Section 1
HIPAA Compliant X12 Version 4010 and 4010A Parser
Model C1D0F252
Standard License
Copyright (c)1992-2008 Com1 Software Development
Com1 Software, Inc.
P.O. Box 482
Hudson, Ohio 44236
(330) 653-3771
Website: http://com1software.com
Email: information@com1software.com
IMPORTANT NOTICE
This computer program is protected by copyright law and
international treaties. Any unauthorized reproduction or
distribution of this program or any portion of it may result
in severe civil or criminal penalties, and will be prosecuted
under the maximum extent possible under the law.
This program and all support programs and documents are
provided "AS IS" without warranty of any kind, either
expressed or implied, including and not limited to the
implied warranties of merchantability and fitness for a
particular purpose.
In no event shall Com1 Software, Inc. or Com1 Software
Development be liable for any damages arising out of the
use or inability to use this program, support programs or
documentation. All prices and other information is subject
to change without notice.
This program and support documents are for trial and
demonstration purposes. Any other use is strictly prohibited.
REGISTRATION
The registration fee for the program is $99.00.
To register online visit http://com1software.com Click on the
Order Online link.
To register without going online call us or print and complete
the C1D0F252 Order Form.
Major credit cards are accepted or send a check or money
order for $99.00 plus 6.25% sales tax to:
Com1 Software, Inc.
P.O. Box 482
Hudson, OH 44236
(330) 653-3771
Section 2
BASIC CONCEPT
The X12 Parser allows a user to convert
X12 837 and 835 files into CSV or XML files.
The X12 Parser can be run from a command prompt
using parameters to specify format,input file,
output file, and options.
The X12 Parser can parse all the x12 files in a
specified folder with a single execution.
The view function allows you to display and print
the contents of standard ANSI X12 837,277,276,835,864,
and 997 files in a user friendly format.
837 Health Care Claims
276 Claim Status Inquiry
277 Claim Status
835 Remittance Advice
997 Functional Acknowledgement
864 Informational Report
Data is displayed in context sensitive screens relative
to their transaction set.
Data can be exported to a file using a CSV or XML formats.
837 Health Care Claims can be printed on
CMS-1500 Forms.
837 Health Care Claims can be converted into 276 Claims
Status Inquries for submission.
Formats data as a HTML and loads the page
to your default browser.
FEATURES
- Ability to call and run the Parser from another
application without user intervention.
- Create XML,CSV,DBF files.
- Create SQL Tables via ODBC.
- HIPAA Compliant X12 Version 4010 and 4010A
- View or Print Listings of Claims
- View or Print Data Sheet of Individual Claims
- View or Print Listings of Remittance
- View or Print Data Sheet of Remittance
- View or Print Functional Acknowledgements
- View or Print X12 Data in segmented lines
- Configurable print and listing fields
- Creates 276 Claim Status Inquiry from an 837 file.
SYSTEM SPECIFICATIONS
Requires a Microsoft Windows 32 bit Operating System.
Section 3
The C1D0F252 X12 Parser can be run in either a user interface
mode, where a user is able to select files and options using
a windows dialog box, or by running the program in a command
line mode where parameters are passed to the program telling
it what to do. By Using the C1D0f252 in the command line mode
you will be able to run the X12 Parser from another application
or script file, and generate files without user intervention.
C1D0F252.EXE parm1 parm2 parm3 parm4
parm1=Parse Output Type
parm2=Source File or Directory
parm3=Destination File or Directory
parm4=Options
Parse Output Types options:
CSV - Comma Separated Value
837 or 835 source files Only
XML - Extensible Markup Language
837 or 835 source files Only
ODBC - Open Database Connectivity
837 or 835 source files Only
TXT - ASCII Text
All x12 source file types
RTF - Rich Text Format
All x12 source file types
PDF - Portable Document Format
All x12 source file types
HTM - Hypertext Markup Language
All input types
EOB - Explanation of Benefits
835 source files Only
CMS1500 - CMS-1500 Form
837p source files Only
837 - X12 837 Claim File
837 source files Only
276 - X12 276 Claim Status Inquiry
837 source files Only
ISA - Create seperate X12 files from a
multi-ISA X12 file.
Source File or Directory:
The progarm will process this parameter
as a directory unless a file with an extension
is specified.
Destination File or Directory
If nothing is specified in this parameter
the file being parsed will be written as the
name of the input file with an extension that is
based on which Parse Output Type Option was specified.
Note: ODBC uses this syntax in the destination parameter:
dsn:table
dsn= data source name
table= name of the table to be used within the data set.
Options:
Options:
IC - Individual Claim
Generates a single output file for each claim in
the file that is being parsed.
OW - Overwrite any existing files.
HO - Add a discriptive field header to each column in
the file.
ST - The ST option will process multiple set transactions
as a single set.
SL - The SL option will process a record for each service
line.
MO - Shuts the progress meters off.
MF - Merge Files into single output.
MAP= - User specified mapping fie.
ML - Allows for multiple pares logs by assigning
a date time stamp to the log.
Multiple options may be used separated by commas.
Option availability is dependent on output type.
Example:
cd\c1d0f252
C1D0F252.EXE CSV \source \output OW,HC
To create a custom map for the fields you would like to
export, load the x12 file that you will be mapping to into
the viewing portion of the parser. Once the data has been
displayed there will be an EXPORT button available on the
screen. Select the EXPORT, and then select export type.
The export screen will be displayed with a basic list of
available fields for export. When you hit the SAVE button
a mapping configuration file is created. The type of X12
file you are working with will determine the name of the
configuration file.
C1837I.XML Institutional 837
C1837P.XML Professional 837
C1837D.XML Dental 837
C1835.XML Remittance 835
These configuration files can be modified using notepad.
If you require more then the 10 service lines defined in
the default mapping, you can add up to 99 additional
service line fields using a text editor like notepad.
Section 4
The X12 Parser can be configured and used to create and
populate a table within an SQL database using ODBC,
Open Database Connectivity for 837 or 835 source files.
Once a ODBC DSN or User Data Source has been created using
the ODBC Data Source Administrator the parser can then be used
to create and then populate a table within that ODBC data set.
The X12 Parser can be run in the user interface mode, where
the user FIRST selects OUTPUT TYPE as ODBC and then sets the DSN and
Table using the DESTINATION FILE button.
It is important to note that the table and its field names
need to be created within the ODBC DSN by the Parser so that all fields
atch want the Parser expects to write to. Each record within the
table will have a unique record ID created by the parser.
If a table has been properly created within the ODBC DSN using
the Parser, then any addition running of the parser against that
table and ODBC DSN will append the current runs records to the
existing table.
Mapping for the table is controlled by the following files.
C1837I.XML Institutional 837
C1837P.XML Professional 837
C1837D.XML Dental 837
C1835.XML Remittance 835
ODBC uses this syntax in the destination parameter:
dsn:table
dsn= data source name
table= name of the table to be used within the data set.
Here is an examples of how to run the Parser in a command line prompt.
c:\c1d0f252\c1d0f252.exe ODBC,sourcefile.837,sqltestdsn:mytable
C1D0F252.EXE parm1 parm2 parm3
parm1=ODBC
parm2=Source File or Directory
parm3=DSN:TABLE
Section 5
With the C1.INI Editor you can customize the product to better
fit your needs.
The C1.INI file is a standard text sequential file and is
located in the product base and data subdirectory. It is loaded
from the data subdirectory upon start up of the program.
Sections and respective commands are set in this file as needed.
- - - - - - - - - - - - - - - - - - - - - - - - - - - -
[PARSER]
XMLENCODING=value
Default value : ISO-8859-1
Can be use to set the type of XML encoding generated by the
parser.
Example : XMLENCODING=UTF-8
MERGEST=option
Option:ON (default)
OFF
Can be used with XML and CSV to generate seperate files for
each ST batch within a file.
MAXFIELDCOUNT=n
This allows you to set the maximum number of fields
in your export. 255 is the set default.
SERVICELINECOUNT=n
This allows you to set the number of service lines.
OTHERDIGNOSISCOUNT=n
This allows you to set the number of Diagnosis.
OTHERPROCEDURECOUNT=n
This allows you to set the number of Procedures .
OCCURANCESPANCOUNT=n
This allows you to set the number Occurance Spans.
OCCURANCECODECOUNT=n
This allows you to set the number Occurance Codes.
VALUECODECOUNT=n
This allows you to set the number Value Codes.
CONDITIONCODECOUNT=n
This allows you to set the number condition Codes.
TREATMENTCODECOUNT=n
This allows you to set the number Treatment Codes.
DBFFIELDCOUNT=n
This allows you to set the maximum number of
DBF fields allowed.
LOOP1000A=option
Option:ON (default)
OFF
LOOP1000B=option
Option:ON (default)
OFF
LOOP2010AABATCH=option
Option:ON (default)
OFF
LOOP2010ABBATCH=option
Option:ON (default)
OFF
LOOP2010AACLAIM=option
Option:ON (default)
OFF
LOOP2010ABCLAIM=option
Option:ON (default)
OFF
LOOP2000=option
Option:ON (default)
OFF
LOOP2300=option
Option:ON (default)
OFF
LOOP2400=option
Option:ON (default)
OFF
NAMEMERGE=option
Option:ON (default)
OFF
- - - - - - - - - - - - - - - - - - - - - - - - - - - -
[X12VIEWER]
- For configuration of general use functions.
SETEXTENSION=scope
This allows you to filter the selection files based on
file extention or on other supported wild card parameters.
Example:
setextension=*.tcf,*.837,*,835
TEXTFORMCONTROL=option
This allows you to set the CMS-1500/UB Formating
TEXTFORMCONTROL=option
Option:FLAT (default)
FORMFEED
- - - - - - - - - - - - - - - - - - - - -
[X12837TO276]
ISA06=value
Allows you to set the value of ISA06, the Interchange Sender ID.
ISA08=value
Allows you to set the value of ISA08, the Interchange Receiver ID.
ISA13=value
Allows you to set the value of ISA13, the Interchange Control Numbe
Also sets IEA02 as well
ISA15=value
Allows you to set the value of ISA15, the Usage Indicator.
GS02=value
Allows you to set the value of GS02, the Application Sender Code.
GS03=value
Allows you to set the value of GS03, the Application Receiver Code.
GS06=value
Allows you to set the value of GS06, the Group Control Number.
Also sets GE02 as well.
ST02=value
Allows you to set the value of ST02, the Group Control Number.
Also sets SE02 as well.
- - - - - - - - - - - - - - - - - - - - -
[X12837TO837]
CONVERSIONTYPE=option
Options: 1 Allows you to set values through the C1.INI
2 (default)
Example:
CONVERSIONTYPE=1
ISA06=value
Allows you to set the value of ISA06, the Interchange Sender ID.
Note: Conversion Type must be set to 1
ISA08=value
Allows you to set the value of ISA08, the Interchange Receiver ID.
Note: Conversion Type must be set to 1
ISA13=value
Allows you to set the value of ISA13, the Interchange Control Numbe
Also sets IEA02 as well
Note: Conversion Type must be set to 1
ISA15=value
Allows you to set the value of ISA15, the Usage Indicator.
Note: Conversion Type must be set to 1
GS02=value
Allows you to set the value of GS02, the Application Sender Code.
Note: Conversion Type must be set to 1
GS03=value
Allows you to set the value of GS03, the Application Receiver Code.
Note: Conversion Type must be set to 1
GS06=value
Allows you to set the value of GS06, the Group Control Number.
Also sets GE02 as well.
Note: Conversion Type must be set to 1
ST02=value
Allows you to set the value of ST02, the Group Control Number.
Also sets SE02 as well.
Note: Conversion Type must be set to 1
- - - - - - - - - - - - - - - - - - - - - - - - - - - -
[X12UDF]
- For configuration of user defined fields.
UDF=udftest1
segment=ref
qualifier=ay
return=3
UDF=udftest2
segment=nm1
loop=2010bb
return=3
- - - - - - - - - - - - - - - - - - - - - - - - - - - -
[CMS1500]
BOX4=OFF
Suppresses boxs 4 and 7.
BOX4=YESALWAYS
Overides use of SAME when the Patient is the same as
the Guarantor for boxs 4 and 7.
BOX6=OFF
Suppresses box 6.
BOX8=OFF
Suppresses box 8.
BOX9=OFF
Suppresses box 9 and its associated Other Insurance
Fields 9a through 9d.
BOX9=YESALWAYS
Overides medicare print supression of box 9 and its
associated Other Insurance Fields 9a through 9d.
BOX10=OFF
Suppresses box 10.
BOX11=OFF
Suppresses box 11.
BOX12=ONFILE **
Will cause the Patient or Authorized Signature to display
SIGNATURE ON FILE in the box for all claims.
BOX12=DATEOFF **
Will leave the date field in box 12 off.
BOX12=TODAY **
Will place the system date in the date field of box 12 for
patient signature on file.
BOX13=ONFILE **
The Insured's Authorized Signature will display SIGNATURE
ON FILE in the box for all claims.
BOX14=OFF
Supresses the printing of information in box 14.
BOX21=OFF
Suppresses the printing of box 21.
BOX21=DECIMALON
Leaves the decimal point in the diagnoses codes displayed
in Box 21.
BOX24B=1992
Standard two character Place of Service.(default)
BOX24B=1984
Previously used one character Place of Service.
BOX24B=OFF
Supresses the printing of box 24b, the Place of Service.
SETPOS=x
Sets the Place of Service to whatever characters are in position
BOX24C=OFF
Supresses the printing of box 24c, the Type of Service.
SETTOS=x
Sets the Type of Service to the characters are in x.
Example: SETTOS=12
SETTOSUDFn=x
This function allows you to create up to 5 user defined types of se
ice
where n represents the user defined funtion 1 through 5 and will se
the
type of service to the characters set in x. The user defined type o
service
is also set in the User Defaults and where the Type of Service is s
at the
claim level.
Example: SETTOSUDF1=18
BOX24D=DESCRIPTION
Uses procedure code discription instead of the procedure code.
BOX24E=DX
Uses the DX code instead of related item number.,
i.e. 1,2,3,4
BOX24E=OFF
Supresses the printing of box 24e diagnosis code link.
BOX24G=NORMAL
Standard central right justified printing of units
on form. Prints the right two characters in field.
Maximum value to display is 99.
Default setting.
BOX24G=MAX
Standard right justified printing of units on form.
Prints full three chracter width in field. Maximum value
to display is 999.
BOX24G=TWOPOS
Units are zero filled and displayed in a right justified
two position format.
BOX24G=THREEPOS
Units are zero filled and displayed in a right justified
three position format.
BOX24K=PROVINSID
Solo Version-will display the Provider Insurance ID#
based on data entered in the Provider Insurance Contract
Table.
Institution Version-will display the Provider Insurance
ID# based on data entered in the Provider Insurance ID
Editor.
BOX24K=REFSINSID
Will display the Referring Source Insurance ID# based on
data entered in the Referring Source Insurance ID Data
Screen.
BOX24K=INSTINSID
Will display the Institution Insurance ID# based on
data entered in the Institution Insurance Contract Table.
BOX25=OFF
Suppresses federal tax ID or social security number and
the checking of the associated box.
BOX25EIN=your id
This will force the population of box25 of the
CMS1500 with your id as an EIN.
BOX25SSN=your id
This will force the population of box25 of the
CMS1500 with your id as an SSN.
BOX26=ALTID
Uses the patient Alternate ID instead of the system
generated ID#.
BOX26=SSN
Use the patient Social Security Number instead of the
system generated ID#.
BOX27=OFF
Turns off Accept Assignment Box 27.
BOX27=YESALWAYS
Set accept assignment to say yes on all claims.
BOX29=OFF
Suppresses Amount Paid box.
BOX30=OFF
Suppresses Balance Due box.
BOX30=BOX28 **
Balance Due Box is equal to Box 28 the Total Charges
BOX31=OFF
Turns of all Data in box.
BOX31=DATEONLY
Print system Date
BOX32=ONALWAYS
Alternate Facility will display on all claims.
BOX33=OFF
Suppresses printing of name, address, pin# and group#.
DATECTL=MMDDYY
Will cause 6-digit dates in field items 12,14,15,16,18,
24a,and 31 on the form.
DATECTL=MMDDCCYY
Will cause 8-digit dates in field items 12,14,15,16,18,
24a,and 31 on the form.
NOTE for DATECTL:
All dates of birth field items 3, 9b, and 11a are
set to 8-digit dates.
FORM=PREPRINTEDNOCHOICE
Use HCFA pre-printed forms only, it doesn't offer the
user the Options choice.
FORM=PREPRINTED
Use pre-printed forms as the default in the Options.
FORM=ARTWORK
Generate an artwork form with your color printer.
FORM=UPPERELITE
Will cause all data printed on form to appear in
10 character per inch upper case letters.
FORMREVISION=0805 **
Will use the 0805 CMS-1500 Form
FORMREVISION=1290 **
Will use the 1290 CMS-1500 Form
TEXTFORMCONTROL=FLAT **
For ASCII text file creation of CMS-1500 data.
Set for 80 characters wide with 72 lines.
TEXTFORMCONTROL=FORMFEED **
For ASCII text file creation of CMS-1500 data.
Set for 80 characters wide with 65 lines followed
with a form feed.
PROCLINE=DESC10
Used to display the first ten characters of a procedure
description starting in 24d, to the right of the procedure
code using Modifier field.
PROCLINE=DESC16
Used to display the first sixteen characters of a procedure
description starting in 24h through 24k.
TOP=OFF
Will control carrier address and ID's top of the HCFA form.
Default is on with internal system ID dislayed. Options are:
OFF
- Address is not printed
SYSTEMIDON
- Address with internal system ID
SUBMITTERIDON
- Address with EMC Submitter ID
INSURANCEIDON
- Address with Insurance/UPIN ID
IDOFF
- Address with out ID
TOPOFFSET=n
Allows for the left to right placement of the carriers name,
address,and ID information on the top of the form. Options
for N are: 0,5,10,15,20,25,30,35,40,45,50,55,60. Offset
increments are equal to one half inch increments. 0 represents
that the original system position is being used. The default
position of the carrier name is at 33. Offsets other than 0
are based on position from the left edge of the form. To move
the name to the right use 35 or greater.
FONT=ARIAL8
Will set the size and font used to print the insurance
form. Options are:
ARIAL8
COURRIERNEW8
TIMESNEWROMAN8
SANSERIEF8
ARIAL10
COURRIERNEW10
TIMESNEWROMAN10
SANSERIEF10
ARIAL12
COURRIERNEW12
TIMESNEWROMAN12
SANSERIEF12
EXAMPLE
In this example, the following text is entered into the
C1.INI editor and saved. This will allow the default of the form
to have Signatures on File with today's date using full eight
digit dates:
[CMS1500]
BOX12=ONFILE
BOX12=TODAY
BOX13=ONFILE
DATECTL=MMDDCCYY
Note:
** Indicates availability in X12 to CMS-1500 Conversions
----------------------------------------------------------------------
Section 6
User Defined Fields can be created to make a custom mapped 837 field.
In the mapping file define your unique field name that
does not duplicate an existing mapped field in the parser.
Example of Mapping Files for:
C1837P.XML
C1837I.XML
C1837D.XML
In the C1.INI you will need to define the characteristics of
your UDF.
Section:
[x12udf]
User Defined Field Name
UDF=udfname
Example:
udf=udftestsubmitter
Segment
SEGMENT=segmentname
Example:
segment=NM1
Second Element Qualifier in the Segment
QUALIFIER=value
Example
qualifier=41
Loop
LOOP=value
Example:
loop=2300
Element Value to return
RETURN=element
Example:
return=4
Example of the c1.INI:
[x12udf]
udf=udftestst
segment=ST
qualifier=837
return=3
udf=udftestver
segment=REF
qualifier=87
return=3
udf=udftestsubmitter
segment=NM1
qualifier=41
return=4
udf=udftestreceiver
segment=NM1
qualifier=40
return=4
udf=udftestk3
segment=K3
loop=2300
return=2
Section 7
This is a list of the fields supported for mapping and are
stored in an XML file called:
C1837I.XML for Institutional
C1837P.XML for Professional
C1837D.XML for Dental
Field names are placed inside the field tags of the xml.
Example :
- - - - - - - - - - - - - - - - - -
CLAIMID
Claim ID
Location : CLM Segment, Element 1
CLAIMAMTDDDDDD_CC
Claim Amount
Location : CLM Segment, Element 2
CLAIMAMT
Claim Amount
Location : CLM Segment, Element 2
CLEARINGIDNUMBER
Clearing Service ID
Location : REF Segment, Element 2
Qualifier D9
MULTICLAIMTOTAL
Multi Claim Total Amount
Location : CLM Segment, Element 2
PRIORAUTHORIZATIONNUMBER
Prior Authorization Number
Location : REF Segment, Element 3
Qualifier G1
ORDERDATE
Order Date
Location : DTP Segment, Element 3
Qualifier 938
INITIALTREATMENTDATE
Initial Treatment Date
Location : DTP Segment, Element 3
Qualifier 454
REFERRALDATE
Referral Date
Location : DTP Segment, Element 3
Qualifier 330
DATELASTSEEN
Date last Seen
Location : DTP Segment, Element 3
Qualifier 304
ONSETOFILLNESDATE
Onset of Current Symptoms or Illness Date
Location : DTP Segment, Element 3
Qualifier 431
ACUTEMANIFESTATIONDATE
Acute Manifestation of a Chronic Condition Date
Location : DTP Segment, Element 3
Qualifier 453
SIMILARILLNESSONSETDATE
Onset of Similar Symptoms or Illness Date
Location : DTP Segment, Element 3
Qualifier 438
ACCIDENTDATE
Accident Date
Location : DTP Segment, Element 3
Qualifier 439
LMPDATE
Last Menstrual Period Date
Location : DTP Segment, Element 3
Qualifier 484
LASTXRAYDATE
Last X-Ray Date
Location : DTP Segment, Element 3
Qualifier 455
ESTIMATEDDATEOFBIRTH
Estimated Date of Birth
Location : DTP Segment, Element 3
Qualifier ABC
HEARINGVISIONPRESCRIPTIONDATE
Hearing and Vision Prescription Date
Location : DTP Segment, Element 3
Qualifier 471
DISABILITYBEGINDATE
Disability Begin Date
Location : DTP Segment, Element 3
Qualifier 360
DISABILITYENDDATE
Disability End Date
Location : DTP Segment, Element 3
Qualifier 361
DATELASTWORKED
Date Last Worked
Location : DTP Segment, Element 3
Qualifier 297
RETURNTOWORKDATE
Return to Work Date
Location : DTP Segment, Element 3
Qualifier 296
ASSUMEDCAREDATE
Assumed Care Start Date
Location : DTP Segment, Element 3
Qualifier 090
RELINQUISHEDCAREDATE
Relinquished Care End Date
Location : DTP Segment, Element 3
Qualifier 091
PROVSIGNATUREONFILE
Provider Signature
Location : CLM Segment, Element 6
PROVACCEPTASSIGNMENTCODE
Provider Assignment
Location : CLM Segment, Element 7
BENEFITINDICATOR
Benefit Indicator
Location : CLM Segment, Element 8
RELEASEOFINFORMATION
Release of Information
Location : CLM Segment, Element 9
RELATEDCAUSECODE
Related Cause
Location : CLM Segment, Element 11
RELATEDCAUSE
Related Cause
Location : CLM Segment, Element 11
DISCHARGEHOUR
Discharge Hour
Location : DTP Segment, Element 3
Qualifier 069
DISCHARGEDATE
Discharge Date
Location : CR6 Segment, Element 5
STATEMENTDATE
Statement Date
Location : DTP Segment, Element 3
Qualifier 434
ADMISSIONDATETIME
Addmission Date Time
Location : DTP Segment, Element 3
Qualifier 435
ADMISSIONTYPECODE
Addmission Type Code
Location : CL1 Segment, Element 1
Qualifier 435
ADMISSIONTYPE
Addmission Type
Location : CL1 Segment, Element 1
Qualifier 435
ADMISSIONSOURCECODE
Addmission Source Code
Location : CL1 Segment, Element 2
ADMISSIONSOURCE
Addmission Source
Location : CL1 Segment, Element 2
PATIENTSTATUSCODE
Patient Status Code
Location : CL1 Segment, Element 3
PATIENTSTATUS
Patient Status
Location : CL1 Segment, Element 3
MEDICALRECORDNUMBER
Medical Record Number
Location : REF Segment, Element 2
Qualifier EA
PATIENTAMOUNTPAID
Patient Amount Paid
Location : AMT Segment, Element 2
Qualifier F5
TOTALPURCHASEDSERVICEAMOUNT
Total Purchased Service Amount
Location : AMT Segment, Element 2
Qualifier NE
PAYERPRIORPAY
Payer Prior Pay
Location : AMT Segment, Element 2
Qualifier C4
OISUBORDER
Other Insurance Subscriber Order
Location : NM1 Segment, Element 1
OISUBID
Other Insurance Subscriber ID
Location : NM1 Segment, Element 9
Qualifier IL
OISUBLNAME
Other Insurance Subscriber Last Name
Location : NM1 Segment, Element 3
Qualifier IL
OISUBFNAME
Other Insurance Subscriber First Name
Location : NM1 Segment, Element 4
Qualifier IL
OISUBMI
Other Insurance Subscriber Middle Initial
Location : NM1 Segment, Element 5
Qualifier IL
OIPAYERADDR1
Other Insurance Subscriber Address 1
Location : N3 Segment, Element 1
OIPAYERADDR2
Other Insurance Subscriber Address 2
Location : N3 Segment, Element 2
OIPAYERCITY
Other Insurance Subscriber City
Location : N4 Segment, Element 1
OIPAYERSTATE
Other Insurance Subscriber State
Location : N4 Segment, Element 2
OIPAYERZIP
Other Insurance Subscriber Zip Code
Location : N4 Segment, Element 3
OIPAYERID
Other Insurance Payer ID
Location : NM1 Segment, Element 9
Qualifier PR
OIPAYERNAME
Other Insurance Payer Name
Location : NM1 Segment, Element 3
Qualifier PR
SEGMENTNOTE
Segment Note
Location : DMG Segment, Element 3
POSDESC
Place of Service Description
Location : CLM Segment, Element 6
FACILITYCODEVALUE
Facility Code Value
Location : CLM Segment, Element 6
FREQUENCYTYPECODE
Frequency Type Code
Location : CLM Segment, Element 6
POSCODE
Place of Service Description
Location : CLM Segment, Element 6
K3DATA
K3 Data
Location : K3 Segment, Element 1
NDCCODE
National Drug Code
Location : LIN Segment, Element 3
Qualifier N4
NDCUNITPRICE
NDC Drug Unit Price
Location : CTP Segment, Element 3
NDCUNITS
NDC Units
Location : CTP Segment, Element 4
TYPEOFBILL
Type of Bill
Location : CLM Segment, Element 6
FREQUENCYCODE
Frequency Type Code
Location : CLM Segment, Element 6
PRINCIPALDX
Principle Diagnosis
Location : HI Segment, Element 1
Qualifier BK
ADMITDX
Admitting Diagnosis
Location : HI Segment, Element 2
Qualifier BJ
ECODE
Vital Statistics E-Code
Location : HI Segment, Element 3
Qualifier BN
DRG
DRG
Location : HI Segment, Element 1
Qualifier DR
OTHERDX01 thru OTHERDX12
Other Diagnosis 1 thru 12
Location : HI Segment, Element 1
Qualifier BF
OTHERDXA01 thru OTHERDXY12
Other Diagnosis 1 thru 12
Multi Segment
Location : HI Segment, Element 1
Qualifier BF
PRINCIPLEPROCDATE
Principle Procedure Date
Location : HI Segment, Element 1
Qualifier BP,BR
PRINCIPLEPROC
Principle Procedure Date
Location : HI Segment, Element 1
Qualifier BP,BR
OTHERPROC01 thru OTHERPROC12
Other Procedures 1 thru 12
Location : HI Segment, Element 1
Qualifier BO,BQ
OTHERPROCA01 thru OTHERPROCY12
Other Procedures 1 thru 12
Multi Segment
Location : HI Segment, Element 1
Qualifier BO,BQ
OCCURRENCESPAN01 thru OCCURRENCESPAN12
Occurance Span 1 thru 12
Location : HI Segment, Element 1
Qualifier BI
OCCURRENCESPANA01 thru OCCURRENCESPANY12
Occurance Span 1 thru 12
Multi Segment
Location : HI Segment, Element 1
Qualifier BI
OCCURRENCECODE01 thru OCCURRENCECODE12
Occurance Code 1 thru 12
Location : HI Segment, Element 1
Qualifier BH
OCCURRENCECODEA01 thru OCCURRENCECODEY12
Occurance Code 1 thru 12
Multi Segment
Location : HI Segment, Element 1
Qualifier BH
OCCURRENCEDATE01 thru OCCURRENCEDATE12
Occurance Date 1 thru 12
Location : HI Segment, Element 1
Qualifier BH
OCCURRENCEDATEA01 thru OCCURRENCEDATEY12
Occurance Date 1 thru 12
Multi Segment
Location : HI Segment, Element 1
Qualifier BH
VALUECODE01 thru VALUECODE12
Value Codes 1 thru 12
Location : HI Segment, Element 1
Qualifier BE
VALUECODEA01 thru VALUECODEY12
Value Codes 1 thru 12
Multi Segment
Location : HI Segment, Element 1
Qualifier BE
VALUEAMOUNT01 thru VALUEAMOUNT12
Value Amounts 1 thru 12
Location : HI Segment, Element 1
Qualifier BE
VALUEAMOUNTA01 thru VALUEAMOUNTY12
Value Amounts 1 thru 12
Multi Segment
Location : HI Segment, Element 1
Qualifier BE
VALUEQTY01 thru VALUEQTY12
Value Quantity 1 thru 12
Location : HI Segment, Element 1
Qualifier BE
VALUEQTYA01 thru VALUEQTYY12
Value Quantity 1 thru 12
Multi segment
Location : HI Segment, Element 1
Qualifier BE
CONDITIONCODE01 thru CONDITIONCODE12
Condition Codes 1 thru 12
Location : HI Segment, Element 1
Qualifier BG
CONDITIONCODEA01 thru CONDITIONCODEY12
Condition Codes 1 thru 12
Multi Segment
Location : HI Segment, Element 1
Qualifier BG
CONDITIONDATE01 thru CONDITIONDATE12
Condition Dates 1 thru 12
Location : HI Segment, Element 1
Qualifier BG
CONDITIONDATEA01 thru CONDITIONDATEY12
Condition Dates 1 thru 12
Multi Segment
Location : HI Segment, Element 1
Qualifier BG
TREATMENTCODE01 thru TREATMENTCODE12
Treatment Codes 1 thru 12
Location : HI Segment, Element 1
Qualifier TC
TREATMENTCODEA01 thru TREATMENTCODEY12
Treatment Codes 1 thru 12
Multi Segment
Location : HI Segment, Element 1
Qualifier TC
SUBCLMTYPECODE
Submitter Claim Type
Location : SBR Segment, Element 9
SUBCLMTYPE
Submitter Claim Type
Location : SBR Segment, Element 9
SUBID
Submitter ID
Location : NM1 Segment, Element 9
Qualifier IL
SUBLNAME
Submitter Last Name
Location : NM1 Segment, Element 3
Qualifier IL
SUBFNAME
Submitter First Name
Location : NM1 Segment, Element 4
Qualifier IL
SUBMI
Submitter Middle Initial
Location : NM1 Segment, Element 5
Qualifier IL
SUBADDR1
Submitter Address 1
Location : N3 Segment, Element 1
SUBADDR2
Submitter Address 2
Location : N3 Segment, Element 2
SUBCITY
Submitter City
Location : N4 Segment, Element 1
SUBST
Submitter State
Location : N4 Segment, Element 2
SUBZIP
Submitter Zip
Location : N4 Segment, Element 3
SUBDOB
Submitter Date of Birth
Location : DMG Segment, Element 2
SUBNAMEPREFIX
Submitter Prefix
Location : NM1 Segment, Element 6
Qualifier IL
SUBNAMESUFIX
Submitter Suffix
Location : NM1 Segment, Element 6
Qualifier IL
SUBMSTATUS
Submitter Prefix
Location : DMG Segment, Element 4
SUBORDER
Submitter Coverage Order
Location : SBR Segment, Element 1
SUBREL
Submitter Relationship to Patient
Location : SBR Segment, Element 2
SUBGROUPNAME
Submitter Group Name
Location : SBR Segment, Element 3
SUBSEX
Submitter Gender
Location : DMG Segment, Element 3
PROPERYCASUALTYCLAIMNUMBER
Added Property Casuality Claim Number
Location : REF Segment, Element 2
Qualifier Y4
PAYERID
Payer ID
Location : NM1 Segment, Element 9
Qualifier PR
PAYERNAME
Payer Name
Location : NM1 Segment, Element 3
Qualifier PR
PAYERADDR1
Payer Address Line 1
Location : N3 Segment, Element 1
PAYERADDR2
Payer Address Line 2
Location : N3 Segment, Element 2
PAYERCITY
Payer City
Location : N4 Segment, Element 1
PAYERSTATE
Payer State
Location : N4 Segment, Element 2
PAYERZIP
Payer Zip Code
Location : N4 Segment, Element 3
PATLNAME
Patient Last Name
Location : NM1 Segment, Element 3
Qualifier QC
PATFNAME
Patient First Name
Location : NM1 Segment, Element 4
Qualifier QC
PATMI
Patient Middle Initial
Location : NM1 Segment, Element 5
Qualifier QC
PATADDR1
Patient Address 1
Location : N3 Segment, Element 1
PATADDR2
Patient Address 2
Location : N3 Segment, Element 2
PATCITY
Patient City
Location : N4 Segment, Element 1
PATST
Patient State
Location : N4 Segment, Element 2
PATZIP
Patient Zip
Location : N4 Segment, Element 3
PATDOB
Patient Date of Birth
Location : DMG Segment, Element 2
PATSEX
Patient Gender
Location : DMG Segment, Element 3
PATREL
Patient Relationship to Subscriber
Location : PAT Segment, Element 2
PATSIGNATURESOURCE
Patient Signature Source
Location : CLM Segment, Element 10
REFLNAME
Referring Provider Last Name
Location : NM1 Segment, Element 3
Qualifier DN
REFFNAME
Referring Provider First Name
Location : NM1 Segment, Element 4
Qualifier DN
REFID
Referring Provider ID
Location : NM1 Segment, Element 9
Qualifier DN
REFIDTYPE
Referring Provider ID Type
Location : NM1 Segment, Element 8
Qualifier DN
REFSECONDARYID
Referring Provider Secondary ID
Location : REF Segment, Element 3
REFSECONDARYIDCODE
Referring Provider Secondary ID Code
Location : REF Segment, Element 2
ATTENDLNAME
Attending Provider Last Name
Location : NM1 Segment, Element 3
Qualifier 71
ATTENDFNAME
Attending Provider First Name
Location : NM1 Segment, Element 4
Qualifier 71
ATTENDID
Attending Provider ID
Location : NM1 Segment, Element 9
Qualifier 71
ATTENDSECONDARYID
Attending Provider Secondary ID
Location : REF Segment, Element 2
ATTENDSECONDARYIDCODE
Attending Provider Secondary ID Code
Location : REF Segment, Element 1
OPERATELNAME
Operating Provider Last Name
Location : NM1 Segment, Element 3
Qualifier 72
OPERATEFNAME
Operating Provider First Name
Location : NM1 Segment, Element 4
Qualifier 72
OPERATEID
Operating Provider Last Name
Location : NM1 Segment, Element 3
Qualifier 72
OPERATESECONDARYID
Operating Provider Secondary ID
Location : REF Segment, Element 2
OPERATESECONDARYIDCODE
Operating Provider Secondary ID Code
Location : REF Segment, Element 1
RENLNAME
Rendering Provider Last Name
Location : NM1 Segment, Element 3
Qualifier 82
RENFNAME
Rendering Provider First Name
Location : NM1 Segment, Element 4
Qualifier 82
RENIDTYPECODE
Rendering Provider ID Type Code
Location : NM1 Segment, Element 8
Qualifier 82
RENIDTYPE
Rendering Provider ID Type
Location : NM1 Segment, Element 8
Qualifier 82
RENID
Rendering Provider ID
Location : NM1 Segment, Element 9
Qualifier 82
FACILITYNAME
Facility Name
Location : NM1 Segment, Element 3
Qualifier FA
FACILITYADDR1
Facility Address Line 1
Location : N3 Segment, Element 1
FACILITYADDR2
Facility Address Line 2
Location : N3 Segment, Element 2
FACILITYCITY
Facility City
Location : N4 Segment, Element 1
FACILITYST
Facility State
Location : N4 Segment, Element 2
FACILITYZIP
Facility Zip Code
Location : N4 Segment, Element 3
FACILITYIDTYPE
Facility ID Type
Location : NM1 Segment, Element 8
Qualifier FA
FACILITYIDCODE
Facility ID Code
Location : NM1 Segment, Element 8
Qualifier FA
FACILITYID
Facility ID
Location : NM1 Segment, Element 9
Qualifier FA
FACILITYSECONDARYIDTYPE
Facility Secondary ID Type
Location : REF Segment, Element 1
FACILITYSECONDARYIDCODE
Facility Secondary ID CODE
Location : REF Segment, Element 1
FACILITYSECONDARYID
Facility Secondary ID Type
Location : REF Segment, Element 2
SERVICELOCATIONNAME
Service Location Name
Location : NM1 Segment, Element 3
Qualifier 77
SERVICELOCATIONADDR1
Service Localtion Address Line 1
Location : N3 Segment, Element 1
SERVICELOCATIONADDR2
Service Localtion Address Line 2
Location : N3 Segment, Element 2
SERVICELOCATIONCITY
Service Localtion City
Location : N4 Segment, Element 1
SERVICELOCATIONST
Service Localtion State
Location : N4 Segment, Element 2
SERVICELOCATIONZIP
Service Localtion Zip Code
Location : N4 Segment, Element 4
SERVICELOCATIONID
Service Location Name
Location : NM1 Segment, Element 9
Qualifier 77
ILABNAME
Independent LAB Name
Location : NM1 Segment, Element 3
Qualifier LI
ILABADDR1
Independent LAB Address Line 1
Location : N3 Segment, Element 1
ILABADDR2
Independent LAB Address Line 2
Location : N3 Segment, Element 2
ILABCITY
Independent LAB City
Location : N4 Segment, Element 1
ILABST
Independent LAB State
Location : N4 Segment, Element 2
ILABZIP
Independent LAB Zip Code
Location : N4 Segment, Element 3
ILABID
Independent LAB Name
Location : NM1 Segment, Element 9
Qualifier LI
TLABNAME
Testing LAB Name
Location : NM1 Segment, Element 3
Qualifier TL
TLABADDR1
Testing LAB Address Line 1
Location : N3 Segment, Element 1
TLABADDR2
Testing LAB Address Line 2
Location : N3 Segment, Element 2
TLABCITY
Testing LAB City
Location : N4 Segment, Element 1
TLABST
Testing LAB State
Location : N4 Segment, Element 2
TLABZIP
Testing LAB Zip Code
Location : N4 Segment, Element 3
TLABID
Independent LAB Name
Location : NM1 Segment, Element 9
Qualifier TL
DX1_XX
Diagnosis Code 1
Location : HI Segment, Element 1
Sub Element 1
DX2_XX
Diagnosis Code 2
Location : HI Segment, Element 1
Sub Element 2
DX3_XX
Diagnosis Code 3
Location : HI Segment, Element 1
Sub Element 3
DX4_XX
Diagnosis Code 4
Location : HI Segment, Element 1
Sub Element 4
DX5_XX
Diagnosis Code 5
Location : HI Segment, Element 1
Sub Element 5
DX1
Diagnosis Code 1
Location : HI Segment, Element 1
Sub Element 1
DX2
Diagnosis Code 2
Location : HI Segment, Element 1
Sub Element 2
DX3
Diagnosis Code 3
Location : HI Segment, Element 1
Sub Element 3
DX4
Diagnosis Code 4
Location : HI Segment, Element 1
Sub Element 4
DX5
Diagnosis Code 5
Location : HI Segment, Element 1
Sub Element 5
MEDICALRECORDNUMBER
Medical Record Number
Location : REF Segment, Element 2
Qualifier EA
CLAIMBILLINGPROVIDERNAME
Claim Billing Provider Name
Location : NM1 Segment, Element 3
Qualifier 85
CLAIMBILLINGPROVIDERADDR1
Claim Billing Provider Address 1
Location : N3 Segment, Element 1
CLAIMBILLINGPROVIDERADDR2
Claim Billing Provider Address 2
Location : N3 Segment, Element 2
CLAIMBILLINGPROVIDERCITY
Claim Billing Provider City
Location : N4 Segment, Element 1
CLAIMBILLINGPROVIDERST
Claim Billing Provider State
Location : N4 Segment, Element 2
CLAIMBILLINGPROVIDERZIP
Claim Billing Provider Zip Code
Location : N4 Segment, Element 3
CLAIMBILLINGPROVIDERIDTYPE
Claim Billing Provider ID Type
Location : NM1 Segment, Element 8
Qualifier 85
CLAIMBILLINGPROVIDERIDCODE
Claim Billing Provider ID Code
Location : NM1 Segment, Element 8
Qualifier 85
CLAIMBILLINGPROVIDERID
Claim Billing Provider ID
Location : NM1 Segment, Element 9
Qualifier 85
CLAIMBILLINGPROVIDERSECONDARYIDTYPE
Claim Billing Provider Secondary ID Type
Location : REF Segment, Element 1
CLAIMBILLINGPROVIDERSECONDARYIDCODE
Claim Billing Provider Secondary ID Code
Location : REF Segment, Element 1
CLAIMBILLINGPROVIDERSECONDARYID
Claim Billing Provider Secondary ID
Location : REF Segment, Element 2
CLAIMPAYTOPROVIDERNAME
Claim Pay to Provider Name
Location : NM1 Segment, Element 3
Qualifier 87
CLAIMPAYTOPROVIDERADDR1
Claim Pay to Provider Address 1
Location : N3 Segment, Element 1
CLAIMPAYTOPROVIDERADDR2
Claim Pay to Provider Address 2
Location : N3 Segment, Element 2
CLAIMPAYTOPROVIDERCITY
Claim Pay to Provider City
Location : N4 Segment, Element 1
CLAIMPAYTOPROVIDERST
Claim Pay to Provider State
Location : N4 Segment, Element 2
CLAIMPAYTOPROVIDERZIP
Claim Pay to Provider Zip Code
Location : N4 Segment, Element 3
CLAIMPAYTOPROVIDERIDTYPE
Claim Pay to Provider ID Type
Location : NM1 Segment, Element 8
Qualifier 87
CLAIMPAYTOPROVIDERIDCODE
Claim Pay to Provider ID Code
Location : NM1 Segment, Element 8
Qualifier 87
CLAIMPAYTOPROVIDERID
Claim Pay to Provider ID
Location : NM1 Segment, Element 9
Qualifier 87
PRIMARYGROUPID
Primary Subscriber Group ID
Location : SBR Segment, Element 2
Qualifier P
PRIMARYGROUPNAME
Primary Subscriber Group Name
Location : SBR Segment, Element 3
Qualifier P
PRIMARYSUBID
Primary Subscriber ID
Location : NM1 Segment, Element 9
Qualifier IL
PRIMARYSUBLNAME
Primary Subscriber Last Name
Location : NM1 Segment, Element 3
Qualifier IL
PRIMARYSUBFNAME
Primary Subscriber First Name
Location : NM1 Segment, Element 4
Qualifier IL
PRIMARYSUBMI
Primary Subscriber Middle Initial
Location : NM1 Segment, Element 5
Qualifier IL
PRIMARYSUBADDR1
Primary Subscriber Address Line 1
Location : N3 Segment, Element 1
PRIMARYSUBADDR2
Primary Subscriber Address Line 2
Location : N3 Segment, Element 2
PRIMARYSUBCITY
Primary Subscriber City
Location : N4 Segment, Element 1
PRIMARYSUBSTATE
Primary Subscriber State
Location : N4 Segment, Element 2
PRIMARYSUBZIP
Primary Subscriber Zip Code
Location : N4 Segment, Element 3
PRIMARYSUBDOB
Primary Subscriber Date of Birth
Location : DMG Segment, Element 2
PRIMARYSUBSEX
Primary Subscriber Gender
Location : DMG Segment, Element 3
PRIMARYPAYERNAME
Primary Payer Name
Location : NM1 Segment, Element 3
Qualifier PR
PRIMARYPAYERADDR1
Primary Payer Address Line 1
Location : N3 Segment, Element 1
PRIMARYPAYERADDR2
Primary Payer Address Line 2
Location : N3 Segment, Element 2
PRIMARYPAYERCITY
Primary Payer City
Location : N4 Segment, Element 1
PRIMARYPAYERSTATE
Primary Payer State
Location : N4 Segment, Element 2
PRIMARYPAYERZIP
Primary Payer Zip Code
Location : N4 Segment, Element 3
PRIMARYPAYERID
Primary Payer ID
Location : NM1 Segment, Element 9
Qualifier PR
SECONDARYGROUPID
Secondary Subscriber Group ID
Location : SBR Segment, Element 2
Qualifier S
SECONDARYGROUPNAME
Secondary Subscriber Group Name
Location : SBR Segment, Element 3
Qualifier S
SECONDARYSUBID
Secondary Subscriber ID
Location : NM1 Segment, Element 9
Qualifier IL
SECONDARYSUBLNAME
Secondary Subscriber Last Name
Location : NM1 Segment, Element 3
Qualifier IL
SECONDARYSUBFNAME
Secondary Subscriber First Name
Location : NM1 Segment, Element 4
Qualifier IL
SECONDARYSUBMI
Secondary Subscriber Middle Initial
Location : NM1 Segment, Element 5
Qualifier IL
SECONDARYSUBADDR1
Secondary Subscriber Address Line 1
Location : N3 Segment, Element 1
SECONDARYSUBADDR2
Secondary Subscriber Address Line 2
Location : N3 Segment, Element 2
SECONDARYSUBCITY
Secondary Subscriber City
Location : N4 Segment, Element 1
SECONDARYSUBSTATE
Secondary Subscriber State
Location : N4 Segment, Element 2
SECONDARYSUBZIP
Secondary Subscriber Zip Code
Location : N4 Segment, Element 3
SECONDARYSUBDOB
Secondary Subscriber Date of Birth
Location : DMG Segment, Element 2
SECONDARYSUBSEX
Secondary Subscriber Gender
Location : DMG Segment, Element 3
SECONDARYPAYERNAME
Secondary Payer Name
Location : NM1 Segment, Element 3
Qualifier PR
SECONDARYPAYERADDR1
Secondary Payer Address Line 1
Location : N3 Segment, Element 1
SECONDARYPAYERADDR2
Secondary Payer Address Line 2
Location : N3 Segment, Element 2
SECONDARYPAYERCITY
Secondary Payer City
Location : N4 Segment, Element 1
SECONDARYPAYERSTATE
Secondary Payer State
Location : N4 Segment, Element 2
SECONDARYPAYERZIP
Secondary Payer Zip Code
Location : N4 Segment, Element 3
SECONDARYPAYERID
Secondary Payer ID
Location : NM1 Segment, Element 9
Qualifier PR
TERTIARYGROUPID
Tertiary Subscriber Group ID
Location : SBR Segment, Element 2
Qualifier T
TERTIARYGROUPNAME
Tertiary Subscriber Group Name
Location : SBR Segment, Element 3
Qualifier T
TERTIARYSUBID
Tertiary Subscriber ID
Location : NM1 Segment, Element 9
Qualifier IL
TERTIARYSUBLNAME
Tertiary Subscriber Last Name
Location : NM1 Segment, Element 3
Qualifier IL
TERTIARYSUBFNAME
Tertiary Subscriber First Name
Location : NM1 Segment, Element 4
Qualifier IL
TERTIARYSUBMI
Tertiary Subscriber Middle Initial
Location : NM1 Segment, Element 5
Qualifier IL
TERTIARYSUBADDR1
Tertiary Subscriber Address Line 1
Location : N3 Segment, Element 1
TERTIARYSUBADDR2
Tertiary Subscriber Address Line 2
Location : N3 Segment, Element 2
TERTIARYSUBCITY
Tertiary Subscriber City
Location : N4 Segment, Element 1
TERTIARYSUBSTATE
Tertiary Subscriber State
Location : N4 Segment, Element 2
TERTIARYSUBZIP
Tertiary Subscriber Zip Code
Location : N4 Segment, Element 3
TERTIARYSUBDOB
Tertiary Subscriber Date of Birth
Location : DMG Segment, Element 2
TERTIARYSUBSEX
Tertiary Subscriber Gender
Location : DMG Segment, Element 3
TERTIARYPAYERNAME
Tertiary Payer Name
Location : NM1 Segment, Element 3
Qualifier PR
TERTIARYPAYERADDR1
Tertiary Payer Address Line 1
Location : N3 Segment, Element 1
TERTIARYPAYERADDR2
Tertiary Payer Address Line 2
Location : N3 Segment, Element 2
TERTIARYPAYERCITY
Tertiary Payer City
Location : N4 Segment, Element 1
TERTIARYPAYERSTATE
Tertiary Payer State
Location : N4 Segment, Element 2
TERTIARYPAYERZIP
Tertiary Payer Zip Code
Location : N4 Segment, Element 3
TERTIARYPAYERID
Tertiary Payer ID
Location : NM1 Segment, Element 9
Qualifier PR
HIERARCHIALCLAIMBILLINGPROVIDERNAME
Hierarchial Claim Billing Provider Name
Location : NM1 Segment, Element 3
Qualifier 85
HIERARCHIALCLAIMBILLINGPROVIDERADDR1
Hierarchial Claim Billing Provider Address Line 1
Location : N3 Segment, Element 1
HIERARCHIALCLAIMBILLINGPROVIDERADDR2
Hierarchial Claim Billing Provider Address Line 2
Location : N3 Segment, Element 2
HIERARCHIALCLAIMBILLINGPROVIDERCITY
Hierarchial Claim Billing Provider City
Location : N4 Segment, Element 1
HIERARCHIALCLAIMBILLINGPROVIDERST
Hierarchial Claim Billing Provider State
Location : N4 Segment, Element 2
HIERARCHIALCLAIMBILLINGPROVIDERZIP
Hierarchial Claim Billing Provider Zip Code
Location : N4 Segment, Element 3
HIERARCHIALCLAIMBILLINGPROVIDERIDTYPE
Hierarchial Claim Billing Provider ID Type
Location : NM1 Segment, Element 8
Qualifier 85
HIERARCHIALCLAIMBILLINGPROVIDERIDCODE
Hierarchial Claim Billing Provider ID Code
Location : NM1 Segment, Element 8
HIERARCHIALCLAIMBILLINGPROVIDERID
Hierarchial Claim Billing Provider ID
Location : NM1 Segment, Element 9
HIERARCHIALCLAIMPAYTOPROVIDERNAME
Hierarchial Claim Pay to Provider Provider Name
Location : NM1 Segment, Element 3
Qualifier 87
HIERARCHIALCLAIMPAYTOPROVIDERADDR1
Hierarchial Claim Pay to Provider Provider Address Line 1
Location : N3 Segment, Element 1
HIERARCHIALCLAIMPAYTOPROVIDERADDR2
Hierarchial Claim Pay to Provider Provider Address Line 2
Location : N3 Segment, Element 2
HIERARCHIALCLAIMPAYTOPROVIDERCITY
Hierarchial Claim Pay to Provider Provider City
Location : N4 Segment, Element 1
HIERARCHIALCLAIMPAYTOPROVIDERST
Hierarchial Claim Pay to Provider Provider State
Location : N4 Segment, Element 2
HIERARCHIALCLAIMPAYTOPROVIDERZIP
Hierarchial Claim Pay to Provider Provider Zip Code
Location : N4 Segment, Element 3
HIERARCHIALCLAIMPAYTOPROVIDERIDTYPE
Hierarchial Claim Pay to Provider Provider ID Type
Location : NM1 Segment, Element 8
Qualifier 87
HIERARCHIALCLAIMPAYTOPROVIDERIDCODE
Hierarchial Claim Pay to Provider Provider ID Code
Location : NM1 Segment, Element 8
Qualifier 87
HIERARCHIALCLAIMPAYTOPROVIDERID
Hierarchial Claim Pay to Provider Provider ID
Location : NM1 Segment, Element 9
Qualifier 87
TSCONTROLNUMBER
Batch Conrol Number
Location : ST Segment, Element 2
BHTREFID
BHT Segment Reference Identification
Location : BHT Segment, Element 4
SUBMITTERNAME
Submitter Name
Location : NM1 Segment, Element 3
Qualifier 41
SUBMITTERADDR1
Submitter Address Line 1
Location : N3 Segment, Element 1
SUBMITTERADDR2
Submitter Address Line 2
Location : N3 Segment, Element 2
SUBMITTERCITY
Submitter City
Location : N4 Segment, Element 1
SUBMITTERST
Submitter State
Location : N4 Segment, Element 2
SUBMITTERZIP
Submitter Zip Code
Location : N4 Segment, Element 3
SUBMITTERCONTACT
Submitter Contact
Location : PER Segment, Element 2
SUBMITTERID
Submitter ID
Location : NM1 Segment, Element 9
Qualifier 41
RECEIVERID
Receiver
Location : NM1 Segment, Element 9
Qualifier 41
RECEIVERNAME
Receiver Name
Location : NM1 Segment, Element 3
Qualifier 40
RECEIVERADDITIONALNAME
Receiver Additional Name
Location : N2 Segment, Element 1
RECEIVERADDR1
Receiver Address Line 1
Location : N3 Segment, Element 1
RECEIVERADDR2
Receiver Address Line 2
Location : N3 Segment, Element 2
RECEIVERCITY
Receiver Address City
Location : N4 Segment, Element 1
RECEIVERST
Receiver Address State
Location : N4 Segment, Element 2
RECEIVERZIP
Receiver Address Zip Code
Location : N4 Segment, Element 3
BILLINGPROVIDERNAME
Billing Provider Name
Location : NM1 Segment, Element 3
Qualifier 85
BILLINGPROVIDERADDR1
Billing Provider Address Line 1
Location : N3 Segment, Element 1
BILLINGPROVIDERADDR2
Billing Provider Address Line 2
Location : N3 Segment, Element 2
BILLINGPROVIDERCITY
Billing Provider City
Location : N4 Segment, Element 1
BILLINGPROVIDERST
Billing Provider State
Location : N4 Segment, Element 2
BILLINGPROVIDERZIP
Billing Provider Zip Code
Location : N4 Segment, Element 3
BILLINGPROVIDERIDTYPE
Billing Provider ID Type
Location : NM1 Segment, Element 8
Qualifier 85
BILLINGPROVIDERIDCODE
Billing Provider ID Code
Location : NM1 Segment, Element 8
Qualifier 85
BILLINGPROVIDERID
Billing Provider ID
Location : NM1 Segment, Element 9
Qualifier 85
PAYTOPROVIDERNAME
Pay to Provider Name
Location : NM1 Segment, Element 3
Qualifier 87
PAYTOPROVIDERADDR1
Pay to Provider Address Line 1
Location : N3 Segment, Element 1
PAYTOPROVIDERADDR2
Pay to Provider Address Line 2
Location : N3 Segment, Element 2
PAYTOPROVIDERCITY
Pay to Provider City
Location : N4 Segment, Element 1
PAYTOPROVIDERST
Pay to Provider State
Location : N4 Segment, Element 2
PAYTOPROVIDERZIP
Pay to Provider Zip Code
Location : N4 Segment, Element 3
PAYTOPROVIDERIDTYPE
Pay to Provider ID Type
Location : NM1 Segment, Element 8
Qualifier 87
PAYTOPROVIDERIDCODE
Pay to Provider ID Code
Location : NM1 Segment, Element 8
Qualifier 87
PAYTOPROVIDERID
Pay to Provider ID
Location : NM1 Segment, Element 9
Qualifier 87
Section 8
This is a list of the fields supported for mapping and are
stored in an XML file called C1835.XML. Field names are placed
inside the field tags of the xml.
Example :
- - - - - - - - - - - - - - - - - -
SETCONTROLNUMBER
Transaction Set Control Number
Location : ST Segment, Element 2
CLAIMPATCTL
Claim Patient Control Number
Location : CLP Segment, Element 1
CLAIMSTATUSCODE
Claim Staus Code
Location : CLP Segment, Element 2
CLAIMSTATUSDESC
Claim Status Description
Location : CLP Segment, Element 2
CLAIMTOTALCHARGE
Claim Total Charge
Location : CLP Segment, Element 3
CLAIMTOTALPAID
Claim Total Paid
Location : CLP Segment, Element 4
PATRESPONSIBLE
Patient Responsibility
Location : CLP Segment, Element 5
FILIND
Filing Indicator
Location : CLP Segment, Element 6
FILINDDESC
Filing Indicator Description
Location : CLP Segment, Element 6
PAYERCLAIMCODE
Payer Claim Code
Location : CLP Segment, Element 7
FACILITYTYPECODE
Facility Type Code
Location : CLP Segment, Element 8
PAYERCLAIMCODE
Payer Claim Code
Location : CLP Segment, Element 8
CLAIMFREQ
Claim Frequency Code
Location : CLP Segment, Element 9
PATSTATCODE
Patient Status Code
Location : CLP Segment, Element 10
DRGCODE
Diagnosis Related Group (DRG) Code
Location : CLP Segment, Element 11
DRGQTY
Diagnosis Related Group (DRG) Weight
Location : CLP Segment, Element 12
DISCHGPCT
Discharge Fraction
Location : CLP Segment, Element 13
CLMADJGRPCODE
Claim Adjustment Group Code
Location : CAS Segment, Element 1
CLMADJGRPDESC
Claim Adjustment Group Code Description
Location : CAS Segment, Element 1
CLMADJCODE
Location : CAS Segment, Element 2
Loop 2100
CLMADJAMT
Location : CAS Segment, Element 3
Loop 2100
CLMADJQTY
Location : CAS Segment, Element 4
Loop 2100
CLMADJCODEn
Claim Adjustment Code 1 thru 99
n = 1 to 99
Location : CAS Segment, Element 2
CLMADJAMTn
Claim Adjustment Amount 1 thru 99
n = 1 to 99
Location : CAS Segment, Element 3
CLMADJQTYn
Claim Adjustment Quantity 1 thru 99
n = 1 to 99
Location : CAS Segment, Element 4
CLAIMDATEEXP
Claim Expiration Date
Location : DTM Segment, Element 2
Element 1 Qualifier 036
CLAIMDATEREC
Claim Date Received
Location : DTM Segment, Element 2
Element 1 Qualifier 050
CLAIMMSTATEMENTPERIODSTART
Claim Statement Period Start
Location : DTM Segment, Element 2
Element 1 Qualifier 232
CLAIMMSTATEMENTPERIODEND
Claim Statement Period End
Location : DTM Segment, Element 2
Element 1 Qualifier 233
TRANSHANDCODE
Transaction Handling Code
Location : BPR Segment, Element 1
TRANSTOTALPAYAMT
Total Actual Provider Payment Amount
Location : BPR Segment, Element 2
TRANSDC
Transaction Type Credit/Debit
Location : BPR Segment, Element 3
TRANSPAYMETHOD
Transaction Payment Method
Location : BPR Segment, Element 4
TRANSDATE
Transaction Date
Location : BPR Segment, Element 16
TRACEREFRENCEID
Trace Reference Identification
Location : TRN Segment, Element 4
TRACEREFID
Trace Reference Identification
Location : TRN Segment, Element 2
TRACEORGID
Trace Originating Identifier
Location : TRN Segment, Element 4
XOVERCARRIER
CROSSOVER CARRIER NAME
Location : NM1 Segment, Element 3
Element 1 Qualifier TT
PAYEEADID
PAYEE ADDITIONAL IDENTIFICATION
Location : REF Segment, Element 2
RECEIVERID
Receiver ID
Location : REF Segment, Element 2
Element 1 Qualifier EV
PRODDATE
Production Date
Location : DTM Segment, Element 2
Element 1 Qualifier 405
PAYERNAME
Payer Name
Location : N1 Segment, Element 2
Element 1 Qualifier PR
PAYERADDRESS1
Payer Address 1
Location : N3 Segment, Element 1
PAYERADDRESS2
Payer Address 2
Location : N3 Segment, Element 2
PAYERCITY
Payer City
Location : N4 Segment, Element 1
PAYERSTATE
Payer State
Location : N4 Segment, Element 2
PAYERZIPCODE
Payer Zip Code
Location : N4 Segment, Element 3
PAYEEIDQUAL
Payee ID Code Qualifier
Location : N1 Segment, Element 3
Element 1 Qualifier PE
PAYEEID
Payee ID Code Qualifier
Location : N1 Segment, Element 4
Element 1 Qualifier PE
PAYEEADIDQUAL
Payee ID Code Qualifier
Location : N1 Segment, Element 3
Element 1 Qualifier PE
PAYEEADID
Payee Additional ID Code
Location : REF Segment, Element 2
PAYEENAME
Payee Name
Location : N1 Segment, Element 2
PAYEEADDRESS1
Payee Address 1
Location : N3 Segment, Element 1
PAYEEADDRESS2
Payee Address 2
Location : N3 Segment, Element 3
PAYEECITY
Payee City
Location : N4 Segment, Element 1
PAYEESTATE
Payee State
Location : N4 Segment, Element 2
PAYEEZIPCODE
Payee Zip Code
Location : N4 Segment, Element 3
SERVICEPROVIDER
Service Provider
Location : NM1 Segment, Element 3
Element 1 Qualifier 82
SERVICEPROVIDERID
Service Provider
Location : NM1 Segment, Element 9
Element 1 Qualifier 82
SERVICEPROVIDERIDQUAL
Service Provider
Location : NM1 Segment, Element 3
Element 1 Qualifier 82
PRIMARYCLAIMPATCTL
Claim Patient Control Number
Location : CLP Segment, Element 1
PRIMARYCLAIMSTATUSCODE
Claim Staus Code
Location : CLP Segment, Element 2
PRIMARYCLAIMSTATUSDESC
Claim Status Description
Location : CLP Segment, Element 2
PRIMARYCLAIMTOTALCHARGE
Claim Total Charge
Location : CLP Segment, Element 3
PRIMARYCLAIMTOTALPAID
Claim Total Paid
Location : CLP Segment, Element 4
PRIMARYPATRESPONSIBLE
Patient Responsibility
Location : CLP Segment, Element 5
PRIMARYFILIND
Filing Indicator
Location : CLP Segment, Element 6
PRIMARYFILINDDESC
Filing Indicator Description
Location : CLP Segment, Element 6
PRIMARYPAYERCLAIMCODE
Payer Claim Code
Location : CLP Segment, Element 7
PRIMARYFACILITYTYPECODE
Facility Type Code
Location : CLP Segment, Element 8
PRIMARYPAYERCLAIMCODE
Payer Claim Code
Location : CLP Segment, Element 8
PRIMARYCLAIMFREQ
Claim Frequency Code
Location : CLP Segment, Element 9
PRIMARYPATSTATCODE
Patient Status Code
Location : CLP Segment, Element 10
PRIMARYDRGCODE
Diagnosis Related Group (DRG) Code
Location : CLP Segment, Element 11
PRIMARYDRGQTY
Diagnosis Related Group (DRG) Weight
Location : CLP Segment, Element 12
PRIMARYDISCHGPCT
Discharge Fraction
Location : CLP Segment, Element 13
SECONDARYCLAIMPATCTL
Claim Patient Control Number
Location : CLP Segment, Element 1
SECONDARYCLAIMSTATUSCODE
Claim Staus Code
Location : CLP Segment, Element 2
SECONDARYCLAIMSTATUSDESC
Claim Status Description
Location : CLP Segment, Element 2
SECONDARYCLAIMTOTALCHARGE
Claim Total Charge
Location : CLP Segment, Element 3
SECONDARYCLAIMTOTALPAID
Claim Total Paid
Location : CLP Segment, Element 4
SECONDARYPATRESPONSIBLE
Patient Responsibility
Location : CLP Segment, Element 5
SECONDARYFILIND
Filing Indicator
Location : CLP Segment, Element 6
SECONDARYFILINDDESC
Filing Indicator Description
Location : CLP Segment, Element 6
SECONDARYPAYERCLAIMCODE
Payer Claim Code
Location : CLP Segment, Element 7
SECONDARYFACILITYTYPECODE
Facility Type Code
Location : CLP Segment, Element 8
SECONDARYPAYERCLAIMCODE
Payer Claim Code
Location : CLP Segment, Element 8
SECONDARYCLAIMFREQ
Claim Frequency Code
Location : CLP Segment, Element 9
SECONDARYPATSTATCODE
Patient Status Code
Location : CLP Segment, Element 10
SECONDARYDRGCODE
Diagnosis Related Group (DRG) Code
Location : CLP Segment, Element 11
SECONDARYDRGQTY
Diagnosis Related Group (DRG) Weight
Location : CLP Segment, Element 12
SECONDARYDISCHGPCT
Discharge Fraction
Location : CLP Segment, Element 13
TERTIARYCLAIMPATCTL
Claim Patient Control Number
Location : CLP Segment, Element 1
TERTIARYCLAIMSTATUSCODE
Claim Staus Code
Location : CLP Segment, Element 2
TERTIARYCLAIMSTATUSDESC
Claim Status Description
Location : CLP Segment, Element 2
TERTIARYCLAIMTOTALCHARGE
Claim Total Charge
Location : CLP Segment, Element 3
TERTIARYCLAIMTOTALPAID
Claim Total Paid
Location : CLP Segment, Element 4
TERTIARYPATRESPONSIBLE
Patient Responsibility
Location : CLP Segment, Element 5
TERTIARYFILIND
Filing Indicator
Location : CLP Segment, Element 6
TERTIARYFILINDDESC
Filing Indicator Description
Location : CLP Segment, Element 6
TERTIARYPAYERCLAIMCODE
Payer Claim Code
Location : CLP Segment, Element 7
TERTIARYFACILITYTYPECODE
Facility Type Code
Location : CLP Segment, Element 8
TERTIARYPAYERCLAIMCODE
Payer Claim Code
Location : CLP Segment, Element 8
TERTIARYCLAIMFREQ
Claim Frequency Code
Location : CLP Segment, Element 9
TERTIARYPATSTATCODE
Patient Status Code
Location : CLP Segment, Element 10
TERTIARYDRGCODE
Diagnosis Related Group (DRG) Code
Location : CLP Segment, Element 11
TERTIARYDRGQTY
Diagnosis Related Group (DRG) Weight
Location : CLP Segment, Element 12
TERTIARYDISCHGPCT
Discharge Fraction
Location : CLP Segment, Element 13
SUBFNAME
Subscribers First Name
Location : NM1 Segment, Element 4
Element 1 Qualifier IL
SUBLNAME
Subscribers Last Name
Location : NM1 Segment, Element 3
Element 1 Qualifier IL
SUBMI
Subscribers Middle Initial
Location : NM1 Segment, Element 5
Element 1 Qualifier IL
SUBID
Subscribers ID
Location : NM1 Segment, Element 9
Element 1 Qualifier IL
SUBIDQUAL
Subscribers ID Qualifier
Location : NM1 Segment, Element 8
Element 1 Qualifier IL
PATFNAME
Patient First Name
Location : NM1 Segment, Element 4
Element 1 Qualifier QC
PATLNAME
Patient Last Name
Location : NM1 Segment, Element 3
Element 1 Qualifier QC
PATMI
Patient Middle Initial
Location : NM1 Segment, Element 5
Element 1 Qualifier QC
PATID
Patient ID
Location : NM1 Segment, Element 9
Element 1 Qualifier QC
PATIDQUAL
Patient ID Qualifier
Location : NM1 Segment, Element 8
Element 1 Qualifier QC
MEDICALRECORDIDNUMBER
OTHER CLAIM RELATED IDENTIFICATION
Medical Record Identification Number
Location : REF Segment, Element 2
Element 1 Qualifier EA
GROUPPOLICYNUMBER
OTHER CLAIM RELATED IDENTIFICATION
Group or Policy Number
Location : REF Segment, Element 2
Element 1 Qualifier 1L
MEMBERIDNUMBER
OTHER CLAIM RELATED IDENTIFICATION
Member Identification Number
Location : REF Segment, Element 2
Element 1 Qualifier 1W
REPRICECLAIMREFNUMBER
OTHER CLAIM RELATED IDENTIFICATION
Repriced Claim Reference Number
Location : REF Segment, Element 2
Element 1 Qualifier 9a
ADJREPRICECLAIMREFNUMBER
OTHER CLAIM RELATED IDENTIFICATION
Adjusted Repriced Claim Reference Number
Location : REF Segment, Element 2
Element 1 Qualifier 9c
EMPLOYEEIDNUMBER
OTHER CLAIM RELATED IDENTIFICATION
Employee Identification Number
Location : REF Segment, Element 2
Element 1 Qualifier A6
AUTHORIZATIONNUMBER
OTHER CLAIM RELATED IDENTIFICATION
Authorization Number
Location : REF Segment, Element 2
Element 1 Qualifier BB
CLASSCONTRACTCODE
OTHER CLAIM RELATED IDENTIFICATION
Class of Contract Code
Location : REF Segment, Element 2
Element 1 Qualifier CE
ORIGINALREFNUMBER
OTHER CLAIM RELATED IDENTIFICATION
Original Reference Number
Location : REF Segment, Element 2
Element 1 Qualifier FB
PRIORAUTHORIZATIONMUMBER
OTHER CLAIM RELATED IDENTIFICATION
Prior Authorization Number
Location : REF Segment, Element 2
Element 1 Qualifier G1
BENEFITIDNUMBER
OTHER CLAIM RELATED IDENTIFICATION
Predetermination of Benefits Identification Number
Location : REF Segment, Element 2
Element 1 Qualifier G3
INSURANCEPOLICYNUMBER
OTHER CLAIM RELATED IDENTIFICATION
Insurance Policy Number
Location : REF Segment, Element 2
Element 1 Qualifier IG
SSN
OTHER CLAIM RELATED IDENTIFICATION
Social Security Number
Location : REF Segment, Element 2
Element 1 Qualifier SY
RENPROVBLUECROSSID
RENDERING PROVIDER INFORMATION
Blue Cross Provider Number
Location : REF Segment, Element 2
Element 1 Qualifier 1A
RENPROVBLUESHIELDID
RENDERING PROVIDER INFORMATION
Blue Shield Provider Number
Location : REF Segment, Element 2
Element 1 Qualifier 1B
RENPROVMEDICAREID
RENDERING PROVIDER INFORMATION
Medicare Provider Number
Location : REF Segment, Element 2
Element 1 Qualifier 1C
RENPROVMEDICAIDID
RENDERING PROVIDER INFORMATION
Medicaid Provider Number
Location : REF Segment, Element 2
Element 1 Qualifier 1D
RENPROVUPINID
RENDERING PROVIDER INFORMATION
UPIN Provider Number
Location : REF Segment, Element 2
Element 1 Qualifier 1G
RENPROVCHAMUSID
RENDERING PROVIDER INFORMATION
Champus Provider Number
Location : REF Segment, Element 2
Element 1 Qualifier 1H
RENPROVFACILITYID
RENDERING PROVIDER INFORMATION
Facility Provider Number
Location : REF Segment, Element 2
Element 1 Qualifier 1J
RENPROVNPIID
RENDERING PROVIDER INFORMATION
Natioanl Provider ID Number
Location : REF Segment, Element 2
Element 1 Qualifier HPI
RENPROVTAXID
RENDERING PROVIDER INFORMATION
Federal Tax ID Number
Location : REF Segment, Element 2
Element 1 Qualifier TJ
CLAIMSUPPLEMENTALCA
Claim Supplemental Quantity Information Covered - Actual
Location : REF Segment, Element 2
Element 1 Qualifier CA
CLAIMSUPPLEMENTALCD
Claim Supplemental Quantity Information Co-insured - Actual
Location : REF Segment, Element 2
Element 1 Qualifier CD
CLAIMSUPPLEMENTALLA
Claim Supplemental Quantity Information Life-time Reserve - Actual
Location : REF Segment, Element 2
Element 1 Qualifier LA
CLAIMSUPPLEMENTALLE
Claim Supplemental Quantity Information Life-time Reserve - Estimate
Location : REF Segment, Element 2
Element 1 Qualifier LE
CLAIMSUPPLEMENTALNA
Claim Supplemental Quantity Information Number of Non-covered Days
Location : REF Segment, Element 2
Element 1 Qualifier NA
CLAIMSUPPLEMENTALNE
Claim Supplemental Quantity Information Non-Covered - Estimated
Location : REF Segment, Element 2
Element 1 Qualifier NE
CLAIMSUPPLEMENTALNR
Claim Supplemental Quantity Information Not Replaced Blood Units
Location : REF Segment, Element 2
Element 1 Qualifier NR
CLAIMSUPPLEMENTALOU
Claim Supplemental Quantity Information Outlier Days
Location : REF Segment, Element 2
Element 1 Qualifier OU
CLAIMSUPPLEMENTALPS
Claim Supplemental Quantity Information Prescription
Location : REF Segment, Element 2
Element 1 Qualifier PS
CLAIMSUPPLEMENTALVS
Claim Supplemental Quantity Information Visits
Location : REF Segment, Element 2
Element 1 Qualifier VS
CLAIMSUPPLEMENTALZK
Claim Supplemental Quantity Information Federal
Medicare or Medicaid Payment Mandate - Category 1
Location : REF Segment, Element 2
Element 1 Qualifier ZK
CLAIMSUPPLEMENTALZL
Claim Supplemental Quantity Information Federal
Medicare or Medicaid Payment Mandate - Category 2
Location : REF Segment, Element 2
Element 1 Qualifier ZL
CLAIMSUPPLEMENTALZM
Claim Supplemental Quantity Information Federal
Medicare or Medicaid Payment Mandate - Category 3
Location : REF Segment, Element 2
Element 1 Qualifier ZM
CLAIMSUPPLEMENTALZN
Claim Supplemental Quantity Information Federal
Medicare or Medicaid Payment Mandate - Category 4
Location : REF Segment, Element 2
Element 1 Qualifier ZN
CLAIMSUPPLEMENTALZO
Claim Supplemental Quantity Information Federal
Medicare or Medicaid Payment Mandate - Category 5
Location : REF Segment, Element 2
Element 1 Qualifier ZO
- - - - - - - - - - - - - -
Service Line Level
01 to 99
- - - - - - - - - - - - - -
DATEOFSERVICE01
Date of Service
Location : DTM Segment, Element 2
Element 1 Qualifier 472
PROCEDURE01
Procedure
Location : SVC Segment, Element 1
Subvalue 2
PROCEDUREMODA01
Procedure Modifier
Location : SVC Segment, Element 1
Subvalue 3
PROCEDUREMODB01
Procedure Modifier
Location : SVC Segment, Element 1
Subvalue 4
PROCEDUREMODC01
Procedure Modifier
Location : SVC Segment, Element 1
Subvalue 5
PROCEDUREMODD01
Procedure Modifier
Location : SVC Segment, Element 1
Subvalue 6
PROCBILLEDAMT01
Procedure Billed Amount
Location : SVC Segment, Element 2
PROCPAYAMT01
Procedure Paid Amount
Location : SVC Segment, Element 3
PROCREVENUECODE01
Procedure Revenue Code
Location : SVC Segment, Element 4
PROCUNITSPAID01
Procedure Units Paid
Location : SVC Segment, Element 5
PROCUNITS01
Procedure Original Units
Location : SVC Segment, Element 7
PROCEDUREDESCRIPTION
Procedure Code Description
Location : SVC Segment, Element 1
Subelement 7
PROCALLOWEDAMT01
Procedure Allowed Amount
Location : AMT Segment, Element 2
Element 1 Qualifier B6
PROCPERDAYLIMITAMT01
Procedure Per Day Limit
Location : AMT Segment, Element 2
Element 1 Qualifier DY
PROCDEDUCTIONAMT01
Procedure Deduction Amount
Location : AMT Segment, Element 2
Element 1 Qualifier KH
PROCNETBILLEDAMT01
Procedure Net Billed
Location : AMT Segment, Element 2
Element 1 Qualifier NE
PROCTAXAMT01
Procedure Tax
Location : AMT Segment, Element 2
Element 1 Qualifier T
PROCTOTALBEFORETAXESAMT01
Procedure Total Claim Before Taxes
Location : AMT Segment, Element 2
Element 1 Qualifier T2
PROCPAYAMT01
Procedure Pay Amount
Location : CAS Segment, Element 3
Element 1 Qualifier PR
PROCDEDUCTAMT01
Procedure Deductable Amount
Location : CAS Segment, Element 1
Element 1 Qualifier PR
PROCCOINSAMT01
Procedure Coinsurance Amount Amount
Location : CAS Segment, Element 2
Element 1 Qualifier PR
PROCCOADJAMT01
Location : CAS Segment, Element 3
Element 1 Qualifier CO
PROCPROTHERAM01
Location : CAS Segment, Element 2,5
Element 1 Qualifier PR
PROCCOPAYAMT01
Location : CAS Segment, Element 3
Element 1 Qualifier PR
SERVICEDATEFROM01
Service Date From
Location : DTM Segment, Element 2
Element 1 Qualifier 150
SERVICEDATETO01
Service Date From
Location : DTM Segment, Element 2
Element 1 Qualifier 151
PROCPRIORAUTHNUMBER01
Prior Auth
Location : REF Segment, Element 2
Element 1 Qualifier G1
PROCCTLNUMBER01
Procedur Line Control Number
Location : REF Segment, Element 2
Element 1 Qualifier 6R
PROCADJGRPCODE01
Procedure Adjustemt Group Code
Location : CAS Segment, Element 2
PROCADJCODE01
Procedure Adjustemt Code
Location : CAS Segment, Element 3
PROCREMARKCODE01
Procedure Remark Code
Location : LQ Segment, Element 1
- - - - - - - - - - - - - -
Provider Adjustment
- - - - - - - - - - - - - -
PROVADJREFID
Provider Adjustment Provider Reference ID
Location : PLB Segment, Element 1
PROVADJPERIOD
Provider Adjustment Period
Location : PLB Segment, Element 2
PROVADJRESONCODE1
Provider Adjustment Reason Code
Location : PLB Segment, Element 3
SubValue 1
PROVADJREASONID1
Provider Adjustment Reason ID
Location : PLB Segment, Element 3
SubValue 2
PROVADJAMT1
Provider Adjustment Amount
Location : PLB Segment, Element 4
PROVADJRESONCODE2
Provider Adjustment Reason Code
Location : PLB Segment, Element 5
SubValue 1
PROVADJREASONID2
Provider Adjustment Reason ID
Location : PLB Segment, Element 5
SubValue 2
PROVADJAMT2
Provider Adjustment Amount
Location : PLB Segment, Element 6
PROVADJRESONCODE3
Provider Adjustment Reason Code
Location : PLB Segment, Element 7
SubValue 1
PROVADJREASONID3
Provider Adjustment Reason ID
Location : PLB Segment, Element 7
SubValue 2
PROVADJAMT3
Provider Adjustment Amount
Location : PLB Segment, Element 8
PROVADJRESONCODE4
Provider Adjustment Reason Code
Location : PLB Segment, Element 9
SubValue 1
PROVADJREASONID4
Provider Adjustment Reason ID
Location : PLB Segment, Element 9
SubValue 2
PROVADJAMT4
Provider Adjustment Amount
Location : PLB Segment, Element 10
PROVADJRESONCODE5
Provider Adjustment Reason Code
Location : PLB Segment, Element 11
SubValue 1
PROVADJREASONID5
Provider Adjustment Reason ID
Location : PLB Segment, Element 11
SubValue 2
PROVADJAMT5
Provider Adjustment Amount
Location : PLB Segment, Element 12
PROVADJRESONCODE6
Provider Adjustment Reason Code
Location : PLB Segment, Element 13
SubValue 1
PROVADJREASONID6
Provider Adjustment Reason ID
Location : PLB Segment, Element 13
SubValue 2
PROVADJAMT6
Provider Adjustment Amount
Location : PLB Segment, Element 14
- - - - - - - - - - - - - -
Medicare Inpatient Adjudication
- - - - - - - - - - - - - -
MIACOVDVC
Covered Days or Visits Count
Location : MIA Segment, Element 1
MIAOPOUTAMT
PPS Operating Outlier Amount
Location : MIA Segment, Element 2
MIALIFPSYDAYS
Lifetime Psychiatric Days Count
Location : MIA Segment, Element 3
MIADRGAMT
Claim DRG Amount
Location : MIA Segment, Element 4
MIAREMARK1
Remark Code
Location : MIA Segment, Element 5
MIASHAREAMT
Claim Disproportionate Share Amount
Location : MIA Segment, Element 6
MIAMSPPASSAMT
Claim MSP Pass-through Amount
Location : MIA Segment, Element 7
MIAPPSCAPAMT
Claim PPS Capital Amount
Location : MIA Segment, Element 8
MIAFSPDRGAMT
PPS-Capital FSP DRG Amount
Location : MIA Segment, Element 9
MIAHSPDRGAMT
PPS-Capital HSP DRG Amount 10
Location : MIA Segment, Element
MIADHSDRGAMT
PPS-Capital DSH DRG Amount
Location : MIA Segment, Element 11
MIAOLDCAPAMT
Old Capital Amount
Location : MIA Segment, Element 12
MIAIMEAMT
PPS-Capital IME amount
Location : MIA Segment, Element 13
MIAOHSDRG
PPS-Operating Hospital Specific DRG Amount
Location : MIA Segment, Element 14
MIACOSTRPTDATCNT
Cost Report Day Count
Location : MIA Segment, Element 15
MIAOFSDRG
PPS-Operating Federal Specific DRG Amount
Location : MIA Segment, Element 16
MIAPPSCAPOUTAMT
Claim PPS Capital Outlier Amount
Location : MIA Segment, Element 17
MIAINDTEACHAMT
Claim Indirect Teaching Amount
Location : MIA Segment, Element 18
MIANONPAYPROAMT
Nonpayable Professional Component Amount
Location : MIA Segment, Element 19
MIAREMARK2
Remark Code
Location : MIA Segment, Element 20
MIAREMARK3
Remark Code
Location : MIA Segment, Element 21
MIAREMARK4
Remark Code
Location : MIA Segment, Element 22
MIAREMARK5
Remark Code
Location : MIA Segment, Element 23
MIACAPEXCPAMT
PPS-Capital Exception Amount
Location : MIA Segment, Element 24
- - - - - - - - - - - - - -
Medicare Outpatient Adjudication
- - - - - - - - - - - - - -
MOAPERCENT
Medicare Outpatient Adjudication Percent
Location : MOA Segment, Element 1
MOAMOUNTPAYABLE"
Medicare Outpatient Adjudication Amount
Location : MOA Segment, Element 2
MOAREMARK1
Medicare Outpatient Adjudication Remark 1
Location : MOA Segment, Element 3
MOAREMARK2
Medicare Outpatient Adjudication Remark 2
Location : MOA Segment, Element 4
MOAREMARK3
Medicare Outpatient Adjudication Remark 3
Location : MOA Segment, Element 5
MOAREMARK4
Medicare Outpatient Adjudication Remark 4
Location : MOA Segment, Element 6
MOAREMARK5
Medicare Outpatient Adjudication Remark 5
Location : MOA Segment, Element 7
MOAPAYMENT
Medicare Outpatient Adjudication Payment Amount
Location : MOA Segment, Element 8
MOANONPAYABLE
Medicare Outpatient Adjudication Non Payable Amount
Location : MOA Segment, Element 9