276/277 Request and Response

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276/277 Request and Response Powered By Docstoc
					PURPOSE OF MAPPING WORKSHEET
This worksheet is intended as a companion to the ASC X12N
Implementation Guide to assist with the identification of data content and
mapping issues as they relate to the HIPAA standard version 004010X093
for this transaction set. The user must refer to the implementation guide
for more detailed, specific information on syntax and data usage
considerations.

Implementation Guides are available for free download from the
Washington Publishing Company web page, www.wpc-edi.com

SEE APPENDIX B OF IMPLEMENTATION GUIDE FOR CONTROL
SEGMENT STRUCTURE:
ISA – IEA (a.k.a. “Outer Envelope”) Interchange Control
GS – GE Functional Group Header / Trailer

DATA ELEMENT USAGE CONSIDERATIONS

Only those data elements listed as “Required” and “Situational” (or
conditional) per the implementation guide view appear in this worksheet.
Required segment names within required or situational loops are bolded in
the worksheet. Required data elements (per the implementation guide)
within required or situational segments have their names bolded in the
worksheet. Required sub-elements within a composite data element are
also bolded.
The “Attributes” column of the worksheet lists the Conditions Designator,
Data Element Type, and Minimum/Maximum characters for each data
element:
A condition designator “M”, “O”, or “X” appears for each data element in
order to provide information about the element’s usage per the standard
view. Please note that this may be different from the implementation guide
view.

Data Element Types:
Nn    Numeric
R     Decimal
ID    Identifier
AN    String
DT    Date
TM     Time
B     Binary
See Appendix A, section A.1.3.1 for additional information.

USE OF COLOR
Color is used in the worksheet to improve the visibility of tables, loops, and
beginning loop segments of the transaction set:
RED – Identifies the beginning of the transaction Header, Table 1, Table 2,
and Trailer levels.
PURPLE – Identifies the name of a required or situationally required loop
and maximum number of times the loop may repeat
GREEN - Identifies the beginning segment of a loop.
PAGE REFERENCE
Implementation Guide page references are listed in the worksheet for each
loop and segment in the transaction set.

NOTES COLUMN

Some usage / syntax notes appear, but the listing is not all-inclusive. The
implementation guide must still be reviewed in context with the worksheet.
As a convenience, qualifiers are listed in the “Notes” column when there is
only one available choice for that particular data element and position.
Where the “Notes” column is blank for the qualifier, this means that
multiple code choices are available; please refer to the implementation
guide.
                                                                                                                                                                                                Policy Memorandum 2004 - 37
                                                                                                                                                                                                Exhibit 2C



                                                                       276 - HEALTH CLAIM STATUS REQUEST
INTERNAL    TABLE /    FIELD    FIELD   FIELD                                                                REF.                                                                               LOOP
RECORD ID   DATABASE   LENGTH   TYPE    NAME    PG. SEGMENT NAME               ELEMENT NAME                  DES.    ELEMENT#          LOOP         ATTRIBUTES        NOTES                     USAGE       REPEAT
                                                                                                                                                                      FUNCTIONAL GROUP ID:
                                                     TABLE 1 - HEADER                                                                                                 HR
                                                     TRANSACTION SET
                                                49   HEADER                                                  ST                        HEADER                                                   R           1
                                                                               TRANSACTION SET
                                                                               IDENTIFIER CODE               ST01    143               HEADER       M    ID    3/3    276
                                                                               TRANSACTION SET                                                                        MUST EQUAL VALUE IN
                                                                               CONTROL NUMBER                ST02    329               HEADER       M    AN    4/9    SE02
                                                     BEGINNING OF
                                                     HIERARCHICAL
                                                50   TRANSACTION                                             BHT                       HEADER                                                   R           1
                                                                               HIERARCHICAL
                                                                               STRUCTURE CODE                BHT01 1005                HEADER       M    ID    4/4    10
                                                                               TRANSACTION SET
                                                                               PURPOSE CODE                  BHT02 353                 HEADER       M    ID    2/2    13
                                                                                                                                                                      TRANSACTION SET
                                                                               DATE                          BHT04 373                 HEADER       O    DT    8/8    CREATION DATE
                                                     TABLE 2 - DETAIL, INFORMATION SOURCE LEVEL
                                                     LOOP ID - 2000A INFORMATION SOURCE LEVEL                                                                                                               >1
                                                     INFORMATION SOURCE
                                                52   LEVEL                                                   HL                        2000A                                                    R           1

                                                                               HIERARCHICAL ID NUMBER HL01           628               2000A        M    AN    1/12
                                                                               HIERARCHICAL LEVEL
                                                                               CODE                   HL03           735               2000A        M    ID    1/2
                                                                               HIERARCHICAL CHILD
                                                                               CODE                   HL04           736               2000A        O    ID    1/1
                                                     LOOP ID - 2100A PAYER NAME                                                                                                                             >1
                                                54   PAYER NAME                                              NM1                       2100A                                                    R           1
                                                                               ENTITY IDENTIFIER CODE        NM101 98                  2100A        M    ID    2/3    PR
                                                                               ENTITY TYPE QUALIFIER         NM102 1065                2100A        M    ID    1/1    2
                                                                               NAME LAST OR
                                                                               ORGANIZATION NAME             NM103 1035                2100A        O    AN    1/35
                                                                               IDENTIFICATION CODE
                                                                               QUALIFIER                     NM108 66                  2100A        X    ID    1/2

                                                                               IDENTIFICATION CODE           NM109 67                  2100A        X    AN    2/80
                                                     PAYER CONTACT
                                                57   INFORMATION                                             PER                       2100A                                                    S           1

                                                                               CONTACT FUNCTION CODE PER01 366                         2100A        M    ID    2/2    IC

                                                                               NAME                 PER02 93                           2100A        O    AN    1/60
                                                                               COMMUNICATION NUMBER
                                                                               QUALIFIER            PER03 365                          2100A        X    ID    2/2

                                                     The tools and templates provided in CalOHI Policy and Information Memoranda have generally been authored by HIPAA workgroups. Users should view the
                                                     information presented in the context of their own organizations and environments. Legal opinions and/or decision documentation may be needed when
                                                     interpreting and/or applying this information.
                                                                                          Page 1
                                                                                                                                                      Policy Memorandum 2004 - 37
                                                                                                                                                      Exhibit 2C



                                                                    276 - HEALTH CLAIM STATUS REQUEST
INTERNAL    TABLE /    FIELD    FIELD   FIELD                                                       REF.                                              LOOP
RECORD ID   DATABASE   LENGTH   TYPE    NAME    PG. SEGMENT NAME           ELEMENT NAME             DES.   ELEMENT#   LOOP    ATTRIBUTES      NOTES   USAGE       REPEAT

                                                                           COMMUNICATION NUMBER PER04 364             2100A   X   AN   1/80
                                                                           COMMUNICATION NUMBER
                                                                           QUALIFIER            PER05 365             2100A   X   ID   2/2    EX

                                                                           COMMUNICATION NUMBER     PER06 364         2100A   X   AN   1/80
                                                                           COMMUNICATION NUMBER
                                                                           QUALIFIER                PER07 365         2100A   X   ID   2/2

                                                                           COMMUNICATION NUMBER     PER08 364         2100A   X   AN   1/80
                                                     TABLE 2 - DETAIL, INFORMATION RECEIVER LEVEL
                                                     LOOP ID - 2000B INFORMATION RECEIVER LEVEL                                                                   >1
                                                     INFORMATION
                                                60   RECEIVER LEVEL                                 HL                2000B                           R           1

                                                                           HIERARCHICAL ID NUMBER HL01     628        2000B   M   AN   1/12

                                                                           HIERARCHICAL PARENT ID   HL02   734        2000B   O   AN   1/12
                                                                           HIERARCHICAL LEVEL
                                                                           CODE                     HL03   735        2000B   M   ID   1/2    21
                                                                           HIERARCHICAL CHILD
                                                                           CODE                     HL04   736        2000B   O   ID   1/1
                                                     LOOP ID - 2100B INFORMATION RECEIVER NAME                                                                    >1
                                                     INFORMATION
                                                62   RECEIVER NAME                                  NM1               2100B                           R           1
                                                                           ENTITY IDENTIFIER CODE   NM101 98          2100B   M   ID   2/3
                                                                           ENTITY TYPE QUALIFIER    NM102 1065        2100B   M   ID   1/1
                                                                           NAME LAST OR
                                                                           ORGANIZATION NAME        NM103 1035        2100B   O   AN   1/35

                                                                           NAME FIRST               NM104 1036        2100B   O   AN   1/25

                                                                           NAME MIDDLE              NM105 1037        2100B   O   AN   1/25

                                                                           NAME SUFFIX              NM107 1039        2100B   O   AN   1/10
                                                                           IDENTIFICATION CODE
                                                                           QUALIFIER                NM108 66          2100B   X   ID   1/2

                                                                           IDENTIFICATION CODE      NM109 67          2100B   X   AN   2/80
                                                     TABLE 2 - DETAIL, SERVICE PROVIDER LEVEL
                                                     LOOP ID - 2000C SERVICE PROVIDER LEVEL                                                                       >1
                                                     SERVICE PROVIDER
                                                65   LEVEL                                          HL                2000C                           R           1

                                                                           HIERARCHICAL ID NUMBER HL01     628        2000C   M   AN   1/12

                                                                           HIERARCHICAL PARENT ID   HL02   734        2000C   O   AN   1/12
                                                                           HIERARCHICAL LEVEL
                                                                           CODE                     HL03   735        2000C   M   ID   1/2    19
                                                                           HIERARCHICAL CHILD
                                                                           CODE                     HL04   736        2000C   O   ID   1/1
                                                                                    Page 2
                                                                                                                                                      Policy Memorandum 2004 - 37
                                                                                                                                                      Exhibit 2C



                                                                    276 - HEALTH CLAIM STATUS REQUEST
INTERNAL    TABLE /    FIELD    FIELD   FIELD                                                       REF.                                              LOOP
RECORD ID   DATABASE   LENGTH   TYPE    NAME    PG. SEGMENT NAME           ELEMENT NAME             DES.   ELEMENT#   LOOP    ATTRIBUTES      NOTES   USAGE       REPEAT
                                                     LOOP ID - 2100C PROVIDER NAME                                                                                >1
                                                67   PROVIDER NAME                                  NM1               2100C                           R           1
                                                                           ENTITY IDENTIFIER CODE   NM101 98          2100C   M   ID   2/3
                                                                           ENTITY TYPE QUALIFIER    NM102 1065        2100C   M   ID   1/1
                                                                           NAME LAST OR
                                                                           ORGANIZATION NAME        NM103 1035        2100C   O   AN   1/35

                                                                           NAME FIRST               NM104 1036        2100C   O   AN   1/25

                                                                           NAME MIDDLE              NM105 1037        2100C   O   AN   1/25

                                                                           NAME SUFFIX              NM107 1039        2100C   O   AN   1/10
                                                                           IDENTIFICATION CODE
                                                                           QUALIFIER                NM108 66          2100C   X   ID   1/2

                                                                           IDENTIFICATION CODE      NM109 67          2100C   X   AN   2/80
                                                     TABLE 2 - DETAIL, SUBSCRIBER LEVEL
                                                     LOOP ID - 2000D SUBSCRIBER LEVEL                                                                             >1
                                                70   SUBSCRIBER LEVEL                               HL                2000D                           R           1

                                                                           HIERARCHICAL ID NUMBER HL01     628        2000D   M   AN   1/12

                                                                           HIERARCHICAL PARENT ID   HL02   734        2000D   O   AN   1/12
                                                                           HIERARCHICAL LEVEL
                                                                           CODE                     HL03   735        2000D   M   ID   1/2
                                                                           HIERARCHICAL CHILD
                                                                           CODE                     HL04   736        2000D   O   ID   1/1
                                                     SUBSCRIBER
                                                     DEMOGRAPHIC
                                                72   INFORMATION                                    DMG               2000D
                                                                           DATE TIME PERIOD
                                                                           FORMAT QUALIFIER         DMG01 1251        2000D   X   ID   2/3

                                                                           DATE TIME PERIOD         DMG02 1250        2000D   X   AN   1/35

                                                                           GENDER CODE              DMG03 1068        2000D   O   ID   1/1


                                                     LOOP ID - 2100D SUBSCRIBER NAME                                                                              1
                                                74   SUBSCRIBER NAME                                NM1               2100D                           R           1
                                                                           ENTITY IDENTIFIER CODE   NM101 98          2100D   M   ID   2/3
                                                                           ENTITY TYPE QUALIFIER    NM102 1065        2100D   M   ID   1/1
                                                                           NAME LAST OR
                                                                           ORGANIZATION NAME        NM103 1035        2100D   O   AN   1/35

                                                                           NAME FIRST               NM104 1036        2100D   O   AN   1/25

                                                                           NAME MIDDLE              NM105 1037        2100D   O   AN   1/25

                                                                           NAME SUFFIX              NM107 1039        2100D   O   AN   1/10
                                                                           IDENTIFICATION CODE
                                                                           QUALIFIER                NM108 66          2100D   X   ID   1/2
                                                                                       Page 3
                                                                                                                                                                   Policy Memorandum 2004 - 37
                                                                                                                                                                   Exhibit 2C



                                                                      276 - HEALTH CLAIM STATUS REQUEST
INTERNAL    TABLE /    FIELD    FIELD   FIELD                                                       REF.                                                           LOOP
RECORD ID   DATABASE   LENGTH   TYPE    NAME    PG. SEGMENT NAME           ELEMENT NAME             DES.   ELEMENT#   LOOP    ATTRIBUTES      NOTES                USAGE       REPEAT

                                                                           IDENTIFICATION CODE      NM109 67          2100D   X   AN   2/80
                                                     LOOP ID - 2200D CLAIM SUBMITTER TRACE NUMBER                                                                              >1
                                                     CLAIM SUBMITTER
                                                77   TRACE NUMBER                                   TRN               2200D                                        S           1
                                                                           TRACE TYPE CODE          TRN01 481         2200D   M   ID   1/2
                                                                           REFERENCE
                                                                           IDENTIFICATION           TRN02 127         2200D   M   AN   1/30 TRACE NUMBER
                                                     PAYER CLAIM
                                                     IDENTIFICATION
                                                78   NUMBER                                         REF               2200D

                                                                           REFERENCE
                                                                           IDENTIFICATION QUALIFIER REF01 128         2200D   M   ID   2/3  ICN, DCN, CCN #
                                                                           REFERENCE                                                        PAYER CLAIM CONTROL
                                                                           IDENTIFICATION           REF02 127         2200D   X   AN   1/30 NUMBER
                                                     INSTITUTIONAL BILL
                                                80   TYPE IDENTIFICATION                            REF               2200D

                                                                           REFERENCE
                                                                           IDENTIFICATION QUALIFIER REF01 128         2200D   M   ID   2/3
                                                                           REFERENCE                                                        BILL TYPE IDENTIFIER
                                                                           IDENTIFICATION           REF02 127         2200D   X   AN   1/30 (UB92)
                                                     MEDICAL RECORD
                                                82   IDENTIFICATION                                 REF               2200D

                                                                           REFERENCE
                                                                           IDENTIFICATION QUALIFIER REF01 128         2200D   M   ID   2/3
                                                                           REFERENCE                                                        MEDICAL RECORD
                                                                           IDENTIFICATION           REF02 127         2200D   X   AN   1/30 NUMBER
                                                     GROUP NUMBER                                   REF               2200D                                        S           1

                                                                           REFERENCE
                                                                           IDENTIFICATION QUALIFIER REF01 128         2200D   M   ID   2.3

                                                                           GROUP NUMBER             REF02 127         2200D   X   AN   1/30
                                                     CLAIM SUBMITTED
                                                84   CHARGES                                        AMT               2200D

                                                                           AMOUNT QUALIFIER CODE    AMT01 522         2200D   M   ID   1/3
                                                                                                                                            TOTAL CLAIM CHARGE
                                                                           MONETARY AMOUNT          AMT02 782         2200D   M   R    1/18 AMOUNT
                                                86   CLAIM SERVICE DATE                             DTP               2200D
                                                                           DATE/TIME QUALIFIER      DTP01 374         2200D   M   ID   3/3
                                                                           DATE TIME PERIOD
                                                                           FORMAT QUALIFIER         DTP02 1250        2200D   M   ID   2/3

                                                                           DATE TIME PERIOD         DTP03 1251        2200D   M   AN   1/35 DATE(S) OF SERVICE
                                                     LOOP ID - 2210D SERVICE LINE INFORMATION                                                                                  >1
                                                     SERVICE LINE
                                                88   INFORMATION                                    SVC               2210D                                        S           1
                                                                           Page 4
                                                                                                                                                                   Policy Memorandum 2004 - 37
                                                                                                                                                                   Exhibit 2C



                                                                    276 - HEALTH CLAIM STATUS REQUEST
INTERNAL    TABLE /    FIELD    FIELD   FIELD                                                       REF.                                                           LOOP
RECORD ID   DATABASE   LENGTH   TYPE    NAME    PG. SEGMENT NAME           ELEMENT NAME             DES.     ELEMENT#   LOOP    ATTRIBUTES      NOTES              USAGE       REPEAT
                                                                           COMPOSITE MEDICAL
                                                                           PROCEDURE IDENTIFIER     SVC01    C003       2210D   M
                                                                           PRODUCT/SERVICE ID       SVC01-
                                                                           QUALIFIER                1        235        2210D   M   ID   2/2
                                                                                                    SVC01-
                                                                           PRODUCT/SERVICE ID       2        234        2210D   M   AN   1/48
                                                                                                    SVC01-
                                                                           PROCEDURE MODIFIER       3        1139       2210D   O   AN   2/2
                                                                                                    SVC01-
                                                                           PROCEDURE MODIFIER       4        1339       2210D   O   AN   2/2
                                                                                                    SVC01-
                                                                           PROCEDURE MODIFIER       5        1339       2210D   O   AN   2/2
                                                                                                    SVC01-
                                                                           PROCEDURE MODIFIER       6        1339       2210D   O   AN   2/2
                                                                                                                                              LINE ITEM CHARGE
                                                                           MONETARY AMOUNT          SVC02 782           2210D   M   R    1/18 AMOUNT

                                                                           PRODUCT/SERVICE ID       SVC04 234           2210D   O   AN   1/48 REVENUE CODE
                                                                                                                                              SUBMITTED UNITS OF
                                                                           QUANTITY                 SVC07 380           2210D   O   R    1/15 SERVICE
                                                     SERVICE LINE ITEM
                                                91   IDENTIFICATION                                 REF                 2210D

                                                                           REFERENCE
                                                                           IDENTIFICATION QUALIFIER REF01 128           2210D   M   ID   2/3
                                                                           REFERENCE                                                          LINE ITEM CONTROL
                                                                           IDENTIFICATION           REF02 127           2210D   X   AN   1/30 NUMBER
                                                93   SERVICE LINE DATE                              DTP                 2210D
                                                                           DATE/TIME QUALIFIER      DTP01 374           2210D   M   ID   3/3    472
                                                                           DATE TIME PERIOD
                                                                           FORMAT QUALIFIER         DTP02 1250          2210D   M   ID   2/3

                                                                           DATE TIME PERIOD         DTP03 1251          2210D   M   AN   1/35 SERVICE LINE DATE
                                                     TABLE 2 - DETAIL, DEPENDENT LEVEL
                                                     LOOP ID - 2000E DEPENDENT LEVEL                                                                                           >1
                                                94   DEPENDENT LEVEL                                HL                  2000E                                      S           1

                                                                           HIERARCHICAL ID NUMBER HL01       628        2000E   M   AN   1/12

                                                                           HIERARCHICAL PARENT ID   HL02     734        2000E   O   AN   1/12
                                                                           HIERARCHICAL LEVEL
                                                                           CODE                     HL03     735        2000E   M   ID   1/2
                                                                                       Page 5
                                                                                                                                                     Policy Memorandum 2004 - 37
                                                                                                                                                     Exhibit 2C



                                                                     276 - HEALTH CLAIM STATUS REQUEST
INTERNAL    TABLE /    FIELD    FIELD   FIELD                                                      REF.                                              LOOP
RECORD ID   DATABASE   LENGTH   TYPE    NAME    PG. SEGMENT NAME          ELEMENT NAME             DES.   ELEMENT#   LOOP    ATTRIBUTES      NOTES   USAGE       REPEAT
                                                    DEPENDENT
                                                    DEMOGRAPHIC
                                                96 INFORMATION                                     DMG               2000E                           R           1
                                                                          DATE TIME PERIOD
                                                                          FORMAT QUALIFIER         DMG01 1251        2000E   X   ID   2/3

                                                                          DATE TIME PERIOD         DMG02 1250        2000E   X   AN   1/35

                                                                          GENDER CODE              DMG03 1068        2000E   O   ID   1/1
                                                     LOOP ID - 2100E DEPENDENT NAME                                                                              1
                                                98   DEPENDENT NAME                                NM1               2100E                           R           1
                                                                          ENTITY IDENTIFIER CODE   NM101 98          2100E   M   ID   2/3    QC
                                                                          ENTITY TYPE QUALIFIER    NM102 1065        2100E   M   ID   1/1    1
                                                                          NAME LAST OR
                                                                          ORGANIZATION NAME        NM103 1035        2100E   O   AN   1/35

                                                                          NAME FIRST               NM104 1036        2100E   O   AN   1/25

                                                                          NAME MIDDLE              NM105 1037        2100E   O   AN   1/25

                                                                          NAME PREFIX              NM106 1038        2100E   O   AN   1/10

                                                                          NAME SUFFIX              NM107 1039        2100E   O   AN   1/10
                                                                          Page 7
                                                                          IDENTIFICATION CODE
                                                                          QUALIFIER                NM108 66          2100E   X   ID   1/2

                                                                          IDENTIFICATION CODE      NM109 67          2100E   X   AN   2/80
                                                    LOOP ID - 2200E CLAIM SUBMITTER TRACE NUMBER                                                                 >1
                                                    CLAIM SUBMITTER
                                                101 TRACE NUMBER                                   TRN               2200E                           R           1
                                                                          TRACE TYPE CODE          TRN01 481         2200E   M   ID   1/2    1

                                                                          REFERENCE
                                                                          IDENTIFICATION           TRN02 127         2200E   M   AN   1/30
                                                    PAYER CLAIM
                                                    IDENTIFICATION
                                                103 NUMBER                                         REF               2200E                           S           1

                                                                          REFERENCE
                                                                          IDENTIFICATION QUALIFIER REF01 128         2200E   M   ID   2/3    1K
                                                                          REFERENCE
                                                                          IDENTIFICATION           REF02 127         2200E   X   AN   1/30
                                                                                      Page 6
                                                                                                                                                                  Policy Memorandum 2004 - 37
                                                                                                                                                                  Exhibit 2C



                                                                   276 - HEALTH CLAIM STATUS REQUEST
INTERNAL    TABLE /    FIELD    FIELD   FIELD                                                      REF.                                                           LOOP
RECORD ID   DATABASE   LENGTH   TYPE    NAME    PG. SEGMENT NAME          ELEMENT NAME             DES.     ELEMENT#   LOOP    ATTRIBUTES      NOTES              USAGE       REPEAT
                                                    INSTITUTIONAL BILL
                                                105 TYPE IDENTIFICATION                            REF                 2200E

                                                                          REFERENCE
                                                                          IDENTIFICATION QUALIFIER REF01 128           2200E   M   ID   2/3    BLT
                                                                          REFERENCE
                                                                          IDENTIFICATION           REF02 127           2200E   X   AN   1/30
                                                    MEDICAL RECORD
                                                107 IDENTIFICATION                                 REF                 2200E

                                                                          REFERENCE
                                                                          IDENTIFICATION QUALIFIER REF01 128           2200E   M   ID   2/3  EA
                                                                          REFERENCE                                                          MEDICAL RECORD
                                                                          IDENTIFICATION           REF02 127           2200E   X   AN   1/30 NUMBER
                                                    CLAIM SUBMITTED
                                                109 CHARGES                                        AMT                 2200E                                      S           1

                                                                          AMOUNT QUALIFIER CODE    AMT01 522           2200E   M   ID   1/3  T3
                                                                                                                                             TOTAL CLAIM CHARGE
                                                                          MONETARY AMOUNT          AMT02 782           2200E   M   R    1/18 AMOUNT
                                                111 CLAIM SERVICE DATE                             DTP                 2200E                                      S           1
                                                                          DATE/TIME QUALIFIER      DTP01 374           2200E   M   ID   3/3    232
                                                                          DATE TIME PERIOD
                                                                          FORMAT QUALIFIER         DTP02 1250          2200E   M   ID   2/3

                                                                          DATE TIME PERIOD         DTP03 1251          2200E   M   AN   1/35
                                                    LOOP ID - 2210E SERVICE LINE INFORMATION                                                                                  >1
                                                    SERVICE LINE
                                                113 INFORMATION                                    SVC                 2210E                                      S           1
                                                                            COMPOSITE MEDICAL
                                                                            PROCEDURE IDENTIFIER   SVC01    C003       2210E   M
                                                                            PRODUCT/SERVICE ID     SVC01-
                                                                            QUALIFIER              1        235        2210E   M   ID   2/2
                                                                                                   SVC01-
                                                                          PRODUCT/SERVICE ID       2        234        2210E   M   AN   1/48
                                                                                                   SVC01-
                                                                          PROCEDURE MODIFIER       3        1139       2210E   O   AN   2/2
                                                                                                   SVC01-
                                                                          PROCEDURE MODIFIER       4        1339       2210E   O   AN   2/2
                                                                                                   SVC01-
                                                                          PROCEDURE MODIFIER       5        1339       2210E   O   AN   2/2
                                                                                   Page 7
                                                                                                                                                                                                      Policy Memorandum 2004 - 37
                                                                                                                                                                                                      Exhibit 2C



                                                                                 276 - HEALTH CLAIM STATUS REQUEST
INTERNAL    TABLE /    FIELD        FIELD      FIELD                                                                   REF.                                                                           LOOP
RECORD ID   DATABASE   LENGTH       TYPE       NAME      PG. SEGMENT NAME                ELEMENT NAME                  DES.   ELEMENT#          LOOP          ATTRIBUTES       NOTES                  USAGE       REPEAT
                                                                                                                       SVC01-
                                                                                         PROCEDURE MODIFIER            6      1339              2210E         O    AN   2/2
                                                                                                                                                                             LINE ITEM CHARGE
                                                                                         MONETARY AMOUNT               SVC02 782                2210E         M    R    1/18 AMOUNT

                                                                                         PRODUCT/SERVICE ID            SVC04 234                2210E         O    AN   1/48 REVENUE CODE
                                                                                                                                                                             SUBMITTED UNITS OF
                                                                                         QUANTITY                      SVC07 380                2210E         O    R    1/15 SERVICE
                                                             SERVICE LINE ITEM
                                                         117 IDENTIFICATION                                       REF                           2210E
                                                                                         REFERENCE
                                                                                         IDENTIFICATION QUALIFIER REF01 128                     2210E         M    ID   2/3  FJ
                                                                                         REFERENCE                                                                           LINE ITEM CONTROL
                                                                                         IDENTIFICATION           REF02 127                     2210E         X    AN   1/30 NUMBER
                                                         118 SERVICE LINE DATE                                         DTP                      2210E
                                                                                         Page 7
                                                                                         DATE/TIME QUALIFIER           DTP01 374                2210E         M    ID   3/3
                                                                                         DATE TIME PERIOD
                                                                                         FORMAT QUALIFIER              DTP02 1250               2210E         M    ID   2/3

                                                                                         DATE TIME PERIOD              DTP03 1251               2210E         M    AN   1/35 SERVICE DATE
                                                             TRANSACTION SET
                                                         120 TRAILER                                                   SE                       TRAILER
                                                                                         NUMBER OF INCLUDED
                                                                                         SEGMENTS                      SE01    96               TRAILER       M    NO   1/10
                                                                                         TRANSACTION SET                                                                       MUST BE IDENTICAL TO
                                                                                         CONTROL NUMBER                SE02    329              TRAILER       M    AN   4/9    ST02
                                                                   Version 4010 with Addenda          Page 8                Revised April 10, 2003
                       The tools and templates provided in CalOHI Policy and Information Memoranda have generally been authored by HIPAA workgroups. Users should view the
                       information presented in the context of their own organizations and environments. Legal opinions and/or decision documentation may be needed when
                       interpreting and/or applying this information.
                                                                                                                                                                                                                                      Policy Memorandum 2004 - 37
                                                                                                                                                                                                                                      Exhibit 2D



                                                                                        277 - HEALTH CLAIM STATUS RESPONSE
INTERNAL    TABLE /    FIELD               FIELD                                                                                     REF.                                                                                             LOOP
RECORD ID   DATABASE   LENGTH   FIELD TYPE NAME    PG. SEGMENT NAME                          ELEMENT NAME                            DES.     ELEMENT#           LOOP               ATTRIBUTES         NOTES                          USAGE          REPEAT

                                                       TABLE 1 - HEADER                                                                                                                                FUNCTIONAL GROUP ID: HN
                                                   125 TRANSACTION SET HEADER                                                        ST                          HEADER                                                               R              1
                                                                                             TRANSACTION SET IDENTIFIER
                                                                                             CODE                                    ST01     143                HEADER             M    ID    3/3     277
                                                                                             TRANSACTION SET CONTROL                                                                                   MUST MATCH VALUE IN
                                                                                             NUMBER                                  ST02     329                HEADER             M    AN    4/9     SE02
                                                       BEGINNING OF HIERARCHICAL
                                                   126 TRANSACTION                                                                   BHT                         HEADER                                                               R              1
                                                                                             HIERARCHICAL STRUCTURE CODE             BHT01 1005                  HEADER             M    ID    4/4     0010

                                                                                             TRANSACTION SET PURPOSE CODE BHT02 353                              HEADER             M    ID    2/2
                                                                                                                                                                                                       NUMBER TO IDENTIFY THIS
                                                                                                                                                                                                       TRANSACTION WITHIN
                                                                                             REFERENCE IDENTIFICATION                BHT03 127                   HEADER             O    AN    1/30    ORIGINATOR'S SYSTEM
                                                                                             DATE                                    BHT04 373                   HEADER             O    DT    8/8
                                                                                             TRANSACTION TYPE CODE                   BHT06 640                   HEADER             O    ID    2/2     DG (RESPONSE)
                                                       TABLE 2 - DETAIL, INFORMATION SOURCE LEVEL
                                                       LOOP ID - 2000A INFORMATION SOURCE LEVEL                                                                                                                                                      >1
                                                   128 INFORMATION SOURCE LEVEL                                                      HL                          2000A                                                                R              1
                                                                                             HIERARCHICAL ID NUMBER                  HL01     628                2000A              M    AN    1/12
                                                                                             HIERARCHICAL LEVEL CODE                 HL03     735                2000A              O    AN    1/12    20
                                                                                             HIERARCHICAL CHILD CODE                 HL04     736                2000A              O    ID    1/1
                                                       LOOP ID - 2100A PAYER NAME                                                                                                                                                                    >1
                                                   130 PAYER NAME                                                                    NM1                         2100A                                                                R              1
                                                                                             ENTITY IDENTIFIER CODE                  NM101 98                    2100A              M    ID    2/3     PR
                                                                                             ENTITY TYPE QUALIFIER                   NM102 1065                  2100A              M    ID    1/1     2
                                                                                             NAME LAST OR ORGANIZATION
                                                                                             NAME                                    NM103 1035                  2100A              O    AN    1/35
                                                                                             IDENTIFICATION CODE QUALIFIER           NM108 66                    2100A              X    ID    1/2
                                                                                             IDENTIFICATION CODE                     NM109 67                    2100A              X    AN    2/80    PAYER IDENTIFIER
                                                   133 PAYER CONTACT INFORMATION                                                     PER                         2100A                                                                S              1


                                                       The tools and templates provided in CalOHI Policy and Information Memoranda have generally been authored by HIPAA workgroups. Users should view the information presented in the context of
                                                       their own organizations and environments. Legal opinions and/or decision documentation may be needed when interpreting and/or applying this information.
                                                                                              Page 1
                                                                                                                                                                                       Policy Memorandum 2004 - 37
                                                                                                                                                                                       Exhibit 2D



                                                                                  277 - HEALTH CLAIM STATUS RESPONSE
INTERNAL    TABLE /    FIELD               FIELD                                                                      REF.                                                             LOOP
RECORD ID   DATABASE   LENGTH   FIELD TYPE NAME    PG. SEGMENT NAME                   ELEMENT NAME                    DES.   ELEMENT#   LOOP    ATTRIBUTES      NOTES                  USAGE        REPEAT
                                                                                      CONTACT FUNCTION CODE           PER01 366         2100A   M   ID  2/2     IC
                                                                                      NAME                            PER02 93          2100A   O   AN   1/60   PAYER CONTACT NAME
                                                                                      COMMUNICATION NUMBER
                                                                                      QUALIFIER                       PER03 365         2100A   X   ID   2/2
                                                                                      COMMUNICATION NUMBER            PER04 364         2100A   X   AN   1/80
                                                                                      COMMUNICATION NUMBER
                                                                                      QUALIFIER                       PER05 365         2100A   X   ID   2/2
                                                                                      COMMUNICATION NUMBER            PER06 364         2100A   X   AN   1/80
                                                                                      COMMUNICATION NUMBER
                                                                                      QUALIFIER                       PER07 365         2100A   X   ID   2/2
                                                                                      COMMUNICATION NUMBER            PER08 364         2100A   X   AN   1/80
                                                       TABLE 2 - DETAIL, INFORMATION RECEIVER LEVEL
                                                       LOOP ID - 2000B INFORMATION RECEIVER LEVEL                                                                                                   >1
                                                   136 INFORMATION RECEIVER LEVEL                                     HL                2000B                                          R            1
                                                                                      HIERARCHICAL ID NUMBER          HL01   628        2000B   M   AN   1/12
                                                                                      HIERARCHICAL PARENT ID          HL02   734        2000B   O   AN   1/12
                                                                                      HIERARCHICAL LEVEL CODE         HL03   735        2000B   M   ID   1/2    21
                                                                                      HIERARCHICAL CHILD CODE         HL04   736        2000B   O   ID   1/1
                                                       LOOP ID - 2100B INFORMATION RECEIVER NAME                                                                                                    >1
                                                   138 INFORMATION RECEIVER NAME                                      NM1               2100B                                          R            1
                                                                                      ENTITY IDENTIFIER CODE          NM101 98          2100B   M   ID   2/3    41 = SUBMITTER
                                                                                      ENTITY TYPE QUALIFIER           NM102 1065        2100B   M   ID   1/1
                                                                                      NAME LAST OR ORGANIZATION
                                                                                      NAME                            NM103 1035        2100B   O   AN   1/35   INFORMATION RECEIVER
                                                                                      NAME FIRST                      NM104 1036        2100B   O   AN   1/25
                                                                                      NAME MIDDLE                     NM105 1037        2100B   O   AN   1/25
                                                                                      NAME PREFIX                     NM106 1038        2100B   M   ID   2/3
                                                                                      NAME SUFFIX                     NM107 1039        2100B   O   AN   1/10
                                                                                      IDENTIFICATION CODE QUALIFIER   NM108 66          2100B   X   ID   1/2
                                                                                      IDENTIFICATION CODE             NM109 67          2100B   X   AN   2/80
                                                       TABLE 2 - DETAIL, SERVICE PROVIDER LEVEL
                                                       LOOP ID - 2000C SERVICE PROVIDER LEVEL                                                                                                       >1
                                                   141 SERVICE PROVIDER LEVEL                                         HL                2000C                                          R            1
                                                                                      HIERARCHICAL ID NUMBER          HL01   628        2000C   M   AN   1/12
                                                                                                      Page 2
                                                                                                                                                                           Policy Memorandum 2004 - 37
                                                                                                                                                                           Exhibit 2D



                                                                                  277 - HEALTH CLAIM STATUS RESPONSE
INTERNAL    TABLE /    FIELD               FIELD                                                                         REF.                                              LOOP
RECORD ID   DATABASE   LENGTH   FIELD TYPE NAME    PG. SEGMENT NAME                      ELEMENT NAME                    DES.   ELEMENT#   LOOP    ATTRIBUTES      NOTES   USAGE        REPEAT
                                                                                         HIERARCHICAL PARENT ID          HL02   734        2000C   O   AN 1/12
                                                                                         HIERARCHICAL LEVEL CODE         HL03   735        2000C   M   ID   1/2    19
                                                                                         HIERARCHICAL CHILD CODE         HL04   736        2000C   O   ID   1/1
                                                       LOOP ID - 2100C PROVIDER NAME                                                                                                    >1
                                                   143 PROVIDER NAME                                                     NM1               2100C                           R            1
                                                                                         ENTITY IDENTIFIER CODE          NM101 98          2100C   M   ID   2/3    1P
                                                                                         ENTITY TYPE QUALIFIER           NM102 1065        2100C   M   ID   1/1
                                                                                         NAME LAST OR ORGANIZATION
                                                                                         NAME                            NM103 1035        2100C   O   AN   1/35
                                                                                         NAME FIRST                      NM104 1036        2100C   O   AN   1/25
                                                                                         NAME MIDDLE                     NM105 1037        2100C   O   AN   1/25
                                                                                         NAME PREFIX                     NM106 1038        2100C   M   ID   2/3
                                                                                         NAME SUFFIX                     NM107 1039        2100C   O   AN   1/10
                                                                                         IDENTIFICATION CODE QUALIFIER   NM108 66          2100C   X   ID   1/2
                                                                                         IDENTIFICATION CODE             NM109 67          2100C   X   AN   2/80
                                                       TABLE 2 - DETAIL, SUBSCRIBER LEVEL
                                                       LOOP ID - 2000D SUBSCRIBER LEVEL                                                                                                 >1
                                                   146 SUBSCRIBER LEVEL                                                  HL                2000D                           R            1
                                                                                         HIERARCHICAL ID NUMBER          HL01   628        2000D   M   AN   1/12
                                                                                         HIERARCHICAL PARENT ID          HL02   734        2000D   O   AN   1/12
                                                                                         HIERARCHICAL LEVEL CODE         HL03   735        2000D   M   ID   1/2    22
                                                                                         HIERARCHICAL CHILD CODE         HL04   736        2000D   O   ID   1/1
                                                       SUBSCRIBER DEMOGRAPHIC
                                                   148 INFORMATION                                                       DMG               2000D                           S            1
                                                                                         DATE TIME PERIOD FORMAT
                                                                                         QUALIFIER                       DMG01 1251        2000D   X   ID   2/3    D8

                                                                                         DATE TIME PERIOD                DMG02 1250        2000D   X   AN   1/35

                                                                                         GENDER CODE                     DMG03 1068        2000D   O   ID   1/1
                                                       LOOP ID - 2100D SUBSCRIBER NAME                                                                                                  1
                                                   150 SUBSCRIBER NAME                                                   NM1               2100D                           R            1
                                                                                         ENTITY IDENTIFIER CODE          NM101 98          2100D   M   ID   2/3
                                                                                         ENTITY TYPE QUALIFIER           NM102 1065        2100D   M   ID   1/1
                                                                                         NAME LAST OR ORGANIZATION
                                                                                         NAME                            NM103 1035        2100D   O   AN   1/35
                                                                                                       Page 3
                                                                                                                                                                                        Policy Memorandum 2004 - 37
                                                                                                                                                                                        Exhibit 2D



                                                                                  277 - HEALTH CLAIM STATUS RESPONSE
INTERNAL    TABLE /    FIELD               FIELD                                                                     REF.                                                               LOOP
RECORD ID   DATABASE   LENGTH   FIELD TYPE NAME    PG. SEGMENT NAME                  ELEMENT NAME                    DES.     ELEMENT#   LOOP    ATTRIBUTES      NOTES                  USAGE        REPEAT
                                                                                     NAME FIRST                      NM104 1036          2100D   O   AN 1/25
                                                                                     NAME MIDDLE                     NM105 1037          2100D   O   AN   1/25
                                                                                     NAME PREFIX                     NM106 1038          2100D   M   ID   2/3
                                                                                     NAME SUFFIX                     NM107 1039          2100D   O   AN   1/10
                                                                                     IDENTIFICATION CODE QUALIFIER   NM108 66            2100D   X   ID   1/2
                                                                                     IDENTIFICATION CODE             NM109 67            2100D   X   AN   2/80
                                                       LOOP ID - 2200D CLAIM SUBMITTER TRACE NUMBER                                                                                                  >1
                                                       CLAIM SUBMITTER TRACE
                                                   153 NUMBER                                                        TRN                 2200D                                          S            1
                                                                                     TRACE TYPE CODE                 TRN01 481           2200D   M   ID   1/2    2
                                                                                     REFERENCE IDENTIFICATION        TRN02 127           2200D   M   AN   1/30   TRACE NUMBER
                                                       CLAIM LEVEL STATUS
                                                   154 INFORMATION                                                   STC                 2200D                                          R            1
                                                                                     HEALTH CARE CLAIM STATUS        STC01    C043       2200D   M
                                                                                                                     STC01-
                                                                                     INDUSTRY CODE                   1        1271       2200D   M   AN   1/30
                                                                                                                     STC01-
                                                                                     INDUSTRY CODE                   2        1271       2200D   M   AN   1/30
                                                                                                                     STC01-
                                                                                     ENTITY IDENTIFIER CODE          3        98         2200D   O   ID   2/3
                                                                                                                                                                 EFFECTIVE DATE OF
                                                                                     DATE                            STC02 373           2200D   O   DT   8/8    STATUS INFORMATION
                                                                                     MONETARY AMOUNT                 STC04 782           2200D   O   R    1/18   TOTAL CLAIM CHARGE
                                                                                     MONETARY AMOUNT                 STC05 782           2200D   O   R    1/18   CLAIM PAYMENT AMOUNT
                                                                                     DATE                            STC06 373           2200D   O   DT   8/8    PAYMENT DATE
                                                                                     PAYMENT METHOD CODE             STC07 591           2200D   O   ID   3/3
                                                                                     DATE                            STC08 373           2200D   O   DT   8/8    CHECK/EFT DATE
                                                                                                                                                                 REQUIRED FOR PAID
                                                                                     CHECK NUMBER                    STC09 429           2200D   O   AN   1/16   CLAIMS
                                                                                                                                                                 USE THIS ELEMENT IF
                                                                                                                                                                 SECOND CLAIM STATUS
                                                                                     HEALTH CARE CLAIM STATUS        STC10    C043       2200D   O               NEEDED.
                                                                                                                     STC10-
                                                                                     INDUSTRY CODE                   1        1271       2200D   M   AN   1/30
                                                                                                                     STC10-
                                                                                     INDUSTRY CODE                   2        1271       2200D   M   AN   1/30
                                                                                                                     STC10-
                                                                                     ENTITY IDENTIFIER CODE          3        98         2200D   O   ID   2/3    USE THIS ELEMENT IF
                                                                                                                                                                 THIRD CLAIM STATUS
                                                                                     HEALTH CARE CLAIM STATUS        STC11 C043          2200D   O               NEEDED.
                                                                                                                     STC11-
                                                                                     INDUSTRY CODE                   1      1271         2200D   M   AN   1/30
                                                                                                   Page 4
                                                                                                                                                                                          Policy Memorandum 2004 - 37
                                                                                                                                                                                          Exhibit 2D



                                                                                    277 - HEALTH CLAIM STATUS RESPONSE
INTERNAL    TABLE /    FIELD               FIELD                                                                      REF.                                                                LOOP
RECORD ID   DATABASE   LENGTH   FIELD TYPE NAME    PG. SEGMENT NAME                    ELEMENT NAME                   DES.   ELEMENT#   LOOP    ATTRIBUTES      NOTES                     USAGE        REPEAT
                                                                                                                      STC11-
                                                                                       INDUSTRY CODE                  2      1271       2200D   M   AN   1/30
                                                                                                                      STC11-
                                                                                       ENTITY IDENTIFIER CODE         3      98         2200D   O   ID   2/3
                                                       PAYER CLAIM IDENTIFICATION
                                                   165 NUMBER                                                         REF               2200D                                             S            1
                                                                                       REFERENCE IDENTIFICATION
                                                                                       QUALIFIER                      REF01 128         2200D   M   ID   2/3    1K
                                                                                                                                                                PAYER CLAIM CONTROL
                                                                                       REFERENCE IDENTIFICATION       REF02 127         2200D   X   AN   1/30   NUMBER
                                                       INSTITUTIONAL BILL TYPE
                                                   167 IDENTIFICATION                                                 REF               2200D                                             S            1
                                                                                       REFERENCE IDENTIFICATION
                                                                                       QUALIFIER                      REF01 128         2200D   M   ID   2/3    BLT = BILLING TYPE
                                                                                       REFERENCE IDENTIFICATION       REF02 127         2200D   X   AN   1/30
                                                   169 MEDICAL RECORD IDENTIFICATION                                  REF               2200D                                             S            1
                                                                                       REFERENCE IDENTIFICATION
                                                                                       QUALIFIER                      REF01 128         2200D   M   ID   2/3    EA = MEDICAL RECORD ID#
                                                                                       REFERENCE IDENTIFICATION       REF02 127         2200D   X   AN   1/30
                                                   171 CLAIM SERVICE DATE                                             DTP               2200D                                             S            1
                                                                                       DATE/TIME QUALIFIER            DTP01 374         2200D   M   ID   3/3    232
                                                                                       DATE TIME PERIOD FORMAT
                                                                                       QUALIFIER                      DTP02 1250        2200D   M   ID   2/3
                                                                                       DATE TIME PERIOD               DTP03 1251        2200D   M   AN   1/35   CLAIM SERVICE PERIOD
                                                       LOOP ID - 2220D SERVICE LINE INFORMATION                                                                                                        >1
                                                   173 SERVICE LINE INFORMATION                                       SVC               2220D                                             S            1
                                                                                        COMPOSITE MEDICAL PROCEDURE
                                                                                        IDENTIFIER                    SVC01    C003     2220D   M
                                                                                                                      SVC01-
                                                                                       PRODUCT/SERVICE ID QUALIFIER   1        235      2220D   M   ID   2/2
                                                                                                                      SVC01-
                                                                                       PRODUCT/SERVICE ID             2        234      2220D   M   AN   1/48
                                                                                                                      SVC01-
                                                                                       PROCEDURE MODIFIER             3        1139     2220D   O   AN   2/2
                                                                                                                      SVC01-
                                                                                       PROCEDURE MODIFIER             4        1339     2220D   O   AN   2/2
                                                                                                                      SVC01-
                                                                                       PROCEDURE MODIFIER             5        1339     2220D   O   AN   2/2
                                                                                                                      SVC01-
                                                                                       PROCEDURE MODIFIER             6        1339     2220D   O   AN   2/2
                                                                                                                                                                LINE ITEM CHARGE
                                                                                       MONETARY AMOUNT                SVC02 782         2220D   M   R    1/18   AMOUNT
                                                                                                                                                                LINE ITEM PROVIDER
                                                                                       MONETARY AMOUNT                SVC03 782         2220D   O   R    1/18   PAYMENT AMOUNT
                                                                                                    Page 5
                                                                                                                                                                           Policy Memorandum 2004 - 37
                                                                                                                                                                           Exhibit 2D



                                                                             277 - HEALTH CLAIM STATUS RESPONSE
INTERNAL    TABLE /    FIELD               FIELD                                                         REF.                                                              LOOP
RECORD ID   DATABASE   LENGTH   FIELD TYPE NAME    PG. SEGMENT NAME           ELEMENT NAME               DES.     ELEMENT#   LOOP    ATTRIBUTES      NOTES                 USAGE        REPEAT
                                                                              PRODUCT/SERVICE ID         SVC04 234           2220D   O   AN 1/48     REVENUE CODE
                                                                                                                                                     SUBMITTED UNITS OF
                                                                              QUANTITY                   SVC07 380           2220D   O   R    1/15   SERVICE
                                                       SERVICE LINE STATUS
                                                   177 INFORMATION                                       STC                 2220D                                         S            1
                                                                              HEALTH CARE CLAIM STATUS   STC01    C043       2220D   M
                                                                                                         STC01-
                                                                              INDUSTRY CODE              1        1271       2220D   M   AN   1/30
                                                                                                         STC01-
                                                                              INDUSTRY CODE              2        1271       2220D   M   AN   1/30
                                                                                                         STC01-
                                                                              ENTITY IDENTIFIER CODE     3        98         2220D   O   ID   2/3
                                                                                                                                                     EFFECTIVE DATE OF
                                                                              DATE                       STC02 373           2220D   O   DT   8/8    STATUS INFORMATION
                                                                                                                                                     LINE ITEM CHARGE
                                                                              MONETARY AMOUNT            STC04 782           2220D   O   R    1/18   AMOUNT
                                                                                                                                                     LINE ITEM PROVIDER
                                                                              MONETARY AMOUNT            STC05 782           2220D   O   R    1/18   PAYMENT AMOUNT
                                                                                                                                                     USE THIS ELEMENT IF
                                                                                                                                                     SECOND CLAIM STATUS
                                                                              HEALTH CARE CLAIM STATUS   STC10    C043       2220D   O               NEEDED.
                                                                                                         STC10-
                                                                              INDUSTRY CODE              1        1271       2220D   M   AN   1/30
                                                                                                         STC10-
                                                                              INDUSTRY CODE              2        1271       2220D   M   AN   1/30
                                                                                                         STC10-
                                                                              ENTITY IDENTIFIER CODE     3        98         2220D   O   ID   2/3    USE THIS ELEMENT IF
                                                                                                                                                     THIRD CLAIM STATUS
                                                                              HEALTH CARE CLAIM STATUS   STC11    C043       2220D   O               NEEDED.
                                                                                                         STC11-
                                                                              INDUSTRY CODE              1        1271       2220D   M   AN   1/30
                                                                                                         STC11-
                                                                              INDUSTRY CODE              2        1271       2220D   M   AN   1/30
                                                                                                         STC11-
                                                                              ENTITY IDENTIFIER CODE     3        98         2220D   O   ID   2/3
                                                       SERVICE LINE ITEM
                                                   187 IDENTIFICATION                                    REF                 2220D                                         S            1
                                                                              REFERENCE IDENTIFICATION
                                                                              QUALIFIER                  REF01 128           2220D   M   ID   2/3    FJ
                                                                                                                                                     LINE ITEM CONTROL
                                                                              REFERENCE IDENTIFICATION   REF02 127           2220D   X   AN   1/30   NUMBER
                                                   188 SERVICE LINE DATE                                 DTP                 2220D                                         S            1
                                                                              DATE/TIME QUALIFIER        DTP01 374           2220D   M   ID   3/3    472
                                                                              DATE TIME PERIOD FORMAT
                                                                              QUALIFIER                  DTP02 1250          2220D   M   ID   2/3
                                                                              DATE TIME PERIOD           DTP03 1251          2220D   M   AN   1/35   SERVICE LINE DATE
                                                                                           Page 6
                                                                                                                                                                             Policy Memorandum 2004 - 37
                                                                                                                                                                             Exhibit 2D



                                                                                  277 - HEALTH CLAIM STATUS RESPONSE
INTERNAL    TABLE /    FIELD               FIELD                                                                         REF.                                                LOOP
RECORD ID   DATABASE   LENGTH   FIELD TYPE NAME    PG. SEGMENT NAME                      ELEMENT NAME                    DES.     ELEMENT#   LOOP    ATTRIBUTES      NOTES   USAGE        REPEAT
                                                       TABLE 2 - DETAIL, DEPENDENT LEVEL
                                                       LOOP ID - 2000E DEPENDENT LEVEL                                                                                                    >1
                                                   190 DEPENDENT LEVEL                                                   HL                  2000E                           S            1
                                                                                         HIERARCHICAL ID NUMBER          HL01     628        2000E   M   AN   1/12
                                                                                         HIERARCHICAL PARENT ID          HL02     734        2000E   O   AN   1/12
                                                                                         HIERARCHICAL LEVEL CODE         HL03     735        2000E   M   ID   1/2    23
                                                       DEPENDENT DEMOGRAPHIC
                                                   192 INFORMATION                                                       DMG                 2000E                           R            1
                                                                                         DATE TIME PERIOD FORMAT
                                                                                         QUALIFIER                       DMG01 1251          2000E   X   ID   2/3    D8

                                                                                         DATE TIME PERIOD                DMG02 1250          2000E   X   AN   1/35

                                                                                         GENDER CODE                     DMG03 1068          2000E   O   ID   1/1
                                                       LOOP ID - 2100E DEPENDENT NAME                                                                                                     1
                                                   194 DEPENDENT NAME                                                    NM1                 2100E                           R            1
                                                                                         ENTITY IDENTIFIER CODE          NM101 98            2100E   M   ID   2/3    QC
                                                                                         ENTITY TYPE QUALIFIER           NM102 1065          2100E   M   ID   1/1    1
                                                                                         NAME LAST OR ORGANIZATION
                                                                                         NAME                            NM103 1035          2100E   O   AN   1/35
                                                                                         NAME FIRST                      NM104 1036          2100E   O   AN   1/25
                                                                                         NAME MIDDLE                     NM105 1037          2100E   O   AN   1/25
                                                                                         NAME PREFIX                     NM106 1038          2100E   O   AN   1/10
                                                                                         NAME SUFFIX                     NM107 1039          2100E   O   AN   1/10
                                                                                         IDENTIFICATION CODE QUALIFIER   NM108 66            2100E   X   ID   1/2
                                                                                         IDENTIFICATION CODE             NM109 67            2100E   X   AN   2/80
                                                       LOOP ID - 2200E CLAIM SUBMITTER TRACE NUMBER                                                                                       >1
                                                       CLAIM SUBMITTER TRACE
                                                   197 NUMBER                                                            TRN                 2200E                           R            1
                                                                                         TRACE TYPE CODE                 TRN01 481           2200E   M   ID   1/2
                                                                                         REFERENCE IDENTIFICATION        TRN02 127           2200E   M   AN   1/30
                                                       CLAIM LEVEL STATUS
                                                   199 INFORMATION                                                       STC                 2200E                           R            1
                                                                                         HEALTH CARE CLAIM STATUS        STC01    C043       2200E   M
                                                                                                                         STC01-
                                                                                         INDUSTRY CODE                   1        1271       2200E   M   AN   1/30
                                                                                                                         STC01-
                                                                                         INDUSTRY CODE                   2        1271       2200E   M   AN   1/30
                                                                                                                         STC01-
                                                                                         ENTITY IDENTIFIER CODE          3        98         2200E   O   ID   2/3
                                                                                                       Page 7
                                                                                                                                                                                     Policy Memorandum 2004 - 37
                                                                                                                                                                                     Exhibit 2D



                                                                                    277 - HEALTH CLAIM STATUS RESPONSE
INTERNAL    TABLE /    FIELD               FIELD                                                                  REF.                                                               LOOP
RECORD ID   DATABASE   LENGTH   FIELD TYPE NAME    PG. SEGMENT NAME                    ELEMENT NAME               DES.     ELEMENT#   LOOP    ATTRIBUTES      NOTES                  USAGE        REPEAT
                                                                                                                                                              EFFECTIVE DATE OF
                                                                                       DATE                       STC02 373           2200E   O   DT   8/8    STATUS INFORMATION
                                                                                                                                                              TOTAL CLAIM CHARGE
                                                                                       MONETARY AMOUNT            STC04 782           2200E   O   R    1/18   AMOUNT
                                                                                       MONETARY AMOUNT            STC05 782           2200E   O   R    1/18   CLAIM PAYMENT AMOUNT
                                                                                       DATE                       STC06 373           2200E   O   DT   8/8    PAYMENT DATE
                                                                                       PAYMENT METHOD CODE        STC07 591           2200E   O   ID   3/3
                                                                                       DATE                       STC08 373           2200E   O   DT   8/8    CHECK/EFT DATE
                                                                                                                                                              REQUIRED FOR PAID
                                                                                       CHECK NUMBER               STC09 429           2200E   O   AN   1/16   CLAIMS
                                                                                                                                                              USE THIS ELEMENT IF
                                                                                                                                                              SECOND CLAIM STATUS
                                                                                       HEALTH CARE CLAIM STATUS   STC10    C043       2200E   O               NEEDED.
                                                                                                                  STC10-
                                                                                       INDUSTRY CODE              1        1271       2200E   M   AN   1/30
                                                                                                                  STC10-
                                                                                       INDUSTRY CODE              2        1271       2200E   M   AN   1/30
                                                                                                                  STC10-
                                                                                       ENTITY IDENTIFIER CODE     3        98         2200E   O   ID   2/3    USE THIS ELEMENT IF
                                                                                                                                                              THIRD CLAIM STATUS
                                                                                       HEALTH CARE CLAIM STATUS   STC11    C043       2200E   O               NEEDED.
                                                                                                                  STC11-
                                                                                       INDUSTRY CODE              1        1271       2200E   M   AN   1/30
                                                                                                                  STC11-
                                                                                       INDUSTRY CODE              2        1271       2200E   M   AN   1/30
                                                                                                                  STC11-
                                                                                       ENTITY IDENTIFIER CODE     3        98         2200E   O   ID   2/3
                                                       PAYER CLAIM IDENTIFICATION
                                                   210 NUMBER                                                     REF                 2200E                                          R            1
                                                                                       REFERENCE IDENTIFICATION
                                                                                       QUALIFIER                  REF01 128           2200E   M   ID   2/3    1K
                                                                                       REFERENCE IDENTIFICATION   REF02 127           2200E   X   AN   1/30
                                                       INSTITUTIONAL BILL TYPE
                                                   212 IDENTIFICATION                                             REF                 2200E                                          S            1
                                                                                       REFERENCE IDENTIFICATION
                                                                                       QUALIFIER                  REF01 128           2200E   M   ID   2/3    BLT
                                                                                       REFERENCE IDENTIFICATION   REF02 127           2200E   X   AN   1/30
                                                   214 MEDICAL RECORD IDENTIFICATION                              REF                 2200E                                          S            1
                                                                                       REFERENCE IDENTIFICATION
                                                                                       QUALIFIER                  REF01 128           2200E   M   ID   2/3    EA
                                                                                       REFERENCE IDENTIFICATION   REF02 127           2200E   X   AN   1/30
                                                   216 CLAIM SERVICE DATE                                         DTP                 2200E                                          S            1
                                                                                       DATE/TIME QUALIFIER        DTP01 374           2200E   M   ID   3/3    232
                                                                                                    Page 8
                                                                                                                                                                                           Policy Memorandum 2004 - 37
                                                                                                                                                                                           Exhibit 2D



                                                                                 277 - HEALTH CLAIM STATUS RESPONSE
INTERNAL    TABLE /    FIELD               FIELD                                                                      REF.                                                                 LOOP
RECORD ID   DATABASE   LENGTH   FIELD TYPE NAME    PG. SEGMENT NAME                  ELEMENT NAME                     DES.     ELEMENT#   LOOP    ATTRIBUTES      NOTES                    USAGE        REPEAT
                                                                                     DATE TIME PERIOD FORMAT
                                                                                     QUALIFIER                        DTP02 1250          2200E   M   ID   2/3    D8
                                                                                     DATE TIME PERIOD                 DTP03 1251          2200E   M   AN   1/35
                                                       LOOP ID - 2220E SERVICE LINE INFORMATION                                                                                                         >1
                                                   218 SERVICE LINE INFORMATION                                       SVC                 2220E                                            S            1
                                                                                        COMPOSITE MEDICAL PROCEDURE
                                                                                        IDENTIFIER                    SVC01 C003          2220E   M
                                                                                                                      SVC01-
                                                                                     PRODUCT/SERVICE ID QUALIFIER     1      235          2220E   M   ID   2/2
                                                                                                                                                                  PROCEDURE CODE; MAY BE
                                                                                                                      SVC01-                                      DIFFERENT FROM CODE
                                                                                     PRODUCT/SERVICE ID               2        234        2220E   M   AN   1/48   SUBMITTED
                                                                                                                      SVC01-
                                                                                     PROCEDURE MODIFIER               3        1139       2220E   O   AN   2/2
                                                                                                                      SVC01-
                                                                                     PROCEDURE MODIFIER               4        1339       2220E   O   AN   2/2
                                                                                                                      SVC01-
                                                                                     PROCEDURE MODIFIER               5        1339       2220E   O   AN   2/2
                                                                                                                      SVC01-
                                                                                     PROCEDURE MODIFIER               6        1339       2220E   O   AN   2/2
                                                                                                                                                                  LINE ITEM CHARGE
                                                                                     MONETARY AMOUNT                  SVC02 782           2220E   M   R    1/18   AMOUNT
                                                                                     PRODUCT/SERVICE ID               SVC04 234           2220E   O   AN   1/48   REVENUE CODE
                                                                                                                                                                  ORIGINAL UNITS OF
                                                                                     QUANTITY                         SVC07 380           2220E   O   R    1/15   SERVICE COUNT
                                                       SERVICE LINE STATUS
                                                   221 INFORMATION                                                    STC                 2220E                                            S            1
                                                                                     HEALTH CARE CLAIM STATUS         STC01    C043       2220E   M
                                                                                                                      STC01-
                                                                                     INDUSTRY CODE                    1        1271       2220E   M   AN   1/30
                                                                                                                      STC01-
                                                                                     INDUSTRY CODE                    2        1271       2220E   M   AN   1/30
                                                                                                                      STC01-
                                                                                     ENTITY IDENTIFIER CODE           3        98         2220E   O   ID   2/3
                                                                                                                                                                  EFFECTIVE DATE OF
                                                                                     DATE                             STC02 373           2220E   O   DT   8/8    STATUS INFORMATION
                                                                                                                                                                  LINE ITEM CHARGE
                                                                                     MONETARY AMOUNT                  STC04 782           2220E   O   R    1/18   AMOUNT
                                                                                                                                                                  LINE ITEM PROVIDER
                                                                                     MONETARY AMOUNT                  STC05 782           2220E   O   R    1/18   PAYMENT AMOUNT
                                                                                                                                                                  USE THIS ELEMENT IF
                                                                                                                                                                  SECOND CLAIM STATUS
                                                                                     HEALTH CARE CLAIM STATUS         STC10    C043       2220E   O               NEEDED.
                                                                                                                      STC10-
                                                                                     INDUSTRY CODE                    1        1271       2220E   M   AN   1/30
                                                                                                                      STC10-
                                                                                     INDUSTRY CODE                    2        1271       2220E   M   AN   1/30
                                                                                                                      STC10-
                                                                                     ENTITY IDENTIFIER CODE           3        98         2220E   O   ID   2/3    USE THIS ELEMENT IF
                                                                                                                                                                  THIRD CLAIM STATUS
                                                                                     HEALTH CARE CLAIM STATUS         STC11 C043          2220E   O               NEEDED.
                                                                                     Page 9
                                                                                                                                                                                                                                      Policy Memorandum 2004 - 37
                                                                                                                                                                                                                                      Exhibit 2D



                                                                                        277 - HEALTH CLAIM STATUS RESPONSE
INTERNAL    TABLE /    FIELD               FIELD                                                                                    REF.                                                                                              LOOP
RECORD ID   DATABASE   LENGTH   FIELD TYPE NAME    PG. SEGMENT NAME                          ELEMENT NAME                           DES.     ELEMENT#           LOOP               ATTRIBUTES         NOTES                           USAGE        REPEAT
                                                                                                                                    STC11-
                                                                                             INDUSTRY CODE                          1        1271               2220E              M    AN    1/30
                                                                                                                                    STC11-
                                                                                             INDUSTRY CODE                          2        1271               2220E              M    AN    1/30
                                                                                                                                    STC11-
                                                                                             ENTITY IDENTIFIER CODE                 3        98                 2220E              O    ID    2/3
                                                       SERVICE LINE ITEM
                                                   231 IDENTIFICATION                                                               REF                         2220E                                                                 S            1
                                                                                             REFERENCE IDENTIFICATION
                                                                                             QUALIFIER                              REF01 128                   2220E              M    ID    2/3     FJ
                                                                                                                                                                                                      LINE ITEM CONTROL
                                                                                             REFERENCE IDENTIFICATION               REF02 127                   2220E              X    AN    1/30    NUMBER
                                                   232 SERVICE LINE DATE                                                            DTP                         2220E                                                                 S            1
                                                                                             DATE/TIME QUALIFIER                    DTP01 374                   2220E              M    ID    3/3     472
                                                                                             DATE TIME PERIOD FORMAT
                                                                                             QUALIFIER                              DTP02 1250                  2220E              M    ID    2/3     RD8 (DATE RANGE)
                                                                                             DATE TIME PERIOD                       DTP03 1251                  2220E              M    AN    1/35    SERVICE DATE
                                                   234 TRANSACTION SET TRAILER                                                      SE                          TRAILER                                                               R            1
                                                                                             NUMBER OF INCLUDED SEGMENTS            SE01     96                 TRAILER            M    NO    1/10
                                                                                             TRANSACTION SET CONTROL                                                                                  MUST BE IDENTICAL TO
                                                                                             NUMBER                                 SE02     329                TRAILER            M    AN    4/9     ST02
                                                       4010 Version with Addenda                 Page 10               Revised April 10, 2003
                                                       The tools and templates provided in CalOHI Policy and Information Memoranda have generally been authored by HIPAA workgroups. Users should view the information presented in
                                                       the context of their own organizations and environments. Legal opinions and/or decision documentation may be needed when interpreting and/or applying this information.

				
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