Auto Accident Claim - Excel

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Auto Accident Claim - Excel Powered By Docstoc
					                                                                                                                       ATTRIBUTES
LOOP    SEGMENT                                  ELEMENT                                      USE   Min/M   Data       Codes/Values         Comments
                                                                                                     ax     Type

        Transaction Set Header             ST                                                 R                                             Required segment is used to indicate the start of a transaction set and to assign a
                                                                                                                                            control number
                                                 Transaction Set Identifier Code      ST01    R      3/3        ID           837            The only valid value within ST01 is 837.
                                                 Transaction Set Control Number       ST02    R      4/9        AN                          ST02=SE02
        Beginning of Hierarchical          BHT                                                R                                             Required segment
        Transaction
                                                 Hierarchical Structure Code          BHT01   R      4/4        ID          0019
                                                 Transaction Set Purpose Code         BHT02   R      2/2        ID      00 = original;      Send value 00 for an original file. Value of 18 is required for files that are being resent
                                                                                                                        18 = reissue        after the original file was rejected as noted in the 997 response.
                                                 Originator Application Transaction   BHT03   R     1/30        AN                          The inventory file number of the tape or transmission assigned by the submitter's
                                                 Identifier                                                                                 system.
                                                 Transaction Set Creation Date        BHT04   R      8/8        DT      CCYYMMDD            Identifies the date the submitter created the file
                                                 Transaction Set Creation Time        BHT05   R      4/8        TM      HHMMSSDD            Time of day that the file was created.
                                                 Claim or Encounter Identifier        BHT06   R      2/2        ID    CH = Chargeable;      Either value is acceptable. All claims/encounters are processed through the ODS
                                                                                                                       RP = Reporting       claims processing system regardless of being 'chargeable' or 'reporting'.
        Transmission Type Identification   REF                                                R

                                                 Reference Identification Qualifier   REF01   R      2/3        ID          87
                                                 Reference Identification             REF02   R     1/30        AN       004010X98          ODS is not dependent on this value to establish Test or Production Status


                                                 Description                          REF03         1/80        AN                          Not Used
                                                 Reference Identifier                 REF04          O                                      Not Used

1000A   Submitter name                     NM1                                                R                                             Required Segment and required loop. Repeat: 1
                                                 Entity Identifier Code               NM101   R      2/3        ID           41
                                                 Entity Type Qualifier                NM102   R      1/1        ID        1=person;
                                                                                                                     2= non-person entity
                                                 Submitter Last or Organization       NM103   R     1/35        AN
                                                 Name
                                                 Submitter First Name                 NM104    S    1/25        AN
                                                 Submitter Middle Name                NM105    S    1/25        AN
                                                 Submitter Name Prefix                NM106         1/10                                    Not Used
                                                 Submitter Name Suffix                NM107         1/10                                    Not Used
                                                 Identification Code Qualifier        NM108   R      1/2        ID           46
                                                 Submitter Identifier                 NM109   R     2/80        AN                          The 3-digit identifier currently used in electronic claims I.e. NDC, CPS, MSS. This
                                                                                                                                            code will be mutually defined by submitter and ODS Health Plans
        Submitter EDI Contact Information PER                                                                                               Repeat: 2




                                                                                                            1
                                                                                                          ATTRIBUTES
LOOP    SEGMENT                         ELEMENT                                  USE   Min/M   Data       Codes/Values      Comments
                                                                                        ax     Type

                                        Contact Function Code            PER01   R      2/2        ID          IC
                                        Submitter Contact Name           PER02   R     1/60        AN
                                        Communication Number Qualifier   PER03   R      2/2        ID   ED = EDI Access #   ODS must be able to view all of the possible communications types that are
                                                                                                           EM = Email       automatically sent.
                                                                                                         FX = Facsimile
                                                                                                         TE = Telephone

                                        Communication Number             PER04   R     1/80        AN                       If FX or TE, format = aaabbbcccc where aaa=Area Code, bbb=??? And cccc=????

                                        Communication Number Qualifier   PER05    S     2/2        ID   ED = EDI Access #   If using code 'EX' for telephone extension, must also use 'TE' for Telephone number.
                                                                                                           EM = Email
                                                                                                         FX = Facsimile
                                                                                                         TE = Telephone
                                                                                                         EX = Telephone
                                                                                                            Extension
                                        Communication Number             PER06    S    1/80        AN                       If FX or TE, format = aaabbbcccc where aaa=Area Code, bbb=??? And cccc=????

                                        Communication Number Qualifier   PER07    S     2/2        ID   ED = EDI Access #   If using code 'EX' for telephone extension, must also use 'TE' for Telephone number.
                                                                                                           EM = Email
                                                                                                         FX = Facsimile
                                                                                                         TE = Telephone
                                                                                                         EX = Telephone
                                                                                                            Extension
                                        Communication Number             PER08    S    1/80        AN

1000B   Receiver Name             NM1                                            R
                                        Entity Identifier Code           NM101   R      2/3        ID          40
                                        Entity Type Qualifier            NM102   R      1/1        ID           2
                                        Receiver Name                    NM103   R     1/35        AN                       ODS Health Plans
                                        Name First                       NM104         1/25                                 Not used
                                        Name Middle                      NM105         1/25                                 Not used
                                        Name Prefix                      NM106         1/10                                 Not used
                                        Name Suffix                      NM107         1/10                                 Not used
                                        Identification Code Qualifier    NM108   R      1/2        ID          46
                                        Receiver Primary Identifier      NM109   R     2/80        AN                       ODS Tax ID for Medical Plan

2000A   Billing/Pay-to Provider   HL                                             R                                          Repeat: >1
        Hierarchical Level
                                        Hierarchical ID Number           HL01    R     1/12        AN
                                        Hierarchical Parent ID No.       HL02          1/12                                 Not used.




                                                                                               2
                                                                                                                         ATTRIBUTES
LOOP   SEGMENT                                   ELEMENT                                      USE   Min/M   Data         Codes/Values          Comments
                                                                                                     ax     Type

                                                 Hierarchical Level Code              HL03    R      1/2        ID             20
                                                 Hierarchical Child Code              HL04    R      1/1        ID              1
       Billing/Pay-to Provider Specialty   PRV                                                                                                 Taxonomy Codes are required on all claims. Required at the claim level when the
       Information                                                                                                                             Rendering Provider is the same entity as the Billing and/or Pay-to Provider. In these
                                                                                                                                               cases, the Rendering Provider is being identified at this level for all subsequent
                                                                                                                                               claims/encounters in this HL and LoopID-2310B is not used.

                                                                                                                                               When the Billing or Pay-to Provider is a group and the individual Rendering Provider is
                                                                                                                                               in loop 2310B then the PRV segment is coded with the Rendering Provider in loop
                                                                                                                                               2310B.
                                                 Provider Code                        PRV01   R      1/3        ID     BI = Billing Provider
                                                                                                                      PT = Pay-to Provider
                                                 Reference Identification Qualifier   PRV02   R      2/3        ID               ZZ
                                                 Provider Taxonomy Code               PRV03   R     1/30        AN   See Provider Taxonomy
                                                                                                                            Code List
       Foreign Currency Information        CUR                                                 S                                               This segment is required only if financial amounts submitted in this ST-SE envelope
                                                                                                                                               are for services provided in a currency that is other than the US dollar.

                                                 Entity Identifer Code                CUR01   R      2/3        ID             85
                                                 Currency Code                        CUR02   R      3/3        ID      Code Source 5:
                                                                                                                      Countries, Currencies
                                                                                                                          and Funds
                                                 Exchange Rate                        CUR03         4/10                                       Not Used
                                                 Entity Identifer Code                CUR04          2/3                                       Not Used
                                                 Currency Code                        CUR05          3/3                                       Not Used
                                                 Exchange Rate                        CUR06          3/3                                       Not Used
                                                 Date/Time Qualifier                  CUR07          3/3                                       Not Used
                                                 Date                                 CUR08          8/8                                       Not Used
                                                 Time                                 CUR09          4/8                                       Not Used
                                                 Date/Time Qualifier                  CUR10          3/3                                       Not Used
                                                 Date                                 CUR11          8/8                                       Not Used
                                                 Time                                 CUR12          4/8                                       Not Used
                                                 Date/Time Qualifier                  CUR13          3/3                                       Not Used
                                                 Date                                 CUR14          8/8                                       Not Used
                                                 Time                                 CUR15          4/8                                       Not Used
                                                 Date/Time Qualifier                  CUR16          3/3                                       Not Used
                                                 Date                                 CUR17          8/8                                       Not Used
                                                 Time                                 CUR18          4/8                                       Not Used
                                                 Date/Time Qualifier                  CUR19          3/3                                       Not Used



                                                                                                            3
                                                                                                                          ATTRIBUTES
LOOP     SEGMENT                                 ELEMENT                                       USE   Min/M   Data         Codes/Values           Comments
                                                                                                      ax     Type

                                                 Date                                  CUR20          8/8                                        Not Used
                                                 Time                                  CUR21          4/8                                        Not Used

2010AA   Billing Provider Name             NM1
                                                 Entity Identifier Code                NM101   R      2/3        ID             85
                                                 Entity Type Qualifier                 NM102   R      1/1        ID          1=person;
                                                                                                                        2= non-person entity
                                                 Billing Provider Last Name or         NM103   R                                                 Must use Legal Name provided on 1099 Form.
                                                 Organization
                                                 Billing Provider First Name           NM104   S     1/25        AN                              Must use Legal Name provided on 1099 Form.
                                                 Billing Provider Middle Name          NM105   S     1/25        AN                              Must use Legal Name provided on 1099 Form.
                                                 Billing Provider Suffix               NM107   S     1/25        AN                              Must use Legal Name provided on 1099 Form.
                                                 Identification Code Qualifier         NM108   R      1/2        ID       24= Employer's         Identifier must match the number on file at ODS.
                                                                                                                       Identification Number;
                                                                                                                              34 = SSN
                                                 Billing Provider Primary Identifier   NM109   R     2/80        AN                              Identifier must match the number on file at ODS.
         Billing Provider Address          N3
                                                 Billing Provider Address Line 1       N301    R     1/55        AN
                                                 Billing Provider Address Line 2       N302    S     1/55        AN
         Billing Provider City/State/Zip   N4
                                                 Billing Provider City Name            N401    R     2/30        AN
                                                 Billing Provider State or Province    N402    R      2/2        ID      Code Source 22
                                                                                                                        States and Outlying
                                                                                                                         Areas of the U.S.
                                                 Billing Provider Postal Code          N403    R     3/15        ID      Code Source 51
                                                                                                                            Zip Code
                                                 Billing Provider Country Code         N404     S     2/3        ID      Code Source 5:
                                                                                                                       Countries, Currencies
                                                                                                                           and Funds
         Billing Provider Secondary        REF
         Identification
                                                 Identification Code Qualifier         REF01    S     2/3        ID     OB - State License       1D - Medicaid Provider Number is required on Oregon Health Plan Claims
                                                                                                                              Number
                                                                                                                      1A - Blue Cross Provider
                                                                                                                              Number
                                                                                                                          1B - Blue Shield
                                                                                                                          Provider Number
                                                                                                                       1C - Medicare Provider
                                                                                                                              Number




                                                                                                             4
                                                                                                                  ATTRIBUTES
LOOP   SEGMENT                           ELEMENT                                       USE   Min/M   Data         Codes/Values          Comments
                                                                                              ax     Type

                                                                                                              1D - Medicaid Provider
                                                                                                                     Number
                                                                                                                1G - Provider UPIN
                                                                                                                     Number
                                                                                                                1H - CHAMPUS ID
                                                                                                                     Number
                                                                                                              1J - Facility ID Number
                                                                                                              B3 - Preferred Provider
                                                                                                               Organization Number

                                                                                                                   BQ - Health
                                                                                                                  Maintenance
                                                                                                                Organization Code
                                                                                                                    Number
                                                                                                                 EI - Employer's ID
                                                                                                                       Number
                                                                                                                FH - Clinic Number
                                                                                                                   G2 - Provider
                                                                                                                Commercial Number
                                                                                                                 G5 - Provider Site
                                                                                                                       Number
                                                                                                               LU - Location Number
                                                                                                                      SY - SSN
                                                                                                              U3 - Unique Supplier ID
                                                                                                                       Number
                                                                                                                X5 - State Industrial
                                                                                                                 Accident Provider
                                                                                                                       Number
                                         Billing Provider Secondary Identifier REF02    S    1/30        AN

       Credit/Debit Card Billing   REF                                                  S
       Information
                                         Reference Identification Qualifier  REF01     R      2/3        ID                             Not applicable to ODS. These fields should not come to ODS with any values.
                                         Billing Provider Credit Card Number REF02     R     1/30        AN                             Not applicable to ODS. These fields should not come to ODS with any values.

       Billing Provider Contact                                                         S                                               This information is required by ODS if different than the contact information
       Information                                                                                                                      present in Loop 1000A.
                                         Contact Function Code               PER01     R      2/2        ID             IC
                                         Billing Provider Contact Name       PER02     R     1/60        AN



                                                                                                     5
                                                                                                                       ATTRIBUTES
LOOP     SEGMENT                                ELEMENT                                      USE   Min/M   Data        Codes/Values          Comments
                                                                                                    ax     Type

                                                Communication Number Qualifier       PER03   R      2/2        ID    ED = EDI Access #
                                                                                                                        EM = Email
                                                                                                                      FX = Facsimile
                                                                                                                      TE = Telephone
                                                Communication Number                 PER04   R     1/80        AN
                                                Communication Number Qualifier       PER05   S      2/2        ID    ED = EDI Access #
                                                                                                                        EM = Email
                                                                                                                      FX = Facsimile
                                                                                                                      TE = Telephone
                                                Communication Number                 PER06    S    1/80        AN
                                                Communication Number Qualifier       PER07    S     2/2        ID    ED = EDI Access #
                                                                                                                        EM = Email
                                                                                                                      FX = Facsimile
                                                                                                                      TE = Telephone
                                                Communication Number                 PER08    S    1/80        AN

2010AB   Pay-To Provider Name             NM1                                                 S                                              Required if the Pay-To Provider is a different entity than the Billing Provider

                                                Entity Identifier Code               NM101   R      2/3        ID           87
                                                Entity Type Qualifier                NM102   R      1/1        ID        1=person;
                                                                                                                    2= non-person entity
                                                Pay To Provider Last Name or         NM103   R                                               Match 1099 form
                                                Organization
                                                Pay To Provider First Name           NM104   S     1/25        AN                            Match 1099 form
                                                Pay to Provider Middle Name          NM105   S     1/25        AN                            Match 1099 form
                                                Pay to Provider Suffix               NM107   S     1/25        AN                            Match 1099 form
                                                Identification Code Qualifier        NM108   R      1/2        ID      24= Employer's        Either code listed is appropriate until the National Provider ID is approved, then only
                                                                                                                    Identification Number;   the value 'XX' will be allowed.
                                                                                                                           34 = SSN
                                                Pay to Provider Primary Identifier   NM109   R     2/80        AN                            Nine digit numeric identifier. No dashes.
         Pay-To Provider Address          N3
                                                Pay-To Provider Address Line 1       N301    R     1/55        AN                            Will pay to the address that is in the ODS claims paying system.
                                                Pay-To Provider Address Line 2       N302    S     1/55        AN
         Pay-To Provider City/State/Zip   N4
                                                Pay-To Provider City Name            N401    R     2/30        AN
                                                Pay-To Provider State or Province    N402    R      2/2        ID     Code Source 22
                                                                                                                     States and Outlying
                                                                                                                      Areas of the U.S.




                                                                                                           6
                                                                                                            ATTRIBUTES
LOOP   SEGMENT                           ELEMENT                                 USE   Min/M   Data         Codes/Values           Comments
                                                                                        ax     Type

                                         Pay-To Provider Postal Code     N403    R     3/15        ID      Code Source 51
                                                                                                              Zip Code
                                         Pay-To Provider Country Code    N404     S     2/3        ID      Code Source 5:
                                                                                                         Countries, Currencies
                                                                                                             and Funds
       Pay-To Provider Secondary   REF
       Identification
                                         Identification Code Qualifier   REF01    S     2/3        ID      OB - State License
                                                                                                                Number
                                                                                                        1A - Blue Cross Provider
                                                                                                                Number
                                                                                                            1B - Blue Shield
                                                                                                            Provider Number
                                                                                                         1C - Medicare Provider
                                                                                                                Number
                                                                                                         1D - Medicaid Provider
                                                                                                                Number
                                                                                                           1G - Provider UPIN
                                                                                                                Number
                                                                                                           1H - CHAMPUS ID
                                                                                                                Number
                                                                                                         1J - Facility ID Number
                                                                                                         B3 - Preferred Provider
                                                                                                          Organization Number

                                                                                                             BQ - Health
                                                                                                            Maintenance
                                                                                                          Organization Code
                                                                                                              Number
                                                                                                           EI - Employer's ID
                                                                                                                 Number
                                                                                                          FH - Clinic Number
                                                                                                             G2 - Provider
                                                                                                          Commercial Number
                                                                                                           G5 - Provider Site
                                                                                                                 Number
                                                                                                         LU - Location Number
                                                                                                                SY - SSN




                                                                                               7
                                                                                                                  ATTRIBUTES
LOOP    SEGMENT                               ELEMENT                                  USE   Min/M   Data         Codes/Values          Comments
                                                                                              ax     Type

                                                                                                              U3 - Unique Supplier ID
                                                                                                                     Number
                                                                                                               X5 - State Industrial
                                                                                                                Accident Provider
                                                                                                                     Number
                                              Pay-To Provider Secondary        REF02    S    1/30        AN
                                              Identifier

2000B   Subscriber Hierarchical Level   HL                                             R                                                If the insured and the patient are the same person, use this HL to identify the
                                                                                                                                        insured/patient, skip the subsequent (PATIENT) HL, and proceed directly to Loop ID-
                                                                                                                                        2300.
                                              Hierarchical ID Number           HL01    R     1/12        AN
                                              Hierarchical Parent ID Number    HL02    R     1/12        AN
                                              Hierarchical Level Code          HL03    R      1/2        ID             22
                                              Hierarchical Child Code          HL04    R      1/1        ID             0,1

        Subscriber Information          SBR
                                              Payer Responsibility Sequence    SBR01   R      1/1        ID        P = Primary
                                              Code                                                                S = Secondary
                                                                                                                   T = Tertiary
                                              Individual Relationship Code     SBR02   R      2/2        ID             18
                                              Insured Group or Policy Number   SBR03   S     1/30        AN                             Required: 6 digit number as noted on ID card
                                              Insured Group Name               SBR04   S     1/60        AN                             Required: ODS cards include a Group or Plan Name.
                                              Insurance Type Code              SBR05   S      1/3        ID                             Not required by ODS. Required on claims being submitted to Medicare
                                              Coordination of Benefits         SBR06          1/1                                       Not Used
                                              Yes/No Condition Code            SBR07          1/1                                       Not Used
                                              Employment Status Code           SBR08          2/2                                       Not Used




                                                                                                     8
                                                                                                           ATTRIBUTES
LOOP   SEGMENT                     ELEMENT                                     USE   Min/M   Data          Codes/Values           Comments
                                                                                      ax     Type

                                   Claim Filing Indicator Code         SBR09   R      1/2        ID   09 = Self-pay; 10 =         Required prior to mandated use of PlanID. Not used after PlanID is mandated. Utilize
                                                                                                      Central Certification, 11   the following: MB for Medicare Part B claims; MC for Medicaid--Oregon Health Plan
                                                                                                      = Other Non-Federal         Claims; CI for commerical insuance.
                                                                                                      Programs, 12 = PPO; 13
                                                                                                      = POS; 14 = EPO; 15 =
                                                                                                      Indemnity; 16 = Health
                                                                                                      Maintenance
                                                                                                      Organization Medicare
                                                                                                      Risk, AM = Automobile
                                                                                                      Medical, BL = Blue
                                                                                                      Cross/Blue Shield, CH
                                                                                                      = Champus, CI =
                                                                                                      Commerical Insurance,
                                                                                                      DS = Disability, HM =
                                                                                                      Health Maintenance
                                                                                                      Organziation, LI =
                                                                                                      Liability, LM = Liability
                                                                                                      Medical, MB = Medicare
                                                                                                      Part B, MC = Medicaid,
                                                                                                      OF = Other Federal
                                                                                                      Program, TV = Title V,
                                                                                                      VA = Veteran Admin
                                                                                                      Plan, WC = Workers'
                                                                                                      Compensation, ZZ =
                                                                                                      Mutually defined

       Patient Information   PAT                                                                                                  Required if the subscriber is the same person as the patient and this PAT segment
                                                                                                                                  information is necessary to file the claim/encounter
                                   Individual Relationship Code        PAT01          2/2                                         Not Used
                                   Patient Location Code               PAT02          1/1                                         Not Used
                                   Employment Status Code              PAT03          2/2                                         Not Used
                                   Student Status Code                 PAT04          1/1                                         Not Used
                                   Date/Time Period Format Qualifier   PAT05    S     2/3        ID           D8
                                   Insured Individual Date of Death    PAT06    S    1/35        AN        CCYYMMDD               Required if patient is known to be deceased and the date of death is available to the
                                                                                                                                  provider billing system
                                   Unit or Basis for Measurement Code PAT07     S     2/2        ID             GR                Required when PAT 08 is used.

                                   Patient Weight                      PAT08    S    1/10        R         Patient Weight         Required for 1) C/E involving EPO (epoetin) for patients on dialysis 2) DMERC
                                                                                                                                  certificate of Medical Necessity (DMERC CMN 02.03 and 10.02. 3) Required when
                                                                                                                                  the patient's age is less than 29 days.
                                   Pregnancy Indicator                 PAT09    S     1/1        ID              Y



                                                                                             9
                                                                                                                 ATTRIBUTES
LOOP     SEGMENT                           ELEMENT                                    USE   Min/M    Data        Codes/Values         Comments
                                                                                             ax      Type

2010BA   Subscriber Name             NM1
                                           Entity Identifier Code             NM101   R      2/3         ID            IL
                                           Entity Type Qualifier              NM102   R      1/1         ID             1
                                           Subscriber Last Name               NM103   R                                               As listed on the Subscriber ID card
                                           Subscriber First Name              NM104   S     1/25         AN                           As listed on the Subscriber ID card
                                           Subscriber Middle Name             NM105   S     1/25         AN                           As listed on the Subscriber ID card
                                           Subscriber Prefix                  NM106         1/10                                      Not Used
                                           Subscriber Suffix                  NM107   S     1/10         AN                           As listed on the Subscriber ID card
                                           Identification Code Qualifier      NM108   R      1/2         ID            MI
                                           Subscriber Primary Identifier      NM109   R     2/80         AN                           Required on all claims. May be the following: Subscriber Identification as shown on
                                                                                                                                      ID card for commercial insurance. If type of insurance is MC, then the subscriber
                                                                                                                                      state assigned ID should be place in this field. If the subscriber is an inmate at the
                                                                                                                                      Oregon Department of Correction (ODOC), this should be the ODOC ID number. If
                                                                                                                                      the member is Medicare Primary, this number should be the HIC number assigned by
                                                                                                                                      Medicare.
         Subscriber Address          N3
                                           Subscriber Address Line 1          N301    R     1/55         AN
                                           Subscriber Address Line 2          N302    S     1/55         AN
         Subscriber City/State/Zip   N4
                                           Subscriber City Name               N401    R     2/30         AN
                                           Subscriber State or Province       N402    R      2/2         ID     Code Source 22
                                                                                                               States and Outlying
                                                                                                                Areas of the U.S.
                                           Subscriber Postal Code             N403    R     3/15         ID     Code Source 51
                                                                                                                   Zip Code
                                           Subscriber Country Code            N404     S     2/3         ID     Code Source 5:
                                                                                                              Countries, Currencies
                                                                                                                  and Funds
         Subscriber Demographic      DMG                                                                                              Required if the patient is the same person as the subscriber.
         Information
                                           Date/Time Period Format Qulifier   DMG01   R      2/3         ID           D8
                                           Subscriber Birth Date              DMG02   R     1/35         AN       CCYYMMDD
                                           Subscriber Gender Code             DMG03   R      1/1         ID         F, M, U
                                           Marital Status Code                DMG04          1/1                                      Not Used
                                           Race or Ethnicity Code             DMG05          1/1                                      Not Used
                                           Citizenship Status Code            DMG06          1/2                                      Not Used
                                           Country Code                       DMG07          2/3                                      Not Used
                                           Basis of Verification Code         DMG08          1/2                                      Not Used
                                           Quantity                           DMG09         1/15                                      Not Used



                                                                                                    10
                                                                                                                      ATTRIBUTES
LOOP     SEGMENT                             ELEMENT                                      USE   Min/M    Data         Codes/Values           Comments
                                                                                                 ax      Type

         Subscriber Secondary          REF                                                 S                                                 Primary ID should be in NM109 of this loop.
         Identification
                                             Identification Code Qualifier        REF01   R      2/3         ID      1W = Member ID #        If Insurance Code is MB; then 1W must be provided.
                                                                                                                  23 = Client Number used
                                                                                                                  by Indian Health Service
                                                                                                                   IG = Insurance Policy #
                                                                                                                          SY = SSN


                                             Subscriber Supplemental Identifier   REF02   R     1/30         AN

                                             Description                          REF03         1/30                                         Not Used
                                             Reference Identifier                 REF04         1/80                                         Not Used
         Property and Casualty Claim   REF                                                 S                                                 Segment Not Used for HIPAA Requirements. Modified by 10/01 Addenda.
         Number
                                             Identification Code Qualifier        REF01   R      2/3         ID             Y4               Not Used
                                             Property/Casualty Claim Number       REF02   R     1/30         AN                              Not Used

2010BB   Payer Name                    NM1                                                R
                                             Entity Identifier Code               NM101   R      2/3         ID             PR
                                             Entity Type Qualifier                NM102   R      1/1         ID              2
                                             Payer Organization Name              NM103   R     1/35         AN                              ODS Health Plan or the name of the self-funded plan for which administrative services
                                                                                                                                             are being performed
                                             Payer First Name                     NM104         1/25                                         Not Used
                                             Payer Middle Name                    NM105         1/25                                         Not Used
                                             Name Prefix                          NM106         1/10                                         Not Used
                                             Name Suffix                          NM107         1/10                                         Not Used
                                             Identification Code Qualifier        NM108   R      1/2         ID             PI               Value of 'XV' will be required when National PlanID is mandated for use.
                                             Payer Primary Identifier             NM109   R     2/80         AN                              If payor is ODS, use xxxxxxxxx. If self funded plan, use that plan ID
         Payer Address                 N3                                                 S                                                  Required when submitter intends for the claim to be printed on paper at the next EDI
                                                                                                                                             location
                                             Payer Address Line 1                 N301    R     1/55         AN
                                             Payer Address Line 2                 N302    S     1/55         AN
         Payer City/State/Zip          N4
                                             Payer City Name                      N401    R     2/30         AN
                                             Payer State or Province              N402    R      2/2         ID      Code Source 22
                                                                                                                    States and Outlying
                                                                                                                     Areas of the U.S.
                                             Payer Postal Code                    N403    R     3/15         ID      Code Source 51
                                                                                                                         Zip Code




                                                                                                        11
                                                                                                                          ATTRIBUTES
LOOP     SEGMENT                                  ELEMENT                                    USE   Min/M    Data          Codes/Values           Comments
                                                                                                    ax      Type

                                                  Payer Country Code                 N404     S     2/3         ID      Code Source 5:
                                                                                                                      Countries, Currencies
                                                                                                                          and Funds
         Payer Secondary Identification     REF                                               S

                                                  Identification Code Qualifier      REF01   R      2/3         ID   2U = Payer Identification   ODS does not require a secondary payor identifier
                                                                                                                            Number
                                                                                                                       FY = Claim Office #
                                                                                                                         NF= NAIC Code
                                                                                                                        TJ = Federal TIN
                                                  Payer Additional Identifier        REF02   R     1/30         AN

2010BC   Responsible Party Name             NM1                                               S                                                  The responsible party is someone who is not the subscriber/patient but who has
                                                                                                                                                 financial responsibility for the bill.
                                                  Entity Identifier Code             NM101   R      2/3         ID             QD
                                                  Entity Type Qualifier              NM102   R      1/1         ID          1=person;
                                                                                                                       2= non-person entity
                                                  Responsible Party Name             NM103   R     1/35         AN
                                                  Responsible Party First Name       NM104   S     1/25         AN
                                                  Responsible Party Middle Name      NM105   S     1/25         AN
                                                  Responsible Party Prefix           NM106         1/10                                          Not Used
                                                  Responsible Party Suffix           NM107   S     1/10         AN
                                                  Identification Code Qualifier      NM108   R      1/2         ID                               Not Used
                                                  Identification Code Qualifier      NM109   R     2/80         AN                               Not Used
                                                  Entity Relationship Code           NM110                                                       Not Used
                                                  Entity Identifier Code             NM111                                                       Not Used
         Responsible Party Address          N3                                               R
                                                  Responsible Party Address Line 1   N301    R     1/55         AN

                                                  Responsible Party Address Line 2   N302     S    1/55         AN

         Responsible Party City/State/Zip   N4                                               R

                                                  Responsible Party City Name         N401   R     2/30         AN
                                                  Responsible Party State or Province N402   R      2/2         ID      Code Source 22
                                                                                                                       States and Outlying
                                                                                                                        Areas of the U.S.
                                                  Responsible Party Postal Code      N403    R     3/15         ID       Code Source 51
                                                                                                                            Zip Code




                                                                                                           12
                                                                                                                       ATTRIBUTES
LOOP     SEGMENT                               ELEMENT                                      USE   Min/M    Data        Codes/Values         Comments
                                                                                                   ax      Type

                                               Responsible Party Country Code       N404     S     2/3         ID     Code Source 5:
                                                                                                                    Countries, Currencies
                                                                                                                        and Funds

2010BD   Credit/Debit Card Holder Name   NM1                                                 S                                              The information in this segment is never to be sent to the payer

                                               Entity Identifier Code               NM101   R      2/3         ID           AO              Not used by ODS
                                               Entity Type Qualifier                NM102   R      1/1         ID        1=person;          Not used by ODS
                                                                                                                    2= non-person entity
                                               Credit/Debit Card Holder Last Name NM103     R                                               Not used by ODS
                                               or Organization
                                               Credit/Debit Card Holder First Name NM104     S    1/25         AN                           Not used by ODS

                                               Credit/Debit Card Holder Middle      NM105    S    1/25         AN                           Not used by ODS
                                               Name
                                               Credit/Debit Card Holder Suffix      NM106         1/10                                      Not Used
                                               Credit/Debit Card Holder Suffix      NM107   S     1/10         AN                           Not used by ODS
                                               Identification Code Qualifier        NM108   R      1/2         ID            MI             Not used by ODS
                                               Credit/Debit Card Number             NM109   R     2/80         AN                           Not used by ODS
         Credit/Debit Card Information   REF                                                S
                                               Reference Identification Qualifier   REF01   R      2/3         ID         AB, BB            Not used by ODS
                                               Credit/Debit Card authorization      REF02   R     1/30         AN                           Not used by ODS
                                               Number

2000C    Patient Hierarchical Level      HL                                                 S                                               This HL is required when the patient is a different person than the subscriber.
                                               Hierarchical ID Number               HL01    R     1/12         AN
                                               Hierarchical Parent ID Number        HL02    R     1/12         AN
                                               Hierarchical Level Code              HL03    R      1/2         ID            23
                                               Hierarchical Child Code              HL04    R      1/1         ID             0
         Patient Information             PAT                                                R
                                               Patient Relationship to Insured      PAT01   R      2/2         ID        01 - Spouse
                                                                                                                     04 - Grandfather or
                                                                                                                         Grandmother
                                                                                                                      05 - Grandson or
                                                                                                                       Granddaughter
                                                                                                                    07 - Nephew or Niece
                                                                                                                     09 - Adopted Child
                                                                                                                      10 - Foster child
                                                                                                                          15 - Ward




                                                                                                          13
                                                                                                      ATTRIBUTES
LOOP     SEGMENT              ELEMENT                                     USE   Min/M    Data         Codes/Values           Comments
                                                                                 ax      Type

                                                                                                       17 - Stepson or
                                                                                                        Stepdaughter
                                                                                                          19 - Child
                                                                                                       20 - Employee
                                                                                                        21 - Unkown
                                                                                                     22 - Handicapped
                                                                                                         Dependent
                                                                                                       23 - Sponsored
                                                                                                         Dependent
                                                                                                    24 - Dependent of a
                                                                                                     Minor Dependent
                                                                                                   29 - Significant Other
                                                                                                         32 - Mother
                                                                                                         33 - Father
                                                                                                      34 - Other Adult
                                                                                                  36 - Emancipated Minor

                                                                                                     39 - Organ Donor
                                                                                                    40 - Cadaver Donor
                                                                                                    41 - Injured Plaintiff
                                                                                                     43 - Child Where
                                                                                                      Insured Has No
                                                                                                  Financial Repsonsibility
                                                                                                      53 - Life Partner
                                                                                                  G8 - Other Relationship

                              Date/Time Period Format Qualifier   PAT05    S     2/3         ID           D8
                              Patient Date of Death               PAT06    S    1/35         AN        CCYYMMDD              Required if patient is known to be deceased and the date of death is available to the
                                                                                                                             provider billing system
                              Unit or Basis for Measurement Code PAT07     S     2/2         ID             GR               Required when PAT 08 is used.

                              Patient Weight                      PAT08    S    1/10         R        Patient Weight         Required for 1) C/E involving EPO (epoetin) for patients on dialysis 2) DMERC
                                                                                                                             certificate of Medical Necessity (DMERC CMN 02.03 and 10.02. 3) Required when
                                                                                                                             the patient's age is less than 29 days.
                              Pregnancy Indicator                 PAT09    S     1/1         ID              N

2010CA   Patient Name   NM1
                              Entity Identifier Code              NM101   R      2/3         ID             QC               QC = Patient
                              Entity Type Qualifier               NM102   R      1/1         ID              1




                                                                                        14
                                                                                                                        ATTRIBUTES
LOOP   SEGMENT                                  ELEMENT                                     USE   Min/M    Data         Codes/Values           Comments
                                                                                                   ax      Type

                                                Patient Last Name or Organization   NM103   R     1/35         AN                              Must match ID Card

                                                Patient First Name                  NM104   R     1/25         AN                              Must match ID Card
                                                Patient Middle Name                 NM105   S     1/10         AN                              Must match ID Card
                                                Patient Prefix                      NM106         1/10                                         Not Used
                                                Patient Suffix                      NM107   S     1/25         AN                              Must match ID Card
                                                Identification Code Qualifier       NM108   R      1/2         ID             MI
                                                Patient Primary Identifier          NM109   S     2/80         AN                              Patient primary identifier is the same as the subscriber identifer as noted on the ID
                                                                                                                                               card.
       Patient Address                    N3
                                                Patient Address Line 1              N301    R     1/55         AN
                                                Patient Address Line 2              N302    S     1/55         AN
       Patient City/State/Zip             N4
                                                Patient City Name                   N401    R     2/30         AN
                                                Patient State or Province           N402    R      2/2         ID      Code Source 22
                                                                                                                      States and Outlying
                                                                                                                       Areas of the U.S.
                                                Patient Postal Code                 N403    R     3/15         ID      Code Source 51
                                                                                                                          Zip Code
                                                Patient Country Code                N404     S     2/3         ID      Code Source 5:
                                                                                                                     Countries, Currencies
                                                                                                                         and Funds
       Patient Demographic Information    DMG

                                                Date/Time Period Format Qulifier    DMG01   R      2/3         ID            D8
                                                Patient Birth Date                  DMG02   R     1/35         AN        CCYYMMDD
                                                Patient Gender Code                 DMG03   R      1/1         ID          F, M, U
       Patient Secondary Identification   REF                                               S

                                                Identification Code Qualifier       REF01   R      2/3         ID      1W = Member ID #        SY' is only valid secondary identifier used by ODS
                                                                                                                    23 = Client Number used
                                                                                                                    by Indian Health Service
                                                                                                                     IG = Insurance Policy #
                                                                                                                            SY = SSN


                                                Patient Secondary Identifier        REF02   R     1/30         AN
       Property and Casualty Claim        REF                                               S                                                  This segment not required for HIPAA.
       Number




                                                                                                          15
                                                                                                 ATTRIBUTES
LOOP    SEGMENT             ELEMENT                                      USE   Min/M    Data     Codes/Values   Comments
                                                                                ax      Type

                            Identification Code Qualifier        REF01   R      2/3         ID       Y4
                            Property/Casualty Claim Number       REF02   R     1/30         AN

   2300 Claim Information                                                R
                            Patient Account Number               CLM01   R     1/38         AN                  Assigned by billing entity
                            Total Claim Charge Amount            CLM02   R     1/18         R
                            Claim Filing Indicator Code          CLM03          1/2                             Not Used
                            Non-Institutional Claims Type Code   CLM04          1/2                             Not Used

                            Place of Service Code                CLM05   R                                      CLM05 applies to all service lines unless it is overwritten at the line level.




                                                                                       16
                                                                             ATTRIBUTES
LOOP   SEGMENT   ELEMENT                        USE   Min/M    Data          Codes/Values            Comments
                                                       ax      Type

                 Facility Type Code   CLM05-1   R      1/2         ID   11 = Office, 12 = Home,
                                                                         21 = Inpatient Hospital,
                                                                        22 = Outpatient Hospital,
                                                                        23 = Emergency Room -
                                                                              Hospital, 24 =
                                                                          Ambulatory Surgical
                                                                          Center, 25 = Birthing
                                                                          Center, 26 = Military
                                                                        Treatment Facility, 31 =
                                                                         Skilled Nursing Facility,
                                                                        32 = Nursing Facility, 33
                                                                            = Custodial Care
                                                                         Facility, 34 = Hospice,
                                                                        41 = Ambulance - Land,
                                                                        42 = Ambulance - Air or
                                                                          Water, 51 = Inpateint
                                                                        Psychiatric Facility, 52 =
                                                                           Psychiatric Facility
                                                                         Partial Hospitalization,
                                                                        53 = Community Mental
                                                                          Health Center, 54 =
                                                                           Intermediate Care
                                                                             Facility/Mentally
                                                                              Retarded, 55 =
                                                                         Residential Substance
                                                                            Abuse Treatment
                                                                        Facility, 56 = Psychiatric
                                                                         Residential Treatment
                                                                         Center, 50 = Federally
                                                                        Qualified Health Center,
                                                                        60 = Mass Immunization
                                                                               Center, 61 =
                                                                             Comprehensive
                                                                        Inpatient Rehab Facility,
                                                                          62 = Comprehensive
                                                                           Outpatient Rehab
                                                                                  Facility




                                                              17
                                                                                          ATTRIBUTES
LOOP   SEGMENT   ELEMENT                                      USE   Min/M    Data         Codes/Values            Comments
                                                                     ax      Type

                                                                                       65 = End Stage Renal
                                                                                         Disease Treatment
                                                                                       Facility, 71 = State or
                                                                                         Local Public Health
                                                                                      Clinic, 72 = Rural Health
                                                                                      Clinic, 81 = Independent
                                                                                      Lab, 99 = Other Unlisted
                                                                                                Facility

                 Facility Code Qualifier            CLM05-2          1/2                                          Not Used

                 Claim Submission Reason Code       CLM05-3   R      1/1         ID     1 = Original, 6 =
                                                                                         Corrected, 7 =
                                                                                      Replacement, 8 = Void
                 Provider Signature on File         CLM06     R      1/1         ID          Yes or No
                 Medicare Assignment Code           CLM07     R      1/1         ID       A=Assigned; B=
                                                                                       Assignment Accepted
                                                                                      on Clinical Lab Services
                                                                                       Only; C=Not assigned;
                                                                                       P=Pateint Refuses to
                                                                                          Assign Benefits


                 Assignment of Benefits Indicator   CLM08     R      1/1         ID          Yes or No




                                                                            18
                                                                                    ATTRIBUTES
LOOP   SEGMENT   ELEMENT                               USE   Min/M    Data          Codes/Values            Comments
                                                              ax      Type

                 Release of Information Code   CLM09   R      1/1         ID   A = Appropriate Release
                                                                               on File at Provider office
                                                                                          or URO
                                                                               I = Informed Consent to
                                                                                    Release Medical
                                                                                      Information for
                                                                                       Conditions or
                                                                               Diagnosies Regulated by
                                                                                     Federal Statues
                                                                               M = Provider has limited
                                                                                 or restricted ability to
                                                                               release data reltaed to a
                                                                                           claim
                                                                                N = No, Provider is not
                                                                                allowed to release data
                                                                                O = On file at Payor or
                                                                                     at Plan Sponsor
                                                                               Y = Yes, Provider has a
                                                                                    signed statement
                                                                                 permitting release of
                                                                                  medical billing data
                                                                                    related to a claim




                                                                     19
                                                                                        ATTRIBUTES
LOOP   SEGMENT   ELEMENT                                   USE   Min/M    Data          Codes/Values             Comments
                                                                  ax      Type

                 Patient Signature Source Code   CLM10      S     1/1         ID      B = Signed signature
                                                                                      authorization form for
                                                                                   both HCFA-1500 Claims
                                                                                     Form blocks 12 and 13
                                                                                            are on file
                                                                                    C = Signed HCFA-1500
                                                                                        Claim Form on file
                                                                                      M = Signed signature
                                                                                      authorization form for
                                                                                    HCFA1500 block 13 on
                                                                                   file                      P
                                                                                     = Signature generated
                                                                                    by provider because the
                                                                                         patient was not
                                                                                      physically present for
                                                                                             services
                                                                                      S = Signed signature
                                                                                      authorization form for
                                                                                    HCFA 1500 block 12 on
                                                                                               file



                 Accident/Employment/Related     CLM11      S                                                    If DTP - Date of Accident - is used, then CLM11 is required.
                 Causes
                 Related Causes Codes            CLM11-1   R      2/3         ID     AA = Auto Accident
                                                                                     AP = Another Party
                                                                                        Responsible
                                                                                   EM = Employment OA
                                                                                      = Other Accident
                 Related Causes Codes            CLM11-2    S     2/3         ID     AA = Auto Accident
                                                                                     AP = Another Party
                                                                                        Responsible
                                                                                   EM = Employment OA
                                                                                      = Other Accident
                 Related Causes Codes            CLM11-3    S     2/3         ID     AA = Auto Accident
                                                                                     AP = Another Party
                                                                                        Responsible
                                                                                   EM = Employment OA
                                                                                      = Other Accident




                                                                         20
                                                                                          ATTRIBUTES
LOOP   SEGMENT   ELEMENT                                      USE   Min/M    Data         Codes/Values            Comments
                                                                     ax      Type

                 Auto Accident State Code           CLM11-4    S     2/2         ID      Code Source 22           If CLM11-1, -2, or -3 = AA, then CLM11-4 must be identified. Use 2 digit state postal
                                                                                        States and Outlying       code.
                                                                                         Areas of the U.S.
                 Country Code                       CLM11-5    S     2/3         ID      Code Source 5:           Required if automobile accident occurred outside of the United States.
                                                                                       Countries, Currencies
                                                                                           and Funds
                 Special Program Code               CLM12      S     2/3         ID    01 = EPSDT or CHAP         Required if the services were rendered under one of the following
                                                                                          02 = Physically         circumstances/programs/projects.
                                                                                      Handicapped Children's
                                                                                       Program 03 = Special
                                                                                       Federal Funding 05 =
                                                                                      Disability 07 = Induced
                                                                                      Abortion - Danger to Life
                                                                                      08 = Induced Abortion -
                                                                                        Rape or Incest 09 =
                                                                                         Second Opinion or
                                                                                               Surgery
                 Condition Response                 CLM13            1/1                                          Not Used
                 Level of Service Code              CLM14            1/3                                          Not Used
                 Condition Response                 CLM15            1/1                                          Not Used
                 Provider Participation Agreement   CLM16      S     1/1         ID              P                Required if a non-participating provider is submitting a participating claim/encounter.
                 Code                                                                                             This is appropriate for on-call practitioners.
                 Claims Status Code                 CLM17            1/2                                          Not Used
                 Condition Response                 CLM18            1/1                                          Not Used
                 Claims Submission Code             CLM19            2/2                                          Not Used




                                                                            21
                                                                                                               ATTRIBUTES
LOOP   SEGMENT                        ELEMENT                                     USE   Min/M    Data          Codes/Values            Comments
                                                                                         ax      Type

                                      Delay Reason Code                   CLM20    S     1/2         ID     1 = Proof of Eligibility
                                                                                                          Unknown or unavailable
                                                                                                              2 = Litigation 3 =
                                                                                                            Authorization Delays
                                                                                                           4 = Delay in Certifying
                                                                                                          Provider      5 = Delay in
                                                                                                          Supplying Billing Forms
                                                                                                           6 = Delay in Delivery of
                                                                                                                 Custom Made
                                                                                                           Applicances 7 = Third
                                                                                                          Party Processing Delay
                                                                                                            8 - Delay in Eligibility
                                                                                                             Determination 9 =
                                                                                                          Original Claim Rejected
                                                                                                             or Denied Due to a
                                                                                                          Reason Unrelated to the
                                                                                                           Billing Limitation Rules
                                                                                                             10 = Administration
                                                                                                              Delay in the Prior
                                                                                                              Approval Process
                                                                                                                  11 = Other




                                                                                                                                       Dates in Loop ID-2300 apply to all service lines with Loop ID-2400 unless a DTP
                                                                                                                                       segment occurs in Loop ID-2400 with the same value in DTP01. If any date
                                                                                                                                       value exists Loop ID 2400, then each line item must have it's own date
                                                                                                                                       submitted.
       Date Initial Treatment   DTP                                               S                                                    Required on all claims involving spinal manipulation.
                                      Date/Time Qualifier                 DTP01   R      3/3         ID            454                 454 = Initial Treatment
                                      Date/Time Period Format Qualifier   DTP02   R      2/3         ID             D8
                                      Initial Treatment Date              DTP03   R     1/35         AN        CCYYMMDD
       Date-Date Last Seen      DTP                                               S                            Medicare Only           Note Changed: Required when Medicare Part B Claims involve services from an
                                                                                                                                       independent physical therapist, occupational thereapist, or physician services
                                                                                                                                       involving routine foot care.
                                      Date/Time Qualifier                 DTP01   R      3/3         ID            304                 304 = Latest Visit or Consultation
                                      Date/Time Period Format Qualifier   DTP02   R      2/3         ID            D8
                                      Last Seen Date                      DTP03   R     1/35         AN         CCYYMMDD




                                                                                                22
                                                                                                                 ATTRIBUTES
LOOP   SEGMENT                              ELEMENT                                      USE   Min/M    Data     Codes/Values   Comments
                                                                                                ax      Type

       Date Onset of Current          DTP                                                 S                                     Required when information is available and if different thatn the date of service. If not
       Illness/Symptom                                                                                                          used, claim/service date is assumed to be the date of onset of illness/symptoms.

                                            Date/Time Qualifier                  DTP01   R      3/3         ID      431         431 = Onset of Current Symptoms or Illness
                                            Date/Time Period Format Qualifier DTP02      R      2/3         ID      D8
                                            Onset of Current Illness/Injury Date DTP03   R     1/35         AN   CCYYMMDD

       Date-Acute Manifestation       DTP                                                 S                                     Required when Loop 2300 CR208 = A or M, the claim involves spinal manipulation,
                                                                                                                                and the payer is Medicare.
                                            Date/Time Qualifier                 DTP01    R      3/3         ID      453         453 = Acute Manifestation of a Chronic Conditions
                                            Date/Time Period Format Qualifier   DTP02    R      2/3         ID      D8
                                            Acute Manifestation Date            DTP03    R     1/35         AN   CCYYMMDD
       Date Similar Illness/Symptom   DTP                                                S                                      Required when claim involves services to a patient experiencing symptoms similar or
       Onset                                                                                                                    identical to previously reported symptoms.
                                            Date/Time Qualifier                 DTP01    R      3/3         ID      431         438 = Onset of Similar Symptoms or Illness
                                            Date/Time Period Format Qualifier   DTP02    R      2/3         ID      D8
                                            Similar Illness or Symptom Date     DTP03    R     1/35         AN   CCYYMMDD
       Date-Accident                  DTP                                                S                                      Required if CLM11-1, CLM11-2 or CLM11-3 = AA, AP, or OA
                                            Date/Time Qualifier                 DTP01    R      3/3         ID      439         439 = Accident
                                            Date/Time Period Format Qualifier   DTP02    R      2/3         ID    D8 or DT
                                            Accident Date                       DTP03    R     1/35         AN   CCYYMMDD
       Date--Last Menstrual Period    DTP                                                S                                      Required when a claim involves a pregnancy.
                                            Date/Time Qualifier                 DTP01    R      3/3         ID      484
                                            Date/Time Period Format Qualifier   DTP02    R      2/3         ID      D8
                                            Last Menstrual Period Date          DTP03    R     1/35         AN   CCYYMMDD
       Date--Last Xray                DTP                                                S                                      Required when claim involves spinal manipulation if an xray was taken
                                            Date/Time Qualifier                 DTP01    R      3/3         ID      455
                                            Date/Time Period Format Qualifier   DTP02    R      2/3         ID      D8
                                            Last Xray Date                      DTP03    R     1/35         AN   CCYYMMDD
       Date-Hearing and Vision        DTP                                                S                                      Required on claims where a presectiption has been written for hearing devices or
       Prescription Date                                                                                                        vision frames and lenses and it is being billed on this claim.
                                            Date/Time Qualifier                 DTP01    R      3/3         ID      471
                                            Date/Time Period Format Qualifier   DTP02    R      2/3         ID      D8
                                            Prescription Date                   DTP03    R     1/35         AN   CCYYMMDD
       Date--Disability Begin         DTP                                                S                                      Segment Not required for HIPAA
                                            Date/Time Qualifier                 DTP01    R      3/3         ID      360
                                            Date/Time Period Format Qualifier   DTP02    R      2/3         ID      D8
                                            Disability From Date                DTP03    R     1/35         AN   CCYYMMDD
       Date--Disability End           DTP                                                S                                      Segment Not required for HIPAA



                                                                                                       23
                                                                                                                   ATTRIBUTES
LOOP   SEGMENT                                 ELEMENT                                     USE   Min/M    Data     Codes/Values   Comments
                                                                                                  ax      Type

                                               Date/Time Qualifier                 DTP01   R      3/3         ID      361
                                               Date/Time Period Format Qualifier   DTP02   R      2/3         ID      D8
                                               Disability To Date                  DTP03   R     1/35         AN   CCYYMMDD
       Date--Last Worked                 DTP                                               S
                                               Date/Time Qualifier                 DTP01   R      3/3         ID      297
                                               Date/Time Period Format Qualifier   DTP02   R      2/3         ID      D8
                                               Last Worked Date                    DTP03   R     1/35         AN   CCYYMMDD
       Date--Authorized Return to Work   DTP                                               S

                                               Date/Time Qualifier                 DTP01   R      3/3         ID      296
                                               Date/Time Period Format Qualifier   DTP02   R      2/3         ID      D8
                                               Return to Work Date                 DTP03   R     1/35         AN   CCYYMMDD
       Date--Admission                   DTP                                               S
                                               Date/Time Qualifier                 DTP01   R      3/3         ID      435
                                               Date/Time Period Format Qualifier   DTP02   R      2/3         ID      D8
                                               Related Hospital Admission Date     DTP03   R     1/35         AN   CCYYMMDD
       Date--Discharge                   DTP                                               S
                                               Date/Time Qualifier                 DTP01   R      3/3         ID      96
                                               Date/Time Period Format Qualifier   DTP02   R      2/3         ID      D8
                                               Related Hospital Discharge Date     DTP03   R     1/35         AN   CCYYMMDD
       Date--Assumed and Relinquished    DTP                                               S
       Care Dates
                                               Date/Time Qualifier                 DTP01   R      3/3         ID     90,091
                                               Date/Time Period Format Qualifier   DTP02   R      2/3         ID       D8
                                               Assumed or Relinquished Date        DTP03   R     1/35         AN   CCYYMMDD

       Claim Supplemental Information    PWK                                                S




                                                                                                         24
                                                                                                         ATTRIBUTES
LOOP   SEGMENT                      ELEMENT                                 USE   Min/M    Data          Codes/Values            Comments
                                                                                   ax      Type

                                    Attachment Report Type code     PWK01   R      2/2         ID     77 = Support Data for
                                                                                                        Verification, AS =
                                                                                                    Admission Summary, B2
                                                                                                       = Prescription, B3 =
                                                                                                     Physician Order, B4 =
                                                                                                       Referral Form, CT =
                                                                                                        Certification, DA =
                                                                                                      Dental Models, DG =
                                                                                                    Diagnostic Report, DS =
                                                                                                    Discharge Summary, EB
                                                                                                         = Explanation of
                                                                                                     Benefits, MT = Models,
                                                                                                    NN = Nursing Notes, OB
                                                                                                    = Operative Note, OZ =
                                                                                                    Support Data for Claim,
                                                                                                     PN = Physical Therapy
                                                                                                    Notes, PO = Prosthetics
                                                                                                    or Orthotic Certification,
                                                                                                     PZ = Physical Therapy
                                                                                                        Certification, RB =
                                                                                                     Radiology Films, RR =
                                                                                                    Radiology Reports, RT =
                                                                                                       Report of Tests and
                                                                                                         Analysis Report




                                    Attachment Transmission Code    PWK02   R      1/2         ID       AA = Available on
                                                                                                      Request at Provider
                                                                                                    Site, BM = By Mail, EL =
                                                                                                    Electronically Only, EM
                                                                                                     = E-Mail, FX = By Fax

                                    Identification Code Qualifier   PWK05    S     1/2         ID       AC = Attachment
                                                                                                        Control Number
       Contract Information   CN1                                           S
                                    Contract Type Code              CN101   R      2/2         ID     02 = Per Diem, 03 =
                                                                                                    Variable Per Diem, 04 =
                                                                                                    Flat, 05 = Capitated, 06
                                                                                                     = Percent, 09 = Other
                                    Contract Amount                 CN102    S    1/18         R



                                                                                          25
                                                                                                                        ATTRIBUTES
LOOP   SEGMENT                                 ELEMENT                                      USE   Min/M    Data         Codes/Values           Comments
                                                                                                   ax      Type

                                               Contract Percentage                  CN103    S     1/6         R
                                               Contract Code                        CN104    S    1/30         AN
                                               Terms Discount Percentage            CN105    S     1/6         R
                                               Contract Version Identifier          CN106    S    1/30         AN
       Credit/Debit Card Maximum         AMT                                                 S
       Amount
                                               Maximumum Amount Qualifier Code AMT01        R      1/3         ID             MA

                                               Debit/Credit Card Max Amt            AMT02   R     1/18         R
       Patient Amount Paid               AMT                                                S                                                  Required if patient has paid any amount toward claim.   Is the sum of all pt. Payments
                                                                                                                                               made on claim.
                                               Patient Amount Paid Qualifier        AMT01   R      1/3         ID             F5
                                               Patient Amount Paid                  AMT02   R     1/18         R
       Total Purchased Service Amount    AMT                                                S                                                  New Notes: #2: Use this segment on vision claims when the acquisition ocost of
                                                                                                                                               lenses is known to impact adjudication or reimbursement. #3. Required on service
                                                                                                                                               lines when the purchased service charge amount is necessary for processing.

                                               Net Billed Qualifier                 AMT01   R      1/3         ID             NE
                                               Total Purchased Service Amt          AMT02   R     1/18         R
       Service Authorization Exception   REF                                                S

                                               Reference Identification Qualifier   REF01   R      2/3         ID               4N
                                               Service Authorization Exception      REF02   R     1/30         AN     1 = Immediate/Urgent
                                               Code                                                                     Care, 2 = Services
                                                                                                                          Rendered in a
                                                                                                                     Retroactive Period, 3 =
                                                                                                                      Emergency Care, 4 =
                                                                                                                       Client as Temporary
                                                                                                                     Medicaid, 5 = Request
                                                                                                                    from County for Second
                                                                                                                    Opinion to Recipient can
                                                                                                                     Work, 6 = Request for
                                                                                                                     Override Pending, 7 =
                                                                                                                         Special Handling

       Mandatory Medicare Crossover      REF                                                 S
       Indicator
                                         REF   Reference Identification Qualifier   REF01   R      2/3         ID             F5               Medicare Claims
                                               Medicare Section 4081 Indicator      REF02   R     1/30         AN           Y or N




                                                                                                          26
                                                                                                                     ATTRIBUTES
LOOP   SEGMENT                                  ELEMENT                                      USE   Min/M    Data     Codes/Values   Comments
                                                                                                    ax      Type

       Mammography Certification          REF                                                 S
       Number
                                                Reference Identification Qualifier REF01     R      2/3         ID       EW
                                                Mammography Certification Number REF02       R     1/30         AN

       Prior Authorization or Referral    REF                                                 S
       Number
                                                Reference Identification Qualifier   REF01   R      2/3         ID     9F or G1
                                                Prior Auth or Referral Number        REF02   R     1/30         AN
       Original Reference Number          REF                                                S
                                                Reference Identification Qualifier   REF01   R      2/3         ID       F8
                                                Claim Original Reference Number      REF02   R     1/30         AN
                                                (ICN/DCN)
       Clinical Labortory Improvement     REF                                                 S
       Amendment Number

                                                Reference Identification Qualifier   REF01   R      2/3         ID       X4
                                                CLIA Number                          REF02   R     1/30         AN
       Repriced Claim Number              REF                                                S
                                                Reference Identification Qualifier   REF01   R      2/3         ID       9A
                                                Repriced Claim Reference Number      REF02   R     1/30         AN

       Adjusted Repriced Claim Number     REF                                                 S

                                                Reference Identification Qualifier REF01     R      2/3         ID       9C
                                                Adjusted Repriced Claim Reference REF02      R     1/30         AN
                                                Number
       Investigational Device Exemption   REF                                                 S
       Number
                                                Reference Identification Qualifier   REF01   R      2/3         ID       LX
                                                Investigational Device Exemption     REF02   R     1/30         AN
                                                Identifier
       Claim Identification Number for    REF                                                 S
       Clearinghouses and other
       Transmission Subsidiaries
                                                Reference Identification Qualifier   REF01   R      2/3         ID       D9
                                                Clearinghouse Trace Number           REF02   R     1/30         AN
       Ambulatory Patient Group           REF                                                S                                      Required for contractural APG arrangement
                                                Reference Identification Qualifier   REF01   R      2/3         ID       1S



                                                                                                           27
                                                                                                                         ATTRIBUTES
LOOP   SEGMENT                                 ELEMENT                                      USE   Min/M    Data          Codes/Values           Comments
                                                                                                   ax      Type

                                               APG Number                           REF02   R     1/30         AN
       Medical Record Number             REF                                                S                                                   Used at submitter descretion
                                               Reference Identification Qualifier   REF01   R      2/3         ID             EA
                                               Medical Record Identification No.    REF02   R     1/30         AN
       Demonstration Project Identifer   REF                                                S

                                               Reference Identification Qualifier   REF01   R      2/3         ID              P4
                                               Demonstration Project ID             REF02   R     1/30         AN
       File Information                  K3                                                 S                                                   Do not use
                                               Fixed Format Information             K301    R     1/80         AN
       Claim Note                        NTE
                                               Note Reference Code                  NTE01   R      3/3         ID     ADD = Additional
                                                                                                                     Information, CER =
                                                                                                                    Certification Narrative,
                                                                                                                        DCP = Goals,
                                                                                                                    Rehabilitation Potential,
                                                                                                                     or Discharge Plans,
                                                                                                                      DGN = Diagnosis
                                                                                                                     Description, PMT =
                                                                                                                    Payment, TPO = Third
                                                                                                                      Party Organization
                                                                                                                             Notes

                                               Claim Note Text                      NTE02   R     1/80         AN
       Ambulance Transport Information   CR1                                                S

                                               Unit or Basis for Measurement        CR101   S      2/2         ID              LB
                                               Patient Weight                       CR102   S     1/10         R
                                               Ambulance Transport Code             CR103   R      1/1         ID      I = Initial Trip, R =
                                                                                                                    Return Trip, T = Transfer
                                                                                                                      Trip, X = Round Trip




                                                                                                          28
                                                                                                                    ATTRIBUTES
LOOP   SEGMENT                             ELEMENT                                     USE   Min/M    Data          Codes/Values             Comments
                                                                                              ax      Type

                                           Ambulance Transport Reason Code CR104       R      1/1         ID        A = Patient was
                                                                                                                transported to nearest
                                                                                                                   facility for care of
                                                                                                                symptoms, complaints,
                                                                                                               or both, B = Patient was
                                                                                                                  transported for the
                                                                                                                 benefit of a preferred
                                                                                                                 physician, C = Patient
                                                                                                                was transported for the
                                                                                                                  nearness of family
                                                                                                                 members, D = Patient
                                                                                                                was transported for the
                                                                                                               care of a specialist or for
                                                                                                               availability of specialized
                                                                                                                equipment, E = Patient
                                                                                                                     Transferred to
                                                                                                                 Rehabilitation Facility

                                           Unit or Basis for Measurement       CR105   R      2/2         ID              DH
                                           Transport Distance                  CR106   R     1/15         R
                                           Round Trip Purpose Description      CR107   S     1/80         AN                                 Required if CR103=X
                                           Stretcher Purpose Description       CR108   S     1/80         AN
       Spinal Manipulation Service   CR2                                               S                                                     Large changes with the addenda
       Information
                                           Treatment Number, Spinal            CR201   R      1/9         N0
                                           Manipulation
                                           Treatment Count, Total              CR202   R     1/15         R
                                           Subluxation Level Code              CR203   S      2/3         ID      See IG 252-253
                                           Subluxation Level Code              CR204   S      2/3         ID      See IG 253-254
                                           Unit or Basis for Measurement       CR205   R      2/2         ID      DA, MO, WK, YR
                                           Treatment Period Count              CR206   R     1/15         R
                                           Monthly Treatment Count             CR207   R     1/15         R
                                           Patient Condition Code              CR208   R      1/1         ID          See IG 255
                                           Complication Indicator              CR209   R      1/1         ID            Y or N
                                           Patient Description                 CF210   S     1/80         AN
                                           Patient Description                 CR211   S     1/80         AN
                                           Xray Availability Indicator         CR212   R      1/1         ID            Y or N
       Ambulance Certification       CRC                                               S
                                           Ambulance Certification Code        CRC01   R      2/2         ID              7
                                           Certification Condition Indicator   CRC02   R      1/1         ID            Y or N



                                                                                                     29
                                                                                                                      ATTRIBUTES
LOOP   SEGMENT                                ELEMENT                                     USE   Min/M    Data         Codes/Values            Comments
                                                                                                 ax      Type

                                              Condition Code                      CRC03   R      2/2         ID        01 = Patient was
                                                                                                                   admitted to a hospital,
                                                                                                                    02 = Patent was bed
                                                                                                                     confined before the
                                                                                                                  ambulance service, 03 =
                                                                                                                       Patient was bed
                                                                                                                      confined after the
                                                                                                                  ambulance service, 04 =
                                                                                                                   Patient was moved by
                                                                                                                   stretcher, 05 = Patient
                                                                                                                   was unconscious or in
                                                                                                                  shock, 06 = Patient was
                                                                                                                      transported in an
                                                                                                                  emergency situation, 07
                                                                                                                     = Patient had to be
                                                                                                                  physically restrained, 08
                                                                                                                    = Patient had visible
                                                                                                                    hemorrhaging, 09 =
                                                                                                                  Ambulance service was
                                                                                                                  medically necessary, 60
                                                                                                                  = Transportation was to
                                                                                                                     the Nearest Facility

                                              Condition Code                      CRC04    S     2/2         ID         See CRC03
                                              Condition Code                      CRC05    S     2/2         ID         See CRC03
                                              Condition Code                      CRC06    S     2/2         ID         See CRC03
                                              Condition Code                      CRC07    S     2/2         ID         See CRC03
       Patient Condition Information:   CRC                                                S                                                  Note now Reads: Required on vision claims/encounters involving replacement lenses
       Vision                                                                                                                                 or frames when this information is known to impact reimbursement. Previously read:
                                                                                                                                              Required on vision claims/ encounters involving replacement lenses or frames.

                                              Ambulance Certification Code        CRC01   R      2/2         ID        E1, E2, E3
                                              Certification Condition Indicator   CRC02   R      1/1         ID           Y or N
                                              Condition Code                      CRC03   R      2/2         ID       Multiple IG 261
                                              Condition Code                      CRC04   S      2/2         ID       Multiple IG 261
                                              Condition Code                      CRC05   S      2/2         ID       Multiple IG 261
                                              Condition Code                      CRC06   S      2/2         ID       Multiple IG 261
                                              Condition Code                      CRC07   S      2/2         ID       Multiple IG 261
       Homebound Indicator              CRC                                               S
                                              Functional Limitations Code         CRC01   R      2/2         ID              75




                                                                                                        30
                                                                                                                 ATTRIBUTES
LOOP   SEGMENT                          ELEMENT                                      USE   Min/M    Data         Codes/Values           Comments
                                                                                            ax      Type

                                        Certification Condition Indicator   CRC02    R      1/1         ID             Yes
                                        Homebound Indicator                 CRC03    R      2/2         ID              IH

       HealthCare Diagnosis Code   HI                                                S
                                        Health Care Code Information        H101     R
                                        Diagnosis Type Code                 H101-1   R      1/3         ID   BK = Principle Diagnosis




                                        Diagnosis Code                      H101-2   R     1/30         AN
                                        Health Care Code Information        H102     S
                                        Diagnosis Type Code                 H102-1   S      1/3         ID       BF = Diagnosis
                                        Diagnosis Code                      H102-2   S     1/30         AN
                                        Health Care Code Information        H103     S
                                        Diagnosis Type Code                 H103-1   S      1/3         ID       BF = Diagnosis
                                        Diagnosis Code                      H103-2   S     1/30         AN
                                        Health Care Code Information        H104     S
                                        Diagnosis Type Code                 H104-1   S      1/3         ID       BF = Diagnosis
                                        Diagnosis Code                      H104-2   S     1/30         AN
                                        Health Care Code Information        H105     S
                                        Diagnosis Type Code                 H105-1   S      1/3         ID       BF = Diagnosis
                                        Diagnosis Code                      H105-2   S     1/30         AN
                                        Health Care Code Information        H106     S
                                        Diagnosis Type Code                 H106-1   S      1/3         ID       BF = Diagnosis
                                        Diagnosis Code                      H106-2   S     1/30         AN
                                        Health Care Code Information        H107     S
                                        Diagnosis Type Code                 H107-1   S      1/3         ID       BF = Diagnosis
                                        Diagnosis Code                      H107-2   S     1/30         AN
                                        Health Care Code Information        H108     S
                                        Diagnosis Type Code                 H108-1   S      1/3         ID       BF = Diagnosis
                                        Diagnosis Code                      H108-2   S     1/30         AN




                                                                                                   31
                                                                                                                 ATTRIBUTES
LOOP   SEGMENT                         ELEMENT                                      USE   Min/M    Data          Codes/Values           Comments
                                                                                           ax      Type

       Claim Pricing/Repricing   HCP                                                 S
       Information
                                       Pricing/Repricing Methodology        HCP01   R      2/2         ID    00 = Zero Pricing, 01 =
                                                                                                                Priced as Billed at
                                                                                                            100%, 02 = Priced at the
                                                                                                            Standard Fee Schedule,
                                                                                                                 03 = Priced at a
                                                                                                            Contractual Percentage,
                                                                                                            04 = Bundled Pricing, 05
                                                                                                             = Peer Review Pricing,
                                                                                                             07 = Flat Rate Pricing,
                                                                                                                08 = Combination
                                                                                                             Pricing, 09 = Maternity
                                                                                                               Pricing, 10 = Other
                                                                                                              Pricing, 11 = Lower of
                                                                                                            Cost, 12 = Ratio of Cost,
                                                                                                             13 = Cost Reimbursed,
                                                                                                            14 = Adjustment Pricing




                                       Repriced Allowed Amount              HCP02   R     1/18         R
                                       Repriced Saving Amount               HCP03   S     1/18         R
                                       Repricing Organization Identifier    HCP04   S     1/30         AN
                                       Repricing PerDiem or Flat Rate Amt   HCP05   S      1/9         R

                                       Repriced Approved APG Code           HCP06    S    1/30         AN




                                                                                                  32
                                                                                  ATTRIBUTES
LOOP   SEGMENT   ELEMENT                             USE   Min/M    Data          Codes/Values           Comments
                                                            ax      Type

                 Repriced Approved APG Amt   HCP07    S    1/18         R




                 Reject Reason Code          HCP13    S     2/2         ID     T1 = Cannot Identify
                                                                                 Provider as TPO
                                                                             Participant, T2 = Cannot
                                                                              Identify Payer as TPO
                                                                             Participant, T3 = Cannot
                                                                             Identify Insured as TPO
                                                                              Participant, T4 = Payer
                                                                                Name or Identifier
                                                                                   Missing, T5 =
                                                                             Certification Information
                                                                               Missing, T6 = Claim
                                                                             does not contain enough
                                                                             information for repricing




                                                                   33
                                                                                                   ATTRIBUTES
LOOP   SEGMENT                        ELEMENT                          USE   Min/M    Data         Codes/Values           Comments
                                                                              ax      Type

                                      Policy Compliance Code   HCP14    S     1/2         ID   1 = Procedure Followed,
                                                                                                2 = Not Followed - Call
                                                                                                  Not Made, 3 = Not
                                                                                                Medically Necessary, 4
                                                                                               = Not Followed Other, 5
                                                                                                = Emergency Admit to
                                                                                                Non-Network Hospital



                                      Exception Code           HCP15    S     1/2         ID       1 = Non-Network
                                                                                               Professional Provider in
                                                                                                Network Hospital, 2 =
                                                                                                Emergency Care, 3 =
                                                                                                Services or Specialist
                                                                                               not in Network, 4 = Out-
                                                                                                 of-Service Area, 5 =
                                                                                                State Mandates, 6 =
                                                                                                        Other



   2305 Home Health Care Plan   CR7                                     S
        Information
                                      Discipline Type Code     CR701   R      2/2         ID   AI = Home Health Aide,
                                                                                                 MS = Medical Social
                                                                                                    Worker, OT =
                                                                                                Occupational Therapy,
                                                                                                PT = Physical Therapy,
                                                                                               SN = Skilled Nursing, ST
                                                                                                  = Speech Therapy




                                                                                     34
                                                                                                                   ATTRIBUTES
LOOP   SEGMENT                               ELEMENT                                       USE   Min/M    Data     Codes/Values   Comments
                                                                                                  ax      Type

                                             Total Visits rendered, home health    CR702   R      1/9         N0




                                             Total visits projected, home health   CR703   R      1/9         N0




       Health Care Services Delivery   HSD                                                  S




                                             Visits                                HSD01    S     2/2         ID       VS
                                             Number of Visits                      HSD02    S    1/15         R




                                                                                                         35
                                                                                ATTRIBUTES
LOOP   SEGMENT   ELEMENT                             USE   Min/M    Data        Codes/Values        Comments
                                                            ax      Type

                 Frequency Period            HSD03    S     2/2         ID     DA = Days, MO =
                                                                             Months, Q1 = Quarter
                                                                              (Time), WK = Week




                 Frequency Count             HSD04    S     1/5         R
                 Duration of Visitis Units   HSD05    S     1/2         ID   7 = Day, 35 = Week
                 Duration of Visitis Units   HSD06    S     1/3         ID




                                                                   36
                                                                                         ATTRIBUTES
LOOP   SEGMENT   ELEMENT                                     USE   Min/M    Data         Codes/Values           Comments
                                                                    ax      Type

                 Ship, Delivery or Clendar Pattern   HSD07    S     1/2         ID    1 = 1st Week of Month,
                 Code                                                                 2= 2nd Week of Month,
                                                                                      3 = 3rd Week of Month,
                                                                                      4 = 4th Week of Month,
                                                                                      5 = 5th Week of Month,
                                                                                      6 = 1st & 3rd Weeks of
                                                                                     the Month, 7 = 2nd & 4th
                                                                                     Weeks of the Month, A =
                                                                                     Moday through Friday, B
                                                                                          = Monday through
                                                                                       Saturday, C = Monday
                                                                                        through Sunday, D =
                                                                                     Monday, E = Tuesday, F
                                                                                         = Wednesday, G =
                                                                                      Thursday, H = Friday, J
                                                                                     = Saturday, K = Sunday,
                                                                                         L = Monday through
                                                                                          Thursday, N = As
                                                                                     Directed, O = Daily Mon.
                                                                                       through Fri., S = Once
                                                                                       any time Mon. through
                                                                                          Fri., SA = Sunday,
                                                                                         Monday, Thrusday,
                                                                                      Friday, Saturday, SB =
                                                                                           Tuesday through
                                                                                     Saturday, SC = Sunday,
                                                                                      Wednesday, Thursday,
                                                                                      Friday, Saturday, SD =
                                                                                       Monday, Wednesday,
                                                                                          Thursday, Friday,
                                                                                      Saturday, SG= Tuesday
                                                                                        through Friday, SL =
                                                                                       Monday, Tuesday and
                                                                                     Thursday, SP = Monday,
                                                                                      Tuesday and Friday, SX
                                                                                          = Wednesday and
                                                                                                Thursday




                                                                           37
                                                                                                                       ATTRIBUTES
LOOP    SEGMENT                              ELEMENT                                       USE   Min/M    Data         Codes/Values           Comments
                                                                                                  ax      Type

                                                                                                                       SY = Monday,
                                                                                                                      Wednesday and
                                                                                                                       Thursday, SZ =
                                                                                                                   Tuesday, Thursday and
                                                                                                                   Friday, W = Whenever
                                                                                                                         Necessary
                                             Delivery Pattern Time Code           HSD08     S     1/1         ID   D = A.M., E = P.M., F =
                                                                                                                        As Directed

2310A   Referring Provider name        NM1                                                 S
                                             Entity Identifier Code               NM101    R      2/3         ID   DN = Referring Provider,
                                                                                                                     P3 = Primary Care
                                                                                                                          Provider
                                             Entity Type Qualifier                NM102    R      1/1         ID             1, 2
                                             Referring Provider Last Name or      NM103    R
                                             Organization




                                             Referring Provider First Name        NM104     S    1/25         AN
                                             Referring Provider Middle Name       NM105     S    1/25         AN
                                             Referring Provider Suffix            NM107    S     1/25         AN
                                             Identification Code Qualifier        NM108    R      1/2         ID       24= Employer's
                                                                                                                    Identification Number;
                                                                                                                           34 = SSN
                                             Referring Provider Primary Identifier NM109   R     2/80         AN

        Referring Provider Specialty   PRV                                                  S                                                 Taxonomy Codes are required on all claims. Required at the claim level when the
        Information                                                                                                                           Rendering Provider is the same entity as the Billing and/or Pay-to Provider. Required
                                                                                                                                              in 2400 Loop for Providers at the Line Item level.
                                             Provider Code                        PRV01    R      1/3         ID             RF
                                             Reference Identification Qualifier   PRV02    R      2/3         ID             ZZ
                                             Provider Taxonomy Code               PRV03    R     1/30         AN
        Additional Referring Name      N2                                                  S                                                  Not Used by ODS
        Information
                                             Referring Provider Additional Name N201       R     1/60         AN




                                                                                                         38
                                                                                                                      ATTRIBUTES
LOOP    SEGMENT                              ELEMENT                                       USE   Min/M    Data        Codes/Values          Comments
                                                                                                  ax      Type

        Referring Provider Secondary   REF
        Identification
                                             Identification Code Qualifier       REF01      S     2/3         ID     OB - State License
                                                                                                                           Number
                                                                                                                      1B - Blue Shield
                                                                                                                      Provider Number
                                                                                                                   1C - Medicare Provider
                                                                                                                           Number
                                                                                                                   1D - Medicaid Provider
                                                                                                                           Number
                                                                                                                    1G - Provider UPIN
                                                                                                                           Number
                                                                                                                     1H - CHAMPUS ID
                                                                                                                           Number
                                                                                                                     EI - Employer's ID
                                                                                                                           Number
                                                                                                                        G2 - Provider
                                                                                                                    Commercial Number
                                                                                                                   LU - Location Number
                                                                                                                     N5 - Provider Plan
                                                                                                                    Network ID Number
                                                                                                                          SY - SSN
                                                                                                                    X5 - State Industrial
                                                                                                                      Accident Provider
                                                                                                                           Number
                                             Referring Provider Primary Identifier REF02    S    1/30         AN



2310B   Rendering Provider Name        NM1                                                 S
                                             Entity Identifier Code              NM101     R      2/3         ID             82
                                             Entity Type Qualifier               NM102     R      1/1         ID            1, 2
                                             Rendering Provider Last Name or     NM103     R
                                             Organization
                                             Rendering Provider First Name       NM104     S     1/25         AN
                                             Rendering Provider Middle Name      NM105     S     1/25         AN
                                             Rendering Provider Suffix           NM107     S     1/25         AN
                                             Identification Code Qualifier       NM108     R      1/2         ID      24= Employer's
                                                                                                                   Identification Number;
                                                                                                                          34 = SSN




                                                                                                         39
                                                                                                                    ATTRIBUTES
LOOP   SEGMENT                              ELEMENT                                      USE   Min/M    Data        Codes/Values          Comments
                                                                                                ax      Type

                                            Rendering Provider Primary           NM109   R     2/80         AN
                                            Identifier
       Rendering Provider Specialty   PRV                                                 S                                               Taxonomy Codes are required on all claims. Required at the claim level when the
       Information                                                                                                                        Rendering Provider is the same entity as the Billing and/or Pay-to Provider. In these
                                                                                                                                          cases, the Rendering Provider is being identified at this level for all subsequent
                                                                                                                                          claims/encounters in this HL and LoopID-2310B is not used.

                                            Provider Code                        PRV01   R      1/3         ID            PE
                                            Reference Identification Qualifier   PRV02   R      2/3         ID            ZZ
                                            Provider Taxonomy Code               PRV03   R     1/30         AN
       Additional Rendering Name      N2                                                 S                                                Not Used by ODS
       Information
                                            Rendering Provider Additional Name N201      R     1/60         AN

       Rendering Provider Secondary   REF
       Identification
                                            Identification Code Qualifier        REF01    S     2/3         ID     OB - State License
                                                                                                                         Number
                                                                                                                    1B - Blue Shield
                                                                                                                    Provider Number
                                                                                                                 1C - Medicare Provider
                                                                                                                         Number
                                                                                                                 1D - Medicaid Provider
                                                                                                                         Number
                                                                                                                  1G - Provider UPIN
                                                                                                                         Number
                                                                                                                   1H - CHAMPUS ID
                                                                                                                         Number
                                                                                                                   EI - Employer's ID
                                                                                                                         Number
                                                                                                                      G2 - Provider
                                                                                                                  Commercial Number
                                                                                                                 LU - Location Number
                                                                                                                   N5 - Provider Plan
                                                                                                                  Network ID Number
                                                                                                                        SY - SSN
                                                                                                                  X5 - State Industrial
                                                                                                                    Accident Provider
                                                                                                                         Number




                                                                                                       40
                                                                                                                     ATTRIBUTES
LOOP    SEGMENT                               ELEMENT                                    USE   Min/M    Data         Codes/Values           Comments
                                                                                                ax      Type

                                              Rendering Provider Secondary     REF02      S    1/30         AN
                                              Identifier

2310C   Purchased Service Provider Name NM1                                               S

                                              Entity Identifier Code           NM101     R      2/3         ID             QB
                                              Entity Type Qualifier            NM102     R      1/1         ID             1, 2
                                              Name Last or Organization Name   NM103     S     1/35         AN                              Usage Changed: This element was previously Not Used. Is now Situational. New
                                                                                                                                            Note: Required if identifier is not used in NM109 or the corresponding REF segment.

                                              Identification Code Qualifier    NM108      S     1/2         ID       24= Employer's
                                                                                                                  Identification Number;
                                                                                                                         34 = SSN
                                              Purchased Service Provider Primary NM109   R     2/80         AN
        Purchased Service Provider     REF
        Secondary Identification
                                              Identification Code Qualifier    REF01      S     2/3         ID      OB - State License
                                                                                                                          Number
                                                                                                                 1A - Blue Cross Provider
                                                                                                                          Number
                                                                                                                     1B - Blue Shield
                                                                                                                     Provider Number
                                                                                                                  1C - Medicare Provider
                                                                                                                          Number
                                                                                                                  1D - Medicaid Provider
                                                                                                                          Number
                                                                                                                   1G - Provider UPIN
                                                                                                                          Number
                                                                                                                    1H - CHAMPUS ID
                                                                                                                          Number
                                                                                                                    EI - Employer's ID
                                                                                                                          Number
                                                                                                                       G2 - Provider
                                                                                                                   Commercial Number
                                                                                                                  LU - Location Number
                                                                                                                    N5 - Provider Plan
                                                                                                                   Network ID Number
                                                                                                                         SY - SSN




                                                                                                       41
                                                                                                                       ATTRIBUTES
LOOP    SEGMENT                                ELEMENT                                     USE   Min/M    Data         Codes/Values           Comments
                                                                                                  ax      Type

                                                                                                                   U3 - Unique Supplier ID
                                                                                                                          Number
                                                                                                                    X5 - State Industrial
                                                                                                                     Accident Provider
                                                                                                                          Number
                                               Purchased Service Provider Primary REF02     S    1/30         AN
                                               Identifier

2310D   Service Facility Location Name   NM1                                                S

                                               Entity Identifier Code              NM101   R      2/3         ID    77 = Service Location,
                                                                                                                       FA = Facility, LI =
                                                                                                                    Independent Lab, TL =
                                                                                                                         Testing Lab
                                               Entity Type Qualifier               NM102   R      1/1         ID                2
                                               Identification Code Qualifier       NM108   S      1/2         ID       24= Employer's
                                                                                                                    Identification Number;
                                                                                                                           34 = SSN
                                               Service Facility Location Primary   NM109   R     2/80         AN
                                               Identifier
        Service Facility Location        REF
                                               Identification Code Qualifier       REF01    S     2/3         ID      OB - State License
                                                                                                                           Number
                                                                                                                   1A - Blue Cross Provider
                                                                                                                           Number
                                                                                                                       1B - Blue Shield
                                                                                                                       Provider Number
                                                                                                                    1C - Medicare Provider
                                                                                                                           Number
                                                                                                                    1D - Medicaid Provider
                                                                                                                           Number
                                                                                                                     1G - Provider UPIN
                                                                                                                           Number
                                                                                                                      1H - CHAMPUS ID
                                                                                                                           Number
                                                                                                                         G2 - Provider
                                                                                                                     Commercial Number
                                                                                                                    LU - Location Number




                                                                                                         42
                                                                                                                         ATTRIBUTES
LOOP   SEGMENT                                  ELEMENT                                      USE   Min/M    Data         Codes/Values           Comments
                                                                                                    ax      Type

                                                                                                                       N5 - Provider Plan
                                                                                                                       Network ID Number
                                                                                                                     TJ - Federal Taxpayer's
                                                                                                                            ID Number
                                                                                                                     X4 - Clinical Laboratory
                                                                                                                           Improvement
                                                                                                                      Amendment Number

                                                                                                                      X5 - State Industrial
                                                                                                                       Accident Provider
                                                                                                                            Number
                                                Service Facility Location Primary    REF02    S    1/30         AN
                                                Identifier
       Service Facility Location Address   N3                                                 S

                                                Laboratory or Facility Location      N301    R     1/55         AN
                                                Address Line 1
                                                Laboratory or Facility Location      N302     S    1/55         AN
                                                Address Line 2
       Service Facility Location           N4
       City/State/Zip
                                                Service Facility Location City Name N401     R     2/30         AN      Code Source 22
                                                                                                                       States and Outlying
                                                                                                                        Areas of the U.S.
                                                Service Facility Location State or   N402    R      2/2         ID     Code Source 51
                                                Province                                                                  Zip Code
                                                Service Facility Location Postal     N403    R     3/15         ID     Code Source 5:
                                                Code                                                                 Countries, Currencies
                                                                                                                         and Funds
                                                Service Facility Location Country    N404     S     2/3         ID
                                                Code




                                                                                                           43
                                                                                                                     ATTRIBUTES
LOOP   SEGMENT                           ELEMENT                                        USE   Min/M    Data          Codes/Values           Comments
                                                                                               ax      Type

       Service Facility Location   REF                                                   S                         OB = State License
       Secondary Identification                                                                                    Number , 1A = Blue
                                                                                                                 Cross Provider Number,
                                                                                                                    1B = Blue Shield
                                                                                                                 Provider Number, 1C =
                                                                                                                    Medicare Provider
                                                                                                                 Number, 1D = Medicaid
                                                                                                                 Provider Number, 1G =
                                                                                                                 Provider UPIN Number,
                                                                                                                   1H = CHAMPUS ID
                                                                                                                 Number, G2 = Provider
                                                                                                                Commercial Number, LU
                                                                                                                 = Location Number, N5
                                                                                                                = Provider Plan Network
                                                                                                                ID Number, TJ = Federal
                                                                                                                 Taxpayer's ID Number,
                                                                                                                 X4 = Clinical Laboratory
                                                                                                                      Improvement
                                                                                                                Amendment Number, X5
                                                                                                                    = State Industrial
                                                                                                                    Accident Provider
                                                                                                                         Number




                                         Identification Code Qualifier          REF01   R      2/3         ID
                                         Service Facility Location Additional   REF02   R     1/30         AN
                                         Identifier
       Supervising Provider Name   NM1                                                  S                                 DQ
                                         Entity Identifier Code                 NM101   R      2/3         ID              1
                                         Entity Type Qualifier                  NM102   R      1/1         ID




                                                                                                      44
                                                                                                                     ATTRIBUTES
LOOP   SEGMENT                                ELEMENT                                     USE   Min/M    Data        Codes/Values          Comments
                                                                                                 ax      Type

                                              Supervising Provider Last Name or   NM103   R
                                              Organization




                                              Supervising Provider First Name     NM104    S    1/25         AN
                                              Supervising Provider Middle Name    NM105    S    1/25         AN

                                              Supervising Provider Suffix         NM107    S    1/10         AN      24= Employer's
                                                                                                                  Identification Number;
                                                                                                                         34 = SSN
                                              Identification Code Qualifier       NM108   R      1/2         ID
                                              Supervising Provider Primary        NM109   R     2/80         AN
                                              Identifier
       Additional Supervising Name      N2                                                 S                                               Not Used by ODS
       Information
                                              Supervising Provider Additional     N201    R     1/60         AN
                                              Name
       Supervising Provider Secondary   REF
       Identification
                                              Identification Code Qualifier       REF01    S     2/3         ID    OB - State License
                                                                                                                        Number



                                                                                                        45
                                                                                                                 ATTRIBUTES
LOOP    SEGMENT                              ELEMENT                                  USE   Min/M    Data        Codes/Values          Comments
                                                                                             ax      Type

                                                                                                                 1B - Blue Shield
                                                                                                                 Provider Number
                                                                                                              1C - Medicare Provider
                                                                                                                      Number
                                                                                                              1D - Medicaid Provider
                                                                                                                      Number
                                                                                                               1G - Provider UPIN
                                                                                                                      Number
                                                                                                                1H - CHAMPUS ID
                                                                                                                      Number
                                                                                                                EI - Employer's ID
                                                                                                                      Number
                                                                                                                   G2 - Provider
                                                                                                               Commercial Number
                                                                                                              LU - Location Number
                                                                                                                N5 - Provider Plan
                                                                                                               Network ID Number
                                                                                                                     SY - SSN
                                                                                                               X5 - State Industrial
                                                                                                                 Accident Provider
                                                                                                                      Number
                                             Supervising Provider Primary     REF02    S    1/30         AN
                                             Identifier

   2320 Other Subscriber Information   SBR
                                             Payer Responsibility Sequence    SBR01   R      1/1         ID           P,S,T
                                             Code
                                             Individual Relationship Code     SBR02   R      2/2         ID            18              Required when subscriber=patient
                                             Insured Group or Policy Number   SBR03   S     1/30         AN
                                             Insured Group Name               SBR04   S     1/60         AN
                                             Insurance Type Code              SBR05   S      1/3         ID    AP = Auto Insurance




                                                                                                    46
                                                                                                            ATTRIBUTES
LOOP   SEGMENT                         ELEMENT                                 USE   Min/M    Data          Codes/Values           Comments
                                                                                      ax      Type

                                       Claim Filing Indicator Code     SBR09   R      1/2         ID   09 = Self-pay; 10 =         Required prior to mandated use of PLANID
                                                                                                       Central Certification, 11
                                                                                                       = Other Non-Federal
                                                                                                       Programs, 12 = PPO; 13
                                                                                                       = POS; 14 = EPO; 15 =
                                                                                                       Indemnity; 16 = Health
                                                                                                       Maintenance
                                                                                                       Organization Medicare
                                                                                                       Risk, AM = Automobile
                                                                                                       Medical, BL = Blue
                                                                                                       Cross/Blue Shield, CH
                                                                                                       = Champus, CI =
                                                                                                       Commerical Insurance,
                                                                                                       DS = Disability, HM =
                                                                                                       Health Maintenance
                                                                                                       Organziation, LI =
                                                                                                       Liability, LM = Liability
                                                                                                       Medical, MB = Medicare
                                                                                                       Part B, MC = Medicaid,
                                                                                                       OF = Other Federal
                                                                                                       Program, TV = Title V,
                                                                                                       VA = Veteran Admin
                                                                                                       Plan, WC = Workers'
                                                                                                       Compensation, ZZ =
                                                                                                       Mutually defined




       Claim Level Adjustments   CAS                                                                      CO = Contractual
                                                                                                          Obligations, CR =
                                                                                                             Correction and
                                                                                                        Reversals, OA = Other
                                                                                                       Adjustments, PI = Payor
                                                                                                        Initiaated Reductions,
                                                                                                              PR = Patient
                                                                                                             Responsibility
                                       Claim Adjustment Group Code     CAS01   R      1/2         ID      Code Source 139
                                       Adjustment Reason Code--Claim   CAS02   R      1/5         ID
                                       Level
                                       Adjustment Amt--Claim Level     CAS03   R     1/18         R



                                                                                             47
                                                                               ATTRIBUTES
LOOP   SEGMENT   ELEMENT                               USE   Min/M    Data     Codes/Values     Comments
                                                              ax      Type

                 Adjusted Units--Claim Level   CAS04    S    1/15         R   Code Source 139




                                                                     48
                                                                                  ATTRIBUTES
LOOP   SEGMENT   ELEMENT                                 USE   Min/M    Data      Codes/Values     Comments
                                                                ax      Type

                 Adjustment Reason Code--Claim   CAS05    S     1/5         ID
                 Level




                 Adjustment Amt--Claim Level     CAS06    S    1/18         R




                 Adjusted Units--Claim Level     CAS07    S    1/15         R    Code Source 139
                 Adjustment Reason Code--Claim   CAS08    S     1/5         ID
                 Level
                 Adjustment Amt--Claim Level     CAS09    S    1/18         R
                 Adjusted Units--Claim Level     CAS10    S    1/15         R    Code Source 139
                 Adjustment Reason Code--Claim   CAS11    S     1/5         ID
                 Level




                                                                       49
                                                                                                             ATTRIBUTES
LOOP   SEGMENT                          ELEMENT                                     USE   Min/M    Data      Codes/Values     Comments
                                                                                           ax      Type

                                        Adjustment Amt--Claim Level         CAS12    S    1/18         R
                                        Adjusted Units--Claim Level         CAS13    S    1/15         R    Code Source 139
                                        Adjustment Reason Code--Claim       CAS14    S     1/5         ID
                                        Level
                                        Adjustment Amt--Claim Level         CAS15    S    1/18         R
                                        Adjusted Units--Claim Level         CAS16    S    1/15         R    Code Source 139
                                        Adjustment Reason Code--Claim       CAS17    S     1/5         ID
                                        Level
                                        Adjustment Amt--Claim Level         CAS18   S     1/18         R
                                        Adjusted Units--Claim Level         CAS19   S     1/15         R
       COB Payer Paid Amount      AMT                                               S                             D
                                        Payor Amt Paid Qualifier Code       AMT01   R      1/3         ID
                                        Payer Paid Amount                   AMT02   R     1/18         R
       COB Approved Amount        AMT                                               S                            AAE
                                        Approved Amt Qualifier Code         AMT01   R      1/3         ID
                                        Approved Amount                     AMT02   R     1/18         R
       COB Allowed Amount         AMT                                               S                             B6
                                        Actual Allowed Amt Qual Code        AMT01   R      1/3         ID
                                        Allowed Amount                      AMT02   R     1/18         R
       COB Patient Resp. Amount   AMT                                                                             F2
                                        Pt. Responsibility Actual Am Qual   AMT01   R      1/3         ID
                                        Code
                                        Patient Responsibility Amt          AMT02   R     1/18         R
       COB Covered Amt            AMT                                               S                             AU
                                        Amount Qualifier Code               AMT01   R      1/3         ID
                                        Other Payer Covered Amount          AMT02   R     1/18         R
       COB Discount Amount        AMT                                               S                             D8
                                        Discount Amt Qual Code              AMT01   R      1/3         ID
                                        Other Payer Discount Amount         AMT02   R     1/18         R
       COB Per Day Limit Amount   AMT                                                                             DY
                                        Per Day Limit Qualifer Code         AMT01   R      1/3         ID
                                        Other Payer Per Day Limit Amt       AMT02   R     1/18         R
       COB Patient Amount Paid    AMT                                               S                             F5
                                        Patient Amount Paid Qualifier       AMT01   R      1/3         ID
                                        Patient Amount Paid                 AMT02   R     1/18         R
       COB Tax Amount             AMT                                               S                             T
                                        Tax Amount Qual Code                AMT01   R      1/3         ID
                                        Other Payer Tax Amount              AMT02   R     1/18         R




                                                                                                  50
                                                                                                                        ATTRIBUTES
LOOP   SEGMENT                                 ELEMENT                                     USE   Min/M    Data          Codes/Values           Comments
                                                                                                  ax      Type

       COB Total Claim Before Taxes      AMT                                                                                  T2
       Amount
                                               Amount Qualifier Code               AMT01   R      1/3         ID
                                               Other Payer Pre-Tax Claim Total     AMT02   R     1/18         R
                                               Amount
       Subscriber Demographic            DMG                                                                                  D8
       Information
                                               Date/Time Period Format Qualifier   DMG01   R      2/3         ID
                                               Other Subscriber Birth Date         DMG02   R     1/35         AN           F, M, U
                                               Other Subscriber Gender Code        DMG03   R      1/1         ID
       Other Insurance Coverage Inform   OI                                                R

                                               Assignment of Benefits Indicator    OI03    R      1/1         ID               N or Y
                                               Patient Signature Souce Code        OI04    S      1/1         ID      B = Signed signature
                                                                                                                      authorization form or
                                                                                                                     forms for both HCFA-
                                                                                                                    1500 Claim Form block
                                                                                                                    12 and block 13 are on
                                                                                                                    file, C = Signed HCFA-
                                                                                                                   1500 Claim Form on file,
                                                                                                                     M = Signed signature
                                                                                                                     authorization form for
                                                                                                                   HCFA-1500 Claim Form
                                                                                                                       block 13 on file, P =
                                                                                                                    Signature generated by
                                                                                                                      provider because the
                                                                                                                          patient was not
                                                                                                                     physically present for
                                                                                                                      services, S = Signed
                                                                                                                    signature authorization
                                                                                                                      form for HCFA-1500
                                                                                                                   Claim Form block 12 on
                                                                                                                                file




                                                                                                         51
                                                                                                                     ATTRIBUTES
LOOP   SEGMENT                                  ELEMENT                                 USE   Min/M    Data          Codes/Values             Comments
                                                                                               ax      Type

                                                Release of Information Code     OI06    R      1/1         ID   A = Appropriate Release
                                                                                                                 of Information on File at
                                                                                                                   Health Care Service
                                                                                                                Provider or at Utilitzation
                                                                                                                Review Organization, I =
                                                                                                                   Informed Consent to
                                                                                                                Release Medical Info for
                                                                                                                Conditions or Diagnoses
                                                                                                                  Regulated by Federal
                                                                                                                  Statutes, M = Provider
                                                                                                                has Limited or Restricted
                                                                                                                 Ability to Release Data
                                                                                                                 Related to a Claim, N =
                                                                                                                    No, Provider is Not
                                                                                                                    Allowed to Release
                                                                                                                    Data, O = On file at
                                                                                                                      Payor or at Plan
                                                                                                                    Sponsor, Y = Yes,
                                                                                                                  Provider has a Signed
                                                                                                                  Statement Permitting
                                                                                                                    Release of Medical
                                                                                                                Billing Data Related to a
                                                                                                                           Claim




       Medicare Outpatient Adjudication   MOA                                            S
       Information
                                                Outpatient Reimbursement Rate   MOA01    S    1/10         R
                                                HCPCS Payable Amount            MOA02    S    1/18         R
                                                Remarks Code                    MOA03    S    1/30         AN




                                                                                                      52
                                                                ATTRIBUTES
LOOP   SEGMENT   ELEMENT                USE   Min/M    Data     Codes/Values   Comments
                                               ax      Type

                 Remarks Code   MOA04    S    1/30         AN




                                                      53
                                                                                                   ATTRIBUTES
LOOP    SEGMENT                 ELEMENT                                    USE   Min/M    Data     Codes/Values   Comments
                                                                                  ax      Type

                                Remarks Code                       MOA05    S    1/30         AN




                                Remarks Code                       MOA06    S    1/30         AN
                                Remarks Code                       MOA07    S    1/30         AN
                                ESRD Paid Amount                   MOA08    S    1/18         R
                                NonPayable Professional            MOA09    S    1/18         R
                                Component Billed Amount

2330A   Other Subscriber Name
                                Entity Identifier Code             NM101   R      2/3         ID        IL
                                Entity Type Qualifier              NM102   R      1/1         ID       1, 2
                                Other Insured Last Name or         NM103   R
                                Organization
                                Other Insured First Name           NM104   S     1/25         AN
                                Other Insured Middle Name          NM105   S     1/25         AN
                                Other Insured Suffix               NM107   S     1/10         AN      MI, ZZ
                                Identification Code Qualifier      NM108   R      1/2         ID
                                Other Insured Primary Identifier   NM109   R     2/80         AN




                                                                                         54
                                                                                                                         ATTRIBUTES
LOOP    SEGMENT                                 ELEMENT                                      USE   Min/M    Data         Codes/Values         Comments
                                                                                                    ax      Type

        Additional Other Subscriber Name N2                                                   S                                               Not used by ODS
        Information
                                                Other Insured Additional Name        N201    R     1/60         AN
                                                Information
        Other Subscriber Address          N3
                                                Other Insured Address Line 1         N301    R     1/55         AN
                                                Other Insured Address Line 2         N302    S     1/55         AN
        Other Subscriber City/State/Zip   N4

                                                Other Subscriber City Name           N401    R     2/30         AN      Code Source 22
                                                                                                                       States and Outlying
                                                                                                                        Areas of the U.S.
                                                Other Subscriber State or Province   N402    R      2/2         ID      Code Source 51
                                                                                                                           Zip Code
                                                Other Subscriber Postal Code         N403    R     3/15         ID      Code Source 5:
                                                                                                                      Countries, Currencies
                                                                                                                          and Funds
                                                Other Subscriber Country Code        N404     S     2/3         ID
        Other Subscriber Secondary        REF                                                 S                        1W = Member ID
        Identification                                                                                                Number, 23 = Client
                                                                                                                     Number, IG = Insurance
                                                                                                                      Policy Number, SY =
                                                                                                                              SSN
                                                Identification Code Qualifier        REF01   R      2/3         ID
                                                Other Subscriber Secondary           REF02   R     1/30         AN
                                                Identifier

2330B   Other Payer Name                  NM1                                                R
                                                Entity Identifier Code               NM101   R      2/3         ID             PR
                                                Entity Type Qualifier                NM102   R      1/1         ID              2
                                                Other Payer Organization Name        NM103   R     1/35         AN          PI or XV
                                                Identification Code Qualifier        NM108   R      1/2         ID
                                                Other Payer Primary Identifier       NM109   R     2/80         AN
        Payer Additional Name Information N2                                                 S                                                Not Used by ODS

                                                Other PayerAdditional Name           N201    R     1/60         AN
        Other Payer Contact Information   PER                                                                                  IC

                                                Contact Function Code                PER01   R      2/2         ID



                                                                                                           55
                                                                                                           ATTRIBUTES
LOOP   SEGMENT                         ELEMENT                                  USE   Min/M    Data        Codes/Values         Comments
                                                                                       ax      Type

                                       Other Payer Contact Name         PER02   R     1/60         AN   ED = Electronic Data
                                                                                                        Interchange Access
                                                                                                           Number, EM =
                                                                                                        Electronic Mail, FX =
                                                                                                          Facsimile, TE =
                                                                                                             Telephone
                                       Communication Number Qualifier   PER03   R      2/2         ID
                                       Communication Number             PER04   R     1/80         AN   ED = Electronic Data
                                                                                                        Interchange Access
                                                                                                           Number, EM =
                                                                                                        Electronic Mail, FX =
                                                                                                          Facsimile, TE =
                                                                                                             Telephone
                                       Communication Number Qualifier   PER05    S     2/2         ID
                                       Communication Number             PER06    S    1/80         AN   ED = Electronic Data
                                                                                                        Interchange Access
                                                                                                           Number, EM =
                                                                                                        Electronic Mail, FX =
                                                                                                          Facsimile, TE =
                                                                                                             Telephone
                                       Communication Number Qualifier   PER07    S     2/2         ID
                                       Communication Number             PER08    S    1/80         AN




       Claim Adjudication Date   DTP                                            S
                                       Date/Time Qualifier              DTP01   R      3/3         ID           573




                                       Date/Time Period Format          DTP02   R      2/3         ID        ccyymmdd




                                                                                              56
                                                                                                                          ATTRIBUTES
LOOP    SEGMENT                                  ELEMENT                                      USE   Min/M    Data         Codes/Values          Comments
                                                                                                     ax      Type

                                                 Adjudication or Payment Date         DTP03   R     1/35         AN




        Other Payer Secondary             REF                                                  S
        Identification
                                                 Identification Code Qualifier        REF01   R      2/3         ID   2U = Payer ID Number,
                                                                                                                      F8 = Original Reference
                                                                                                                        Number, FY = Claim
                                                                                                                       Office Number, NF =
                                                                                                                         NAIC Code, TJ =
                                                                                                                       Federal Taypayer's ID
                                                                                                                              Number
                                                 Other Payer Secondary Identifier     REF02   R     1/30         AN
        Other Payer Prior Authorization or REF                                                S
        Referral Number

                                                 Reference Identification Qualifier   REF01   R      2/3         ID          9F or G1
                                                 Other Payer Prior Auth or Referral   REF02   R     1/30         AN
                                                 Number
2330B   Other Payer Claim Adjustment      REF                                                  S
        Indicator
                                                 Reference Identification Qualifier   REF01   R      2/3         ID             T4




                                                 Other Payer Claim Adjustment         REF02   R     1/30         AN
                                                 Indicator
2330C   Other Payer Patient Information   NM1                                                  S

                                                 Entity Identifier Code               NM101   R      2/3         ID            QC
                                                 Entity Type Qualifier                NM102   R      1/1         ID             1
                                                 Patient Last Name                    NM103   R                                                 Change usage from Required to Not Used
                                                 Identification Code Qualifier        NM108   R      1/2         ID             MI




                                                                                                            57
                                                                                                                            ATTRIBUTES
LOOP    SEGMENT                                    ELEMENT                                      USE   Min/M    Data         Codes/Values         Comments
                                                                                                       ax      Type

                                                   Patient's Other Payer Primary        NM109   R     2/80         AN
                                                   Identification Number
        Other Payer Patient Identification                                                                                1W = Member ID
                                                                                                                         Number, 23 = Client
                                                                                                                        Number, IG = Insurance
                                                                                                                         Policy Number, SY =
                                                                                                                                 SSN
                                                   Reference Identification Qualifier   REF01   R      2/3         ID
                                                   Patient's Other Payer Secondary      REF02   R     1/30         AN
                                                   Identifier
2330D   Other Payer Referring Provider       NM1                                                 S

                                                   Entity Identifier Code               NM101   R      2/3         ID          DN, P3
                                                   Entity Type Qualifier                NM102   R      1/1         ID           1, 2
                                                   Referring Provider Last Name or      NM103   R     1/35         AN                            Usage change from Required to Not Used
                                                   Organization
        Other Payer Referring Provider       REF                                                 S
        Identification
                                                   Reference Identification Qualifier   REF01   R      2/3         ID      1B - Blue Shield
                                                                                                                          Provider Number
                                                                                                                        1C - Medicare Provider
                                                                                                                                Number
                                                                                                                        1D - Medicaid Provider
                                                                                                                                Number
                                                                                                                          EI - Employer's ID
                                                                                                                                Number
                                                                                                                             G2 - Provider
                                                                                                                         Commercial Number
                                                                                                                        LU - Location Number
                                                                                                                          N5 - Provider Plan
                                                                                                                         Network ID Number

                                                   Other Payer Referring Provider       REF02   R     1/30         AN
                                                   Identification
2330E   Other Payer Rendering Provider       NM1                                                 S

                                                   Entity Identifier Code               NM101   R      2/3         ID             82
                                                   Entity Type Qualifier                NM102   R      1/1         ID            1, 2




                                                                                                              58
                                                                                                                       ATTRIBUTES
LOOP    SEGMENT                                ELEMENT                                      USE   Min/M    Data        Codes/Values          Comments
                                                                                                   ax      Type

                                               Rendering Provider Last Name or      NM103   R     1/35         AN                            Usage change from Required to Not Used
                                               Organization
        Other Payer Rendering Provider   REF                                                 S
        Secondary Identification

                                               Reference Identification Qualifier   REF01   R      2/3         ID      1B - Blue Shield
                                                                                                                      Provider Number
                                                                                                                    1C - Medicare Provider
                                                                                                                            Number
                                                                                                                    1D - Medicaid Provider
                                                                                                                            Number
                                                                                                                      EI - Employer's ID
                                                                                                                            Number
                                                                                                                         G2 - Provider
                                                                                                                     Commercial Number
                                                                                                                    LU - Location Number
                                                                                                                      N5 - Provider Plan
                                                                                                                     Network ID Number
                                               Other Payer Rendering Provider       REF02   R     1/30         AN
                                               Secondary Identification
2330F   Other Payer Purchased Service    NM1                                                 S
        Provider
                                               Entity Identifier Code               NM101   R      2/3         ID            QB
                                               Entity Type Qualifier                NM102   R      1/1         ID            1, 2
                                               Purchased Service Provider Last      NM103   R     1/35         AN                            Usage change from Required to Not Used
                                               Name or Organization
        Other Payer Purchased Service    REF                                                 S
        Provider Identification

                                               Reference Identification Qualifier   REF01   R      2/3         ID      1A = Blue Cross
                                                                                                                      Provider Number
                                                                                                                       1B - Blue Shield
                                                                                                                      Provider Number
                                                                                                                    1C - Medicare Provider
                                                                                                                            Number
                                                                                                                    1D - Medicaid Provider
                                                                                                                            Number
                                                                                                                      EI - Employer's ID
                                                                                                                            Number



                                                                                                          59
                                                                                                                         ATTRIBUTES
LOOP    SEGMENT                                  ELEMENT                                      USE   Min/M    Data        Codes/Values          Comments
                                                                                                     ax      Type

                                                                                                                          G2 - Provider
                                                                                                                       Commercial Number
                                                                                                                      LU - Location Number
                                                                                                                        N5 - Provider Plan
                                                                                                                       Network ID Number
                                                 Other Payer Rendering Provider       REF02   R     1/30         AN
                                                 Secondary Identification
2330G   Other Payer Service Facility       NM1                                                 S
        Location
                                                 Entity Identifier Code               NM101   R      2/3         ID   77 = Service Location,
                                                                                                                         FA = Facility, LI =
                                                                                                                      Independent Lab, TL =
                                                                                                                           Testing Lab
                                                 Entity Type Qualifier                NM102   R      1/1         ID             2
                                                 Service Facility Name                NM103   R     1/25         AN                            Usage change from Required to Not Used
        Other Payer Service Facility       REF                                                S
        Location Identification
                                                 Reference Identification Qualifier   REF01   R      2/3         ID      1A = Blue Cross
                                                                                                                        Provider Number
                                                                                                                         1B - Blue Shield
                                                                                                                        Provider Number
                                                                                                                      1C - Medicare Provider
                                                                                                                              Number
                                                                                                                      1D - Medicaid Provider
                                                                                                                              Number
                                                                                                                        EI - Employer's ID
                                                                                                                              Number
                                                                                                                           G2 - Provider
                                                                                                                       Commercial Number
                                                                                                                      LU - Location Number
                                                                                                                        N5 - Provider Plan
                                                                                                                       Network ID Number
                                                 Other Payer Service Facility         REF02   R     1/30         AN
                                                 Location Identification
2330H   Other Payer Supervising Provider   NM1                                                 S

                                                 Entity Identifier Code               NM101   R      2/3         ID            DQ
                                                 Entity Type Qualifier                NM102   R      1/1         ID             1
                                                 Supervising Provider Last Name       NM103   R     1/35         AN                            Usage change from Required to Not Used



                                                                                                            60
                                                                                                                            ATTRIBUTES
LOOP    SEGMENT                                  ELEMENT                                        USE   Min/M    Data         Codes/Values           Comments
                                                                                                       ax      Type

        Other Payer Supervising Provider   REF                                                   S
        Identification
                                                 Reference Identification Qualifier   REF01     R      2/3         ID      1B - Blue Shield
                                                                                                                          Provider Number
                                                                                                                        1C - Medicare Provider
                                                                                                                                Number
                                                                                                                        1D - Medicaid Provider
                                                                                                                                Number
                                                                                                                          EI - Employer's ID
                                                                                                                                Number
                                                                                                                             G2 - Provider
                                                                                                                         Commercial Number
                                                                                                                        LU - Location Number
                                                                                                                          N5 - Provider Plan
                                                                                                                         Network ID Number
                                                 Other Payer Supervising Provider     REF02     R     1/30         AN
                                                 Identification

   2400 Service Line                       LX                                                   R
                                                 Line Counter                         LX01      R      1/6         N0
        Professional Service               SV1                                                  R
                                                 Procedure Identifier                 SV101     R
                                                 Product or Service ID Qualifier      SV101-1   R      2/2         ID    HC = HCPCS Codes;         Additional Note: Code IV is not allowed for use under HIPAA, though it remains on
                                                                                                                              IV=HEIC;             the list. Codes N1, N2 and N3 --all different versions of the NDC codes--were deleted.
                                                                                                                         N4=NDC;ZZ=Mutually        New Note for Code N4: Only used if J Codes are not allowed for use under HIPAA.
                                                                                                                               Defined             Previouly there was not a note.
                                                 Procedure Code                       SV101-2   R     1/48         AN
                                                 Procedure Modifier 1                 SV101-3   S      2/2         AN

                                                 Procedure Modifier 2                 SV101-4    S     2/2         AN

                                                 Procedure Modifier 3                 SV101-5    S     2/2         AN

                                                 Procedure Modifier 4                 SV101-6    S     2/2         AN

                                                 Line Item Charge Amount              SV102     R     1/18         R
                                                 Unit or Basis For Measurement        SV103     S      2/2         ID   F2 = International Unit;   New Note Added to Code MJ: Required for Anesthesia Claims
                                                                                                                        MJ = Minutes; UN = Unit




                                                                                                              61
                                                                                                               ATTRIBUTES
LOOP   SEGMENT                           ELEMENT                                   USE   Min/M    Data         Codes/Values          Comments
                                                                                          ax      Type

                                         Units or Minutes                SV104      S    1/15         R
                                         Place of Service Code           SV105      S     1/2         AN
                                         Diagnosis Code Pointer          SV107
                                         Diagnosis Code Pointer          SV107-1   R      1/2         N0

                                         Diagnosis Code Pointer          SV107-2   R      1/2         N0

                                         Diagnosis Code Pointer          SV107-3   R      1/2         N0

                                         Diagnosis Code Pointer          SV107-4   R      1/2         N0

                                         Emergency Indicator             SV109      S     1/1         ID           Y or N            Usage of the Emergency Indicator now Situational rather than Required. New Note:
                                                                                                                                     Required when the service is k own to be an emergency by the provider. There was
                                                                                                                                     no previous note. Code Change: Code N has been deleted. Previously the values
                                                                                                                                     were N or Y.
                                         EPSDT Indicator                 SV109     R      1/1         ID             Y
                                         Family Planning Indicator       SV109     R      1/1         ID         Y or blank
                                         CoPay Waiver                    SV109     R      1/1         ID

       Durable Medical Equipment   SV5                                              S                                                Segement SV5 is a new segment
       Service
                                         Composite Medical Procedure     SV501     R                                HC
                                         Identifier
                                         Procedure Identifier            SV501-1   R      2/2         ID   Must be the same value
                                                                                                               as in SV101-2
                                         Procedure Code                  SV501-2   R     1/48         AN             DA

                                         Unit or Basis for Measurement   SV 502    R      2/2         ID
                                         Length of Medical Necessity     SV503     R     1/15         R
                                         DME Rental Price                SV504     S     1/18         R    1 = Weekly; 4= Monthly;
                                                                                                                  6= Daily
                                         DME Purchase Price              SV505     S     1/18         R
                                         Rental Unit Price Indicator     SV506     S      1/1         ID
       DMERC CMN Indicator         PWK                                             S
                                         DMERC Report Type Code          PWK01     R      2/2         ID             CT




                                                                                                 62
                                                                                                                    ATTRIBUTES
LOOP   SEGMENT                                 ELEMENT                                 USE   Min/M    Data          Codes/Values             Comments
                                                                                              ax      Type

                                               Attachment Transmission Code    PWK02   R      1/2         ID        AB = Previously
                                                                                                               Submitted to Payer, AD
                                                                                                                = Certification Included
                                                                                                                  in this Claim, AF =
                                                                                                                  Narrative Segment
                                                                                                                Included in this Claim,
                                                                                                               AG = No Documentation
                                                                                                                is Required, NS = Not
                                                                                                                        Specified


       Ambulance Transport Information   CR1                                            S

                                               Unit or Basis for Measurement   CR101   S      2/2         ID
                                               Patient Weight                  CR102   S     1/10         R
                                               Ambulance Transport Code        CR103   R      1/1         ID      I = Initial Trip, R =
                                                                                                               Return Trip, T = Transfer
                                                                                                                Trip, X = Return Trip

                                               Ambulance Transport Reason Code CR104   R      1/1         ID        A = Patient was
                                                                                                                transported to nearest
                                                                                                                   facility for care of
                                                                                                                symptoms, complaints,
                                                                                                               or both, B = Patient was
                                                                                                                  transported for the
                                                                                                                 benefit of a preferred
                                                                                                                 physician, C = Patient
                                                                                                                was transported for the
                                                                                                                  nearness of family
                                                                                                                 members, D = Patient
                                                                                                                was transported for the
                                                                                                               care of a specialist or for
                                                                                                               availablity of specialized
                                                                                                                       equipment




                                                                                                     63
                                                                                                             ATTRIBUTES
LOOP   SEGMENT                             ELEMENT                                  USE   Min/M    Data      Codes/Values    Comments
                                                                                           ax      Type

                                           Unit or Basis for Measurement    CR105   R      2/2         ID        DH




                                           Transport Distance               CR106   R     1/15         R
                                           Round Trip Purpose Description   CR107   S     1/80         AN
                                           Stretcher Purpose Description    CR108   S     1/80         AN
       Spinal Manipulation Service   CR2                                            S
       Information



                                           Treatment Number, Spinal         CR201   R      1/9         N0
                                           Manipulation




                                           Treatment Count, Total           CR202   R     1/15         R
                                           Subluxation Level Code           CR203   S      2/3         ID   See IG 252-253
                                           Subluxation Level Code           CR204   S      2/3         ID   See IG 253-254
                                           Unit or Basis for Measurement    CR205   R      2/2         ID   DA, MO, WK, YR   Data Element changed from Situational to Not Used
                                           Treatment Period Count           CR206   R     1/15         R                     Data Element changed from Situational to Not Used
                                           Monthly Treatment Count          CR207   R     1/15         R                     Data Element changed from Situational to Not Used
                                           Patient Condition Code           CR208   R      1/1         ID     See IG 255
                                           Complication Indicator           CR209   R      1/1         ID                    Data Element changed from Situational to Not Used




                                                                                                  64
                                                                                                                      ATTRIBUTES
LOOP   SEGMENT                                ELEMENT                                     USE   Min/M    Data         Codes/Values            Comments
                                                                                                 ax      Type

                                              Patient Description                 CF210    S    1/80         AN            Y or N
                                              Patient Description                 CR211    S    1/80         AN
                                              Xray Availability Indicator         CR212    S     1/1         ID            Y or N             Usage change from Required to Situational. New Note: Reqired for service dates
                                                                                                                                              prior to January 1, 2000
       Durable Medical Equipment Cert   CR3                                                S

                                              Certification Type Code             CR301   R      1/1         ID   I = Initial, R = Renewal,
                                                                                                                         S = Revised
                                              Unit or Basis For Measurement       CR302   R      2/2         ID                MO
                                              Quantity                            CR303   R     1/15         R
       Home Oxygen Therapy Information CR5

                                              Certification Type Code             CR501   R      1/1         ID   I = Initial, R = Renewal,
                                                                                                                         S = Revised
                                              Certification Period; Home 02       CR502   R     1/15         R
                                              Arterial Blood Gas Quantity         CR510   R     1/15         R
                                              Oxygen Saturation Quantity          CR511   R     1/15         R
                                              Oxygen Test Condition Code          CR512   R      1/1         ID   E = Exercising, R = At
                                                                                                                   rest on room air, S =
                                                                                                                         Sleeping
                                              Oxygen Test Findings Code           CR513    S     1/1         ID              1
                                              Oxygen Test Findings Code           CR514    S     1/1         ID              2
                                              Oxygen Test Findings Code           CR515    S     1/1         ID              3
       Ambulance Certification
                                        CRC                                               S
                                              Ambulance Certification Code        CRC01   R      2/2         ID
                                              Certification Condition Indicator   CRC02   R      1/1         ID




                                                                                                        65
                                                                                               ATTRIBUTES
LOOP   SEGMENT                            ELEMENT                  USE   Min/M    Data         Codes/Values            Comments
                                                                          ax      Type

                                          Condition Code   CRC03   R      2/2         ID        01 = Patient was
                                                                                            admitted to a hospital,
                                                                                             02 = Patent was bed
                                                                                              confined before the
                                                                                           ambulance service, 03 =
                                                                                                Patient was bed
                                                                                               confined after the
                                                                                           ambulance service, 04 =
                                                                                            Patient was moved by
                                                                                            stretcher, 05 = Patient
                                                                                            was unconscious or in
                                                                                           shock, 06 = Patient was
                                                                                               transported in an
                                                                                           emergency situation, 07
                                                                                              = Patient had to be
                                                                                           physically restrained, 08
                                                                                             = Patient had visible
                                                                                             hemorrhaging, 09 =
                                                                                           Ambulance service was
                                                                                           medically necessary, 60
                                                                                           = Transportation was to
                                                                                              the Nearest Facility




                                          Condition Code   CRC04    S     2/2         ID         See CRC03
                                          Condition Code   CRC05    S     2/2         ID         See CRC03
                                          Condition Code   CRC06    S     2/2         ID         See CRC03
                                          Condition Code   CRC07    S     2/2         ID         See CRC03
       Hospice Employee Indicator   CRC                             S




                                                                                 66
                                                                                                                  ATTRIBUTES
LOOP   SEGMENT                           ELEMENT                                     USE   Min/M    Data          Codes/Values           Comments
                                                                                            ax      Type

                                         Code Catetogy                       CRC01   R      2/2         ID              70




                                         Certification Condition Indicator   CRC02   R      1/1         ID            Y or N
                                         Condition Code                      CRC03   R      2/2         ID              65
       DMERC Condition Indicator   CRC                                               S
                                         Code Catetogy                       CRC01   R      2/2         ID               09, 11
                                         Certification Condition Indicator   CRC02   R      1/1         ID               Y or N
                                         Condition Indicator                 CRC03   R      2/2         ID     37 = Oxygen delivery
                                                                                                             equipment is stationary,
                                                                                                             38 = Certification signed
                                                                                                               by the physician is on
                                                                                                                file at the supplier's
                                                                                                              office, AL = Ambulation
                                                                                                             Limitations, P1 = Patient
                                                                                                             was Discharged from the
                                                                                                                 First Facility, ZV =
                                                                                                                 Replacement Item




                                                                                                   67
                                                                                                                    ATTRIBUTES
LOOP   SEGMENT                                  ELEMENT                                     USE   Min/M    Data     Codes/Values   Comments
                                                                                                   ax      Type

                                                Condition Indicator                 CRC03   R      2/2         ID
                                                Condition Indicator                 CRC04   S      2/2         ID
                                                Condition Indicator                 CRC05   S      2/2         ID
                                                Condition Indicator                 CRC06   S      2/2         ID
       Date-Service Date                  DTP                                               S
                                                Date/Time Qualifier                 DTP01   R      3/3         ID       472




                                                Date/Time Period Format Qualifier   DTP02   R      2/3         ID     D8, RD8
                                                Service Date                        DTP03   R     1/35         AN
       Date-Certification Revision Date   DTP                                               S

                                                Date/Time Qualifier                 DTP01   R      3/3         ID       607
                                                Date/Time Period Format Qualifier   DTP02   R      2/3         ID       D8
                                                Certification Revision Date         DTP03   R     1/35         AN
       Date-Referral Date                 DTP                                               S                                      Segment DTP for Referral deleted
                                                Date/Time Qualifier                 DTP01   R      3/3         ID       330
                                                Date/Time Period Format Qualifier   DTP02   R      2/3         ID       D8
                                                Referral Date                       DTP03   R     1/35         AN
       Date - Begin Therapy Date          DTP                                               S                           D8
                                                Date/Time Qualifier                 DTP01   R      3/3         ID       463
                                                Date/Time Period Format Qualifier   DTP02   R      2/3         ID       D8
                                                Begin Therapy Date                  DTP03   R     1/35         AN
       Date - Last Certification Date     DTP                                               S
                                                Date/Time Qualifier                 DTP01   R      3/3         ID       461
                                                Date/Time Period Format Qualifier   DTP02   R      2/3         ID       D8
                                                Date - Last Certification Date      DTP03   R     1/35         AN
       Date--Order Date                   DTP                                               S                                      Segment DTP for Order Date deleted
                                                Date/Time Qualifier                 DTP01   R      3/3         ID       938
                                                Date/Time Period Format Qualifier   DTP02   R      2/3         ID       D8
                                                Order Date                          DTP03   R     1/35         AN




                                                                                                          68
                                                                                                                 ATTRIBUTES
LOOP   SEGMENT                          ELEMENT                                      USE   Min/M    Data         Codes/Values           Comments
                                                                                            ax      Type

       Date -- Date Last Seen     DTP                                                 S                                                 Note now reads: Required when Medicare Part B claims involve services from an
                                                                                                                                        independent physical therapist, occupational therapist, or physician services involving
                                                                                                                                        routine foot care and is different thatn the date listsed at the claim level (Loop-ID
                                                                                                                                        2300) Previously read: Required when claims is from an independent ......

                                        Date/Time Qualifier                 DTP01    R      3/3         ID             304
                                        Date/Time Period Format Qualifier   DTP02    R      2/3         ID             D8
                                        Lastest Visit or consult            DTP03    R     1/35         AN
       Date--Test                 DTP                                                S
                                        Date/Time Qualifier                 DTP01    R      3/3         ID          738, 739
                                        Date/Time Period Format Qualifier   DTP02    R      2/3         ID            D8
                                        Test Performed Date                 DTP03    R     1/35         AN
       Date--O2 Sat/ABG           DTP                                                S
                                        Date/Time Qualifier                 DTP01    R      3/3         ID    119 = Test Performed,
                                                                                                             480 = Arterial Blood Gas
                                                                                                               Test, 481 = Oxygen
                                                                                                                 Saturation Test

                                        Date/Time Period Format Qualifier   DTP02    R      2/3         ID             D8
                                        Oxygen Saturation Test Done         DTP03    R     1/35         AN
       Date-Shipped               DTP                                                S
                                        Date/Time Qualifier                 DTP01    R      3/3         ID             011
                                        Date/Time Period Format Qualifier   DTP02    R      2/3         ID             D8
                                        Shipped Date                        DTP03    R     1/35         AN
       Date Onset of Current      DTP                                                S
       Illness/Symptom
                                        Date/Time Qualifier                  DTP01   R      3/3         ID             431
                                        Date/Time Period Format Qualifier DTP02      R      2/3         ID             D8
                                        Onset of Current Illness/Injury Date DTP03   R     1/35         AN

       Date--Last Xray            DTP                                                S
                                        Date/Time Qualifier                 DTP01    R      3/3         ID             455
                                        Date/Time Period Format Qualifier   DTP02    R      2/3         ID             D8
                                        Last Xray Date                      DTP03    R     1/35         AN
       Date-Acute Manifestation   DTP                                                S
                                        Date/Time Qualifier                 DTP01    R      3/3         ID             374
                                        Date/Time Period Format Qualifier   DTP02    R      2/3         ID             D8
                                        Acute Manifestation Date            DTP03    R     1/35         AN
       Date Initial Treatment     DTP                                                S



                                                                                                   69
                                                                                                                     ATTRIBUTES
LOOP   SEGMENT                               ELEMENT                                     USE   Min/M    Data         Codes/Values           Comments
                                                                                                ax      Type

                                             Date/Time Qualifier                 DTP01   R      3/3         ID             454
                                             Date/Time Period Format Qualifier   DTP02   R      2/3         ID             D8
                                             Initial Treatment Date              DTP03   R     1/35         AN
       Date--Similar Illness/Symptom   DTP                                               S
       Onset
                                             Date/Time Qualifier                 DTP01   R      3/3         ID             438
                                             Date/Time Period Format Qualifier   DTP02   R      2/3         ID             D8
                                             Date--Similar Illness/Symptom       DTP03   R     1/35         AN
                                             Onset
       Anesthesia Modifying Units      QTY                                               S                                                  Segment for Anesthesia Quantity deleted
                                             Quantity Qualifier                  QTY01   R      2/2         ID
                                             Anesthesia Modifying Units          QTY02   R     1/15         R
       Test Result                     MEA                                               S                                                  Note #1 Changed: Required on service lines for Dialysis for ESRD. Use R1, R2, R3,
                                                                                                                                            R4 to qualify the Hemoglobin, hematocrit, Epoetin Starting Dosage and Creatinine test
                                                                                                                                            results. New Notes: #2 Required on Osygent Therapy service lines to reprt the O2
                                                                                                                                            Saturation measurement from the CMN. Use ZO qualifier. #3. Required on O2
                                                                                                                                            Therapy service lines to report the ABG measurement from the CMN. Use GRA
                                                                                                                                            Qualifier. 4. Required on DMERC service lines to report the Patient's height from the
                                                                                                                                            CMN. Use HT qualifier.
                                             Measurement Reference ID Code       MEA01   R      2/2         ID         OG, TR
                                             Measurement Qualifier               MEA02   R      1/3         ID   CON = Concentration,       Code CON Deleted
                                                                                                                 GRA = Gas Test Rate;
                                                                                                                   HT = Heiight; R1=
                                                                                                                     Hemoglobin;;
                                                                                                                    R2=Hematocrit;
                                                                                                                  R3=Epoetin Starting
                                                                                                                 Dosage; R4=Creatin;
                                                                                                                     ZO=Osygen
                                             Test Results                        MEA03   R     1/20         R                               Note Change: NSF Reference Note
       Contract Information            CN1                                               S
                                             Contract Type Code                  CN101   R      2/2         ID   01 = Diagnosis Related
                                                                                                                  Group, 02 = Per Diem,
                                                                                                                 03 = Variable Per Diem,
                                                                                                                     04 = Flat, 05 =
                                                                                                                 Capitated, 06 = Percent,
                                                                                                                        09 = Other


                                             Contract Amount                     CN102    S    1/18         R
                                             Contract Percentage                 CN103    S     1/6         R



                                                                                                       70
                                                                                                                     ATTRIBUTES
LOOP   SEGMENT                                  ELEMENT                                      USE   Min/M    Data     Codes/Values   Comments
                                                                                                    ax      Type

                                                Contract Code                        CN104    S    1/30         AN




                                                Terms Discount Percentage            CN105    S     1/6         R

                                                Contract Version Identifier          CN106    S    1/30         AN
       Repriced Line Item Reference No.   REF                                                 S




                                                Reference Identification Qualifier   REF01   R      2/3         ID       9B
                                                Repriced Line Item Reference No.     REF02   R     1/30         AN

       Adjusted Repriced Line Item        REF                                                 S
       Reference Number
                                                Reference Identification Qualifier   REF01   R      2/3         ID       9D
                                                Adjusted Repriced Line Item          REF02   R     1/30         AN
                                                Reference Number
       Prior Authorization or Referral    REF                                                 S
       Number
                                                Reference Identification Qualifier   REF01   R      2/3         ID     9F or G1
                                                Prior Auth or Referral Number        REF02   R     1/30         AN
       Line Item Control Number           REF
                                                Reference Identification Qualifier   REF01   R      2/3         ID       6R
                                                Line Item Control Number             REF02   R     1/30         AN
       Mammography Certification          REF                                                                                       Note Now reads: Required when mammography services are rendered by a certified
       Number                                                                                                                       mammography provider. Previously read: Required for Medicare Claims for all
                                                                                                                                    mammography services .
                                                Reference Identification Qualifier   REF01   R      2/3         ID       EW
                                                Mammography Certification NO         REF02   R     1/30         AN
       CLIA Number                        REF
                                                Reference Identification Qualifier   REF01   R      2/3         ID       X4
                                                CLIA Number                          REF02   R     1/30         AN



                                                                                                           71
                                                                                                                    ATTRIBUTES
LOOP   SEGMENT                           ELEMENT                                        USE   Min/M    Data         Codes/Values           Comments
                                                                                               ax      Type

       Referring CLIA Facility     REF
       Identification
                                         Reference Identification Qualifier     REF01   R      2/3         ID             F4
                                         Referring CLIA Facility Identification REF02   R     1/30         AN

       Immunization Batch Number   REF
                                         Reference Identification Qualifier   REF01     R      2/3         ID             BT
                                         Immunization Batch Number            REF02     R     1/30         AN
       Ambulatory Patient Group    REF
                                         Reference Identification Qualifier   REF01     R      2/3         ID             1S
                                         Ambulatory Patient Group Number      REF02     R     1/30         AN

       Oxygen Flow Rate            REF
                                         Reference Identification Qualifier   REF01     R      2/3         ID             TP
                                         Oxygen Flow Rate                     REF02     R     1/30         AN
       Universal Product Number    REF
                                         Reference Identification Qualifier   REF01     R      2/3         ID          OZ or VP
                                         Universal Product Number             REF02     R     1/30         AN
       Sales Tax Amount            AMT                                                  S
                                         Tax Amount Qualifier Code            AMT01     R      1/3         ID              T
                                         Sales Tax Amount                     AMT02     R     1/18         R
       Approved Amount             AMT
                                         Approved Amount Qualifer Code        AMT01     R      1/3         ID            AAE
                                         Approved Amount                      AMT02     R     1/18         R
       Postage Claimed Amount      AMT                                                  S
                                         Postage Paid Qualifier               AMT01     R      1/3         ID             F4
                                         Postage Claimed Amount               AMT02     R     1/18         R
       File Information            K3                                                   S
                                         Fixed Format Information             K301      R     1/80         AN
       Line Note                   NTE                                                  S
                                         Note Reference Code                  NTE01     R      3/3         ID       ADD = Additional
                                                                                                                  Information, DCP =
                                                                                                                Goals, Rehab Potential,
                                                                                                                  or Discharge Plans,
                                                                                                                PMT = Payment, TPO =
                                                                                                                Third Party Organization


                                         Line Note Text                       NTE02     R     1/80         AN




                                                                                                      72
                                                                                                               ATTRIBUTES
LOOP   SEGMENT                               ELEMENT                                USE   Min/M    Data        Codes/Values         Comments
                                                                                           ax      Type

       Purchased Service Information   PS1                                           S                                              Note #2 Changed to Read: Required on service lines when the purchased service
                                                                                                                                    charge amount is necessary for processing. Previously Read: Required on service
                                                                                                                                    lines involving purchased services/tests if different than the information fiven at the
                                                                                                                                    claims level (Loop ID=2310C). New Note: #3. Use this segment on vision claims
                                                                                                                                    when the acquisition cost of lenses is known to impact adjudication or reimbursement.


                                             Purchased Service Provider     AMT01   R     1/30         AN
                                             Identifier
                                             Purchased Service Charge Amt   AMT02   R     1/18         R
       Health Care Services Delivery   HSD                                          S
                                             Visits                         HSD01   S      2/2         ID            VS




                                             Number of Visits               HSD02    S    1/15         R
                                             Frequency Period               HSD03    S     2/2         ID     DA = Days, MO =
                                                                                                            Months, Q1 = Quarter
                                                                                                             (Time), WK = Week
                                             Frequency Count                HSD04    S     1/5         R
                                             Duration of Visitis Units      HSD05    S     1/2         ID   7 = Week, 34 = Month,
                                                                                                                 35 = Week
                                             Duration of Visitis Units      HSD06    S     1/3         ID




                                                                                                  73
                                                                                         ATTRIBUTES
LOOP   SEGMENT   ELEMENT                                     USE   Min/M    Data         Codes/Values           Comments
                                                                    ax      Type

                 Ship, Delivery or Clendar Pattern   HSD07    S     1/2         ID    1 = 1st Week of Month,
                 Code                                                                 2= 2nd Week of Month,
                                                                                      3 = 3rd Week of Month,
                                                                                      4 = 4th Week of Month,
                                                                                      5 = 5th Week of Month,
                                                                                      6 = 1st & 3rd Weeks of
                                                                                     the Month, 7 = 2nd & 4th
                                                                                     Weeks of the Month, A =
                                                                                     Moday through Friday, B
                                                                                          = Monday through
                                                                                       Saturday, C = Monday
                                                                                        through Sunday, D =
                                                                                     Monday, E = Tuesday, F
                                                                                         = Wednesday, G =
                                                                                      Thursday, H = Friday, J
                                                                                     = Saturday, K = Sunday,
                                                                                         L = Monday through
                                                                                          Thursday, N = As
                                                                                     Directed, O = Daily Mon.
                                                                                       through Fri., S = Once
                                                                                       any time Mon. through
                                                                                          Fri., SA = Sunday,
                                                                                         Monday, Thrusday,
                                                                                      Friday, Saturday, SB =
                                                                                           Tuesday through
                                                                                     Saturday, SC = Sunday,
                                                                                      Wednesday, Thursday,
                                                                                      Friday, Saturday, SD =
                                                                                       Monday, Wednesday,
                                                                                          Thursday, Friday,
                                                                                      Saturday, SG= Tuesday
                                                                                        through Friday, SL =
                                                                                       Monday, Tuesday and
                                                                                     Thursday, SP = Monday,
                                                                                      Tuesday and Friday, SX
                                                                                          = Wednesday and
                                                                                                Thursday




                                                                           74
                                                                                                                     ATTRIBUTES
LOOP   SEGMENT                                  ELEMENT                                 USE   Min/M    Data          Codes/Values           Comments
                                                                                               ax      Type

                                                                                                                    SY = Monday,
                                                                                                                   Wednesday and
                                                                                                                    Thursday, SZ =
                                                                                                                Tuesday, Thursday and
                                                                                                                Friday, W = Whenever
                                                                                                                      Necessary
                                                Delivery Pattern Time Code      HSD08    S     1/1         ID   D = A.M., E = P.M., F =
                                                                                                                     As Directed

       Line Pricing/Repricing Information HCP                                            S

                                                Pricing/Repricing Methodology   HCP01   R      2/2         ID    00 = Zero Pricing, 01 =
                                                                                                                    Priced as Billed at
                                                                                                                100%, 02 = Priced at the
                                                                                                                Standard Fee Schedule,
                                                                                                                     03 = Priced at a
                                                                                                                Contractual Percentage,
                                                                                                                04 = Bundled Pricing, 05
                                                                                                                 = Peer Review Pricing,
                                                                                                                 06 = Per Diem Pricing,
                                                                                                                 07 = Flat Rate Pricing,
                                                                                                                    08 = Combination
                                                                                                                 Pricing, 09 = Maternity
                                                                                                                   Pricing, 10 = Other
                                                                                                                  Pricing, 11 = Lower of
                                                                                                                Cost, 12 = Ratio of Cost,
                                                                                                                 13 = Cost Reimbursed,
                                                                                                                14 = Adjustment Pricing




                                                Repriced Allowed Amount         HCP02   R     1/18         R




                                                                                                      75
                                                                         ATTRIBUTES
LOOP   SEGMENT   ELEMENT                          USE   Min/M    Data    Codes/Values   Comments
                                                         ax      Type

                 Repriced Saving Amount   HCP03    S    1/18         R




                                                                76
                                                                                          ATTRIBUTES
LOOP   SEGMENT   ELEMENT                                     USE   Min/M    Data          Codes/Values           Comments
                                                                    ax      Type

                 Repricing Organization Identifier   HCP04    S    1/30         AN




                 Repricing PerDiem or Flat Rate Amt HCP05     S     1/9         R

                 Repriced Approved APG Code          HCP06    S    1/30         AN
                 Repriced Approved APG Amt           HCP07    S    1/18         R
                 Reject Reason Code                  HCP13    S     2/2         ID     T1 = Cannot Identify
                                                                                         Provider as TPO
                                                                                     Participant, T2 = Cannot
                                                                                      Identify Payer as TPO
                                                                                     Participant, T3 = Cannot
                                                                                     Identify Insured as TPO
                                                                                      Participant, T4 = Payer
                                                                                        Name or Identifier
                                                                                           Missing, T5 =
                                                                                     Certification Information
                                                                                       Missing, T6 = Claim
                                                                                     does not contain enough
                                                                                     information for repricing




                 Policy Compliance Code              HCP14    S     1/2         ID   1 = Procedure Followed,
                                                                                      2 = Not Followed - Call
                                                                                        Not Made, 3 = Not
                                                                                      Medically Necessary, 4
                                                                                     = Not Followed Other, 5
                                                                                      = Emergency Admit to
                                                                                      Non-Network Hospital




                                                                           77
                                                                                                    ATTRIBUTES
LOOP   SEGMENT                     ELEMENT                              USE   Min/M    Data         Codes/Values           Comments
                                                                               ax      Type

                                   Exception Code               HCP15    S     1/2         ID       1 = Non-Network
                                                                                                Professional Provider in
                                                                                                 Network Hospital, 2 =
                                                                                                 Emergency Care, 3 =
                                                                                                 Services or Specialist
                                                                                                not in Network, 4 = Out-
                                                                                                  of-Service Area, 5 =
                                                                                                 State Mandates, 6 =
                                                                                                         Other



2410   Drug Identification   LIN                                         S                                                 Note #1. Required when NDC usage is necessary to further define the service
                                                                                                                           provided in SV101-2. Note #2: Use Loop ID 2410 to specify billing/reporting for
                                                                                                                           drugs provided that may be part of the service(s) described in SV1.

                                   Product/Service Identifier   LIN02   R      2/2         ID             N4
                                   National Drug Code           LIN03   R     1/48         AN




       Drug Pricing          CTP                                         S                                                 Requried when it is necessary to provide a price specific to the NDC provided in LIN03
                                                                                                                           that is different than the price reported in SV102




                                                                                      78
                                                                                                                     ATTRIBUTES
LOOP    SEGMENT                              ELEMENT                                     USE   Min/M    Data         Codes/Values            Comments
                                                                                                ax      Type

                                             Drug Unit Price                   CTP03     R     1/17         R




                                             National Drug Unit Count          CTP04     R     1/15         R
                                             Unit/Basis of Measurement         CTP05     R
                                             Code Qualifier                    CTP05-1   R      2/2         ID     GR= Grams; ME=
                                                                                                                 milligram; ML=Milliliter;
                                                                                                                         UN= Unit
        Prescription Number            REF                                                S                                                  #1. Required if dispensing of the drug has been done with an assigned Rx number.
                                                                                                                                             #2. In cases where a compound drug is being billed, the componenets of the
                                                                                                                                             compound will all have the same prescription number. Payers receving the claim can
                                                                                                                                             relate all the componenets by matching the prescription number.

                                             Code Qualifier                    REF01     R      1/1         ID             XZ
                                             Prescription Number               REF02     R     1/30         AN



2420A   Rendering Provider Name        NM1                                               S                                                   Usage change from Required to situational
                                             Entity Identifier Code            NM101     R      2/3         ID              82
                                             Entity Type Qualifier             NM102     R      1/1         ID             1, 2
                                             Rendering Provider Last Name or   NM103     R
                                             Organization
                                             Rendering Provider First Name     NM104     S     1/25         AN
                                             Rendering Provider Middle Name    NM105     S     1/25         AN
                                             Rendering Provider Suffix         NM107     S     1/25         AN
                                             Identification Code Qualifier     NM108     R      1/2         ID     24 = Employer's ID
                                                                                                                   Number, 34 = SSN
                                             Rendering Provider Primary        NM109     R     2/80         AN
                                             Identifier
        Rendering Provider Specialty   PRV                                               R                                                   Taxonomy Codes are required on all claims. Required at the claim level when the
        Information                                                                                                                          Rendering Provider is the same entity as the Billing and/or Pay-to Provider. In these
                                                                                                                                             cases, the Rendering Provider is being identified at this level for all subsequent
                                                                                                                                             claims/encounters in this HL and LoopID-2310B is not used.




                                                                                                       79
                                                                                                                      ATTRIBUTES
LOOP    SEGMENT                               ELEMENT                                      USE   Min/M    Data        Codes/Values          Comments
                                                                                                  ax      Type

                                              Provider Code                        PRV01   R      1/3         ID            PE
                                              Reference Identification Qualifier   PRV02   R      2/3         ID            ZZ
                                              Provider Taxonomy Code               PRV03   R     1/30         AN
        Additional Rendering Name      N2                                                  S                                                Not Used by ODS
        Information
                                              Rendering Provider Additional Name N201      R     1/60         AN

        Rendering Provider Secondary   REF
        Identification
                                              Identification Code Qualifier        REF01    S     2/3         ID     OB - State License
                                                                                                                           Number
                                                                                                                      1B - Blue Shield
                                                                                                                      Provider Number
                                                                                                                   1C - Medicare Provider
                                                                                                                           Number
                                                                                                                   1D - Medicaid Provider
                                                                                                                           Number
                                                                                                                    1G - Provider UPIN
                                                                                                                           Number
                                                                                                                     1H - CHAMPUS ID
                                                                                                                           Number
                                                                                                                     EI - Employer's ID
                                                                                                                           Number
                                                                                                                        G2 - Provider
                                                                                                                    Commercial Number
                                                                                                                   LU - Location Number
                                                                                                                     N5 - Provider Plan
                                                                                                                    Network ID Number
                                                                                                                          SY - SSN
                                                                                                                    X5 - State Industrial
                                                                                                                      Accident Provider
                                                                                                                           Number
                                              Rendering Provider Primary           REF02    S    1/30         AN
                                              Identifier

2420B   Purchased Service Provider Name NM1                                                 S

                                              Entity Identifier Code               NM101   R      2/3         ID            QB
                                              Entity Type Qualifier                NM102   R      1/1         ID            1, 2



                                                                                                         80
                                                                                                                      ATTRIBUTES
LOOP    SEGMENT                                ELEMENT                                    USE   Min/M    Data         Codes/Values           Comments
                                                                                                 ax      Type

                                               Identification Code Qualifier    NM108      S     1/2         ID     24 = Employer's ID
                                                                                                                    Number, 34 = SSN
                                               Purchased Service Provider Primary NM109   R     2/80         AN
                                               Identifier
        Purchased Service Provider       REF
        Secondary Identification
                                               Identification Code Qualifier    REF01      S     2/3         ID      OB - State License
                                                                                                                           Number
                                                                                                                  1A - Blue Cross Provider
                                                                                                                           Number
                                                                                                                      1B - Blue Shield
                                                                                                                      Provider Number
                                                                                                                   1C - Medicare Provider
                                                                                                                           Number
                                                                                                                   1D - Medicaid Provider
                                                                                                                           Number
                                                                                                                    1G - Provider UPIN
                                                                                                                           Number
                                                                                                                     1H - CHAMPUS ID
                                                                                                                           Number
                                                                                                                     EI - Employer's ID
                                                                                                                           Number
                                                                                                                        G2 - Provider
                                                                                                                    Commercial Number
                                                                                                                   LU - Location Number
                                                                                                                     N5 = Provider Plan
                                                                                                                    Network ID Number
                                                                                                                          SY - SSN
                                                                                                                  U3 - Unique Supplier ID
                                                                                                                           Number
                                                                                                                    X5 - State Industrial
                                                                                                                      Accident Provider
                                                                                                                           Number
                                               Purchased Service Provider Primary REF02    S    1/30         AN
                                               Identifier

2420C   Service Facility Location Name   NM1                                               S




                                                                                                        81
                                                                                                                            ATTRIBUTES
LOOP   SEGMENT                                   ELEMENT                                        USE   Min/M    Data         Codes/Values           Comments
                                                                                                       ax      Type

                                                 Entity Identifier Code                 NM101   R      2/3         ID    77 = Service Location,
                                                                                                                            FA = Facility, LI =
                                                                                                                         Independent Lab, TL =
                                                                                                                              Testing Lab
                                                 Entity Type Qualifier                  NM102   R      1/1         ID            2
                                                 Identification Code Qualifier          NM108   S      1/2         ID     24 = Employer's ID
                                                                                                                          Number, 34 = SSN
                                                 Service Facility Location Primary      NM109   R     2/80         AN
                                                 Identifier
       Service Facility Location           N2                                                    S                                                 Not used by ODS
       Additional Name Information
                                                 Additional Service Facility Location   N201    R     1/60         AN
                                                 Name
       Service Facility Location Address   N3                                                    S

                                                 Laboratory or Facility Location        N301    R     1/55         AN
                                                 Address Line 1
                                                 Laboratory or Facility Location        N302     S    1/55         AN
                                                 Address Line 2
       Service Facility Location           N4
       City/State/Zip
                                                 Service Facility Location City Name N401       R     2/30         AN

                                                 Service Facility Location State or     N402    R      2/2         ID      Code Source 22
                                                 Province                                                                 States and Outlying
                                                                                                                           Areas of the U.S.
                                                 Service Facility Location Postal       N403    R     3/15         ID       Code Source 51
                                                 Code
                                                 Service Facility Location Country      N404     S     2/3         ID      Code Source 5:
                                                 Code                                                                    Countries, Currencies
                                                                                                                             and Funds
       Service Facility Location           REF                                                   S
       Secondary Identification
                                                 Identification Code Qualifier          REF01   R      2/3         ID     OB - State License
                                                                                                                                Number
                                                                                                                        1A - Blue Cross Provider
                                                                                                                                Number
                                                                                                                            1B - Blue Shield
                                                                                                                            Provider Number



                                                                                                              82
                                                                                                                       ATTRIBUTES
LOOP    SEGMENT                             ELEMENT                                        USE   Min/M    Data         Codes/Values          Comments
                                                                                                  ax      Type

                                                                                                                   1C - Medicare Provider
                                                                                                                           Number
                                                                                                                    1D - Medicaid Provider
                                                                                                                            Number
                                                                                                                     1G - Provider UPIN
                                                                                                                           Number
                                                                                                                      1H - CHAMPUS ID
                                                                                                                            Number
                                                                                                                         G2 - Provider
                                                                                                                     Commercial Number
                                                                                                                    LU - Location Number
                                                                                                                      N5 = Provider Plan
                                                                                                                     Network ID Number
                                                                                                                   TJ = Federal Taxpayer's
                                                                                                                          ID Number
                                                                                                                       X4 = Clinical Lab
                                                                                                                         Improvement
                                                                                                                     Amendment Number
                                                                                                                     X5 - State Industrial
                                                                                                                      Accident Provider
                                                                                                                           Number
                                            Service Facility Location Additional   REF02   R     1/30         AN
                                            Identifier

2420D   Supervising Provider Name     NM1                                                  S
                                            Entity Identifier Code                 NM101   R      2/3         ID             DQ
                                            Entity Type Qualifier                  NM102   R      1/1         ID              1
                                            Supervising Provider Last Name or      NM103   R
                                            Organization
                                            Supervising Provider First Name        NM104   S     1/25         AN
                                            Supervising Provider Middle Name       NM105   S     1/25         AN
                                            Supervising Provider Suffix            NM107   S     1/10         AN
                                            Identification Code Qualifier          NM108   R      1/2         ID     24 = Employer's ID
                                                                                                                     Number, 34 = SSN
                                            Supervising Provider Primary           NM109   R     2/80         AN
                                            Identifier
        Additional Supervising Name   N2                                                    S                                                Not used by ODS
        Information




                                                                                                         83
                                                                                                                    ATTRIBUTES
LOOP    SEGMENT                                ELEMENT                                   USE   Min/M    Data        Codes/Values          Comments
                                                                                                ax      Type

                                               Supervising Provider Additional   N201    R     1/60         AN
                                               Name
        Supervising Provider Secondary   REF
        Identification
                                               Identification Code Qualifier     REF01    S     2/3         ID
                                                                                                                   OB - State License
                                                                                                                         Number
                                                                                                                    1B - Blue Shield
                                                                                                                    Provider Number
                                                                                                                 1C - Medicare Provider
                                                                                                                         Number
                                                                                                                 1D - Medicaid Provider
                                                                                                                         Number
                                                                                                                  1G - Provider UPIN
                                                                                                                         Number
                                                                                                                   1H - CHAMPUS ID
                                                                                                                         Number
                                                                                                                   EI - Employer's ID
                                                                                                                         Number
                                                                                                                      G2 - Provider
                                                                                                                  Commercial Number
                                                                                                                 LU - Location Number
                                                                                                                   N5 - Provider Plan
                                                                                                                  Network ID Number
                                                                                                                        SY - SSN
                                                                                                                  X5 - State Industrial
                                                                                                                    Accident Provider
                                                                                                                         Number
                                               Supervising Provider Primary      REF02    S    1/30         AN
                                               Identifier

2420E   Ordering Provider Name           NM1                                             S
                                               Entity Identifier Code            NM101   R      2/3         ID            DK
                                               Entity Type Qualifier             NM102   R      1/1         ID             1
                                               Ordering Provider Last Name or    NM103   R
                                               Organization
                                               Ordering Provider First Name      NM104    S    1/25         AN
                                               Ordering Provider Middle Name     NM105    S    1/25         AN
                                               Ordering Provider Suffix          NM107    S    1/10         AN




                                                                                                       84
                                                                                                                         ATTRIBUTES
LOOP   SEGMENT                                  ELEMENT                                      USE   Min/M    Data         Codes/Values           Comments
                                                                                                    ax      Type

                                                Identification Code Qualifier       NM108    R      1/2         ID     24 = Employer's ID
                                                                                                                       Number, 34 = SSN
                                                Ordering Provider Primary Identifier NM109   R     2/80         AN

       Additional Ordering Name           N2                                                  S                                                 Not used by ODS
       Information
                                                Ordering Provider Additional Name   N201     R     1/60         AN

       Ordering Provider Address          N3
                                                Ordering Provider Address Line 1    N301     R     1/55         AN

                                                Ordering Provider Address Line 2    N302      S    1/55         AN

       Ordering Provider City/State/Zip   N4

                                                Ordering Provider City Name         N401     R     2/30         AN
                                                Ordering Provider State or Province N402     R      2/2         ID      Code Source 22
                                                                                                                       States and Outlying
                                                                                                                        Areas of the U.S.
                                                Ordering Provider Postal Code       N403     R     3/15         ID      Code Source 51
                                                Ordering Provider Country Code      N404     S      2/3         ID      Code Source 5:
                                                                                                                      Countries, Currencies
                                                                                                                          and Funds
       Ordering Provider Secondary        REF
       Identification
                                                Identification Code Qualifier       REF01     S     2/3         ID     OB - State License
                                                                                                                             Number
                                                                                                                     1A - Blue Cross Provider
                                                                                                                             Number
                                                                                                                         1B - Blue Shield
                                                                                                                         Provider Number
                                                                                                                      1C - Medicare Provider
                                                                                                                             Number
                                                                                                                      1D - Medicaid Provider
                                                                                                                             Number
                                                                                                                       1G - Provider UPIN
                                                                                                                             Number
                                                                                                                       1H - CHAMPUS ID
                                                                                                                             Number



                                                                                                           85
                                                                                                                   ATTRIBUTES
LOOP    SEGMENT                           ELEMENT                                      USE   Min/M    Data         Codes/Values           Comments
                                                                                              ax      Type

                                                                                                                  EI - Employer's ID
                                                                                                                        Number
                                                                                                                    G2 - Provider
                                                                                                                 Commercial Number
                                                                                                                LU - Location Number
                                                                                                                  N5 = Provider Plan
                                                                                                                 Network ID Number
                                                                                                                       SY - SSN
                                                                                                                 X5 - State Industrial
                                                                                                                  Accident Provider
                                                                                                                        Number
                                          Ordering Provider Primary Identifier REF02    S    1/30         AN

        Ordering Provider Contact                                                       S
        Information
                                          Contact Function Code              PER01     R      2/2         ID             IC
                                          Ordering Provider Contact Name     PER02     R     1/60         AN
                                          Communication Number Qualifier     PER03     R      2/2         ID   EM = Electronic Mail, FX
                                                                                                                 = Facsimile, TE =
                                                                                                                     Telephone
                                          Communication Number               PER04     R     1/80         AN
                                          Communication Number Qualifier     PER05     S      2/2         ID   EM = Electronic Mail, EX
                                                                                                               = Telephone Extension,
                                                                                                                FX = Facsimile, TE =
                                                                                                                     Telephone

                                          Communication Number               PER06      S    1/80         AN
                                          Communication Number Qualifier     PER07      S     2/2         ID   EM = Electronic Mail, EX
                                                                                                               = Telephone Extension,
                                                                                                                FX = Facsimile, TE =
                                                                                                                     Telephone

                                          Communication Number               PER08      S    1/80         AN

2420F   Referring Provider Name     NM1                                                S
                                          Entity Identifier Code             NM101     R      2/3         ID              82
                                          Entity Type Qualifier              NM102     R      1/1         ID             1, 2
                                          Referring Provider Last Name or    NM103     R
                                          Organization



                                                                                                     86
                                                                                                                     ATTRIBUTES
LOOP   SEGMENT                              ELEMENT                                       USE   Min/M    Data        Codes/Values          Comments
                                                                                                 ax      Type

                                            Referring Provider First Name        NM104    S     1/25         AN
                                            Referring Provider Middle Name       NM105    S     1/25         AN
                                            Referring Provider Suffix            NM107    S     1/25         AN
                                            Identification Code Qualifier        NM108    R      1/2         ID    24 = Employer's ID
                                                                                                                   Number, 34 = SSN
                                            Referring Provider Primary Identifier NM109   R     2/80         AN

       Referring Provider Specialty   PRV                                                 R                                                Taxonomy Codes are required on all claims. Required at the claim level when the
       Information                                                                                                                         Rendering Provider is the same entity as the Billing and/or Pay-to Provider. In these
                                                                                                                                           cases, the Rendering Provider is being identified at this level for all subsequent
                                                                                                                                           claims/encounters in this HL and LoopID-2310B is not used.

                                            Provider Code                        PRV01    R      1/3         ID            PE
                                            Reference Identification Qualifier   PRV02    R      2/3         ID            ZZ
                                            Provider Taxonomy Code               PRV03    R     1/30         AN
       Additional Referring Name      N2                                                  S                                                Not used by ODS
       Information
                                            Referring Provider Additional Name N201       R     1/60         AN

       Referring Provider Secondary   REF
       Identification
                                            Identification Code Qualifier        REF01     S     2/3         ID     OB - State License
                                                                                                                          Number
                                                                                                                     1B - Blue Shield
                                                                                                                     Provider Number
                                                                                                                  1C - Medicare Provider
                                                                                                                          Number
                                                                                                                  1D - Medicaid Provider
                                                                                                                          Number
                                                                                                                   1G - Provider UPIN
                                                                                                                          Number
                                                                                                                    1H - CHAMPUS ID
                                                                                                                          Number
                                                                                                                    EI - Employer's ID
                                                                                                                          Number
                                                                                                                       G2 - Provider
                                                                                                                   Commercial Number
                                                                                                                  LU - Location Number




                                                                                                        87
                                                                                                                          ATTRIBUTES
LOOP    SEGMENT                                  ELEMENT                                        USE   Min/M    Data       Codes/Values          Comments
                                                                                                       ax      Type

                                                                                                                         N5 - Provider Plan
                                                                                                                        Network ID Number
                                                                                                                             SY - SSN
                                                                                                                        X5 - State Industrial
                                                                                                                         Accident Provider
                                                                                                                              Number
                                                 Referring Provider Primary Identifier REF02     S    1/30         AN



        Other Payer Prior Authorization or NM1                                                   S
        Referral Number

                                                 Entity Identifier Code               NM101     R      2/3         ID           PR
                                                 Entity Type Qualifier                NM102     R      1/1         ID            2
                                                 Payer Name                           NM103     R
                                                 Identification Code Qualifier        NM108     R      1/2         ID         PI or XV
                                                 Other payer Identification Number    NM109     R     2/80         AN
        Other Payer Prior Authorization or REF                                                  S
        Referral Number

                                                 Reference Identification Qualifier   REF01     R      2/3         ID        9F or G1
                                                 Prior Auth or Referral Number        REF02     R     1/30         AN

   2430 Line Adjudication Information     SVD                                                   S
                                                 Other payer Identification Number    SVD01     R     2/80         AN

                                                 Service Line Paid Amount             SVD02     R     1/18         R
                                                 Procedure Identifier                 SVD03     R
                                                 Product or Service ID Qualifier      SVD03-1   R      2/2         ID   HC = HCPCS Codes;       Additional Note: Code IV is not allowed for use under HIPAA, though it remains on
                                                                                                                             IV=HEIC;           the list. Codes N1, N2 and N3 --all different versions of the NDC codes--were deleted.
                                                                                                                        N4=NDC;ZZ=Mutually      New Note for Code N4: Only used if J Codes are not allowed for use under HIPAA.
                                                                                                                              Defined           Previouly there was not a note.
                                                 Procedure Code                       SVD03-2   R     1/48         AN
                                                 Procedure Modifier 1                 SVD03-3   S      2/2         AN

                                                 Procedure Modifier 2                 SVD03-4    S     2/2         AN

                                                 Procedure Modifier 3                 SVD03-5    S     2/2         AN




                                                                                                              88
                                                                                                     ATTRIBUTES
LOOP   SEGMENT                 ELEMENT                                   USE   Min/M    Data         Codes/Values            Comments
                                                                                ax      Type

                               Procedure Modifier 4            SVD03-6    S     2/2         AN

                               Procedure Code Description      SVD03-7    S    1/80         AN

                               Paid Units of Service           SV105      S    1/15         R
                               Bundled Line Number             SV106      S     1/6         N0                               Name was Bundled/Unbundled Line Number. Note Changed to: Use the LX from this
                                                                                                                             transaction which points to the bundled line. Required if payer bundled this service
                                                                                                                             line. Previously read: Use the LX from this transaction which points to the
                                                                                                                             bundled/unbundled line. Required if payer bundled/unbundled this service line .

       Line Adjustment   CAS                                             S
                               Claim Adjustment Group Code     CAS01     R      1/2         ID        CO = Contractual
                                                                                                     Obligations, CR =
                                                                                                       Correction and
                                                                                                  Reversals, OA = Other
                                                                                                 Adjustments, PI = Payer
                                                                                                 Initiated Reductions, PR
                                                                                                  = Patient Repsonsibility


                               Adjustment Reason Code--Claim   CAS02     R      1/5         ID      Code Source 139
                               Level
                               Adjustment Amt--Claim Level     CAS03     R     1/18         R
                               Adjusted Units--Claim Level     CAS04     S     1/15         R
                               Adjustment Reason Code--Claim   CAS05     S      1/5         ID      Code Source 139
                               Level
                               Adjustment Amt--Claim Level     CAS06      S    1/18         R
                               Adjusted Units--Claim Level     CAS07      S    1/15         R




                               Adjustment Reason Code--Claim   CAS08      S     1/5         ID      Code Source 139
                               Level
                               Adjustment Amt--Claim Level     CAS09      S    1/18         R
                               Adjusted Units--Claim Level     CAS10      S    1/15         R




                                                                                       89
                                                                                                             ATTRIBUTES
LOOP    SEGMENT                          ELEMENT                                  USE   Min/M    Data        Codes/Values        Comments
                                                                                         ax      Type

                                         Adjustment Reason Code--Claim    CAS11    S     1/5         ID     Code Source 139
                                         Level
                                         Adjustment Amt--Claim Level      CAS12    S    1/18         R
                                         Adjusted Units--Claim Level      CAS13    S    1/15         R
                                         Adjustment Reason Code--Claim    CAS14    S     1/5         ID     Code Source 139
                                         Level
                                         Adjustment Amt--Claim Level      CAS15    S    1/18         R
                                         Adjusted Units--Claim Level      CAS16    S    1/15         R
                                         Adjustment Reason Code--Claim    CAS17    S     1/5         ID     Code Source 139
                                         Level
                                         Adjustment Amt--Claim Level      CAS18    S    1/18         R
                                         Adjusted Units--Claim Level      CAS19    S    1/15         R
        Line Adjudication Date     DTP
                                         Date/Time Qualifier              DTP01   R      3/3         ID           573
                                         Date/Time Period Format          DTP02   R      2/3         ID           D8
                                         Adjudication or Payment Date     DTP03   R     1/35         AN

   2440 Form Identification Code   LQ                                             R
                                         Form Identification Code         LQ01    R      1/3         ID   AS = Form Type code,
                                                                                                               UT = HCFA
        Supporting Documentation   FRM                                            R
                                         Question Number/Letter           FRM01   R     1/20         AN
                                         Question Response                FRM02   S      1/1         ID         N, W, Y
                                         Question Response                FRM03   S     1/30         AN
                                         Question Reponse Date            FRM04   S      8/8         DT        ccyymmdd
                                         Question Response Percent        FRM05   S      1/6         R

        Transaction Set Trailer    SE                                             R
                                         Number of Included Segments      SE01    R     1/10         N0
                                         Transaction Set Control Number   SE02    R      4/9         AN                          ST02=SE02




                                                                                                90
Oregon Companion Document for 837 Dental Claim
The objectives of this document are:
         *To clarify what information is needed by ODS where the guide indicates that the choice is dependent on the Payor.
         *To point out preferred selections for data element where multiple alternatives exist.

This document does not:
         *Modify the definition, condition, or use of data element or segment in the standard Implementation Guide.
         *Add any additional data elements or segments to the standard Implementation Guide.
         *Utilize any code or data values which are not valid in the standard Implementation Guide.
         *Change the meaning or intent of the standard Implementation Guide.

This document is based on the version of the 837 Dental Claim Implementation Guide version 004010X97. With the following exception, the Addenda
(NPRM) have only been referenced, but not made part of this guide.
         *N2 Segments supporting additional Last Name information have been removed.



Important Information about the ODS & Regence Adjudication system:
                 1. Information regarding the Rendering provider is supported at the Claim Level (2300) only. If there are multiple rendering providers for
                 services, the applicable service (s) and corresponding rendering provider must be submitted on one claim. This may result in multiple
                 claims
                 2. Adjudication occurs at the service line (2400) level not at the claim level--line item coordination of benefits information is important.

Participants:
Natasha Farvan- OHSU                                         Beryl Fletcher- ODA                         Peter Williams- The Regence Group
Mary Lloyd- OHSU                                             Harold Powers- First Pacific Corp.          Jeff Anderson- working with FPC
Denice Stewart-OHSU                                          Joseph Archer- First Pacific Corp.          Pat Van Dyke- ODS
Rose Russell- OHSU                                           Sharon Brown- First Pacific Corp            Ashish Gupta- First Pacific
Pam Olbrich- Multnomah Co Health Dept.                       Diana Lindsley- First Pacific               Chris Baker- Core Policy
Paula Young- OCHIN                                           M. Alex Harkins- Core Policy Systems        Dean Hill- Payer Connection
Joy Allen- Multicare Dental Multnomah County




ODS Health Plans
837 Dental Claim/Encounter                                                                                                                        Version 1.0
Version 00401098                                                            91                                                                       062402
ISA - Interchange Control Header
Usage: Required
Segment Max Use within Loop: 1
Loop Repeat: None
Loop ID: None

Example: ISA*00*bbbbbbbbbb*00*bbbbbbbbbb*30*123456789bbbbbb*30*381791480bbbbbb*010801*1452*U*00402*0000000001*0*P*:~

                                                              ATTRIBUTES
SEGMENT         ELEMENT                       USE   Min/Max   Data Type Codes/Values    Comments
                Authorization Information
ISA01           Qualifier                     R       2/2                    00
ISA02           Authorization Information     R      10/10                              No information required
                Security Information
ISA03           Qualifier                     R       2/2                    00
ISA04           Security Information          R      10/10                              No information required
                Sender Interchange ID
ISA05           Qualifier                     R       2/2                    ZZ
ISA06           Interchange Sender ID         R      15/15                              ODS
                Interchange Receiver ID
ISA07           Qualifier                     R       2/2                    ZZ
ISA08           Interchange Receiver ID       R      15/15                              ODS
ISA09           Interchange Date              R       6/6                 YYMMDD
ISA10           Interchange Time              R       4/4                  HHMM
ISA11           Interchange Control and ID    R       1/1                    U

ISA12           Interchange Control Version   R       5/5                  00401

ISA13           Interchange Control Number    R       9/9                               Assigned by Sender
                Acknowledgement
ISA14           Requested                     R       1/1                    0
                                                                        P=Production,
ISA15           Usage Indicator               R       1/1                 T=Test
ISA16           Component element             R       1/1                    :




ODS Health Plans
837 Dental Claim/Encounter                                                                                             Version 1.0
Version 00401098                                               92                                                         062402
GS - Functional Group Header
Usage: Required
Segment Max Use within Loop: 1
Loop Repeat: None
Loop ID: None

Example: GS*HC*123456789*381791480*20010801*1452*000000001*X*004010~

                                                                  ATTRIBUTES
SEGMENT         ELEMENT                           USE   Min/Max   Data Type Codes/Values   Comments
GS01            Functional Identifier Code        R       2/2                    HC
GS02            Application Senders Code          R      2/15                              Assigned by ODS during Trading Partner setup
                                                                                           Conference Call
GS03            Application Receiver's Code       R      2/15                              ODS
GS04            Date                              R       8/8               CCYYMMDD
GS05            Time                              R       4/4                 HHMM
GS06            Group Control Number              R       1/9                              Assigned by Sender
GS07            Responsibility Agency Code        R       1/1                    X
                Version/Release/Industry
GS08            Identifier Code                   R      1/12                004010X098

ST -- Transaction Set Header
Usage: Required
Segment Max Use within Loop: 1
Loop Repeat: 1
Loop ID: None

Example: ST*837*987654~

                                                                  ATTRIBUTES
SEGMENT         ELEMENT                           USE   Min/Max   Data Type Codes/Values   Comments
ST01            Transaction Set Identifier Code   R       3/3        ID         837
ST02            Transaction Set Control           R       4/9        AN                    Assigned by sender
                Number




ODS Health Plans
837 Dental Claim/Encounter                                                                                                     Version 1.0
Version 00401098                                                   93                                                             062402
BHT -- Beginning of Hierarchical Transaction
Usage: Required
Segment Max Use within Loop: 1
Loop Repeat: 1
Loop ID: None

Example: BHT*0019*00*0123*19980108*0932*CH~

                                                                ATTRIBUTES
SEGMENT         ELEMENT                         USE   Min/Max   Data Type Codes/Values      Comments
BHT01           Hierarchical Structure Code     R       4/4        ID          0019
BHT02           Transaction Set Purpose Code    R       2/2        ID      00 = original;   Send value 00 for an original file. Value of 18 is
                                                                           18 = reissue     required for files that are being resent after the
                                                                                            original file was rejected as noted in the 997
                                                                                            response.

BHT03           Originator Application          R      1/30        AN                       The inventory file number of the tape or
                Transaction Identifier                                                      transmission assigned by the submitter's system.
BHT04           Transaction Set Creation Date   R       8/8        DT      CCYYMMDD         Identifies the date the submitter created the file

BHT05           Transaction Set Creation Time   R       4/8        TM      HHMMSSDD         Time of day that the file was created.

BHT06           Claim or Encounter Identifier   R       2/2        ID         CH =          Either value is acceptable. All claims/encounters
                                                                           Chargeable;      are processed through the ODS claims processing
                                                                          RP = Reporting    system regardless of being 'chargeable' or
                                                                                            'reporting'.

REF -- Transmission Type Identifier
Usage: Required
Segment Max Use within Loop: 3
Loop Repeat: 1
Loop ID: None

Example: REF*87*004010X097D~

                                                                ATTRIBUTES
SEGMENT         ELEMENT                         USE   Min/Max   Data Type Codes/Values      Comments
REF01           Reference Identification        R       2/3        ID           87
                Qualifier
REF02           Reference Identification        R      1/30        AN      004010X97        ODS is not dependent on this value to determine
                                                                                            Test or Production status.

ODS Health Plans
837 Dental Claim/Encounter                                                                                                                Version 1.0
Version 00401098                                                 94                                                                          062402
NM1 -- Submitter Name
Usage: Required
Segment Max Use within Loop: 1
Loop Repeat: 1
Loop ID: 1000A

Example: NM1*41*2*CRAMMER, DOLE, PALMER, AND JOHANSON*****46*W7933THU~

                                                                 ATTRIBUTES
SEGMENT         ELEMENT                          USE   Min/Max   Data Type Codes/Values    Comments
NM101           Entity Identifier Code           R       2/3        ID          41
NM102           Entity Type Qualifier            R       1/1        ID       1=person;
                                                                           2= non-person
                                                                               entity
NM103           Submitter Last or Organization   R      1/35        AN
                Name
NM104           Submitter First Name              S     1/25        AN
NM105           Submitter Middle Name             S     1/25        AN
NM108           Identification Code Qualifier    R       1/2        ID          46
NM109           Submitter Identifier             R      2/80        AN                     Mutually defined by submitter and ODS Health
                                                                                           Plans.




ODS Health Plans
837 Dental Claim/Encounter                                                                                                          Version 1.0
Version 00401098                                                  95                                                                   062402
PER -- Submitter EDI Contact Information
Usage: Required
Segment Max Use within Loop: 2
Loop Repeat: 2
Loop ID: 1000A

Example: PER*1C*JANE DOE*TE*9005555555~

                                                                ATTRIBUTES
SEGMENT         ELEMENT                         USE   Min/Max   Data Type Codes/Values   Comments
PER01           Contact Function Code           R       2/2        ID          IC
PER02           Submitter Contact Name          R      1/60        AN
PER03           Communication Number            R       2/2        ID
PER04           Qualifier
                Communication Number            R      1/80        AN                    Telephone and FAX numbers should include the
                                                                                         area code.
PER05           Communication Number             S      2/2        ID
                Qualifier
PER06           Communication Number             S     1/80        AN
PER07           Communication Number             S      2/2        ID
                Qualifier
PER08           Communication Number             S     1/80        AN

NM1 -- Receiver Name
Usage: Required
Segment Max Use within Loop: 1
Loop Repeat: 1
Loop ID: 1000B

Example: NM1*40*2*UNION MUTUAL OF OREGON*****46*11122333~

                                                                ATTRIBUTES
SEGMENT         ELEMENT                         USE   Min/Max   Data Type Codes/Values   Comments
NM101           Entity Identifier Code          R       2/3        ID          40
NM102           Entity Type Qualifier           R       1/1        ID          2
NM103           Receiver Name                   R      1/35        AN                    ODS Health Plans
NM108           Identification Code Qualifier   R       1/2        ID          46
NM109           Receiver Primary Identifier     R      2/80        AN                    ODS Tax ID for Dental Plan




ODS Health Plans
837 Dental Claim/Encounter                                                                                                      Version 1.0
Version 00401098                                                 96                                                                062402
HL -- Billing Provider Hierarchical Level
Usage: Required
Segment Max Use within Loop: 1
Loop Repeat: >1
Loop ID: 2000A

Example: HL*1**20*1~

                                                           ATTRIBUTES
SEGMENT         ELEMENT                    USE   Min/Max   Data Type Codes/Values   Comments
HL01            Hierarchical ID Number     R      1/12        AN
HL03            Hierarchical Level Code    R       1/2        ID          20
HL04            Hierarchical Child Code    R       1/1        ID           1

PRV -- Billing Provider Specialty Information
Usage: Situational
Segment Max Use within Loop: 1
Loop Repeat: 1
Loop ID: 2000A

Example: PRV*PT*ZZ*1223S0112Y~

                                                           ATTRIBUTES
SEGMENT         ELEMENT                    USE   Min/Max   Data Type Codes/Values   Comments
                                                                                    Taxonomy Codes are required on all claims for
                                                                                    ODS & Regence. If Billing/ Pay to and rendering
                                                                                    provider are the same, then the specialty
                                                                                    information is populated at the Loop 2000A.

                                                                                    When the Billing or Pay-to Provider is a group and
                                                                                    the individual Rendering Provider is in loop 2310B
                                                                                    then the PRV segment is coded with the Rendering
                                                                                    Provider in loop 2310B.
PRV01           Provider Code              R       1/3        ID         BI, PT
PRV02           Reference Identification   R       2/3        ID          ZZ
                Qualifier
PRV03           Provider Taxonomy Code     R      1/30        AN




ODS Health Plans
837 Dental Claim/Encounter                                                                                                    Version 1.0
Version 00401098                                            97                                                                   062402
CUR -- Foreign Currency
Usage: Situational
Segment Max Use within Loop: 1
Loop Repeat: 1
Loop ID: 2000A

Example: CUR*85*CAN ~

                                                                ATTRIBUTES
SEGMENT         ELEMENT                         USE   Min/Max   Data Type Codes/Values   Comments
CUR01           Entity Identifier Code          R       2/3        ID          85        Use only for claims where the currency value is not
                                                                                         the US dollar.
CUR02           Currency Code                   R       3/3        ID

NM1 -- Billing Provider Name
Usage: Required
Segment Max Use within Loop: 1
Loop Repeat: 1
Loop ID: 2010AA

Example: NM1*85*2*DENTAL ASSOCIATES*****34*123456789~

                                                                ATTRIBUTES
SEGMENT         ELEMENT                         USE   Min/Max   Data Type Codes/Values   Comments
NM101           Entity Identifier Code          R       2/3        ID          85
NM102           Entity Type Qualifier           R       1/1        ID         1, 2
NM103           Billing Provider Last Name or   R                                        Must use Legal Name provided on 1099 Form.
                Organization
NM104           Billing Provider First Name      S     1/25        AN                    Must use Legal Name provided on 1099 Form.
NM105           Billing Provider Middle Name     S     1/25        AN                    Must use Legal Name provided on 1099 Form.
NM107           Billing Provider Suffix          S     1/25        AN                    Must use Legal Name provided on 1099 Form.
NM108           Identification Code Qualifier   R       1/2        ID        24, 34      Identifier must match the number filed with ODS.
NM109           Billing Provider Primary        R      2/80        AN                    Identifier must match the number filed with ODS.
                Identifier




ODS Health Plans
837 Dental Claim/Encounter                                                                                                          Version 1.0
Version 00401098                                                 98                                                                    062402
N3 -- Billing Provider Address
Usage: Required
Segment Max Use within Loop: 2
Loop Repeat: 1
Loop ID: 2010AA

Example: N3*225 MAIN STREET*BARKLEY BUILDING~

                                                                  ATTRIBUTES
SEGMENT         ELEMENT                           USE   Min/Max   Data Type Codes/Values   Comments
N301            Billing Provider Address Line 1   R      1/55        AN
N302            Billing Provider Address Line 2    S     1/55        AN

N4 -- Billing Provider City/State/Zip Code
Usage: Required
Segment Max Use within Loop: 1
Loop Repeat: 1
Loop ID: 2010AA

Example: N4*CENTERVILLE*PA*17111~

                                                                  ATTRIBUTES
SEGMENT         ELEMENT                           USE   Min/Max   Data Type Codes/Values   Comments
N401            Billing Provider City Name        R      2/30        AN
N402            Billing Provider State or         R       2/2        ID
                Province
N403            Billing Provider Postal Code      R      3/15        ID
N404            Billing Provider Country Code      S      2/3        ID




ODS Health Plans
837 Dental Claim/Encounter                                                                            Version 1.0
Version 00401098                                                   99                                    062402
REF -- Billing Provider Secondary Identification Number
Usage: Situational
Segment Max Use within Loop: 20
Loop Repeat: 5
Loop ID: 2010AA

Example: REF*SY*111223333~

                                                                ATTRIBUTES
SEGMENT         ELEMENT                         USE   Min/Max   Data Type Codes/Values   Comments
REF01           Identification Code Qualifier    S      2/3        ID          1E        1E = State License Number is desired if billing/pay-
                                                                                         to/and rendering provider are all the same entity.

REF02           Billing Provider Secondary       S     1/30        AN                    State License Number
                Identifier

NM1 -- Pay-To Provider's Name
Usage: Situational
Segment Max Use within Loop: 1
Loop Repeat: 1
Loop ID: 2010AB

Example: NM1*87*1*JONES*WILLIAM****XX*0987654321~

                                                                ATTRIBUTES
SEGMENT         ELEMENT                         USE   Min/Max   Data Type Codes/Values   Comments
                                                 S                                       Required if the Pay-To Provider is a different
                                                                                         entity than the Billing Provider
NM101           Entity Identifier Code          R       2/3        ID          87
NM102           Entity Type Qualifier           R       1/1        ID
NM103           Pay To Provider Last Name or    R                                        Match 1099 form
                Organization
NM104           Pay To Provider First Name       S     1/25        AN                    Match 1099 form
NM105           Pay to Provider Middle Name      S     1/25        AN                    Match 1099 form
NM107           Pay to Provider Suffix           S     1/25        AN                    Match 1099 form
NM108           Identification Code Qualifier   R       1/2        ID        24, 34
NM109           Pay to Provider Primary         R      2/80        AN                    Nine digit numeric identifier. No dashes.
                Identifier



ODS Health Plans
837 Dental Claim/Encounter                                                                                                           Version 1.0
Version 00401098                                                 100                                                                    062402
N3 -- Pay-To Provider Address
Usage: Required
Segment Max Use within Loop: 2
Loop Repeat: 1
Loop ID: 2010AB

Example: N3*225 MAIN STREET*BARKLEY BUILDING~

                                                                 ATTRIBUTES
SEGMENT         ELEMENT                          USE   Min/Max   Data Type Codes/Values   Comments
N301            Pay-To Provider Address Line 1   R      1/55        AN                    Will pay to the address that is in the ODS claims
                                                                                          paying system. Regence checking on which
                                                                                          address they'll pay to.
N302            Pay-To Provider Address Line 2    S     1/55        AN

N4 -- Pay-To Provider City, State, Zip
Usage: Required
Segment Max Use within Loop: 1
Loop Repeat: 1
Loop ID: 2010AB

Example: N4*CENTERVILLE*PA*17111~

                                                                 ATTRIBUTES
SEGMENT         ELEMENT                          USE   Min/Max   Data Type Codes/Values   Comments
N401            Pay-To Provider City Name        R      2/30        AN
N402            Pay-To Provider State or         R       2/2        ID
                Province
N403            Pay-To Provider Postal Code      R      3/15        ID
N404            Pay-To Provider Country Code      S      2/3        ID




ODS Health Plans
837 Dental Claim/Encounter                                                                                                            Version 1.0
Version 00401098                                                  101                                                                    062402
REF -- Pay-To Provider Secondary Identification
Usage: Situational
Segment Max Use within Loop: 20
Loop Repeat: 5
Loop ID: 2010AB

Example: REF*SY*111222333~

                                                                ATTRIBUTES
SEGMENT         ELEMENT                         USE   Min/Max   Data Type Codes/Values   Comments
REF01           Identification Code Qualifier    S      2/3        ID                    1E = State License Number is required of pay-to
                                                                                         provider is also rendering provider.
REF02           Pay-To Provider Secondary        S     1/30        AN
                Identifier

HL -- Subscriber Hierarchical Level
Usage: Required
Segment Max Use within Loop: 1
Loop Repeat: 1
Loop ID: 2000B

Example: HL*2*1*22*1~

                                                                ATTRIBUTES
SEGMENT         ELEMENT                         USE   Min/Max   Data Type Codes/Values   Comments
                                                R                                        If the insured and the patient are the same person,
                                                                                         use this HL to identify the insured/patient, skip the
                                                                                         subsequent (PATIENT) HL, and proceed directly to
                                                                                         Loop ID-2300.
HL01            Hierarchical ID Number          R      1/12        AN
HL02            Hierarchical Parent ID Number   R      1/12        AN
HL03            Hierarchical Level Code         R       1/2        ID          22
HL04            Hierarchical Child Code         R       1/1        ID          0,1




ODS Health Plans
837 Dental Claim/Encounter                                                                                                            Version 1.0
Version 00401098                                                 102                                                                     062402
SBR -- Subscriber Information
Usage: Required
Segment Max Use within Loop: 1
Loop Repeat: 1
Loop ID: 2000B

Example: SBR*P**GRP01020102***6***CI~

                                                                ATTRIBUTES
SEGMENT         ELEMENT                         USE   Min/Max   Data Type Codes/Values    Comments
SBR01           Payer Responsibility Sequence   R       1/1        ID      P = Primary
                Code                                                      S = Secondary
                                                                           T = Tertiary
SBR02           Individual Relationship Code    R       2/2        ID          18
SBR03           Insured Group or Policy          S     1/30        AN                     Required when present on ID Card.      6 digit
                Number                                                                    number as noted on ID card
SBR04           Insured Group Name               S     1/60        AN                     Required when present on ID Card
SBR05           Insurance Type Code              S      1/3        ID                     Not required by ODS. Required on claims being
                                                                                          submitted to Medicare
SBR09           Claim Filing Indicator Code     R       1/2        ID                     Required prior to mandated use of PlanID. Utilize
                                                                                          the following: MB for Medicare Part B claims; MC
                                                                                          for Medicaid--Oregon Health Plan Claims; CI for
                                                                                          commercial insurance.




ODS Health Plans
837 Dental Claim/Encounter                                                                                                          Version 1.0
Version 00401098                                                 103                                                                   062402
NM1 -- Subscriber Name
Usage: Required
Segment Max Use within Loop: 1
Loop Repeat: 1
Loop ID: 2010BA

Example: NM1*IL*1*DOE*JOHN*T**JR*MI*123456789~

                                                                ATTRIBUTES
SEGMENT         ELEMENT                         USE   Min/Max   Data Type Codes/Values   Comments
NM101           Entity Identifier Code          R       2/3        ID          IL
NM102           Entity Type Qualifier           R       1/1        ID          1
NM103           Subscriber Last Name            R                                        As listed on the Subscriber ID card
NM104           Subscriber First Name            S     1/25        AN                    As listed on the Subscriber ID card
NM105           Subscriber Middle Name           S     1/25        AN                    As listed on the Subscriber ID card
NM107           Subscriber Suffix                S     1/10        AN                    As listed on the Subscriber ID card
NM108           Identification Code Qualifier   R       1/2        ID          MI
NM109           Subscriber Primary Identifier   R      2/80        AN                    Required on all claims. May be the following:
                                                                                         Subscriber Identification as shown on ID card for
                                                                                         commercial insurance. If type of insurance is MC
                                                                                         (Oregon Health Plan Dental) , then the subscriber
                                                                                         state assigned ID should be place in this field.


N3 -- Subscriber Address
Usage: Situational
Segment Max Use within Loop: 2
Loop Repeat: 1
Loop ID: 2010BA

Example: N3*125 CITY STREET~

                                                                ATTRIBUTES
SEGMENT         ELEMENT                         USE   Min/Max   Data Type Codes/Values   Comments
N301            Subscriber Address Line 1       R      1/55        AN
N302            Subscriber Address Line 2        S     1/55        AN




ODS Health Plans
837 Dental Claim/Encounter                                                                                                         Version 1.0
Version 00401098                                                 104                                                                  062402
N4 -- Subscriber City/State/Zip Code
Usage: Situational
Segment Max Use within Loop: 1
Loop Repeat: 1
Loop ID: 2010BA

Example: N4*CENTERVILLE*PA*17111~

                                                               ATTRIBUTES
SEGMENT         ELEMENT                        USE   Min/Max   Data Type Codes/Values   Comments
N401            Subscriber City Name           R      2/30        AN
N402            Subscriber State or Province   R       2/2        ID
N403            Subscriber Postal Code         R      3/15        ID
N404            Subscriber Country Code         S      2/3        ID

DMG -- Subscriber Demographic Information
Usage: Situational
Segment Max Use within Loop: 1
Loop Repeat: 1
Loop ID: 2010BA

Example: DMG*D8*19491117*M~

                                                               ATTRIBUTES
SEGMENT         ELEMENT                        USE   Min/Max   Data Type Codes/Values   Comments
                                                                                        Required if the patient is the same person as the
                                                                                        subscriber.
DMG01           Date/Time Period Format        R       2/3        ID          D8
                Qualifier
DMG02           Subscriber Birth Date          R      1/35        AN      CCYYMMDD
DMG03           Subscriber Gender Code         R       1/1        ID        F, M, U




ODS Health Plans
837 Dental Claim/Encounter                                                                                                      Version 1.0
Version 00401098                                                105                                                                062402
REF -- Subscriber Secondary Information
Usage: Situational
Segment Max Use within Loop: 20
Loop Repeat: 4
Loop ID: 2010BA

Example: REF*1W*98765~

                                                                ATTRIBUTES
SEGMENT         ELEMENT                         USE   Min/Max   Data Type Codes/Values   Comments
REF01           Identification Code Qualifier   R       2/3        ID          SY        If value in NM109 is OMAP ID, then ODS &
                                                                                         Regence prefer to receive the value of 'SY' in
                                                                                         this field.
REF02           Subscriber Supplemental         R      1/30        AN                    Social Security Number
                Identifier

NM1 -- Payer Name
Usage: Required
Segment Max Use within Loop: 1
Loop Repeat: 1
Loop ID: 2010BB

Example: NM1*PR*2*UNION MUTUAL OF OREGON*****PI*123123123~

                                                                ATTRIBUTES
SEGMENT         ELEMENT                         USE   Min/Max   Data Type Codes/Values   Comments
NM101           Entity Identifier Code          R       2/3        ID          PR
NM102           Entity Type Qualifier           R       1/1        ID          2
NM103           Payer Organization Name         R      1/35        AN
NM108           Identification Code Qualifier   R       1/2        ID          PI
NM109           Payer Primary Identifier        R      2/80        AN                    Dental Tax Identifier




ODS Health Plans
837 Dental Claim/Encounter                                                                                                        Version 1.0
Version 00401098                                                 106                                                                 062402
N3 -- Payer Address
Usage: Situational
Segment Max Use within Loop: 2
Loop Repeat: 1
Loop ID: 2010BB

Example: N3*225 MAIN STREET*BARKLEY BUILDING~

                                                          ATTRIBUTES
SEGMENT         ELEMENT                   USE   Min/Max   Data Type Codes/Values   Comments
N301            Payer Address Line 1      R      1/55        AN
N302            Payer Address Line 2       S     1/55        AN

N4 -- Payer City/State/Zip
Usage: Situational
Segment Max Use within Loop: 1
Loop Repeat: 1
Loop ID: 2010BB

Example: N4*CENTERVILLE*PA*17111~

                                                          ATTRIBUTES
SEGMENT         ELEMENT                   USE   Min/Max   Data Type Codes/Values   Comments
N401            Payer City Name           R      2/30        AN
N402            Payer State or Province   R       2/2        ID
N403            Payer Postal Code         R      3/15        ID
N404            Payer Country Code         S      2/3        ID




ODS Health Plans
837 Dental Claim/Encounter                                                                    Version 1.0
Version 00401098                                           107                                   062402
REF -- Payor Secondary Identification
Usage: Situational
Segment Max Use within Loop: 20
Loop Repeat: 3
Loop ID: 2010BB

Example: REF*2U*435261708~

                                                                ATTRIBUTES
SEGMENT         ELEMENT                         USE   Min/Max   Data Type Codes/Values   Comments
REF01           Identification Code Qualifier   R       2/3        ID        See Iq.     ODS does not require a secondary payor identifier.
                                                                                         Regence will check if they want it.
REF02           Payer Additional Identifier     R      1/30        AN

HL -- Patient Hierarchical Level
Usage: Situational
Segment Max Use within Loop: 1
Loop Repeat: 1
Loop ID: 2000C

Example: HL*3*2*23*0~

                                                                ATTRIBUTES
SEGMENT         ELEMENT                         USE   Min/Max   Data Type Codes/Values   Comments
                                                 S                                       This HL is required when the patient is a different
                                                                                         person than the subscriber.
HL01            Hierarchical ID Number          R      1/12        AN
HL02            Hierarchical Parent ID Number   R      1/12        AN
HL03            Hierarchical Level Code         R       1/2        ID          23
HL04            Hierarchical Child Code         R       1/1        ID          0




ODS Health Plans
837 Dental Claim/Encounter                                                                                                            Version 1.0
Version 00401098                                                 108                                                                     062402
PAT -- Patient Information
Usage: Required
Segment Max Use within Loop: 1
Loop Repeat: 1
Loop ID: 2000C

Example: PAT*01~

                                                                  ATTRIBUTES
SEGMENT         ELEMENT                           USE   Min/Max   Data Type Codes/Values   Comments
PAT01           Patient Relationship to Insured   R       2/2        ID

PAT04           Student Status Code                S      1/1        ID        F, N, P     Required to indicate student status of the patient if
                                                                                           19 years of age or older.

NM1 -- Patient Name
Usage: Required
Segment Max Use within Loop: 1
Loop Repeat: 1
Loop ID: 2010CA

Example: NM1*QC*1*DOE*SALLY~

                                                                  ATTRIBUTES
SEGMENT         ELEMENT                           USE   Min/Max   Data Type Codes/Values   Comments
NM101           Entity Identifier Code            R       2/3        ID          QC
NM102           Entity Type Qualifier             R       1/1        ID          1
NM103           Patient Last Name or              R      1/35        AN                    Must match ID Card
                Organization
NM104           Patient First Name                R      1/25        AN                    Must match ID Card
NM105           Patient Middle Name                S     1/10        AN                    Must match ID Card
NM107           Patient Suffix                     S     1/25        AN                    Must match ID Card
NM108           Identification Code Qualifier     R       1/2        ID          MI
NM109           Patient Primary Identifier         S     2/80        AN                    Patient primary identifier is the same as the
                                                                                           subscriber identifier as noted on the ID card.




ODS Health Plans
837 Dental Claim/Encounter                                                                                                              Version 1.0
Version 00401098                                                   109                                                                     062402
N3 -- Patient Address
Usage: Required
Segment Max Use within Loop: 2
Loop Repeat: 1
Loop ID: 2010CA

Example: N3*RFD 10*100 COUNTRY LANE~

                                                            ATTRIBUTES
SEGMENT         ELEMENT                     USE   Min/Max   Data Type Codes/Values   Comments
N301            Patient Address Line 1      R      1/55        AN
N302            Patient Address Line 2       S     1/55        AN

N4 -- Patient City/State/Zip Code
Usage: Required
Segment Max Use within Loop: 1
Loop Repeat: 1
Loop ID: 2010CA

Example: N4*CORNFIELD TOWNSHIP*IA*99999~

                                                            ATTRIBUTES
SEGMENT         ELEMENT                     USE   Min/Max   Data Type Codes/Values   Comments
N401            Patient City Name           R      2/30        AN
N402            Patient State or Province   R       2/2        ID
N403            Patient Postal Code         R      3/15        ID
N404            Patient Country Code         S      2/3        ID




ODS Health Plans
837 Dental Claim/Encounter                                                                      Version 1.0
Version 00401098                                             110                                   062402
DMG -- Patient Demographic Information
Usage: Required
Segment Max Use within Loop: 1
Loop Repeat: 1
Loop ID: 2010CA

Example: DMG*D8*19530101*F~

                                                                ATTRIBUTES
SEGMENT         ELEMENT                         USE   Min/Max   Data Type Codes/Values   Comments
DMG01           Date/Time Period Format         R       2/3        ID          D8
                Qualifier
DMG02           Patient Birth Date              R      1/35        AN      CCYYMMDD
DMG03           Patient Gender Code             R       1/1        ID        F, M, U

REF -- Patient Secondary Information
Usage: Situational
Segment Max Use within Loop: 20
Loop Repeat: 5
Loop ID: 2010CA

Example: REF*1W*98765~

                                                                ATTRIBUTES
SEGMENT         ELEMENT                         USE   Min/Max   Data Type Codes/Values   Comments
REF01           Identification Code Qualifier   R       2/3        ID                    SY' is only valid secondary identifier used by ODS

REF02           Patient Secondary Identifier    R      1/30        AN                    SSN




ODS Health Plans
837 Dental Claim/Encounter                                                                                                          Version 1.0
Version 00401098                                                 111                                                                   062402
CLM -- Claim Information
Usage: Required
Segment Max Use within Loop: 1
Loop Repeat: 1
Loop ID: 2300

Example: CLM*0131930000001*500***11::1*Y*A*Y*Y~

                                                               ATTRIBUTES
SEGMENT         ELEMENT                        USE   Min/Max   Data Type Codes/Values   Comments
CLM01           Patient Account Number         R      1/38        AN                    Assigned by billing entity
CLM02           Total Claim Charge Amount      R      1/18        R                     For Encounters, '0' is a valid amount
CLM05           Place of Service Code          R                                        CLM05 applies to all service lines unless it is
                                                                                        overwritten at the line level.
CLM05-1         Facility Type Code             R       1/2        ID
CLM05-3         Claim Submission Reason        R       1/1        ID
                Code
CLM06           Provider Signature on File     R       1/1        ID        Y or N
CLM07           Medicare Assignment Code       R       1/1        ID
CLM08           Assignment of Benefits         R       1/1        ID        Y or N
                Indicator
CLM09           Release of Information Code    R       1/1        ID        Y or N
CLM11           Accident/Employment/Related     S                                       If DTP - Date of Accident - is used, then CLM11 is
                Causes                                                                  required.
CLM11-1         Related Causes Codes           R       2/3        ID      AA, EM, OA
CLM11-2         Related Causes Codes            S      2/3        ID      AA, EM, OA
CLM11-3         Related Causes Codes            S      2/3        ID      AA, EM, OA
CLM11-4         Auto Accident State Code        S      2/2        ID                    If CLM11-1, -2, or -3 = AA, then CLM11-4 must be
                                                                                        identified. Use 2 digit state postal code.
CLM11-5         Country Code                    S      2/3        ID                    Required if automobile accident occurred outside of
                                                                                        the United States.
CLM12           Special Program Code            S      2/3        ID                    Required if the services were rendered under one of
                                                                                        the identified circumstances/programs/projects.

CLM19           Predetermination of Benefits    S      2/2        ID          PB
                Code
CLM20           Delay Reason Code               S      1/2        ID                    Required when claim is submitted past the contract
                                                                                        date of filing limitations and any of the codes
                                                                                        identified apply.




ODS Health Plans
837 Dental Claim/Encounter                                                                                                           Version 1.0
Version 00401098                                                112                                                                     062402
                                                                                      Dates in Loop ID-2300 apply to all service lines
                                                                                      with Loop ID-2400 unless a DTP segment occurs
                                                                                      in Loop ID-2400 with the same value in DTP01.
                                                                                      If any date value exists Loop ID 2400, then each
                                                                                      line item must have it's own date submitted.

DTP -- Date-Admission
Usage: Situational
Segment Max Use within Loop: 150
Loop Repeat: 1
Loop ID: 2300

Example: DTP*435*D8*199980108~

                                                             ATTRIBUTES
SEGMENT         ELEMENT                      USE   Min/Max   Data Type Codes/Values   Comments
DTP01           Date/Time Qualifier          R       3/3        ID         435        Required on claims related to inpatient services.

DTP02           Date/Time Period Format      R       2/3        ID          D8
                Qualifier
DTP03           Related Hospital Admission   R      1/35        AN      CCYYMMDD
                Date

DTP -- Date-Discharge
Usage: Situational
Segment Max Use within Loop: 150
Loop Repeat: 1
Loop ID: 2300

Example: DTP*096*D8*199980108~

                                                             ATTRIBUTES
SEGMENT         ELEMENT                      USE   Min/Max   Data Type Codes/Values   Comments
DTP01           Date/Time Qualifier          R       3/3        ID         096        Required on claims related to inpatient services, if
                                                                                      information is known.
DTP02           Date/Time Period Format      R       2/3        ID          D8
                Qualifier
DTP03           Related Hospital Discharge   R      1/35        AN      CCYYMMDD
                Date




ODS Health Plans
837 Dental Claim/Encounter                                                                                                         Version 1.0
Version 00401098                                              113                                                                     062402
DTP -- Date - Referral
Usage: Situational
Segment Max Use within Loop: 150
Loop Repeat: 1
Loop ID: 2300

Example: DTP*330*D8*19980617~

                                                               ATTRIBUTES
SEGMENT         ELEMENT                        USE   Min/Max   Data Type Codes/Values   Comments
DTP01           Date/Time Qualifier            R       3/3        ID         330        Required when claim has a referral. Must also fill
                                                                                        out 2310A Referring Provider
DTP02           Date/Time Period Format        R       2/3        ID          D8
                Qualifier
DTP03           Assumed or Relinquished Date   R      1/35        AN      CCYYMMDD

DTP -- Date - Accident
Usage: Situational
Segment Max Use within Loop: 150
Loop Repeat: 1
Loop ID: 2300

Example: DTP*439*D8*19980108~

                                                               ATTRIBUTES
SEGMENT         ELEMENT                        USE   Min/Max   Data Type Codes/Values   Comments
DTP01           Date/Time Qualifier            R       3/3        ID         439        Required if CLM 11-1, 11-2 or 11-3 = OA, AA, or EM

DTP02           Date/Time Period Format        R       2/3        ID          D8
                Qualifier
DTP03           Accident Date                  R      1/35        AN      CCYYMMDD




ODS Health Plans
837 Dental Claim/Encounter                                                                                                          Version 1.0
Version 00401098                                                114                                                                    062402
DTP -- Date - Appliance Placement
Usage: Situational
Segment Max Use within Loop: 150
Loop Repeat: 5
Loop ID: 2300

Example: DTP*452*D8*19980108~

                                                           ATTRIBUTES
SEGMENT         ELEMENT                    USE   Min/Max   Data Type Codes/Values   Comments
DTP01           Date/Time Qualifier        R       3/3        ID         452        Required on orthodontic claims or where CDT-4
                                                                                    code is D8XXX.
DTP02           Date/Time Period Format    R       2/3        ID          D8
                Qualifier
DTP03           Orthodontic Banding Date   R      1/35        AN      CCYYMMDD

DTP -- Date - Service
Usage: Situational
Segment Max Use within Loop: 150
Loop Repeat: 1
Loop ID: 2300

Example: DTP*472*D8*19980108~

                                                           ATTRIBUTES
SEGMENT         ELEMENT                    USE   Min/Max   Data Type Codes/Values   Comments
DTP01           Date/Time Qualifier        R       3/3        ID         472        Required if all of the services were performed. Do
                                                                                    not use this DTP for claim being submitted for
                                                                                    Predetermination of Benefits.
DTP02           Date/Time Period Format    R       2/3        ID          D8
                Qualifier
DTP03           Service Date               R      1/35        AN      CCYYMMDD




ODS Health Plans
837 Dental Claim/Encounter                                                                                                     Version 1.0
Version 00401098                                            115                                                                   062402
DN1 -- Orthodontic Total Months of Treatment
Usage: Situational
Segment Max Use within Loop: 1
Loop Repeat: 1
Loop ID: 2300

Example: DN1*36*27~

                                                               ATTRIBUTES
SEGMENT         ELEMENT                        USE   Min/Max   Data Type Codes/Values   Comments
DN101           Orthodontic Total Months of    R      1/15                              Required for claims with Orthodontic services
                Treatment                                                               (D8XXX.)
DN102           Orthodontic Treatment Months   R      1/15
                Remaining
DN103           Question Response              R       1/1        ID          Y         Required to indicate that services reported on the
                                                                                        claim are for orthodontic purposes when the DN101
                                                                                        and DN102 are not used.

DN2 -- Tooth Status
Usage: Situational
Segment Max Use within Loop: 35
Loop Repeat: 35
Loop ID: 2300

Example: DN2*8*E~

                                                               ATTRIBUTES
SEGMENT         ELEMENT                        USE   Min/Max   Data Type Codes/Values   Comments
DN201           Tooth Number                   R      1/15        AN
DN202           Tooth Status Code              R      1/15        ID        E, I, M




ODS Health Plans
837 Dental Claim/Encounter                                                                                                         Version 1.0
Version 00401098                                                116                                                                   062402
PWK - Claim Supplemental Information
Usage: Situational
Segment Max Use within Loop: 10
Loop Repeat: 10
Loop ID: 2300

Example: PWK*DA*BM***AC*DMN0012~

                                                                ATTRIBUTES
SEGMENT         ELEMENT                         USE   Min/Max   Data Type Codes/Values   Comments
PWK01           Attachment Report Type code     R       2/2        ID                    Important to have in order to relate requested paper
                                                                                         documents to this claim. Submit if applicable.

PWK02           Attachment Transmission Code    R       1/2        ID

PWK05           Identification Code Qualifier    S      1/2        ID          AC
PWK06           Attachment Control Number        S     2/80        AN                    Required if PWK02 = EM, EL, BM or FX

AMT - Patient Amount Paid
Usage: Situational
Segment Max Use within Loop: 40
Loop Repeat: 1
Loop ID: 2300

Example: AMT*F5*8.5~

                                                                ATTRIBUTES
SEGMENT         ELEMENT                         USE   Min/Max   Data Type Codes/Values   Comments
AMT01           Patient Amount Paid Qualifier   R       1/3        ID          F5        Required if patient has paid any amount toward
                                                                                         claim. Is the sum of all pt. Payments made on
                                                                                         claim.
AMT02           Patient Amount Paid             R      1/18        R




ODS Health Plans
837 Dental Claim/Encounter                                                                                                          Version 1.0
Version 00401098                                                 117                                                                   062402
REF - Predetermination Identification
Usage: Situational
Segment Max Use within Loop: 30
Loop Repeat: 5
Loop ID: 2300

Example: REF*G3*13579~

                                                                  ATTRIBUTES
SEGMENT         ELEMENT                           USE   Min/Max   Data Type Codes/Values   Comments
REF01           Predetermination of Benefits ID   R       2/3        ID          G3        Use when PD has been approved and is now being
                Number                                                                     submitted for payment.
REF02           Predetermination of Benefits      R      1/30        R
                Identifier

REF - Service Authorization Exception Code
Usage: Situational
Segment Max Use within Loop: 30
Loop Repeat: 1
Loop ID: 2300

Example: REF*4N*1~

                                                                  ATTRIBUTES
SEGMENT         ELEMENT                           USE   Min/Max   Data Type Codes/Values   Comments
REF01           Reference Identification          R       2/3        ID          4N        Not applicable in Oregon.
                Qualifier
REF02           Service Authorization Exception   R      1/30        AN
                Code




ODS Health Plans
837 Dental Claim/Encounter                                                                                                        Version 1.0
Version 00401098                                                   118                                                               062402
REF - Original Reference Number (ICN/DCN)
Usage: Situational
Segment Max Use within Loop: 30
Loop Repeat: 1
Loop ID: 2300

Example: REF*F5*N~

                                                                ATTRIBUTES
SEGMENT         ELEMENT                         USE   Min/Max   Data Type Codes/Values   Comments
REF01           Reference Identification        R       2/3        ID          F8        Use only when CLM05-3 is a value of 6, 7 or 8 and
                Qualifier                                                                previous claim number is known.
REF02           Claim Original Reference        R      1/30        AN
                Number

REF - Prior Authorization or Referral Number
Usage: Situational
Segment Max Use within Loop: 30
Loop Repeat: 2
Loop ID: 2300

Example: REF*9F*12345~

                                                                ATTRIBUTES
SEGMENT         ELEMENT                         USE   Min/Max   Data Type Codes/Values   Comments
REF01           Reference Identification        R       2/3        ID          9F
                Qualifier
REF02           Prior Auth or Referral Number   R      1/30        AN                    County & OCHIN require this.




ODS Health Plans
837 Dental Claim/Encounter                                                                                                         Version 1.0
Version 00401098                                                 119                                                                  062402
REF - Claim Identification Number for Clearinghouses and Other Transmission Subsidiaries
Usage: Situational
Segment Max Use within Loop: 30
Loop Repeat: 1
Loop ID: 2300

Example: REF*D9*TJ98UU321~

                                                                ATTRIBUTES
SEGMENT         ELEMENT                      USE     Min/Max    Data Type Codes/Values   Comments
REF01           Reference Identification     R         2/3         ID          D9        Used by Clearinghouse
                Qualifier
REF02           Clearinghouse Trace Number   R         1/30        AN

NTE - Claim Note
Usage: Situational
Segment Max Use within Loop: 20
Loop Repeat: 1
Loop ID: 2300

Example: NTE*ADD*#5 DL4/L5/ML6/MB4, #6 L6/ML5/MB4/B5, #7 ext~

                                                                ATTRIBUTES
SEGMENT         ELEMENT                      USE     Min/Max    Data Type Codes/Values   Comments
NTE01           Note Reference Code          R         3/3         ID         ADD        Notes/ Remarks are used today in electronic/paper
                                                                                         claims.
NTE02           Claim Note Text              R         1/80        AN




ODS Health Plans
837 Dental Claim/Encounter                                                                                                        Version 1.0
Version 00401098                                                 120                                                                 062402
NM1 - Referring Provider Name
Usage: Situational
Segment Max Use within Loop: 1
Loop Repeat: 1
Loop ID: 2310A

Example: NM1*DN*1*SWANSON*HARRY****24*123123123~

                                                                ATTRIBUTES
SEGMENT         ELEMENT                         USE   Min/Max   Data Type Codes/Values   Comments
NM101           Entity Identifier Code          R       2/3        ID        DN, P3
NM102           Entity Type Qualifier           R       1/1        ID         1, 2
NM103           Referring Provider Last Name    R
                or Organization
NM104           Referring Provider First Name    S     1/25        AN
NM105           Referring Provider Middle        S     1/25        AN
                Name
NM107           Referring Provider Suffix        S     1/25        AN
NM108           Identification Code Qualifier   R       1/2        ID        24, 34
NM109           Referring Provider Primary      R      2/80        AN
                Identifier

PRV - Referring Provider Specialty Information
Usage: Situational
Segment Max Use within Loop: 1
Loop Repeat: 1
Loop ID: 2310A

Example: PRV*RF*ZZ*1223E0200Y~

                                                                ATTRIBUTES
SEGMENT         ELEMENT                         USE   Min/Max   Data Type Codes/Values   Comments
PRV01           Provider Code                   R       1/3        ID          RF        Taxonomy Codes not required for referring provider
                                                                                         for ODS. Regence will confirm.
PRV02           Reference Identification        R       2/3        ID          ZZ
                Qualifier
PRV03           Provider Taxonomy Code          R      1/30        AN




ODS Health Plans
837 Dental Claim/Encounter                                                                                                         Version 1.0
Version 00401098                                                 121                                                                  062402
REF - Referring Provider Secondary Information
Usage: Situational
Segment Max Use within Loop: 20
Loop Repeat: 5
Loop ID: 2310A

Example: REF*OB*123123311~

                                                                ATTRIBUTES
SEGMENT         ELEMENT                         USE   Min/Max   Data Type Codes/Values   Comments
REF01           Identification Code Qualifier    S      2/3        ID

NM1 - Rendering Provider Name
Usage: Situational
Segment Max Use within Loop: 1
Loop Repeat: 1
Loop ID: 2310B

Example: NM1*82*1*SMITH*BRAD****34*123456789~

                                                                ATTRIBUTES
SEGMENT         ELEMENT                         USE   Min/Max   Data Type Codes/Values   Comments
NM101           Entity Identifier Code          R       2/3        ID          82        Provide this information if the Rendering Provider is
                                                                                         not also the Billing/Pay to Provider.
NM102           Entity Type Qualifier           R       1/1        ID         1, 2
NM103           Rendering Provider Last Name    R
                or Organization
NM104           Rendering Provider First Name    S     1/25        AN
NM105           Rendering Provider Middle        S     1/25        AN
                Name
NM107           Rendering Provider Suffix        S     1/25        AN
NM108           Identification Code Qualifier   R       1/2        ID        24, 34
NM109           Rendering Provider Primary      R      2/80        AN
                Identifier




ODS Health Plans
837 Dental Claim/Encounter                                                                                                           Version 1.0
Version 00401098                                                 122                                                                    062402
PRV - Rendering Provider Specialty Information
Usage: Situational
Segment Max Use within Loop: 1
Loop Repeat: 1
Loop ID: 2310B

Example: PRV*PE*ZZ*1223E0200Y~

                                                                ATTRIBUTES
SEGMENT         ELEMENT                         USE   Min/Max   Data Type Codes/Values   Comments
                                                 S                                       If Rendering provider is valued, then populate
                                                                                         the specialty code. ODS wants the taxonomy
                                                                                         Codes for the Rendering provider. Regence will
                                                                                         check.




PRV01           Provider Code                   R       1/3        ID          PE
PRV02           Reference Identification        R       2/3        ID          ZZ
                Qualifier
PRV03           Provider Taxonomy Code          R      1/30        AN

REF - Rendering Provider Secondary Identification
Usage: Situational
Segment Max Use within Loop: 20
Loop Repeat: 5
Loop ID: 2310B

Example: REF*OB*12312321~

                                                                ATTRIBUTES
SEGMENT         ELEMENT                         USE   Min/Max   Data Type Codes/Values   Comments
REF01           Identification Code Qualifier    S      2/3        ID                    Please provide the State Dental license number
                                                                                         (1E) for the rendering provider.
REF02           Rendering Provider Secondary    R      1/30        AN
                Identifier




ODS Health Plans
837 Dental Claim/Encounter                                                                                                        Version 1.0
Version 00401098                                                 123                                                                 062402
NM1 - Service Facility Location
Usage: Situational
Segment Max Use within Loop: 1
Loop Repeat: 1
Loop ID: 2310C

Example: NM1*TL*2*A-OK MOBILE CLINIC*****24*11122333~

                                                                   ATTRIBUTES
SEGMENT            ELEMENT                         USE   Min/Max   Data Type Codes/Values   Comments
NM101              Entity Identifier Code          R       2/3        ID          FA        Required if the service was rendered in other than
                                                                                            an office (11) setting.
                                                                                            ODS treats this more as informational.
                                                                                            Does this apply to mobile vans? Applies for the
                                                                                            County & OHP.
NM102              Entity Type Qualifier           R       1/1        ID          2
NM103              Laboratory or Facility Name     R      1/35        AN
NM108              Identification Code Qualifier    S     1/2         ID        24, 34
NM109              Service Facility Location       R      2/80        AN
                   Primary Identifier

REF - Service Facility Location Secondary Identification
Usage: Situational
Segment Max Use within Loop: 20
Loop Repeat: 5
Loop ID: 2310C

Example: REF*OB*12312321~

                                                                   ATTRIBUTES
SEGMENT            ELEMENT                         USE   Min/Max   Data Type Codes/Values   Comments
REF01              Identification Code Qualifier   R       2/3        ID                    This segment is not needed.
REF02              Service Facility Location       R      1/30        AN
                   Additional Identifier


NM1 - Assistant Surgeon Name - New Loop & Segment added October 2002 Addenda
ODS thinks it would appear as a pro fee claim.
Does this apply to dental anesthesiologist?



ODS Health Plans
837 Dental Claim/Encounter                                                                                                             Version 1.0
Version 00401098                                                    124                                                                   062402
Usage: Situational
Segment Max Use within Loop: 1
Loop Repeat: 1
Loop ID: 2310D

Example: NM1*DD*1*SMITH*JOHN*S***34*123456789~

                                                                 ATTRIBUTES
SEGMENT          ELEMENT                         USE   Min/Max   Data Type Codes/Values   Comments
NM101            Entity Identifier Code           R      2/3        ID                    Required when the assistant Surgeon info is needed
                                                                                          to facilitate reimbursement of the claim.

NM102            Entity Type Qualifier           R       1/1        AN
NM103            Name Last or Organization       R      1/35
                 Name
NM104            Name First                      S      1/25
NM105            Name Middle                     S      1/25
NM107            Name Suffix                     S      1/10
NM108            Identification Code Qualifier   R       1/2
NM109            Identification Code             R      2/80



PRV - Assistant Surgeon Specialty Information - New Loop & Segment added October 2002 Addenda

Usage: Situational
Segment Max Use within Loop: 1
Loop Repeat: 1
Loop ID: 2310D

Example: NM1*DD*1*SMITH*JOHN*S***34*123456789~

                                                                 ATTRIBUTES
SEGMENT          ELEMENT                         USE   Min/Max   Data Type Codes/Values   Comments
PRV01            Provider code                    R      1/3        ID                    Required when the assistant Surgeon specialty info
                                                                                          is needed to facilitate reimbursement of the claim.

PRV02            Reference ID Qualifier          R       2/3        AN
PRV03            Reference ID                    R      1/30


REF - Assistant Surgeon Secondary Identification - New Loop & Segment added October 2002 Addenda
ODS Health Plans
837 Dental Claim/Encounter                                                                                                           Version 1.0
Version 00401098                                                  125                                                                   062402
Usage: Situational
Segment Max Use within Loop: 1
Loop Repeat: 1
Loop ID: 2310D

                                                         ATTRIBUTES
SEGMENT         ELEMENT                  USE   Min/Max   Data Type Codes/Values   Comments
REF01           Reference ID Qualifier    R      2/3        ID                    Use this REF segment only if a 2nd number is
                                                                                  necessary to identify the provider. The primary ID
                                                                                  number should be contained in the NM109.
REF02           Reference ID             R      1/30        AN




ODS Health Plans
837 Dental Claim/Encounter                                                                                                    Version 1.0
Version 00401098                                          126                                                                    062402
SBR - Other Subscriber Information
Usage: Situational
Segment Max Use within Loop: 1
Loop Repeat: 1
Loop ID: 2320

Example: SBR*P*01*003450*GOLDEN PLUS****CI~

                                                                ATTRIBUTES
SEGMENT         ELEMENT                         USE   Min/Max   Data Type Codes/Values   Comments
SBR01           Payer Responsibility Sequence   R       1/1        ID         P,S,T      Coordination of Benefits Information. Submit if
                Code                                                                     known.If other subscriber info is known, send it.

SBR02           Individual Relationship Code    R       2/2        ID
SBR03           Insured Group or Policy          S     1/30        AN
                Number
SBR04           Plan Name                        S     1/60        AN
SBR09           Claim Filing Indicator Code     R       1/2        ID




ODS Health Plans
837 Dental Claim/Encounter                                                                                                           Version 1.0
Version 00401098                                                 127                                                                    062402
CAS - Claim Adjustments
Usage: Situational
Segment Max Use within Loop: 99
Loop Repeat: 5
Loop ID: 2320

Example: CAS*PR*1*793~

                                                              ATTRIBUTES
SEGMENT         ELEMENT                       USE   Min/Max   Data Type Codes/Values   Comments
CAS01           Claim Adjustment Group Code   R       1/2        ID                    Coordination of Benefits information. Submit if
                                                                                       known.
CAS02           Adjustment Reason Code--      R       1/5        ID
                Claim Level
CAS03           Adjustment Amt--Claim Level   R      1/18        R
CAS04           Adjusted Units--Claim Level    S     1/15        R
CAS05           Adjustment Reason Code--       S      1/5        ID
                Claim Level
CAS06           Adjustment Amt--Claim Level    S     1/18        R
CAS07           Adjusted Units--Claim Level    S     1/15        R
CAS08           Adjustment Reason Code--       S      1/5        ID
                Claim Level
CAS09           Adjustment Amt--Claim Level    S     1/18        R
CAS10           Adjusted Units--Claim Level    S     1/15        R
CAS11           Adjustment Reason Code--       S      1/5        ID
                Claim Level
CAS12           Adjustment Amt--Claim Level    S     1/18        R
CAS13           Adjusted Units--Claim Level    S     1/15        R
CAS14           Adjustment Reason Code--       S      1/5        ID
                Claim Level
CAS15           Adjustment Amt--Claim Level    S     1/18        R
CAS16           Adjusted Units--Claim Level    S     1/15        R
CAS17           Adjustment Reason Code--       S      1/5        ID
                Claim Level
CAS18           Adjustment Amt--Claim Level    S     1/18        R
CAS19           Adjusted Units--Claim Level    S     1/15        R




ODS Health Plans
837 Dental Claim/Encounter                                                                                                        Version 1.0
Version 00401098                                               128                                                                   062402
AMT - COB Payer Paid Amount
Usage: Situational
Segment Max Use within Loop: 15
Loop Repeat: 1
Loop ID: 2320

Example: AMT*D*411~

                                                                ATTRIBUTES
SEGMENT         ELEMENT                         USE   Min/Max   Data Type Codes/Values   Comments
AMT01           Payor Amt Paid Qualifier Code   R       1/3        ID          D         Coordination of Benefits information. Required if
                                                                                         the claim has been adjudicated by payer identified
                                                                                         in this loop.
AMT02           Payer Paid Amount               R      1/18        R

AMT - COB Approved Amount
Usage: Situational
Segment Max Use within Loop: 15
Loop Repeat: 1
Loop ID: 2320

Example: AMT*AAE*500~

                                                                ATTRIBUTES
SEGMENT         ELEMENT                         USE   Min/Max   Data Type Codes/Values   Comments
AMT01           Approved Amt Qualifier Code     R       1/3        ID         AAE        Used in Payor to Payor COB
AMT02           Approved Amount                 R      1/18        R




ODS Health Plans
837 Dental Claim/Encounter                                                                                                          Version 1.0
Version 00401098                                                 129                                                                   062402
AMT - COB Allowed Amount
Usage: Situational
Segment Max Use within Loop: 15
Loop Repeat: 1
Loop ID: 2320

Example: AMT*B6*500~

                                                               ATTRIBUTES
SEGMENT         ELEMENT                        USE   Min/Max   Data Type Codes/Values   Comments
AMT01           Actual Allowed Amt Qual Code   R       1/3        ID          B6        Used in Payor to Payor COB

AMT02           Allowed Amount                 R      1/18        R

AMT - COB Patient Responsibility Amount
Usage: Situational
Segment Max Use within Loop: 15
Loop Repeat: 1
Loop ID: 2320

Example: AMT*F2*15~

                                                               ATTRIBUTES
SEGMENT         ELEMENT                        USE   Min/Max   Data Type Codes/Values   Comments
AMT01           Pt. Responsibility Actual Am   R       1/3        ID          F2        Coordination of Benefits. Required if patient is
                Qual Code                                                               responsible for payment according to another
                                                                                        payor's adjudication.
AMT02           Patient Responsibility Amt     R      1/18        R




ODS Health Plans
837 Dental Claim/Encounter                                                                                                          Version 1.0
Version 00401098                                                130                                                                    062402
AMT - COB Covered Amount
Usage: Situational
Segment Max Use within Loop: 15
Loop Repeat: 1
Loop ID: 2320

Example: AMT*AU*203~

                                                              ATTRIBUTES
SEGMENT         ELEMENT                       USE   Min/Max   Data Type Codes/Values   Comments
AMT01           Amount Qualifier Code         R       1/3        ID          AU        Coordination of Benefits. Payor to Payor only
AMT02           Other Payer Covered Amount    R      1/18        R

AMT - COB Discount Amount
Usage: Situational
Segment Max Use within Loop: 15
Loop Repeat: 1
Loop ID: 2320

Example: AMT*D8*35~

                                                              ATTRIBUTES
SEGMENT         ELEMENT                       USE   Min/Max   Data Type Codes/Values   Comments
AMT01           Discount Amt Qual Code        R       1/3        ID          D8        Coordination of Benefits. Required if claim has
                                                                                       been adjudicated by the payer identified in this loop
                                                                                       and if this information was included in the
                                                                                       remittance advice reporting those adjudication
                                                                                       results.
AMT02           Other Payer Discount Amount   R      1/18        R




ODS Health Plans
837 Dental Claim/Encounter                                                                                                         Version 1.0
Version 00401098                                               131                                                                    062402
AMT - COB Patient Paid Amount
Usage: Situational
Segment Max Use within Loop: 15
Loop Repeat: 1
Loop ID: 2320

Example: AMT*F5*15~

                                                                ATTRIBUTES
SEGMENT         ELEMENT                         USE   Min/Max   Data Type Codes/Values   Comments
AMT01           Patient Amount Paid Qualifier   R       1/3        ID          F5        Coordination of Benefits. Required if claim has
                                                                                         been adjudicated by the payer identified in this loop
                                                                                         and if this information was included in the
                                                                                         remittance advice reporting those adjudication
                                                                                         results.
AMT02           Other Payer Patient Amount      R      1/18        R
                Paid

DMG - Other Insured Demographic Information
Usage: Situational
Segment Max Use within Loop: 1
Loop Repeat: 1
Loop ID: 2320

Example: DMG*D8*19561105*M~

                                                                ATTRIBUTES
SEGMENT         ELEMENT                         USE   Min/Max   Data Type Codes/Values   Comments
DMG01           Date/Time Period Format         R       2/3        ID          D8        Coordination of Benefits. Required when 233A
                Qualifier                                                                NM102 = '1' Person
DMG02           Other Subscriber Birth Date     R      1/35        AN
DMG03           Other Subscriber Gender Code    R       1/1        ID        F, M, U




ODS Health Plans
837 Dental Claim/Encounter                                                                                                           Version 1.0
Version 00401098                                                 132                                                                    062402
OI - Other Insurance Coverage Information
Usage: Required
Segment Max Use within Loop: 1
Loop Repeat: 1
Loop ID: 2320

Example: OI***Y***Y~

                                                                   ATTRIBUTES
SEGMENT         ELEMENT                            USE   Min/Max   Data Type Codes/Values   Comments
OI03            Assignment of Benefits             R       1/1        ID        Y or N      Coordination of Benefits.
                Indicator
OI06            Release of Information Code        R       1/1        ID        Y or N

NM1 - Other Subscriber Name
Usage: Required
Segment Max Use within Loop: 1
Loop Repeat: 1
Loop ID: 2330A

Example: NM1*IL*1*DOE*JOHN*T**JR*MI*333224444~

                                                                   ATTRIBUTES
SEGMENT         ELEMENT                            USE   Min/Max   Data Type Codes/Values   Comments
NM101           Entity Identifier Code             R       2/3        ID          IL        Coordination of Benefits.
NM102           Entity Type Qualifier              R       1/1        ID         1, 2
NM103           Other Insured Last Name or         R
                Organization
NM104           Other Insured First Name            S     1/25        AN
NM105           Other Insured Middle Name           S     1/25        AN
NM107           Other Insured Suffix                S     1/10        AN
NM108           Identification Code Qualifier      R       1/2        ID          MI
NM109           Other Insured Primary Identifier   R      2/80        AN




ODS Health Plans
837 Dental Claim/Encounter                                                                                              Version 1.0
Version 00401098                                                    133                                                    062402
N3 - Other Subscriber Address
Usage: Situational
Segment Max Use within Loop: 2
Loop Repeat: 1
Loop ID: 2330A

Example: N3*4320 WASHINGTON ST*SUITE 100~

                                                                ATTRIBUTES
SEGMENT         ELEMENT                         USE   Min/Max   Data Type Codes/Values   Comments
N301            Other Insured Address Line 1    R      1/55        AN                    Coordination of Benefits
N302            Other Insured Address Line 2     S     1/55        AN

N4 - Other Subscriber City/State/Zip
Usage: Situational
Segment Max Use within Loop: 1
Loop Repeat: 1
Loop ID: 2330A

Example: N4*PALISADES*OR*23119~

                                                                ATTRIBUTES
SEGMENT         ELEMENT                         USE   Min/Max   Data Type Codes/Values   Comments
N401            Other Subscriber City Name      R      2/30        AN                    Coordination of Benefits
N402            Other Subscriber State or       R       2/2        ID
                Province
N403            Other Subscriber Postal Code    R      3/15        ID
N404            Other Subscriber Country Code    S      2/3        ID




ODS Health Plans
837 Dental Claim/Encounter                                                                                          Version 1.0
Version 00401098                                                 134                                                   062402
REF - Other Subscriber Secondary Identification
Usage: Situational
Segment Max Use within Loop: 3
Loop Repeat: 3
Loop ID: 2330A

Example: REF*SY*528446666~

                                                                 ATTRIBUTES
SEGMENT         ELEMENT                          USE   Min/Max   Data Type Codes/Values   Comments
REF01           Identification Code Qualifier    R       2/3        ID                    Coordination of Benefits. This segment is not
                                                                                          needed
REF02           Other Subscriber Secondary       R      1/30        AN
                Identifier

NM1 - Other Payer Name
Usage: Required
Segment Max Use within Loop: 1
Loop Repeat: 1
Loop ID: 2330B

Example: NM1*PR*2*UNION MUTUAL OF OREGON*****XV*43~

                                                                 ATTRIBUTES
SEGMENT         ELEMENT                          USE   Min/Max   Data Type Codes/Values   Comments
NM101           Entity Identifier Code           R       2/3        ID          PR        Coordination of Benefits
NM102           Entity Type Qualifier            R       1/1        ID          2
NM103           Other Payer Organization         R      1/35        AN
                Name
NM108           Identification Code Qualifier    R       1/2        ID          PI
NM109           Other Payer Primary Identifier   R      2/80        AN




ODS Health Plans
837 Dental Claim/Encounter                                                                                                          Version 1.0
Version 00401098                                                  135                                                                  062402
PER - Other Payer Contact Information
Usage: Situational
Segment Max Use within Loop: 2
Loop Repeat: 2
Loop ID: 2330B

Example: PER*IC*SHELLY*TE*5552340000~

                                                               ATTRIBUTES
SEGMENT         ELEMENT                        USE   Min/Max   Data Type Codes/Values   Comments
PER01           Contact Function Code          R       2/2        ID          IC        Coordination of Benefits. Provide if known.
PER02           Other Payer Contact Name       R      1/60        AN
PER03           Communication Number           R       2/2        ID
                Qualifier
PER04           Communication Number           R      1/80        AN
PER05           Communication Number            S      2/2        ID
                Qualifier
PER06           Communication Number            S     1/80        AN
PER07           Communication Number            S      2/2        ID
                Qualifier
PER08           Communication Number            S     1/80        AN

DTP - Claim Paid Date
Usage: Situational
Segment Max Use within Loop: 9
Loop Repeat: 1
Loop ID: 2330B

Example: DTP*573*D8*1991212~

                                                               ATTRIBUTES
SEGMENT         ELEMENT                        USE   Min/Max   Data Type Codes/Values   Comments
DTP01           Date/Time Qualifier            R       3/3        ID         573        Coordination of Benefits. Required when Loop ID
                                                                                        2430 is not used
DTP02           Date/Time Period Format        R       2/3        ID          D8
DTP03           Adjudication or Payment Date   R      1/35        AN       ccyymmdd




ODS Health Plans
837 Dental Claim/Encounter                                                                                                            Version 1.0
Version 00401098                                                136                                                                      062402
REF - Other Payer Secondary Identifier
Usage: Situational
Segment Max Use within Loop: 3
Loop Repeat: 3
Loop ID: 2330B

Example: REF*FY*435261708~

                                                                ATTRIBUTES
SEGMENT         ELEMENT                         USE   Min/Max   Data Type Codes/Values   Comments
REF01           Identification Code Qualifier   R       2/3        ID                    Coordination of Benefits. This segment is not
                                                                                         needed.
REF02           Other Payer Secondary           R      1/30        AN
                Identifier

REF - Other Payer Prior Authorization or Referral Number
Usage: Situational
Segment Max Use within Loop: 3
Loop Repeat: 1
Loop ID: 2330B

Example: REF*9F*AB333-Y5~

                                                                ATTRIBUTES
SEGMENT         ELEMENT                         USE   Min/Max   Data Type Codes/Values   Comments
REF01           Reference Identification        R       2/3        ID          9F        Coordination of Benefits. This segment is not
                Qualifier                                                                needed.
REF02           Other Payer Prior Auth or       R      1/30        AN
                Referral Number




ODS Health Plans
837 Dental Claim/Encounter                                                                                                         Version 1.0
Version 00401098                                                 137                                                                  062402
REF - Other Payer Claim Adjustment Indicator
Usage: Situational
Segment Max Use within Loop: 3
Loop Repeat: 1
Loop ID: 2330B

Example: REF*T4*Y~

                                                                     ATTRIBUTES
SEGMENT         ELEMENT                          USE       Min/Max   Data Type Codes/Values   Comments
REF01           Reference Identification           R         2/3        ID          T4        Coordination of Benefits. Only used in payor to
                Qualifier                                                                     payor COB
REF02           Other Payer Claim Adjustment       R        1/30        AN
                Indicator

NM1 - Other Payer Patient Information
Usage: Situational
Segment Max Use within Loop: 1
Loop Repeat: 1
Loop ID: 2330C

Example: NM1*QC*1******MI*6677U801~

                                                                     ATTRIBUTES
SEGMENT         ELEMENT                          USE       Min/Max   Data Type Codes/Values   Comments
NM101           Entity Identifier Code             R         2/3        ID          QC        Coordination of Benefits. Provide if known.
NM102           Entity Type Qualifier              R         1/1        ID          1
NM103           Patient Last Name               Not used
NM108           Identification Code Qualifier      R         1/2        ID          MI
NM109           Patient's Other Payer Primary      R        2/80        AN
                Identification Number




ODS Health Plans
837 Dental Claim/Encounter                                                                                                                  Version 1.0
Version 00401098                                                      138                                                                      062402
NM1 - Other Payer Patient Identification
Usage: Situational
Segment Max Use within Loop: 3
Loop Repeat: 3
Loop ID: 2330C

Example: REF*AZ*B333-Y5~

                                                           ATTRIBUTES
SEGMENT         ELEMENT                    USE   Min/Max   Data Type Codes/Values   Comments
REF01           Reference Identification   R       2/3        ID                    Coordination of Benefits. This segment is not
                Qualifier                                                           needed.
REF02           Patient's Other Payer      R      1/30        AN
                Secondary Identifier

NM1 - Other Payer Referring Provider
Usage: Situational
Segment Max Use within Loop: 1
Loop Repeat: 1
Loop ID: 2330D

Example: NM1*DN*1~

                                                           ATTRIBUTES
SEGMENT         ELEMENT                    USE   Min/Max   Data Type Codes/Values   Comments
NM101           Entity Identifier Code     R       2/3        ID        DN, P3      Coordination of Benefits. Provide if known.
NM102           Entity Type Qualifier      R       1/1        ID         1, 2




ODS Health Plans
837 Dental Claim/Encounter                                                                                                        Version 1.0
Version 00401098                                            139                                                                      062402
REF - Other Payer Referring Provider Identification
Usage: Required
Segment Max Use within Loop: 3
Loop Repeat: 3
Loop ID: 2330D

Example: REF*EI*RF446~

                                                                 ATTRIBUTES
SEGMENT         ELEMENT                          USE   Min/Max   Data Type Codes/Values   Comments
REF01           Reference Identification         R       2/3        ID                    Coordination of Benefits. Provide if known.
                Qualifier
REF02           Other Payer Referring Provider   R      1/30        AN
                Identification

NM1- Other Payer Rendering Provider
Usage: Situational
Segment Max Use within Loop: 1
Loop Repeat: 1
Loop ID: 2330E

Example: NM1*82*1~

                                                                 ATTRIBUTES
SEGMENT         ELEMENT                          USE   Min/Max   Data Type Codes/Values   Comments
NM101           Entity Identifier Code           R       2/3        ID          82        Coordination of Benefits. Provide if known.
NM102           Entity Type Qualifier            R       1/1        ID         1, 2




ODS Health Plans
837 Dental Claim/Encounter                                                                                                              Version 1.0
Version 00401098                                                  140                                                                      062402
REF - Other Payer Rendering Provider Identification
Usage: Required
Segment Max Use within Loop: 3
Loop Repeat: 3
Loop ID: 2330E

Example: REF*LU*SLC987~

                                                            ATTRIBUTES
SEGMENT          ELEMENT                    USE   Min/Max   Data Type Codes/Values   Comments
REF01            Reference Identification   R       2/3        ID                    Coordination of Benefits. Provide if known.
                 Qualifier
REF02            Other Payer Rendering      R      1/30        AN
                 Provider Secondary
                 Identification

LX - Line Counter
Usage: Required
Segment Max Use within Loop: 1
Loop Repeat: 1
Loop ID: 2400

Example: LX*1~

                                                            ATTRIBUTES
SEGMENT          ELEMENT                    USE   Min/Max   Data Type Codes/Values   Comments
LX01             Line Counter               R       1/6        N0




ODS Health Plans
837 Dental Claim/Encounter                                                                                                         Version 1.0
Version 00401098                                             141                                                                      062402
SV3 - Dental Service
Usage: Required
Segment Max Use within Loop: 1
Loop Repeat: 1
Loop ID: 2400

Example: SV3*AD:D2150*80****1~

                                                                  ATTRIBUTES
SEGMENT         ELEMENT                           USE   Min/Max   Data Type Codes/Values   Comments
SV301           Procedure Identifier              R
SV301-1         Product or Service ID Qualifier   R       2/2        ID          AD        American Dental Association Codes are only valid
                                                                                           Code set
SV301-2         Procedure Code                    R      1/48        AN
SV301-3         Procedure Modifier 1               S      2/2        AN                    Modifiers are not used in dental coding at this time.

SV301-4         Procedure Modifier 2               S      2/2        AN                    Modifiers are not used in dental coding at this time.

SV301-5         Procedure Modifier 3               S      2/2        AN                    Modifiers are not used in dental coding at this time.

SV301-6         Procedure Modifier 4               S      2/2        AN                    Modifiers are not used in dental coding at this time.

SV302           Line Item Charge Amount           R      1/18        R
SV303           Facility Type Code                 S      2/2        ID
SV304           Oral Cavity Designation            S     1/15        R                     Required to report areas of the mouth that are being
                                                                                           treated. Preferred values for ODS are: 00 (entire
                                                                                           oral cavity); 10 (Upper Right Quadrant, 20 (Upper
                                                                                           Left Quadrant); 30 (Lower Left Quadrant); 40 (Lower
                                                                                           Right Quadrant)
SV304-1         Oral Cavity Designation Code      R       1/3        ID

SV304-2         Oral Cavity Designation Code       S      1/3        ID
SV304-3         Oral Cavity Designation Code       S      1/3        ID
SV304-4         Oral Cavity Designation Code      R       1/3        ID
SV304-5         Oral Cavity Designation Code      R       1/3        ID
SV305           Prothesis, Crown or Inlay Code     S      1/1        ID          I, R

SV306           Procedure Count                   R       1/2        R




ODS Health Plans
837 Dental Claim/Encounter                                                                                                              Version 1.0
Version 00401098                                                   142                                                                     062402
TOOTH - Tooth Information
Usage: Situational
Segment Max Use within Loop: 32
Loop Repeat: 32
Loop ID: 2400

Example: TOO*JP*12*L:O~

                                                           ATTRIBUTES
SEGMENT         ELEMENT                    USE   Min/Max   Data Type Codes/Values   Comments
                                                                                    Required to report tooth number and/or tooth
TOO01           Code List Qualifier Code   R       1/3        ID          JP        surface related to this procedure line.
TOO02           Tooth Number               S      1/30        AN
                                                                                    Required if the procedure code requires tooth
TOO03           Tooth Surface              S                                        surfaces.
TOO03-1         Tooth Surface Code         R       1/2        ID
TOO03-2         Tooth Surface Code          S      1/2        ID
TOO03-3         Tooth Surface Code          S      1/2        ID
TOO03-4         Tooth Surface Code          S      1/2        ID
TOO03-5         Tooth Surface Code          S      1/2        ID

DTP - Date - Service Date
Usage: Required
Segment Max Use within Loop: 15
Loop Repeat: 1
Loop ID: 2400

Example: DTP*472*D8*19980108~

                                                           ATTRIBUTES
SEGMENT         ELEMENT                    USE   Min/Max   Data Type Codes/Values   Comments
DTP01           Date/Time Qualifier        R       3/3        ID         472
DTP02           Date/Time Period Format    R       2/3        ID          D8
                Qualifier
DTP03           Service Date               R      1/35        AN      CCYYMMDD




ODS Health Plans
837 Dental Claim/Encounter                                                                                                 Version 1.0
Version 00401098                                            143                                                               062402
DTP - Date - Prior Placement
Usage: Situational
Segment Max Use within Loop: 15
Loop Repeat: 1
Loop ID: 2400

Example: DTP*441*D8*19980108~

                                                           ATTRIBUTES
SEGMENT         ELEMENT                    USE   Min/Max   Data Type Codes/Values   Comments
DTP01           Date/Time Qualifier        R       3/3        ID         441        Required if the services performed are prosthetic
                                                                                    services that were previously placed. If the SV305 =
                                                                                    'R', then the Prior Placement date is required.

DTP02           Date/Time Period Format    R       2/3        ID          D8
                Qualifier
DTP03           Prior Placement Date       R      1/35        AN      CCYYMMDD

DTP - Date - Appliance Placement
Usage: Situational
Segment Max Use within Loop: 15
Loop Repeat: 1
Loop ID: 2400

Example: DTP*452*D8*19980108~

                                                           ATTRIBUTES
SEGMENT         ELEMENT                    USE   Min/Max   Data Type Codes/Values   Comments
DTP01           Date/Time Qualifier        R       3/3        ID         452        Required if the appliance placement date is different
                                                                                    than the appliance placement date in the 2300 loop.

DTP02           Date/Time Period Format    R       2/3        ID          D8
                Qualifier
DTP03           Orthodontic Banding Date   R      1/35        AN      CCYYMMDD




ODS Health Plans
837 Dental Claim/Encounter                                                                                                      Version 1.0
Version 00401098                                            144                                                                    062402
DTP - Date - Replacement
Usage: Situational
Segment Max Use within Loop: 15
Loop Repeat: 1
Loop ID: 2400

Example: DTP*446*D8*19980108~

                                                          ATTRIBUTES
SEGMENT         ELEMENT                   USE   Min/Max   Data Type Codes/Values   Comments
DTP01           Date/Time Qualifier       R       3/3        ID         446        Replacement of an orthodontic appliance.
DTP02           Date/Time Period Format   R       2/3        ID          D8
                Qualifier
DTP03           Replacement Date          R      1/35        AN

QTY - Date - Anesthesia Quantity
Usage: Situational
Segment Max Use within Loop: 5
Loop Repeat: 5
Loop ID: 2400

Example: QTY*BF*3~

                                                          ATTRIBUTES
SEGMENT         ELEMENT                   USE   Min/Max   Data Type Codes/Values   Comments
QTY01           Quantity Qualifier        R       2/2        ID
QTY02           Anesthesia Unit Count     R       2/3        ID




ODS Health Plans
837 Dental Claim/Encounter                                                                                                    Version 1.0
Version 00401098                                           145                                                                   062402
REF - Service Predetermination Identification
Usage: Situational
Segment Max Use within Loop: 30
Loop Repeat: 1
Loop ID: 2400

Example: REF**G3*MCN12345~

                                                                  ATTRIBUTES
SEGMENT         ELEMENT                           USE   Min/Max   Data Type Codes/Values   Comments
REF01           Reference Identification          R       2/3        ID          G3        Line Level Predetermination of Benefits
                Qualifier                                                                  Identification Number for a service that was
                                                                                           previously predetermined and is now being
                                                                                           submitted for payment. Not needed if identified at
                                                                                           the 2300 level.
REF02           Predetermination of Benefits ID   R       2/3        ID
                Number

REF - Prior Authorization or Referral Number
Usage: Situational
Segment Max Use within Loop: 30
Loop Repeat: 1
Loop ID: 2400

Example: REF*9F*123456567~

                                                                  ATTRIBUTES
SEGMENT         ELEMENT                           USE   Min/Max   Data Type Codes/Values   Comments
REF01           Reference Identification          R       2/3        ID          9F
                Qualifier
REF02           Referral Number                   R       2/3        ID




ODS Health Plans
837 Dental Claim/Encounter                                                                                                            Version 1.0
Version 00401098                                                   146                                                                   062402
REF - Line Item Control Number
Usage: Situational
Segment Max Use within Loop: 30
Loop Repeat: 1
Loop ID: 2400

Example: REF*6R*54321~

                                                            ATTRIBUTES
SEGMENT         ELEMENT                     USE   Min/Max   Data Type Codes/Values   Comments
REF01           Reference Identification    R       2/3        ID          6R        Submitted by provider
                Qualifier
REF02           Line Item Control Number    R      1/30        AN

AMT - Approved Amount
Usage: Situational
Segment Max Use within Loop: 15
Loop Repeat: 1
Loop ID: 2400

Example: AMT*AAE*300~

                                                            ATTRIBUTES
SEGMENT         ELEMENT                     USE   Min/Max   Data Type Codes/Values   Comments
AMT01           Approved Amount Qualifier   R       1/3        ID         AAE        Coordination of Benefits. Used only in Payer to
                Code                                                                 Payer COB.
AMT02           Approved Amount             R      1/18        R




ODS Health Plans
837 Dental Claim/Encounter                                                                                                      Version 1.0
Version 00401098                                             147                                                                   062402
NTE - Line Note
Usage: Situational
Segment Max Use within Loop: 10
Loop Repeat: 10
Loop ID: 2400

Example: NTE*ADD*PATIENT IS HANDICAPPED AND REQUIRED BEHAVIORAL MANAGEMENT TO COMPLETE TREATMENT~

                                                                ATTRIBUTES
SEGMENT         ELEMENT                         USE   Min/Max   Data Type Codes/Values   Comments
NTE01           Note Reference Code             R       3/3        ID         ADD
NTE02           Claim Note Text                 R      1/80        AN

NM1 - Rendering Provider Name
Usage: Situational
Segment Max Use within Loop: 1
Loop Repeat: 1
Loop ID: 2420A

Example: NM1*82*1*DICE*LINDA****34*123456789~

                                                                ATTRIBUTES
SEGMENT         ELEMENT                         USE   Min/Max   Data Type Codes/Values   Comments
NM101           Entity Identifier Code          R       2/3        ID          82        ODS & Regence adjudication system does not
                                                                                         accommodate rendering provider at the service
                                                                                         line level. Claims must be submitted with the
                                                                                         rendering provider identified in the 2300 loop.
                                                                                         EPIC practice management system does
                                                                                         accommodate it.

NM102           Entity Type Qualifier           R       1/1        ID         1, 2
NM103           Rendering Provider Last Name    R
                or Organization
NM104           Rendering Provider First Name    S     1/25        AN
NM105           Rendering Provider Middle        S     1/25        AN
                Name
NM107           Rendering Provider Suffix        S     1/25        AN
NM108           Identification Code Qualifier   R       1/2        ID        24, 34



ODS Health Plans
837 Dental Claim/Encounter                                                                                                       Version 1.0
Version 00401098                                                 148                                                                062402
NM109           Rendering Provider Primary   R   2/80     AN
                Identifier




ODS Health Plans
837 Dental Claim/Encounter                                     Version 1.0
Version 00401098                                        149       062402
PRV - Rendering Provider Specialty Information
Usage: Situational
Segment Max Use within Loop: 1
Loop Repeat: 1
Loop ID: 2420A

Example: PRV*PE*ZZ*1223P0300Y~

                                                                ATTRIBUTES
SEGMENT         ELEMENT                         USE   Min/Max   Data Type Codes/Values   Comments
PRV01           Provider Code                   R       1/3        ID          PE        ODS & Regence adjudication system does not
                                                                                         accommodate rendering provider at the service
                                                                                         line level. Claims must be submitted with the
                                                                                         rendering provider identified in the 2300 loop.
                                                                                         (N/A for this field)

PRV02           Reference Identification        R       2/3        ID          ZZ
                Qualifier
PRV03           Provider Taxonomy Code          R      1/30        AN

REF - Rendering Provider Secondary Identification
Usage: Situational
Segment Max Use within Loop: 20
Loop Repeat: 5
Loop ID: 2420A

Example: REF*OB*A12345~

                                                                ATTRIBUTES
SEGMENT         ELEMENT                         USE   Min/Max   Data Type Codes/Values   Comments
REF01           Identification Code Qualifier    S      2/3        ID                    ODS & Regence adjudication system does not
                                                                                         accommodate rendering provider at the service
                                                                                         line level. Claims must be submitted with the
                                                                                         rendering provider identified in the 2300 loop.
                                                                                         (N/A for this field)

REF02           Rendering Provider Primary       S     1/30        AN
                Identifier




ODS Health Plans
837 Dental Claim/Encounter                                                                                                       Version 1.0
Version 00401098                                                 150                                                                062402
NM1 - Other Payer Prior Authorization or Referral Number
Usage: Situational
Segment Max Use within Loop: 1
Loop Repeat: 1
Loop ID: 2420B

Example: NM1*PR*2*PAYER 1*****PI*111222333~

                                                                   ATTRIBUTES
SEGMENT            ELEMENT                         USE   Min/Max   Data Type Codes/Values   Comments
NM101              Entity Identifier Code          R       2/3        ID          PR        Coordination of Benefits. This segment is not
                                                                                            needed.
NM102              Entity Type Qualifier           R       1/1        ID          2
NM103              Payer Name                      R
NM108              Identification Code Qualifier   R       1/2        ID          PI
NM109              Other payer Identification      R      2/80        AN
                   Number

                                                                                            Used when COB Payer has one or more line
REF - Other Payer Prior Authorization or Referral Number                                    level referral numbers for this service line.

Usage: Situational
Segment Max Use within Loop: 20
Loop Repeat: 1
Loop ID: 2420B

Example: REF*9F*AB333-Y6~

                                                                   ATTRIBUTES
SEGMENT            ELEMENT                         USE   Min/Max   Data Type Codes/Values   Comments
REF01              Reference Identification        R       2/3        ID          9F        Coordination of Benefits. This segment is not
                   Qualifier                                                                needed.
REF02              Prior Auth or Referral Number   R      1/30        AN


NM1 - Assistant Surgeon Name - New Loop & Segment added October 2002 Addenda
ODS thinks it would appear as a pro fee claim.
Does this apply to dental anesthesiologist?

Usage: Situational
Segment Max Use within Loop: 1


ODS Health Plans
837 Dental Claim/Encounter                                                                                                            Version 1.0
Version 00401098                                                    151                                                                  062402
Loop Repeat: 1
Loop ID: 2420C

Example: NM1*DD*1*SMITH*JOHN*S***34*123456789~

                                                                 ATTRIBUTES
SEGMENT          ELEMENT                         USE   Min/Max   Data Type Codes/Values   Comments
NM101            Entity Identifier Code           R      2/3        ID                    ODS & Regence adjudication system does not
                                                                                          accommodate rendering provider at the service
                                                                                          line level. Claims must be submitted with the
                                                                                          rendering provider identified in the 2300 loop.
                                                                                          (N/A for this field)

NM102            Entity Type Qualifier           R       1/1        AN
NM103            Name Last or Organization       R      1/35
                 Name
NM104            Name First                      S      1/25
NM105            Name Middle                     S      1/25
NM107            Name Suffix                     S      1/10
NM108            Identification Code Qualifier   R       1/2
NM109            Identification Code             R      2/80




PRV - Assistant Surgeon Specialty Information - New Loop & Segment added October 2002 Addenda

Usage: Situational
Segment Max Use within Loop: 1
Loop Repeat: 1
Loop ID: 2420C

Example: NM1*DD*1*SMITH*JOHN*S***34*123456789~

                                                                 ATTRIBUTES
SEGMENT          ELEMENT                         USE   Min/Max   Data Type Codes/Values   Comments
PRV01            Provider code                    R      1/3        ID                    ODS & Regence adjudication system does not
                                                                                          accommodate rendering provider at the service
                                                                                          line level. Claims must be submitted with the
                                                                                          rendering provider identified in the 2300 loop.
                                                                                          (N/A for this field)



ODS Health Plans
837 Dental Claim/Encounter                                                                                                        Version 1.0
Version 00401098                                                  152                                                                062402
PRV02           Reference ID Qualifier   R       2/3        AN
PRV03           Reference ID             R      1/30


REF - Assistant Surgeon Secondary Identification - New Loop & Segment added October 2002 Addenda
Usage: Situational
Segment Max Use within Loop: 1
Loop Repeat: 1
Loop ID: 2420C

                                                         ATTRIBUTES
SEGMENT         ELEMENT                  USE   Min/Max   Data Type Codes/Values   Comments
REF01           Reference ID Qualifier    R      2/3        ID                    ODS & Regence adjudication system does not
                                                                                  accommodate rendering provider at the service
                                                                                  line level. Claims must be submitted with the
                                                                                  rendering provider identified in the 2300 loop.
                                                                                  (N/A for this field)

REF02           Reference ID             R      1/30        AN




ODS Health Plans
837 Dental Claim/Encounter                                                                                                Version 1.0
Version 00401098                                          153                                                                062402
SVD - Line Adjudication Information
Usage: Situational
Segment Max Use within Loop: 1
Loop Repeat: 1
Loop ID: 2430

Example: SVD*43*55*AD:D0330**1~

                                                                  ATTRIBUTES
SEGMENT         ELEMENT                           USE   Min/Max   Data Type Codes/Values   Comments
SVD01           Other Payer Identification        R      2/80        AN                    Coordination of Benefits information.
                Number
SVD02           Service Line Paid Amount          R      1/18        R
SVD03           Procedure Identifier              R
SVD03-1         Product or Service ID Qualifier   R       2/2        ID          AD        Only CDT codes are approved for use with the 837D
                                                                                           transaction.
SVD03-2         Procedure Code                    R      1/48        AN
SVD03-3         Procedure Modifier 1               S      2/2        AN                    Modifiers are not used in dental coding at this time.

SVD03-4         Procedure Modifier 2               S      2/2        AN                    Modifiers are not used in dental coding at this time.

SVD03-5         Procedure Modifier 3               S      2/2        AN                    Modifiers are not used in dental coding at this time.

SVD03-6         Procedure Modifier 4               S      2/2        AN                    Modifiers are not used in dental coding at this time.

SVD03-7         Procedure Code Description         S     1/80        AN                    This is expected only if the Procedure code is Not
                                                                                           otherwise classified (NOC)
SVD05           Paid Units of Service Count        S     1/15        R
SVD06           Bundled/Unbundled Line             S      1/6        N0
                Number




ODS Health Plans
837 Dental Claim/Encounter                                                                                                              Version 1.0
Version 00401098                                                   154                                                                     062402
CAS - Service Adjustment
Usage: Situational
Segment Max Use within Loop: 99
Loop Repeat: 99
Loop ID: 2430

Example: CAS*PR*1*793~

                                                               ATTRIBUTES
SEGMENT         ELEMENT                        USE   Min/Max   Data Type Codes/Values   Comments
CAS01           Claim Adjustment Group Code    R       1/2        ID                    Coordination of Benefits information.

CAS02           Adjustment Reason Code--Line   R       1/5        ID
                item
CAS03           Adjustment Amt--Line item      R      1/18        R
CAS04           Adjusted Units--Line item      S      1/15        R
CAS05           Adjustment Reason Code--Line    S      1/5        ID
                item
CAS06           Adjustment Amt--Line item       S     1/18        R
CAS07           Adjusted Units--Line item       S     1/15        R
CAS08           Adjustment Reason Code--Line    S      1/5        ID
                item
CAS09           Adjustment Amt--Line item       S     1/18        R
CAS10           Adjusted Units--Claim Level     S     1/15        R
CAS11           Adjustment Reason Code--Line    S      1/5        ID
                item
CAS12           Adjustment Amt--Line item       S     1/18        R
CAS13           Adjusted Units--Line item       S     1/15        R
CAS14           Adjustment Reason Code--Line    S      1/5        ID
                item
CAS15           Adjustment Amt--Line item       S     1/18        R
CAS16           Adjusted Units--Line item       S     1/15        R
CAS17           Adjustment Reason Code--Line    S      1/5        ID
                item
CAS18           Adjustment Amt--Line item       S     1/18        R
CAS19           Adjusted Units--Line item       S     1/15        R




ODS Health Plans
837 Dental Claim/Encounter                                                                                                      Version 1.0
Version 00401098                                                155                                                                062402
CAS - Line Adjudication Date
Usage: Required
Segment Max Use within Loop: 9
Loop Repeat: 1
Loop ID: 2430

Example: DTP*573*D8*19961131~

                                                               ATTRIBUTES
SEGMENT         ELEMENT                        USE   Min/Max   Data Type Codes/Values   Comments
DTP01           Date/Time Qualifier            R       3/3        ID         573
DTP02           Date/Time Period Format        R       2/3        ID          D8
DTP03           Adjudication or Payment Date   R      1/35        AN      CCYYMMDD

SE - Transaction Set Trailer
Usage: Required
Segment Max Use within Loop: 1
Loop Repeat: 1
Loop ID:

Example: SE*211*987654~

                                                               ATTRIBUTES
SEGMENT         ELEMENT                        USE   Min/Max   Data Type Codes/Values   Comments
SE01            Number of Included Segments    R      1/10        N0
SE02            Transaction Set Control        R       4/9        AN                    ST02=SE02
                Number




ODS Health Plans
837 Dental Claim/Encounter                                                                          Version 1.0
Version 00401098                                                156                                    062402
GE - Functional Group Trailer
Usage: Required
Segment Max Use within Loop:
Loop Repeat: 1
Loop ID:

Example: GE*1*1~

                                                             ATTRIBUTES
SEGMENT         ELEMENT                      USE   Min/Max   Data Type Codes/Values   Comments
GE01            Number of Transaction         R      1/6
                Transaction Set Control              1/9
GE02            Number                        R

IEA - Interchange Control Trailer
Usage: Required
Segment Max Use within Loop:
Loop Repeat: 1
Loop ID:

Example: IEA*1*000000001~

                                                             ATTRIBUTES
SEGMENT         ELEMENT                      USE   Min/Max   Data Type Codes/Values   Comments
IEA01           Number of Included            R      1/5
IEA02           Interchange Control Number    R      9/9




ODS Health Plans
837 Dental Claim/Encounter                                                                       Version 1.0
Version 00401098                                              157                                   062402

				
DOCUMENT INFO
Description: Auto Accident Claim document sample