.

2400 CRC DMERC Condition Indicator Certification Condition Indicator

Segment Repeat: 2


2400 CRC01 DMERC Condition Indicator Certification Condition Indicator

09: Durable Medical Equipment Certification

11: Oxygen Therapy Certification

09: Durable Medical Equipment Certification

Code Deleted

2400 CRC03 CRC04

DMERC Condition Indicator Certification Condition Indicator

Length: 2/2 Length: 3/3 Maximum length increase from 2/2 – 3/3.

2400 CRC03 CRC05

DMERC Condition Indicator Condition Indicator

37: Oxygen delivery equipment is stationary

38: Certification signed by the physician is on file at the supplier’s office

AL: Ambulation Limitations

P1: Patient was Discharged from the First Facility

ZV: Replacement Item

38: Certification signed

by the physician is on file at the supplier’s office

ZV: Replacement Item

Codes Deleted

2400 CRC06 CRC07 CRC08

DMERC Condition Indicator Condition Indicator

Element Deleted

Page 103 of 140

Loop Segment /


4010

Valid Values

and

Descriptions

5010

Valid Values

and

Descriptions

5010A1

Valid Values

and

Descriptions

Notes

2400 DTP Date – Prescription Date New Segment


Required when a drug is billed for this line and a

prescription was written (or otherwise communicated

by the prescriber if not written). If not required by this


2400 DTP01 Date – Prescription Date Date Time Qualifier

New Element 471: Prescription

Usage: Required when Prescription Date segment is used

2400 DTP02 Date – Prescription Date Date Time Period Format Qualifier


Format CCYYMMDD

Usage: Required when Prescription Date segment is used

2400 DTP03 Date – Prescription Date Prescription Date

New Element Usage: Required when Prescription Date segment is used

2400 DTP Date – Oxygen Saturation/Arterial Blood Gas Test

Segment Deleted

2400 DTP01

Date – Oxygen Saturation/Arterial Blood Gas Test Date Time Qualifier

Element Deleted 119: 480: 481:

2400 DTP02

Date – Oxygen Saturation/Arterial Blood Gas Test Date Time Period Format Qualifier

Element Deleted D8:

2400 DTP03 Date – Oxygen Saturation/Arterial Blood Gas Test

Element Deleted

2400 DTP Date – Onset of Current Symptom/Illness

Segment Deleted

2400 DTP01

Date – Onset of Current Symptom/Illness Date Time Qualifier


2400 DTP02

Date – Onset of Current Symptom/Illness Date Time Period Format Qualifier

Element Deleted D8:

2400 DTP03 Date – Onset of Current Symptom/Illness

Element Deleted

2400 DTP Date – Acute Manifestation Segment Deleted

Page 104 of 140

Loop Segment /


4010

Valid Values

and

Descriptions

5010

Valid Values

and

Descriptions

5010A1

Valid Values

and

Descriptions

Notes

2400 DTP01 Date – Acute Manifestation Date Time Qualifier


2400 DTP02 Date – Acute Manifestation Date Time Period Format Qualifier

Element Deleted D8:

2400 DTP03 Date – Acute Manifestation Element Deleted


Segment Deleted

2400 DTP01



2400 DTP02

Date – Similar Illness/Symptom Onset Date Time Period Format Qualifier

Element Deleted D8:

2400 DTP03 Date – Similar Illness/Symptom Onset

Element Deleted

2400 QTY Ambulance Patient Count New Segment


Required when more than one patient is transported

in the same vehicle for Ambulance or non-emergency

transportation services. If not required by this


2400 QTY01 Ambulance Patient Count Quantity Qualifier

New Element PT: Patients

Usage: Required when segment Ambulance Patient Count is used

2400 QTY02 Ambulance Patient Count New Element Usage: Required when segment Ambulance Patient Count is used

2400 QTY Obstetric Anesthesia Additional Units

New Segment


Required in conjunction with anesthesia for obstetric

services when the anesthesia provider chooses to

report additional complexity beyond the normal

services reflected by the procedure base units and

anesthesia time.


send.

Page 105 of 140

Loop Segment /


4010

Valid Values

and

Descriptions

5010

Valid Values

and

Descriptions

5010A1

Valid Values

and

Descriptions

Notes

2400 QTY01

Obstetric Anesthesia Additional Units Quantity Qualifier

New Element FL: Units

Usage: Required when segment Obstetric Anesthesia Additional Units is used

2400 QTY02 Obstetric Anesthesia Additional Units

New Element Usage: Required when segment Obstetric Anesthesia Additional Units is used

2400 MEA Test Results Segment Repeat:

20 Segment Repeat: 5

Change in maximum segment repeat

2400 MEA02 Test Results Measurement Qualifier

GRA: Gas Test Rate

HT: Height R1: Hemoglobin R2: Hematocrit R3: Epoetin

Starting Dosage

R4: Creatin ZO: Oxygen

HT: Height R1: Hemoglobin R2: Hematocrit R3: Epoetin Starting

Dosage R4: Creatin

Codes Deleted

2400 CN104 Contract Information Contract Code


2400 REF02 Repriced Line Item Reference Number

Length: 1 - 30 Length: 1 - 50 REF01 qualifier value ‘9B’ Maximum length increase from 30 – 50

2400 REF02 Adjusted Repriced Line Item Reference Number

Length: 1 - 30 Length: 1 - 50 REF01 qualifier value ‘9D’ Maximum length increase from 30 – 50

2400 REF Prior Authorization Number Segment Repeat: 2 Segment Repeat: 10

Change in maximum segment repeat Note: Prior Authorization or Referral Number was one segment in 4010, and now separated into two segments in 5010.

2400 REF02 Prior Authorization Number Length: 1 - 30 Length: 1 - 50 REF01 qualifier value ‘G1’ Maximum length increase from 30 – 50

2400 REF04 Prior Authorization Number Reference Identifier

New Element

TR3 Usage Rule:

SITUATIONAL RULE: Required when the Prior

Authorization Number reported in REF02 of this

segment is for a non-destination payer.

2400 REF04-01 Prior Authorization Number Reference Identification Qualifier

New Sub-Element 2U: Payer Identification

Number

Usage: Required when element REF04 is used.

Page 106 of 140

Loop Segment /


4010

Valid Values

and

Descriptions

5010

Valid Values

and

Descriptions

5010A1

Valid Values

and

Descriptions

Notes

2400 REF04-02 Prior Authorization Number Other Payer Primary Identifier

New Sub-element Length: 1 - 50


2400 REF02 Line Item Control Number Reference Identification

Length: 1 - 30 Length: 1 - 50 REF01 qualifier value ‘6R’ Maximum length increase from 30 – 50

2400 REF02

Mammography Certification Number Reference Identification

Length: 1 - 30 Length: 1 - 50 REF01 qualifier value ‘EW’ Maximum length increase from 30 – 50

2400 REF02

Clinical Laboratory Improvement Amendment (CLIA) Number Reference Identification

Length: 1 - 30 Length: 1 - 50 REF01 qualifier value ‘X4’ Maximum length increase from 30 – 50

2400 REF02 Immunization Batch Number Reference Identification

Length: 1 - 30 Length: 1 - 50 REF01 qualifier value ‘BT’ Maximum length increase from 30 – 50

2400 REF Ambulatory Patient Group Segment Deleted

2400 REF01 Ambulatory Patient Group Reference Identification Qualifier

Element Deleted 1S:

2400 REF02 Ambulatory Patient Group Number Element Deleted

2400 REF Oxygen Flow Rate Segment Deleted

2400 REF01 Oxygen Flow Rate Reference Identification Qualifier

Element Deleted TP:

2400 REF02 Oxygen Flow Rate Element Deleted

2400 REF Universal Product Number Segment Deleted

2400 REF01 Universal Product Number Reference Identification Qualifier

Element Deleted OZ: VP:

2400 REF02 Universal Product Number Element Deleted

Page 107 of 140

Loop Segment /


4010

Valid Values

and

Descriptions

5010

Valid Values

and

Descriptions

5010A1

Valid Values

and

Descriptions

Notes

2400 REF Referral Number New Segment


Required when this service line involved a referral

number that is different than the number reported at

the claim level (Loop-ID 2300).


send.

TR3 Notes: 1. When it is necessary to report one or

more non-destination payer Referral Numbers, the

composite data element in REF04 is used to identify

the payer which assigned this referral number.

Note: Prior Authorization or Referral Number was one segment in 4010, and now separated into two segments in 5010.

2400 REF01 Referral Number Identification Qualifier

New element 9F: Referral Number

Usage: Required if Referral Number segment is present

2400 REF02 Referral Number Length: 1 - 50 Usage: Required if Referral Number segment is present

2400 REF04 Referral Number Reference Identifier

New Element

TR3 Usage Rule:

SITUATIONAL RULE: Required when the Referral Number

reported in REF02 of this segment is for a non-

destination payer.

2400 REF04-01 Referral Number Reference Identification Qualifier


Number


2400 REF04-02 Referral Number Other Payer Primary Identifier

New Sub-element

Length: 1 - 50 Usage: Required when element REF04 is used.

2400 AMT Approved Amount Segment Deleted

2400 AMT01 Approved Amount Amount Qualifier Code

Element Deleted AAE: Total Claim

Before Taxes

2400 AMT02 Approved Amount Other Payer Tax Amount

Element Deleted

Page 108 of 140

Loop Segment /


4010

Valid Values

and

Descriptions

5010

Valid Values

and

Descriptions

5010A1

Valid Values

and

Descriptions

Notes

2400 NTE Line Note

THIRD PARTY ORGANIZATION NOTES NTE Segment split into separate entry in TR3. TR3 Usage Rule Change for Line Notes NTE Segment: Usage: Situational

Required when in the judgment of the provider, the

information is needed to substantiate the medical

treatment and is not supported elsewhere within the

claim data set.


send.

TR3 Notes:

1. Use SV101-7 to describe non-specific procedure

codes. Do not use this NTE Segment to describe a

non-specific procedure code. If an NDC code is

reported in Loop 2410, do not use this segment for a

description of the procedure code. The NDC in loop

2410 will provide the description.

2400 NTE01 Line Note Note Reference Code



PMT: Payment TPO: Third Party

Organization Notes



Codes Deleted Usage for ‘TPO’ qualifier described in separate segment.

2400 NTE Third Party Organization note

THIRD PARTY ORGANIZATION NOTES NTE Segment split into separate entry in TR3. TR3 Usage Rule Change for Third Party Organization notes NTE Segment: Usage: Situational

Required when the TPO/repricer needs to forward

additional information to the payer. This segment is

not completed by providers. If not required by this


2400 NTE01 Third Party Organization note Note Reference Code

TPO: Third Party

Organization Notes

2400 PS1 Purchased Service Information Reference identification


Page 109 of 140

Loop Segment /


4010

Valid Values

and

Descriptions

5010

Valid Values

and

Descriptions

5010A1

Valid Values

and

Descriptions

Notes

2400 HSD Health Care Services Delivery Segment Deleted

2400 HSD01 Health Care Services Delivery Visits

Element Deleted

2400 HSD02 Health Care Services Delivery Number of Visits

Element Deleted

2400 HSD03 Health Care Services Delivery Frequency Period

Element Deleted

2400 HSD04 Health Care Services Delivery Frequency Count

Element Deleted

2400 HSD05 Health Care Services Delivery Duration of Visits Units

Element Deleted

2400 HSD06 Health Care Services Delivery Duration of Visits, Number of Units

Element Deleted

2400 HSD07

Health Care Services Delivery Ship, Delivery or Calendar Pattern Code

Element Deleted

2400 HSD08 Health Care Services Delivery Delivery Pattern Time Code

Element Deleted

2400 HCP04 HCP06

Line Pricing/Repricing Information Reference Identification


Page 110 of 140

Loop Segment /


4010

Valid Values

and

Descriptions

5010

Valid Values

and

Descriptions

5010A1

Valid Values

and

Descriptions

Notes

2400 HCP09

Line Pricing / Repricing Information Product or Service ID Qualifier

HC: Health Care



ZZ: Mutually

Defined

ER: Jurisdiction Specific Procedure and Supply Codes

HC: Health Care Financing Administration Common Procedural Coding System (HCPCS) Codes

IV: Home Infusion EDI

Coalition (HIEC) Product/Service Code













parties registered in the pilot project and their trading

partners,

OR



set under HIPAA,

OR






these codes.

2400 HCP11

Line Pricing / Repricing Information Unit or Basis for Measurement Code

DA: Days UN: Unit


Code Deleted Code Added

Loop 2410 Drug Identification

Loop Segment /


4010

Valid Values

and

Descriptions

5010

Valid Values

and

Descriptions

5010A1

Valid Values

and

Descriptions

Notes

Page 111 of 140

2410 LIN Drug Identification Loop Repeat: 25 Loop Repeat: 1

Loop repeat changed from 25 to 1 Situational Rule in 5010A1: 5010A1:Required when government regulation mandates that prescribed drugs and biologics are reported with NDC numbers. OR Required when the provider or submitter chooses to report NDC numbers to enhance the claim reporting or adjudication processes. OR Required when an HHS approved pilot project specifies reporting of Universal Product Number (UPN) by parties registered in the pilot and their trading partners. OR Required when government regulation mandates that medical and surgical supplies are reported with UPN’s. If not required by this implementation guide, do not send.

2410 LIN02 Drug Identification Product/’Service ID Qualifier

N4: National Drug Code

5-4-2 Format

N4: National Drug Code-5-4-2 Format

EN: EAC/UCC – 13

HI: HIBC (Health Care Industry Bar Code) Supplier Labeling Standard Primary Data Message

ON: Customer Order Number

UK: GTIN 14 – digit Data Structure

UP: USS - 12

Usage: Required TR3 50100A1 Notes: At the time of this writing, UPN code sets designated by values EN, EO, HI, ON, UK, and UP have been approved by the Secretary of HHS as a pilot project allowed under HIPPA law. During the pilot, these code values may only be used by parties registered in the pilot project and their trading partners. Beyond the pilot, these codes may only be used if mandated by government regulation.

2410 LIN02 Drug Identification Product/’Service ID

Implementation Name:

National Drug Code

Implementation Name: National Drug Code or Universal Product Number

Usage: Requried

2410 CTP Drug Pricing Usage: Situational Usage: Required Usage change from situational to required

2410 CTP03 Drug Pricing Drug Unit Price

Element Deleted

Page 112 of 140

2410 CTP05-01

Drug Pricing Unit or Basis for Measurement Code

F2: International Unit

GR: Gram ML: Milliliter UN: Unit

F2: International Unit GR: Gram ME: Milligram ML: Milliliter UN: Unit

Code Added

2410 REF01 Prescription Number Reference Identification Qualifier

XZ: Pharmacy

Prescription Number

VY: Link Sequence Number

XZ: Pharmacy

Prescription Number

TR3 Usage Notes for ‘VY’ – Link Sequence Number

Required when dispensing of the drug has been done

with an assigned prescription number.

OR

Required when the provided medication involves the

compounding of two or more drugs being reported

and there is no prescription number.


send.

TR3 Notes:

1. In cases where a compound drug is being billed,

the components of the compound will all have the

same prescription number. Payers receiving the

claim can relate all the components by matching the

prescription number.

2. For cases where the drug is provided without a

prescription (for example, from a physician’s office),

the value provided in this segment is a “link

sequence number”. The link sequence number is a

provider assigned number that is unique to this

claim. Its purpose is to enable the receiver to piece

together the components of the compound.

2410 REF02 Prescription Number Length: 1 - 30 Length: 1 - 50 Maximum length increase from 30 - 50

Loop 2420A Rendering Provider

Loop Segment


4010

Valid Values

and

Descriptions

5010

Valid Values

and

Descriptions

5010A1

Valid Values

and

Descriptions

Notes

2420A NM103 Rendering Provider Name Name Last or organization Name


Page 113 of 140

Loop Segment


4010

Valid Values

and

Descriptions

5010

Valid Values

and

Descriptions

5010A1

Valid Values

and

Descriptions

Notes

2420A NM104 Rendering Provider Name Name First







2420A NM108 Rendering Provider Name Identification Code Qualifier









United States or its territories on or after the

mandated HIPAA National Provider Identifier (NPI)

implementation date when the provider is eligible to

receive an NPI.

OR



Provider Identifier (NPI) implementation date when

the provider has received an NPI.

OR


implementation date when the provider has received

an NPI and the submitter has the capability to send it.


send.


2420A NM109 Rendering Provider Name Billing Provider Identifier

In 4010A1, could be Tax ID, SSN, or NPI. In 5010, must be NPI

2420A PRV02

Rendering Provider Specialty Information Reference Identification Qualifier



Qualifier code change only. No functional impact

2420A PRV03

Rendering Provider Specialty Information Reference Identification


2420A REF Rendering Provider Secondary Identification

Segment Repeat: 5


Page 114 of 140

Loop Segment


4010

Valid Values

and

Descriptions

5010

Valid Values

and

Descriptions

5010A1

Valid Values

and

Descriptions

Notes

2420A REF01










LU: Location Number





1G: Provider UPIN

Number G2: Provider

Commercial Number

LU: Location Number

Codes Deleted

2420A REF02 Rendering Provider Secondary Identification


2420A REF04

Rendering Provider Secondary Identification Reference Identifier

New Element

TR3 Usage Rule:

SITUATIONAL RULE: Required when the identifier


destination payer.

Do not use this composite when the value reported

in REF01 is either 0B or 1G.

Page 115 of 140

Loop Segment


4010

Valid Values

and

Descriptions

5010

Valid Values

and

Descriptions

5010A1

Valid Values

and

Descriptions

Notes

2420A REF04-01



Number


2420A REF04-02

Rendering Provider Secondary Identification Other Payer Primary Identifier



Loop 2420B Purchased Service Provider

Loop Segment


4010

Valid Values

and

Descriptions

5010

Valid Values

and

Descriptions

5010A1

Valid Values

and

Descriptions

Notes

2420B NM103

Purchased Service Provider Name Name Last or Organization Name


2420B NM104

Purchased Service Provider Name Name First


2420B NM108

Purchased Service Provider Name Identification Code Qualifier




XX: Health Care



2420B NM109

Purchased Service Provider Name Purchased Service Provider Identifier


2420B REF Purchased Service Provider Secondary Identification

Segment Repeat: 5 Segment Repeat: 20 Change in maximum segment repeat

Page 116 of 140

Loop Segment


4010

Valid Values

and

Descriptions

5010

Valid Values

and

Descriptions

5010A1

Valid Values

and

Descriptions

Notes

2420B REF01










LU: Location Number



U3: Unique Supplier Identification Number (USIN)



1G: Provider UPIN

Number G2: Provider

Commercial Number

Codes Deleted

2420B REF02 Purchased Service Provider Secondary Identification


Page 117 of 140

Loop Segment


4010

Valid Values

and

Descriptions

5010

Valid Values

and

Descriptions

5010A1

Valid Values

and

Descriptions

Notes

2420B REF04

Purchased Service Provider Secondary Identification Reference Identifier

New Element

TR3 Usage Rule:

SITUATIONAL RULE: Required when the identifier


destination payer.

Do not use this composite when the value reported

in REF01 is either 0B or 1G.

2420B REF04-01


New Sub-Element 2U: Payer



2420B REF04-02

Purchased Service Provider Secondary Identification Other Payer Primary Identifier



Loop 2420C Service Facility Location

Loop Segment


4010

Valid Values

and

Descriptions

5010

Valid Values

and

Descriptions

5010A1

Valid Values

and

Descriptions

Notes

2420C NM101 Service Facility Location Entity Identifier Code



Lab TL: Testing

Laboratory


Codes Deleted

2420C NM103 Service Facility Location Name Last or organization Name


Page 118 of 140

Loop Segment


4010

Valid Values

and

Descriptions

5010

Valid Values

and

Descriptions

5010A1

Valid Values

and

Descriptions

Notes

2420C NM108 Service Facility Location Identification Code Qualifier




XX: Health Care


Codes Deleted

2420C NM109 Service Facility Location Referring Provider Identifier


2420C N402 Service Facility Location State or Province code






do not send.

2420C N403 Service Facility Location Postal code







do not send.

2420C N407 Service Facility Location Country Subdivision Code

New Element in 5010








2420C REF Service Facility Location Secondary Identification


Page 119 of 140

Loop Segment


4010

Valid Values

and

Descriptions

5010

Valid Values

and

Descriptions

5010A1

Valid Values

and

Descriptions

Notes

2420C REF01










LU: Location Number





G2: Provider

Commercial Number

LU: Location Number

Codes Deleted

2420C REF02

Service Facility Location Secondary Identification Laboratory or Facility Secondary Identifier


Page 120 of 140

Loop Segment


4010

Valid Values

and

Descriptions

5010

Valid Values

and

Descriptions

5010A1

Valid Values

and

Descriptions

Notes

2420C REF04

Service Facility Location Secondary Identification Reference Identifier

New Element

TR3 Usage Rule:

SITUATIONAL RULE: Required when the identifier reported

in REF02 of this segment is for a non-destination

payer.

Do not use this composite when the value reported in

REF01 is either 0B or 1G.

2420C REF04-01





2420C REF04-02

Service Facility Location Secondary Identification Other Payer Primary Identifier



Loop 2420D Supervising Provider Name

Loop Segment


4010

Valid Values

and

Descriptions

5010

Valid Values

and

Descriptions

5010A1

Valid Values

and

Descriptions

Notes

2420D NM103 Supervising Provider Name Name Last or organization Name

Length: 1 – 35 Length: 1 – 60 Maximum length increase from 35 – 60

2420D NM104 Supervising Provider Name Name First

Usage: Required Length: 1 – 25


Usage changed from required to situational Maximum length increase from 25 - 35 New TR3 rule:





Page 121 of 140

Loop Segment


4010

Valid Values

and

Descriptions

5010

Valid Values

and

Descriptions

5010A1

Valid Values

and

Descriptions

Notes

2420D NM108 Supervising Provider Name Identification Code Qualifier




XX: Health Care



2420D NM109 Supervising Provider Name Supervising Provider Identifier


2420D REF Supervising Provider Secondary Identification


Page 122 of 140

Loop Segment


4010

Valid Values

and

Descriptions

5010

Valid Values

and

Descriptions

5010A1

Valid Values

and

Descriptions

Notes

2420D REF01

Supervising Provider Secondary Identification Reference Identification Qualifier









LU: Location Number





1G: Provider UPIN

Number G2: Provider

Commercial Number

LU: Location Number

Codes Deleted

2420D REF02 Supervising Provider Secondary Identification


2420D REF04

Supervising Provider Secondary Identification Reference Identifier

New Element

TR3 Usage Rule:



payer.



Page 123 of 140

Loop Segment


4010

Valid Values

and

Descriptions

5010

Valid Values

and

Descriptions

5010A1

Valid Values

and

Descriptions

Notes

2420D REF04-01

Supervising Provider Secondary Identification Reference Identification Qualifier




2420D REF04-02

Supervising Provider Secondary Identification Other Payer Primary Identifier



Loop 2420E Ordering Provider Name

Loop Segment /


4010

Valid Values

and

Descriptions

5010

Valid Values

and

Descriptions

5010A1

Valid Values

and

Descriptions

Notes

2420E NM103

Ordering Provider Name Name Last or organization Name


2420E NM104 Ordering Provider Name Name First








2420E NM108 Ordering Provider Name Identification Code Qualifier




XX: Health Care



Page 124 of 140

Loop Segment /


4010

Valid Values

and

Descriptions

5010

Valid Values

and

Descriptions

5010A1

Valid Values

and

Descriptions

Notes

2420E NM109 Ordering Provider Name Ordering Provider Identifier


2420E N4 Ordering Provider City, State, Zip Code


Usage changed from required to situational in 5010A1. Situational Rule in 5010A1: Required when a Durable Medical Equipment Regional Carrier Certificate of Medical Necessity (DMERC CMN) or DMERC Information Form (DIF), or Oxygen Therapy Certification is included on this service line. If not required by this implementation guide, do not send.

2420E N402

Ordering Provider City, State, ZIP Code State or Province code






do not send.

2420E N403

Ordering Provider City, State, ZIP Code Postal code







do not send.

2420E N407

Ordering Provider City, State, ZIP Code Country Subdivision Code

New Element in 5010





administrative subdivisions such as but not limited to

states, provinces, cantons, etc. If not required by this


2420E REF Ordering Provider Secondary Identification


Page 125 of 140

Loop Segment /


4010

Valid Values

and

Descriptions

5010

Valid Values

and

Descriptions

5010A1

Valid Values

and

Descriptions

Notes

2420E REF01

Ordering Provider Secondary Identification Reference Identification Qualifier









LU: Location Number





1G: Provider UPIN

Number G2: Provider

Commercial Number

Codes Deleted

2420E REF02 Supervising Provider Secondary Identification


2420E REF04

Ordering Provider Secondary Identification Reference Identifier

New Element

TR3 Usage Rule:



payer.



Page 126 of 140

Loop Segment /


4010

Valid Values

and

Descriptions

5010

Valid Values

and

Descriptions

5010A1

Valid Values

and

Descriptions

Notes

2420E REF04-01

Ordering Provider Secondary Identification Reference Identification Qualifier

New Sub-Element 2U: Payer Identification Number


2420E REF04-02

Ordering Provider Secondary Identification Other Payer Primary Identifier



2420E PER02

Ordering Provider Contact Information Name

Usage: Required Usage: Situational Usage changed from required to situational

2420E PER04 PER06 PER08

Ordering Provider Contact Information Communication Number

Length: 80 Length: 256 Maximum length increase from 80 - 256

Loop 2420F Referring Provider Name

Loop Segment


4010

Valid Values

and

Descriptions

5010

Valid Values

and

Descriptions

5010A1

Valid Values

and

Descriptions

Notes

2420F NM103 Referring Provider Name Name Last or organization Name


2420F NM104 Referring Provider Name Name First








Page 127 of 140

Loop Segment


4010

Valid Values

and

Descriptions

5010

Valid Values

and

Descriptions

5010A1

Valid Values

and

Descriptions

Notes

2420F NM108 Referring Provider Name Identification Code Qualifier




XX: Health Care



2420F NM109 Referring Provider Name Ordering Provider Identifier


2420F PRV Referring Provider Specialty Information

Segment Deleted

2420F PRV01

Referring Provider Specialty Information Provider Code

Element Deleted

2420F PRV02

Referring Provider Specialty Information Reference Identification Code

Element Deleted

2420F PRV03

Referring Provider Specialty Information Provider Taxonomy Code

Element Deleted

2420F REF Referring Provider Secondary Identification


Page 128 of 140

Loop Segment


4010

Valid Values

and

Descriptions

5010

Valid Values

and

Descriptions

5010A1

Valid Values

and

Descriptions

Notes

2420F REF01










LU: Location Number





1G: Provider UPIN

Number G2: Provider

Commercial Number

Codes Deleted

2420F REF02 Referring Provider Secondary Identification


2420F REF04

Referring Provider Secondary Identification Reference Identifier

New Element

TR3 Usage Rule:



payer.



Page 129 of 140

Loop Segment


4010

Valid Values

and

Descriptions

5010

Valid Values

and

Descriptions

5010A1

Valid Values

and

Descriptions

Notes

2420F REF04-01





2420F REF04-02

Referring Provider Secondary Identification Other Payer Primary Identifier



Loop 2420G Other Payer Prior Authorization or Referral Number

Loop Segment


4010

Valid Values

and

Descriptions

5010

Valid Values

and

Descriptions

5010A1

Valid Values

and

Descriptions

Notes

2420G Other Payer Prior Authorization or Referral Number Loop

Loop Deleted

4010A1 2420G Other Payer Prior Authorization or

Referral Number Loop Deleted

5010 Standard creates new 2420G loop – Ambulance

Pick-up Location

2420G NM1 Other Payer Prior Authorization or Referral Number

Segment Deleted

2420G NM101

Other Payer Prior Authorization or Referral Number Entity Qualifier Code

Element Deleted

2420G NM102

Other Payer Prior Authorization or Referral Number Entity Type Qualifier

Element Deleted

2420G NM103

Other Payer Prior Authorization or Referral Number payer Name

Element Deleted

2420G NM108

Other Payer Prior Authorization or Referral Number Identification Code Qualifier

Element Deleted

Page 130 of 140

Loop Segment


4010

Valid Values

and

Descriptions

5010

Valid Values

and

Descriptions

5010A1

Valid Values

and

Descriptions

Notes

2420G NM109

Other Payer Prior Authorization or Referral Number Other Payer Identification Number

Element Deleted

2420G REF Other Payer Prior Authorization or Referral Number

Segment Deleted

2420G REF01

Other Payer Prior Authorization or Referral Number Reference Identification Qualifier

Element Deleted

2420G REF02

Other Payer Prior Authorization or Referral Number Secondary Identification

Element Deleted

Loop 2420G Ambulance Pick Up Location (New in 5010)

Loop Segment


4010

Valid Values

and

Descriptions

5010

Valid Values

and

Descriptions

5010A1

Valid Values

and

Descriptions

Notes

2420G Ambulance Pick Up Location New Loop

TR3 Usage Rules:

Usage: Situational

Required when the ambulance pick-up location for

this service line is different than the ambulance

pick-up location provided in Loop ID-2310E.


send.

2420G NM1 Ambulance Pick Up Location New Segment Usage: Required Required when 2420G Loop is present

2420G NM101 Ambulance Pick Up Location Entity Identifier Code

New Element PW: Pickup Address


2420G NM102 Ambulance Pick Up Location Entity Type Qualifier



Page 131 of 140

Loop Segment


4010

Valid Values

and

Descriptions

5010

Valid Values

and

Descriptions

5010A1

Valid Values

and

Descriptions

Notes

2420G N3 Ambulance Pick Up Location Address

New Segment

Usage: Required Required when 2420G Loop is present TR3 Usage Rules:

If the ambulance pickup location is in an area where

there are no street addresses, enter a description of

where the service was rendered (for example,

“crossroad of State Road 34 and 45” or “Exit

near Mile marker 265 on Interstate 80”.)

2420G N301 Ambulance Pick Up Location Address Line


Usage: Required

2420G N302 Ambulance Pick Up Location Address Line





guide, do not send.

2420G N4 Ambulance Pick Up Location City/State/Zip Code

New Segment Usage: Required Required when 2420G Loop is present

2420G N401 Ambulance Pick Up Location City


2420G N402 Ambulance Pick Up Location State or Province code

New Element




Canada. If not required by this implementation

guide, do not send.

2420G N403 Ambulance Pick Up Location Postal code

New Element





in N404. If not required by this implementation

guide, do not send.

2420G N404 Ambulance Pick Up Location Country Code

New Element





Page 132 of 140

Loop Segment


4010

Valid Values

and

Descriptions

5010

Valid Values

and

Descriptions

5010A1

Valid Values

and

Descriptions

Notes

2420G N407 Ambulance Pick Up Location Country Subdivision Code

New Element



the United States of America, including its

territories, or Canada, and the country in N404 has




Loop 2420H Ambulance Drop Off Location (New in 5010)

Loop Segment


4010

Valid Values

and

Descriptions

5010

Valid Values

and

Descriptions

5010A1

Valid Values

and

Descriptions

Notes

2420H Ambulance Drop Off Location New Loop

TR3 Usage Rules:

Usage: Situational

Required when the ambulance drop-off location for

this service line is different than the ambulance

drop-off location provided in Loop ID-2310F.


send.

2420H NM1 Ambulance Drop Off Location New Segment Usage: Required Required when 2420H Loop is present

2420H NM101 Ambulance Drop Off Location Entity Identifier Code

New Element 45: Pickup Address


2420H NM102 Ambulance Drop Off Location Entity Type Qualifier



2420H N3 Ambulance Drop Off Location Address

New Segment Usage: Required Required when 2420H Loop is present

2420H N301 Ambulance Drop Off Location Address Line


Usage: Required

Page 133 of 140

Loop Segment


4010

Valid Values

and

Descriptions

5010

Valid Values

and

Descriptions

5010A1

Valid Values

and

Descriptions

Notes

2420H N302 Ambulance Drop Off Location Address Line





guide, do not send.

2420H N4 Ambulance Drop Off Location City/State/Zip Code

New Segment Usage: Required Required when 2420H Loop is present

2420H N401 Ambulance Drop Off Location City


2420H N402 Ambulance Drop Off Location State or Province code

New Element




Canada. If not required by this implementation

guide, do not send.

2420H N403 Ambulance Drop Off Location Postal code

New Element





in N404. If not required by this implementation

guide, do not send.

2420H N404 Ambulance Drop Off Location Country Code

New Element





2420H N407 Ambulance Drop Off Location Country Subdivision Code

New Element



the United States of America, including its

territories, or Canada, and the country in N404 has




Page 134 of 140

Loop 2430 Line Adjudication Information Changes

Loop Segment


4010

Valid Values

and

Descriptions

5010

Valid Values

and

Descriptions

5010A1

Valid Values

and

Descriptions

Notes

2430 Line Adjudication Information Loop

Loop Repeat: 25 Loop Repeat: 15 Loop Repeat changed from 25 to 15

2430 SVD03-01 Line Adjudication Information Product or Service Qualifier ID

HC: Health Care



ZZ: Mutually

Defined

ER Jurisdiction Specific Procedure and Supply Codes

HC: Health Care Financing Administration Common Procedural Coding System (HCPCS) Coeds

IV: Home Infusion

EDI Coalition (HIEC) Product/Service Code













parties registered in the pilot project and their

trading partners,

OR



set under HIPAA,

OR






these codes.

2430 CAS Line Adjustment Segment Repeat:

99 Segment Repeat: 5

Segment repeat changed from 99 to 5

Page 135 of 140

Loop Segment


4010

Valid Values

and

Descriptions

5010

Valid Values

and

Descriptions

5010A1

Valid Values

and

Descriptions

Notes

2430 AMT Remaining Patient Liability

New Segment Usage: Situational TR3 Usage Rule:

Required when the Other Payer referenced in SVD01

of this iteration of Loop ID-2430 has adjudicated this

claim, provided line level information, and the

provider has the ability to report line item

information. If not required by this implementation

guide, do not send.

TR3 Notes:

1. In the judgment of the provider, this is the

remaining amount to be paid after adjudication by

the Other Payer referenced in SVD01 of this iteration

of Loop ID-2430.

2. This segment is only used in provider submitted

claims. It is not used in Payer-to-Payer Coordination

of Benefits (COB).

3. This segment is not used if the claim level (Loop

ID-2320) Remaining Patient Liability AMT segment is

used for this Other Payer.

2430 AMT01 Remaining Patient Liability Amount Qualifier Code

New Element EAF: Amount Owed

Usage: Required

2430 AMT02 Remaining Patient Liability Amount

New Element

Usage: Required

Loop 2440 Supporting Documentation Loo

p

Segment

/ Element

Element Name 4010

Valid Values

and

Descriptions

5010

Valid Values

and

Descriptions

5010A1

Valid Values

and

Descriptions

Notes

2440 FRM03 Supporting Documentation Question Response


Page 136 of 140

Interchange Trailer Changes Loop Segment /

Element

Element Name 4010

Valid Values

and

Descriptions

5010

Valid Values and

Descriptions

5010A1

Valid Values

and

Descriptions

Notes

N/A GE Segment Repeat: Not specified



N/A IEA Segment Repeat: Not specified



Page 137 of 140

Appendices

Change Log

Version Description Author Date 1.00 Initial Release J. Michael Stevens December 1, 2008

1.01 Minor Clean-up J. Michael Stevens January 29, 2009

1.10 Correction of errors/typos

Format standardization with other 5010 Business Impacts

documents

J. Michael Stevens June 18, 2009

1.11 Correction in ‘Loops Moved’ section J. Michael Stevens January 27, 2010

1.20 Loop 2010BA, Segment REF (secondary subscriber ID – repeat

added.

Loop 2300, segment DTP (acute manifestation) repeat change

added

Loop 2300, segment REF (Clinical Laboratory Improvement

Amendment (CLIA) Number) repeat change added.

Loop 2310C, segment REF (Service Facility Location Secondary

Identification) repeat change added

Loop 2310D, segment REF (Supervising Provider Secondary


Loop 2330A, segment REF (Other Subscriber Secondary


Loop 2300, segment DTP (accident date) repeat change added

Loop 2330B, segment REF (Other payer claim adjustment

indicator) repeat change added.

Loop 2400, segment MEA (Test Results) segment repeat change

added.

Loop 2420A, segment REF (Rendering Provider Secondary

Identification) segment repeat change added

Loop 2420B, Segment REF (Purchased Service Provider Secondary


Loop 2420C, Segment REF Service Facility Location Secondary

Identification) Segment repeat change added

Loop 2420D, Segment REF (Supervising Provider Secondary

Identification) segment repeat change added.

Loop 2420E, Segment REF (Ordering Provider Secondary


Loop 2420F, Segment REF (Referring Provider Secondary


J. Michael Stevens February 1, 2010

Page 138 of 140

Loop 2410 – repeat change added

Loop 2420B – removed NM103/NM104 listing – ‘Not used in both

standards

Loop 2430 – repeat change added

Loop 2430, Segment CAS – repeat change added

Typos corrected

1.30 Updated in correspondent to latest 837P Data Transformation

Analysis for following loops/segments/elements:

2010CA NM104 – Patient Name First name, usage change added

2010CA REF02 – Property and Casualty Claim Number Reference

Identification length changed

2300 REF02 – Service Authorization Exception Code Reference


2300 REF02 – Mandatory Medicare (Section 4081) Crossover

Indicator Reference Identification length changed

2300 REF02 – Clinical Laboratory Improvement Amendment

(CLIA) Reference Identification length changed

2300 HI – Healthcare Diagnosis Code usage changed

2310B PRV03 – Rendering Provider Specialty Information

Reference Identification length changed

2310C NM103 Service Facility Location Name Last or

Organization Name usage changed

2310D – NM103 Supervising Provider Name First usage changed

2320 SBR01 – Other Subscriber Information Payer Responsibility

Sequence Number Code new codes added

2330A N40 – Other Subscriber City/State/ZIP Code – usage

changed

2330C – REF01 Other Payer Referring Provider Secondary

Identification Reference Identification Qualifier code deleted

2330D REF 01 – Other Payer Rendering Provider Secondary

Identification Reference Identification Qualifier – new codes added

2330D REF02 – Other Payer Rendering Provider Secondary

Identification Reference Identification length changed

2330E REF01 – Other Payer Service Facility Location Secondary

Identification Reference Identification Qualifier – new codes added

2330E REF02 – Other Payer Service Facility Location Secondary

Identification Reference Identifier length changed

2330F REF01 – Other Payer Supervising Provider Secondary

Identification Reference Identification Qualifier new codes added

2330F REF02 – Other Payer Supervising Provider Secondary

Identification Reference Identifier length changed

2400 CRC03 – Hospice Employee Indicator Condition Indicator

Sun Park May 17, 2010

Page 139 of 140

length changed

2300 CRC Condition Indicator / Durable Medical Equipment

segment repeat changed

2300 CRC03/CRC04 – Condition Indicator / Durable Medical

Equipment length changed

2400 REF Prior Authorization or Referral Number segment repeat

changed, segment split into two

2400 REF02 – Line Item Control Number Reference Identification

length changed

2400 REF02 – Clinical Laboratory Improvement Amendment

(CLIA) Number Identification length changed

2400 PS101 – Purchased Service Information Reference


2400 HCP04/HCP06 – Line Pricing/Repricing Information


2410 CTP – Drug Pricing usage changed

2420A PRV03 – Rendering Provider Specialty Information


2420B NM103/.Nm104 – Purchased Service Provider Last Name

or Organization Name length changed

2420D NM104 – Supervising Provider First Name usage changed

2420E – NM104 Ordering Provider First Name usage changed

2420E PER02 – Ordering Provider Contact Information Name

usage changed

2420E PER04/PER06/PER08 – Ordering Provider Contact

Information Communication Number length changed

2420F NM104 – Referring Provider First Name usage changed

1.31 ISA & GS segment repeat change added Sun Park May 18, 2010

1.32 IEA & GE segment repeat change added Sun Park May 20, 2010

1.40 1000A PER04/PER06/PER08 – Submitter EDI Contact Information

Communication Number length changed

2010AA PER04/PER06/PER08 – Billing Provider Contact

Information Communication Number length changed

Sun Park June 22, 2010

1.50 Page Numbers Center Aligned Sun Park July 26, 2010

2.00 Added a new column for “5010A1 Valid Values and Description” Sun Park August 11, 2010

2.01 ISA – segment repeat count deleted in 5010A1

GS – segment repeat count deleted in 5010A1

GS08 – Functional Group Header Version / Release / Industry

Identifier Code updated

ST03 – Transaction Set Header Implementation Convention

Reference updated

2010BA NM108 – Subscriber Name Identification Code Qualifier

Sun Park August 12, 2010

Page 140 of 140

usage change added & situational rule added

2010BA NM109 – Subscriber Name Identification Code usage

change added & situational rule added

2010BA N4 – Subscriber City, State, Zip Code usage change added

& situational rule added

2010BB N4 – Payer City, State, Zip Code usage change added &

situational rule added

2010CA REF – Property and Casualty Patient Identifier added as a

new segment

2010CA REF01 – Property and Casualty Patient Identifier

Reference Identification Qualifier added as a new element

2010CA REF02 – Property and Casualty Patient Identifier

Reference Identification added as a new element

2330A N4 – Other Subscriber City, State, Zip Code usage change

added & situational rule added

2330B N4 – Other Payer City, State, Zip Code usage change added

& situational rule added

2410 LIN – Drug Identification segment situational rule replaced

2410 LIN02 – Drug Identification Product/Service ID Qualifier new

codes added & TR3 Rule (5010A1) notes added

2410 LIN03 – Drug Identification Product Service ID

Implementation Name replaced

2420E N4 – Ordering Provider City, State, Zip Code usage change

added & situational rule added

GE – segment repeat count deleted in 5010A1

IEA – segment repeat count deleted in 5010A1

Documents

837 P 5010A1 Conversion Business Impacts · 837 P 5010A1 Conversion Business Impacts Title Business impacts in conversion of the 837P transaction to 5010A1 5010A1 Transaction Identifier