837 Professional_ Dental _ Institutional mapping worksheet by liwenting

VIEWS: 32 PAGES: 109

									PURPOSE OF MAPPING WORKSHEET
 This worksheet is intended as a companion to the ASC X12N
Implementation Guide to assist with the identification of data content and
mapping issues as they relate to the HIPAA standard version 004010X096,
097, and 098 for this transaction. The user must refer to the
implementation guide for more detailed, specific information on syntax and
data usage considerations.
Note: 004010X096A1, 097A1 and 098A1 Addenda added 1 April 2003

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

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

DATA ELEMENT USAGE CONSIDERATIONS

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

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

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

NOTES COLUMN

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



                                                               837 - HEALTH CLAIMS AND ENCOUNTERS (PROFESSIONAL)
INTERNAL    TABLE  /   FIELD    FIELD   FIELD   Old    A1                                                                         REF     ELEMENT
RECORD ID   DATABASE   LENGTH   TYPE    NAME    PG     PG   SEGMENT NAME                        ELEMENT NAME                      DES.     NUMBER     LOOP ATTRIBUTES      NOTES                USE      REPEAT
                                                                                                                                                                           FUNCTIONAL
                                                            TABLE 1 - HEADER                                                                                               GROUP: HC
                                                  62   61   TRANSACTION SET HEADER                                                ST                HEADER                                      R             1

                                                                                                TRANSACTION SET IDENTIFIER CODE   ST01        143   HEADER M   ID   3/3    MUST BE 837
                                                                                                TRANSACTION SET CONTROL                                                    MUST MATCH VALUE
                                                                                                NUMBER                            ST02        329   HEADER M   AN   4/9    IN SE02
                                                            BEGINNING OF HIERARCHICAL
                                                  63   62   TRANSACTION                                                           BHT               HEADER                                      R             1
                                                                                                HIERARCHICAL STRUCTURE CODE       BHT01      1005   HEADER M   ID   4/4    0019
                                                                                                                                                                           00 = ORIGINAL
                                                                                                TRANSACTION SET PURPOSE CODE      BHT02       353   HEADER M   ID   2/2    18 = REISSUE
                                                                                                                                                                           SUBMITTER'S FILE
                                                                                                REFERENCE IDENTIFICATION          BHT03       127   HEADER O   AN   1/30   NUMBER
                                                                                                                                                                           TRANSACTION SET
                                                                                                DATE                              BHT04       373   HEADER O   DT   8/8    CREATION DATE
                                                                                                TIME                              BHT05       337   HEADER O   TM   4/8    CREATION TIME
                                                                                                                                                                           CH = FEE-FOR-
                                                                                                                                                                           SERVICE
                                                                                                TRANSACTION TYPE CODE             BHT06       640   HEADER O   ID   2/2    RP = ENCOUNTERS

                                                  66   65   TRANSMISSION TYPE IDENTIFICATION                                      REF               HEADER                                      R             1
                                                                                                REFERENCE IDENTIFICATION
                                                                                                QUALIFIER                         REF01       128   HEADER M   ID   2/3    87
                                                                                                REFERENCE IDENTIFICATION          REF02       127   HEADER X   AN   1/30   VERSION NUMBER
                                                            LOOP ID - 1000A SUBMITTER NAME                                                                                                                    1
                                                  67   66   SUBMITTER NAME                                                        NM1                1000A                                      R             1
                                                                                                ENTITY IDENTIFIER CODE            NM101        98    1000A M   ID   2/3    41 (SUBMITTER)
                                                                                                ENTITY TYPE QUALIFIER             NM102      1065    1000A M   ID   1/1

                                                                                                NAME LAST OR ORGANIZATION NAME NM103         1035    1000A O   AN   1/35   SUBMITTER NAME
                                                                                                                                                                           SUBMITTER FIRST
                                                                                                NAME FIRST                        NM104      1036    1000A O   AN   1/25   NAME
                                                                                                                                                                           SUBMITTER MIDDLE
                                                                                                NAME MIDDLE                       NM105      1037    1000A O   AN   1/25   NAME


                                                                                                IDENTIFICATION CODE QUALIFIER     NM108        66    1000A X   ID   1/2    46
                                                                                                                                                                           SUBMITTER ID
                                                                                                IDENTIFICATION CODE               NM109        67    1000A X   AN   2/80   NUMBER

                                                  70   69   SUBMITTER EDI CONTACT INFORMATION                                     PER                1000A                                      R             2
                                                                                                CONTACT FUNCTION CODE             PER01       366    1000A M   ID   2/2    IC


                                                                                                 3
                                                                                                                                                                                      Policy Memorandum 2004 - 37
                                                                                                                                                                                      Exhibit 2J



                                                               837 - HEALTH CLAIMS AND ENCOUNTERS (PROFESSIONAL)
INTERNAL    TABLE  /   FIELD    FIELD   FIELD   Old    A1                                                                              REF          ELEMENT
RECORD ID   DATABASE   LENGTH   TYPE    NAME    PG     PG   SEGMENT NAME                             ELEMENT NAME                      DES.          NUMBER     LOOP ATTRIBUTES       NOTES                 USE     REPEAT


                                                                                                     NAME                              PER02              93    1000A O   AN   1/60

                                                                                                     COMMUNICATION NUMBER QUALIFIER PER03                365    1000A X   ID   2/2
                                                                                                     COMMUNICATION NUMBER           PER04                364    1000A X   AN   1/80
                                                                                                     COMMUNICATION NUMBER QUALIFIER PER05                365    1000A X   ID   2/2
                                                                                                     COMMUNICATION NUMBER           PER06                364    1000A X   AN   1/80
                                                                                                     COMMUNICATION NUMBER QUALIFIER PER07                365    1000A X   ID   2/2
                                                                                                     COMMUNICATION NUMBER           PER08                364    1000A X   AN   1/80
                                                            LOOP ID - 1000B RECEIVER NAME                                                                                                                                1
                                                  74   72   RECEIVER NAME                                                              NM1                      1000B                                       R            1
                                                                                                     ENTITY IDENTIFIER CODE            NM101              98    1000B M   ID   2/3    40
                                                                                                     ENTITY TYPE QUALIFIER             NM102            1065    1000B M   ID   1/1    2

                                                                                                     NAME LAST OR ORGANIZATION NAME NM103               1035    1000B O   AN   1/35   RECEIVER NAME
                                                                                                     IDENTIFICATION CODE QUALIFIER  NM108                 66    1000B X   ID   1/2    46
                                                                                                                                                                                      RECEIVER ID
                                                                                                     IDENTIFICATION CODE               NM109              67    1000B X   AN   2/80   NUMBER
                                                                                                          TABLE 2 - DETAIL, BILLING/PAY-TO PROVIDER HIERARCHICAL LEVEL
                                                                                                LOOP ID - 2000A BILLING/PAY-TO PROVIDER HIERARCHICAL LEVEL                                                              >1
                                                            BILLING/PAY-TO PROVIDER
                                                  77   74   HIERARCHICAL LEVEL                                                         HL                       2000A                                       R            1
                                                                                                     HIERARCHICAL ID NUMBER            HL01              628    2000A M   AN   1/12
                                                                                                     HIERARCHICAL LEVEL CODE           HL03              735    2000A M   ID   1/2    20
                                                                                                     HIERARCHICAL CHILD CODE           HL04              736    2000A O   ID   1/1    1
                                                            BILLING/PAY-TO PROVIDER SPECIALTY
                                                  79   76   INFORMATION                                                                PRV                      2000A                                       S            1
                                                                                                                                                                                      BI = BILLING   PT =
                                                                                                     PROVIDER CODE                     PRV01            1221    2000A M   ID   1/3    PAY TO
                                                                                                     REFERENCE IDENTIFICATION
                                                                                                     QUALIFIER                         PRV02             128    2000A M   ID   2/3    ZZ
                                                                                                                                                                                      PROVIDER
                                                                                                     REFERENCE IDENTIFICATION          PRV03             127    2000A M   AN   1/30   TAXONOMY CODE
                                                  81   78   FOREIGN CURRENCY INFORMATION                                               CUR                      2000A                                       S            1
                                                                                                                                                                                      85 (BILLING
                                                                                                     ENTITY IDENTIFIER CODE            CUR01              98    2000A M   ID   2/3    PROVIDER)
                                                                                                     CURRENCY CODE                     CUR02             100    2000A M   ID   3/3
                                                            LOOP ID - 2010AA BILLING PROVIDER NAME                                                                                                                       1
                                                  84   81   BILLING PROVIDER NAME                                                      NM1                     2010AA                                       R            1
                                                                                                     ENTITY IDENTIFIER CODE            NM101              98   2010AA M   ID   2/3    85
                                                                                                     ENTITY TYPE QUALIFIER             NM102            1065   2010AA M   ID   1/1

                                                                                                      4
                                                                                                                                                                               Policy Memorandum 2004 - 37
                                                                                                                                                                               Exhibit 2J



                                                               837 - HEALTH CLAIMS AND ENCOUNTERS (PROFESSIONAL)
INTERNAL    TABLE  /   FIELD    FIELD   FIELD   Old    A1                                                                           REF     ELEMENT
RECORD ID   DATABASE   LENGTH   TYPE    NAME    PG     PG   SEGMENT NAME                            ELEMENT NAME                    DES.     NUMBER    LOOP ATTRIBUTES         NOTES                USE      REPEAT
                                                                                                                                                                               BILLING PROVIDER
                                                                                                    NAME LAST OR ORGANIZATION NAME NM103       1035   2010AA O     AN   1/35   NAME
                                                                                                    NAME FIRST                     NM104       1036   2010AA O     AN   1/25
                                                                                                    NAME MIDDLE                     NM105      1037   2010AA O     AN   1/25
                                                                                                    NAME SUFFIX                     NM107      1039   2010AA O     AN   1/10
                                                                                                    IDENTIFICATION CODE QUALIFIER   NM108        66   2010AA X     ID   1/2
                                                                                                    IDENTIFICATION CODE             NM109        67   2010AA X     AN   2/80
                                                  88   84   BILLING PROVIDER ADDRESS                                                N3                2010AA                                        R             1
                                                                                                    ADDRESS INFORMATION             N301        166            M   AN   1/55   ADDRESS LINE 1
                                                                                                    ADDRESS INFORMATION             N302        166   2010AA O     AN   1/55   ADDRESS LINE 2

                                                  89   85   BILLING PROVIDER CITY/STATE/ZIP CODE                                    N4                2010AA                                        R             1
                                                                                                    CITY NAME                       N401         19   2010AA O     AN   2/30
                                                                                                    STATE OR PROVINCE CODE          N402        156   2010AA O     ID   2/2
                                                                                                    POSTAL CODE                     N403        116   2010AA O     ID   3/15
                                                                                                    COUNTRY CODE                    N404         26   2010AA O     ID   2/3
                                                            BILLING PROVIDER SECONDARY
                                                  91   87   INFORMATION                                                             REF               2010AA                                        S             8
                                                                                                    REFERENCE IDENTIFICATION
                                                                                                    QUALIFIER                       REF01       128   2010AA M     ID   2/3    SEE CODE LIST
                                                                                                    REFERENCE IDENTIFICATION        REF02       127   2010AA M     AN   1/30
                                                            CREDIT/DEBIT CARD BILLING
                                                  94   90   INFORMATION                                                             REF               2010AA                                        S             8
                                                                                                    REFERENCE IDENTIFICATION
                                                                                                    QUALIFIER                       REF01       128   2010AA M     ID   2/3    SEE CODE LIST
                                                                                                    REFERENCE IDENTIFICATION        REF02       127   2010AA M     AN   1/30
                                                            BILLING PROVIDER CONTACT
                                                  96   92   INFORMATION                                                             PER               2010AA                                        S             2
                                                                                                    CONTACT FUNCTION CODE           PER01       366   2010AA M     ID   2/2    IC
                                                                                                    NAME                            PER02        93   2010AA O     AN   1/60

                                                                                                    COMMUNICATION NUMBER QUALIFIER PER03        365   2010AA X     ID   2/2
                                                                                                    COMMUNICATION NUMBER           PER04        364   2010AA X     AN   1/80
                                                                                                    COMMUNICATION NUMBER QUALIFIER PER05        365   2010AA X     ID   2/2
                                                                                                    COMMUNICATION NUMBER           PER06        364   2010AA X     AN   1/80
                                                                                                    COMMUNICATION NUMBER QUALIFIER PER07        365   2010AA X     ID   2/2
                                                                                                    COMMUNICATION NUMBER           PER08        364   2010AA X     AN   1/80
                                                            LOOP ID - 2010AB PAY-TO PROVIDER NAME                                                                                                                 1
                                                  99   95   PAY-TO PROVIDER NAME                                                    NM1               2010AB                                        S             1
                                                                                                    ENTITY IDENTIFIER CODE          NM101        98   2010AB M     ID   2/3    87
                                                                                                    ENTITY TYPE QUALIFIER           NM102      1065   2010AB M     ID   1/1

                                                                                                     5
                                                                                                                                                                           Policy Memorandum 2004 - 37
                                                                                                                                                                           Exhibit 2J



                                                               837 - HEALTH CLAIMS AND ENCOUNTERS (PROFESSIONAL)
INTERNAL    TABLE  /   FIELD    FIELD   FIELD   Old   A1                                                                          REF     ELEMENT
RECORD ID   DATABASE   LENGTH   TYPE    NAME    PG    PG    SEGMENT NAME                          ELEMENT NAME                    DES.     NUMBER    LOOP ATTRIBUTES       NOTES                USE      REPEAT

                                                                                                  NAME LAST OR ORGANIZATION NAME NM103       1035   2010AB O   AN   1/35
                                                                                                  NAME FIRST                     NM104       1036   2010AB O   AN   1/25
                                                                                                  NAME MIDDLE                     NM105      1037   2010AB O   AN   1/25
                                                                                                  NAME SUFFIX                     NM107      1039   2010AB O   AN   1/10
                                                                                                  IDENTIFICATION CODE QUALIFIER   NM108        66   2010AB X   ID   1/2
                                                                                                  IDENTIFICATION CODE             NM109        67   2010AB X   AN   2/80
                                                103   98    PAY-TO PROVIDER ADDRESS                                               N3                2010AB                                      R             1
                                                                                                  ADDRESS INFORMATION             N301        166   2010AB M   AN   1/55   ADDRESS LINE 1
                                                                                                  ADDRESS INFORMATION             N302        166   2010AB O   AN   1/55   ADDRESS LINE 2

                                                104   99    PAY-TO PROVIDER CITY/STATE/ZIP CODE                                   N4                2010AB                                      R             1

                                                                                                  CITY NAME                       N401         19   2010AB O   AN   2/30
                                                                                                  STATE OR PROVINCE CODE          N402        156   2010AB O   ID   2/2
                                                                                                  POSTAL CODE                     N403        116   2010AB O   ID   3/15
                                                                                                  COUNTRY CODE                    N404         26   2010AB O   ID   2/3
                                                            PAY-TO PROVIDER SECONDARY
                                                106   101   INFORMATION                                                           REF               2010AB                                      S             5
                                                                                                  REFERENCE IDENTIFICATION
                                                                                                  QUALIFIER                       REF01       128   2010AB M   ID   2/3    SEE CODE LIST
                                                                                                  REFERENCE IDENTIFICATION        REF02       127   2010AB M   AN   1/30


                                                            TABLE 2 - DETAIL, SUBSCRIBER HIERARCHICAL LEVEL
                                                            LOOP ID - 2000B SUBSCRIBER HIERARCHICAL LEVEL                                                                                                    >1
                                                                                                                                                                           SEE NOTES ON
                                                108   103   SUBSCRIBER HIERARCHICAL LEVEL                                         HL                 2000B                 SEGMENT USAGE        R             1
                                                                                                  HIERARCHICAL ID NUMBER          HL01        628    2000B M   AN   1/12
                                                                                                  HIERARCHICAL PARENT ID          HL02        734    2000B O   AN   1/12
                                                                                                  HIERARCHICAL LEVEL CODE         HL03        735    2000B M   ID   1/2    22 (SUBSCRIBER)
                                                                                                  HIERARCHICAL CHILD CODE         HL04        736    2000B O   ID   1/1
                                                110   105   SUBSCRIBER INFORMATION                                                SBR                2000B                                      R             1
                                                                                                  PAYER RESPONSIBILITY SEQUENCE
                                                                                                  NUMBER CODE                     SBR01      1138    2000B M   ID   1/1




                                                                                                   6
                                                                                                                                                                        Policy Memorandum 2004 - 37
                                                                                                                                                                        Exhibit 2J



                                                               837 - HEALTH CLAIMS AND ENCOUNTERS (PROFESSIONAL)
INTERNAL    TABLE  /   FIELD    FIELD   FIELD   Old   A1                                                                       REF     ELEMENT
RECORD ID   DATABASE   LENGTH   TYPE    NAME    PG    PG    SEGMENT NAME                       ELEMENT NAME                    DES.     NUMBER    LOOP ATTRIBUTES       NOTES                USE      REPEAT
                                                                                               INDIVIDUAL RELATIONSHIP CODE    SBR02      1069    2000B O   ID   2/2    18 (SELF)
                                                                                               REFERENCE IDENTIFICATION        SBR03       127    2000B O   AN   1/30
                                                                                               NAME                            SBR04        93    2000B O   AN   1/60
                                                                                                                                                                        REQUIRED FOR
                                                                                                                                                                        MEDICARE
                                                                                               INSURANCE TYPE CODE             SBR05      1336    2000B O   ID   1/3    SECONDARY
                                                                                               CLAIM FILING INDICATOR CODE     SBR09      1032    2000B O   ID   1/2
                                                114   109   PATIENT INFORMATION                                                PAT                2000B                                      S             1
                                                                                               DATE TIME FORMAT QUALIFIER      PAT05      1250    2000B X   ID   2/3
                                                                                               DATE TIME PERIOD                PAT06      1251    2000B X   AN   1/35
                                                                                               UNIT OR BASIS FOR MEASUREMENT
                                                                                               CODE                            PAT07       355    2000B X   ID   2/2
                                                                                               WEIGHT                          PAT08        81    2000B X   R    1/10
                                                                                               YES/NO CONDITION OR RESPONSE                                             PREGNANCY
                                                                                               CODE                            PAT09      1073    2000B O   ID   1/1    INDICATOR
                                                            LOOP ID - 2010BA SUBSCRIBER NAME                                                                                                               1
                                                117   112   SUBSCRIBER NAME                                                    NM1               2010BA                                      R             1
                                                                                               ENTITY IDENTIFIER CODE          NM101        98   2010BA M   ID   2/3    IL
                                                                                               ENTITY TYPE QUALIFIER           NM102      1065   2010BA M   ID   1/1

                                                                                               NAME LAST OR ORGANIZATION NAME NM103       1035   2010BA O   AN   1/35
                                                                                               NAME FIRST                     NM104       1036   2010BA O   AN   1/25
                                                                                               NAME MIDDLE                     NM105      1037   2010BA O   AN   1/25
                                                                                               NAME SUFFIX                     NM107      1039   2010BA O   AN   1/10
                                                                                               IDENTIFICATION CODE QUALIFIER   NM108        66   2010BA X   ID   1/2
                                                                                               IDENTIFICATION CODE             NM109        67   2010BA X   AN   2/80
                                                121   115   SUBSCRIBER ADDRESS                                                 N3                2010BA                                      S             1
                                                                                               ADDRESS INFORMATION             N301        166   2010BA M   AN   1/55   ADDRESS LINE 1
                                                                                               ADDRESS INFORMATION             N302        166   2010BA O   AN   1/55   ADDRESS LINE 2
                                                122   116   SUBSCRIBER CITY/STATE/ZIP CODE                                     N4                2010BA                                      S             1
                                                                                               CITY NAME                       N401         19   2010BA O   AN   2/30
                                                                                               STATE OR PROVINCE CODE          N402        156   2010BA O   ID   2/2
                                                                                               POSTAL CODE                     N403        116   2010BA O   ID   3/15




                                                                                                7
                                                                                                                                                                          Policy Memorandum 2004 - 37
                                                                                                                                                                          Exhibit 2J



                                                               837 - HEALTH CLAIMS AND ENCOUNTERS (PROFESSIONAL)
INTERNAL    TABLE  /   FIELD    FIELD   FIELD   Old   A1                                                                        REF      ELEMENT
RECORD ID   DATABASE   LENGTH   TYPE    NAME    PG    PG    SEGMENT NAME                          ELEMENT NAME                  DES.      NUMBER    LOOP ATTRIBUTES       NOTES                USE      REPEAT
                                                                                                  COUNTRY CODE                  N404          26   2010BA O   ID   2/3
                                                            SUBSCRIBER DEMOGRAPHIC
                                                124   118   INFORMATION                                                         DMG                2010BA                                      S             1
                                                                                                  DATE TIME FORMAT QUALIFIER    DMG01       1250   2010BA X   ID   2/3
                                                                                                  DATE TIME PERIOD              DMG02       1251   2010BA X   AN   1/35
                                                                                                  GENDER CODE                   DMG03       1068   2010BA O   ID   1/1

                                                126   120   SUBSCRIBER SECONDARY IDENTIFICATION                                 REF                2010BA                                      S             4
                                                                                                  REFERENCE IDENTIFICATION
                                                                                                  QUALIFIER                     REF01        128   2010BA M   ID   2/3
                                                                                                  REFERENCE IDENTIFICATION      REF02        127   2010BA M   AN   1/30
                                                            PROPERTY AND CASUALTY CLAIM
                                                128   122   NUMBER                                                              REF                2010BA                                      S             1
                                                                                                  REFERENCE IDENTIFICATION
                                                                                                  QUALIFIER                     REF01        128   2010BA M   ID   2/3
                                                                                                  REFERENCE IDENTIFICATION      REF02        127   2010BA M   AN   1/30
                                                            LOOP ID - 2010BB PAYER NAME                                                                                                                      1
                                                130   124   PAYER NAME                                                          NM1                2010BB                                      R             1
                                                                                                  ENTITY IDENTIFIER CODE        NM101         98   2010BB M   ID   2/3    PR (PAYER)
                                                                                                  ENTITY TYPE QUALIFIER         NM102       1065   2010BB M   ID   1/1    2

                                                                                                  NAME LAST OR ORGANIZATION NAME NM103      1035   2010BB O   AN   1/35
                                                                                                  IDENTIFICATION CODE QUALIFIER  NM108        66   2010BB X   ID   1/2
                                                                                                  IDENTIFICATION CODE           NM109         67   2010BB X   AN   2/80
                                                134   127   PAYER ADDRESS                                                       N3                 2010BB                                      S             1
                                                                                                  ADDRESS INFORMATION           N301         166   2010BB M   AN   1/55   ADDRESS LINE 1
                                                                                                  ADDRESS INFORMATION           N302         166   2010BB O   AN   1/55   ADDRESS LINE 2
                                                135   128   PAYER CITY/STATE/ZIP CODE                                           N4                 2010BB                                      S             1
                                                                                                  CITY NAME                     N401          19   2010BB O   AN   2/30
                                                                                                  STATE OR PROVINCE CODE        N402         156   2010BB O   ID   2/2
                                                                                                  POSTAL CODE                   N403         116   2010BB O   ID   3/15
                                                                                                  COUNTRY CODE                  N404          26   2010BB O   ID   2/3


                                                137   130   PAYER SECONDARY IDENTIFICATION                                      REF                2010BB                                      S             3
                                                                                                  REFERENCE IDENTIFICATION
                                                                                                  QUALIFIER                     REF01        128   2010BB M   ID   2/3
                                                                                                  REFERENCE IDENTIFICATION      REF02        127   2010BB M   AN   1/30




                                                                                                   8
                                                                                                                                                                           Policy Memorandum 2004 - 37
                                                                                                                                                                           Exhibit 2J



                                                               837 - HEALTH CLAIMS AND ENCOUNTERS (PROFESSIONAL)
INTERNAL    TABLE  /   FIELD    FIELD   FIELD   Old   A1                                                                          REF     ELEMENT
RECORD ID   DATABASE   LENGTH   TYPE    NAME    PG    PG    SEGMENT NAME                          ELEMENT NAME                    DES.     NUMBER    LOOP ATTRIBUTES       NOTES                USE      REPEAT
                                                            LOOP ID - 2010BC RESPONSIBLE PARTY NAME                                                                                                           1
                                                139   132   RESPONSIBLE PARTY NAME                                                NM1               2010BC                                      S             1
                                                                                                  ENTITY IDENTIFIER CODE          NM101        98   2010BC M   ID   2/3
                                                                                                  ENTITY TYPE QUALIFIER           NM102      1065   2010BC M   ID   1/1

                                                                                                  NAME LAST OR ORGANIZATION NAME NM103       1035   2010BC O   AN   1/35
                                                                                                  NAME FIRST                     NM104       1036   2010BC O   AN   1/25
                                                                                                  NAME MIDDLE                     NM105      1037   2010BC O   AN   1/25
                                                                                                  NAME SUFFIX                     NM107      1039   2010BC O   AN   1/10
                                                143   135   RESPONSIBLE PARTY ADDRESS                                             N3                2010BC                                      S             1
                                                                                                  ADDRESS INFORMATION             N301        166   2010BC M   AN   1/55   ADDRESS LINE 1
                                                                                                  ADDRESS INFORMATION             N302        166   2010BC O   AN   1/55   ADDRESS LINE 2
                                                            RESPONSIBLE PARTY CITY/STATE/ZIP
                                                144   136   CODE                                                                  N4                2010BC                                      R             1
                                                                                                  CITY NAME                       N401         19   2010BC O   AN   2/30
                                                                                                  STATE OR PROVINCE CODE          N402        156   2010BC O   ID   2/2
                                                                                                  POSTAL CODE                     N403        116   2010BC O   ID   3/15
                                                                                                  COUNTRY CODE                    N404         26   2010BC O   ID   2/3
                                                            LOOP ID - 2010BD CREDIT/DEBIT CARD HOLDER NAME                                                                                                    1
                                                146   138   CREDIT/DEBIT CARD HOLDER NAME                                         NM1               2010BD                                      S             1
                                                                                                  ENTITY IDENTIFIER CODE          NM101        98   2010BD M   ID   2/3    AO
                                                                                                  ENTITY TYPE QUALIFIER           NM102      1065   2010BD M   ID   1/1

                                                                                                  NAME LAST OR ORGANIZATION NAME NM103       1035   2010BD O   AN   1/35
                                                                                                  NAME FIRST                     NM104       1036   2010BD O   AN   1/25
                                                                                                  NAME MIDDLE                     NM105      1037   2010BD O   AN   1/25
                                                                                                  NAME SUFFIX                     NM107      1039   2010BD O   AN   1/10
                                                                                                  IDENTIFICATION CODE QUALIFIER   NM108        66   2010BD X   ID   1/2
                                                                                                  IDENTIFICATION CODE             NM109        67   2010BD X   AN   2/80
                                                150   141   CREDIT/DEBIT CARD INFORMATION                                         REF               2010BD                                      S             1
                                                                                                  REFERENCE IDENTIFICATION
                                                                                                  QUALIFIER                       REF01       128   2010BD M   ID   2/3
                                                                                                  REFERENCE IDENTIFICATION        REF02       127   2010BD M   AN   1/30
                                                            TABLE 2 - DETAIL, PATIENT HIERARCHICAL LEVEL
                                                            LOOP ID - 2000C PATIENT HIERARCHICAL LEVEL                                                                                                       >1




                                                                                                    9
                                                                                                                                                                        Policy Memorandum 2004 - 37
                                                                                                                                                                        Exhibit 2J



                                                               837 - HEALTH CLAIMS AND ENCOUNTERS (PROFESSIONAL)
INTERNAL    TABLE  /   FIELD    FIELD   FIELD   Old   A1                                                                       REF     ELEMENT
RECORD ID   DATABASE   LENGTH   TYPE    NAME    PG    PG    SEGMENT NAME                       ELEMENT NAME                    DES.     NUMBER    LOOP ATTRIBUTES       NOTES                USE      REPEAT
                                                152   143   PATIENT HIERARCHICAL LEVEL                                         HL                 2000C                                      S             1
                                                                                               HIERARCHICAL ID NUMBER          HL01        628    2000C M   AN   1/12
                                                                                               HIERARCHICAL PARENT ID          HL02        734    2000C O   AN   1/12
                                                                                               HIERARCHICAL LEVEL CODE         HL03        735    2000C M   ID   1/2    22
                                                                                               HIERARCHICAL CHILD CODE         HL04        736    2000C O   ID   1/1
                                                154   145   PATIENT INFORMATION                                                PAT                2000C                                      R             1
                                                                                               INDIVIDUAL RELATIONSHIP CODE    PAT01      1069    2000C O   ID   2/2
                                                                                               DATE TIME FORMAT QUALIFIER      PAT05      1250    2000C X   ID   2/3
                                                                                               DATE TIME PERIOD                PAT06      1251    2000C X   AN   1/35
                                                                                               UNIT OR BASIS FOR MEASUREMENT
                                                                                               CODE                            PAT07       355    2000C X   ID   2/2
                                                                                               WEIGHT                          PAT08        81    2000C X   R    1/10
                                                            LOOP ID - 2010CA PATIENT NAME                                                                                                                  1
                                                157   148   PATIENT NAME                                                       NM1               2010CA                                      R             1
                                                                                               ENTITY IDENTIFIER CODE          NM101        98   2010CA M   ID   2/3    QC
                                                                                               ENTITY TYPE QUALIFIER           NM102      1065   2010CA M   ID   1/1

                                                                                               NAME LAST OR ORGANIZATION NAME NM103       1035   2010CA O   AN   1/35
                                                                                               NAME FIRST                     NM104       1036   2010CA O   AN   1/25
                                                                                               NAME MIDDLE                     NM105      1037   2010CA O   AN   1/25
                                                                                               NAME SUFFIX                     NM107      1039   2010CA O   AN   1/10
                                                                                               IDENTIFICATION CODE QUALIFIER   NM108        66   2010CA X   ID   1/2
                                                                                               IDENTIFICATION CODE             NM109        67   2010CA X   AN   2/80
                                                161   151   PATIENT ADDRESS                                                    N3                2010CA                                      R             1

                                                                                               ADDRESS INFORMATION             N301        166   2010CA M   AN   1/55   ADDRESS LINE 1
                                                                                               ADDRESS INFORMATION             N302        166   2010CA O   AN   1/55   ADDRESS LINE 2
                                                162   152   PATIENT CITY/STATE/ZIP CODE                                        N4                2010CA                                      R             1
                                                                                               CITY NAME                       N401         19   2010CA O   AN   2/30
                                                                                               STATE OR PROVINCE CODE          N402        156   2010CA O   ID   2/2
                                                                                               POSTAL CODE                     N403        116   2010CA O   ID   3/15
                                                                                               COUNTRY CODE                    N404         26   2010CA O   ID   2/3
                                                164   154   PATIENT DEMOGRAPHIC INFORMATION                                    DMG               2010CA                                      R             1
                                                                                               DATE TIME FORMAT QUALIFIER      DMG01      1250   2010CA X   ID   2/3
                                                                                               DATE TIME PERIOD                DMG02      1251   2010CA X   AN   1/35
                                                                                               GENDER CODE                     DMG03      1068   2010CA O   ID   1/1
                                                166   156   PATIENT SECONDARY IDENTIFICATION                                   REF               2010CA                                      S             5
                                                                                               REFERENCE IDENTIFICATION
                                                                                               QUALIFIER                       REF01       128   2010CA M   ID   2/3
                                                                                               REFERENCE IDENTIFICATION        REF02       127   2010CA M   AN   1/30

                                                                                                10
                                                                                                                                                                          Policy Memorandum 2004 - 37
                                                                                                                                                                          Exhibit 2J



                                                               837 - HEALTH CLAIMS AND ENCOUNTERS (PROFESSIONAL)
INTERNAL    TABLE  /   FIELD    FIELD   FIELD   Old   A1                                                                       REF       ELEMENT
RECORD ID   DATABASE   LENGTH   TYPE    NAME    PG    PG    SEGMENT NAME                       ELEMENT NAME                    DES.       NUMBER    LOOP ATTRIBUTES       NOTES                USE      REPEAT
                                                            PROPERTY AND CASUALTY CLAIM
                                                168   158   NUMBER                                                             REF                 2010CA                                      S             1
                                                                                               REFERENCE IDENTIFICATION
                                                                                               QUALIFIER                       REF01         128   2010CA M   ID   2/3
                                                                                               REFERENCE IDENTIFICATION        REF02         127   2010CA M   AN   1/30
                                                            LOOP ID - 2300 CLAIM INFORMATION                                                                                                               100
                                                170   160   CLAIM INFORMATION                                                  CLM                   2300                                      R             1
                                                                                                                                                                          MUST SUPPORT UP
                                                                                               CLAIM SUBMITTER'S IDENTIFIER    CLM01        1028     2300 M   AN   1/38   TO 20 CHARACTERS
                                                                                                                                                                          TOTAL CLAIM
                                                                                               MONETARY AMOUNT                 CLM02         782     2300 O   R    1/18   CHARGE AMOUNT
                                                                                               HEALTH CARE SERVICE LOCATION                                               PLACE OF SERVICE
                                                                                               INFORMATION                     CLM05        C023     2300 O               CODE
                                                                                               FACILITY CODE VALUE             CLM05-1      1331     2300 M   AN   1/2
                                                                                               CLAIM FREQUENCY TYPE CODE       CLM05-3      1325     2300 O   ID   1/1
                                                                                               YES/NO CONDITION OR RESPONSE
                                                                                               CODE                            CLM06        1073     2300 O   ID   1/1
                                                                                               PROVIDER ACCEPT ASSIGNMENT                                                 MEDICARE
                                                                                               CODE                            CLM07        1359     2300 O   ID   1/1    ASSIGNMENT CODE
                                                                                                                                                                          ASSIGNMENT OF
                                                                                               YES/NO CONDITION OR RESPONSE                                               BENEFITS
                                                                                               CODE                            CLM08        1073     2300 O   ID   1/1    INDICATOR
                                                                                               RELEASE OF INFORMATION CODE     CLM09        1363     2300 O   ID   1/1
                                                                                               PATIENT SIGNATURE SOURCE CODE   CLM10        1351     2300 O   ID   1/1
                                                                                               RELATED CAUSES INFORMATION      CLM11        C024     2300 O
                                                                                               RELATED-CAUSES CODE             CLM11-1      1362     2300 M   ID   2/3

                                                                                               RELATED-CAUSES CODE             CLM11-2      1362     2300 O   ID   2/3
                                                                                               RELATED-CAUSES CODE             CLM11-3      1362     2300 O   ID   2/3
                                                                                               STATE OR PROVINCE CODE          CLM11-4       156     2300 O   ID   2/2

                                                                                               COUNTRY CODE                    CLM11-5        26     2300 O   ID   2/3
                                                                                               SPECIAL PROGRAM CODE            CLM12        1366     2300 O   ID   2/3
                                                                                                                                                                          PARTICIPATION
                                                                                               PROVIDER AGREEMENT CODE         CLM16        1360     2300 O   ID   1/1    AGREEMENT

                                                                                                                                                                          REASON FOR LATE
                                                                                               DELAY REASON CODE               CLM20        1514     2300 O   ID   1/2    FILING
                                                182   170   DATE - INITIAL TREATMENT                                           DTP                   2300                                      S             1
                                                                                               DATE/TIME QUALIFIER             DTP01         374     2300 M   ID   3/3    454
                                                                                               DATE TIME PERIOD FORMAT
                                                                                               QUALIFIER                       DTP02        1250     2300 M   ID   2/3    D8 (DATE FORMAT)

                                                                                                11
                                                                                                                                                                    Policy Memorandum 2004 - 37
                                                                                                                                                                    Exhibit 2J



                                                               837 - HEALTH CLAIMS AND ENCOUNTERS (PROFESSIONAL)
INTERNAL    TABLE  /   FIELD    FIELD   FIELD   Old   A1                                                                     REF     ELEMENT
RECORD ID   DATABASE   LENGTH   TYPE    NAME    PG    PG    SEGMENT NAME                           ELEMENT NAME              DES.     NUMBER   LOOP ATTRIBUTES      NOTES                USE      REPEAT
                                                                                                   DATE                      DTP03      1251   2300 M   AN   1/35
                                                                                                   DATE                      DTP03      1251   2300 M   AN   1/35



                                                186   172   DATE - DATE LAST SEEN                                            DTP               2300                                      S             1
                                                                                                   DATE/TIME QUALIFIER       DTP01       374   2300 M   ID   3/3    304
                                                                                                   DATE TIME PERIOD FORMAT
                                                                                                   QUALIFIER                 DTP02      1250   2300 M   ID   2/3    D8 (DATE FORMAT)
                                                                                                   DATE                      DTP03      1251   2300 M   AN   1/35
                                                            DATE - ONSET OF CURRENT
                                                188   174   ILLNESS/SYMPTOM                                                  DTP               2300                                      S             1
                                                                                                   DATE/TIME QUALIFIER       DTP01       374   2300 M   ID   3/3    431
                                                                                                   DATE TIME PERIOD FORMAT
                                                                                                   QUALIFIER                 DTP02      1250   2300 M   ID   2/3    D8 (DATE FORMAT)
                                                                                                   DATE                      DTP03      1251   2300 M   AN   1/35

                                                190   175   DATE - ACUTE MANIFESTATION                                       DTP               2300                                      S             5

                                                                                                   DATE/TIME QUALIFIER       DTP01       374   2300 M   ID   3/3    453
                                                                                                   DATE TIME PERIOD FORMAT
                                                                                                   QUALIFIER                 DTP02      1250   2300 M   ID   2/3    D8 (DATE FORMAT)

                                                                                                   DATE                      DTP03      1251   2300 M   AN   1/35

                                                192   178   DATE - SIMILAR ILLNESS/SYMPTOM ONSET                             DTP               2300                                      S            10
                                                                                                   DATE/TIME QUALIFIER       DTP01       374   2300 M   ID   3/3    438
                                                                                                   DATE TIME PERIOD FORMAT
                                                                                                   QUALIFIER                 DTP02      1250   2300 M   ID   2/3    D8 (DATE FORMAT)
                                                                                                   DATE                      DTP03      1251   2300 M   AN   1/35
                                                194   180   DATE - ACCIDENT                                                  DTP               2300                                      S            10

                                                                                                   DATE/TIME QUALIFIER       DTP01       374   2300 M   ID   3/3    439
                                                                                                   DATE TIME PERIOD FORMAT
                                                                                                   QUALIFIER                 DTP02      1250   2300 M   ID   2/3    D8 (DATE FORMAT)
                                                                                                   DATE                      DTP03      1251   2300 M   AN   1/35
                                                196   182   DATE - LAST MENSTRUAL PERIOD                                     DTP               2300                                      S             1
                                                                                                   DATE/TIME QUALIFIER       DTP01       374   2300 M   ID   3/3    484
                                                                                                   DATE TIME PERIOD FORMAT
                                                                                                   QUALIFIER                 DTP02      1250   2300 M   ID   2/3    D8 (DATE FORMAT)
                                                                                                   DATE                      DTP03      1251   2300 M   AN   1/35
                                                197   183   DATE - LAST X-RAY                                                DTP               2300                                      S             1
                                                                                                   DATE/TIME QUALIFIER       DTP01       374   2300 M   ID   3/3    455


                                                                                                    12
                                                                                                                                                                Policy Memorandum 2004 - 37
                                                                                                                                                                Exhibit 2J



                                                               837 - HEALTH CLAIMS AND ENCOUNTERS (PROFESSIONAL)
INTERNAL    TABLE  /   FIELD    FIELD   FIELD   Old   A1                                                                 REF     ELEMENT
RECORD ID   DATABASE   LENGTH   TYPE    NAME    PG    PG    SEGMENT NAME                       ELEMENT NAME              DES.     NUMBER   LOOP ATTRIBUTES      NOTES                USE      REPEAT
                                                                                               DATE TIME PERIOD FORMAT
                                                                                               QUALIFIER                 DTP02      1250   2300 M   ID   2/3    D8 (DATE FORMAT)
                                                                                               DATE                      DTP03      1251   2300 M   AN   1/35
                                                            DATE - HEARING AND VISION
                                                200   185   PRESCRIPTION DATE                                            DTP               2300                                      S             1
                                                                                               DATE/TIME QUALIFIER       DTP01       374   2300 M   ID   3/3    471
                                                                                               DATE TIME PERIOD FORMAT
                                                                                               QUALIFIER                 DTP02      1250   2300 M   ID   2/3    D8 (DATE FORMAT)
                                                                                               DATE                      DTP03      1251   2300 M   AN   1/35
                                                201   186   DATE - DISABILITY BEGAN                                      DTP               2300                                      S             5
                                                                                               DATE/TIME QUALIFIER       DTP01       374   2300 M   ID   3/3    360
                                                                                               DATE TIME PERIOD FORMAT
                                                                                               QUALIFIER                 DTP02      1250   2300 M   ID   2/3    D8 (DATE FORMAT)
                                                                                               DATE                      DTP03      1251   2300 M   AN   1/35
                                                203   188   DATE - DISABILITY END                                        DTP               2300                                      S             5
                                                                                               DATE/TIME QUALIFIER       DTP01       374   2300 M   ID   3/3    361
                                                                                               DATE TIME PERIOD FORMAT
                                                                                               QUALIFIER                 DTP02      1250   2300 M   ID   2/3    D8 (DATE FORMAT)
                                                                                               DATE                      DTP03      1251   2300 M   AN   1/35
                                                                                                                         DTP               2300
                                                205   190   DATE - LAST WORKED                                           DTP               2300                                      S             1
                                                                                               DATE/TIME QUALIFIER       DTP01       374   2300 M   ID   3/3    297
                                                                                               DATE TIME PERIOD FORMAT
                                                                                               QUALIFIER                 DTP02      1250   2300 M   ID   2/3    D8 (DATE FORMAT)
                                                                                               DATE                      DTP03      1251   2300 M   AN   1/35
                                                206   191   DATE - AUTHORIZED RETURN TO WORK                             DTP               2300                                      S             1
                                                                                               DATE/TIME QUALIFIER       DTP01       374   2300 M   ID   3/3    296
                                                                                               DATE TIME PERIOD FORMAT
                                                                                               QUALIFIER                 DTP02      1250   2300 M   ID   2/3    D8 (DATE FORMAT)
                                                                                               DATE                      DTP03      1251   2300 M   AN   1/35
                                                208   193   DATE - ADMISSION                                             DTP               2300                                      S             1
                                                                                               DATE/TIME QUALIFIER       DTP01       374   2300 M   ID   3/3    435
                                                                                               DATE TIME PERIOD FORMAT
                                                                                               QUALIFIER                 DTP02      1250   2300 M   ID   2/3    D8 (DATE FORMAT)
                                                                                               DATE                      DTP03      1251   2300 M   AN   1/35
                                                210   195   DATE - DISCHARGE                                             DTP               2300                                      S             1
                                                                                               DATE/TIME QUALIFIER       DTP01       374   2300 M   ID   3/3    096
                                                                                               DATE TIME PERIOD FORMAT
                                                                                               QUALIFIER                 DTP02      1250   2300 M   ID   2/3    D8 (DATE FORMAT)
                                                                                               DATE                      DTP03      1251   2300 M   AN   1/35
                                                            DATE - ASSUMED AND RELINQUISHED
                                                212   197   CARE DATES                                                   DTP               2300                                      S             2

                                                                                                13
                                                                                                                                                                      Policy Memorandum 2004 - 37
                                                                                                                                                                      Exhibit 2J



                                                               837 - HEALTH CLAIMS AND ENCOUNTERS (PROFESSIONAL)
INTERNAL    TABLE  /   FIELD    FIELD   FIELD   Old   A1                                                                       REF     ELEMENT
RECORD ID   DATABASE   LENGTH   TYPE    NAME    PG    PG    SEGMENT NAME                       ELEMENT NAME                    DES.     NUMBER   LOOP ATTRIBUTES      NOTES                 USE     REPEAT
                                                                                                                                                                      090 = ASSUME
                                                                                               DATE/TIME QUALIFIER             DTP01       374   2300 M   ID   3/3    091 = RELINQUISH
                                                                                               DATE TIME PERIOD FORMAT
                                                                                               QUALIFIER                       DTP02      1250   2300 M   ID   2/3    D8 (DATE FORMAT)
                                                                                               DATE                            DTP03      1251   2300 M   AN   1/35
                                                                                                                                                                      SEE NOTES ON
                                                214   199   CLAIM SUPPLEMENTAL INFORMATION                                     PWK               2300                 SEGMENT USAGE         S           10
                                                                                               REPORT TYPE CODE                PWK01       755   2300 M   ID   2/2
                                                                                               REPORT TRANSMISSION CODE        PWK02       756   2300 O   ID   1/2
                                                                                               IDENTIFICATION CODE QUALIFIER   PWK05        66   2300 X   AN   2/80
                                                                                               IDENTIFICATION CODE             PWK06        67   2300 O   AN   1/80
                                                217   202   CONTRACT INFORMATION                                               CN1               2300                                       S            1
                                                                                               CONTRACT TYPE CODE              CN101      1166   2300 M   ID   2/2
                                                                                               MONETARY AMOUNT                 CN102       782   2300 O   R    1/18
                                                                                               PERCENT                         CN103       332   2300 O   R    1/6
                                                                                               REFERENCE IDENTIFICATION        CN104       127   2300 O   AN   1/30
                                                                                               TERMS DISCOUNT PERCENT          CN105       338   2300 O   R    1/6
                                                                                               VERSION IDENTIFIER              CN106       799   2300 O   AN   1/30
                                                                                                                                                 2300


                                                219   204   CREDIT/DEBIT CARD MAXIMUM AMOUNT                                   AMT               2300                                       S            1
                                                                                                                                                                      MA = MAXIMUM
                                                                                               AMOUNT QUALIFIER CODE           AMT01       522   2300 M   ID   1/3    AMOUNT
                                                                                               MONETARY AMOUNT                 AMT02       782   2300 M   R    1/18
                                                220   205   PATIENT AMOUNT PAID                                                AMT               2300                                       S            1
                                                                                               AMOUNT QUALIFIER CODE           AMT01       522   2300 M   ID   1/3    F5 = PAT. AMT. PAID
                                                                                               MONETARY AMOUNT                 AMT02       782   2300 M   R    1/18
                                                221   206   TOTAL PURCHASED SERVICE AMOUNT                                     AMT               2300                                       S            1
                                                                                               AMOUNT QUALIFIER CODE           AMT01       522   2300 M   ID   1/3    NE
                                                                                               MONETARY AMOUNT                 AMT02       782   2300 M   R    1/18
                                                            SERVICE AUTHORIZATION EXCEPTION
                                                222   208   CODE                                                               REF               2300                                       S            1
                                                                                               REFERENCE IDENTIFICATION
                                                                                               QUALIFIER                       REF01       128   2300 M   ID   2/3
                                                                                               REFERENCE IDENTIFICATION        REF02       127   2300 X   AN   1/30
                                                            MANDATORY MEDICARE (SEC.4081)
                                                224   210   CROSSOVER INDICATOR                                                REF               2300                                       S            1
                                                                                               REFERENCE IDENTIFICATION
                                                                                               QUALIFIER                       REF01       128   2300 M   ID   2/3
                                                                                               REFERENCE IDENTIFICATION        REF02       127   2300 X   AN   1/30


                                                                                                14
                                                                                                                                                                   Policy Memorandum 2004 - 37
                                                                                                                                                                   Exhibit 2J



                                                               837 - HEALTH CLAIMS AND ENCOUNTERS (PROFESSIONAL)
INTERNAL    TABLE  /   FIELD    FIELD   FIELD   Old   A1                                                                    REF     ELEMENT
RECORD ID   DATABASE   LENGTH   TYPE    NAME    PG    PG    SEGMENT NAME                         ELEMENT NAME               DES.     NUMBER   LOOP ATTRIBUTES      NOTES                USE      REPEAT

                                                226   212   MAMMOGRAPHY CERTIFICATION NUMBER                                REF               2300                                      S             1
                                                                                                 REFERENCE IDENTIFICATION
                                                                                                 QUALIFIER                  REF01       128   2300 M   ID   2/3
                                                                                                 REFERENCE IDENTIFICATION   REF02       127   2300 X   AN   1/30
                                                            PRIOR AUTHORIZATION OR REFERRAL
                                                227   214   NUMBER                                                          REF               2300                                      S             2
                                                                                                 REFERENCE IDENTIFICATION
                                                                                                 QUALIFIER                  REF01       128   2300 M   ID   2/3
                                                                                                 REFERENCE IDENTIFICATION   REF02       127   2300 X   AN   1/30


                                                229   216   ORIGINAL REFERENCE NUMBER(ICN/DCN)                              REF               2300                                      S             1
                                                                                                 REFERENCE IDENTIFICATION
                                                                                                 QUALIFIER                  REF01       128   2300 M   ID   2/3
                                                                                                 REFERENCE IDENTIFICATION   REF02       127   2300 X   AN   1/30
                                                            CLINICAL LABORATORY IMPROVEMENT
                                                231   218   AMENDMENT (CLIA                                                 REF               2300                                      S             3
                                                                                                 REFERENCE IDENTIFICATION
                                                                                                 QUALIFIER                  REF01       128   2300 M   ID   2/3
                                                                                                 REFERENCE IDENTIFICATION   REF02       127   2300 X   AN   1/30
                                                233   220   REPRICED CLAIM NUMBER                                           REF               2300                                      S             1
                                                                                                 REFERENCE IDENTIFICATION
                                                                                                 QUALIFIER                  REF01       128   2300 M   ID   2/3    9A
                                                                                                 REFERENCE IDENTIFICATION   REF02       127   2300 X   AN   1/30

                                                235   222   ADJUSTED REPRICED CLAIM NUMBER                                  REF               2300                                      S             1
                                                                                                 REFERENCE IDENTIFICATION
                                                                                                 QUALIFIER                  REF01       128   2300 M   ID   2/3    9C
                                                                                                 REFERENCE IDENTIFICATION   REF02       127   2300 X   AN   1/30
                                                            INVESTIGATIONAL DEVICE EXEMPTION
                                                236   223   NUMBER                                                          REF               2300                                      S             1
                                                                                                 REFERENCE IDENTIFICATION
                                                                                                 QUALIFIER                  REF01       128   2300 M   ID   2/3    LX
                                                                                                 REFERENCE IDENTIFICATION   REF02       127   2300 X   AN   1/30
                                                            CLAIM IDENTIFICATION NUMBER FOR
                                                238   225   CLEARING HOUSES AND OTHER                                       REF               2300                                      S             1
                                                                                                 REFERENCE IDENTIFICATION
                                                                                                 QUALIFIER                  REF01       128   2300 M   ID   2/3    D9
                                                                                                 REFERENCE IDENTIFICATION   REF02       127   2300 X   AN   1/30



                                                240   227   AMBULATORY PATIENT GROUP                                        REF               2300                                      S             4


                                                                                                  15
                                                                                                                                                                      Policy Memorandum 2004 - 37
                                                                                                                                                                      Exhibit 2J



                                                               837 - HEALTH CLAIMS AND ENCOUNTERS (PROFESSIONAL)
INTERNAL    TABLE  /   FIELD    FIELD   FIELD   Old   A1                                                                       REF     ELEMENT
RECORD ID   DATABASE   LENGTH   TYPE    NAME    PG    PG    SEGMENT NAME                       ELEMENT NAME                    DES.     NUMBER   LOOP ATTRIBUTES      NOTES                USE      REPEAT

                                                                                               REFERENCE IDENTIFICATION
                                                                                               QUALIFIER                       REF01       128   2300 M   ID   2/3    1S
                                                                                               REFERENCE IDENTIFICATION        REF02       127   2300 X   AN   1/30
                                                241   228   MEDICAL RECORD NUMBER                                              REF               2300                                      S             1
                                                                                               REFERENCE IDENTIFICATION
                                                                                               QUALIFIER                       REF01       128   2300 M   ID   2/3    EA
                                                                                               REFERENCE IDENTIFICATION        REF02       127   2300 X   AN   1/30
                                                242   229   DEMONSTRATION PROJECT IDENTIFIER                                   REF               2300                                      S             1
                                                                                               REFERENCE IDENTIFICATION
                                                                                               QUALIFIER                       REF01       128   2300 M   ID   2/3    P4
                                                                                               REFERENCE IDENTIFICATION        REF02       127   2300 X   AN   1/30
                                                244   231   FILE INFORMATION                                                   K3                2300                                      S            10
                                                                                               FIXED FORM INFORMATION          K301        449   2300 M   AN   1/80
                                                246   233   CLAIM NOTE                                                         NTE               2300                                      S             1
                                                                                               NOTE REFERENCE CODE             NTE01       363   2300 O   ID   3/3


                                                                                               DESCRIPTION                     NTE02       352   2300 M   AN   1/80   FREE FORM TEXT


                                                248   235   AMBULANCE TRANSPORT INFORMATION                                    CR1               2300                                      S             1

                                                                                               UNIT OR BASIS FOR MEASUREMENT
                                                                                               CODE                            CR101       355   2300 X   ID   2/2    LB


                                                                                               WEIGHT                          CR102        81   2300 X   R    1/10

                                                                                               AMBULANCE TRANSPORT CODE        CR103      1316   2300 O   ID   1/1

                                                                                               AMBULANCE TRANSPORT REASON
                                                                                               CODE                            CR104      1317   2300 O   ID   1/1
                                                                                               UNIT OR BASIS FOR MEASUREMENT
                                                                                               CODE                            CR105       355   2300 X   ID   2/2
                                                                                               QUANTITY                        CR106       380   2300 X   R    1/15



                                                                                               DESCRIPTION                     CR109       352   2300 O   AN   1/80


                                                                                               DESCRIPTION                     CR110       352   2300 O   AN   1/80
                                                            SPINAL MANIPULATION SERVICE
                                                251   238   IDENTIFICATION                                                     CR2               2300                                      S             1

                                                                                                16
                                                                                                                                                                          Policy Memorandum 2004 - 37
                                                                                                                                                                          Exhibit 2J



                                                               837 - HEALTH CLAIMS AND ENCOUNTERS (PROFESSIONAL)
INTERNAL    TABLE  /   FIELD    FIELD   FIELD   Old   A1                                                                           REF     ELEMENT
RECORD ID   DATABASE   LENGTH   TYPE    NAME    PG    PG    SEGMENT NAME                            ELEMENT NAME                   DES.     NUMBER   LOOP ATTRIBUTES      NOTES                USE      REPEAT


                                                                                                    NATURE OF CONDITION CODE       CR208      1342   2300 O   ID   1/1



                                                                                                    DESCRIPTION                    CR210       352   2300 O   AN   1/80


                                                                                                    DESCRIPTION                    CR211       352   2300 O   AN   1/80
                                                                                                    YES/NO CONDITION OR RESPONSE
                                                                                                    CODE                           CR212      1073   2300 O   ID   1/1



                                                257   241   AMBULANCE CERTIFICATION                                                CRC               2300                                      S             3


                                                                                                    CODE CATEGORY                  CRC01      1136   2300 M   ID   2/2
                                                                                                    YES/NO CONDITION OR RESPONSE
                                                                                                    CODE                           CRC02      1073   2300 M   ID   1/1

                                                                                                    CERTIFICATE CONDITION CODE     CRC03      1321   2300 M   ID   2/2
                                                                                                    CERTIFICATE CONDITION CODE     CRC04      1321   2300 O   ID   2/2
                                                                                                    CERTIFICATE CONDITION CODE     CRC05      1321   2300 O   ID   2/2
                                                                                                    CERTIFICATE CONDITION CODE     CRC06      1321   2300 O   ID   2/2


                                                                                                    CERTIFICATE CONDITION CODE     CRC07      1321   2300 O   ID   2/2

                                                260   246   PATIENT CONDITION INFORMATION: VISION                                  CRC               2300                                      S             3
                                                                                                    CODE CATEGORY                  CRC01      1136   2300 M   ID   2/2
                                                                                                    YES/NO CONDITION OR RESPONSE
                                                                                                    CODE                           CRC02      1073   2300 M   ID   1/1


                                                                                                    CERTIFICATE CONDITION CODE     CRC03      1321   2300 M   ID   2/2
                                                                                                    CERTIFICATE CONDITION CODE     CRC04      1321   2300 O   ID   2/2
                                                                                                    CERTIFICATE CONDITION CODE     CRC05      1321   2300 O   ID   2/2

                                                                                                    CERTIFICATE CONDITION CODE     CRC06      1321   2300 O   ID   2/2

                                                                                                    CERTIFICATE CONDITION CODE     CRC07      1321   2300 O   ID   2/2

                                                263   249   HOMEBOUND INDICATOR                                                    CRC               2300                                      S             1

                                                                                                    CODE CATEGORY                  CRC01      1136   2300 M   ID   2/2
                                                                                                    YES/NO CONDITION OR RESPONSE
                                                                                                    CODE                           CRC02      1073   2300 M   ID   1/1

                                                                                                     17
                                                                                                                                                                Policy Memorandum 2004 - 37
                                                                                                                                                                Exhibit 2J



                                                               837 - HEALTH CLAIMS AND ENCOUNTERS (PROFESSIONAL)
INTERNAL    TABLE  /   FIELD    FIELD   FIELD   Old   A1                                                                REF      ELEMENT
RECORD ID   DATABASE   LENGTH   TYPE    NAME    PG    PG    SEGMENT NAME                 ELEMENT NAME                   DES.      NUMBER   LOOP ATTRIBUTES      NOTES                USE      REPEAT

                                                                                         CERTIFICATE CONDITION CODE     CRC03       1321   2300 M   ID   2/2
                                                      251   EPSDT Referal                                               CRC                2300                                      S             3

                                                                                         CODE CATEGORY                  CRC01       1136   2300 M   ID   2/2
                                                                                         YES/NO CONDITION OR RESPONSE
                                                                                         CODE                           CRC02       1073   2300 M   ID   1/1

                                                                                         CERTIFICATE CONDITION CODE     CRC03       1321   2300 M   ID   2/2


                                                                                         CERTIFICATE CONDITION CODE     CRC04       1321   2300 O   ID   2/2
                                                                                         CERTIFICATE CONDITION CODE     CRC05       1321   2300 O   ID   2/2
                                                      254   HEALTH CARE DIAGNOSIS CODE                                  HI                 2300                                      S             1
                                                                                         HEALTH CARE CODE INFORMATION   HI01        C022   2300 M
                                                                                         CODE LIST QUALIFIER CODE       HI01-1      1270   2300 M   ID   1/3
                                                                                         INDUSTRY CODE                  HI01-2      1271   2300 M   AN   1/30
                                                                                         HEALTH CARE CODE INFORMATION   HI02        C022   2300 O
                                                                                         CODE LIST QUALIFIER CODE       HI02-1      1270   2300 M   ID   1/3
                                                                                         INDUSTRY CODE                  HI02-2      1271   2300 M   AN   1/30
                                                                                         HEALTH CARE CODE INFORMATION   HI03        C022   2300 O
                                                                                         CODE LIST QUALIFIER CODE       HI03-1      1270   2300 M   ID   1/3
                                                                                         INDUSTRY CODE                  HI03-2      1271   2300 M   AN   1/30
                                                                                         HEALTH CARE CODE INFORMATION   HI04        C022   2300 O
                                                                                         CODE LIST QUALIFIER CODE       HI04-1      1270   2300 M   ID   1/3
                                                                                         INDUSTRY CODE                  HI04-2      1271   2300 M   AN   1/30
                                                                                         HEALTH CARE CODE INFORMATION   HI05        C022   2300 O
                                                                                         CODE LIST QUALIFIER CODE       HI05-1      1270   2300 M   ID   1/3
                                                                                         INDUSTRY CODE                  HI05-2      1271   2300 M   AN   1/30
                                                                                         HEALTH CARE CODE INFORMATION   HI06        C022   2300 O
                                                                                         CODE LIST QUALIFIER CODE       HI06-1      1270   2300 M   ID   1/3
                                                                                         INDUSTRY CODE                  HI06-2      1271   2300 M   AN   1/30
                                                                                         HEALTH CARE CODE INFORMATION   HI07        C022   2300 O
                                                                                         CODE LIST QUALIFIER CODE       HI07-1      1270   2300 M   ID   1/3
                                                                                         INDUSTRY CODE                  HI07-2      1271   2300 M   AN   1/30

                                                                                         HEALTH CARE CODE INFORMATION   HI08        C022   2300 O
                                                                                         CODE LIST QUALIFIER CODE       HI08-1      1270   2300 M   ID   1/3


                                                                                         INDUSTRY CODE                  HI08-2      1271   2300 M   AN   1/30


                                                                                          18
                                                                                                                                                                         Policy Memorandum 2004 - 37
                                                                                                                                                                         Exhibit 2J



                                                               837 - HEALTH CLAIMS AND ENCOUNTERS (PROFESSIONAL)
INTERNAL    TABLE  /   FIELD    FIELD   FIELD   Old   A1                                                                          REF     ELEMENT
RECORD ID   DATABASE   LENGTH   TYPE    NAME    PG    PG    SEGMENT NAME                          ELEMENT NAME                    DES.     NUMBER   LOOP ATTRIBUTES      NOTES                USE      REPEAT


                                                271   260   CLAIM PRICING/REPRICING INFORMATION                                   HCP               2300                                      S             1


                                                                                                  PRICING METHODOLOGY             HCP01      1473   2300 X   ID   2/2


                                                                                                  MONETARY AMOUNT                 HCP02       782   2300 O   R    1/18


                                                                                                  MONETARY AMOUNT                 HCP03       782   2300 O   R    1/18

                                                                                                  REFERENCE IDENTIFICATION        HCP04       127   2300 O   AN   1/30

                                                                                                  RATE                            HCP05       118   2300 O   R    1/9


                                                                                                  REFERENCE IDENTIFICATION        HCP06       127   2300 O   AN   1/30

                                                                                                  MONETARY AMOUNT                 HCP07       782   2300 O   R    1/18
                                                                                                  REJECT REASON CODE              HCP13       901   2300 X   ID   2/2


                                                                                                  POLICY COMPLIANCE CODE          HCP14      1526   2300 O   ID   1/2

                                                                                                  EXCEPTION CODE                  HCP15      1527   2300 O   ID   1/2

                                                            LOOP ID - 2305 HOME HEALTH CARE PLAN INFORMATION                                                                                                6
                                                276   265   HOME HEALTH CARE PLAN INFORMATION                                     CR7                                                                       1

                                                                                                  DISCIPLINE TYPE CODE            CR701       921   2305 M   ID   2/2
                                                                                                  NUMBER                          CR702      1470   2305 M   NO   1/9


                                                                                                  NUMBER                          CR703      1470   2305 M   NO   1/9

                                                278   267   HEALTH CARE SERVICES DELIVERY                                         HSD               2305                                      S             3
                                                                                                  QUANTITY QUALIFIER              HSD01       673   2305 X   ID   2/2


                                                                                                  QUANTITY                        HSD02       380   2305 X   R    1/15
                                                                                                  UNIT OR BASIS FOR MEASUREMENT
                                                                                                  CODE                            HSD03       355   2305 O   ID   2/2
                                                                                                  SAMPLE SELECTION MODULUS        HSD04      1167   2305 O   R    1/6


                                                                                                  TIME PERIOD QUALIFIER           HSD05       615   2305 X   ID   1/2


                                                                                                   19
                                                                                                                                                                          Policy Memorandum 2004 - 37
                                                                                                                                                                          Exhibit 2J



                                                               837 - HEALTH CLAIMS AND ENCOUNTERS (PROFESSIONAL)
INTERNAL    TABLE  /   FIELD    FIELD   FIELD   Old   A1                                                                          REF     ELEMENT
RECORD ID   DATABASE   LENGTH   TYPE    NAME    PG    PG    SEGMENT NAME                         ELEMENT NAME                     DES.     NUMBER   LOOP ATTRIBUTES       NOTES                USE      REPEAT
                                                                                                 NUMBER OF PERIODS                HSD06       616    2305 O   NO   1/3
                                                                                                 SHIP/DELIVERY OR CALENDAR
                                                                                                 PATTERN CODE                     HSD07       678    2305 O   ID   1/2
                                                                                                 SHIP/DELIVER PATTERN TIME CODE   HSD08       679    2305 O   ID   1/1
                                                            LOOP ID - 2310A REFERRING PROVIDER NAME                                                                                                          2
                                                282   271   REFERRING PROVIDER NAME                                               NM1                                                          S             1
                                                                                                 ENTITY IDENTIFIER CODE           NM101        98   2310A M   ID   2/3
                                                                                                 ENTITY TYPE QUALIFIER            NM102      1065   2310A M   ID   1/1

                                                                                                 NAME LAST OR ORGANIZATION NAME NM103        1035   2310A O   AN   1/35
                                                                                                 NAME FIRST                     NM104        1036   2310A O   AN   1/25

                                                                                                 NAME MIDDLE                      NM105      1037   2310A O   AN   1/25


                                                                                                 NAME SUFFIX                      NM107      1039   2310A O   AN   1/10


                                                                                                 IDENTIFICATION CODE QUALIFIER    NM108        66   2310A X   ID   1/2
                                                                                                 IDENTIFICATION CODE              NM109        67   2310A X   AN   2/80
                                                            REFERRING PROVIDER SPECIALTY
                                                285   274   INFORMATION                                                           PRV               2310A                                      S             1
                                                                                                 PROVIDER CODE                    PRV01      1221   2310A M   ID   1/3
                                                                                                 REFERENCE IDENTIFICATION
                                                                                                 QUALIFIER                        PRV02       128   2310A M   ID   2/3
                                                                                                 REFERENCE IDENTIFICATION         PRV03       127   2310A M   AN   1/30
                                                            REFERRING PROVIDER SECONDARY
                                                288   276   IDENTIFICATION                                                        REF               2310A                                      S             5
                                                                                                 REFERENCE IDENTIFICATION
                                                                                                 QUALIFIER                        REF01       128   2310A M   ID   2/3
                                                                                                 REFERENCE IDENTIFICATION         REF02       127   2310A M   AN   1/30


                                                            LOOP ID - 2310B RENDERING PROVIDER NAME                                                                                                          1
                                                290   278   RENDERING PROVIDER NAME                                               NM1                                                          S             1
                                                                                                 ENTITY IDENTIFIER CODE           NM101        98   2310B M   ID   2/3
                                                                                                 ENTITY TYPE QUALIFIER            NM102      1065   2310B M   ID   1/1

                                                                                                 NAME LAST OR ORGANIZATION NAME NM103        1035   2310B O   AN   1/35
                                                                                                 NAME FIRST                     NM104        1036   2310B O   AN   1/25
                                                                                                 NAME MIDDLE                      NM105      1037   2310B O   AN   1/25
                                                                                                 NAME SUFFIX                      NM107      1039   2310B O   AN   1/10
                                                                                                 IDENTIFICATION CODE QUALIFIER    NM108        66   2310B X   ID   1/2
                                                                                                 IDENTIFICATION CODE              NM109        67   2310B X   AN   2/80

                                                                                                  20
                                                                                                                                                                           Policy Memorandum 2004 - 37
                                                                                                                                                                           Exhibit 2J



                                                               837 - HEALTH CLAIMS AND ENCOUNTERS (PROFESSIONAL)
INTERNAL    TABLE  /   FIELD    FIELD   FIELD   Old   A1                                                                          REF     ELEMENT
RECORD ID   DATABASE   LENGTH   TYPE    NAME    PG    PG    SEGMENT NAME                          ELEMENT NAME                    DES.     NUMBER   LOOP ATTRIBUTES        NOTES                USE      REPEAT
                                                            RENDERING PROVIDER SPECIALTY
                                                293   281   INFORMATION                                                           PRV               2310B                                       S             1
                                                                                                  PROVIDER CODE                   PRV01      1221   2310B M   ID   1/3
                                                                                                  REFERENCE IDENTIFICATION
                                                                                                  QUALIFIER                       PRV02       128   2310B M   ID   2/3
                                                                                                  REFERENCE IDENTIFICATION        PRV03       127   2310B M   AN   1/30
                                                            RENDERING PROVIDER SECONDARY
                                                296   283   IDENTIFICATION                                                        REF               2310B                                       S             5
                                                                                                  REFERENCE IDENTIFICATION
                                                                                                  QUALIFIER                       REF01       128   2310B M   ID   2/3
                                                                                                  REFERENCE IDENTIFICATION        REF02       127   2310B X   AN   1/30
                                                            LOOP ID - 2310C PURCHASED SERVICE PROVIDER NAME                                                                                                   1
                                                298   285   PURCHASED SERVICE PROVIDER NAME                                       NM1                                                           S             1
                                                                                                  ENTITY IDENTIFIER CODE          NM101        98   2310C M   ID   2/3
                                                                                                  ENTITY TYPE QUALIFIER           NM102      1065   2310C M   ID   1/1

                                                                                                  NAME LAST OR ORGANIZATION NAME NM103       1035   2310C O   AN   1/35
                                                                                                  NAME FIRST                     NM104       1036   2310C O   AN   1/25
                                                                                                  NAME MIDDLE                     NM105      1037   2310C O   AN   1/25\
                                                                                                  IDENTIFICATION CODE QUALIFIER   NM108        66   2310C X   ID   1/2
                                                                                                  IDENTIFICATION CODE             NM109        67   2310C X   AN   2/80
                                                            PURCHASED SERVICE PROVIDER
                                                301   288   SECONDARY IDENTIFICATION                                              REF               2310C                                       S             5
                                                                                                  REFERENCE IDENTIFICATION
                                                                                                  QUALIFIER                       REF01       128   2310C M   ID   2/3
                                                                                                  REFERENCE IDENTIFICATION        REF02       127   2310C X   AN   1/30
                                                            LOOP ID - 2310D SERVICE FACILITY LOCATION                                                                                                         1
                                                303   290   SERVICE FACILITY LOCATION                                             NM1                                                           S             1
                                                                                                  ENTITY IDENTIFIER CODE          NM101        98   2310D M   ID   2/3
                                                                                                  ENTITY TYPE QUALIFIER           NM102      1065   2310D M   ID   1/1

                                                                                                  NAME LAST OR ORGANIZATION NAME NM103       1035   2310D O   AN   1/35
                                                                                                  IDENTIFICATION CODE QUALIFIER  NM108         66   2310D X   ID   1/2
                                                                                                  IDENTIFICATION CODE             NM109        67   2310D X   AN   2/80


                                                307   293   SERVICE FACILITY LOCATION ADDRESS                                     N3                2310D                                       R             1
                                                                                                  ADDRESS INFORMATION             N301        166   2310D M   AN   1/55
                                                                                                  ADDRESS INFORMATION             N302        166   2310D O   AN   1/55

                                                            SERVICE FACILITY LOCATION
                                                308   294   CITY/STATE/ZIP                                                        N4                2310D                                       R             1

                                                                                                    21
                                                                                                                                                                          Policy Memorandum 2004 - 37
                                                                                                                                                                          Exhibit 2J



                                                               837 - HEALTH CLAIMS AND ENCOUNTERS (PROFESSIONAL)
INTERNAL    TABLE  /   FIELD    FIELD   FIELD   Old   A1                                                                          REF     ELEMENT
RECORD ID   DATABASE   LENGTH   TYPE    NAME    PG    PG    SEGMENT NAME                          ELEMENT NAME                    DES.     NUMBER   LOOP ATTRIBUTES       NOTES                USE      REPEAT
                                                                                                  CITY NAME                       N401         19   2310D O   AN   2/30
                                                                                                  STATE OR PROVINCE CODE          N402        156   2310D O   ID   2/2
                                                                                                  POSTAL CODE                     N403        116   2310D O   ID   3/15
                                                                                                  COUNTRY CODE                    N404         26   2310D O   ID   2/3
                                                            SERVICE FACILITY LOCATION SECONDARY
                                                310   296   IDENTIFICATION                                                        REF               2310D                                      S             5

                                                                                                  REFERENCE IDENTIFICATION
                                                                                                  QUALIFIER                       REF01       128   2310D M   ID   2/3
                                                                                                  REFERENCE IDENTIFICATION        REF02       127   2310D X   AN   1/30
                                                            LOOP ID 2310E SUPERVISING PROVIDER NAME                                                                                                          1
                                                312   298   SUPERVISING PROVIDER NAME                                             NM1                                                          S             1
                                                                                                  ENTITY IDENTIFIER CODE          NM101        98   2310E M   ID   2/3
                                                                                                  ENTITY TYPE QUALIFIER           NM102      1065   2310E M   ID   1/1

                                                                                                  NAME LAST OR ORGANIZATION NAME NM103       1035   2310E O   AN   1/35


                                                                                                  NAME FIRST                      NM104      1036   2310E O   AN   1/25
                                                                                                  NAME MIDDLE                     NM105      1037   2310E O   AN   1/25



                                                                                                  NAME SUFFIX                     NM107      1039   2310E O   AN   1/10
                                                                                                  IDENTIFICATION CODE QUALIFIER   NM108        66   2310E X   ID   1/2
                                                                                                  IDENTIFICATION CODE             NM109        67   2310E X   AN   2/80
                                                            SUPERVISING PROVIDER SECONDARY
                                                316   201   IDENTIFICATION                                                        REF               2310E                                      S             5
                                                                                                  REFERENCE IDENTIFICATION
                                                                                                  QUALIFIER                       REF01       128   2310E M   ID   2/3
                                                                                                  REFERENCE IDENTIFICATION        REF02       127   2310E X   AN   1/30
                                                            LOOP ID - 2320 OTHER SUBSCRIBER INFORMATION                                                                                                     10
                                                318   303   OTHER SUBSCRIBER INFORMATION                                          SBR                                                          S             1
                                                                                                  PAYER RESPONSIBILITY SEQUENCE
                                                                                                  NUMBER CODE                     SBR01      1138    2320 M   ID   1/1
                                                                                                  INDIVIDUAL RELATIONSHIP CODE    SBR02      1069    2320 O   ID   2/2
                                                                                                  REFERENCE IDENTIFICATION        SBR03       127    2320 O   AN   1/30
                                                                                                  NAME                            SBR04        93    2320 O   AN   1/60
                                                                                                  INSURANCE TYPE CODE             SBR05      1336    2320 O   ID   1/3
                                                                                                  CLAIM FILING INDICATOR CODE     SBR09      1032    2320 O   ID   1/2
                                                323   308   CLAIM LEVEL ADJUSTMENTS                                               CAS                2320                                      S             5
                                                                                                  CLAIM ADJUSTMENT GROUP CODE     CAS01      1033    2320 M   ID   1/2


                                                                                                   22
                                                                                                                                                                   Policy Memorandum 2004 - 37
                                                                                                                                                                   Exhibit 2J



                                                               837 - HEALTH CLAIMS AND ENCOUNTERS (PROFESSIONAL)
INTERNAL    TABLE  /   FIELD    FIELD   FIELD   Old   A1                                                                    REF     ELEMENT
RECORD ID   DATABASE   LENGTH   TYPE    NAME    PG    PG    SEGMENT NAME                     ELEMENT NAME                   DES.     NUMBER   LOOP ATTRIBUTES      NOTES                USE      REPEAT

                                                                                             CLAIM ADJUSTMENT REASON CODE   CAS02      1034   2320 M   ID   1/5
                                                                                             MONETARY AMOUNT                CAS03       782   2320 M   R    1/18
                                                                                             QUANTITY                       CAS04       380   2320 O   R    1/15
                                                                                             CLAIM ADJUSTMENT REASON CODE   CAS05      1034   2320 M   ID   1/5



                                                                                             MONETARY AMOUNT                CAS06       782   2320 M   R    1/18
                                                                                             QUANTITY                       CAS07       380   2320 O   R    1/15
                                                                                             CLAIM ADJUSTMENT REASON CODE   CAS08      1034   2320 M   ID   1/5
                                                                                             MONETARY AMOUNT                CAS09       782   2320 M   R    1/18
                                                                                             QUANTITY                       CAS10       380   2320 O   R    1/15
                                                                                             CLAIM ADJUSTMENT REASON CODE   CAS11      1034   2320 M   ID   1/5
                                                                                             MONETARY AMOUNT                CAS12       782   2320 M   R    1/18
                                                                                             QUANTITY                       CAS13       380   2320 O   R    1/15
                                                                                             CLAIM ADJUSTMENT REASON CODE   CAS14      1034   2320 M   ID   1/5

                                                                                             MONETARY AMOUNT                CAS15       782   2320 M   R    1/18

                                                                                             QUANTITY                       CAS16       380   2320 O   R    1/15


                                                                                             CLAIM ADJUSTMENT REASON CODE   CAS17      1034   2320 M   ID   1/5


                                                                                             MONETARY AMOUNT                CAS18       782   2320 M   R    1/18
                                                                                             QUANTITY                       CAS19       380   2320 O   R    1/15

                                                            COORDINATION OF BENEFITS (COB)
                                                332   317   PAYER PAID AMOUNT                                               AMT               2320                                      S             1
                                                                                             AMOUNT QUALIFIER CODE          AMT01       522   2320 M   ID   1/3
                                                                                             MONETARY AMOUNT                AMT02       782   2320 M   R    1/18
                                                            COORDINATION OF BENEFITS
                                                333   318   (COB)APPROVED AMOUNT                                            AMT               2320                                      S             1
                                                                                             AMOUNT QUALIFIER CODE          AMT01       522   2320 M   ID   1/3
                                                                                             MONETARY AMOUNT                AMT02       782   2320 M   R    1/18
                                                            COORDINATION OF BENEFITS (COB)
                                                334   319   ALLOWED AMOUNT                                                  AMT               2320                                      S             1
                                                                                             AMOUNT QUALIFIER CODE          AMT01       522   2320 M   ID   1/3
                                                                                             MONETARY AMOUNT                AMT02       782   2320 M   R    1/18
                                                            COORDINATION OF BENEFITS (COB)
                                                335   320   PATIENT RESPONSIBILITY AMOUNT                                   AMT               2320                                      S             1
                                                                                             AMOUNT QUALIFIER CODE          AMT01       522   2320 M   ID   1/3

                                                                                              23
                                                                                                                                                                          Policy Memorandum 2004 - 37
                                                                                                                                                                          Exhibit 2J



                                                               837 - HEALTH CLAIMS AND ENCOUNTERS (PROFESSIONAL)
INTERNAL    TABLE  /   FIELD    FIELD   FIELD   Old   A1                                                                           REF     ELEMENT
RECORD ID   DATABASE   LENGTH   TYPE    NAME    PG    PG    SEGMENT NAME                           ELEMENT NAME                    DES.     NUMBER   LOOP ATTRIBUTES      NOTES                USE      REPEAT
                                                                                                   MONETARY AMOUNT                 AMT02       782   2320 M   R    1/18
                                                            COORDINATION OF BENEFITS (COB)
                                                336   321   COVERED AMOUNT                                                         AMT               2320                                      S             1
                                                                                                   AMOUNT QUALIFIER CODE           AMT01       522   2320 M   ID   1/3
                                                                                                   MONETARY AMOUNT                 AMT02       782   2320 M   R    1/18
                                                            COORDINATION OF BENEFITS (COB)
                                                337   322   DISCOUNT AMOUNT                                                        AMT               2320                                      S             1
                                                                                                   AMOUNT QUALIFIER CODE           AMT01       522   2320 M   ID   1/3
                                                                                                   MONETARY AMOUNT                 AMT02       782   2320 M   R    1/18
                                                            COORDINATION OF BENEFITS (COB) PER
                                                338   323   DAY LIMIT AMOUNT                                                       AMT               2320                                      S             1
                                                                                                   AMOUNT QUALIFIER CODE           AMT01       522   2320 M   ID   1/3
                                                                                                   MONETARY AMOUNT                 AMT02       782   2320 M   R    1/18
                                                            COORDINATION OF BENEFITS (COB)
                                                339   324   PATIENT PAID AMOUNT                                                    AMT               2320                                      S             1
                                                                                                   AMOUNT QUALIFIER CODE           AMT01       522   2320 M   ID   1/3
                                                                                                   MONETARY AMOUNT                 AMT02       782   2320 M   R    1/18
                                                            COORDINATION OF BENEFITS (COB) TAX
                                                340   325   AMOUNT                                                                 AMT               2320                                      S             1
                                                                                                   AMOUNT QUALIFIER CODE           AMT01       522   2320 M   ID   1/3
                                                                                                   MONETARY AMOUNT                 AMT02       782   2320 M   R    1/18
                                                            COORDINATION OF BENEFITS (COB) TOTAL
                                                341   326   CLAIM BEFORE TAXES                                                     AMT               2320                                      S             1
                                                                                                   AMOUNT QUALIFIER CODE           AMT01       522   2320 M   ID   1/3
                                                                                                   MONETARY AMOUNT                 AMT02       782   2320 M   R    1/18
                                                            SUBSCRIBER DEMOGRAPHIC
                                                343   327   INFORMATION                                                            DMG               2320                                      S             1

                                                                                                   DATE TIME FORMAT QUALIFIER      DMG01      1250   2320 X   ID   2/3
                                                                                                   DATE TIME PERIOD                DMG02      1251   2320 X   AN   1/35
                                                                                                   GENDER CODE                     DMG03      1068   2320 O   ID   1/1
                                                            OTHER INSURANCE COVERAGE
                                                344   329   INFORMATION                                                            OI                2320                                      R             1
                                                                                                   YES/NO CONDITION OR RESPONSE
                                                                                                   CODE                            OI03       1073   2320 O   ID   1/1
                                                                                                   PATIENT SIGNATURE SOURCE CODE   OI04       1351   2320 O   ID   1/1

                                                                                                   RELEASE OF INFORMATION CODE     OI06       1363   2320 O   ID   1/1
                                                            MEDICARE OUTPATIENT ADJUDICATION
                                                347   332   INFORMATION                                                            MOA               2320                                      S             1
                                                                                                   PERCENT                         MOA01       954   2320 O   R    1/10

                                                                                                   MONETARY AMOUNT                 MOA02       782   2320 O   R    1/18

                                                                                                    24
                                                                                                                                                                           Policy Memorandum 2004 - 37
                                                                                                                                                                           Exhibit 2J



                                                               837 - HEALTH CLAIMS AND ENCOUNTERS (PROFESSIONAL)
INTERNAL    TABLE  /   FIELD    FIELD   FIELD   Old   A1                                                                           REF     ELEMENT
RECORD ID   DATABASE   LENGTH   TYPE    NAME    PG    PG    SEGMENT NAME                           ELEMENT NAME                    DES.     NUMBER   LOOP ATTRIBUTES       NOTES                USE      REPEAT
                                                                                                   REFERENCE IDENTIFIER            MOA03       127    2320 O   AN   1/30
                                                                                                   REFERENCE IDENTIFIER            MOA04       127    2320 O   AN   1/30

                                                                                                   REFERENCE IDENTIFIER            MOA05       127    2320 O   AN   1/30
                                                                                                   REFERENCE IDENTIFIER            MOA06       127    2320 O   AN   1/30
                                                                                                   REFERENCE IDENTIFIER            MOA07       127    2320 O   AN   1/30

                                                                                                   MONETARY AMOUNT                 MOA08       782    2320 O   R    1/18
                                                                                                   MONETARY AMOUNT                 MOA09       782    2320 O   R    1/18
                                                            LOOP ID - 2330A OTHER SUBSCRIBER NAME                                                                                                             1

                                                350   335   OTHER SUBSCRIBER NAME                                                  NM1                                                          R             1
                                                                                                   ENTITY IDENTIFIER CODE          NM101        98   2330A M   ID   2/3
                                                                                                   ENTITY TYPE QUALIFIER           NM102      1065   2330A M   ID   1/1

                                                                                                   NAME LAST OR ORGANIZATION NAME NM103       1035   2330A O   AN   1/35
                                                                                                   NAME FIRST                     NM104       1036   2330A O   AN   1/25
                                                                                                   NAME MIDDLE                     NM105      1037   2330A O   AN   1/25

                                                                                                   NAME SUFFIX                     NM107      1039   2330A O   AN   1/10
                                                                                                   IDENTIFICATION CODE QUALIFIER   NM108        66   2330A X   ID   1/2
                                                                                                   IDENTIFICATION CODE             NM109        67   2330A X   AN   2/80

                                                354   338   OTHER SUBSCRIBER ADDRESS                                               N3                2330A                                      S             1
                                                                                                   ADDRESS INFORMATION             N301        166   2330A M   AN   1/55
                                                                                                   ADDRESS INFORMATION             N302        166   2330A O   AN   1/55

                                                355   339   OTHER SUBSCRIBER CITY/STATE/ZIP CODE                                   N4                2330A                                      S             1
                                                                                                   CITY NAME                       N401         19   2330A O   AN   2/30
                                                                                                   STATE OR PROVINCE CODE          N402        156   2330A O   ID   2/2
                                                                                                   POSTAL CODE                     N403        116   2330A O   ID   3/15
                                                                                                   COUNTRY CODE                    N404         26   2330A O   ID   2/3
                                                            OTHER SUBSCRIBER SECONDARY
                                                357   341   INFORMATION                                                            REF               2330A                                      S             3
                                                                                                   REFERENCE IDENTIFICATION
                                                                                                   QUALIFIER                       REF01       128   2330A M   ID   2/3
                                                                                                   REFERENCE IDENTIFICATION        REF02       127   2330A X   AN   1/30
                                                            LOOP ID - 2330B OTHER PAYER NAME                                                                                                                  1
                                                359   343   OTHER PAYER NAME                                                       NM1                                                          R             1
                                                                                                   ENTITY IDENTIFIER CODE          NM101        98   2330B M   ID   2/3
                                                                                                   ENTITY TYPE QUALIFIER           NM102      1065   2330B M   ID   1/1


                                                                                                    25
                                                                                                                                                                         Policy Memorandum 2004 - 37
                                                                                                                                                                         Exhibit 2J



                                                               837 - HEALTH CLAIMS AND ENCOUNTERS (PROFESSIONAL)
INTERNAL    TABLE  /   FIELD    FIELD   FIELD   Old   A1                                                                         REF     ELEMENT
RECORD ID   DATABASE   LENGTH   TYPE    NAME    PG    PG    SEGMENT NAME                         ELEMENT NAME                    DES.     NUMBER   LOOP ATTRIBUTES       NOTES                USE      REPEAT

                                                                                                 NAME LAST OR ORGANIZATION NAME NM103       1035   2330B O   AN   1/35
                                                                                                 IDENTIFICATION CODE QUALIFIER  NM108         66   2330B X   ID   1/2
                                                                                                 IDENTIFICATION CODE             NM109        67   2330B X   AN   2/80
                                                363   346   OTHER PAYER CONTACT INFORMATION                                      PER               2330B                                      S             2
                                                                                                 CONTACT FUNCTION CODE           PER01       366   2330B M   ID   2/2
                                                                                                 NAME                            PER02        93   2330B O   AN   1/60


                                                                                                 COMMUNICATION NUMBER QUALIFIER PER03        365   2330B X   ID   2/2
                                                                                                 COMMUNICATION NUMBER           PER04        364   2330B X   AN   1/80
                                                                                                 COMMUNICATION NUMBER QUALIFIER PER05        365   2330B X   ID   2/2
                                                                                                 COMMUNICATION NUMBER           PER06        364   2330B X   AN   1/80
                                                                                                 COMMUNICATION NUMBER QUALIFIER PER07        365   2330B X   ID   2/2
                                                                                                 COMMUNICATION NUMBER           PER08        364   2330B X   AN   1/80
                                                366   349   CLAIM ADJUDICATION DATE                                              DTP               2330B                                      S             1
                                                                                                 DATE/TIME QUALIFIER             DTP01       374   2330B M   ID   3/3
                                                                                                 DATE TIME PERIOD FORMAT
                                                                                                 QUALIFIER                       DTP02      1250   2330B M   ID   2/3
                                                                                                 DATE TIME PERIOD                DTP03      1251   2330B M   AN   1/35
                                                368   351   OTHER PAYER SECONDARY IDENTIFIER                                     REF               2330B                                      S             2
                                                                                                 REFERENCE IDENTIFICATION
                                                                                                 QUALIFIER                       REF01       128   2330B M   ID   2/3
                                                                                                 REFERENCE IDENTIFICATION        REF02       127   2330B X   AN   1/30
                                                            OTHER PAYER PRIOR AUTHORIZATION OR
                                                370   353   REFERRAL NUMBER                                                      REF               2330B                                      S             2
                                                                                                 REFERENCE IDENTIFICATION
                                                                                                 QUALIFIER                       REF01       128   2330B M   ID   2/3
                                                                                                 REFERENCE IDENTIFICATION        REF02       127   2330B X   AN   1/30
                                                            OTHER PAYER CLAIM ADJUSTMENT
                                                372   355   INDICATOR                                                            REF               2330B                                      S             2
                                                                                                 REFERENCE IDENTIFICATION
                                                                                                 QUALIFIER                       REF01       128   2330B M   ID   2/3
                                                                                                 REFERENCE IDENTIFICATION        REF02       127   2330B X   AN   1/30
                                                            LOOP ID 2330C OTHER PAYER PATIENT INFORMATION                                                                                                   1
                                                374   357   OTHER PAYER PATIENT INFORMATION                                      NM1                                                          S             1
                                                                                                 ENTITY IDENTIFIER CODE          NM101        98   2330C M   ID   2/3
                                                                                                 ENTITY TYPE QUALIFIER           NM102      1065   2330C M   ID   1/1
                                                                                                 IDENTIFICATION CODE QUALIFIER   NM108        66   2330C X   ID   1/2
                                                                                                 IDENTIFICATION CODE             NM109        67   2330C X   AN   2/80
                                                376   359   OTHER PAYER PATIENT IDENTIFICATION                                   REF               2330C                                      S             3


                                                                                                  26
                                                                                                                                                                    Policy Memorandum 2004 - 37
                                                                                                                                                                    Exhibit 2J



                                                               837 - HEALTH CLAIMS AND ENCOUNTERS (PROFESSIONAL)
INTERNAL    TABLE  /   FIELD    FIELD   FIELD   Old   A1                                                                    REF     ELEMENT
RECORD ID   DATABASE   LENGTH   TYPE    NAME    PG    PG    SEGMENT NAME                         ELEMENT NAME               DES.     NUMBER   LOOP ATTRIBUTES       NOTES                USE      REPEAT
                                                                                                 REFERENCE IDENTIFICATION
                                                                                                 QUALIFIER                  REF01       128   2330C M   ID   2/3


                                                                                                 REFERENCE IDENTIFICATION   REF02       127   2330C X   AN   1/30
                                                            LOOP ID 2330D OTHER PAYER REFERRING PROVIDER                                                                                               2
                                                378   361   OTHER PAYER REFERRING PROVIDER                                  NM1                                                          S             1
                                                                                                 ENTITY IDENTIFIER CODE     NM101        98   2330D M   ID   2/3

                                                                                                 ENTITY TYPE QUALIFIER      NM102      1065   2330D M   ID   1/1
                                                            OTHER PAYER REFERRING PROVIDER
                                                380   363   IDENTIFICATION                                                  REF               2330D                                      R             3
                                                                                                 REFERENCE IDENTIFICATION
                                                                                                 QUALIFIER                  REF01       128   2330D M   ID   2/3
                                                                                                 REFERENCE IDENTIFICATION   REF02       127   2330D X   AN   1/30
                                                            LOOP ID 2330E OTHER PAYER RENDERING PROVIDER                                                                                               1
                                                382   365   OTHER PAYER RENDERING PROVIDER                                  NM1                                                          S             1

                                                                                                 ENTITY IDENTIFIER CODE     NM101        98   2330E M   ID   2/3
                                                                                                 ENTITY TYPE QUALIFIER      NM102      1065   2330E M   ID   1/1
                                                            OTHER PAYER RENDERING PROVIDER
                                                384   367   SECONDARY IDENTIFICATION                                        REF               2330E                                      R             3
                                                                                                 REFERENCE IDENTIFICATION
                                                                                                 QUALIFIER                  REF01       128   2330E M   ID   2/3
                                                                                                 REFERENCE IDENTIFICATION   REF02       127   2330E X   AN   1/30
                                                            LOOP ID - 2330F OTHER PAYER PURCHASED SERVICE PROVIDER                                                                                     1
                                                            OTHER PAYER PURCHASED SERVICE
                                                386   369   PROVIDER                                                        NM1                                                          S             1
                                                                                                 ENTITY IDENTIFIER CODE     NM101        98   2330F M   ID   2/3



                                                                                                 ENTITY TYPE QUALIFIER      NM102      1065   2330F M   ID   1/1
                                                            OTHER PAYER SERVICE FACILITY
                                                388   371   LOCATION IDENTIFICATION                                         REF               2330F

                                                                                                 REFERENCE IDENTIFICATION
                                                                                                 QUALIFIER                  REF01       128   2330F M   ID   2/3
                                                                                                 REFERENCE IDENTIFICATION   REF02       127   2330F X   AN   1/30
                                                            LOOP ID - 2330G OTHER PAYER SERVICE FACILITY LOCATION                                                                                      1
                                                            OTHER PAYER SERVICE FACILITY
                                                390   373   LOCATION                                                        NM1                                                          S             1
                                                                                                 ENTITY IDENTIFIER CODE     NM101        98   2330G M   ID   2/3
                                                                                                 ENTITY TYPE QUALIFIER      NM102      1065   2330G M   ID   1/1

                                                                                                   27
                                                                                                                                                                           Policy Memorandum 2004 - 37
                                                                                                                                                                           Exhibit 2J



                                                               837 - HEALTH CLAIMS AND ENCOUNTERS (PROFESSIONAL)
INTERNAL    TABLE  /   FIELD    FIELD   FIELD   Old   A1                                                                         REF       ELEMENT
RECORD ID   DATABASE   LENGTH   TYPE    NAME    PG    PG    SEGMENT NAME                         ELEMENT NAME                    DES.       NUMBER   LOOP ATTRIBUTES       NOTES                USE      REPEAT
                                                            OTHER PAYER SERVICE FACILITY
                                                392   375   LOCATION IDENTIFICATION                                              REF                 2330G                                      R             3
                                                                                                 REFERENCE IDENTIFICATION
                                                                                                 QUALIFIER                       REF01         128   2330G M   ID   2/3
                                                                                                 REFERENCE IDENTIFICATION        REF02         127   2330G X   AN   1/30
                                                            LOOP ID - 2330H OTHER PAYER SUPERVISING PROVIDER                                                                                                  1
                                                394   377   OTHER PAYER SUPERVISING PROVIDER                                     NM1                                                            S             1
                                                                                                 ENTITY IDENTIFIER CODE          NM101          98   2330H M   ID   2/3
                                                                                                 ENTITY TYPE QUALIFIER           NM102        1065   2330H M   ID   1/1
                                                            OTHER PAYER SUPERVISING PROVIDER
                                                396   379   IDENTIFICATION                                                       REF                 2330H                                      R             3
                                                                                                 REFERENCE IDENTIFICATION
                                                                                                 QUALIFIER                       REF01         128   2330H M   ID   2/3
                                                                                                 REFERENCE IDENTIFICATION        REF02         127   2330H X   AN   1/30
                                                            LOOP ID - 2400 SERVICE LINE                                                                                                                      50
                                                398   381   SERVICE LINE                                                         LX                                                             R             1
                                                                                                 ASSIGNED NUMBER                 LX01          554    2400 M   NO   1/6
                                                400   383   PROFESSIONAL SERVICE                                                 SV1                  2400                                      R             1
                                                                                                 COMPOSITE MEDICAL PROCEDURE
                                                                                                 IDENTIFIER                      SV101        C003    2400 M

                                                                                                 PRODUCT/SERVICE ID QUALIFIER    SV101-1       235    2400 M   ID   2/2
                                                                                                 PRODUCT/SERVICE ID              SV101-2       234    2400 M   AN   1/48



                                                                                                 PROCEDURE MODIFIER              SV101-3      1339    2400 O   AN   2/2



                                                                                                 PROCEDURE MODIFIER              SV101-4      1339    2400 O   AN   2/2
                                                                                                 PROCEDURE MODIFIER              SV101-5      1339    2400 O   AN   2/2
                                                                                                 PROCEDURE MODIFIER              SV101-6      1339    2400 O   AN   2/2
                                                                                                 MONETARY AMOUNT                 SV102         782    2400 O   R    1/18
                                                                                                 UNIT OR BASIS FOR MEASUREMENT
                                                                                                 CODE                            SV103         355    2400 X   ID   2/2
                                                                                                 QUANTITY                        SV104         380    2400 X   R    1/15
                                                                                                 FACILITY CODE VALUE             SV105        1331    2400 O   AN   1/2
                                                                                                 SERVICE TYPE CODE               SV106        1365    2400 O   ID   1/2

                                                                                                 COMPOSITE DIAGNOSIS CODE
                                                                                                 POINTER                         SV107        C004    2400 O
                                                                                                 DIAGNOSIS CODE POINTER          SV107-1      1328    2400 M   NO   1/2

                                                                                                  28
                                                                                                                                                                         Policy Memorandum 2004 - 37
                                                                                                                                                                         Exhibit 2J



                                                               837 - HEALTH CLAIMS AND ENCOUNTERS (PROFESSIONAL)
INTERNAL    TABLE  /   FIELD    FIELD   FIELD   Old   A1                                                                        REF       ELEMENT
RECORD ID   DATABASE   LENGTH   TYPE    NAME    PG    PG    SEGMENT NAME                        ELEMENT NAME                    DES.       NUMBER   LOOP ATTRIBUTES      NOTES                USE      REPEAT
                                                                                                DIAGNOSIS CODE POINTER          SV107-2      1328   2400 O   NO   1/2
                                                                                                DIAGNOSIS CODE POINTER          SV107-3      1328   2400 O   NO   1/2
                                                                                                DIAGNOSIS CODE POINTER          SV107-4      1328   2400 O   NO   1/2
                                                                                                YES/NO CONDITION OR RESPONSE
                                                                                                CODE                            SV109        1073   2400 O   ID   1/1
                                                                                                YES/NO CONDITION OR RESPONSE
                                                                                                CODE                            SV111        1073   2400 O   ID   1/1
                                                                                                YES/NO CONDITION OR RESPONSE
                                                                                                CODE                            SV112        1073   2400 O   ID   1/1



                                                                                                COPAY STATUS CODE               SV115        1327   2400 O   ID   1/1


                                                      391   DURABLE MEDICAL EQUIPMENT SERVICE                                   SV5                 2400                                      S             1
                                                                                                COMPOSIT MEDICAL PROCEDURE
                                                                                                IDENTIFIER                      SV501        C003   2400 M
                                                                                                PROCEDURE QUALIFIER             SV501-1       235   2400 M   ID   2/2
                                                                                                PROCEDURE CODE                  SV501-2       234   2400 M   AN   1/48
                                                                                                UNIT OR BASIS FOR MEASUREMENT
                                                                                                CODE                            SV502         355   2400 M   ID   2/2

                                                                                                LENGTH OF MEDICAL NECESSITY     SV503         380   2400 M   R    1/15
                                                                                                DME RENTAL PROCE                SV504         782   2400 X   R    1/18
                                                                                                DME PRUCHASE PRICE              SV505         782   2400 X   R    1/18

                                                                                                RENTAL UNIT PRICE INDICATOR     SV506         594   2400 O   ID   1/1


                                                410   394   DMERC CMN INDICATOR                                                 PWK                 2400                                      S             1
                                                                                                REPORT TYPE CODE                PWK01         755   2400 M   ID   2/2
                                                                                                REPORT TRANSMISSION CODE        PWK02         756   2400 O   ID   1/2


                                                412   396   AMBULANCE TRANSPORT INFORMATION                                     CR1                 2400                                      S             1
                                                                                                UNIT OR BASIS FOR MEASUREMENT
                                                                                                CODE                            CR101         355   2400 X   ID   2/2    LB



                                                                                                WEIGHT                          CR102          81   2400 X   R    1/10
                                                                                                AMBULANCE TRANSPORT CODE        CR103        1316   2400 O   ID   1/1
                                                                                                AMBULANCE TRANSPORT REASON
                                                                                                CODE                            CR104        1317   2400 O   ID   1/1
                                                                                                UNIT OR BASIS FOR MEASUREMENT
                                                                                                CODE                            CR105         355   2400 X   ID   2/2

                                                                                                 29
                                                                                                                                                                     Policy Memorandum 2004 - 37
                                                                                                                                                                     Exhibit 2J



                                                               837 - HEALTH CLAIMS AND ENCOUNTERS (PROFESSIONAL)
INTERNAL    TABLE  /   FIELD    FIELD   FIELD   Old   A1                                                                      REF     ELEMENT
RECORD ID   DATABASE   LENGTH   TYPE    NAME    PG    PG    SEGMENT NAME                      ELEMENT NAME                    DES.     NUMBER   LOOP ATTRIBUTES      NOTES                USE      REPEAT
                                                                                              QUANTITY                        CR106       380   2400 X   R    1/15
                                                                                              DESCRIPTION                     CR109       352   2400 O   AN   1/80
                                                                                              DESCRIPTION                     CR110       352   2400 O   AN   1/80
                                                            SPINAL MANIPULATION SERVICE
                                                415   399   INFORMATION                                                       CR2               2400                                      S             5
                                                                                              NATURE OF CONDITION CODE        CR208      1342   2400 O   ID   1/1
                                                                                              DESCRIPTION                     CR210       352   2400 O   AN   1/80
                                                                                              DESCRIPTION                     CR211       352   2400 O   AN   1/80
                                                                                              YES/NO CONDITION OR RESPONSE
                                                                                              CODE                            CR212      1073   2400 O   ID   1/1
                                                            DURABLE MEDICAL EQUIPMENT
                                                421   402   CERTIFICATION                                                     CR3               2400                                      S             1
                                                                                              CERTIFICATE TYPE CODE           CR301      1322   2400 O   ID   1/1
                                                                                              UNIT OR BASIS FOR MEASUREMENT
                                                                                              CODE                            CR302       355   2400 X   ID   2/2
                                                                                              QUANTITY                        CR303       380   2400 X   R    1/15


                                                423   404   HOME OXYGEN THERAPY INFORMATION                                   CR5               2400                                      S             1
                                                                                              CERTIFICATE TYPE CODE           CR501      1322   2400 O   ID   1/1
                                                                                              QUANTITY                        CR502       380   2400 O   R    1/15
                                                                                              QUANTITY                        CR510       380   2400 O   R    1/15
                                                                                              QUANTITY                        CR511       380   2400 O   R    1/15
                                                                                              OXYGEN TEST CONDITION CODE      CR512      1349   2400 O   ID   1/10
                                                                                              OXYGEN TEST FINDINGS CODE       CR513      1350   2400 O   ID   1/1
                                                                                              OXYGEN TEST FINDINGS CODE       CR514      1350   2400 O   ID   1/1


                                                                                              OXYGEN TEST FINDINGS CODE       CR515      1350   2400 O   ID   1/1
                                                427   408   AMBULANCE CERTIFICATION                                           CRC               2400                                      S             3
                                                                                              CODE CATEGORY                   CRC01      1136   2400 M   ID   2/2
                                                                                              YES/NO CONDITION OR RESPONSE
                                                                                              CODE                            CRC02      1073   2400 M   ID   1/1


                                                                                              CERTIFICATE CONDITION CODE      CRC03      1321   2400 M   ID   2/2
                                                                                              CERTIFICATE CONDITION CODE      CRC04      1321   2400 O   ID   2/2
                                                                                              CERTIFICATE CONDITION CODE      CRC05      1321   2400 O   ID   2/2

                                                                                              CERTIFICATE CONDITION CODE      CRC06      1321   2400 O   ID   2/2

                                                                                              CERTIFICATE CONDITION CODE      CRC07      1321   2400 O   ID   2/2



                                                                                               30
                                                                                                                                                                       Policy Memorandum 2004 - 37
                                                                                                                                                                       Exhibit 2J



                                                               837 - HEALTH CLAIMS AND ENCOUNTERS (PROFESSIONAL)
INTERNAL    TABLE  /   FIELD    FIELD   FIELD   Old   A1                                                                        REF     ELEMENT
RECORD ID   DATABASE   LENGTH   TYPE    NAME    PG    PG    SEGMENT NAME                         ELEMENT NAME                   DES.     NUMBER   LOOP ATTRIBUTES      NOTES                USE      REPEAT



                                                430   411   HOSPICE EMPLOYEE INDICATOR                                          CRC               2400                                      S             1

                                                                                                 CODE CATEGORY                  CRC01      1136   2400 M   ID   2/2
                                                                                                 YES/NO CONDITION OR RESPONSE
                                                                                                 CODE                           CRC02      1073   2400 M   ID   1/1
                                                                                                 CERTIFICATE CONDITION CODE     CRC03      1321   2400 M   ID   2/2
                                                432   413   DMERC CONDITION INDICATOR                                           CRC               2400                                      S             2
                                                                                                 CODE CATEGORY                  CRC01      1136   2400 M   ID   2/2
                                                                                                 YES/NO CONDITION OR RESPONSE
                                                                                                 CODE                           CRC02      1073   2400 M   ID   1/1
                                                                                                 CERTIFICATE CONDITION CODE     CRC03      1321   2400 M   ID   2/2
                                                                                                 CERTIFICATE CONDITION CODE     CRC04      1321   2400 O   ID   2/2
                                                                                                 CERTIFICATE CONDITION CODE     CRC05      1321   2400 O   ID   2/2

                                                                                                 CERTIFICATE CONDITION CODE     CRC06      1321   2400 O   ID   2/2

                                                                                                 CERTIFICATE CONDITION CODE     CRC07      1321   2400 O   ID   2/2
                                                435   416   DATE - SERVICE DATE                                                 DTP               2400                                      R             1
                                                                                                 DATE/TIME QUALIFIER            DTP01       374   2400 M   ID   3/3
                                                                                                 DATE/TIME FORMAT QUALIFIER     DTP02      1250   2400 M   ID   2/3
                                                                                                 DATE TIME PERIOD               DTP03      1251   2400 M   AN   1/35
                                                437   418   DATE - CERTIFICATION REVISION DATE                                  DTP               2400                                      S             1

                                                                                                 DATE/TIME QUALIFIER            DTP01       374   2400 M   ID   3/3
                                                                                                 DATE/TIME FORMAT QUALIFIER     DTP02      1250   2400 M   ID   2/3
                                                                                                 DATE TIME PERIOD               DTP03      1251   2400 M   AN   1/35
                                                440   420   DATE - BEGIN THERAPY DATE                                           DTP               2400                                      S             1
                                                                                                 DATE/TIME QUALIFIER            DTP01       374   2400 M   ID   3/3

                                                                                                 DATE/TIME FORMAT QUALIFIER     DTP02      1250   2400 M   ID   2/3
                                                                                                 DATE TIME PERIOD               DTP03      1251   2400 M   AN   1/35
                                                442   422   DATE - LAST CERTIFICATION DATE                                      DTP               2400                                      S             1
                                                                                                 DATE/TIME QUALIFIER            DTP01       374   2400 M   ID   3/3
                                                                                                 DATE/TIME FORMAT QUALIFIER     DTP02      1250   2400 M   ID   2/3
                                                                                                 DATE TIME PERIOD               DTP03      1251   2400 M   AN   1/35
                                                445   424   DATE - DATE LAST SEEN                                               DTP               2400                                      S             1
                                                                                                 DATE/TIME QUALIFIER            DTP01       374   2400 M   ID   3/3
                                                                                                 DATE/TIME FORMAT QUALIFIER     DTP02      1250   2400 M   ID   2/3
                                                                                                 DATE TIME PERIOD               DTP03      1251   2400 M   AN   1/35
                                                447   426   DATE - TEST                                                         DTP               2400                                      S             2

                                                                                                  31
                                                                                                                                                                        Policy Memorandum 2004 - 37
                                                                                                                                                                        Exhibit 2J



                                                               837 - HEALTH CLAIMS AND ENCOUNTERS (PROFESSIONAL)
INTERNAL    TABLE  /   FIELD    FIELD   FIELD   Old   A1                                                                        REF      ELEMENT
RECORD ID   DATABASE   LENGTH   TYPE    NAME    PG    PG    SEGMENT NAME                           ELEMENT NAME                 DES.      NUMBER   LOOP ATTRIBUTES      NOTES                USE      REPEAT
                                                                                                   DATE/TIME QUALIFIER          DTP01        374   2400 M   ID   3/3
                                                                                                   DATE/TIME FORMAT QUALIFIER   DTP02       1250   2400 M   ID   2/3
                                                                                                   DATE TIME PERIOD             DTP03       1251   2400 M   AN   1/35
                                                            DATE - OXYGEN SATURATION/ARTERIAL
                                                449   428   BLOOD GAS TEST                                                      DTP                2400                                      S             3
                                                                                                   DATE/TIME QUALIFIER          DTP01        374   2400 M   ID   3/3
                                                                                                   DATE/TIME FORMAT QUALIFIER   DTP02       1250   2400 M   ID   2/3
                                                                                                   DATE TIME PERIOD             DTP03       1251   2400 M   AN   1/35
                                                451   430   DATE - SHIPPED                                                      DTP                2400                                      S             1
                                                                                                   DATE/TIME QUALIFIER          DTP01        374   2400 M   ID   3/3
                                                                                                   DATE/TIME FORMAT QUALIFIER   DTP02       1250   2400 M   ID   2/3
                                                                                                   DATE TIME PERIOD             DTP03       1251   2400 M   AN   1/35
                                                            DATE - ONSET OF CURRENT
                                                452   431   SYMPTOM/ILLNESS                                                     DTP                2400                                      S             1
                                                                                                   DATE/TIME QUALIFIER          DTP01        374   2400 M   ID   3/3
                                                                                                   DATE/TIME FORMAT QUALIFIER   DTP02       1250   2400 M   ID   2/3
                                                                                                   DATE TIME PERIOD             DTP03       1251   2400 M   AN   1/35
                                                454   433   DATE - LAST X-RAY                                                   DTP                2400                                      S             1
                                                                                                   DATE/TIME QUALIFIER          DTP01        374   2400 M   ID   3/3
                                                                                                   DATE/TIME FORMAT QUALIFIER   DTP02       1250   2400 M   ID   2/3
                                                                                                   DATE TIME PERIOD             DTP03       1251   2400 M   AN   1/35
                                                456   435   DATE - ACUTE MANIFESTATION                                          DTP                2400                                      S             1
                                                                                                   DATE/TIME QUALIFIER          DTP01        374   2400 M   ID   3/3
                                                                                                   DATE/TIME FORMAT QUALIFIER   DTP02       1250   2400 M   ID   2/3
                                                                                                   DATE TIME PERIOD             DTP03       1251   2400 M   AN   1/35
                                                458   437   DATE - INITIAL TREATMENT                                            DTP                2400                                      S             1
                                                                                                   DATE/TIME QUALIFIER          DTP01        374   2400 M   ID   3/3
                                                                                                   DATE/TIME FORMAT QUALIFIER   DTP02       1250   2400 M   ID   2/3
                                                                                                   DATE TIME PERIOD             DTP03       1251   2400 M   AN   1/35

                                                460   439   DATE - SIMILAR ILLNESS/SYMPTOM ONSET                                DTP                2400                                      S             1
                                                                                                   DATE/TIME QUALIFIER          DTP01        374   2400 M   ID   3/3
                                                                                                   DATE/TIME FORMAT QUALIFIER   DTP02       1250   2400 M   ID   2/3
                                                                                                   DATE TIME PERIOD             DTP03       1251   2400 M   AN   1/35
                                                464   441   TEST RESULT                                                         MEA                2400                                      S            20

                                                                                                   MEASUREMENT REFERENCE ID CODE MEA01       737   2400 O   ID   2/2
                                                                                                   MEASUREMENT QUALIFIER         MEA02       738   2400 O   ID   1/3
                                                                                                   MEASUREMENT VALUE            MEA03        739   2400 X   R    1/20
                                                466   444   CONTRACT INFORMATION                                                CN1                2400                                      S             1

                                                                                                    32
                                                                                                                                                                 Policy Memorandum 2004 - 37
                                                                                                                                                                 Exhibit 2J



                                                               837 - HEALTH CLAIMS AND ENCOUNTERS (PROFESSIONAL)
INTERNAL    TABLE  /   FIELD    FIELD   FIELD   Old   A1                                                                  REF     ELEMENT
RECORD ID   DATABASE   LENGTH   TYPE    NAME    PG    PG    SEGMENT NAME                       ELEMENT NAME               DES.     NUMBER   LOOP ATTRIBUTES      NOTES                USE      REPEAT
                                                                                                                                                                 TYPE CODE IS
                                                                                                                                                                 RECOMMENDED FOR
                                                                                               CONTRACT TYPE CODE         CN101      1166   2400 M   ID   2/2    ENCOUNTERS
                                                                                                                                                                 CN102-106
                                                                                                                                                                 REQUIRED IF INFO
                                                                                                                                                                 DIFFERENT THAN
                                                                                               MONETARY AMOUNT            CN102       782   2400 O   R    1/18   2300 LOOP
                                                                                               PERCENT                    CN103       332   2400 O   R    1/6
                                                                                               REFERENCE IDENTIFICATION   CN104       127   2400 O   AN   1/30
                                                                                               TERMS DISCOUNT PERCENT     CN105       338   2400 O   R    1/6
                                                                                               VERSION IDENTIFIER         CN106       799   2400 O   AN   1/30
                                                                                                                                                                 SEGMENT INTENDED
                                                            REPRICED LINE ITEM REFERENCE                                                                         FOR REPRICING
                                                468   446   NUMBER                                                        REF               2400                 ORG.             S                 1
                                                                                               REFERENCE IDENTIFICATION
                                                                                               QUALIFIER                  REF01       128   2400 M   ID   2/3    9B
                                                                                               REFERENCE IDENTIFICATION   REF02       127   2400 X   AN   1/30
                                                            ADJUSTED REPRICED LINE ITEM
                                                469   447   REFERENCE NUMBER                                              REF               2400                                      S             1
                                                                                               REFERENCE IDENTIFICATION
                                                                                               QUALIFIER                  REF01       128   2400 M   ID   2/3    9D
                                                                                               REFERENCE IDENTIFICATION   REF02       127   2400 X   AN   1/30
                                                            PRIOR AUTHORIZATION OR REFERRAL
                                                470   448   NUMBER                                                        REF               2400                                      S             2
                                                                                               REFERENCE IDENTIFICATION                                          9F = REFERRAL #
                                                                                               QUALIFIER                  REF01       128   2400 M   ID   2/3    G1 = PRIOR AUTH#
                                                                                               REFERENCE IDENTIFICATION   REF02       127   2400 X   AN   1/30
                                                472   450   LINE ITEM CONTROL NUMBER                                      REF               2400                                      S             1
                                                                                               REFERENCE IDENTIFICATION
                                                                                               QUALIFIER                  REF01       128   2400 M   ID   2/3    6R
                                                                                               REFERENCE IDENTIFICATION   REF02       127   2400 X   AN   1/30


                                                474   452   MAMMOGRAPHY CERTIFICATION NUMBER                              REF               2400                                      S             1
                                                                                               REFERENCE IDENTIFICATION
                                                                                               QUALIFIER                  REF01       128   2400 M   ID   2/3    EW
                                                                                               REFERENCE IDENTIFICATION   REF02       127   2400 X   AN   1/30
                                                            CLINICAL LABORATORY IMPROVEMENT
                                                475   454   AMENDMENT (CLIA) IDENTIFICATION                               REF               2400                                      S             1
                                                                                               REFERENCE IDENTIFICATION
                                                                                               QUALIFIER                  REF01       128   2400 M   ID   2/3    X4
                                                                                               REFERENCE IDENTIFICATION   REF02       127   2400 X   AN   1/30



                                                                                                33
                                                                                                                                                               Policy Memorandum 2004 - 37
                                                                                                                                                               Exhibit 2J



                                                               837 - HEALTH CLAIMS AND ENCOUNTERS (PROFESSIONAL)
INTERNAL    TABLE  /   FIELD    FIELD   FIELD   Old   A1                                                                REF     ELEMENT
RECORD ID   DATABASE   LENGTH   TYPE    NAME    PG    PG    SEGMENT NAME                     ELEMENT NAME               DES.     NUMBER   LOOP ATTRIBUTES      NOTES                  USE    REPEAT
                                                            REFERRING CLINICAL LABORATORY
                                                            IMPROVEMENT AMENDMENT (CLIA)
                                                477   456   IDENTIFICATION                                              REF               2400                                        S           1
                                                                                             REFERENCE IDENTIFICATION
                                                                                             QUALIFIER                  REF01       128   2400 M   ID   2/3    F4
                                                                                             REFERENCE IDENTIFICATION   REF02       127   2400 X   AN   1/30   CLIA #
                                                478   457   IMMUNIZATION BATCH NUMBER                                   REF               2400                                        S           1
                                                                                             REFERENCE IDENTIFICATION
                                                                                             QUALIFIER                  REF01       128   2400 M   ID   2/3    BT
                                                                                             REFERENCE IDENTIFICATION   REF02       127   2400 X   AN   1/30
                                                479   458   AMBULAROTY PATIENT GROUP (APG)                              REF               2400                                        S           4
                                                                                             REFERENCE IDENTIFICATION
                                                                                             QUALIFIER                  REF01       128   2400 M   ID   2/3    1S
                                                                                             REFERENCE IDENTIFICATION   REF02       127   2400 X   AN   1/30
                                                480   459   OXYGEN FLOW RATE                                            REF               2400                                        S           1
                                                                                             REFERENCE IDENTIFICATION
                                                                                             QUALIFIER                  REF01       128   2400 M   ID   2/3    TP
                                                                                                                                                               1-999 LITERS PER
                                                                                             REFERENCE IDENTIFICATION   REF02       127   2400 X   AN   1/30   MIN, OR X IF>1
                                                482   461   UNIVERSAL PRODUCT NUMBER (UPN)                              REF               2400                                        S           1
                                                                                                                                                               OZ = PRODUCT #     ,
                                                                                             REFERENCE IDENTIFICATION                                          VP = VENDOR
                                                                                             QUALIFIER                  REF01       128   2400 M   ID   2/3    PRODUCT #
                                                                                             REFERENCE IDENTIFICATION   REF02       127   2400 X   AN   1/30   UPN
                                                484   463   SALES TAX AMOUNT                                            AMT               2400                                        S           1
                                                                                             REFERENCE IDENTIFICATION
                                                                                             QUALIFIER                  REF01       128   2400 M   ID   2/3    T
                                                                                             REFERENCE IDENTIFICATION   REF02       127   2400 X   AN   1/30
                                                485   464   APPROVED AMOUNT                                             AMT               2400                                        S           1
                                                                                             AMOUNT QUALIFIER CODE      AMT01       522   2400 M   ID   1/3    AAE
                                                                                             MONETARY AMOUNT            AMT02       782   2400 M   R    1/18
                                                486   465   POSTAGE CLAIMED AMOUNT                                      AMT                                                           S           1
                                                                                             AMOUNT QUALIFIER CODE      AMT01       522   2400 M   ID   1/3    F4
                                                                                             MONETARY AMOUNT            AMT02       782   2400 M   R    1/18
                                                                                                                                                               MAY BE USED BY
                                                                                                                                                               STATES TO MEET
                                                                                                                                                               EMERG.
                                                487   466   FILE INFORMATION                                            K3                                     LEGISLATIVE REQ.       S          10
                                                                                                                                                               MAPS FROM NSF
                                                                                             FIXED FORM INFORMATION     K301        449   2400 M   AN   1/80   COMMENT FIELD
                                                488   467   LINE NOTE                                                   NTE                                                           S           1
                                                                                             NOTE REFERENCE CODE        NTE01       363   2400 O   ID   3/3

                                                                                              34
                                                                                                                                                                         Policy Memorandum 2004 - 37
                                                                                                                                                                         Exhibit 2J



                                                               837 - HEALTH CLAIMS AND ENCOUNTERS (PROFESSIONAL)
INTERNAL    TABLE  /   FIELD    FIELD   FIELD   Old   A1                                                                          REF     ELEMENT
RECORD ID   DATABASE   LENGTH   TYPE    NAME    PG    PG    SEGMENT NAME                         ELEMENT NAME                     DES.     NUMBER   LOOP ATTRIBUTES      NOTES                USE      REPEAT
                                                                                                 DESCRIPTION                      NTE02       352   2400 M   AN   1/80   FREE FORM TEXT
                                                489   468   PURCHASED SERVICE INFORMATION                                         PS1               2400                                      S             1
                                                                                                                                                                         PURCHASED
                                                                                                 REFERENCE IDENTIFICATION         PS101       127   2400 M   AN   1/30   SERVICE PROV. ID#
                                                                                                                                                                         PURCH. SVC.
                                                                                                 MONETARY AMOUNT                  PS102       782   2400 M   R    1/18   CHARGE AMOUNT
                                                                                                                                                                         REQUIRED IF INFO
                                                                                                                                                                         DIFFERENT FROM
                                                491   470   HEALTH CARE SERVICES DELIVERY                                         HSD               2400                 2300 LOOP            S             1
                                                                                                 QUANTITY QUALIFIER               HSD01       673   2400 X   ID   2/2    VS
                                                                                                 QUANTITY                         HSD02       380   2400 X   R    1/15
                                                                                                 UNIT OR BASIS FOR MEASUREMENT
                                                                                                 CODE                             HSD03       355   2400 O   ID   2/2
                                                                                                 SAMPLE SELECTION MODULUS         HSD04      1167   2400 O   R    1/6
                                                                                                 TIME PERIOD QUALIFIER            HSD05       615   2400 X   ID   1/2
                                                                                                 NUMBER OF PERIODS                HSD06       616   2400 O   NO   1/3
                                                                                                 SHIP/DELIVERY OR CALENDAR
                                                                                                 PATTERN CODE                     HSD07       678   2400 O   ID   1/2
                                                                                                 SHIP/DELIVER PATTERN TIME CODE   HSD08       679   2400 O   ID   1/1
                                                495   474   LINE PRICING/REPRICING INFORMATION                                    HCP               2400                                      S             1
                                                                                                 PRICING METHODOLOGY              HCP01      1473   2400 X   IS   2/2
                                                                                                                                                                         REPRICED ALLOWED
                                                                                                 MONETARY AMOUNT                  HCP02       782   2400 O   R    1/18   AMT.
                                                                                                                                                                         REPRICED SAVINGS
                                                                                                 MONETARY AMOUNT                  HCP03       782   2400 O   R    1/18   AMT.
                                                                                                 REFERENCE IDENTIFICATION         HCP04       127   2400 O   AN   1/30   REPRICING ORG ID
                                                                                                 RATE                             HCP05       118   2400 O   R    1/9
                                                                                                 REFERENCE IDENTIFICATION         HCP06       127   2400 O   AN   1/30   APG CODE

                                                                                                 MONETARY AMOUNT                  HCP07       782   2400 O   R    1/18   APPROVED APG AMT
                                                                                                 PRODUCT/SERVICE ID QUALIFIER     HCP09       235   2400 O   AN   1/48
                                                                                                 PRODUCT/SERVICE ID               HCP10       234   2400 X   AN   1/48   PROCEDURE CODE
                                                                                                 UNIT OR BASIS FOR MEASUREMENT
                                                                                                 CODE                             HCP11       355   2400 X   ID   2/2
                                                                                                 QUANTITY                         HCP12       380   2400 X   R    1/15
                                                                                                 REJECT REASON CODE               HCP13       901   2400 X   ID   2/2
                                                                                                 POLICY COMPLIANCE CODE           HCP14      1526   2400 O   ID   1/2
                                                                                                 EXCEPTION CODE                   HCP15      1527   2400 O   ID   1/2
                                                            LOOP ID - 2410 DRUG IDENTIFICATION                                                                                                             25
                                                      480   DRUG IDENTIFICATION                                                   LIN               2410                                      S             1


                                                                                                  35
                                                                                                                                                                            Policy Memorandum 2004 - 37
                                                                                                                                                                            Exhibit 2J



                                                               837 - HEALTH CLAIMS AND ENCOUNTERS (PROFESSIONAL)
INTERNAL    TABLE  /   FIELD    FIELD   FIELD   Old   A1                                                                          REF       ELEMENT
RECORD ID   DATABASE   LENGTH   TYPE    NAME    PG    PG    SEGMENT NAME                        ELEMENT NAME                      DES.       NUMBER   LOOP ATTRIBUTES       NOTES                 USE     REPEAT


                                                                                                PRODUCT OR SERVICE ID QUALIFIER   LIN02         235    2410 M   ID   2/2
                                                                                                PRODUCT OR SERVICE ID             LIN03         234    2410 M   AN   1/48
                                                      483   DRUG PRICING                                                          CTP                  2410                                       S            1
                                                                                                DRUG UNIT PRICE                   CTP03         212    2410 X   R    1/17
                                                                                                NATIONAL DRUG UNIT COUNT          CTP04         380    2410 X   R    1/15
                                                                                                UNIT OR BASIS OF MEASUREMENT      CTP05        C001    2410 X
                                                                                                CODE QUALIFIER                    CTP05-1       335    2410 M   ID   2/2
                                                      486   PRESCRIPTION NUMBER                                                   REF                  2410                                       S            1
                                                                                                CODE QUALIFIER                    REF01         128    2410 M   ID   2/3
                                                                                                PRESCRIPTION NUMBER               REF02         127    2410 X   AN   1/30
                                                            LOOP ID - 2420A RENDERING PROVIDER NAME                                                                                                            1
                                                501   488   RENDERING PROVIDER NAME                                               NM1                 2420A                                       S            1

                                                                                                                                                                            REQUIRED IF
                                                                                                                                                                            DIFFERENT FROM
                                                                                                                                                                            2310B, OR 2010AA/AB
                                                                                                ENTITY IDENTIFIER CODE            NM101          98   2420A M   ID   2/3    82
                                                                                                ENTITY TYPE QUALIFIER             NM102        1065   2420A M   ID   1/1

                                                                                                NAME LAST OR ORGANIZATION NAME NM103           1035   2420A O   AN   1/35
                                                                                                NAME FIRST                     NM104           1036   2420A O   AN   1/25
                                                                                                NAME MIDDLE                       NM105        1037   2420A O   AN   1/25
                                                                                                NAME SUFFIX                       NM107        1039   2420A O   AN   1/10
                                                                                                IDENTIFICATION CODE QUALIFIER     NM108          66   2420A X   ID   1/2
                                                                                                IDENTIFICATION CODE               NM109          67   2420A X   AN   2/80
                                                            RENDERING PROVIDER SPECIALTY
                                                504   491   INFORMATION                                                           PRV                 2420A                                       S            1
                                                                                                PROVIDER CODE                     PRV01        1221   2420A M   ID   1/3    PE
                                                                                                REFERENCE IDENTIFICATION
                                                                                                QUALIFIER                         PRV02         128   2420A M   ID   2/3    ZZ
                                                                                                                                                                            PROVIDER
                                                                                                REFERENCE IDENTIFICATION          PRV03         127   2420A M   AN   1/30   TAXONOMY CODE
                                                            RENDERING PROVIDER SECONDARY
                                                507   493   IDENTIFICATION                                                        REF                 2420A                                       S            5
                                                                                                REFERENCE IDENTIFICATION
                                                                                                QUALIFIER                         REF01         128   2420A M   ID   2/3
                                                                                                REFERENCE IDENTIFICATION          REF02         127   2420A X   AN   1/30
                                                            LOOP ID - 2420B PURCHASED SERVICE PROVIDER NAME                                                                                                    1
                                                509   495   PURCHASED SERVICE PROVIDER NAME                                       NM1                                                             S            1
                                                                                                ENTITY IDENTIFIER CODE            NM101          98   2420B M   ID   2/3    QB

                                                                                                  36
                                                                                                                                                                           Policy Memorandum 2004 - 37
                                                                                                                                                                           Exhibit 2J



                                                               837 - HEALTH CLAIMS AND ENCOUNTERS (PROFESSIONAL)
INTERNAL    TABLE  /   FIELD    FIELD   FIELD   Old   A1                                                                           REF     ELEMENT
RECORD ID   DATABASE   LENGTH   TYPE    NAME    PG    PG    SEGMENT NAME                          ELEMENT NAME                     DES.     NUMBER   LOOP ATTRIBUTES       NOTES                USE      REPEAT



                                                                                                  ENTITY TYPE QUALIFIER            NM102      1065   2420B M   ID   1/1
                                                                                                  ID CODE QUALIFIER                NM108        66   2420B X   ID   1/2
                                                                                                  ID CODE                          NM109        67   2420B X   AN   2/80
                                                            PURCHASED SERVICE PROVIDER
                                                512   498   SECONDARY IDENTIFICATION                                               REF               2420B                                      S             5
                                                                                                  REFERENCE IDENTIFICATION
                                                                                                  QUALIFIER                        REF01       128   2420B M   ID   2/3
                                                                                                  REFERENCE IDENTIFICATION         REF02       127   2420B X   AN   1/30
                                                            LOOP ID - 2420C SERVICE FACILITY LOCATION                                                                                                         1
                                                                                                                                                                           REQUIRED IF
                                                                                                                                                                           DIFFERENT FROM
                                                                                                                                                                           2010AA,2010AB,
                                                514   500   SERVICE FACILITY LOCATION                                              NM1                                     2310D LOOPS          S             1
                                                                                                  ENTITY IDENTIFIER CODE           NM101        98   2420C M   ID   2/3
                                                                                                  ENTITY TYPE QUALIFIER            NM102      1065   2420C M   ID   1/1

                                                                                                  NAME LAST OR ORGANIZATION NAME   NM103      1035   2420C O   AN   1/35
                                                                                                  NAME FIRST                       NM104      1036   2420C O   AN   1/25
                                                                                                  NAME MIDDLE                      NM105      1037   2420C O   AN   1/25
                                                                                                  NAME SUFFIX                      NM107      1039   2420C O   AN   1/10
                                                                                                  IDENTIFICATION CODE QUALIFIER    NM108        66   2420C X   ID   1/2
                                                                                                  IDENTIFICATION CODE              NM109        67   2420C X   AN   2/80
                                                518   503   SERVICE FACILITY LOCATION ADDRESS                                      N3                2420C                                      R             1


                                                                                                  ADDRESS INFORMATION              N301        166   2420C M   AN   1/55

                                                                                                  ADDRESS INFORMATION              N301        166   2420C O   AN   1/55
                                                            SERVICE FACILITY LOCATION
                                                519   504   CITY/STATE/ZIP                                                         N4                2420C                                      R             1
                                                                                                  CITY NAME                        N401         19   2420C O   AN   2/30
                                                                                                  STATE OR PROVINCE CODE           N402        156   2420C O   ID   2/2
                                                                                                  POSTAL CODE                      N403        116   2420C O   ID   3/15
                                                                                                  COUNTRY CODE                     N404         26   2420C O   ID   2/3
                                                            SERVICE FACILITY LOCATION SECONDARY
                                                521   506   IDENTIFICATION                                                         REF               2420C                                      S             5
                                                                                                  REFERENCE IDENTIFICATION
                                                                                                  QUALIFIER                        REF01       128   2420C M   ID   2/3
                                                                                                  REFERENCE IDENTIFICATION         REF02       127   2420C X   AN   1/30
                                                            LOOP ID - 2420D SUPERVISING PROVIDER NAME                                                                                                         1
                                                523   508   SUPERVISING PROVIDER NAME                                              NM1                                                          S             1

                                                                                                    37
                                                                                                                                                                         Policy Memorandum 2004 - 37
                                                                                                                                                                         Exhibit 2J



                                                               837 - HEALTH CLAIMS AND ENCOUNTERS (PROFESSIONAL)
INTERNAL    TABLE  /   FIELD    FIELD   FIELD   Old   A1                                                                         REF     ELEMENT
RECORD ID   DATABASE   LENGTH   TYPE    NAME    PG    PG    SEGMENT NAME                         ELEMENT NAME                    DES.     NUMBER   LOOP ATTRIBUTES       NOTES                USE      REPEAT
                                                                                                 ENTITY IDENTIFIER CODE          NM101        98   2420D M   ID   2/3    DQ
                                                                                                 ENTITY TYPE QUALIFIER           NM102      1065   2420D M   ID   1/1

                                                                                                 NAME LAST OR ORGANIZATION NAME NM103       1035   2420D O   AN   1/35
                                                                                                 NAME FIRST                     NM104       1036   2420D O   AN   1/25
                                                                                                 NAME MIDDLE                     NM105      1037   2420D O   AN   1/25


                                                                                                 NAME SUFFIX                     NM107      1039   2420D O   AN   1/10
                                                                                                 IDENTIFICATION CODE QUALIFIER   NM108        66   2420D X   ID   1/2
                                                                                                 IDENTIFICATION CODE             NM109        67   2420D X   AN   2/80
                                                            SUPERVISING PROVIDER SECONDARY
                                                527   511   IDENTIFICATION                                                       REF               2420D                                      S             5
                                                                                                 REFERENCE IDENTIFICATION
                                                                                                 QUALIFIER                       REF01       128   2420D M   ID   2/3
                                                                                                 REFERENCE IDENTIFICATION        REF02       127   2420D X   AN   1/30
                                                            LOOP ID - 2420E ORDERING PROVIDER NAME                                                                                                          1
                                                529   513   ORDERING PROVIDER NAME                                               NM1                                                          S             1
                                                                                                 ENTITY IDENTIFIER CODE          NM101        98   2420E M   ID   2/3    DK
                                                                                                 ENTITY TYPE QUALIFIER           NM102      1065   2420E M   ID   1/1

                                                                                                 NAME LAST OR ORGANIZATION NAME NM103       1035   2420E O   AN   1/35
                                                                                                 NAME FIRST                     NM104       1036   2420E O   AN   1/25
                                                                                                 NAME MIDDLE                     NM105      1037   2420E O   AN   1/25
                                                                                                 NAME SUFFIX                     NM107      1039   2420E O   AN   1/10
                                                                                                 IDENTIFICATION CODE QUALIFIER   NM108        66   2420E X   ID   1/2
                                                                                                 IDENTIFICATION CODE             NM109        67   2420E X   AN   2/80
                                                533   516   ORDERING PROVIDER ADDRESS                                            N3                2420E                                      S             1
                                                                                                 ADDRESS INFORMATION             N301        166   2420E M   AN   1/55
                                                                                                 ADDRESS INFORMATION             N301        166   2420E O   AN   1/55
                                                            ORDERING PROVIDER CITY/STATE/ZIP
                                                534   517   CODE                                                                 N4                2420E                                      S             1
                                                                                                 CITY NAME                       N401         19   2420E O   AN   2/30
                                                                                                 STATE OR PROVINCE CODE          N402        156   2420E O   ID   2/2
                                                                                                 POSTAL CODE                     N403        116   2420E O   ID   3/15
                                                                                                 COUNTRY CODE                    N404         26   2420E O   ID   2/3
                                                            ORDERING PROVIDER SECONDARY
                                                536   519   IDENTIFICATION                                                       REF               2420E                                      S             5
                                                                                                 REFERENCE IDENTIFICATION
                                                                                                 QUALIFIER                       REF01       128   2420E M   ID   2/3
                                                                                                 REFERENCE IDENTIFICATION        REF02       127   2420E X   AN   1/30


                                                                                                     38
                                                                                                                                                                         Policy Memorandum 2004 - 37
                                                                                                                                                                         Exhibit 2J



                                                               837 - HEALTH CLAIMS AND ENCOUNTERS (PROFESSIONAL)
INTERNAL    TABLE  /   FIELD    FIELD   FIELD   Old   A1                                                                         REF     ELEMENT
RECORD ID   DATABASE   LENGTH   TYPE    NAME    PG    PG    SEGMENT NAME                         ELEMENT NAME                    DES.     NUMBER   LOOP ATTRIBUTES       NOTES                USE      REPEAT
                                                            ORDERING PROVIDER CONTACT
                                                538   521   INFORMATION                                                          PER               2420E                 SEE USAGE NOTES      S             1


                                                                                                 CONTACT FUNCTION CODE           PER01       366   2420E M   ID   2/2    IC
                                                                                                 NAME                            PER02        93   2420E O   AN   1/60

                                                                                                 COMMUNICATION NUMBER QUALIFIER PER03        365   2420E X   ID   2/2
                                                                                                 COMMUNICATION NUMBER           PER04        364   2420E X   AN   1/80
                                                                                                 COMMUNICATION NUMBER QUALIFIER PER05        365   2420E X   ID   2/2
                                                                                                 COMMUNICATION NUMBER           PER06        364   2420E X   AN   1/80
                                                                                                 COMMUNICATION NUMBER QUALIFIER PER07        365   2420E X   ID   2/2
                                                                                                 COMMUNICATION NUMBER           PER08        364   2420E X   AN   1/80
                                                            LOOP ID - 2420F REFERRING PROVIDER NAME                                                                                                         2
                                                541   524   REFERRING PROVIDER NAME                                              NM1                                                          S             1
                                                                                                 ENTITY IDENTIFIER CODE          NM101        98   2420F M   ID   2/3    DK
                                                                                                 ENTITY TYPE QUALIFIER           NM102      1065   2420F M   ID   1/1

                                                                                                 NAME LAST OR ORGANIZATION NAME NM103       1035   2420F O   AN   1/35
                                                                                                 NAME FIRST                     NM104       1036   2420F O   AN   1/25
                                                                                                 NAME MIDDLE                     NM105      1037   2420F O   AN   1/25
                                                                                                 NAME SUFFIX                     NM107      1039   2420F O   AN   1/10
                                                                                                 IDENTIFICATION CODE QUALIFIER   NM108        66   2420F X   ID   1/2
                                                                                                 IDENTIFICATION CODE             NM109        67   2420F X   AN   2/80
                                                            REFERRING PROVIDER SPECIALTY
                                                544   527   INFORMATION                                                          PRV               2420F                                      S             1
                                                                                                 PROVIDER CODE                   PRV01      1221   2420F M   ID   1/3    RF
                                                                                                 REFERENCE IDENTIFICATION
                                                                                                 QUALIFIER                       PRV02       128   2420F M   ID   2/3    ZZ
                                                                                                 REFERENCE IDENTIFICATION        PRV03       127   2420F M   AN   1/30   PROV. TAXONOMY
                                                            REFERRING ROVIDER SECONDARY
                                                547   529   IDENTIFICATION                                                       REF               2420F                                      S             5
                                                                                                 REFERENCE IDENTIFICATION
                                                                                                 QUALIFIER                       REF01       128   2420F M   ID   2/3
                                                                                                 REFERENCE IDENTIFICATION        REF02       127   2420F X   AN   1/30
                                                            LOOP ID - 2420G OTHER PAYER PRIOR AUTHORIZATION OR REFERRAL NUMBER                                                                              4
                                                                                                                                                                         USED IF 2 COB
                                                            OTHER PAYER PRIOR AUTHORIZATION OR                                                                           PAYERS;FOR PRIOR
                                                549   531   REFERRAL NUMBER                                                      NM1                                     AUTH/REFERRAL        S             1
                                                                                                 ENTITY IDENTIFIER CODE          NM101        98   2420G M   ID   2/3    PR
                                                                                                 ENTITY TYPE QUALIFIER           NM102      1065   2420G M   ID   1/1    2


                                                                                                  39
                                                                                                                                                                           Policy Memorandum 2004 - 37
                                                                                                                                                                           Exhibit 2J



                                                               837 - HEALTH CLAIMS AND ENCOUNTERS (PROFESSIONAL)
INTERNAL    TABLE  /   FIELD    FIELD   FIELD   Old   A1                                                                         REF       ELEMENT
RECORD ID   DATABASE   LENGTH   TYPE    NAME    PG    PG    SEGMENT NAME                          ELEMENT NAME                   DES.       NUMBER   LOOP ATTRIBUTES       NOTES                USE      REPEAT

                                                                                                  NAME LAST OR ORGANIZATION NAME NM103        1035   2420G O   AN   1/35
                                                                                                  IDENTIFICATION CODE QUALIFIER  NM108          66   2420G X   ID   1/2
                                                                                                                                                                           MUST MATCH NM109
                                                                                                  IDENTIFICATION CODE            NM109          67   2420G X   AN   2/80   IN 2330B
                                                            OTHER PAYER PRIOR AUTHORIZATION OR
                                                552   534   REFERRAL NUMBER                                                      REF                 2420G                                      R             2
                                                                                                  REFERENCE IDENTIFICATION
                                                                                                  QUALIFIER                      REF01         128   2420G M   ID   2/3
                                                                                                  REFERENCE IDENTIFICATION       REF02         127   2420G X   AN   1/30
                                                            LOOP ID - 2430 LINE ADJUDICATION INFORMATION                                                                                                     25
                                                                                                                                                                           COB; TO SHOW
                                                                                                                                                                           UNBUNDLED SVC
                                                554   536   LINE ADJUDICATION INFORMATION                                        SVD                                       LINES                S             1
                                                                                                                                                                           MATCH NM109 IN
                                                                                                  ID CODE                        SVD01          67    2430 M   AN   2/80   2330B
                                                                                                                                                                           SERVICE LINE PAID
                                                                                                  MONETARY AMOUNT                SVD02         782    2430 M   R    1/18   AMT
                                                                                                  COMPOSITE MEDICAL PROCEDURE
                                                                                                  IDENTIFIER                     SVD03        C003    2430 O
                                                                                                  PRODUCT/SERVICE ID QUALIFIER   SVD03-1       235    2430 M   ID   2/2
                                                                                                  PRODUCT/SERVICE ID             SVD03-2       234    2430 M   AN   1/48
                                                                                                  PROCEDURE MODIFIER             SVD03-3      1339    2430 O   AN   2/2
                                                                                                  PROCEDURE MODIFIER             SVD03-4      1339    2430 O   AN   2/2
                                                                                                  PROCEDURE MODIFIER             SVD03-5      1339    2430 O   AN   2/2
                                                                                                  PROCEDURE MODIFIER             SVD03-6      1339    2430 O   AN   2/2
                                                                                                  DESCRIPTION                    SVD03-7       352    2430 O   AN   1/80
                                                                                                  QUANTITY                       SVD05         380    2430 O   R    1/15
                                                                                                  ASSIGNED NUMBER                SVD06         554    2430 O   NO   1/6
                                                558   540   LINE ADJUSTMENT                                                      CAS                  2430                 SEE USAGE NOTES      S            99
                                                                                                  CLAIM ADJUSTMENT GROUP CODE    CAS01        1033    2430 M   ID   1/2

                                                                                                  CLAIM ADJUSTMENT REASON CODE   CAS02        1034    2430 M   ID   1/5
                                                                                                  MONETARY AMOUNT                CAS03         782    2430 M   R    1/18

                                                                                                  QUANTITY                       CAS04         380    2430 O   R    1/15
                                                                                                  CLAIM ADJUSTMENT REASON CODE   CAS05        1034    2430 M   ID   1/5
                                                                                                  MONETARY AMOUNT                CAS06         782    2430 M   R    1/18

                                                                                                  QUANTITY                       CAS07         380    2430 O   R    1/15
                                                                                                  CLAIM ADJUSTMENT REASON CODE   CAS08        1034    2430 M   ID   1/5


                                                                                                   40
                                                                                                                                                                                                                              Policy Memorandum 2004 - 37
                                                                                                                                                                                                                              Exhibit 2J



                                                                                837 - HEALTH CLAIMS AND ENCOUNTERS (PROFESSIONAL)
INTERNAL    TABLE  /   FIELD        FIELD     FIELD         Old    A1                                                                                                 REF             ELEMENT
RECORD ID   DATABASE   LENGTH       TYPE      NAME          PG     PG       SEGMENT NAME                                   ELEMENT NAME                               DES.             NUMBER           LOOP ATTRIBUTES       NOTES                USE      REPEAT

                                                                                                                           MONETARY AMOUNT                            CAS09                  782         2430 M   R    1/18
                                                                                                                           QUANTITY                                   CAS10                  380         2430 O   R    1/15

                                                                                                                           CLAIM ADJUSTMENT REASON CODE               CAS11                 1034         2430 M   ID   1/5
                                                                                                                           MONETARY AMOUNT                            CAS12                  782         2430 M   R    1/18
                                                                                                                           QUANTITY                                   CAS13                  380         2430 O   R    1/15
                                                                                                                           CLAIM ADJUSTMENT REASON CODE               CAS14                 1034         2430 M   ID   1/5
                                                                                                                           MONETARY AMOUNT                            CAS15                  782         2430 M   R    1/18
                                                                                                                           QUANTITY                                   CAS16                  380         2430 O   R    1/15
                                                                                                                           CLAIM ADJUSTMENT REASON CODE               CAS17                 1034         2430 M   ID   1/5
                                                                                                                           MONETARY AMOUNT                            CAS18                  782         2430 M   R    1/18
                                                                                                                           QUANTITY                                   CAS19                  380         2430 O   R    1/15
                                                             566   548      LINE ADJUDICATION DATE                                                                    DTP                                2430                                      R             1


                                                                                                                           DATE/TIME QUALIFIER                        DTP01                  374         2430 M   ID   3/3    573
                                                                                                                           DATE/TIME FORMAT QUALIFIER                 DTP02                 1250         2430 M   ID   2/3    D8
                                                                                                                           DATE TIME PERIOD                           DTP03                 1251         2430 M   AN   1/35
                                                                            LOOP ID - 2440 FORM IDENTIFICATION CODE                                                                                                                                              5
                                                                                                                                                                                                                              USED FOR HOME
                                                             567   549      FORM IDENTIFICATION CODE                                                                  LQ                                                      HEALTH OR DME        S             1
                                                                                                                           CODE LIST QUALIFIER CODE                   LQ01                  1270         2440 O   ID   1/3
                                                                                                                           INDUSTRY CODE                              LQ02                  1271         2440 X   AN   1/30
                                                             569   551      SUPPORTING DOCUMENTATION                                                                  FRM                                2440                                      R            99
                                                                                                                                                                                                                              QUESTION
                                                                                                                           ASSIGNED IDENTIFICATION                    FRM01                  350         2440 M   AN   1/20   NUMBER/LETTER
                                                                                                                           YES/NO CONDITION OR RESPONSE
                                                                                                                           CODE                                       FRM02                 1073         2440 X   ID   1/1
                                                                                                                                                                                                                              USED IF ANSWER IS
                                                                                                                           REFERENCE IDENTIFICATION                   FRM03                  127         2440 X   AN   1/30   TEXT FORMAT
                                                                                                                           DATE                                       FRM04                  373         2440 X   DT   8/8
                                                                                                                           PERCENT                                    FRM05                  332         2440 X   R    1/6
                                                             572   554      TRANSACTION SET TRAILER                                                                   SE                              TRAILER                                      R             1
                                                                                                                           NUMBER OF INCLUDED SEGMENTS                SE01                       96   TRAILER M   NO   1/10
                                                                                                                           TRANSACTION SET CONTROL
                                                                                                                           NUMBER                                     SE02                   329      TRAILER M   AN   4/9    MUST MATCH ST02
                                                                     4010 and Addenda                            Revised April 10, 2003
                       The tools and templates provided in CalOHI Policy and Information Memoranda have generally been authored by HIPAA workgroups. Users should view the information
                       presented in the context of their own organizations and environments. Legal opinions and/or decision documentation may be needed when interpreting and/or applying this
                       information.


                                                                                                                             41
                                                                                                                                                                                      Policy Memorandum 2004 - 3
                                                                                                                                                                                      Exhibit 2K




                                                                           837 - HEALTH CLAIMS AND ENCOUNTERS (DENTAL)
INTERNAL    TABLE  /   FIELD    FIELD   FIELD   Old A1                                                                    REF     ELEMENT
RECORD ID   DATABASE   LENGTH   TYPE    NAME    PG PG     SEGMENT NAME                       ELEMENT NAME                 DES.     NUMBER     LOOP ATTRIBUTES      NOTES              USE       REPEAT
                                                                                                                                                                   FUNCTIONAL
                                                          TABLE 1 - HEADER                                                                                         GROUP: HC
                                                53   53   TRANSACTION SET HEADER                                          ST                HEADER                                    R               1
                                                                                             TRANSACTION SET IDENTIFIER
                                                                                             CODE                         ST01        143   HEADER M   ID   3/3    MUST BE 837
                                                                                             TRANSACTION SET CONTROL                                               MUST MATCH VALUE
                                                                                             NUMBER                       ST02        329   HEADER M   AN   4/9    IN SE02
                                                          BEGINNING OF HIERARCHICAL
                                                54   54   TRANSACTION                                                     BHT               HEADER                                    R               1
                                                                                             HIERARCHICAL STRUCTURE
                                                                                             CODE                         BHT01      1005   HEADER M   ID   4/4    0019
                                                                                             TRANSACTION SET PURPOSE                                               00 = ORIGINAL
                                                                                             CODE                         BHT02       353   HEADER M   ID   2/2    18 = REISSUE
                                                                                                                                                                   SUBMITTER'S FILE
                                                                                             REFERENCE IDENTIFICATION     BHT03       127   HEADER O   AN   1/30   NUMBER
                                                                                                                                                                   TRANSACTION SET
                                                                                             DATE                         BHT04       373   HEADER O   DT   8/8    CREATION DATE
                                                                                             TIME                         BHT05       337   HEADER O   TM   4/8    CREATION TIME
                                                                                                                                                                   CH = FEE-FOR-
                                                                                                                                                                   SERVICE
                                                                                             TRANSACTION TYPE CODE        BHT06       640   HEADER O   ID   2/2    RP = ENCOUNTERS


                                                57   57   TRANSMISSION TYPE IDENTIFICATION                                REF               HEADER                                    R               1
                                                                                             REFERENCE IDENTIFICATION
                                                                                             QUALIFIER                    REF01       128   HEADER M   ID   2/3    87


                                                                                             REFERENCE IDENTIFICATION     REF02       127   HEADER X   AN   1/30   VERSION NUMBER
                                                          LOOP ID - 1000A SUBMITTER NAME                                                                                                              1
                                                59   59   SUBMITTER NAME                                                  NM1                1000A                                    R               1
                                                                                             ENTITY IDENTIFIER CODE       NM101        98    1000A M   ID   2/3    41 (SUBMITTER)
                                                                                             ENTITY TYPE QUALIFIER        NM102      1065    1000A M   ID   1/1
                                                                                             NAME LAST OR ORGANIZATION
                                                                                             NAME                         NM103      1035    1000A O   AN   1/35   SUBMITTER NAME
                                                                                                                                                                   SUBMITTER FIRST
                                                                                             NAME FIRST                   NM104      1036    1000A O   AN   1/25   NAME
                                                                                                                                                                   SUBMITTER MIDDLE
                                                                                             NAME MIDDLE                  NM105      1037    1000A O   AN   1/25   NAME
                                                                                             IDENTIFICATION CODE
                                                                                             QUALIFIER                    NM108        66    1000A X   ID   1/2    46
                                                                                                                                                                   SUBMITTER ID
                                                                                             IDENTIFICATION CODE          NM109        67    1000A X   AN   2/80   NUMBER

                                                                                              42
                                                                                                                                                                  Policy Memorandum 2004 - 3
                                                                                                                                                                  Exhibit 2K




                                                                         837 - HEALTH CLAIMS AND ENCOUNTERS (DENTAL)
INTERNAL    TABLE  /   FIELD    FIELD   FIELD   Old A1                                                            REF     ELEMENT
RECORD ID   DATABASE   LENGTH   TYPE    NAME    PG PG     SEGMENT NAME                    ELEMENT NAME            DES.     NUMBER   LOOP ATTRIBUTES       NOTES   USE       REPEAT

                                                63   62   SUBMITTER CONTACT INFORMATION                           PER               1000A                         R               2
                                                                                          CONTACT FUNCTION CODE   PER01       366   1000A M   ID   2/2    IC
                                                                                          NAME                    PER02        93   1000A O   AN   1/60




                                                                                           43
                                                                                                                                                                                         Policy Memorandum 2004 - 3
                                                                                                                                                                                         Exhibit 2K




                                                                          837 - HEALTH CLAIMS AND ENCOUNTERS (DENTAL)
INTERNAL    TABLE  /   FIELD    FIELD   FIELD   Old A1                                                                    REF     ELEMENT
RECORD ID   DATABASE   LENGTH   TYPE    NAME    PG PG     SEGMENT NAME                        ELEMENT NAME                DES.     NUMBER    LOOP ATTRIBUTES       NOTES                 USE       REPEAT
                                                                                              COMMUNICATION NUMBER
                                                                                              QUALIFIER                   PER03       365    1000A X   ID   2/2
                                                                                              COMMUNICATION NUMBER        PER04       364    1000A X   AN   1/80
                                                                                              COMMUNICATION NUMBER
                                                                                              QUALIFIER                   PER05       365    1000A X   ID   2/2
                                                                                              COMMUNICATION NUMBER        PER06       364    1000A X   AN   1/80
                                                                                              COMMUNICATION NUMBER
                                                                                              QUALIFIER                   PER07       365    1000A X   ID   2/2
                                                                                              COMMUNICATION NUMBER        PER08       364    1000A X   AN   1/80
                                                          LOOP ID - 1000B RECEIVER NAME                                                                                                                  1
                                                66   65   RECEIVER NAME                                                   NM1                1000B                                       R               1
                                                                                              ENTITY IDENTIFIER CODE      NM101        98    1000B M   ID   2/3    40
                                                                                              ENTITY TYPE QUALIFIER       NM102      1065    1000B M   ID   1/1    2
                                                                                              NAME LAST OR ORGANIZATION
                                                                                              NAME                        NM103      1035    1000B O   AN   1/35   RECEIVER NAME
                                                                                              IDENTIFICATION CODE
                                                                                              QUALIFIER                   NM108        66    1000B X   ID   1/2    46
                                                                                                                                                                   RECEIVER ID
                                                                                              IDENTIFICATION CODE         NM109        67    1000B X   AN   2/80   NUMBER
                                                          TABLE 2 - DETAIL, BILLING/PAY-TO PROVIDER HIERARCHICAL LEVEL
                                                          LOOP ID - 2000A BILLING/PAY-TO PROVIDER HIERARCHICAL LEVEL                                                                                    >1
                                                          BILLING/PAY-TO PROVIDER
                                                69   67   HIERARCHICAL LEVEL                                              HL                 2000A                                       R               1
                                                                                              HIERARCHICAL ID NUMBER      HL01        628    2000A M   AN   1/12
                                                                                              HIERARCHICAL LEVEL CODE     HL03        735    2000A M   ID   1/2    20
                                                                                              HIERARCHICAL CHILD CODE     HL04        736    2000A O   ID   1/1    1
                                                          BILLING/PAY-TO PROVIDER SPECIALTY
                                                71   69   INFORMATION                                                     PRV                2000A                                       S               1
                                                                                                                                                                   BI = BILLING   PT =
                                                                                              PROVIDER CODE               PRV01      1221    2000A M   ID   1/3    PAY TO
                                                                                              REFERENCE IDENTIFICATION
                                                                                              QUALIFIER                   PRV02       128    2000A M   ID   2/3    ZZ
                                                                                                                                                                   PROVIDER
                                                                                              REFERENCE IDENTIFICATION    PRV03       127    2000A M   AN   1/30   TAXONOMY CODE
                                                73   71   FOREIGN CURRENCY INFORMATION                                    CUR                2000A                                       S               1
                                                                                                                                                                   85 (BILLING
                                                                                              ENTITY IDENTIFIER CODE      CUR01        98    2000A M   ID   2/3    PROVIDER)
                                                                                              CURRENCY CODE               CUR02       100    2000A M   ID   3/3
                                                          LOOP ID - 2010AA BILLING PROVIDER NAME                                                                                                         1
                                                76   74   BILLING PROVIDER NAME                                           NM1               2010AA                                       R               1


                                                                                               44
                                                                                                                                                                         Policy Memorandum 2004 - 3
                                                                                                                                                                         Exhibit 2K




                                                                        837 - HEALTH CLAIMS AND ENCOUNTERS (DENTAL)
INTERNAL    TABLE  /   FIELD    FIELD   FIELD   Old A1                                                       REF     ELEMENT
RECORD ID   DATABASE   LENGTH   TYPE    NAME    PG PG    SEGMENT NAME            ELEMENT NAME                DES.     NUMBER    LOOP ATTRIBUTES       NOTES              USE       REPEAT
                                                                                 ENTITY IDENTIFIER CODE      NM101        98   2010AA M   ID   2/3    85
                                                                                 ENTITY TYPE QUALIFIER       NM102      1065   2010AA M   ID   1/1
                                                                                 NAME LAST OR ORGANIZATION                                            BILLING PROVIDER
                                                                                 NAME                        NM103      1035   2010AA O   AN   1/35   NAME




                                                                                  45
                                                                                                                                                                                      Policy Memorandum 2004 - 3
                                                                                                                                                                                      Exhibit 2K




                                                                          837 - HEALTH CLAIMS AND ENCOUNTERS (DENTAL)
INTERNAL    TABLE  /   FIELD    FIELD   FIELD   Old A1                                                                    REF     ELEMENT
RECORD ID   DATABASE   LENGTH   TYPE    NAME    PG PG     SEGMENT NAME                        ELEMENT NAME                DES.     NUMBER    LOOP ATTRIBUTES         NOTES            USE       REPEAT
                                                                                              NAME FIRST                  NM104      1036   2010AA O     AN   1/25
                                                                                              NAME MIDDLE                 NM105      1037   2010AA O     AN   1/25
                                                                                              NAME SUFFIX                 NM107      1039   2010AA O     AN   1/10
                                                                                              IDENTIFICATION CODE
                                                                                              QUALIFIER                   NM108        66   2010AA X     ID   1/2

                                                                                              IDENTIFICATION CODE         NM109        67   2010AA X     AN   2/80
                                                80   77   BILLING PROVIDER ADDRESS                                        N3                2010AA                                    R               1
                                                                                              ADDRESS INFORMATION         N301        166            M   AN   1/55   ADDRESS LINE 1
                                                                                              ADDRESS INFORMATION         N302        166   2010AA O     AN   1/55   ADDRESS LINE 2
                                                          BILLING PROVIDER CITY/STATE/ZIP
                                                81   78   CODE                                                            N4                2010AA                                    R               1
                                                                                              CITY NAME                   N401         19   2010AA O     AN   2/30
                                                                                              STATE OR PROVINCE CODE      N402        156   2010AA O     ID   2/2
                                                                                              POSTAL CODE                 N403        116   2010AA O     ID   3/15
                                                                                              COUNTRY CODE                N404         26   2010AA O     ID   2/3
                                                          BILLING PROVIDER SECONDARY
                                                83   80   IDENTIFICATION NUMBER                                           REF               2010AA                                    S               5
                                                                                              REFERENCE IDENTIFICATION
                                                                                              QUALIFIER                   REF01       128   2010AA M     ID   2/3    SEE CODE LIST
                                                                                              REFERENCE IDENTIFICATION    REF02       127   2010AA M     AN   1/30
                                                          CLAIM SUBMITTER CREDIT/DEBIT CARD
                                                85   82   INFOAMTION                                                      REF               2010AA                                    S               8
                                                                                              REFERENCE IDENTIFICATION
                                                                                              QUALIFIER                   REF01       128   2010AA M     ID   2/3    SEE CODE LIST
                                                                                              REFERENCE IDENTIFICATION    REF02       127   2010AA M     AN   1/30
                                                          LOOP ID - 2010AB PAY-TO PROVIDER NAME                                                                                                       1
                                                87   84   PAY-TO PROVIDER NAME                                            NM1               2010AB                                    S               1
                                                                                              ENTITY IDENTIFIER CODE      NM101        98   2010AB M     ID   2/3    87
                                                                                              ENTITY TYPE QUALIFIER       NM102      1065   2010AB M     ID   1/1
                                                                                              NAME LAST OR ORGANIZATION
                                                                                              NAME                        NM103      1035   2010AB O     AN   1/35
                                                                                              NAME FIRST                  NM104      1036   2010AB O     AN   1/25
                                                                                              NAME MIDDLE                 NM105      1037   2010AB O     AN   1/25
                                                                                              NAME SUFFIX                 NM107      1039   2010AB O     AN   1/10
                                                                                              IDENTIFICATION CODE
                                                                                              QUALIFIER                   NM108        66   2010AB X     ID   1/2
                                                                                              IDENTIFICATION CODE         NM109        67   2010AB X     AN   2/80
                                                91   87   PAY-TO PROVIDER ADDRESS                                         N3                2010AB                                    R               1
                                                                                              ADDRESS INFORMATION         N301        166   2010AB M     AN   1/55   ADDRESS LINE 1

                                                                                               46
                                                                                                                                                                          Policy Memorandum 2004 - 3
                                                                                                                                                                          Exhibit 2K




                                                                          837 - HEALTH CLAIMS AND ENCOUNTERS (DENTAL)
INTERNAL    TABLE  /   FIELD    FIELD   FIELD   Old A1                                                           REF    ELEMENT
RECORD ID   DATABASE   LENGTH   TYPE    NAME    PG PG     SEGMENT NAME                     ELEMENT NAME          DES.    NUMBER    LOOP ATTRIBUTES       NOTES            USE       REPEAT
                                                                                           ADDRESS INFORMATION   N302       166   2010AB O   AN   1/55   ADDRESS LINE 2
                                                          PAY-TO PROVIDER CITY/STATE/ZIP
                                                92   88   CODE                                                   N4               2010AB                                  R               1
                                                                                           CITY NAME             N401        19   2010AB O   AN   2/30




                                                                                            47
                                                                                                                                                                                       Policy Memorandum 2004 - 3
                                                                                                                                                                                       Exhibit 2K




                                                                          837 - HEALTH CLAIMS AND ENCOUNTERS (DENTAL)
INTERNAL    TABLE  /   FIELD    FIELD   FIELD   Old A1                                                                      REF     ELEMENT
RECORD ID   DATABASE   LENGTH   TYPE    NAME    PG PG      SEGMENT NAME                       ELEMENT NAME                  DES.     NUMBER    LOOP ATTRIBUTES       NOTES             USE       REPEAT
                                                                                              STATE OR PROVINCE CODE        N402        156   2010AB O   ID   2/2
                                                                                              POSTAL CODE                   N403        116   2010AB O   ID   3/15
                                                                                              COUNTRY CODE                  N404         26   2010AB O   ID   2/3
                                                           PAY-TO PROVIDER SECONDARY
                                                94    90   IDENTIFICATION NUMBER                                            REF               2010AB                                   S               5
                                                                                              REFERENCE IDENTIFICATION
                                                                                              QUALIFIER                     REF01       128   2010AB M   ID   2/3    SEE CODE LIST
                                                                                              REFERENCE IDENTIFICATION      REF02       127   2010AB M   AN   1/30
                                                           TABLE 2 - DETAIL, SUBSCRIBER HIERARCHICAL LEVEL
                                                           LOOP ID - 2000B SUBSCRIBER HIERARCHICAL LEVEL                                                                                              >1
                                                                                                                                                                     SEE NOTES ON
                                                96    92   SUBSCRIBER HIERARCHICAL LEVEL                                    HL                 2000B                 SEGMENT USAGE     R               1
                                                                                              HIERARCHICAL ID NUMBER        HL01        628    2000B M   AN   1/12
                                                                                              HIERARCHICAL PARENT ID        HL02        734    2000B O   AN   1/12
                                                                                              HIERARCHICAL LEVEL CODE       HL03        735    2000B M   ID   1/2    22 (SUBSCRIBER)
                                                                                              HIERARCHICAL CHILD CODE       HL04        736    2000B O   ID   1/1
                                                99    95   SUBSCRIBER INFORMATION                                           SBR                2000B                                   R               1
                                                                                              PAYER RESPONSIBILITY
                                                                                              SEQUENCE NUMBER CODE          SBR01      1138    2000B M   ID   1/1

                                                                                              INDIVIDUAL RELATIONSHIP CODE SBR02       1069    2000B O   ID   2/2    18 (SELF)
                                                                                              REFERENCE IDENTIFICATION     SBR03        127    2000B O   AN   1/30
                                                                                              NAME                          SBR04        93    2000B O   AN   1/60
                                                                                              COORDINATION OF BENEFITS
                                                                                              CODE                          SBR06      1143    2000B O   ID   1/1

                                                                                              CLAIM FILING INDICATOR CODE   SBR09      1032    2000B O   ID   1/2
                                                           LOOP ID - 2010BA SUBSCRIBER NAME                                                                                                            1
                                                103   99   SUBSCRIBER NAME                                                  NM1               2010BA                                   R               1
                                                                                              ENTITY IDENTIFIER CODE        NM101        98   2010BA M   ID   2/3    IL
                                                                                              ENTITY TYPE QUALIFIER         NM102      1065   2010BA M   ID   1/1
                                                                                              NAME LAST OR ORGANIZATION
                                                                                              NAME                          NM103      1035   2010BA O   AN   1/35
                                                                                              NAME FIRST                    NM104      1036   2010BA O   AN   1/25
                                                                                              NAME MIDDLE                   NM105      1037   2010BA O   AN   1/25
                                                                                              NAME SUFFIX                   NM107      1039   2010BA O   AN   1/10
                                                                                              IDENTIFICATION CODE
                                                                                              QUALIFIER                     NM108        66   2010BA X   ID   1/2
                                                                                              IDENTIFICATION CODE           NM109        67   2010BA X   AN   2/80


                                                                                               48
                                                                                                                                                                            Policy Memorandum 2004 - 3
                                                                                                                                                                            Exhibit 2K




                                                                           837 - HEALTH CLAIMS AND ENCOUNTERS (DENTAL)
INTERNAL    TABLE  /   FIELD    FIELD   FIELD   Old A1                                                             REF    ELEMENT
RECORD ID   DATABASE   LENGTH   TYPE    NAME    PG PG       SEGMENT NAME                     ELEMENT NAME          DES.    NUMBER    LOOP ATTRIBUTES       NOTES            USE       REPEAT
                                                108   103   SUBSCRIBER ADDRESS                                     N3               2010BA                                  S               1
                                                                                             ADDRESS INFORMATION   N301       166   2010BA M   AN   1/55   ADDRESS LINE 1
                                                                                             ADDRESS INFORMATION   N302       166   2010BA O   AN   1/55   ADDRESS LINE 2
                                                109   104   SUBSCRIBER CITY/STATE/ZIP CODE                         N4               2010BA                                  S               1




                                                                                              49
                                                                                                                                                                                    Policy Memorandum 2004 - 3
                                                                                                                                                                                    Exhibit 2K




                                                                            837 - HEALTH CLAIMS AND ENCOUNTERS (DENTAL)
INTERNAL    TABLE  /   FIELD    FIELD   FIELD   Old A1                                                                    REF     ELEMENT
RECORD ID   DATABASE   LENGTH   TYPE    NAME    PG PG       SEGMENT NAME                     ELEMENT NAME                 DES.     NUMBER    LOOP ATTRIBUTES       NOTES            USE       REPEAT
                                                                                             CITY NAME                    N401         19   2010BA O   AN   2/30
                                                                                             STATE OR PROVINCE CODE       N402        156   2010BA O   ID   2/2
                                                                                             POSTAL CODE                  N403        116   2010BA O   ID   3/15
                                                                                             COUNTRY CODE                 N404         26   2010BA O   ID   2/3
                                                            SUBSCRIBER DEMOGRAPHIC
                                                111   106   INFORMATION                                                   DMG               2010BA                                  S               1

                                                                                             DATE TIME FORMAT QUALIFIER   DMG01      1250   2010BA X   ID   2/3    D8
                                                                                             DATE TIME PERIOD             DMG02      1251   2010BA X   AN   1/35
                                                                                             GENDER CODE                  DMG03      1068   2010BA O   ID   1/1
                                                            SUBSCRIBER SECONDARY
                                                113   108   IDENTIFICATION                                                REF               2010BA                                  S               4
                                                                                             REFERENCE IDENTIFICATION
                                                                                             QUALIFIER                    REF01       128   2010BA M   ID   2/3
                                                                                             REFERENCE IDENTIFICATION     REF02       127   2010BA M   AN   1/30
                                                            PROPERTY AND CASUALTY CLAIM
                                                115   110   NUMBER                                                        REF               2010BA                                  S               1
                                                                                             REFERENCE IDENTIFICATION
                                                                                             QUALIFIER                    REF01       128   2010BA M   ID   2/3    Y4
                                                                                             REFERENCE IDENTIFICATION     REF02       127   2010BA M   AN   1/30
                                                            LOOP ID - 2010BB PAYER NAME                                                                                                             1
                                                117   112   PAYER NAME                                                    NM1               2010BB                                  R               1
                                                                                             ENTITY IDENTIFIER CODE       NM101        98   2010BB M   ID   2/3    PR (PAYER)
                                                                                             ENTITY TYPE QUALIFIER        NM102      1065   2010BB M   ID   1/1    2
                                                                                             NAME LAST OR ORGANIZATION
                                                                                             NAME                         NM103      1035   2010BB O   AN   1/35
                                                                                             IDENTIFICATION CODE
                                                                                             QUALIFIER                    NM108        66   2010BB X   ID   1/2
                                                                                             IDENTIFICATION CODE          NM109        67   2010BB X   AN   2/80
                                                121   115   PAYER ADDRESS                                                 N3                2010BB                                  S               1
                                                                                             ADDRESS INFORMATION          N301        166   2010BB M   AN   1/55   ADDRESS LINE 1
                                                                                             ADDRESS INFORMATION          N302        166   2010BB O   AN   1/55   ADDRESS LINE 2
                                                122   116   PAYER CITY/STATE/ZIP CODE                                     N4                2010BB                                  S               1
                                                                                             CITY NAME                    N401         19   2010BB O   AN   2/30
                                                                                             STATE OR PROVINCE CODE       N402        156   2010BB O   ID   2/2
                                                                                             POSTAL CODE                  N403        116   2010BB O   ID   3/15
                                                                                             COUNTRY CODE                 N404         26   2010BB O   ID   2/3
                                                            PAYER SECONDARY IDENTIFICATION
                                                124   118   NUMBER                                                        REF               2010BB                                  S               3


                                                                                              50
                                                                                                                                                                              Policy Memorandum 2004 - 3
                                                                                                                                                                              Exhibit 2K




                                                                            837 - HEALTH CLAIMS AND ENCOUNTERS (DENTAL)
INTERNAL    TABLE  /   FIELD    FIELD   FIELD   Old A1                                                                     REF     ELEMENT
RECORD ID   DATABASE   LENGTH   TYPE    NAME    PG PG       SEGMENT NAME                       ELEMENT NAME                DES.     NUMBER    LOOP ATTRIBUTES         NOTES   USE       REPEAT
                                                                                               REFERENCE IDENTIFICATION
                                                                                               QUALIFIER                   REF01       128   2010BB M     ID   2/3
                                                                                               REFERENCE IDENTIFICATION    REF02       127   2010BB M     AN   1/30
                                                            LOOP ID - 2010BC RESPONSIBLE PARTY NAME                                                                                           1
                                                126   120   CREDIT/DEBIT CARD HOLDER NAME                                  NM1                                                S               1
                                                                                               ENTITY IDENTIFIER CODE      NM101        98            M   ID   2/3    AO
                                                                                               ENTITY TYPE QUALIFIER       NM102      1065            M   ID   1/1
                                                                                               NAME LAST OR ORGANIZATION
                                                                                               NAME                        NM103      1035            O   AN   1/35
                                                                                               NAME FIRST                  NM104      1036            O   AN   1/25
                                                                                               NAME MIDDLE                 NM105      1037            O   AN   1/25
                                                                                               NAME SUFFIX                 NM107      1039            O   AN   1/10

                                                                                               IDENTIFICATION CODE
                                                                                               QUALIFIER                   NM108        66            X   ID   1/2
                                                                                               IDENTIFICATION CODE         NM109        67            X   AN   2/80
                                                130   123   CREDIT/DEBIT CARD INFORMATION                                  REF                                                S               3
                                                                                               REFERENCE IDENTIFICATION
                                                                                               QUALIFIER                   REF01       128            M   ID   2/3
                                                                                               REFERENCE IDENTIFICATION    REF02       127            M   AN   1/30
                                                            TABLE 2 - DETAIL, PATIENT HIERARCHICAL LEVEL
                                                            LOOP ID - 2000C PATIENT HIERARCHICAL LEVEL                                                                                       >1
                                                132   125   PATIENT HIERARCHICAL LEVEL                                     HL                 2000C                           S               1
                                                                                               HIERARCHICAL ID NUMBER      HL01        628    2000C M     AN   1/12
                                                                                               HIERARCHICAL PARENT ID      HL02        734    2000C O     AN   1/12
                                                                                               HIERARCHICAL LEVEL CODE     HL03        735    2000C M     ID   1/2    23
                                                                                               HIERARCHICAL CHILD CODE     HL04        736    2000C O     ID   1/1    0
                                                134   127   PATIENT INFORMATION                                            PAT                2000C                           R               1
                                                                                               INDIVIDUAL RELATIONSHIP
                                                                                               CODE                        PAT01      1069    2000C O     ID   2/2
                                                                                               STUDENT STATUS CODE         PAT04      1220    2000C O     ID   1/1
                                                                                               DATE TIME PERIOD            PAT06      1251    2000C X     AN   1/35
                                                                                               UNIT OR BASIS FOR
                                                                                               MEASUREMENT CODE            PAT07       355    2000C X     ID   2/2
                                                                                               WEIGHT                      PAT08        81    2000C X     R    1/10
                                                            LOOP ID - 2010CA PATIENT NAME                                                                                                     1
                                                136   129   PATIENT NAME                                                   NM1               2010CA                           R               1
                                                                                               ENTITY IDENTIFIER CODE      NM101        98   2010CA M     ID   2/3    QC
                                                                                               ENTITY TYPE QUALIFIER       NM102      1065   2010CA M     ID   1/1


                                                                                                 51
                                                                                                                                                                                      Policy Memorandum 2004 - 3
                                                                                                                                                                                      Exhibit 2K




                                                                            837 - HEALTH CLAIMS AND ENCOUNTERS (DENTAL)
INTERNAL    TABLE  /   FIELD    FIELD   FIELD   Old A1                                                                      REF     ELEMENT
RECORD ID   DATABASE   LENGTH   TYPE    NAME    PG PG       SEGMENT NAME                       ELEMENT NAME                 DES.     NUMBER    LOOP ATTRIBUTES       NOTES            USE       REPEAT
                                                                                               NAME LAST OR ORGANIZATION
                                                                                               NAME                         NM103      1035   2010CA O   AN   1/35
                                                                                               NAME FIRST                   NM104      1036   2010CA O   AN   1/25
                                                                                               NAME MIDDLE                  NM105      1037   2010CA O   AN   1/25
                                                                                               NAME SUFFIX                  NM107      1039   2010CA O   AN   1/10
                                                                                               IDENTIFICATION CODE
                                                                                               QUALIFIER                    NM108        66   2010CA X   ID   1/2


                                                                                               IDENTIFICATION CODE          NM109        67   2010CA X   AN   2/80
                                                140   132   PATIENT ADDRESS                                                 N3                2010CA                                  R               1
                                                                                               ADDRESS INFORMATION          N301        166   2010CA M   AN   1/55   ADDRESS LINE 1
                                                                                               ADDRESS INFORMATION          N302        166   2010CA O   AN   1/55   ADDRESS LINE 2
                                                141   133   PATIENT CITY/STATE/ZIP CODE                                     N4                2010CA                                  R               1
                                                                                               CITY NAME                    N401         19   2010CA O   AN   2/30
                                                                                               STATE OR PROVINCE CODE       N402        156   2010CA O   ID   2/2
                                                                                               POSTAL CODE                  N403        116   2010CA O   ID   3/15
                                                                                               COUNTRY CODE                 N404         26   2010CA O   ID   2/3


                                                143   135   PATIENT DEMOGRAPHIC INFORMATION                                 DMG               2010CA                                  R               1


                                                                                               DATE TIME FORMAT QUALIFIER   DMG01      1250   2010CA X   ID   2/3
                                                                                               DATE TIME PERIOD             DMG02      1251   2010CA X   AN   1/35
                                                                                               GENDER CODE                  DMG03      1068   2010CA O   ID   1/1
                                                145   137   PATIENT SECONDARY IDENTIFICATION                                REF               2010CA                                  S               5
                                                                                               REFERENCE IDENTIFICATION
                                                                                               QUALIFIER                    REF01       128   2010CA M   ID   2/3

                                                                                               REFERENCE IDENTIFICATION     REF02       127   2010CA M   AN   1/30
                                                            PROPERTY AND CASUALTY CLAIM
                                                147   139   NUMBER                                                          REF               2010CA                                  S               1
                                                                                               REFERENCE IDENTIFICATION
                                                                                               QUALIFIER                    REF01       128   2010CA M   ID   2/3

                                                                                               REFERENCE IDENTIFICATION     REF02       127   2010CA M   AN   1/30
                                                            LOOP ID - 2300 CLAIM INFORMATION                                                                                                        100
                                                149   141   CLAIM INFORMATION                                               CLM                 2300                                  R               1
                                                                                                                                                                     MAXIMUM OF 20
                                                                                                                                                                     CHARACTERS
                                                                                               CLAIM SUBMITTER'S IDENTIFIER CLM01      1028     2300 M   AN   1/38   REQUIRED

                                                                                                52
                                                                                                                                                                 Policy Memorandum 2004 - 3
                                                                                                                                                                 Exhibit 2K




                                                                        837 - HEALTH CLAIMS AND ENCOUNTERS (DENTAL)
INTERNAL    TABLE  /   FIELD    FIELD   FIELD   Old A1                                                  REF     ELEMENT
RECORD ID   DATABASE   LENGTH   TYPE    NAME    PG PG    SEGMENT NAME            ELEMENT NAME           DES.     NUMBER   LOOP ATTRIBUTES     NOTES              USE       REPEAT
                                                                                                                                              TOTAL CLAIM
                                                                                 MONETARY AMOUNT        CLM02       782   2300 O   R   1/18   CHARGE AMOUNT
                                                                                 HEALTH CARE SERVICE                                          PLACE OF SERVICE
                                                                                 LOCATION INFORMATION   CLM05      C023   2300 O              CODE




                                                                                  53
                                                                                                                                                                                Policy Memorandum 2004 - 3
                                                                                                                                                                                Exhibit 2K




                                                                               837 - HEALTH CLAIMS AND ENCOUNTERS (DENTAL)
INTERNAL    TABLE  /   FIELD    FIELD   FIELD   Old A1                                                              REF       ELEMENT
RECORD ID   DATABASE   LENGTH   TYPE    NAME    PG PG       SEGMENT NAME                ELEMENT NAME                DES.       NUMBER   LOOP ATTRIBUTES      NOTES              USE       REPEAT
                                                                                        FACILITY CODE VALUE         CLM05-1      1331   2300 M   AN   1/2
                                                                                        CLAIM FREQUENCY TYPE CODE   CLM05-3      1325   2300 O   ID   1/1
                                                                                        YES/NO CONDITION OR
                                                                                        RESPONSE CODE               CLM06        1073   2300 O   ID   1/1

                                                                                        PROVIDER ACCEPT                                                      MEDICARE
                                                                                        ASSIGNMENT CODE             CLM07        1359   2300 O   ID   1/1    ASSIGNMENT CODE
                                                                                                                                                             ASSIGNMENT OF
                                                                                        YES/NO CONDITION OR                                                  BENEFITS
                                                                                        RESPONSE CODE               CLM08        1073   2300 O   ID   1/1    INDICATOR

                                                                                        RELEASE OF INFORMATION
                                                                                        CODE                        CLM09        1363   2300 O   ID   1/1

                                                                                        RELATED CAUSES INFORMATION CLM11         C024   2300 O
                                                                                        RELATED-CAUSES CODE        CLM11-1       1362   2300 M   ID   2/3
                                                                                        RELATED-CAUSES CODE         CLM11-2      1362   2300 O   ID   2/3
                                                                                        RELATED-CAUSES CODE         CLM11-3      1362   2300 O   ID   2/3

                                                                                        STATE OR PROVINCE CODE      CLM11-4       156   2300 O   ID   2/2

                                                                                        COUNTRY CODE                CLM11-5        26   2300 O   ID   2/3

                                                                                        SPECIAL PROGRAM CODE        CLM12        1366   2300 O   ID   2/3
                                                                                                                                                             REASON FOR LATE
                                                                                        DELAY REASON CODE           CLM20        1514   2300 O   ID   1/2    FILING
                                                157   148   DATE - ADMISSION                                        DTP                 2300                                    S               1
                                                                                        DATE/TIME QUALIFIER         DTP01         374   2300 M   ID   3/3    435
                                                                                        DATE TIME PERIOD FORMAT
                                                                                        QUALIFIER                   DTP02        1250   2300 M   ID   2/3    D8 (DATE FORMAT)
                                                                                        DATE                        DTP03        1251   2300 M   AN   1/35

                                                158   149   DATE - DISCHARGE                                        DTP                 2300                                    S               1
                                                                                        DATE/TIME QUALIFIER         DTP01         374   2300 M   ID   3/3    096
                                                                                        DATE TIME PERIOD FORMAT
                                                                                        QUALIFIER                   DTP02        1250   2300 M   ID   2/3    D8 (DATE FORMAT)
                                                                                        DATE                        DTP03        1251   2300 M   AN   1/35
                                                160   151   DATE - REFERRAL                                         DTP                 2300                                    S               1
                                                                                        DATE/TIME QUALIFIER         DTP01         374   2300 M   ID   3/3    330
                                                                                        DATE TIME PERIOD FORMAT
                                                                                        QUALIFIER                   DTP02        1250   2300 M   ID   2/3    D8 (DATE FORMAT)
                                                                                        DATE                        DTP03        1251   2300 M   AN   1/35

                                                                                         54
                                                                                                                                                                               Policy Memorandum 2004 - 3
                                                                                                                                                                               Exhibit 2K




                                                                              837 - HEALTH CLAIMS AND ENCOUNTERS (DENTAL)
INTERNAL    TABLE  /   FIELD    FIELD   FIELD   Old A1                                                               REF     ELEMENT
RECORD ID   DATABASE   LENGTH   TYPE    NAME    PG PG       SEGMENT NAME                  ELEMENT NAME               DES.     NUMBER   LOOP ATTRIBUTES      NOTES              USE       REPEAT
                                                161   152   DATE - ACCIDENT                                          DTP               2300                                    S               1
                                                                                          DATE/TIME QUALIFIER        DTP01       374   2300 M   ID   3/3    439
                                                                                          DATE TIME PERIOD FORMAT
                                                                                          QUALIFIER                  DTP02      1250   2300 M   ID   2/3    D8 (DATE FORMAT)
                                                                                          DATE                       DTP03      1251   2300 M   AN   1/35
                                                162   153   DATE - APPLIANCE PLACEMENT                               DTP               2300                                    S               1
                                                                                          DATE/TIME QUALIFIER        DTP01       374   2300 M   ID   3/3    452
                                                                                          DATE TIME PERIOD FORMAT
                                                                                          QUALIFIER                  DTP02      1250   2300 M   ID   2/3    D8 (DATE FORMAT)
                                                                                          DATE                       DTP03      1251   2300 M   AN   1/35
                                                164   155   DATE - SERVICE                                           DTP               2300                                    S               5
                                                                                          DATE/TIME QUALIFIER        DTP01       374   2300 M   ID   3/3    472
                                                                                          DATE TIME PERIOD FORMAT
                                                                                          QUALIFIER                  DTP02      1250   2300 M   ID   2/3    D8 (DATE FORMAT)
                                                                                          DATE                       DTP03      1251   2300 M   AN   1/35
                                                            ORTHODONTIC TOTAL MONTHS OF
                                                166   157   TREATMENT                                                DN1               2300                                    S               1
                                                                                          QUANTITY                   DN101       380   2300 O   R    1/15
                                                                                          QUANTITY                   DN102       380   2300 O   R    1/15
                                                                                          YES/NO CONDITION OR
                                                                                          RESPONSE CODE              DN103      1073   2300 O   ID   1/1    Y
                                                168   159   TOOTH STATUS                                             DN2               2300                                    S              35
                                                                                          REFERENCE IDENTIFICATION   DN201       127   2300 M   AN   1/30   TOOTH NUMBER
                                                                                          TOOTH STATUS CODE          DN202      1368   2300 M   ID   1/2




                                                                                           55
                                                                                                                                                                                      Policy Memorandum 2004 - 3
                                                                                                                                                                                      Exhibit 2K




                                                                           837 - HEALTH CLAIMS AND ENCOUNTERS (DENTAL)
INTERNAL    TABLE  /   FIELD    FIELD   FIELD   Old A1                                                                   REF     ELEMENT
RECORD ID   DATABASE   LENGTH   TYPE    NAME    PG PG       SEGMENT NAME                      ELEMENT NAME               DES.     NUMBER   LOOP ATTRIBUTES      NOTES                 USE       REPEAT
                                                                                                                                                                SEE NOTES ON
                                                170   161   CLAIM SUPPLEMENTAL INFORMATION                               PWK               2300                 SEGMENT USAGE         S              10
                                                                                              REPORT TYPE CODE           PWK01       755   2300 M   ID   2/2

                                                                                              REPORT TRANSMISSION CODE   PWK02       756   2300 O   ID   1/2
                                                                                              IDENTIFICATION CODE
                                                                                              QUALIFIER                  PWK05        66   2300 X   AN   2/80
                                                                                              IDENTIFICATION CODE        PWK06        67   2300 O   AN   1/80
                                                173   164   PATIENT AMOUNT PAID                                          AMT               2300                                       S               1

                                                                                              AMOUNT QUALIFIER CODE      AMT01       522   2300 M   ID   1/3    F5 = PAT. AMT. PAID
                                                                                              MONETARY AMOUNT            AMT02       782   2300 M   R    1/18
                                                            CREDIT/DEBIT CARD - MAXIMUM
                                                174   165   AMOUNT                                                       AMT               2300                                       S               1

                                                                                              AMOUNT QUALIFIER CODE      AMT01       522   2300 M   ID   1/3    MA
                                                                                              MONETARY AMOUNT            AMT02       782   2300 M   R    1/18
                                                175   166   PREDETERMINATION IDENTIFICATION                              REF               2300                                       S               5

                                                                                              REFERENCE IDENTIFICATION
                                                                                              QUALIFIER                  REF01       128   2300 M   ID   2/3    G3


                                                                                              REFERENCE IDENTIFICATION   REF02       127   2300 X   AN   1/30
                                                            SERVICE AUTHORIZATION EXCEPTION
                                                177   168   CODE                                                         REF               2300                                       S               1

                                                                                              REFERENCE IDENTIFICATION
                                                                                              QUALIFIER                  REF01       128   2300 M   ID   2/3    4N


                                                                                              REFERENCE IDENTIFICATION   REF02       127   2300 X   AN   1/30

                                                            ORIGINAL REFERENCE NUMBER
                                                179   170   (ICN/DCN)                                                    REF               2300                                       S               1

                                                                                              REFERENCE IDENTIFICATION
                                                                                              QUALIFIER                  REF01       128   2300 M   ID   2/3    F8


                                                                                              REFERENCE IDENTIFICATION   REF02       127   2300 X   AN   1/30
                                                            PRIOR AUTHORIZATION OR REFERRAL
                                                181   172   IDENTIFICATION                                               REF               2300                                       S               2


                                                                                               56
                                                                                                                                                           Policy Memorandum 2004 - 3
                                                                                                                                                           Exhibit 2K




                                                                        837 - HEALTH CLAIMS AND ENCOUNTERS (DENTAL)
INTERNAL    TABLE  /   FIELD    FIELD   FIELD   Old A1                                                      REF     ELEMENT
RECORD ID   DATABASE   LENGTH   TYPE    NAME    PG PG    SEGMENT NAME            ELEMENT NAME               DES.     NUMBER   LOOP ATTRIBUTES      NOTES   USE       REPEAT

                                                                                 REFERENCE IDENTIFICATION
                                                                                 QUALIFIER                  REF01       128   2300 M   ID   2/3    9F


                                                                                 REFERENCE IDENTIFICATION   REF02       127   2300 X   AN   1/30




                                                                                  57
                                                                                                                                                                          Policy Memorandum 2004 - 3
                                                                                                                                                                          Exhibit 2K




                                                                           837 - HEALTH CLAIMS AND ENCOUNTERS (DENTAL)
INTERNAL    TABLE  /   FIELD    FIELD   FIELD   Old A1                                                                    REF     ELEMENT
RECORD ID   DATABASE   LENGTH   TYPE    NAME    PG PG       SEGMENT NAME                      ELEMENT NAME                DES.     NUMBER   LOOP ATTRIBUTES       NOTES   USE       REPEAT
                                                            CLAIM IDENTIFICATION NUMBER FOR
                                                            CLEARINGHOUSES AND OTHER
                                                183   174   TRANSMISSION INTERMEDIARIES                                   REF                2300                         S               1

                                                                                              REFERENCE IDENTIFICATION
                                                                                              QUALIFIER                   REF01       128    2300 M   ID   2/3    D9


                                                                                              REFERENCE IDENTIFICATION    REF02       127    2300 X   AN   1/30
                                                185   176   CLAIM NOTE                                                    NTE                2300                         S              20
                                                                                              NOTE REFERENCE CODE         NTE01       363    2300 O   ID   3/3    ADD
                                                                                              DESCRIPTION                 NTE02       352    2300 M   AN   1/80
                                                            LOOP ID - 2310A REFERRING PROVIDER NAME                                                                                       2
                                                187   178   REFERRING PROVIDER NAME                                       NM1                                             S               1
                                                                                              ENTITY IDENTIFIER CODE      NM101        98   2310A M   ID   2/3
                                                                                              ENTITY TYPE QUALIFIER       NM102      1065   2310A M   ID   1/1
                                                                                              NAME LAST OR ORGANIZATION
                                                                                              NAME                        NM103      1035   2310A O   AN   1/35
                                                                                              NAME FIRST                  NM104      1036   2310A O   AN   1/25
                                                                                              NAME MIDDLE                 NM105      1037   2310A O   AN   1/25
                                                                                              NAME SUFFIX                 NM107      1039   2310A O   AN   1/10
                                                                                              IDENTIFICATION CODE
                                                                                              QUALIFIER                   NM108        66   2310A X   ID   1/2


                                                                                              IDENTIFICATION CODE         NM109        67   2310A X   AN   2/80
                                                            REFERRING PROVIDER SPECIALTY
                                                190   181   INFORMATION                                                   PRV               2310A                         S               1
                                                                                              PROVIDER CODE               PRV01      1221   2310A M   ID   1/3    RF

                                                                                              REFERENCE IDENTIFICATION
                                                                                              QUALIFIER                   PRV02       128   2310A M   ID   2/3
                                                                                              REFERENCE IDENTIFICATION    PRV03       127   2310A M   AN   1/30
                                                            REFERRING PROVIDER SECONDARY
                                                193   183   IDENTIFICATION                                                REF               2310A                         S               5

                                                                                              REFERENCE IDENTIFICATION
                                                                                              QUALIFIER                   REF01       128   2310A M   ID   2/3
                                                                                              REFERENCE IDENTIFICATION    REF02       127   2310A M   AN   1/30
                                                            LOOP ID - 2310B RENDERING PROVIDER NAME                                                                                       1
                                                195   185   RENDERING PROVIDER NAME                                       NM1                                             S               1


                                                                                               58
                                                                                                                                                                           Policy Memorandum 2004 - 3
                                                                                                                                                                           Exhibit 2K




                                                                            837 - HEALTH CLAIMS AND ENCOUNTERS (DENTAL)
INTERNAL    TABLE  /   FIELD    FIELD   FIELD   Old A1                                                                     REF     ELEMENT
RECORD ID   DATABASE   LENGTH   TYPE    NAME    PG PG       SEGMENT NAME                       ELEMENT NAME                DES.     NUMBER   LOOP ATTRIBUTES       NOTES   USE       REPEAT
                                                                                               ENTITY IDENTIFIER CODE      NM101        98   2310B M   ID   2/3    82
                                                                                               ENTITY TYPE QUALIFIER       NM102      1065   2310B M   ID   1/1
                                                                                               NAME LAST OR ORGANIZATION
                                                                                               NAME                        NM103      1035   2310B O   AN   1/35
                                                                                               NAME FIRST                  NM104      1036   2310B O   AN   1/25
                                                                                               NAME MIDDLE                 NM105      1037   2310B O   AN   1/25
                                                                                               NAME SUFFIX                 NM107      1039   2310B O   AN   1/10
                                                                                               IDENTIFICATION CODE
                                                                                               QUALIFIER                   NM108        66   2310B X   ID   1/2


                                                                                               IDENTIFICATION CODE         NM109        67   2310B X   AN   2/80
                                                            RENDERING PROVIDER SPECIALTY
                                                198   188   INFORMATION                                                    PRV               2310B                         S               1
                                                                                               PROVIDER CODE               PRV01      1221   2310B M   ID   1/3    PE

                                                                                               REFERENCE IDENTIFICATION
                                                                                               QUALIFIER                   PRV02       128   2310B M   ID   2/3
                                                                                               REFERENCE IDENTIFICATION    PRV03       127   2310B M   AN   1/30
                                                            RENDERING PROVIDER SECONDARY
                                                201   190   IDENTIFICATION                                                 REF               2310B                         S               5

                                                                                               REFERENCE IDENTIFICATION
                                                                                               QUALIFIER                   REF01       128   2310B M   ID   2/3
                                                                                               REFERENCE IDENTIFICATION    REF02       127   2310B X   AN   1/30

                                                            LOOP ID 2310C - SERVICE FACILITY LOCATION                                                                                      1
                                                203   192   SERVICE FACILITY LOCATION                                      NM1                                             S               1
                                                                                               ENTITY IDENTIFIER CODE      NM101        98   2310C M   ID   2/3    FA
                                                                                               ENTITY TYPE QUALIFIER       NM102      1065   2310C M   ID   1/1




                                                                                                 59
                                                                                                                                                                         Policy Memorandum 2004 - 3
                                                                                                                                                                         Exhibit 2K




                                                                           837 - HEALTH CLAIMS AND ENCOUNTERS (DENTAL)
INTERNAL    TABLE  /   FIELD    FIELD   FIELD   Old A1                                                                   REF     ELEMENT
RECORD ID   DATABASE   LENGTH   TYPE    NAME    PG PG       SEGMENT NAME                     ELEMENT NAME                DES.     NUMBER   LOOP ATTRIBUTES       NOTES   USE       REPEAT
                                                                                             IDENTIFICATION CODE
                                                                                             QUALIFIER                   NM108        66   2310C X   ID   1/2


                                                                                             IDENTIFICATION CODE         NM109        67   2310C X   AN   2/80
                                                            SERVICE FACILITY LOCATION
                                                207   195   SECONDARY INFORMATION                                        REF               2310C                         S               5

                                                                                             REFERENCE IDENTIFICATION
                                                                                             QUALIFIER                   REF01       128   2310C M   ID   2/3
                                                            LOOP ID - 2310D ASSISTANT SURGEON NAME
                                                      197   ASSISTANT SURGEON NAME                                       NM1                                             S               1
                                                                                             ENTITY IDENTIFIER CODE      NM101        98   2310D M   ID   2/3
                                                                                             ENTITY TYPE QUALIFIER       NM102      1065   2310D M   ID   1/1
                                                                                             ASSISTANT SURGEON LAST OR
                                                                                             ORGANIZATIONAL NAME         NM103      1035   2310D O   AN   1/35
                                                                                             ASSISTANT SURGEON FIRST
                                                                                             NAME                        NM104      1036   2310D O   AN   1/25
                                                                                             ASSISTANT SURGEON MIDDLE
                                                                                             NAME                        NM105      1037   2310D O   AN   1/25
                                                                                             ASSISTANT SURGEON NAME
                                                                                             SUFFIX                      NM107      1039   2310D O   AN   1/10
                                                                                             IDENTIFICATION CODE
                                                                                             QUALIFIER                   NM108        66   2310D X   ID   1/2
                                                                                             ASSISTANT SURGEON
                                                                                             IDENTIFIER                  NM109        67   2310D X   AN   2/80
                                                            ASSISTANT SURGEON SPECIALITY
                                                      200   CODE                                                         PRV                                             S               1

                                                                                             PROVIDER CODE               PRV01      1221   2310D M   ID   1/3
                                                                                             REFERENCE IDENTIFICATION
                                                                                             QUALIFIER                   PRV02       128   2310D M   ID   2/3
                                                                                             PROVIDER SPECIALITY CODE    PRV03       127   2310D M   AN   1/30
                                                            ASSISTANT SURGEON SECONDARY
                                                      202   IDENTIFICATION                                               REF                                             S               1
                                                                                             REFERENCE IDENTIFICATON
                                                                                             QUALIFIER                   REF01       128   2310D M   ID   2/3
                                                                                             ASSISTANT SURGEON
                                                                                             SECONDARY IDENTIFICATION
                                                                                             NUMNER                      REF02       127   2310D X   AN   1/30


                                                                                               60
                                                                                                                                                                           Policy Memorandum 2004 - 3
                                                                                                                                                                           Exhibit 2K




                                                                           837 - HEALTH CLAIMS AND ENCOUNTERS (DENTAL)
INTERNAL    TABLE  /   FIELD    FIELD   FIELD   Old A1                                                                      REF     ELEMENT
RECORD ID   DATABASE   LENGTH   TYPE    NAME    PG PG       SEGMENT NAME                      ELEMENT NAME                  DES.     NUMBER   LOOP ATTRIBUTES      NOTES   USE       REPEAT
                                                            LOOP ID - 2320 OTHER SUBSCRIBER INFORMATION                                                                                   10
                                                209   204   OTHER SUBSCRIBER INFORMATION                                    SBR                                            S               1
                                                                                               PAYER RESPONSIBILITY
                                                                                               SEQUENCE NUMBER CODE         SBR01      1138   2320 M   ID   1/1
                                                                                               INDIVIDUAL RELATIONSHIP
                                                                                               CODE                         SBR02      1069   2320 O   ID   2/2

                                                                                              REFERENCE IDENTIFICATION      SBR03       127   2320 O   AN   1/30
                                                                                              NAME                          SBR04        93   2320 O   AN   1/60
                                                                                              CLAIM FILING INDICATOR CODE   SBR09      1032   2320 O   ID   1/2
                                                213   208   CLAIM ADJUSTMENT                                                CAS               2320                         S               5
                                                                                              CLAIM ADJUSTMENT GROUP
                                                                                              CODE                          CAS01      1033   2320 M   ID   1/2
                                                                                              CLAIM ADJUSTMENT REASON
                                                                                              CODE                          CAS02      1034   2320 M   ID   1/5
                                                                                              MONETARY AMOUNT               CAS03       782   2320 M   R    1/18
                                                                                              QUANTITY                      CAS04       380   2320 O   R    1/15
                                                                                              CLAIM ADJUSTMENT REASON
                                                                                              CODE                          CAS05      1034   2320 M   ID   1/5
                                                                                              MONETARY AMOUNT               CAS06       782   2320 M   R    1/18




                                                                                                61
                                                                                                                                                                      Policy Memorandum 2004 - 3
                                                                                                                                                                      Exhibit 2K




                                                                           837 - HEALTH CLAIMS AND ENCOUNTERS (DENTAL)
INTERNAL    TABLE  /   FIELD    FIELD   FIELD   Old A1                                                                 REF     ELEMENT
RECORD ID   DATABASE   LENGTH   TYPE    NAME    PG PG       SEGMENT NAME                     ELEMENT NAME              DES.     NUMBER   LOOP ATTRIBUTES      NOTES   USE       REPEAT
                                                                                             QUANTITY                  CAS07       380   2320 O   R    1/15
                                                                                             CLAIM ADJUSTMENT REASON
                                                                                             CODE                      CAS08      1034   2320 M   ID   1/5
                                                                                             MONETARY AMOUNT           CAS09       782   2320 M   R    1/18
                                                                                             QUANTITY                  CAS10       380   2320 O   R    1/15
                                                                                             CLAIM ADJUSTMENT REASON
                                                                                             CODE                      CAS11      1034   2320 M   ID   1/5
                                                                                             MONETARY AMOUNT           CAS12       782   2320 M   R    1/18
                                                                                             QUANTITY                  CAS13       380   2320 O   R    1/15
                                                                                             CLAIM ADJUSTMENT REASON
                                                                                             CODE                      CAS14      1034   2320 M   ID   1/5
                                                                                             MONETARY AMOUNT           CAS15       782   2320 M   R    1/18
                                                                                             QUANTITY                  CAS16       380   2320 O   R    1/15
                                                                                             CLAIM ADJUSTMENT REASON
                                                                                             CODE                      CAS17      1034   2320 M   ID   1/5
                                                                                             MONETARY AMOUNT           CAS18       782   2320 M   R    1/18
                                                                                             QUANTITY                  CAS19       380   2320 O   R    1/15
                                                            COORDINATION OF BENEFITS (COB)
                                                220   215   PAYER PAID AMOUNT                                          AMT               2320                         S               1

                                                                                             AMOUNT QUALIFIER CODE     AMT01       522   2320 M   ID   1/3    D
                                                                                             MONETARY AMOUNT           AMT02       782   2320 M   R    1/18
                                                            COORDINATION OF BENEFITS
                                                221   216   (COB)APPROVED AMOUNT                                       AMT               2320                         S               1

                                                                                             AMOUNT QUALIFIER CODE     AMT01       522   2320 M   ID   1/3    AAE
                                                                                             MONETARY AMOUNT           AMT02       782   2320 M   R    1/18
                                                            COORDINATION OF BENEFITS (COB)
                                                222   217   ALLOWED AMOUNT                                             AMT               2320                         S               1

                                                                                             AMOUNT QUALIFIER CODE     AMT01       522   2320 M   ID   1/3    B6
                                                                                             MONETARY AMOUNT           AMT02       782   2320 M   R    1/18
                                                            COORDINATION OF BENEFITS (COB)
                                                223   218   PATIENT RESPONSIBILITY AMOUNT                              AMT               2320                         S               1

                                                                                             AMOUNT QUALIFIER CODE     AMT01       522   2320 M   ID   1/3    F2
                                                                                             MONETARY AMOUNT           AMT02       782   2320 M   R    1/18
                                                            COORDINATION OF BENEFITS (COB)
                                                224   219   COVERED AMOUNT                                             AMT               2320                         S               1

                                                                                             AMOUNT QUALIFIER CODE     AMT01       522   2320 M   ID   1/3    AU


                                                                                              62
                                                                                                                                                                          Policy Memorandum 2004 - 3
                                                                                                                                                                          Exhibit 2K




                                                                           837 - HEALTH CLAIMS AND ENCOUNTERS (DENTAL)
INTERNAL    TABLE  /   FIELD    FIELD   FIELD   Old A1                                                                    REF     ELEMENT
RECORD ID   DATABASE   LENGTH   TYPE    NAME    PG PG       SEGMENT NAME                     ELEMENT NAME                 DES.     NUMBER   LOOP ATTRIBUTES       NOTES   USE       REPEAT
                                                                                             MONETARY AMOUNT              AMT02       782    2320 M   R    1/18
                                                            COORDINATION OF BENEFITS (COB)
                                                225   220   DISCOUNT AMOUNT                                               AMT                2320                         S               1

                                                                                             AMOUNT QUALIFIER CODE        AMT01       522    2320 M   ID   1/3    D8
                                                                                             MONETARY AMOUNT              AMT02       782    2320 M   R    1/18
                                                            COORDINATION OF BENEFITS (COB)
                                                226   221   PATIENT PAID AMOUNT                                           AMT                2320                         S               1

                                                                                             AMOUNT QUALIFIER CODE        AMT01       522    2320 M   ID   1/3    F5
                                                                                             MONETARY AMOUNT              AMT02       782    2320 M   R    1/18
                                                            OTHER INSURED DEMOGRAPHIC
                                                227   222   INFORMATION                                                   DMG                2320                         S               1

                                                                                             DATE TIME FORMAT QUALIFIER   DMG01      1250    2320 X   ID   2/3    D8
                                                                                             DATE TIME PERIOD             DMG02      1251    2320 X   AN   1/35
                                                                                             GENDER CODE                  DMG03      1068    2320 O   ID   1/1
                                                            OTHER INSURANCE COVERAGE
                                                229   224   INFORMATION                                                   OI                 2320                         R               1
                                                                                             YES/NO CONDITION OR
                                                                                             RESPONSE CODE                OI03       1073    2320 O   ID   1/1
                                                                                             RELEASE OF INFORMATION
                                                                                             CODE                         OI06       1363    2320 O   ID   1/1
                                                            LOOP ID - 2330A OTHER SUBSCRIBER NAME                                                                                         1


                                                231   226   OTHER SUBSCRIBER NAME                                         NM1                                             R               1
                                                                                             ENTITY IDENTIFIER CODE       NM101        98   2330A M   ID   2/3    IL




                                                                                               63
                                                                                                                                                                           Policy Memorandum 2004 - 3
                                                                                                                                                                           Exhibit 2K




                                                                           837 - HEALTH CLAIMS AND ENCOUNTERS (DENTAL)
INTERNAL    TABLE  /   FIELD    FIELD   FIELD   Old A1                                                                     REF     ELEMENT
RECORD ID   DATABASE   LENGTH   TYPE    NAME    PG PG       SEGMENT NAME                       ELEMENT NAME                DES.     NUMBER   LOOP ATTRIBUTES       NOTES   USE       REPEAT
                                                                                               ENTITY TYPE QUALIFIER       NM102      1065   2330A M   ID   1/1
                                                                                               NAME LAST OR ORGANIZATION
                                                                                               NAME                        NM103      1035   2330A O   AN   1/35
                                                                                               NAME FIRST                  NM104      1036   2330A O   AN   1/25
                                                                                               NAME MIDDLE                 NM105      1037   2330A O   AN   1/25
                                                                                               NAME SUFFIX                 NM107      1039   2330A O   AN   1/10
                                                                                               IDENTIFICATION CODE
                                                                                               QUALIFIER                   NM108        66   2330A X   ID   1/2


                                                                                               IDENTIFICATION CODE         NM109        67   2330A X   AN   2/80
                                                235   229   OTHER SUBSCRIBER ADDRESS                                       N3                2330A                         S               1
                                                                                               ADDRESS INFORMATION         N301        166   2330A M   AN   1/55
                                                                                               ADDRESS INFORMATION         N302        166   2330A O   AN   1/55
                                                            OTHER SUBSCRIBER CITY/STATE/ZIP
                                                236   230   CODE                                                           N4                2330A                         S               1
                                                                                               CITY NAME                   N401         19   2330A O   AN   2/30
                                                                                               STATE OR PROVINCE CODE      N402        156   2330A O   ID   2/2
                                                                                               POSTAL CODE                 N403        116   2330A O   ID   3/15
                                                                                               COUNTRY CODE                N404         26   2330A O   ID   2/3
                                                            OTHER SUBSCRIBER SECONDARY
                                                238   232   INFORMATION                                                    REF               2330A                         S               3

                                                                                               REFERENCE IDENTIFICATION
                                                                                               QUALIFIER                   REF01       128   2330A M   ID   2/3
                                                                                               REFERENCE IDENTIFICATION    REF02       127   2330A X   AN   1/30
                                                            LOOP ID - 2330B OTHER PAYER NAME                                                                                               1
                                                240   234   OTHER PAYER NAME                                               NM1                                             R               1
                                                                                               ENTITY IDENTIFIER CODE      NM101        98   2330B M   ID   2/3
                                                                                               ENTITY TYPE QUALIFIER       NM102      1065   2330B M   ID   1/1
                                                                                               NAME LAST OR ORGANIZATION
                                                                                               NAME                        NM103      1035   2330B O   AN   1/35
                                                                                               IDENTIFICATION CODE
                                                                                               QUALIFIER                   NM108        66   2330B X   ID   1/2


                                                                                               IDENTIFICATION CODE         NM109        67   2330B X   AN   2/80

                                                243   236   OTHER PAYER CONTACT INFORMATION                                PER               2330B                         S               2

                                                                                               CONTACT FUNCTION CODE       PER01       366   2330B M   ID   2/2
                                                                                               NAME                        PER02        93   2330B O   AN   1/60

                                                                                                64
                                                                                                                                                                          Policy Memorandum 2004 - 3
                                                                                                                                                                          Exhibit 2K




                                                                              837 - HEALTH CLAIMS AND ENCOUNTERS (DENTAL)
INTERNAL    TABLE  /   FIELD    FIELD   FIELD   Old A1                                                                    REF     ELEMENT
RECORD ID   DATABASE   LENGTH   TYPE    NAME    PG PG       SEGMENT NAME                       ELEMENT NAME               DES.     NUMBER   LOOP ATTRIBUTES       NOTES   USE       REPEAT
                                                                                               COMMUNICATION NUMBER
                                                                                               QUALIFIER                  PER03       365   2330B X   ID   2/2

                                                                                               COMMUNICATION NUMBER       PER04       364   2330B X   AN   1/80
                                                                                               COMMUNICATION NUMBER
                                                                                               QUALIFIER                  PER05       365   2330B X   ID   2/2

                                                                                               COMMUNICATION NUMBER       PER06       364   2330B X   AN   1/80
                                                                                               COMMUNICATION NUMBER
                                                                                               QUALIFIER                  PER07       365   2330B X   ID   2/2

                                                                                               COMMUNICATION NUMBER       PER08       364   2330B X   AN   1/80
                                                246   239   CLAIM PAID DATE                                               DTP               2330B                         S               1
                                                                                               DATE/TIME QUALIFIER        DTP01       374   2330B M   ID   3/3
                                                                                               DATE TIME PERIOD FORMAT
                                                                                               QUALIFIER                  DTP02      1250   2330B M   ID   2/3
                                                                                               DATE TIME PERIOD           DTP03      1251   2330B M   AN   1/35

                                                247   240   OTHER PAYER SECONDARY IDENTIFIER                              REF               2330B                         S               3

                                                                                               REFERENCE IDENTIFICATION
                                                                                               QUALIFIER                  REF01       128   2330B M   ID   2/3    2U
                                                                                               REFERENCE IDENTIFICATION   REF02       127   2330B X   AN   1/30
                                                            OTHER PAYER PRIOR AUTHORIZATION
                                                249   242   OR REFERRAL NUMBER                                            REF               2330B                         S               2

                                                                                               REFERENCE IDENTIFICATION
                                                                                               QUALIFIER                  REF01       128   2330B M   ID   2/3    9F
                                                                                               REFERENCE IDENTIFICATION   REF02       127   2330B X   AN   1/30




                                                                                                65
                                                                                                                                                                          Policy Memorandum 2004 - 3
                                                                                                                                                                          Exhibit 2K




                                                                            837 - HEALTH CLAIMS AND ENCOUNTERS (DENTAL)
INTERNAL    TABLE  /   FIELD    FIELD   FIELD   Old A1                                                                    REF     ELEMENT
RECORD ID   DATABASE   LENGTH   TYPE    NAME    PG PG        SEGMENT NAME                     ELEMENT NAME                DES.     NUMBER   LOOP ATTRIBUTES       NOTES   USE       REPEAT
                                                             OTHER PAYER CLAIM ADJUSTMENT
                                                251`   244   INDICATOR                                                    REF               2330B                         S               1

                                                                                              REFERENCE IDENTIFICATION
                                                                                              QUALIFIER                   REF01       128   2330B M   ID   2/3    T4
                                                                                              REFERENCE IDENTIFICATION    REF02       127   2330B X   AN   1/30


                                                             LOOP ID 2330C OTHER PAYER PATIENT INFORMATION                                                                                1
                                                253    246   OTHER PAYER PATIENT INFORMATION                              NM1                                             S               1
                                                                                              ENTITY IDENTIFIER CODE      NM101        98   2330C M   ID   2/3    QC
                                                                                              ENTITY TYPE QUALIFIER       NM102      1065   2330C M   ID   1/1    1
                                                                                              IDENTIFICATION CODE
                                                                                              QUALIFIER                   NM108        66   2330C X   ID   1/2    MI


                                                                                              IDENTIFICATION CODE         NM109        67   2330C X   AN   2/80
                                                             OTHER PAYER PATIENT
                                                255    248   IDENTIFICATION                                               REF               2330C                         S               3

                                                                                              REFERENCE IDENTIFICATION
                                                                                              QUALIFIER                   REF01       128   2330C M   ID   2/3
                                                                                              REFERENCE IDENTIFICATION    REF02       127   2330C X   AN   1/30
                                                             LOOP ID 2330D OTHER PAYER REFERRING PROVIDER                                                                                 1
                                                257    250   OTHER PAYER REFERRING PROVIDER                               NM1                                             S               1
                                                                                              ENTITY IDENTIFIER CODE      NM101        98   2330D M   ID   2/3
                                                                                              ENTITY TYPE QUALIFIER       NM102      1065   2330D M   ID   1/1
                                                                                              NAME LAST OR ORGANIZATION
                                                                                              NAME                        NM103      1035   2330D O   AN   1/35
                                                             OTHER PAYER REFERRING PROVIDER
                                                259    252   IDENTIFICATION                                               REF               2330D                         S               3

                                                                                              REFERENCE IDENTIFICATION
                                                                                              QUALIFIER                   REF01       128   2330D M   ID   2/3
                                                                                              REFERENCE IDENTIFICATION    REF02       127   2330D X   AN   1/30
                                                             LOOP ID 2330E OTHER PAYER RENDERING PROVIDER                                                                                 1
                                                261    254   OTHER PAYER RENDERING PROVIDER                               NM1                                             S               1
                                                                                              ENTITY IDENTIFIER CODE      NM101        98   2330E M   ID   2/3    82
                                                                                              ENTITY TYPE QUALIFIER       NM102      1065   2330E M   ID   1/1
                                                                                              NAME LAST OR ORGANIZATION
                                                                                              NAME                        NM103      1035   2330E O   AN   1/35


                                                                                                66
                                                                                                                                                                          Policy Memorandum 2004 - 3
                                                                                                                                                                          Exhibit 2K




                                                                             837 - HEALTH CLAIMS AND ENCOUNTERS (DENTAL)
INTERNAL    TABLE  /   FIELD    FIELD   FIELD   Old A1                                                                  REF       ELEMENT
RECORD ID   DATABASE   LENGTH   TYPE    NAME    PG PG       SEGMENT NAME                     ELEMENT NAME               DES.       NUMBER   LOOP ATTRIBUTES       NOTES   USE       REPEAT


                                                            OTHER PAYER RENDERING PROVIDER
                                                263   256   SECONDARY IDENTIFICATION                                    REF                 2330E                         S               3

                                                                                             REFERENCE IDENTIFICATION
                                                                                             QUALIFIER                  REF01         128   2330E M   ID   2/3
                                                                                             REFERENCE IDENTIFICATION   REF02         127   2330E X   AN   1/30
                                                            LOOP ID 2400 - LINE COUNTER                                                                                                  50
                                                265   258   LINE COUNTER                                                LX                                                R               1
                                                                                             ASSIGNED NUMBER            LX01          554    2400 M   NO   1/6
                                                266   259   DENTAL SERVICE                                              SV3                  2400                         R               1
                                                                                             COMPOSITE MEDICAL
                                                                                             PROCEDURE IDENTIFIER       SV301        C003    2400 M
                                                                                             PRODUCT/SERVICE ID
                                                                                             QUALIFIER                  SV301-1       235    2400 M   ID   2/2    AD
                                                                                             PRODUCT/SERVICE ID         SV301-2       234    2400 M   AN   1/48
                                                                                             PROCEDURE MODIFIER         SV301-3      1339    2400 O   AN   2/2
                                                                                             PROCEDURE MODIFIER         SV301-4      1339    2400 O   AN   2/2
                                                                                             PROCEDURE MODIFIER         SV301-5      1339    2400 O   AN   2/2
                                                                                             PROCEDURE MODIFIER         SV301-6      1339    2400 O   AN   2/2
                                                                                             MONETARY AMOUNT            SV302         782    2400 O   R    1/18
                                                                                             FACILITY CODE VALUE        SV303        1331    2400 O   AN   1/2
                                                                                             ORAL CAVITY DESIGNATION    SV304        C006    2400 O
                                                                                             ORAL CAVITY DESIGNATION
                                                                                             CODE                       SV304-1      1361    2400 M   ID   1/3
                                                                                             ORAL CAVITY DESIGNATION
                                                                                             CODE                       SV304-2      1361    2400 M   ID   1/3




                                                                                              67
                                                                                                                                                                       Policy Memorandum 2004 - 3
                                                                                                                                                                       Exhibit 2K




                                                                             837 - HEALTH CLAIMS AND ENCOUNTERS (DENTAL)
INTERNAL    TABLE  /   FIELD    FIELD   FIELD   Old A1                                                                REF       ELEMENT
RECORD ID   DATABASE   LENGTH   TYPE    NAME    PG PG       SEGMENT NAME                 ELEMENT NAME                 DES.       NUMBER   LOOP ATTRIBUTES      NOTES   USE       REPEAT
                                                                                         ORAL CAVITY DESIGNATION
                                                                                         CODE                         SV304-3      1361   2400 M   ID   1/3
                                                                                         ORAL CAVITY DESIGNATION
                                                                                         CODE                         SV304-4      1361   2400 M   ID   1/3
                                                                                         ORAL CAVITY DESIGNATION
                                                                                         CODE                         SV304-5      1361   2400 M   ID   1/3
                                                                                         PROSTHESIS, CROWN OR INLAY
                                                                                         CODE                         SV305        1358   2400 O   ID   1/1
                                                                                         QUANTITY                     SV306         380   2400 O   R    1/15
                                                271   265   TOOTH INFORMATION                                         TOO                 2400                         S              32
                                                                                         CODE LIST QUALIFIER CODE     TOO01        1270   2400 X   ID   1/3    JP
                                                                                         INDUSTRY CODE                TOO02        1271   2400 X   AN   1/30
                                                                                         TOOTH SURFACE                TOO03        C005   2400 O
                                                                                         TOOTH SURFACE CODE           TOO03-1      1369   2400 O   ID   1/2
                                                                                         TOOTH SURFACE CODE           TOO03-2      1369   2400 O   ID   1/2
                                                                                         TOOTH SURFACE CODE           TOO03-3      1369   2400 O   ID   1/2
                                                                                         TOOTH SURFACE CODE           TOO03-4      1369   2400 O   ID   1/2
                                                                                         TOOTH SURFACE CODE           TOO03-5      1369   2400 O   ID   1/2
                                                273   268   DATE - SERVICE                                            DTP                 2400                         S               1
                                                                                         DATE/TIME QUALIFIER          DTP01         374   2400 M   ID   3/3    472

                                                                                         DATE/TIME FORMAT QUALIFIER   DTP02        1250   2400 M   ID   2/3    D8
                                                                                         DATE TIME PERIOD             DTP03        1251   2400 M   AN   1/35
                                                275   270   DATE - PRIOR PLACEMENT                                    DTP                 2400                         S               1
                                                                                         DATE/TIME QUALIFIER          DTP01         374   2400 M   ID   3/3    441

                                                                                         DATE/TIME FORMAT QUALIFIER   DTP02        1250   2400 M   ID   2/3    D8
                                                                                         DATE TIME PERIOD             DTP03        1251   2400 M   AN   1/35
                                                277   272   DATE - APPLIANCE PLACEMENT                                DTP                 2400                         S               1
                                                                                         DATE/TIME QUALIFIER          DTP01         374   2400 M   ID   3/3    452

                                                                                         DATE/TIME FORMAT QUALIFIER   DTP02        1250   2400 M   ID   2/3    D8
                                                                                         DATE TIME PERIOD             DTP03        1251   2400 M   AN   1/35
                                                279   274   DATE - REPLACEMENT                                        DTP                 2400                         S               1
                                                                                         DATE/TIME QUALIFIER          DTP01         374   2400 M   ID   3/3    374

                                                                                         DATE/TIME FORMAT QUALIFIER   DTP02        1250   2400 M   ID   2/3    D8
                                                                                         DATE TIME PERIOD             DTP03        1251   2400 M   AN   1/35
                                                281   276   ANESTHESIA QUANTITY                                       QTY                 2400                         S               5


                                                                                          68
                                                                                                                                                                                   Policy Memorandum 2004 - 3
                                                                                                                                                                                   Exhibit 2K




                                                                           837 - HEALTH CLAIMS AND ENCOUNTERS (DENTAL)
INTERNAL    TABLE  /   FIELD    FIELD   FIELD   Old A1                                                                    REF     ELEMENT
RECORD ID   DATABASE   LENGTH   TYPE    NAME    PG PG       SEGMENT NAME                      ELEMENT NAME                DES.     NUMBER   LOOP ATTRIBUTES       NOTES            USE       REPEAT
                                                                                              QUANTITY QUALIFIER          QTY01       673    2400 M   ID   2/2
                                                                                              QUANTITY                    QTY02       380    2400 X   R    1/15
                                                            SERVICE PREDETERMINATION
                                                283   278   IDENTIFICATION                                                REF                2400                                  S               1
                                                                                              REFERENCE IDENTIFICATION
                                                                                              QUALIFIER                   REF01       128    2400 M   ID   2/3    G3
                                                                                              REFERENCE IDENTIFICATION    REF02       127    2400 X   AN   1/30
                                                            PRIOR AUTHORIZATION OR REFERRAL
                                                284   279   NUMBER                                                        REF                2400                                  S               2
                                                                                              REFERENCE IDENTIFICATION
                                                                                              QUALIFIER                   REF01       128    2400 M   ID   2/3    9F
                                                                                              REFERENCE IDENTIFICATION    REF02       127    2400 X   AN   1/30
                                                285   281   LINE ITEM CONTROL NUMBER                                      REF                2400                                  S               1
                                                                                              REFERENCE IDENTIFICATION
                                                                                              QUALIFIER                   REF01       128    2400 M   ID   2/3    6R
                                                                                              REFERENCE IDENTIFICATION    REF02       127    2400 X   AN   1/30
                                                287   283   APPROVED AMOUNT                                               AMT                2400                                  S               1
                                                                                              AMOUNT QUALIFIER CODE       AMT01       522    2400 M   ID   1/3    AAE
                                                                                              MONETARY AMOUNT             AMT02       782    2400 M   R    1/18
                                                      284   SALES TAX AMOUNT                                              AMT                                                      S               1
                                                                                              AMOUNT QUALIFIER CODE       AMT01       522    2400 M   ID   1/3
                                                                                              MONETARY AMOUNT             AMT02       782    2400 M   R    1/18
                                                288   285   LINE NOTE                                                     NTE                                                      S              10
                                                                                              NOTE REFERENCE CODE         NTE01       363    2400 O   ID   3/3    ADD
                                                                                              DESCRIPTION                 NTE02       352    2400 M   AN   1/80   FREE FORM TEXT
                                                            LOOP ID - 2420A RENDERING PROVIDER NAME                                                                                                1
                                                289   286   RENDERING PROVIDER NAME                                       NM1               2420A                                  S               1
                                                                                              ENTITY IDENTIFIER CODE      NM101        98   2420A M   ID   2/3    82
                                                                                              ENTITY TYPE QUALIFIER       NM102      1065   2420A M   ID   1/1
                                                                                              NAME LAST OR ORGANIZATION
                                                                                              NAME                        NM103      1035   2420A O   AN   1/35




                                                                                               69
                                                                                                                                                                                  Policy Memorandum 2004 - 3
                                                                                                                                                                                  Exhibit 2K




                                                                           837 - HEALTH CLAIMS AND ENCOUNTERS (DENTAL)
INTERNAL    TABLE  /   FIELD    FIELD   FIELD   Old A1                                                                    REF     ELEMENT
RECORD ID   DATABASE   LENGTH   TYPE    NAME    PG PG       SEGMENT NAME                      ELEMENT NAME                DES.     NUMBER   LOOP ATTRIBUTES       NOTES           USE       REPEAT
                                                                                              NAME FIRST                  NM104      1036   2420A O   AN   1/25
                                                                                              NAME MIDDLE                 NM105      1037   2420A O   AN   1/25
                                                                                              NAME SUFFIX                 NM107      1039   2420A O   AN   1/10

                                                                                              IDENTIFICATION CODE
                                                                                              QUALIFIER                   NM108        66   2420A X   ID   1/2


                                                                                              IDENTIFICATION CODE         NM109        67   2420A X   AN   2/80
                                                            RENDERING PROVIDER SPECIALTY
                                                292   289   INFORMATION                                                   PRV               2420A                                 S               1
                                                                                              PROVIDER CODE               PRV01      1221   2420A M   ID   1/3    PE
                                                                                              REFERENCE IDENTIFICATION
                                                                                              QUALIFIER                   PRV02       128   2420A M   ID   2/3    ZZ
                                                                                                                                                                  PROVIDER
                                                                                              REFERENCE IDENTIFICATION    PRV03       127   2420A M   AN   1/30   TAXONOMY CODE
                                                            RENDERING PROVIDER SECONDARY
                                                295   291   IDENTIFICATION                                                REF               2420A                                 S               5
                                                                                              REFERENCE IDENTIFICATION
                                                                                              QUALIFIER                   REF01       128   2420A M   ID   2/3
                                                                                              REFERENCE IDENTIFICATION    REF02       127   2420A X   AN   1/30
                                                            LOOP ID - 2420B OTHER PAYER PRIOR AUTHORIZATION OR REFERRAL NUMBER                                                                    1
                                                            OTHER PAYER PRIOR AUTHORIZATION
                                                297   293   OR REFERRAL NUMBER                                            NM1                                                     S               1
                                                                                              ENTITY IDENTIFIER CODE      NM101        98   2420B M   ID   2/3    PR
                                                                                              ENTITY TYPE QUALIFIER       NM102      1065   2420B M   ID   1/1
                                                                                              ID CODE QUALIFIER           NM108        66   2420B X   ID   1/2
                                                                                              ID CODE                     NM109        67   2420B X   AN   2/80
                                                            OTHER PAYER PRIOR AUTHORIZATION
                                                300   296   ORREFERRAL NUMBER                                             REF               2420B                 9F              S               2
                                                                                              REFERENCE IDENTIFICATION
                                                                                              QUALIFIER                   REF01       128   2420B M   ID   2/3
                                                                                              REFERENCE IDENTIFICATION    REF02       127   2420B X   AN   1/30
                                                            LOOP ID - 2420C ASSISTANT SURGEON NAME
                                                      298   ASSISTANT SURGEON NAME                                        NM1                                                     S               1
                                                                                              ENTITY IDENTIFIER CODE      NM101        98   2310D M   ID   2/3
                                                                                              ENTITY TYPE QUALIFIER       NM102      1065   2310D M   ID   1/1
                                                                                              ASSISTANT SURGEON LAST OR
                                                                                              ORGANIZATIONAL NAME         NM103      1035   2310D O   AN   1/35
                                                                                              ASSISTANT SURGEON FIRST
                                                                                              NAME                        NM104      1036   2310D O   AN   1/25


                                                                                               70
                                                                                                                                                                                     Policy Memorandum 2004 - 3
                                                                                                                                                                                     Exhibit 2K




                                                                           837 - HEALTH CLAIMS AND ENCOUNTERS (DENTAL)
INTERNAL    TABLE  /   FIELD    FIELD   FIELD   Old A1                                                                   REF     ELEMENT
RECORD ID   DATABASE   LENGTH   TYPE    NAME    PG PG      SEGMENT NAME                       ELEMENT NAME               DES.     NUMBER   LOOP ATTRIBUTES       NOTES               USE       REPEAT
                                                                                              ASSISTANT SURGEON MIDDLE
                                                                                              NAME                       NM105      1037   2310D O   AN   1/25
                                                                                              ASSISTANT SURGEON NAME
                                                                                              SUFFIX                     NM107      1039   2310D O   AN   1/10
                                                                                              IDENTIFICATION CODE
                                                                                              QUALIFIER                  NM108        66   2310D X   ID   1/2

                                                                                              ASSISTANT SURGEON'S
                                                                                              PRIMARY IDENTIFICATION
                                                                                              NUMBER                     NM109        67   2310D X   AN   2/80
                                                           ASSISTANT SURGEON SPECIALITY
                                                     301   CODE                                                          PRV                                                         S               1
                                                                                              PROVIDER CODE              PRV01      1221   2310D M   ID   1/3
                                                                                              REFERENCE IDENTIFICATION
                                                                                              QUALIFIER                  PRV02       128   2310D M   ID   2/3
                                                                                              PROVIDER SPECIALITY CODE   PRV03       127   2310D M   AN   1/30
                                                           ASSISTANT SURGEON SECONDARY
                                                     303   IDENTIFICATION                                                REF                                                         S               1
                                                                                              REFERENCE IDENTIFICATON
                                                                                              QUALIFIER                  REF01       128   2310D M   ID   2/3
                                                                                              ASSISTANT SURGEON
                                                                                              SECONDARY IDENTIFICATION
                                                                                              NUMNER                     REF02       127   2310D X   AN   1/30


                                                           LOOP ID - 2430 LINE ADJUDICATION INFORMATION                                                                                             25
                                                31   305   LINE ADJUDICATION INFORMATION                                 SVD                                                         S               1
                                                                                                                                                                 MATCH NM109 IN
                                                                                              ID CODE                    SVD01        67    2430 M   AN   2/80   2330B
                                                                                                                                                                 SERVICE LINE PAID
                                                                                              MONETARY AMOUNT            SVD02       782    2430 M   R    1/18   AMT
                                                                                              COMPOSITE MEDICAL
                                                                                              PROCEDURE IDENTIFIER       SVD03      C003    2430 O




                                                                                                71
                                                                                                                                                                          Policy Memorandum 2004 - 3
                                                                                                                                                                          Exhibit 2K




                                                                           837 - HEALTH CLAIMS AND ENCOUNTERS (DENTAL)
INTERNAL    TABLE  /   FIELD    FIELD   FIELD   Old A1                                                         REF       ELEMENT
RECORD ID   DATABASE   LENGTH   TYPE    NAME    PG PG       SEGMENT NAME             ELEMENT NAME              DES.       NUMBER   LOOP ATTRIBUTES      NOTES             USE       REPEAT
                                                                                     PRODUCT/SERVICE ID
                                                                                     QUALIFIER                 SVD03-1       235   2430 M   ID   2/2
                                                                                     PRODUCT/SERVICE ID        SVD03-2       234   2430 M   AN   1/48
                                                                                     PROCEDURE MODIFIER        SVD03-3      1339   2430 O   AN   2/2
                                                                                     PROCEDURE MODIFIER        SVD03-4      1339   2430 O   AN   2/2
                                                                                     PROCEDURE MODIFIER        SVD03-5      1339   2430 O   AN   2/2
                                                                                     PROCEDURE MODIFIER        SVD03-6      1339   2430 O   AN   2/2
                                                                                     DESCRIPTION               SVD03-7       352   2430 O   AN   1/80
                                                                                     QUANTITY                  SVD05         380   2430 O   R    1/15
                                                                                     ASSIGNED NUMBER           SVD06         554   2430 O   NO   1/6
                                                305   309   SERVICE ADJUSTMENT                                 CAS                 2430                 SEE USAGE NOTES   S              99

                                                                                     CLAIM ADJUSTMENT GROUP
                                                                                     CODE                      CAS01        1033   2430 M   ID   1/2
                                                                                     CLAIM ADJUSTMENT REASON
                                                                                     CODE                      CAS02        1034   2430 M   ID   1/5
                                                                                     MONETARY AMOUNT           CAS03         782   2430 M   R    1/18
                                                                                     QUANTITY                  CAS04         380   2430 O   R    1/15
                                                                                     CLAIM ADJUSTMENT REASON
                                                                                     CODE                      CAS05        1034   2430 M   ID   1/5
                                                                                     MONETARY AMOUNT           CAS06         782   2430 M   R    1/18
                                                                                     QUANTITY                  CAS07         380   2430 O   R    1/15
                                                                                     CLAIM ADJUSTMENT REASON
                                                                                     CODE                      CAS08        1034   2430 M   ID   1/5
                                                                                     MONETARY AMOUNT           CAS09         782   2430 M   R    1/18
                                                                                     QUANTITY                  CAS10         380   2430 O   R    1/15
                                                                                     CLAIM ADJUSTMENT REASON
                                                                                     CODE                      CAS11        1034   2430 M   ID   1/5
                                                                                     MONETARY AMOUNT           CAS12         782   2430 M   R    1/18
                                                                                     QUANTITY                  CAS13         380   2430 O   R    1/15
                                                                                     CLAIM ADJUSTMENT REASON
                                                                                     CODE                      CAS14        1034   2430 M   ID   1/5
                                                                                     MONETARY AMOUNT           CAS15         782   2430 M   R    1/18
                                                                                     QUANTITY                  CAS16         380   2430 O   R    1/15

                                                                                     CLAIM ADJUSTMENT REASON
                                                                                     CODE                      CAS17        1034   2430 M   ID   1/5
                                                                                     MONETARY AMOUNT           CAS18         782   2430 M   R    1/18
                                                                                     QUANTITY                  CAS19         380   2430 O   R    1/15
                                                312   316   LINE ADJUDICATION DATE                             DTP                 2430                                   R               1


                                                                                      72
                                                                                                                                                                                                                                        Policy Memorandum 2004 - 3
                                                                                                                                                                                                                                        Exhibit 2K




                                                                                                 837 - HEALTH CLAIMS AND ENCOUNTERS (DENTAL)
INTERNAL    TABLE  /   FIELD         FIELD    FIELD           Old A1                                                                                         REF             ELEMENT
RECORD ID   DATABASE   LENGTH        TYPE     NAME            PG PG         SEGMENT NAME                                ELEMENT NAME                         DES.             NUMBER             LOOP ATTRIBUTES      NOTES             USE       REPEAT
                                                                                                                        DATE/TIME QUALIFIER                  DTP01                  374          2430 M   ID   3/3    573

                                                                                                                        DATE/TIME FORMAT QUALIFIER           DTP02                 1250          2430 M   ID   2/3    D8
                                                                                                                        DATE TIME PERIOD                     DTP03                 1251          2430 M   AN   1/35
                                                             313   317      TRANSACTION SET TRAILER                                                          SE                            TRAILER                                      R               1
                                                                                                                        NUMBER OF INCLUDED
                                                                                                                        SEGMENTS                             SE01                     96   TRAILER M      NO   1/10
                                                                                                                        TRANSACTION SET CONTROL
                                                                                                                        NUMBER                               SE02                   329    TRAILER M      AN   4/9    MUST MATCH ST02
                                                                   4010 with Addenda                         Revised April 10, 2003

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




                                                                                                                           73
                                                                                                                                                                                                                                      Policy Memorandum 2004 - 37
                                                                                                                                                                                                                                      Exhibit 2L



                                                               837 - HEALTH CLAIMS AND ENCOUNTERS (INSTITUTIONAL)
INTERNAL    TABLE  /   FIELD               FIELD   Old                                                                                                 REF             ELEMENT
RECORD ID   DATABASE   LENGTH   FIELD TYPE NAME    PG A1 PG SEGMENT NAME                                 ELEMENT NAME                                  DES.             NUMBER        LOOP ATTRIBUTES          NOTES                  USE      REPEAT
                                                                                                                                                                                                               FUNCTIONAL
                                                            TABLE 1 - HEADER                                                                                                                                   GROUP: HC

                                                   56 56    TRANSACTION SET HEADER                                                                     ST                           HEADER                                            R          1

                                                                                                         TRANSACTION SET IDENTIFIER CODE               ST01                  143    HEADER M       ID   3/3    MUST BE 837
                                                                                                                                                                                                               MUST MATCH VALUE
                                                                                                         TRANSACTION SET CONTROL NUMBER                ST02                  329    HEADER M       AN   4/9    IN SE02
                                                            BEGINNING OF HIERARCHICAL
                                                   57 57    TRANSACTION                                                                                BHT                          HEADER                                            R          1
                                                                                                         HIERARCHICAL STRUCTURE CODE                   BHT01                1005    HEADER M       ID   4/4    0019
                                                                                                                                                                                                               00 = ORIGINAL
                                                                                                         TRANSACTION SET PURPOSE CODE                  BHT02                 353    HEADER M       ID   2/2    18 = REISSUE
                                                                                                                                                                                                               SUBMITTER'S FILE
                                                                                                         REFERENCE IDENTIFICATION                      BHT03                 127    HEADER O       AN   1/30   NUMBER
                                                                                                                                                                                                               TRANSACTION SET
                                                                                                         DATE                                          BHT04                 373    HEADER O       DT   8/8    CREATION DATE
                                                                                                         TIME                                          BHT05                 337    HEADER O       TM   4/8    CREATION TIME
                                                                                                                                                                                                               CH = FEE-FOR-
                                                                                                                                                                                                               SERVICE
                                                                                                         TRANSACTION TYPE CODE                         BHT06                 640    HEADER O       ID   2/2    RP = ENCOUNTERS

                                                   60 60    TRANSMISSION TYPE IDENTIFICATION                                                           REF                          HEADER                                            R          1
                                                                                                         REFERENCE IDENTIFICATION QUALIFIER            REF01                 128    HEADER M       ID   2/3    87
                                                                                                         REFERENCE IDENTIFICATION                      REF02                 127    HEADER X       AN   1/30   VERSION NUMBER
                                                            LOOP ID - 1000A SUBMITTER NAME                                                                                                                                                       1
                                                   61 61    SUBMITTER NAME                                                                             NM1                            1000A                                           R          1
                                                                                                         ENTITY IDENTIFIER CODE                        NM101                   98     1000A M      ID   2/3    41 (SUBMITTER)
                                                                                                         ENTITY TYPE QUALIFIER                         NM102                1065      1000A M      ID   1/1
                                                                                                         NAME LAST OR ORGANIZATION NAME                NM103                1035      1000A O      AN   1/35   SUBMITTER NAME
                                                                                                                                                                                                               SUBMITTER FIRST
                                                                                                         NAME FIRST                                    NM104                1036      1000A O      AN   1/25   NAME
                                                                                                                                                                                                               SUBMITTER MIDDLE
                                                                                                         NAME MIDDLE                                   NM105                1037      1000A O      AN   1/25   NAME

                                                                                                         IDENTIFICATION CODE QUALIFIER                 NM108                   66     1000A X      ID   1/2    46
                                                                                                                                                                                                               SUBMITTER ID
                                                                                                         IDENTIFICATION CODE                           NM109                   67     1000A X      AN   2/80   NUMBER


                                                   64 64    SUBMITTER EDI CONTACT INFORMATION                                                          PER                            1000A                                           R          2
                                                                                                         CONTACT FUNCTION CODE                         PER01                 366      1000A M      ID   2/2    IC


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




                                                                                                                   74
                                                                                                                                                                                                     Policy Memorandum 2004 - 37
                                                                                                                                                                                                     Exhibit 2L



                                                              837 - HEALTH CLAIMS AND ENCOUNTERS (INSTITUTIONAL)
INTERNAL    TABLE  /   FIELD               FIELD   Old                                                                                REF     ELEMENT
RECORD ID   DATABASE   LENGTH   FIELD TYPE NAME    PG A1 PG SEGMENT NAME                         ELEMENT NAME                         DES.     NUMBER    LOOP ATTRIBUTES       NOTES                 USE     REPEAT
                                                                                                 NAME                                 PER02        93    1000A O   AN   1/60
                                                                                                 COMMUNICATION NUMBER QUALIFIER       PER03       365    1000A X   ID   2/2
                                                                                                 COMMUNICATION NUMBER                 PER04       364    1000A X   AN   1/80
                                                                                                 COMMUNICATION NUMBER QUALIFIER       PER05       365    1000A X   ID   2/2
                                                                                                 COMMUNICATION NUMBER                 PER06       364    1000A X   AN   1/80
                                                                                                 COMMUNICATION NUMBER QUALIFIER       PER07       365    1000A X   ID   2/2
                                                                                                 COMMUNICATION NUMBER                 PER08       364    1000A X   AN   1/80
                                                            LOOP ID - 1000B RECEIVER NAME                                                                                                                       1
                                                   67 67    RECEIVER NAME                                                             NM1                1000B                                       R          1
                                                                                                 ENTITY IDENTIFIER CODE               NM101        98    1000B M   ID   2/3    40
                                                                                                 ENTITY TYPE QUALIFIER                NM102      1065    1000B M   ID   1/1    2
                                                                                                 NAME LAST OR ORGANIZATION NAME       NM103      1035    1000B O   AN   1/35   RECEIVER NAME
                                                                                                 IDENTIFICATION CODE QUALIFIER        NM108        66    1000B X   ID   1/2    46
                                                                                                                                                                               RECEIVER ID
                                                                                                 IDENTIFICATION CODE                  NM109        67    1000B X   AN   2/80   NUMBER
                                                            TABLE 2 - DETAIL, BILLING/PAY-TO PROVIDER HIERARCHICAL LEVEL
                                                            LOOP ID - 2000A BILLING/PAY-TO PROVIDER HIERARCHICAL LEVEL                                                                                         >1
                                                            BILLING/PAY-TO PROVIDER                                                                                            RECOMMENDED
                                                   69 69    HIERARCHICAL LEVEL                                                        HL                 2000A                 MAX = 5000            R          1
                                                                                                 HIERARCHICAL ID NUMBER               HL01        628    2000A M   AN   1/12
                                                                                                 HIERARCHICAL LEVEL CODE              HL03        735    2000A M   ID   1/2    20
                                                                                                 HIERARCHICAL CHILD CODE              HL04        736    2000A O   ID   1/1    1
                                                            BILLING/PAY-TO PROVIDER SPECIALTY
                                                   71 71    INFORMATION                                                               PRV                2000A                                       S          1
                                                                                                                                                                               BI = BILLING   PT =
                                                                                                 PROVIDER CODE                        PRV01      1221    2000A M   ID   1/3    PAY TO
                                                                                                 REFERENCE IDENTIFICATION QUALIFIER   PRV02       128    2000A M   ID   2/3    ZZ
                                                                                                                                                                               PROVIDER
                                                                                                 REFERENCE IDENTIFICATION             PRV03       127    2000A M   AN   1/30   TAXONOMY CODE
                                                   73 73    FOREIGN CURRENCY INFORMATION                                              CUR                2000A                                       S          1
                                                                                                                                                                               85 (BILLING
                                                                                                 ENTITY IDENTIFIER CODE               CUR01        98    2000A M   ID   2/3    PROVIDER)
                                                                                                 CURRENCY CODE                        CUR02       100    2000A M   ID   3/3
                                                            LOOP ID - 2010AA BILLING PROVIDER NAME                                                                                                              1
                                                   76 76    BILLING PROVIDER NAME                                                     NM1               2010AA                                       R          1
                                                                                                 ENTITY IDENTIFIER CODE               NM101        98   2010AA M   ID   2/3    85
                                                                                                 ENTITY TYPE QUALIFIER                NM102      1065   2010AA M   ID   1/1    2


                                                                                                 NAME LAST OR ORGANIZATION NAME       NM103      1035   2010AA O   AN   1/35
                                                                                                 IDENTIFICATION CODE QUALIFIER        NM108        66   2010AA X   ID   1/2
                                                                                                 IDENTIFICATION CODE                  NM109        67   2010AA X   AN   2/80
                                                   79 79    BILLING PROVIDER ADDRESS                                                  N3                2010AA                                       R          1
                                                                                                 ADDRESS INFORMATION                  N301        166   2010AA M   AN   1/55   ADDRESS LINE 1
                                                                                                 ADDRESS INFORMATION                  N302        166   2010AA O   AN   1/55   ADDRESS LINE 2

                                                                                                         75
                                                                                                                                                                                                   Policy Memorandum 2004 - 37
                                                                                                                                                                                                   Exhibit 2L



                                                              837 - HEALTH CLAIMS AND ENCOUNTERS (INSTITUTIONAL)
INTERNAL    TABLE  /   FIELD               FIELD   Old                                                                                   REF     ELEMENT
RECORD ID   DATABASE   LENGTH   FIELD TYPE NAME    PG A1 PG SEGMENT NAME                            ELEMENT NAME                         DES.     NUMBER    LOOP ATTRIBUTES       NOTES            USE     REPEAT


                                                   80 80    BILLING PROVIDER CITY/STATE/ZIP CODE                                         N4                2010AA                                  R          1
                                                                                                    CITY NAME                            N401         19   2010AA O   AN   2/30
                                                                                                    STATE OR PROVINCE CODE               N402        156   2010AA O   ID   2/2
                                                                                                    POSTAL CODE                          N403        116   2010AA O   ID   3/15
                                                                                                    COUNTRY CODE                         N404         26   2010AA O   ID   2/3
                                                            BILLING PROVIDER SECONDARY
                                                   82 82    INFORMATION                                                                  REF               2010AA                                  S          8
                                                                                                    REFERENCE IDENTIFICATION QUALIFIER   REF01       128   2010AA M   ID   2/3    SEE CODE LIST
                                                                                                    REFERENCE IDENTIFICATION             REF02       127   2010AA M   AN   1/30
                                                            CREDIT/DEBIT CARD BILLING
                                                   85 85    INFORMATION                                                                  REF               2010AA                                  S          8
                                                                                                    REFERENCE IDENTIFICATION QUALIFIER   REF01       128   2010AA M   ID   2/3    SEE CODE LIST
                                                                                                    REFERENCE IDENTIFICATION             REF02       127   2010AA M   AN   1/30
                                                            BILLING PROVIDER CONTACT
                                                   87 87    INFORMATION                                                                  PER               2010AA                                  S          2
                                                                                                    CONTACT FUNCTION CODE                PER01       366   2010AA M   ID   2/2    IC
                                                                                                    NAME                                 PER02        93   2010AA O   AN   1/60
                                                                                                    COMMUNICATION NUMBER QUALIFIER       PER03       365   2010AA X   ID   2/2
                                                                                                    COMMUNICATION NUMBER                 PER04       364   2010AA X   AN   1/80
                                                                                                    COMMUNICATION NUMBER QUALIFIER       PER05       365   2010AA X   ID   2/2
                                                                                                    COMMUNICATION NUMBER                 PER06       364   2010AA X   AN   1/80
                                                                                                    COMMUNICATION NUMBER QUALIFIER       PER07       365   2010AA X   ID   2/2
                                                                                                    COMMUNICATION NUMBER                 PER08       364   2010AA X   AN   1/80
                                                            LOOP ID - 2010AB PAY-TO PROVIDER NAME                                                                                                             1
                                                   91 91    PAY-TO PROVIDER NAME                                                         NM1               2010AB                                  S          1
                                                                                                    ENTITY IDENTIFIER CODE               NM101        98   2010AB M   ID   2/3    87
                                                                                                    ENTITY TYPE QUALIFIER                NM102      1065   2010AB M   ID   1/1
                                                                                                    NAME LAST OR ORGANIZATION NAME       NM103      1035   2010AB O   AN   1/35
                                                                                                    IDENTIFICATION CODE QUALIFIER        NM108        66   2010AB X   ID   1/2
                                                                                                    IDENTIFICATION CODE                  NM109        67   2010AB X   AN   2/80
                                                   94 94    PAY-TO PROVIDER ADDRESS                                                      N3                2010AB                                  R          1
                                                                                                    ADDRESS INFORMATION                  N301        166   2010AB M   AN   1/55   ADDRESS LINE 1
                                                                                                    ADDRESS INFORMATION                  N302        166   2010AB O   AN   1/55   ADDRESS LINE 2


                                                   95 95    PAY-TO PROVIDER CITY/STATE/ZIP CODE                                          N4                2010AB                                  R          1
                                                                                                    CITY NAME                            N401         19   2010AB O   AN   2/30
                                                                                                    STATE OR PROVINCE CODE               N402        156   2010AB O   ID   2/2
                                                                                                    POSTAL CODE                          N403        116   2010AB O   ID   3/15
                                                                                                    COUNTRY CODE                         N404         26   2010AB O   ID   2/3
                                                            PAY-TO PROVIDER SECONDARY
                                                   97 97    INFORMATION                                                                  REF               2010AB                                  S          5
                                                                                                    REFERENCE IDENTIFICATION QUALIFIER   REF01       128   2010AB M   ID   2/3    SEE CODE LIST


                                                                                                           76
                                                                                                                                                                                                  Policy Memorandum 2004 - 37
                                                                                                                                                                                                  Exhibit 2L



                                                               837 - HEALTH CLAIMS AND ENCOUNTERS (INSTITUTIONAL)
INTERNAL    TABLE  /   FIELD               FIELD   Old                                                                                 REF     ELEMENT
RECORD ID   DATABASE   LENGTH   FIELD TYPE NAME    PG A1 PG SEGMENT NAME                          ELEMENT NAME                         DES.     NUMBER    LOOP ATTRIBUTES       NOTES             USE     REPEAT
                                                                                                  REFERENCE IDENTIFICATION             REF02       127   2010AB M   AN   1/30
                                                             TABLE 2 - DETAIL, SUBSCRIBER HIERARCHICAL LEVEL
                                                             LOOP ID - 2000B SUBSCRIBER HIERARCHICAL LEVEL                                                                                                  >1
                                                                                                                                                                                SEE NOTES ON
                                                   99 99     SUBSCRIBER HIERARCHICAL LEVEL                                             HL                 2000B                 SEGMENT USAGE     R          1
                                                                                                  HIERARCHICAL ID NUMBER               HL01        628    2000B M   AN   1/12
                                                                                                  HIERARCHICAL PARENT ID               HL02        734    2000B O   AN   1/12
                                                                                                  HIERARCHICAL LEVEL CODE              HL03        735    2000B M   ID   1/2    22 (SUBSCRIBER)
                                                                                                  HIERARCHICAL CHILD CODE              HL04        736    2000B O   ID   1/1
                                                   101 101   SUBSCRIBER INFORMATION                                                    SBR                2000B                                   R          1
                                                                                                  PAYER RESPONSIBILITY SEQUENCE
                                                                                                  NUMBER CODE                          SBR01      1138    2000B M   ID   1/1
                                                                                                  INDIVIDUAL RELATIONSHIP CODE         SBR02      1069    2000B O   ID   2/2    18 (SELF)
                                                                                                  REFERENCE IDENTIFICATION             SBR03       127    2000B O   AN   1/30
                                                                                                  NAME                                 SBR04        93    2000B O   AN   1/60
                                                                                                  CLAIM FILING INDICATOR CODE          SBR09      1032    2000B O   ID   1/2
                                                             LOOP ID - 2010BA SUBSCRIBER NAME                                                                                                                1
                                                   108 106   SUBSCRIBER NAME                                                           NM1               2010BA                                   R          1
                                                                                                  ENTITY IDENTIFIER CODE               NM101        98   2010BA M   ID   2/3    IL
                                                                                                  ENTITY TYPE QUALIFIER                NM102      1065   2010BA M   ID   1/1
                                                                                                  NAME LAST OR ORGANIZATION NAME       NM103      1035   2010BA O   AN   1/35
                                                                                                  NAME FIRST                           NM104      1036   2010BA O   AN   1/25
                                                                                                  NAME MIDDLE                          NM105      1037   2010BA O   AN   1/25
                                                                                                  NAME SUFFIX                          NM107      1039   2010BA O   AN   1/10
                                                                                                  IDENTIFICATION CODE QUALIFIER        NM108        66   2010BA X   ID   1/2
                                                                                                  IDENTIFICATION CODE                  NM109        67   2010BA X   AN   2/80
                                                   112 109   SUBSCRIBER ADDRESS                                                        N3                2010BA                                   S          1
                                                                                                  ADDRESS INFORMATION                  N301        166   2010BA M   AN   1/55   ADDRESS LINE 1
                                                                                                  ADDRESS INFORMATION                  N302        166   2010BA O   AN   1/55   ADDRESS LINE 2
                                                   113 110   SUBSCRIBER CITY/STATE/ZIP CODE                                            N4                2010BA                                   S          1
                                                                                                  CITY NAME                            N401         19   2010BA O   AN   2/30
                                                                                                  STATE OR PROVINCE CODE               N402        156   2010BA O   ID   2/2
                                                                                                  POSTAL CODE                          N403        116   2010BA O   ID   3/15
                                                                                                  COUNTRY CODE                         N404         26   2010BA O   ID   2/3
                                                             SUBSCRIBER DEMOGRAPHIC
                                                   115 112   INFORMATION                                                               DMG               2010BA                                   S          1
                                                                                                  DATE TIME FORMAT QUALIFIER           DMG01      1250   2010BA X   ID   2/3
                                                                                                  DATE TIME PERIOD                     DMG02      1251   2010BA X   AN   1/35
                                                                                                  GENDER CODE                          DMG03      1068   2010BA O   ID   1/1
                                                             SUBSCRIBER SECONDARY
                                                   117 114   IDENTIFICATION                                                            REF               2010BA                                   S          4
                                                                                                  REFERENCE IDENTIFICATION QUALIFIER   REF01       128   2010BA M   ID   2/3
                                                                                                  REFERENCE IDENTIFICATION             REF02       127   2010BA M   AN   1/30


                                                                                                         77
                                                                                                                                                                                                  Policy Memorandum 2004 - 37
                                                                                                                                                                                                  Exhibit 2L



                                                               837 - HEALTH CLAIMS AND ENCOUNTERS (INSTITUTIONAL)
INTERNAL    TABLE  /   FIELD               FIELD   Old                                                                                REF     ELEMENT
RECORD ID   DATABASE   LENGTH   FIELD TYPE NAME    PG A1 PG SEGMENT NAME                         ELEMENT NAME                         DES.     NUMBER    LOOP ATTRIBUTES       NOTES              USE     REPEAT
                                                            PROPERTY AND CASUALTY CLAIM
                                                   119 116  NUMBER                                                                    REF               2010BA                                    S          1

                                                                                                 REFERENCE IDENTIFICATION QUALIFIER   REF01       128   2010BA M   ID   2/3
                                                                                                 REFERENCE IDENTIFICATION             REF02       127   2010BA M   AN   1/30
                                                             LOOP ID 2010BB - CREDIT/DEBIT CARD ACCOUNT HOLDER NAME                                                                                          1
                                                             CREDIT/DEBIT CARD ACCOUNT HOLDER
                                                   121 118   NAME                                                                     NM1               2010BB                                    S          1
                                                                                                 ENTITY IDENTIFIER CODE               NM101        98   2010BB M   ID   2/3    AO
                                                                                                 ENTITY TYPE QUALIFIER                NM102      1065   2010BB M   ID   1/1
                                                                                                 NAME LAST OR ORGANIZATION NAME       NM103      1035   2010BB O   AN   1/35
                                                                                                                                                                               REQUIRED IF
                                                                                                 NAME FIRST                           NM104      1036   2010BB O   AN   1/25   NM102=1
                                                                                                 NAME MIDDLE                          NM105      1037   2010BB O   AN   1/25
                                                                                                 IDENTIFICATION CODE QUALIFIER        NM108        66   2010BB X   ID   1/2


                                                                                                 IDENTIFICATION CODE                  NM109        67   2010BB X   AN   2/80
                                                   124 121   CREDIT/DEBIT CARD INFORMATION                                            REF               2010BB                                    S          2
                                                                                                 REFERENCE IDENTIFICATION QUALIFIER   REF01       128   2010BB M   ID   2/3


                                                                                                 REFERENCE IDENTIFICATION             REF02       127   2010BB M   AN   1/30
                                                             LOOP ID - 2010BC PAYER NAME                                                                                                                     1
                                                   126 123   PAYER NAME                                                               NM1               2010BC                                    R          1
                                                                                                 ENTITY IDENTIFIER CODE               NM101        98   2010BC M   ID   2/3    PR
                                                                                                 ENTITY TYPE QUALIFIER                NM102      1065   2010BC M   ID   1/1    2
                                                                                                 NAME LAST OR ORGANIZATION NAME       NM103      1035   2010BC O   AN   1/35
                                                                                                 IDENTIFICATION CODE QUALIFIER        NM108        66   2010BC X   ID   1/2
                                                                                                 IDENTIFICATION CODE                  NM109        67   2010BC X   AN   2/80   PAYER IDENTIFIER
                                                   129 126   PAYER ADDRESS                                                            N3                2010BC                                    S          1


                                                                                                 ADDRESS INFORMATION                  N301        166   2010BC M   AN   1/55   ADDRESS LINE 1
                                                                                                 ADDRESS INFORMATION                  N302        166   2010BC O   AN   1/55   ADDRESS LINE 2
                                                   130 127   PAYER CITY/STATE/ZIP CODE                                                N4                2010BC                                    S          1
                                                                                                 CITY NAME                            N401         19   2010BC O   AN   2/30
                                                                                                 STATE OR PROVINCE CODE               N402        156   2010BC O   ID   2/2
                                                                                                 POSTAL CODE                          N403        116   2010BC O   ID   3/15
                                                                                                 COUNTRY CODE                         N404         26   2010BC O   ID   2/3
                                                   132       PAYER SECONDARY IDENTIFICATION                                           REF               2010BC
                                                                                                 REFERENCE IDENTIFICATION QUALIFIER   REF01       128   2010BC M   ID   2/3
                                                                                                 REFERENCE IDENTIFICATION             REF02       127   2010BC M   AN   1/30
                                                             LOOP ID - 2010BD RESPONSIBLE PARTY NAME                                                                                                         1
                                                   134 131   RESPONSIBLE PARTY NAME                                                   NM1               2010BD                                    S          1
                                                                                                 ENTITY IDENTIFIER CODE               NM101        98   2010BD M   ID   2/3    QD

                                                                                                        78
                                                                                                                                                                                              Policy Memorandum 2004 - 37
                                                                                                                                                                                              Exhibit 2L



                                                               837 - HEALTH CLAIMS AND ENCOUNTERS (INSTITUTIONAL)
INTERNAL    TABLE  /   FIELD               FIELD   Old                                                                              REF     ELEMENT
RECORD ID   DATABASE   LENGTH   FIELD TYPE NAME    PG A1 PG SEGMENT NAME                           ELEMENT NAME                     DES.     NUMBER    LOOP ATTRIBUTES       NOTES            USE     REPEAT
                                                                                                   ENTITY TYPE QUALIFIER            NM102      1065   2010BD M   ID   1/1
                                                                                                   NAME LAST OR ORGANIZATION NAME   NM103      1035   2010BD O   AN   1/35
                                                                                                   NAME FIRST                       NM104      1036   2010BD O   AN   1/25
                                                                                                   NAME MIDDLE                      NM105      1037   2010BD O   AN   1/25
                                                                                                   NAME SUFFIX                      NM107      1039   2010BD O   AN   1/10
                                                   136 133   RESPONSIBLE PARTY ADDRESS                                              N3                2010BD                                  R          1
                                                                                                   ADDRESS INFORMATION              N301        166   2010BD M   AN   1/55   ADDRESS LINE 1
                                                                                                   ADDRESS INFORMATION              N302        166   2010BD O   AN   1/55   ADDRESS LINE 2
                                                   137 134   RESPONSIBLE PARTY CITY/STATE/ZIP                                       N4                2010BD                                  R          1
                                                                                                   CITY NAME                        N401         19   2010BD O   AN   2/30
                                                                                                   STATE OR PROVINCE CODE           N402        156   2010BD O   ID   2/2
                                                                                                   POSTAL CODE                      N403        116   2010BD O   ID   3/15
                                                                                                   COUNTRY CODE                     N404         26   2010BD O   ID   2/3
                                                             TABLE 2 - DETAIL, PATIENT HIERARCHICAL LEVEL
                                                             LOOP ID - 2000C PATIENT HIERARCHICAL LEVEL                                                                                                 >1
                                                   139 136   PATIENT HIERARCHICAL LEVEL                                             HL                 2000C                                  S          1
                                                                                                   HIERARCHICAL ID NUMBER           HL01        628    2000C M   AN   1/12
                                                                                                   HIERARCHICAL PARENT ID           HL02        734    2000C O   AN   1/12
                                                                                                   HIERARCHICAL LEVEL CODE          HL03        735    2000C M   ID   1/2    23
                                                                                                   HIERARCHICAL CHILD CODE          HL04        736    2000C O   ID   1/1    0
                                                   141 138   PATIENT INFORMATION                                                    PAT                2000C                                  R          1
                                                                                                   INDIVIDUAL RELATIONSHIP CODE     PAT01      1069    2000C O   ID   2/2
                                                             LOOP ID - 2010CA PATIENT NAME                                                                                                               1
                                                   145 142   PATIENT NAME                                                           NM1               2010CA                                  R          1
                                                                                                   ENTITY IDENTIFIER CODE           NM101        98   2010CA M   ID   2/3    QC


                                                                                                   ENTITY TYPE QUALIFIER            NM102      1065   2010CA M   ID   1/1    1
                                                                                                   NAME LAST OR ORGANIZATION NAME   NM103      1035   2010CA O   AN   1/35
                                                                                                   NAME FIRST                       NM104      1036   2010CA O   AN   1/25
                                                                                                   NAME MIDDLE                      NM105      1037   2010CA O   AN   1/25
                                                                                                   NAME SUFFIX                      NM107      1039   2010CA O   AN   1/10
                                                                                                   IDENTIFICATION CODE QUALIFIER    NM108        66   2010CA X   ID   1/2
                                                                                                   IDENTIFICATION CODE              NM109        67   2010CA X   AN   2/80
                                                   148 145   PATIENT ADDRESS                                                        N3                2010CA                                  R          1
                                                                                                   ADDRESS INFORMATION              N301        166   2010CA M   AN   1/55   ADDRESS LINE 1
                                                                                                   ADDRESS INFORMATION              N302        166   2010CA O   AN   1/55   ADDRESS LINE 2
                                                   149 146   PATIENT CITY/STATE/ZIP CODE                                            N4                2010CA                                  R          1
                                                                                                   CITY NAME                        N401         19   2010CA O   AN   2/30
                                                                                                   STATE OR PROVINCE CODE           N402        156   2010CA O   ID   2/2


                                                                                                   POSTAL CODE                      N403        116   2010CA O   ID   3/15
                                                                                                   COUNTRY CODE                     N404         26   2010CA O   ID   2/3

                                                                                                            79
                                                                                                                                                                                                   Policy Memorandum 2004 - 37
                                                                                                                                                                                                   Exhibit 2L



                                                               837 - HEALTH CLAIMS AND ENCOUNTERS (INSTITUTIONAL)
INTERNAL    TABLE  /   FIELD               FIELD   Old                                                                               REF       ELEMENT
RECORD ID   DATABASE   LENGTH   FIELD TYPE NAME    PG A1 PG SEGMENT NAME                        ELEMENT NAME                         DES.       NUMBER    LOOP ATTRIBUTES       NOTES              USE     REPEAT
                                                   151 148   PATIENT DEMOGRAPHIC INFORMATION                                         DMG                 2010CA                                    R          1
                                                                                                DATE TIME FORMAT QUALIFIER           DMG01        1250   2010CA X   ID   2/3
                                                                                                DATE TIME PERIOD                     DMG02        1251   2010CA X   AN   1/35
                                                                                                GENDER CODE                          DMG03        1068   2010CA O   ID   1/1
                                                   153 150   PATIENT SECONDARY IDENTIFICATION                                        REF                 2010CA                                    S          5
                                                                                                REFERENCE IDENTIFICATION QUALIFIER   REF01         128   2010CA M   ID   2/3
                                                                                                REFERENCE IDENTIFICATION             REF02         127   2010CA M   AN   1/30
                                                             PROPERTY AND CASUALTY CLAIM
                                                   155 152   NUMBER                                                                  REF                 2010CA                                    S          1


                                                                                                REFERENCE IDENTIFICATION QUALIFIER   REF01         128   2010CA M   ID   2/3
                                                                                                REFERENCE IDENTIFICATION             REF02         127   2010CA M   AN   1/30
                                                             LOOP ID - 2300 CLAIM INFORMATION                                                                                                                100
                                                   157 154   CLAIM INFORMATION                                                       CLM                   2300                                    R          1
                                                                                                                                                                                MUST SUPPORT UP
                                                                                                CLAIM SUBMITTER'S IDENTIFIER         CLM01        1028     2300 M   AN   1/38   TO 20 CHARACTERS
                                                                                                                                                                                TOTAL CLAIM
                                                                                                MONETARY AMOUNT                      CLM02         782     2300 O   R    1/18   CHARGE AMOUNT
                                                                                                HEALTH CARE SERVICE LOCATION                                                    PLACE OF SERVICE
                                                                                                INFORMATION                          CLM05        C023     2300 O               CODE
                                                                                                FACILITY CODE VALUE                  CLM05-1      1331     2300 M   AN   1/2

                                                                                                FACILITY CODE QUALIFIER              CLM05-2      1332     2300 O   ID   1/2    A
                                                                                                CLAIM FREQUENCY TYPE CODE            CLM05-3      1325     2300 O   ID   1/1

                                                                                                YES/NO CONDITION OR RESPONSE CODE CLM06           1073     2300 O   ID   1/1

                                                                                                                                                                                MEDICARE
                                                                                                PROVIDER ACCEPT ASSIGNMENT CODE      CLM07        1359     2300 O   ID   1/1    ASSIGNMENT CODE
                                                                                                                                                                                ASSIGNMENT OF
                                                                                                                                                                                BENEFITS
                                                                                                YES/NO CONDITION OR RESPONSE CODE CLM08           1073     2300 O   ID   1/1    INDICATOR
                                                                                                RELEASE OF INFORMATION CODE       CLM09           1363     2300 O   ID   1/1

                                                                                                YES/NO CONDITION OR RESPONSE CODE CLM18           1073     2300 O   ID   1/1
                                                                                                                                                                                REASON FOR LATE
                                                                                                DELAY REASON CODE                    CLM20        1514     2300 O   ID   1/2    FILING
                                                   165 162   DISCHARGE HOUR                                                          DTP                   2300                                    S          1
                                                                                                DATE/TIME QUALIFIER                  DTP01         374     2300 M   ID   3/3    096

                                                                                                DATE TIME PERIOD FORMAT QUALIFIER    DTP02        1250     2300 M   ID   2/3    TM

                                                                                                DATE TIME PERIOD                     DTP03        1251     2300 M   AN   1/35

                                                   167 164   STATEMENT DATES                                                         DTP                   2300                                    R          1



                                                                                                       80
                                                                                                                                                                                            Policy Memorandum 2004 - 37
                                                                                                                                                                                            Exhibit 2L



                                                               837 - HEALTH CLAIMS AND ENCOUNTERS (INSTITUTIONAL)
INTERNAL    TABLE  /   FIELD               FIELD   Old                                                                               REF     ELEMENT
RECORD ID   DATABASE   LENGTH   FIELD TYPE NAME    PG A1 PG SEGMENT NAME                        ELEMENT NAME                         DES.     NUMBER   LOOP ATTRIBUTES      NOTES           USE     REPEAT

                                                                                                DATE/TIME QUALIFIER                  DTP01       374   2300 M   ID   3/3    434

                                                                                                DATE TIME PERIOD FORMAT QUALIFIER    DTP02      1250   2300 M   ID   2/3
                                                                                                DATE                                 DTP03      1251   2300 M   AN   1/35
                                                   169 166   ADMISSION DATE/HOUR                                                     DTP               2300                                 S          1
                                                                                                DATE/TIME QUALIFIER                  DTP01       374   2300 M   ID   3/3    435

                                                                                                DATE TIME PERIOD FORMAT QUALIFIER    DTP02      1250   2300 M   ID   2/3    DT

                                                                                                DATE                                 DTP03      1251   2300 M   AN   1/35
                                                   171 168   INSTITUTIONAL CLAIM CODE                                                CL1               2300                                 S          1
                                                                                                ADMISSION TYPE CODE                  CL101      1315   2300 O   ID   1/1    19
                                                                                                ADMISSION SOURCE CODE                CL102      1314   2300 O   ID   1/1
                                                                                                PATIENT STATUS CODE                  CL103      1352   2300 O   ID   1/2
                                                                                                                                                                            SEE NOTES ON
                                                   173 170   CLAIM SUPPLEMENTAL INFORMATION                                          PWK               2300                 SEGMENT USAGE   S          10
                                                                                                REPORT TYPE CODE                     PWK01       755   2300 M   ID   2/2
                                                                                                REPORT TRANSMISSION CODE             PWK02       756   2300 O   ID   1/2
                                                                                                IDENTIFICATION CODE QUALIFIER        PWK05        66   2300 X   ID   1/2    AC
                                                                                                IDENTIFICATION CODE                  PWK06        67   2300 X   AN   2/80
                                                                                                DESCRIPTION                          PWK07       352   2300 O   AN   1/80
                                                   176 173   CONTRACT INFORMATION                                                    CN1               2300                                 S          1
                                                                                                CONTRACT TYPE CODE                   CN101      1166   2300 M   ID   2/2
                                                                                                MONETARY AMOUNT                      CN102       782   2300 O   R    1/18
                                                                                                PERCENT                              CN103       332   2300 O   R    1/6
                                                                                                REFERENCE IDENTIFICATION             CN104       127   2300 O   AN   1/30
                                                                                                TERMS DISCOUNT PERCENT               CN105       338   2300 O   R    1/6
                                                                                                VERSION IDENTIFIER                   CN106       799   2300 O   AN   1/30
                                                   178 175   PAYER ESTIMATED AMOUNT DUE                                              AMT               2300                                 S          1
                                                                                                AMOUNT QUALIFIER CODE                AMT01       522   2300 M   ID   1/3    C5
                                                                                                MONETARY AMOUNT                      AMT02       782   2300 M   R    1/18
                                                   180 177   PATIENT ESTIMATED AMOUNT DUE                                            AMT               2300                                 S          1
                                                                                                AMOUNT QUALIFIER CODE                AMT01       522   2300 M   ID   1/3    F3
                                                                                                MONETARY AMOUNT                      AMT02       782   2300 M   R    1/18
                                                   182 179   PATIENT PAID AMOUNT                                                     AMT               2300                                 S          1
                                                                                                AMOUNT QUALIFIER CODE                AMT01       522   2300 M   ID   1/3    F5
                                                                                                MONETARY AMOUNT                      AMT02       782   2300 M   R    1/18
                                                   184 181   CREDIT/DEBIT CARD MAXIMUM AMOUNT                                        AMT               2300                                 S          1
                                                                                                AMOUNT QUALIFIER CODE                AMT01       522   2300 M   ID   1/3    MA

                                                                                                MONETARY AMOUNT                      AMT02       782   2300 M   R    1/18
                                                   185 181   ADJUSTED REPRICED CLAIM NUMBER                                          REF               2300                                 S          1
                                                                                                REFERENCE IDENTIFICATION QUALIFIER   REF01       128   2300 M   ID   2/3    9C


                                                                                                       81
                                                                                                                                                                                      Policy Memorandum 2004 - 37
                                                                                                                                                                                      Exhibit 2L



                                                               837 - HEALTH CLAIMS AND ENCOUNTERS (INSTITUTIONAL)
INTERNAL    TABLE  /   FIELD               FIELD   Old                                                                                 REF     ELEMENT
RECORD ID   DATABASE   LENGTH   FIELD TYPE NAME    PG A1 PG SEGMENT NAME                          ELEMENT NAME                         DES.     NUMBER   LOOP ATTRIBUTES      NOTES   USE     REPEAT

                                                                                                  REFERENCE IDENTIFICATION             REF02       127   2300 X   AN   1/30
                                                   186 182   REPRICED CLAIM NUMBER                                                     REF               2300                         S          1
                                                                                                  REFERENCE IDENTIFICATION QUALIFIER   REF01       128   2300 M   ID   2/3    9A
                                                                                                  REFERENCE IDENTIFICATION             REF02       127   2300 X   AN   1/30
                                                             CLAIM IDENTIFICATION NUMBER FOR
                                                             CLEARING HOUSES AND OTHER
                                                   187 182   TRANSMISSION INTERMEDIARIES                                               REF               2300                         S          1
                                                                                                  REFERENCE IDENTIFICATION QUALIFIER   REF01       128   2300 M   ID   2/3    D9

                                                                                                  REFERENCE IDENTIFICATION             REF02       127   2300 X   AN   1/30

                                                   189 184   DOCUMENT IDENTIFICATION CODE                                              REF               2300                         S          2
                                                                                                  REFERENCE IDENTIFICATION QUALIFIER   REF01       128   2300 M   ID   2/3    DD
                                                                                                  REFERENCE IDENTIFICATION             REF02       127   2300 X   AN   1/30
                                                   191 185   ORIGINAL REFERENCE NUMBER(ICN/DCN)                                        REF               2300                         S          1
                                                                                                  REFERENCE IDENTIFICATION QUALIFIER   REF01       128   2300 M   ID   2/3    F8
                                                                                                  REFERENCE IDENTIFICATION             REF02       127   2300 X   AN   1/30
                                                             INVESTIGATIONAL DEVICE EXEMPTION
                                                   193 188   NUMBER                                                                    REF               2300                         S          1
                                                                                                  REFERENCE IDENTIFICATION QUALIFIER   REF01       128   2300 M   ID   2/3    LX
                                                                                                  REFERENCE IDENTIFICATION             REF02       127   2300 X   AN   1/30
                                                             SERVICE AUTHORIZATION EXCEPTION
                                                   195 190   CODE                                                                      REF               2300                         S          1
                                                                                                  REFERENCE IDENTIFICATION QUALIFIER   REF01       128   2300 M   ID   2/3    4N
                                                                                                  REFERENCE IDENTIFICATION             REF02       127   2300 X   AN   1/30
                                                             PEER REVIEW ORGANIZATION (PRO)
                                                   197 192   APPROVAL NUMBER                                                           REF               2300                         S          1
                                                                                                  REFERENCE IDENTIFICATION QUALIFIER   REF01       128   2300 M   ID   2/3    G4
                                                                                                  REFERENCE IDENTIFICATION             REF02       127   2300 X   AN   1/30
                                                             PRIOR AUTHORIZATION OR REFERRAL
                                                   198 193   NUMBER                                                                    REF               2300                         S          2

                                                                                                  REFERENCE IDENTIFICATION QUALIFIER   REF01       128   2300 M   ID   2/3
                                                                                                  REFERENCE IDENTIFICATION             REF02       127   2300 X   AN   1/30


                                                   200 195   MEDICAL RECORD NUMBER                                                     REF               2300                         S          1
                                                                                                  REFERENCE IDENTIFICATION QUALIFIER   REF01       128   2300 M   ID   2/3    EA
                                                                                                  REFERENCE IDENTIFICATION             REF02       127   2300 X   AN   1/30

                                                   202 197   DEMONSTRATION PROJECT IDENTIFIER                                          REF               2300                         S          1
                                                                                                  REFERENCE IDENTIFICATION QUALIFIER   REF01       128   2300 M   ID   2/3    P4
                                                                                                  REFERENCE IDENTIFICATION             REF02       127   2300 X   AN   1/30
                                                   204 199   FILE INFORMATION                                                          K3                2300                         S          10


                                                                                                         82
                                                                                                                                                                                                 Policy Memorandum 2004 - 37
                                                                                                                                                                                                 Exhibit 2L



                                                               837 - HEALTH CLAIMS AND ENCOUNTERS (INSTITUTIONAL)
INTERNAL    TABLE  /   FIELD               FIELD   Old                                                                                REF     ELEMENT
RECORD ID   DATABASE   LENGTH   FIELD TYPE NAME    PG A1 PG SEGMENT NAME                          ELEMENT NAME                        DES.     NUMBER   LOOP ATTRIBUTES      NOTES               USE     REPEAT
                                                                                                  FIXED FORM INFORMATION              K301        449   2300 M   AN   1/80
                                                   205 200   CLAIM NOTE                                                               NTE               2300                                     S          10
                                                                                                  NOTE REFERENCE CODE                 NTE01       363   2300 O   ID   3/3    SEE CODE LIST
                                                                                                  DESCRIPTION                         NTE02       352   2300 M   AN   1/80   FREE FORM TEXT



                                                   208 203   BILLING NOTE                                                             NTE                                                        S          1
                                                                                                  NOTE REFERENCE CODE                 NTE01       363   2300 O   ID   3/3    ADD
                                                                                                  DESCRIPTION                         NTE02       352   2300 M   AN   1/80   FREE FORM TEXT

                                                   210 205   HOME HEALTH CARE INFORMATION                                             CR6               2300                                     S          1
                                                                                                  PROGNOSIS CODE                      CR601       923   2300 M   ID   1/1
                                                                                                                                                                             SERVICE FROM
                                                                                                  DATE                                CR602       373   2300 M   DT   8/8    DATE
                                                                                                  DATE TIME PERIOD FORMAT QUALIFIER   CR603      1250   2300 X   ID   2/3    RD8
                                                                                                  DATE TIME PERIOD                    CR604      1251   2300 X   AN   1/35
                                                                                                  DATE                                CR605       373   2300 O   DT   8/8    DATE OF ONSET

                                                                                                  YES/NO CONDITION OR RESPONSE CODE CR606        1073   2300 O   ID   1/1

                                                                                                  YES/NO CONDITION OR RESPONSE CODE CR607        1073   2300 O   ID   1/1
                                                                                                  CERTIFICATION TYPE CODE           CR608        1322   2300 M   ID   1/1
                                                                                                  DATE                                CR609       373   2300 X   DT   8/8    SURGERY DATE
                                                                                                  PRODUCT/SERVICE ID QUALIFIER        CR610       235   2300 X   ID   2/2
                                                                                                  MEDICAL CODE VALUE                  CR611      1137   2300 X   AN   1/15
                                                                                                  DATE                                CR612       373   2300 O   DT   8/8
                                                                                                  DATE                                CR613       373   2300 O   DT   8/8
                                                                                                  DATE                                CR614       373   2300 O   DT   8/8
                                                                                                  DATE TIME PERIOD FORMAT QUALIFIER   CR615      1250   2300 X   ID   2/3    RD8
                                                                                                  DATE TIME PERIOD                    CR616      1251   2300 X   AN   1/35
                                                                                                  PATIENT LOCATION CODE               CR617      1384   2300 X   ID   1/1
                                                                                                  DATE                                CR618       373   2300 O   DT   8/8
                                                                                                  DATE                                CR619       373   2300 O   DT   8/8    DIAGNOSIS DATE #2
                                                                                                  DATE                                CR620       373   2300 O   DT   8/8    DIAGNOSIS DATE #3
                                                                                                  DATE                                CR621       373   2300 O   DT   8/8    DIAGNOSIS DATE #4
                                                   219 213   HOME HEALTH FUNCTIONAL LIMITATIONS                                       CRC               2300                                     S          3
                                                                                                  CODE CATEGORY                       CRC01      1136   2300 M   ID   2/2

                                                                                                  YES/NO CONDITION OR RESPONSE CODE CRC02        1073   2300 M   ID   1/1
                                                                                                  CONDITION INDICATOR               CRC03        1321   2300 M   ID   2/2

                                                                                                  CONDITION INDICATOR                 CRC04      1321   2300 O   ID   2/2

                                                                                                  CONDITION INDICATOR                 CRC05      1321   2300 O   ID   2/2


                                                                                                         83
                                                                                                                                                                                     Policy Memorandum 2004 - 37
                                                                                                                                                                                     Exhibit 2L



                                                               837 - HEALTH CLAIMS AND ENCOUNTERS (INSTITUTIONAL)
INTERNAL    TABLE  /   FIELD               FIELD   Old                                                                             REF      ELEMENT
RECORD ID   DATABASE   LENGTH   FIELD TYPE NAME    PG A1 PG SEGMENT NAME                          ELEMENT NAME                     DES.      NUMBER   LOOP ATTRIBUTES        NOTES   USE     REPEAT

                                                                                                  CONDITION INDICATOR              CRC06       1321   2300 O     ID   2/2

                                                                                                  CONDITION INDICATOR              CRC07       1321   2300 O     ID   2/2

                                                   221 220   HOME HEALTH ACTIVITIES PERMITTED                                      CRC                2300                           S          3

                                                                                                  CODE CATEGORY                    CRC01       1136   2300 M     ID   2/2    76

                                                                                                  YES/NO CONDITION OR RESPONSE CODE CRC02      1073   2300 M     ID   1/1

                                                                                                  CONDITION INDICATOR              CRC03       1321   2300 M     ID   2/2

                                                                                                  CONDITION INDICATOR              CRC04       1321   2300 O     ID   2/2

                                                                                                  CONDITION INDICATOR              CRC05       1321   2300 O     ID   2/2

                                                                                                  CONDITION INDICATOR              CRC06       1321   2300 O     ID   2/2
                                                                                                  CONDITION INDICATOR              CRC07       1321   2300 O     ID   2/2

                                                   224 228   HOME HEALTH MENTAL STATUS                                             CRC                2300                           S          2

                                                                                                  CODE CATEGORY                    CRC01       1136   2300 M     ID   1/1    77

                                                                                                  YES/NO CONDITION OR RESPONSE CODE CRC02      1073   2300 M     ID   1/1

                                                                                                  CONDITION INDICATOR              CRC03       1321   2300 M     ID   2/2
                                                                                                  CONDITION INDICATOR              CRC04       1321   2300 O     ID   2/2
                                                                                                  CONDITION INDICATOR              CRC05       1321   2300 O     ID   2/2

                                                                                                  CONDITION INDICATOR              CRC06       1321   2300 O     ID   2/2

                                                                                                  CONDITION INDICATOR              CRC07       1321   2300 O     ID   2/2
                                                             PRINCIPAL, ADMITTING, E-CODE AND
                                                             PATIENT REASON FOR VISIT DIAGNOSIS
                                                   227 234   INFORMATION                                                           HI                 2300                           S          1

                                                                                                  HEALTH CARE CODE INFORMATION     HI01        C022   2300 M

                                                                                                  CODE LIST QUALIFIER CODE         HI01-1      1270   2300 M     ID   1/3    BK
                                                                                                  INDUSTRY CODE                    HI01-2      1271   2300 M     AN   1/30

                                                                                                  HEALTH CARE CODE INFORMATION     HI02        C022   2300 O

                                                                                                  CODE LIST QUALIFIER CODE         HI02-1      1270   2300 M     ID   1/3

                                                                                                  INDUSTRY CODE                    HI02-2      1271          M   AN   1/30
                                                                                                  HEALTH CARE CODE INFORMATION     HI03        C022   2300 O

                                                                                                         84
                                                                                                                                                                            Policy Memorandum 2004 - 37
                                                                                                                                                                            Exhibit 2L



                                                               837 - HEALTH CLAIMS AND ENCOUNTERS (INSTITUTIONAL)
INTERNAL    TABLE  /   FIELD               FIELD   Old                                                                      REF      ELEMENT
RECORD ID   DATABASE   LENGTH   FIELD TYPE NAME    PG A1 PG SEGMENT NAME                     ELEMENT NAME                   DES.      NUMBER   LOOP ATTRIBUTES      NOTES   USE     REPEAT

                                                                                             CODE LIST QUALIFIER CODE       HI03-1      1270   2300 M   ID   1/3    BN
                                                                                             INDUSTRY CODE                  HI03-2      1271   2300 M   AN   1/30

                                                             DIAGNOSIS RELATED GROUP (DRG)
                                                   230 237   INFORMATION                                                    HI                 2300                         S          1

                                                                                             HEALTH CARE CODE INFORMATION   HI01        C022   2300 O


                                                                                             CODE LIST QUALIFIER CODE       HI01-1      1270   2300 M   ID   1/3    DR
                                                                                             INDUSTRY CODE                  HI01-2      1271   2300 M   AN   1/30
                                                   232 239   OTHER DIAGNOSIS INFORMATION                                    HI                 2300                         S          2
                                                                                             HEALTH CARE CODE INFORMATION   HI01        C022   2300 O
                                                                                             CODE LIST QUALIFIER CODE       HI01-1      1270   2300 M   ID   1/3    BF
                                                                                             INDUSTRY CODE                  HI01-2      1271   2300 M   AN   1/30
                                                                                             HEALTH CARE CODE INFORMATION   HI02        C022   2300 O

                                                                                             CODE LIST QUALIFIER CODE       HI02-1      1270   2300 M   ID   1/3    BF


                                                                                             INDUSTRY CODE                  HI02-2      1271   2300 M   AN   1/30
                                                                                             HEALTH CARE CODE INFORMATION   HI03        C022   2300 O
                                                                                             CODE LIST QUALIFIER CODE       HI03-1      1270   2300 M   ID   1/3    BF
                                                                                             INDUSTRY CODE                  HI03-2      1271   2300 M   AN   1/30
                                                                                             HEALTH CARE CODE INFORMATION   HI04        C022   2300 O
                                                                                             CODE LIST QUALIFIER CODE       HI04-1      1270   2300 M   ID   1/3    BF
                                                                                             INDUSTRY CODE                  HI04-2      1271   2300 M   AN   1/30
                                                                                             HEALTH CARE CODE INFORMATION   HI05        C022   2300 O
                                                                                             CODE LIST QUALIFIER CODE       HI05-1      1270   2300 M   ID   1/3    BF
                                                                                             INDUSTRY CODE                  HI05-2      1271   2300 M   AN   1/30
                                                                                             HEALTH CARE CODE INFORMATION   HI06        C022   2300 O
                                                                                             CODE LIST QUALIFIER CODE       HI06-1      1270   2300 M   ID   1/3    BF
                                                                                             INDUSTRY CODE                  HI06-2      1271   2300 M   AN   1/30
                                                                                             HEALTH CARE CODE INFORMATION   HI07        C022   2300 O
                                                                                             CODE LIST QUALIFIER CODE       HI07-1      1270   2300 M   ID   1/3    BF
                                                                                             INDUSTRY CODE                  HI07-2      1271   2300 M   AN   1/30
                                                                                             HEALTH CARE CODE INFORMATION   HI08        C022   2300 O
                                                                                             CODE LIST QUALIFIER CODE       HI08-1      1270   2300 M   ID   1/3    BF
                                                                                             INDUSTRY CODE                  HI08-2      1271   2300 M   AN   1/30
                                                                                             HEALTH CARE CODE INFORMATION   HI09        C022   2300 M
                                                                                             CODE LIST QUALIFIER CODE       HI09-1      1270   2300 M   ID   1/3    BF
                                                                                             INDUSTRY CODE                  HI09-2      1271   2300 M   AN   1/30
                                                                                             HEALTH CARE CODE INFORMATION   HI10        C022   2300 M
                                                                                             CODE LIST QUALIFIER CODE       HI10-1      1270   2300 M   ID   1/3    BF

                                                                                                    85
                                                                                                                                                                                           Policy Memorandum 2004 - 37
                                                                                                                                                                                           Exhibit 2L



                                                               837 - HEALTH CLAIMS AND ENCOUNTERS (INSTITUTIONAL)
INTERNAL    TABLE  /   FIELD               FIELD   Old                                                                             REF      ELEMENT
RECORD ID   DATABASE   LENGTH   FIELD TYPE NAME    PG A1 PG SEGMENT NAME                       ELEMENT NAME                        DES.      NUMBER   LOOP ATTRIBUTES      NOTES           USE     REPEAT
                                                                                               INDUSTRY CODE                       HI10-2      1271   2300 M   AN   1/30
                                                                                               HEALTH CARE CODE INFORMATION        HI11        C022   2300 M
                                                                                               CODE LIST QUALIFIER CODE            HI11-1      1270   2300 M   ID   1/3    BF
                                                                                               INDUSTRY CODE                       HI11-2      1271   2300 M   AN   1/30
                                                                                               HEALTH CARE CODE INFORMATION        HI12        C022   2300 M
                                                                                               CODE LIST QUALIFIER CODE            HI12-1      1270   2300 M   ID   1/3    BF
                                                                                               INDUSTRY CODE                       HI12-2      1271   2300 M   AN   1/30
                                                   242 248   PRINCIPAL PROCEDURE INFORMATION                                       HI                 2300                                 S          1
                                                                                               HEALTH CARE CODE INFORMATION        HI01        C022   2300 M
                                                                                               CODE LIST QUALIFIER CODE            HI01-1      1270   2300 M   ID   1/3    BP
                                                                                               INDUSTRY CODE                       HI01-2      1271   2300 M   AN   1/30
                                                                                               DATE TIME PERIOD FORMAT QUALIFIER   HI01-3      1250   2300 X   ID   2/3
                                                                                               DATE TIME PERIOD                    HI01-4      1251   2300 X   AN   1/35

                                                                                                                                                                           REQUIRED ON HOME
                                                   244 250   OTHER PROCEDURE INFORMATION                                           HI                 2300                 IV THERAPY       S         2
                                                                                               HEALTH CARE CODE INFORMATION        HI01        C022   2300 O
                                                                                               CODE LIST QUALIFIER CODE            HI01-1      1270   2300 M   ID   1/3
                                                                                               INDUSTRY CODE                       HI01-2      1271   2300 M   AN   1/30
                                                                                               DATE TIME PERIOD FORMAT QUALIFIER   HI01-3      1250   2300 X   ID   2/3
                                                                                               DATE TIME PERIOD                    HI01-4      1251   2300 X   AN   1/35
                                                                                               HEALTH CARE CODE INFORMATION        HI02        C022   2300 O
                                                                                               CODE LIST QUALIFIER CODE            HI02-1      1270   2300 M   ID   1/3
                                                                                               INDUSTRY CODE                       HI02-2      1271   2300 M   AN   1/30
                                                                                               DATE TIME PERIOD FORMAT QUALIFIER   HI02-3      1250   2300 X   ID   2/3
                                                                                               DATE TIME PERIOD                    HI02-4      1251   2300 X   AN   1/35
                                                                                               HEALTH CARE CODE INFORMATION        HI03        C022   2300 O
                                                                                               CODE LIST QUALIFIER CODE            HI03-1      1270   2300 M   ID   1/3
                                                                                               INDUSTRY CODE                       HI03-2      1271   2300 M   AN   1/30
                                                                                               DATE TIME PERIOD FORMAT QUALIFIER   HI03-3      1250   2300 X   ID   2/3
                                                                                               DATE TIME PERIOD                    HI03-4      1251   2300 X   AN   1/35
                                                                                               HEALTH CARE CODE INFORMATION        HI04        C022   2300 O
                                                                                               CODE LIST QUALIFIER CODE            HI04-1      1270   2300 M   ID   1/3
                                                                                               INDUSTRY CODE                       HI04-2      1271   2300 M   AN   1/30
                                                                                               DATE TIME PERIOD FORMAT QUALIFIER   HI04-3      1250   2300 X   ID   2/3
                                                                                               DATE TIME PERIOD                    HI04-4      1251   2300 X   AN   1/35
                                                                                               HEALTH CARE CODE INFORMATION        HI05        C022   2300 O
                                                                                               CODE LIST QUALIFIER CODE            HI05-1      1270   2300 M   ID   1/3
                                                                                               INDUSTRY CODE                       HI05-2      1271   2300 M   AN   1/30
                                                                                               DATE TIME PERIOD FORMAT QUALIFIER   HI05-1      1250   2300 X   ID   2/3
                                                                                               DATE TIME PERIOD                    HI05-2      1251   2300 X   AN   1/35
                                                                                               HEALTH CARE CODE INFORMATION        HI06        C022   2300 O
                                                                                               CODE LIST QUALIFIER CODE            HI06-1      1270   2300 M   ID   1/3

                                                                                                      86
                                                                                                                                                                               Policy Memorandum 2004 - 37
                                                                                                                                                                               Exhibit 2L



                                                               837 - HEALTH CLAIMS AND ENCOUNTERS (INSTITUTIONAL)
INTERNAL    TABLE  /   FIELD               FIELD   Old                                                                         REF      ELEMENT
RECORD ID   DATABASE   LENGTH   FIELD TYPE NAME    PG A1 PG SEGMENT NAME                   ELEMENT NAME                        DES.      NUMBER   LOOP ATTRIBUTES      NOTES   USE     REPEAT
                                                                                           INDUSTRY CODE                       HI06-2      1271   2300 M   AN   1/30
                                                                                           DATE TIME PERIOD FORMAT QUALIFIER   HI06-3      1250   2300 X   ID   2/3
                                                                                           DATE TIME PERIOD                    HI06-4      1251   2300 X   AN   1/35
                                                                                           HEALTH CARE CODE INFORMATION        HI07        C022   2300 O
                                                                                           CODE LIST QUALIFIER CODE            HI07-1      1270   2300 M   ID   1/3
                                                                                           INDUSTRY CODE                       HI07-2      1271   2300 M   AN   1/30
                                                                                           DATE TIME PERIOD FORMAT QUALIFIER   HI07-3      1250   2300 X   ID   2/3
                                                                                           DATE TIME PERIOD                    HI07-4      1251   2300 X   AN   1/35
                                                                                           HEALTH CARE CODE INFORMATION        HI08        C022   2300 O
                                                                                           CODE LIST QUALIFIER CODE            HI08-1      1270   2300 M   ID   1/3
                                                                                           INDUSTRY CODE                       HI08-2      1271   2300 M   AN   1/30
                                                                                           DATE TIME PERIOD FORMAT QUALIFIER   HI08-3      1250   2300 X   ID   2/3
                                                                                           DATE TIME PERIOD                    HI08-4      1251   2300 X   AN   1/35
                                                                                           HEALTH CARE CODE INFORMATION        HI09        C022   2300 M
                                                                                           CODE LIST QUALIFIER CODE            HI09-1      1270   2300 M   ID   1/3
                                                                                           INDUSTRY CODE                       HI09-2      1271   2300 M   AN   1/30
                                                                                           DATE TIME PERIOD FORMAT QUALIFIER   HI09-3      1250   2300 X   ID   2/3
                                                                                           DATE TIME PERIOD                    HI09-4      1251   2300 X   AN   1/35
                                                                                           HEALTH CARE CODE INFORMATION        HI10        C022   2300 M
                                                                                           CODE LIST QUALIFIER CODE            HI10-1      1270   2300 M   ID   1/3
                                                                                           INDUSTRY CODE                       HI10-2      1271   2300 M   AN   1/30
                                                                                           DATE TIME PERIOD FORMAT QUALIFIER   HI10-3      1250   2300 X   ID   2/3
                                                                                           DATE TIME PERIOD                    HI10-4      1251   2300 X   AN   1/35
                                                                                           HEALTH CARE CODE INFORMATION        HI11        C022   2300 M
                                                                                           CODE LIST QUALIFIER CODE            HI11-1      1270   2300 M   ID   1/3
                                                                                           INDUSTRY CODE                       HI11-2      1271   2300 M   AN   1/30
                                                                                           DATE TIME PERIOD FORMAT QUALIFIER   HI11-3      1250   2300 X   ID   2/3
                                                                                           DATE TIME PERIOD                    HI11-4      1251   2300 X   AN   1/35
                                                                                           HEALTH CARE CODE INFORMATION        HI12        C022   2300 M
                                                                                           CODE LIST QUALIFIER CODE            HI12-1      1270   2300 M   ID   1/3
                                                                                           INDUSTRY CODE                       HI12-2      1271   2300 M   AN   1/30
                                                                                           DATE TIME PERIOD FORMAT QUALIFIER   HI12-3      1250   2300 X   ID   2/3
                                                                                           DATE TIME PERIOD                    HI12-4      1251   2300 X   AN   1/35
                                                   256 263   OCCURRENCE SPAN INFORMATION                                       HI                 2300                         S          2
                                                                                           HEALTH CARE CODE INFORMATION        HI01        C022   2300 O
                                                                                           CODE LIST QUALIFIER CODE            HI01-1      1270   2300 M   ID   1/3    BI
                                                                                           INDUSTRY CODE                       HI01-2      1271   2300 M   AN   1/30

                                                                                           DATE TIME PERIOD FORMAT QUALIFIER   HI01-3      1250   2300 X   ID   2/3    RD8
                                                                                           DATE TIME PERIOD                    HI01-4      1251   2300 X   AN   1/35
                                                                                           HEALTH CARE CODE INFORMATION        HI02        C022   2300 O
                                                                                           CODE LIST QUALIFIER CODE            HI02-1      1270   2300 M   ID   1/3    BI


                                                                                                  87
                                                                                                                                                               Policy Memorandum 2004 - 37
                                                                                                                                                               Exhibit 2L



                                                              837 - HEALTH CLAIMS AND ENCOUNTERS (INSTITUTIONAL)
INTERNAL    TABLE  /   FIELD               FIELD   Old                                                         REF      ELEMENT
RECORD ID   DATABASE   LENGTH   FIELD TYPE NAME    PG A1 PG SEGMENT NAME   ELEMENT NAME                        DES.      NUMBER   LOOP ATTRIBUTES      NOTES   USE     REPEAT
                                                                           INDUSTRY CODE                       HI02-2      1271   2300 M   AN   1/30

                                                                           DATE TIME PERIOD FORMAT QUALIFIER   HI02-3      1250   2300 X   ID   2/3    RD8
                                                                           DATE TIME PERIOD                    HI02-4      1251   2300 X   AN   1/35
                                                                           HEALTH CARE CODE INFORMATION        HI03        C022   2300 O
                                                                           CODE LIST QUALIFIER CODE            HI03-1      1270   2300 M   ID   1/3    BI
                                                                           INDUSTRY CODE                       HI03-2      1271   2300 M   AN   1/30

                                                                           DATE TIME PERIOD FORMAT QUALIFIER   HI03-3      1250   2300 X   ID   2/3    RD8
                                                                           DATE TIME PERIOD                    HI03-4      1251   2300 X   AN   1/35
                                                                           HEALTH CARE CODE INFORMATION        HI04        C022   2300 O
                                                                           CODE LIST QUALIFIER CODE            HI04-1      1270   2300 M   ID   1/3    BI
                                                                           INDUSTRY CODE                       HI04-2      1271   2300 M   AN   1/30

                                                                           DATE TIME PERIOD FORMAT QUALIFIER   HI04-3      1250   2300 X   ID   2/3    RD8


                                                                           DATE TIME PERIOD                    HI04-4      1251   2300 X   AN   1/35
                                                                           HEALTH CARE CODE INFORMATION        HI05        C022   2300 O
                                                                           CODE LIST QUALIFIER CODE            HI05-1      1270   2300 M   ID   1/3    BI
                                                                           INDUSTRY CODE                       HI05-2      1271   2300 M   AN   1/30

                                                                           DATE TIME PERIOD FORMAT QUALIFIER   HI05-3      1250   2300 X   ID   2/3    RD8
                                                                           DATE TIME PERIOD                    HI05-4      1251   2300 X   AN   1/35
                                                                           HEALTH CARE CODE INFORMATION        HI06        C022   2300 O
                                                                           CODE LIST QUALIFIER CODE            HI06-1      1270   2300 M   ID   1/3    BI
                                                                           INDUSTRY CODE                       HI06-2      1271   2300 M   AN   1/30

                                                                           DATE TIME PERIOD FORMAT QUALIFIER   HI06-3      1250   2300 X   ID   2/3    RD8
                                                                           DATE TIME PERIOD                    HI06-4      1251   2300 X   AN   1/35
                                                                           HEALTH CARE CODE INFORMATION        HI07        C022   2300 O
                                                                           CODE LIST QUALIFIER CODE            HI07-1      1270   2300 M   ID   1/3    BI
                                                                           INDUSTRY CODE                       HI07-2      1271   2300 M   AN   1/30

                                                                           DATE TIME PERIOD FORMAT QUALIFIER   HI07-3      1250   2300 X   ID   2/3    RD8


                                                                           DATE TIME PERIOD                    HI07-4      1251   2300 X   AN   1/35
                                                                           HEALTH CARE CODE INFORMATION        HI08        C022   2300 O
                                                                           CODE LIST QUALIFIER CODE            HI08-1      1270   2300 M   ID   1/3    BI
                                                                           INDUSTRY CODE                       HI08-2      1271   2300 M   AN   1/30

                                                                           DATE TIME PERIOD FORMAT QUALIFIER   HI08-3      1250   2300 X   ID   2/3    RD8


                                                                           DATE TIME PERIOD                    HI08-4      1251   2300 X   AN   1/35
                                                                           HEALTH CARE CODE INFORMATION        HI09        C022   2300 M


                                                                                  88
                                                                                                                                                                          Policy Memorandum 2004 - 37
                                                                                                                                                                          Exhibit 2L



                                                               837 - HEALTH CLAIMS AND ENCOUNTERS (INSTITUTIONAL)
INTERNAL    TABLE  /   FIELD               FIELD   Old                                                                    REF      ELEMENT
RECORD ID   DATABASE   LENGTH   FIELD TYPE NAME    PG A1 PG SEGMENT NAME              ELEMENT NAME                        DES.      NUMBER   LOOP ATTRIBUTES      NOTES   USE     REPEAT
                                                                                      CODE LIST QUALIFIER CODE            HI09-1      1270   2300 M   ID   1/3    BI
                                                                                      INDUSTRY CODE                       HI09-2      1271   2300 M   AN   1/30

                                                                                      DATE TIME PERIOD FORMAT QUALIFIER   HI09-3      1250   2300 X   ID   2/3    RD8
                                                                                      DATE TIME PERIOD                    HI09-4      1251   2300 X   AN   1/35


                                                                                      HEALTH CARE CODE INFORMATION        HI10        C022   2300 M
                                                                                      CODE LIST QUALIFIER CODE            HI10-1      1270   2300 M   ID   1/3    BI
                                                                                      INDUSTRY CODE                       HI10-2      1271   2300 M   AN   1/30

                                                                                      DATE TIME PERIOD FORMAT QUALIFIER   HI10-3      1250   2300 X   ID   2/3    RD8
                                                                                      DATE TIME PERIOD                    HI10-4      1251   2300 X   AN   1/35
                                                                                      HEALTH CARE CODE INFORMATION        HI11        C022   2300 M
                                                                                      CODE LIST QUALIFIER CODE            HI11-1      1270   2300 M   ID   1/3    BI
                                                                                      INDUSTRY CODE                       HI11-2      1271   2300 M   AN   1/30

                                                                                      DATE TIME PERIOD FORMAT QUALIFIER   HI11-3      1250   2300 X   ID   2/3    RD8


                                                                                      DATE TIME PERIOD                    HI11-4      1251   2300 X   AN   1/35


                                                                                      HEALTH CARE CODE INFORMATION        HI12        C022   2300 M
                                                                                      CODE LIST QUALIFIER CODE            HI12-1      1270   2300 M   ID   1/3    BI
                                                                                      INDUSTRY CODE                       HI12-2      1271   2300 M   AN   1/30

                                                                                      DATE TIME PERIOD FORMAT QUALIFIER   HI12-3      1250   2300 X   ID   2/3    RD8
                                                                                      DATE TIME PERIOD                    HI12-4      1251   2300 X   AN   1/35
                                                   267 274   OCCURRENCE INFORMATION                                       HI                 2300                         S          2
                                                                                      HEALTH CARE CODE INFORMATION        HI01        C022   2300 O
                                                                                      CODE LIST QUALIFIER CODE            HI01-1      1270   2300 M   ID   1/3    BH
                                                                                      INDUSTRY CODE                       HI01-2      1271   2300 M   AN   1/30

                                                                                      DATE TIME PERIOD FORMAT QUALIFIER   HI01-3      1250   2300 X   ID   2/3    D8


                                                                                      DATE TIME PERIOD                    HI01-4      1251   2300 X   AN   1/35
                                                                                      HEALTH CARE CODE INFORMATION        HI02        C022   2300 O

                                                                                      CODE LIST QUALIFIER CODE            HI02-1      1270   2300 M   ID   1/3    BH


                                                                                      INDUSTRY CODE                       HI02-2      1271   2300 M   AN   1/30

                                                                                      DATE TIME PERIOD FORMAT QUALIFIER   HI02-3      1250   2300 X   ID   2/3    D8




                                                                                             89
                                                                                                                                                               Policy Memorandum 2004 - 37
                                                                                                                                                               Exhibit 2L



                                                              837 - HEALTH CLAIMS AND ENCOUNTERS (INSTITUTIONAL)
INTERNAL    TABLE  /   FIELD               FIELD   Old                                                         REF      ELEMENT
RECORD ID   DATABASE   LENGTH   FIELD TYPE NAME    PG A1 PG SEGMENT NAME   ELEMENT NAME                        DES.      NUMBER   LOOP ATTRIBUTES      NOTES   USE     REPEAT

                                                                           DATE TIME PERIOD                    HI02-4      1251   2300 X   AN   1/35


                                                                           HEALTH CARE CODE INFORMATION        HI03        C022   2300 O
                                                                           CODE LIST QUALIFIER CODE            HI03-1      1270   2300 M   ID   1/3    BH


                                                                           INDUSTRY CODE                       HI03-2      1271   2300 M   AN   1/30

                                                                           DATE TIME PERIOD FORMAT QUALIFIER   HI03-3      1250   2300 X   ID   2/3    D8
                                                                           DATE TIME PERIOD                    HI03-4      1251   2300 X   AN   1/35
                                                                           HEALTH CARE CODE INFORMATION        HI04        C022   2300 O
                                                                           CODE LIST QUALIFIER CODE            HI04-1      1270   2300 M   ID   1/3    BH
                                                                           INDUSTRY CODE                       HI04-2      1271   2300 M   AN   1/30

                                                                           DATE TIME PERIOD FORMAT QUALIFIER   HI04-3      1250   2300 X   ID   2/3    D8
                                                                           DATE TIME PERIOD                    HI04-4      1251   2300 X   AN   1/35
                                                                           HEALTH CARE CODE INFORMATION        HI05        C022   2300 O
                                                                           CODE LIST QUALIFIER CODE            HI05-1      1270   2300 M   ID   1/3    BH
                                                                           INDUSTRY CODE                       HI05-2      1271   2300 M   AN   1/30

                                                                           DATE TIME PERIOD FORMAT QUALIFIER   HI05-3      1250   2300 X   ID   2/3    D8
                                                                           DATE TIME PERIOD                    HI05-4      1251   2300 X   AN   1/35
                                                                           HEALTH CARE CODE INFORMATION        HI06        C022   2300 O
                                                                           CODE LIST QUALIFIER CODE            HI06-1      1270   2300 M   ID   1/3    BH
                                                                           INDUSTRY CODE                       HI06-2      1271   2300 M   AN   1/30

                                                                           DATE TIME PERIOD FORMAT QUALIFIER   HI06-3      1250   2300 X   ID   2/3    D8
                                                                           DATE TIME PERIOD                    HI06-4      1251   2300 X   AN   1/35
                                                                           HEALTH CARE CODE INFORMATION        HI07        C022   2300 O
                                                                           CODE LIST QUALIFIER CODE            HI07-1      1270   2300 M   ID   1/3    BH
                                                                           INDUSTRY CODE                       HI07-2      1271   2300 M   AN   1/30

                                                                           DATE TIME PERIOD FORMAT QUALIFIER   HI07-3      1250   2300 X   ID   2/3    D8


                                                                           DATE TIME PERIOD                    HI07-4      1251   2300 X   AN   1/35


                                                                           HEALTH CARE CODE INFORMATION        HI08        C022   2300 O
                                                                           CODE LIST QUALIFIER CODE            HI08-1      1270   2300 M   ID   1/3    BH
                                                                           INDUSTRY CODE                       HI08-2      1271   2300 M   AN   1/30

                                                                           DATE TIME PERIOD FORMAT QUALIFIER   HI08-3      1250   2300 X   ID   2/3    D8
                                                                           DATE TIME PERIOD                    HI08-4      1251   2300 X   AN   1/35
                                                                           HEALTH CARE CODE INFORMATION        HI09        C022   2300 M

                                                                                  90
                                                                                                                                                                    Policy Memorandum 2004 - 37
                                                                                                                                                                    Exhibit 2L



                                                              837 - HEALTH CLAIMS AND ENCOUNTERS (INSTITUTIONAL)
INTERNAL    TABLE  /   FIELD               FIELD   Old                                                              REF      ELEMENT
RECORD ID   DATABASE   LENGTH   FIELD TYPE NAME    PG A1 PG SEGMENT NAME        ELEMENT NAME                        DES.      NUMBER   LOOP ATTRIBUTES      NOTES   USE     REPEAT
                                                                                CODE LIST QUALIFIER CODE            HI09-1      1270   2300 M   ID   1/3    BH
                                                                                INDUSTRY CODE                       HI09-2      1271   2300 M   AN   1/30

                                                                                DATE TIME PERIOD FORMAT QUALIFIER   HI09-3      1250   2300 X   ID   2/3    D8

                                                                                DATE TIME PERIOD                    HI09-4      1251   2300 X   AN   1/35
                                                                                HEALTH CARE CODE INFORMATION        HI10        C022   2300 M
                                                                                CODE LIST QUALIFIER CODE            HI10-1      1270   2300 M   ID   1/3    BH
                                                                                INDUSTRY CODE                       HI10-2      1271   2300 M   AN   1/30

                                                                                DATE TIME PERIOD FORMAT QUALIFIER   HI10-3      1250   2300 X   ID   2/3    D8
                                                                                DATE TIME PERIOD                    HI10-4      1251   2300 X   AN   1/35
                                                                                HEALTH CARE CODE INFORMATION        HI11        C022   2300 M
                                                                                CODE LIST QUALIFIER CODE            HI11-1      1270   2300 M   ID   1/3    BH
                                                                                INDUSTRY CODE                       HI11-2      1271   2300 M   AN   1/30

                                                                                DATE TIME PERIOD FORMAT QUALIFIER   HI11-3      1250   2300 X   ID   2/3    D8
                                                                                DATE TIME PERIOD                    HI11-4      1251   2300 X   AN   1/35
                                                                                HEALTH CARE CODE INFORMATION        HI12        C022   2300 M
                                                                                CODE LIST QUALIFIER CODE            HI12-1      1270   2300 M   ID   1/3    BH
                                                                                INDUSTRY CODE                       HI12-2      1271   2300 M   AN   1/30

                                                                                DATE TIME PERIOD FORMAT QUALIFIER   HI12-3      1250   2300 X   ID   2/3    D8
                                                                                DATE TIME PERIOD                    HI12-4      1251   2300 X   AN   1/35
                                                      280   VALUE INFORMATION                                       HI                 2300                         S          2
                                                                                HEALTH CARE CODE INFORMATION        HI01        C022   2300 O
                                                                                CODE LIST QUALIFIER CODE            HI01-1      1270   2300 M   ID   1/3    BE
                                                                                INDUSTRY CODE                       HI01-2      1271   2300 M   AN   1/30

                                                                                MONETARY AMOUNT                     HI01-5       782   2300 O   R    1/18


                                                                                HEALTH CARE CODE INFORMATION        HI02        C022   2300 O
                                                                                CODE LIST QUALIFIER CODE            HI02-1      1270   2300 M   ID   1/3    BE

                                                                                INDUSTRY CODE                       HI02-2      1271   2300 M   AN   1/30
                                                                                MONETARY AMOUNT                     HI02-5       782   2300 O   R    1/18
                                                                                HEALTH CARE CODE INFORMATION        HI03        C022   2300 O
                                                                                CODE LIST QUALIFIER CODE            HI03-1      1270   2300 M   ID   1/3    BE
                                                                                INDUSTRY CODE                       HI03-2      1271   2300 M   AN   1/30
                                                                                MONETARY AMOUNT                     HI03-5       782   2300 O   R    1/18
                                                                                HEALTH CARE CODE INFORMATION        HI04        C022   2300 O
                                                                                CODE LIST QUALIFIER CODE            HI04-1      1270   2300 M   ID   1/3    BE
                                                                                INDUSTRY CODE                       HI04-2      1271   2300 M   AN   1/30


                                                                                       91
                                                                                                                                                                    Policy Memorandum 2004 - 37
                                                                                                                                                                    Exhibit 2L



                                                               837 - HEALTH CLAIMS AND ENCOUNTERS (INSTITUTIONAL)
INTERNAL    TABLE  /   FIELD               FIELD   Old                                                              REF      ELEMENT
RECORD ID   DATABASE   LENGTH   FIELD TYPE NAME    PG A1 PG SEGMENT NAME             ELEMENT NAME                   DES.      NUMBER   LOOP ATTRIBUTES      NOTES   USE     REPEAT
                                                                                     MONETARY AMOUNT                HI04-5       782   2300 O   R    1/18
                                                                                     HEALTH CARE CODE INFORMATION   HI05        C022   2300 O
                                                                                     CODE LIST QUALIFIER CODE       HI05-1      1270   2300 M   ID   1/3    BE
                                                                                     INDUSTRY CODE                  HI05-2      1271   2300 M   AN   1/30
                                                                                     MONETARY AMOUNT                HI05-5       782   2300 O   R    1/18
                                                                                     HEALTH CARE CODE INFORMATION   HI06        C022   2300 O
                                                                                     CODE LIST QUALIFIER CODE       HI06-1      1270   2300 M   ID   1/3    BE
                                                                                     INDUSTRY CODE                  HI06-2      1271   2300 M   AN   1/30
                                                                                     MONETARY AMOUNT                HI06-5       782   2300 O   R    1/18
                                                                                     HEALTH CARE CODE INFORMATION   HI07        C022   2300 O

                                                                                     CODE LIST QUALIFIER CODE       HI07-1      1270   2300 M   ID   1/3    BE


                                                                                     INDUSTRY CODE                  HI07-2      1271   2300 M   AN   1/30


                                                                                     MONETARY AMOUNT                HI07-5       782   2300 O   R    1/18
                                                                                     HEALTH CARE CODE INFORMATION   HI08        C022   2300 O
                                                                                     CODE LIST QUALIFIER CODE       HI08-1      1270   2300 M   ID   1/3    BE
                                                                                     INDUSTRY CODE                  HI08-2      1271   2300 M   AN   1/30
                                                                                     MONETARY AMOUNT                HI08-5       782   2300 O   R    1/18
                                                                                     HEALTH CARE CODE INFORMATION   HI09        C022   2300 M
                                                                                     CODE LIST QUALIFIER CODE       HI09-1      1270   2300 M   ID   1/3    BE
                                                                                     INDUSTRY CODE                  HI09-2      1271   2300 M   AN   1/30


                                                                                     MONETARY AMOUNT                HI09-5       782   2300 O   R    1/18
                                                                                     HEALTH CARE CODE INFORMATION   HI10        C022   2300 M
                                                                                     CODE LIST QUALIFIER CODE       HI10-1      1270   2300 M   ID   1/3    BE
                                                                                     INDUSTRY CODE                  HI10-2      1271   2300 M   AN   1/30
                                                                                     MONETARY AMOUNT                HI10-5       782   2300 O   R    1/18
                                                                                     HEALTH CARE CODE INFORMATION   HI11        C022   2300 M
                                                                                     CODE LIST QUALIFIER CODE       HI11-1      1270   2300 M   ID   1/3    BE
                                                                                     INDUSTRY CODE                  HI11-2      1271   2300 M   AN   1/30
                                                                                     MONETARY AMOUNT                HI11-5       782   2300 O   R    1/18
                                                                                     HEALTH CARE CODE INFORMATION   HI12        C022   2300 M
                                                                                     CODE LIST QUALIFIER CODE       HI12-1      1270   2300 M   ID   1/3    BE
                                                                                     INDUSTRY CODE                  HI12-2      1271   2300 M   AN   1/30
                                                                                     MONETARY AMOUNT                HI12-5       782   2300 O   R    1/18
                                                   290 295   CONDITION INFORMATION                                  HI                 2300                         S          2
                                                                                     HEALTH CARE CODE INFORMATION   HI01        C022   2300 O


                                                                                     CODE LIST QUALIFIER CODE       HI01-1      1270   2300 M   ID   1/3    BG
                                                                                     INDUSTRY CODE                  HI01-2      1271   2300 M   AN   1/30

                                                                                            92
                                                                                                                                                          Policy Memorandum 2004 - 37
                                                                                                                                                          Exhibit 2L



                                                              837 - HEALTH CLAIMS AND ENCOUNTERS (INSTITUTIONAL)
INTERNAL    TABLE  /   FIELD               FIELD   Old                                                    REF      ELEMENT
RECORD ID   DATABASE   LENGTH   FIELD TYPE NAME    PG A1 PG SEGMENT NAME   ELEMENT NAME                   DES.      NUMBER   LOOP ATTRIBUTES      NOTES   USE     REPEAT
                                                                           HEALTH CARE CODE INFORMATION   HI02        C022   2300 O
                                                                           CODE LIST QUALIFIER CODE       HI02-1      1270   2300 M   ID   1/3    BG
                                                                           INDUSTRY CODE                  HI02-2      1271   2300 M   AN   1/30

                                                                           HEALTH CARE CODE INFORMATION   HI03        C022   2300 O


                                                                           CODE LIST QUALIFIER CODE       HI03-1      1270   2300 M   ID   1/3    BG
                                                                           INDUSTRY CODE                  HI03-2      1271   2300 M   AN   1/30

                                                                           HEALTH CARE CODE INFORMATION   HI04        C022   2300 O
                                                                           CODE LIST QUALIFIER CODE       HI04-1      1270   2300 M   ID   1/3    BG


                                                                           INDUSTRY CODE                  HI04-2      1271   2300 M   AN   1/30
                                                                           HEALTH CARE CODE INFORMATION   HI05        C022   2300 O


                                                                           CODE LIST QUALIFIER CODE       HI05-1      1270   2300 M   ID   1/3    BG


                                                                           INDUSTRY CODE                  HI05-2      1271   2300 M   AN   1/30

                                                                           HEALTH CARE CODE INFORMATION   HI06        C022   2300 O


                                                                           CODE LIST QUALIFIER CODE       HI06-1      1270   2300 M   ID   1/3    BG


                                                                           INDUSTRY CODE                  HI06-2      1271   2300 M   AN   1/30

                                                                           HEALTH CARE CODE INFORMATION   HI07        C022   2300 O


                                                                           CODE LIST QUALIFIER CODE       HI07-1      1270   2300 M   ID   1/3    BG


                                                                           INDUSTRY CODE                  HI07-2      1271   2300 M   AN   1/30

                                                                           HEALTH CARE CODE INFORMATION   HI08        C022   2300 O
                                                                           CODE LIST QUALIFIER CODE       HI08-1      1270   2300 M   ID   1/3    BG
                                                                           INDUSTRY CODE                  HI08-2      1271   2300 M   AN   1/30
                                                                           HEALTH CARE CODE INFORMATION   HI09        C022   2300 M
                                                                           CODE LIST QUALIFIER CODE       HI09-1      1270   2300 M   ID   1/3    BG
                                                                           INDUSTRY CODE                  HI09-2      1271   2300 M   AN   1/30
                                                                           HEALTH CARE CODE INFORMATION   HI10        C022   2300 M
                                                                           CODE LIST QUALIFIER CODE       HI10-1      1270   2300 M   ID   1/3    BG

                                                                           INDUSTRY CODE                  HI10-2      1271   2300 M   AN   1/30

                                                                           HEALTH CARE CODE INFORMATION   HI11        C022   2300 M


                                                                                  93
                                                                                                                                                                         Policy Memorandum 2004 - 37
                                                                                                                                                                         Exhibit 2L



                                                               837 - HEALTH CLAIMS AND ENCOUNTERS (INSTITUTIONAL)
INTERNAL    TABLE  /   FIELD               FIELD   Old                                                                   REF      ELEMENT
RECORD ID   DATABASE   LENGTH   FIELD TYPE NAME    PG A1 PG SEGMENT NAME                  ELEMENT NAME                   DES.      NUMBER   LOOP ATTRIBUTES      NOTES   USE     REPEAT
                                                                                          CODE LIST QUALIFIER CODE       HI11-1      1270   2300 M   ID   1/3    BG
                                                                                          INDUSTRY CODE                  HI11-2      1271   2300 M   AN   1/30


                                                                                          HEALTH CARE CODE INFORMATION   HI12        C022   2300 M
                                                                                          CODE LIST QUALIFIER CODE       HI12-1      1270   2300 M   ID   1/3    BG
                                                                                          INDUSTRY CODE                  HI12-2      1271   2300 M   AN   1/30
                                                   299 304   TREATMENT CODE INFORMATION                                  HI                 2300                         S          2
                                                                                          HEALTH CARE CODE INFORMATION   HI01        C022   2300 O
                                                                                          CODE LIST QUALIFIER CODE       HI01-1      1270   2300 M   ID   1/3    TC


                                                                                          INDUSTRY CODE                  HI01-2      1271   2300 M   AN   1/30
                                                                                          HEALTH CARE CODE INFORMATION   HI02        C022   2300 O
                                                                                          CODE LIST QUALIFIER CODE       HI02-1      1270   2300 M   ID   1/3    TC

                                                                                          INDUSTRY CODE                  HI02-2      1271   2300 M   AN   1/30

                                                                                          HEALTH CARE CODE INFORMATION   HI03        C022   2300 O


                                                                                          CODE LIST QUALIFIER CODE       HI03-1      1270   2300 M   ID   1/3    TC
                                                                                          INDUSTRY CODE                  HI03-2      1271   2300 M   AN   1/30
                                                                                          HEALTH CARE CODE INFORMATION   HI04        C022   2300 O
                                                                                          CODE LIST QUALIFIER CODE       HI04-1      1270   2300 M   ID   1/3    TC
                                                                                          INDUSTRY CODE                  HI04-2      1271   2300 M   AN   1/30

                                                                                          HEALTH CARE CODE INFORMATION   HI05        C022   2300 O


                                                                                          CODE LIST QUALIFIER CODE       HI05-1      1270   2300 M   ID   1/3    TC


                                                                                          INDUSTRY CODE                  HI05-2      1271   2300 M   AN   1/30

                                                                                          HEALTH CARE CODE INFORMATION   HI06        C022   2300 O


                                                                                          CODE LIST QUALIFIER CODE       HI06-1      1270   2300 M   ID   1/3    TC


                                                                                          INDUSTRY CODE                  HI06-2      1271   2300 M   AN   1/30

                                                                                          HEALTH CARE CODE INFORMATION   HI07        C022   2300 O
                                                                                          CODE LIST QUALIFIER CODE       HI07-1      1270   2300 M   ID   1/3    TC
                                                                                          INDUSTRY CODE                  HI07-2      1271   2300 M   AN   1/30
                                                                                          HEALTH CARE CODE INFORMATION   HI08        C022   2300 O
                                                                                          CODE LIST QUALIFIER CODE       HI08-1      1270   2300 M   ID   1/3    TC
                                                                                          INDUSTRY CODE                  HI08-2      1271   2300 M   AN   1/30


                                                                                                 94
                                                                                                                                                                                    Policy Memorandum 2004 - 37
                                                                                                                                                                                    Exhibit 2L



                                                               837 - HEALTH CLAIMS AND ENCOUNTERS (INSTITUTIONAL)
INTERNAL    TABLE  /   FIELD               FIELD   Old                                                                             REF       ELEMENT
RECORD ID   DATABASE   LENGTH   FIELD TYPE NAME    PG A1 PG SEGMENT NAME                           ELEMENT NAME                    DES.       NUMBER   LOOP ATTRIBUTES      NOTES   USE     REPEAT
                                                                                                   HEALTH CARE CODE INFORMATION    HI09         C022   2300 M
                                                                                                   CODE LIST QUALIFIER CODE        HI09-1       1270   2300 M   ID   1/3    TC
                                                                                                   INDUSTRY CODE                   HI09-2       1271   2300 M   AN   1/30

                                                                                                   HEALTH CARE CODE INFORMATION    HI10         C022   2300 M


                                                                                                   CODE LIST QUALIFIER CODE        HI10-1       1270   2300 M   ID   1/3    TC

                                                                                                   INDUSTRY CODE                   HI10-2       1271   2300 M   AN   1/30

                                                                                                   HEALTH CARE CODE INFORMATION    HI11         C022   2300 M
                                                                                                   CODE LIST QUALIFIER CODE        HI11-1       1270   2300 M   ID   1/3    TC
                                                                                                   INDUSTRY CODE                   HI11-2       1271   2300 M   AN   1/30


                                                                                                   HEALTH CARE CODE INFORMATION    HI12         C022   2300 M
                                                                                                   CODE LIST QUALIFIER CODE        HI12-1       1270   2300 M   ID   1/3    TC
                                                                                                   INDUSTRY CODE                   HI12-2       1271   2300 M   AN   1/30
                                                   306 311   CLAIM QUANTITY                                                        QTY                 2300                         S          4
                                                                                                   QUANTITY QUALIFIER              QTY01         673   2300 M   ID   2/2    CA
                                                                                                   QUANTITY                        QTY02         380   2300 X   R    1/15
                                                                                                   COMPOSITE UNIT OF MEASURE       QTY03        C001   2300 O
                                                                                                   UNIT OR BASIS FOR MEASUREMENT
                                                                                                   CODE                            QTY03-1       355   2300 M   ID   2/2    DA
                                                   308 313   CLAIM PRICING/REPRICING INFORMATION                                   HCP                 2300                         S          1
                                                                                                   PRICING METHODOLOGY             HCP01        1473   2300 X   ID   2/2

                                                                                                   MONETARY AMOUNT                 HCP02         782   2300 O   R    1/18

                                                                                                   MONETARY AMOUNT                 HCP03         782   2300 O   R    1/18

                                                                                                   REFERENCE                       HCP04         127   2300 O   AN   1/30

                                                                                                   RATE                            HCP05         118   2300 O   R    1/9

                                                                                                   REFERENCE IDENTIFICATION        HCP06         127   2300 O   AN   1/30

                                                                                                   MONETARY AMOUNT                 HCP07         782   2300 O   R    1/18

                                                                                                   PRODUCT/SERVICE ID              HCP08         234   2300 O   AN   1/48

                                                                                                   PRODUCT/SERVICE ID QUALIFIER    HCP09         235   2300 X   ID   2/2    HC

                                                                                                   PRODUCT/SERVICE ID              HCP10         234   2300 X   AN   1/48
                                                                                                   UNIT OR BASIS FOR MEASUREMENT
                                                                                                   CODE                            HCP11         355   2300 X   ID   2/2



                                                                                                          95
                                                                                                                                                                                       Policy Memorandum 2004 - 37
                                                                                                                                                                                       Exhibit 2L



                                                               837 - HEALTH CLAIMS AND ENCOUNTERS (INSTITUTIONAL)
INTERNAL    TABLE  /   FIELD               FIELD   Old                                                                                 REF     ELEMENT
RECORD ID   DATABASE   LENGTH   FIELD TYPE NAME    PG A1 PG SEGMENT NAME                          ELEMENT NAME                         DES.     NUMBER   LOOP ATTRIBUTES       NOTES   USE     REPEAT

                                                                                                  QUANTITY                             HCP12       380    2300 X   R    1/15

                                                                                                  REJECT REASON CODE                   HCP13       901    2300 X   ID   2/2

                                                                                                  POLICY COMPLIANCE CODE               HCP14      1526    2300 O   ID   1/2

                                                                                                  EXCEPTION CODE                       HCP15      1527    2300 O   ID   1/2

                                                             LOOP ID - 2305 HOME HEALTH CARE PLAN INFORMATION                                                                                     6

                                                   314 319   HOME HEALTH CARE PLAN INFORMATION                                         CR7                                             S          1

                                                                                                  DISCIPLINE TYPE CODE                 CR701       921    2305 M   ID   2/2

                                                                                                  NUMBER                               CR702      1470    2305 M   NO   1/9
                                                                                                  NUMBER                               CR703      1470    2305 M   NO   1/9
                                                   316 321   HEALTH CARE SERVICES DELIVERY                                             HSD                2305                         S          12
                                                                                                  QUANTITY QUALIFIER                   HSD01       673    2305 X   ID   2/2    VS
                                                                                                  QUANTITY                             HSD02       380    2305 X   R    1/15
                                                                                                  UNIT OR BASIS FOR MEASUREMENT
                                                                                                  CODE                                 HSD03       355    2305 O   ID   2/2
                                                                                                  SAMPLE SELECTION MODULUS             HSD04      1167    2305 O   R    1/6
                                                                                                  TIME PERIOD QUALIFIER                HSD05       615    2305 X   ID   1/2
                                                                                                  NUMBER OF PERIODS                    HSD06       616    2305 O   NO   1/3
                                                                                                  SHIP/DELIVERY OR CALENDAR PATTERN
                                                                                                  CODE                                 HSD07       678    2305 O   ID   1/2
                                                                                                  SHIP/DELIVER PATTERN TIME CODE       HSD08       679    2305 O   ID   1/1
                                                             LOOP ID - 2310A ATTENDING PHYSICIAN NAME                                                                                             1
                                                   321 326   ATTENDING PHYSICIAN NAME                                                  NM1                                             S          1
                                                                                                  ENTITY IDENTIFIER CODE               NM101        98   2310A M   ID   2/3
                                                                                                  ENTITY TYPE QUALIFIER                NM102      1065   2310A M   ID   1/1
                                                                                                  NAME LAST OR ORGANIZATION NAME       NM103      1035   2310A O   AN   1/35
                                                                                                  NAME FIRST                           NM104      1036   2310A O   AN   1/25
                                                                                                  NAME MIDDLE                          NM105      1037   2310A O   AN   1/25
                                                                                                  NAME SUFFIX                          NM107      1039   2310A O   AN   1/10
                                                                                                  IDENTIFICATION CODE QUALIFIER        NM108        66   2310A X   ID   1/2
                                                                                                  IDENTIFICATION CODE                  NM109        67   2310A X   AN   2/80
                                                             ATTENDING PHYSICIAN SPECIALTY
                                                   324 329   INFORMATION                                                               PRV               2310A                         S          1
                                                                                                  PROVIDER CODE                        PRV01      1221   2310A M   ID   1/3
                                                                                                  REFERENCE IDENTIFICATION QUALIFIER   PRV02       128   2310A M   ID   2/3
                                                                                                  REFERENCE IDENTIFICATION             PRV03       127   2310A M   AN   1/30
                                                             ATTENDING PHYSICIAN SECONDARY
                                                   326 331   INFORMATION                                                               REF               2310A                         S          5
                                                                                                  REFERENCE IDENTIFICATION QUALIFIER   REF01       128   2310A M   ID   2/3


                                                                                                           96
                                                                                                                                                                                          Policy Memorandum 2004 - 37
                                                                                                                                                                                          Exhibit 2L



                                                               837 - HEALTH CLAIMS AND ENCOUNTERS (INSTITUTIONAL)
INTERNAL    TABLE  /   FIELD               FIELD   Old                                                                                    REF     ELEMENT
RECORD ID   DATABASE   LENGTH   FIELD TYPE NAME    PG A1 PG SEGMENT NAME                             ELEMENT NAME                         DES.     NUMBER   LOOP ATTRIBUTES       NOTES   USE     REPEAT


                                                                                                     REFERENCE IDENTIFICATION             REF02       127   2310A M   AN   1/30
                                                             LOOP ID - 2310B OPERATING PHYSICIAN NAME                                                                                                1

                                                   328 333   OPERATING PHYSICIAN NAME                                                     NM1                                             S          1



                                                                                                     ENTITY IDENTIFIER CODE               NM101        98   2310B M   ID   2/3    72
                                                                                                     ENTITY TYPE QUALIFIER                NM102      1065   2310B M   ID   1/1    1
                                                                                                     NAME LAST OR ORGANIZATION NAME       NM103      1035   2310B O   AN   1/35



                                                                                                     NAME FIRST                           NM104      1036   2310B O   AN   1/25
                                                                                                     NAME MIDDLE                          NM105      1037   2310B O   AN   1/25
                                                                                                     NAME SUFFIX                          NM107      1039   2310B O   AN   1/10
                                                                                                     IDENTIFICATION CODE QUALIFIER        NM108        66   2310B X   ID   1/2
                                                                                                     IDENTIFICATION CODE                  NM109        67   2310B X   AN   2/80
                                                             RENDERING PROVIDER SECONDARY
                                                   333 338   IDENTIFICATION                                                               REF               2310B                         S          5
                                                                                                     REFERENCE IDENTIFICATION QUALIFIER   REF01       128   2310B M   ID   2/3
                                                                                                     REFERENCE IDENTIFICATION             REF02       127   2310B X   AN   1/30
                                                             LOOP ID - 2310C OTHER PROVIDER NAME                                                                                                     1
                                                   335 340   OTHER PROVIDER NAME                                                          NM1                                             S          1
                                                                                                     ENTITY IDENTIFIER CODE               NM101        98   2310C M   ID   2/3    73


                                                                                                     ENTITY TYPE QUALIFIER                NM102      1065   2310C M   ID   1/1
                                                                                                     NAME LAST OR ORGANIZATION NAME       NM103      1035   2310C O   AN   1/35
                                                                                                     NAME FIRST                           NM104      1036   2310C O   AN   1/25



                                                                                                     NAME MIDDLE                          NM105      1037   2310C O   AN   1/25
                                                                                                     NAME SUFFIX                          NM107      1039   2310C O   AN   1/10
                                                                                                     IDENTIFICATION CODE QUALIFIER        NM108        66   2310C X   ID   1/2



                                                                                                     IDENTIFICATION CODE                  NM109        67   2310C X   AN   2/80
                                                             OTHER PROVIDER SECONDARY
                                                   340 345   IDENTIFICATION                                                               REF               2310C                         S          5

                                                                                                     REFERENCE IDENTIFICATION QUALIFIER   REF01       128   2310C M   ID   2/3
                                                                                                     REFERENCE IDENTIFICATION             REF02       127   2310C X   AN   1/30


                                                             LOOP ID 2310E - SERVICE FACILITY NAME                                                                                                   1



                                                                                                            97
                                                                                                                                                                                                  Policy Memorandum 2004 - 37
                                                                                                                                                                                                  Exhibit 2L



                                                               837 - HEALTH CLAIMS AND ENCOUNTERS (INSTITUTIONAL)
INTERNAL    TABLE  /   FIELD               FIELD   Old                                                                                   REF     ELEMENT
RECORD ID   DATABASE   LENGTH   FIELD TYPE NAME    PG A1 PG SEGMENT NAME                            ELEMENT NAME                         DES.     NUMBER   LOOP ATTRIBUTES       NOTES            USE     REPEAT


                                                   349 347   SERVICE FACILITY NAME                                                       NM1                                                      S          1


                                                                                                    ENTITY IDENTIFIER CODE               NM101        98   2310E M   ID   2/3    FA
                                                                                                    ENTITY TYPE QUALIFIER                NM102      1065   2310E M   ID   1/1    2
                                                                                                    NAME LAST OR ORGANIZATION NAME       NM103      1035   2310E O   AN   1/35
                                                                                                    NAME FIRST                           NM104      1036   2310E O   AN   1/25

                                                                                                    NAME MIDDLE                          NM105      1037   2310E O   AN   1/25


                                                                                                    NAME SUFFIX                          NM107      1039   2310E O   AN   1/10


                                                                                                    IDENTIFICATION CODE QUALIFIER        NM108        66   2310E X   ID   1/2
                                                                                                    IDENTIFICATION CODE                  NM109        67   2310E X   AN   2/80



                                                   354 352   SERVICE FACILITY ADDRESS                                                    N3                2310E                                  R          1
                                                                                                    ADDRESS INFORMATION                  N301        166   2310E M   AN   1/55   ADDRESS LINE 1
                                                                                                    ADDRESS INFORMATION                  N302        166   2310E O   AN   1/55   ADDRESS LINE 2



                                                   355 353   SERVICE FACILITY CITY/STATE/ZIP CODE                                        N4                2310E                                  R          1
                                                                                                    CITY NAME                            N401         19   2310E O   AN   2/30
                                                                                                    STATE OR PROVINCE CODE               N402        156   2310E O   ID   2/2
                                                                                                    POSTAL CODE                          N403        116   2310E O   ID   3/15
                                                                                                    COUNTRY CODE                         N404         26   2310E O   ID   2/3
                                                             SERVICE FACILITY SECONDARY
                                                   357 355   IDENTIFICATION                         REFERENCE IDENTIFICATION QUALIFIER   REF01       128   2310E M   ID   2/3                     S          5
                                                                                                    REFERENCE IDENTIFICATION             REF02       127   2310E X   AN   1/30
                                                             LOOP ID - 2320 OTHER SUBSCRIBER INFORMATION                                                                                                     10


                                                   359 357   OTHER SUBSCRIBER INFORMATION                                                SBR                                                      S          1
                                                                                                    PAYER RESPONSIBILITY SEQUENCE
                                                                                                    NUMBER CODE                          SBR01      1138    2320 M   ID   1/1
                                                                                                    INDIVIDUAL RELATIONSHIP CODE         SBR02      1069    2320 O   ID   2/2



                                                                                                    REFERENCE IDENTIFICATION             SBR03       127    2320 O   AN   1/30
                                                                                                    NAME                                 SBR04        93    2320 O   AN   1/60


                                                                                                    CLAIM FILING INDICATOR CODE          SBR09      1032    2320 O   ID   1/2




                                                                                                           98
                                                                                                                                                                                     Policy Memorandum 2004 - 37
                                                                                                                                                                                     Exhibit 2L



                                                               837 - HEALTH CLAIMS AND ENCOUNTERS (INSTITUTIONAL)
INTERNAL    TABLE  /   FIELD               FIELD   Old                                                                       REF     ELEMENT
RECORD ID   DATABASE   LENGTH   FIELD TYPE NAME    PG A1 PG SEGMENT NAME                      ELEMENT NAME                   DES.     NUMBER   LOOP ATTRIBUTES      NOTES            USE     REPEAT



                                                   365 363   CLAIM LEVEL ADJUSTMENTS                                         CAS               2320                                  S          5
                                                                                              CLAIM ADJUSTMENT GROUP CODE    CAS01      1033   2320 M   ID   1/2
                                                                                              CLAIM ADJUSTMENT REASON CODE   CAS02      1034   2320 M   ID   1/5
                                                                                              MONETARY AMOUNT                CAS03       782   2320 M   R    1/18
                                                                                                                                                                    UNITS OF SVC.
                                                                                              QUANTITY                       CAS04       380   2320 O   R    1/15   BEING ADJUSTED
                                                                                              CLAIM ADJUSTMENT REASON CODE   CAS05      1034   2320 M   ID   1/5
                                                                                              MONETARY AMOUNT                CAS06       782   2320 M   R    1/18
                                                                                              QUANTITY                       CAS07       380   2320 O   R    1/15
                                                                                              CLAIM ADJUSTMENT REASON CODE   CAS08      1034   2320 M   ID   1/5

                                                                                              MONETARY AMOUNT                CAS09       782   2320 M   R    1/18

                                                                                              QUANTITY                       CAS10       380   2320 O   R    1/15


                                                                                              CLAIM ADJUSTMENT REASON CODE   CAS11      1034   2320 M   ID   1/5


                                                                                              MONETARY AMOUNT                CAS12       782   2320 M   R    1/18
                                                                                              QUANTITY                       CAS13       380   2320 O   R    1/15



                                                                                              CLAIM ADJUSTMENT REASON CODE   CAS14      1034   2320 M   ID   1/5
                                                                                              MONETARY AMOUNT                CAS15       782   2320 M   R    1/18


                                                                                              QUANTITY                       CAS16       380   2320 O   R    1/15
                                                                                              CLAIM ADJUSTMENT REASON CODE   CAS17      1034   2320 M   ID   1/5
                                                                                              MONETARY AMOUNT                CAS18       782   2320 M   R    1/18

                                                                                              QUANTITY                       CAS19       380   2320 O   R    1/15
                                                   371 369   PAYER PRIOR PAYMENT                                             AMT               2320                                  S          1
                                                                                              AMOUNT QUALIFIER CODE          AMT01       522   2320 M   ID   1/3    C4
                                                                                              MONETARY AMOUNT                AMT02       782   2320 M   R    1/18
                                                             COORDINATION OF BENEFITS (COB)
                                                   371 370   TOTAL ALLOWED AMOUNT                                            AMT               2320                                  S          1



                                                                                              AMOUNT QUALIFIER CODE          AMT01       522   2320 M   ID   1/3    B6
                                                                                              MONETARY AMOUNT                AMT02       782   2320 M   R    1/18
                                                             COORDINATION OF BENEFITS (COB)
                                                   373 371   TOTAL SUBMITTED CHARGES                                         AMT               2320                                  S          1
                                                                                              AMOUNT QUALIFIER CODE          AMT01       522   2320 M   ID   1/3    T3
                                                                                              MONETARY AMOUNT                AMT02       782   2320 M   R    1/18

                                                                                                     99
                                                                                                                                                                                  Policy Memorandum 2004 - 37
                                                                                                                                                                                  Exhibit 2L



                                                               837 - HEALTH CLAIMS AND ENCOUNTERS (INSTITUTIONAL)
INTERNAL    TABLE  /   FIELD               FIELD   Old                                                                             REF     ELEMENT
RECORD ID   DATABASE   LENGTH   FIELD TYPE NAME    PG A1 PG SEGMENT NAME                         ELEMENT NAME                      DES.     NUMBER   LOOP ATTRIBUTES      NOTES   USE     REPEAT
                                                            DIAGNOSTIC RELATED GROUP (DRG)
                                                   374 372  OUTLIER AMOUNT                                                         AMT               2320                         S          1

                                                                                                 AMOUNT QUALIFIER CODE             AMT01       522   2320 M   ID   1/3    ZZ
                                                                                                 MONETARY AMOUNT                   AMT02       782   2320 M   R    1/18
                                                             COORDINATION OF BENEFITS (COB)
                                                   376 374   TOTAL MEDICARE PAID AMOUNT                                            AMT               2320                         S          1
                                                                                                 AMOUNT QUALIFIER CODE             AMT01       522   2320 M   ID   1/3    N1
                                                                                                 MONETARY AMOUNT                   AMT02       782   2320 M   R    1/18

                                                   378 376   MEDICARE PAID AMOUNT - 100%                                           AMT               2320                         S          1
                                                                                                 AMOUNT QUALIFIER CODE             AMT01       522   2320 M   ID   1/3    KF
                                                                                                 MONETARY AMOUNT                   AMT02       782   2320 M   R    1/18
                                                   380 378   MEDICARE PAID AMOUNT - 80%                                            AMT               2320                         S          1
                                                                                                 AMOUNT QUALIFIER CODE             AMT01       522   2320 M   ID   1/3
                                                                                                 MONETARY AMOUNT                   AMT02       782   2320 M   R    1/18

                                                             COORDINATION OF BENEFITS (COB)
                                                   382 380   MEDICARE A TRUST FUND PAID AMOUNT                                     AMT               2320                         S          1
                                                                                                 AMOUNT QUALIFIER CODE             AMT01       522   2320 M   ID   1/3    AA
                                                                                                 MONETARY AMOUNT                   AMT02       782   2320 M   R    1/18
                                                             COORDINATION OF BENEFITS (COB)
                                                   394 382   MEDICARE B TRUST FUND PAID AMOUNT                                     AMT               2320                         S          1
                                                                                                 AMOUNT QUALIFIER CODE             AMT01       522   2320 M   ID   1/3    B1
                                                                                                 MONETARY AMOUNT                   AMT02       782   2320 M   R    1/18
                                                             COORDINATION OF BENEFITS (COB)
                                                   386 384   TOTAL NON-COVERED AMOUNT                                              AMT               2320                         S          1
                                                                                                 AMOUNT QUALIFIER CODE             AMT01       522   2320 M   ID   1/3    A8
                                                                                                 MONETARY AMOUNT                   AMT02       782   2320 M   R    1/18
                                                             COORDINATION OF BENEFITS (COB)
                                                   387 385   TOTAL DENIED AMOUNT                                                   AMT               2320
                                                                                                 AMOUNT QUALIFIER CODE             AMT01       522   2320 M   ID   1/3    YT
                                                                                                 MONETARY AMOUNT                   AMT02       782   2320 M   R    1/18
                                                             OTHER SUBSCRIBER DEMOGRAPHIC
                                                   388 386   INFORMATION                                                           DMG               2320                         S          1

                                                                                                 DATE TIME FORMAT QUALIFIER        DMG01      1250   2320 X   ID   2/3    D8
                                                                                                 DATE TIME PERIOD                  DMG02      1251   2320 X   AN   1/35
                                                                                                 GENDER CODE                       DMG03      1068   2320 O   ID   1/1
                                                             OTHER INSURANCE COVERAGE
                                                   390 388   INFORMATION                                                           OI                2320                         R          1

                                                                                                 YES/NO CONDITION OR RESPONSE CODE OI03       1073   2320 O   ID   1/1
                                                                                                 RELEASE OF INFORMATION CODE       OI06       1363   2320 O   ID   1/1



                                                                                                       100
                                                                                                                                                                                      Policy Memorandum 2004 - 37
                                                                                                                                                                                      Exhibit 2L



                                                               837 - HEALTH CLAIMS AND ENCOUNTERS (INSTITUTIONAL)
INTERNAL    TABLE  /   FIELD               FIELD   Old                                                                     REF     ELEMENT
RECORD ID   DATABASE   LENGTH   FIELD TYPE NAME    PG A1 PG SEGMENT NAME                        ELEMENT NAME               DES.     NUMBER   LOOP ATTRIBUTES      NOTES               USE     REPEAT
                                                                                                                                                                  INPATIENT REMARK
                                                             MEDICARE INPATIENT ADJUDICATION                                                                      CODES IF
                                                   392 390   INFORMATION                                                   MIA               2320                 RETURNED IN 835     S          1
                                                                                                                                                                  COVERED
                                                                                                QUANTITY                   MIA01       380   2320 M   R    1/15   DAYS/VISITS
                                                                                                                                                                  LIFETIME RESERVE
                                                                                                QUANTITY                   MIA02       380   2320 O   R    1/15   DAYS
                                                                                                                                                                  LIFETIME PSYCH
                                                                                                QUANTITY                   MIA03       380   2320 O   R    1/15   DAYS
                                                                                                MONETARY AMOUNT            MIA04       782   2320 O   R    1/18   CLAIM DRG AMT.
                                                                                                REFERENCE IDENTIFICATION   MIA05       127   2330 O   AN   1/30   REMARK CODE
                                                                                                                                                                  DISPROPORTIONATE
                                                                                                MONETARY AMOUNT            MIA06       782   2320 O   R    1/18   SHARE AMOUNT
                                                                                                                                                                  MSP PASS-
                                                                                                MONETARY AMOUNT            MIA07       782   2320 O   R    1/18   THROUGH
                                                                                                MONETARY AMOUNT            MIA08       782   2320 O   R    1/18   PPS CAPITAL AMT
                                                                                                                                                                  PPS CAPITAL FSP
                                                                                                MONETARY AMOUNT            MIA09       782   2320 O   R    1/18   DRG AMOUNT
                                                                                                                                                                  PPS CAPITAL HSP
                                                                                                MONETARY AMOUNT            MIA10       782   2320 O   R    1/18   DRG AMOUNT
                                                                                                                                                                  PPS CAPITAL DSH
                                                                                                MONETARY AMOUNT            MIA11       782   2320 O   R    1/18   DRG AMOUNT
                                                                                                                                                                  OLD CAPITAL
                                                                                                MONETARY AMOUNT            MIA12       782   2320 O   R    1/18   AMOUNT
                                                                                                                                                                  PPS CAPITAL IME
                                                                                                MONETARY AMOUNT            MIA13       782   2320 O   R    1/18   AMOUNT
                                                                                                MONETARY AMOUNT            MIA14       782   2320 O   R    1/18   DRG AMOUNT
                                                                                                                                                                  COST REPORT DAY
                                                                                                QUANTITY                   MIA15       380   2320 O   R    1/15   COUNT

                                                                                                                                                                  PPS OPERATING
                                                                                                MONETARY AMOUNT            MIA16       782   2320 O   R    1/18   FEDERAL SPEC. DRG
                                                                                                                                                                  CAPITAL OUTLIER
                                                                                                MONETARY AMOUNT            MIA17       782   2320 O   R    1/18   AMOUNT
                                                                                                                                                                  INDIRECT TEACHING
                                                                                                MONETARY AMOUNT            MIA18       782   2320 O   R    1/18   AMOUNT
                                                                                                                                                                  NONPAYABLE PROF.
                                                                                                MONETARY AMOUNT            MIA19       782   2320 O   R    1/18   COMPONENT
                                                                                                REFERENCE IDENTIFICATION   MIA20       127   2320 O   AN   1/30   REMARK CODE

                                                                                                REFERENCE IDENTIFICATION   MIA21       127   2320 O   AN   1/30   REMARK CODE
                                                                                                REFERENCE IDENTIFICATION   MIA22       127   2320 O   AN   1/30   REMARK CODE
                                                                                                REFERENCE IDENTIFICATION   MIA23       127   2320 O   AN   1/30   REMARK CODE
                                                                                                                                                                  PPS CAPITAL
                                                                                                MONETARY AMOUNT            MIA24       782   2320 O   R    1/18   EXCEPTION AMT
                                                             MEDICARE OUTPATIENT ADJUDICATION
                                                   397 395   INFORMATION                                                   MOA               2320                                     S          1



                                                                                                      101
                                                                                                                                                                                                 Policy Memorandum 2004 - 37
                                                                                                                                                                                                 Exhibit 2L



                                                               837 - HEALTH CLAIMS AND ENCOUNTERS (INSTITUTIONAL)
INTERNAL    TABLE  /   FIELD               FIELD   Old                                                                                REF     ELEMENT
RECORD ID   DATABASE   LENGTH   FIELD TYPE NAME    PG A1 PG SEGMENT NAME                         ELEMENT NAME                         DES.     NUMBER   LOOP ATTRIBUTES       NOTES              USE     REPEAT
                                                                                                                                                                              REIMBURSEMENT
                                                                                                 PERCENT                              MOA01       954    2320 O   R    1/10   RATE
                                                                                                                                                                              HCPCS PAYABLE
                                                                                                 MONETARY AMOUNT                      MOA02       782    2320 O   R    1/18   AMOUNT
                                                                                                 REFERENCE IDENTIFIER                 MOA03       127    2320 O   AN   1/30   REMARK CODE
                                                                                                 REFERENCE IDENTIFIER                 MOA04       127    2320 O   AN   1/30   REMARK CODE
                                                                                                 REFERENCE IDENTIFIER                 MOA05       127    2320 O   AN   1/30   REMARK CODE
                                                                                                 REFERENCE IDENTIFIER                 MOA06       127    2320 O   AN   1/30   REMARK CODE


                                                                                                 REFERENCE IDENTIFIER                 MOA07       127    2320 O   AN   1/30   REMARK CODE

                                                                                                                                                                              ESRD PAYMENT
                                                                                                 MONETARY AMOUNT                      MOA08       782    2320 O   R    1/18   AMOUNT

                                                                                                                                                                              NONPAYABLE PROF.
                                                                                                 MONETARY AMOUNT                      MOA09       782    2320 O   R    1/18   COMPONENT
                                                             LOOP ID - 2330A OTHER SUBSCRIBER NAME                                                                                                          1
                                                   400 398   OTHER SUBSCRIBER NAME                                                    NM1                                                        R          1
                                                                                                 ENTITY IDENTIFIER CODE               NM101        98   2330A M   ID   2/3    IL
                                                                                                 ENTITY TYPE QUALIFIER                NM102      1065   2330A M   ID   1/1
                                                                                                 NAME LAST OR ORGANIZATION NAME       NM103      1035   2330A O   AN   1/35
                                                                                                 NAME FIRST                           NM104      1036   2330A O   AN   1/25
                                                                                                 NAME MIDDLE                          NM105      1037   2330A O   AN   1/25
                                                                                                 NAME SUFFIX                          NM107      1039   2330A O   AN   1/10
                                                                                                 IDENTIFICATION CODE QUALIFIER        NM108        66   2330A X   ID   1/2
                                                                                                 IDENTIFICATION CODE                  NM109        67   2330A X   AN   2/80
                                                   404 402   OTHER SUBSCRIBER ADDRESS                                                 N3                2330A                                    S          1
                                                                                                 ADDRESS INFORMATION                  N301        166   2330A M   AN   1/55

                                                                                                 ADDRESS INFORMATION                  N302        166   2330A O   AN   1/55
                                                             OTHER SUBSCRIBER CITY/STATE/ZIP
                                                   406 404   CODE                                                                     N4                2330A                                    S          1
                                                                                                 CITY NAME                            N401         19   2330A O   AN   2/30
                                                                                                 STATE OR PROVINCE CODE               N402        156   2330A O   ID   2/2
                                                                                                 POSTAL CODE                          N403        116   2330A O   ID   3/15


                                                                                                 COUNTRY CODE                         N404         26   2330A O   ID   2/3
                                                             OTHER SUBSCRIBER SECONDARY
                                                   408 406   INFORMATION                                                              REF               2330A                                    S          3
                                                                                                 REFERENCE IDENTIFICATION QUALIFIER   REF01       128   2330A M   ID   2/3
                                                                                                 REFERENCE IDENTIFICATION             REF02       127   2330A X   AN   1/30
                                                             LOOP ID - 2330B OTHER PAYER NAME                                                                                                               1
                                                   410 408   OTHER PAYER NAME                                                         NM1                                                        R          1
                                                                                                 ENTITY IDENTIFIER CODE               NM101        98   2330B M   ID   2/3    PR


                                                                                                        102
                                                                                                                                                                                       Policy Memorandum 2004 - 37
                                                                                                                                                                                       Exhibit 2L



                                                               837 - HEALTH CLAIMS AND ENCOUNTERS (INSTITUTIONAL)
INTERNAL    TABLE  /   FIELD               FIELD   Old                                                                                 REF     ELEMENT
RECORD ID   DATABASE   LENGTH   FIELD TYPE NAME    PG A1 PG SEGMENT NAME                          ELEMENT NAME                         DES.     NUMBER   LOOP ATTRIBUTES       NOTES   USE     REPEAT
                                                                                                  ENTITY TYPE QUALIFIER                NM102      1065   2330B M   ID   1/1    2
                                                                                                  NAME LAST OR ORGANIZATION NAME       NM103      1035   2330B O   AN   1/35
                                                                                                  IDENTIFICATION CODE QUALIFIER        NM108        66   2330B X   ID   1/2
                                                                                                  IDENTIFICATION CODE                  NM109        67   2330B X   AN   2/80
                                                   412 410   OTHER PAYER ADDRESS                                                       N3                2330B                         S          1
                                                                                                  ADDRESS INFORMATION                  N301        166   2330B M   AN   1/55
                                                                                                  ADDRESS INFORMATION                  N302        166   2330B O   AN   1/55
                                                   413 411   OTHER PAYER CITY/STATE/ZIP CODE                                           N4                2330B                         S          1


                                                                                                  CITY NAME                            N401         19   2330B O   AN   2/30
                                                                                                  STATE OR PROVINCE CODE               N402        156   2330B O   ID   2/2


                                                                                                  POSTAL CODE                          N403        116   2330B O   ID   3/15
                                                                                                  COUNTRY CODE                         N404         26   2330B O   ID   2/3
                                                   415 413   CLAIM ADJUDICATION DATE                                                   DTP               2330B                         S          1
                                                                                                  DATE/TIME QUALIFIER                  DTP01       374   2330B M   ID   3/3    573

                                                                                                  DATE TIME PERIOD FORMAT QUALIFIER    DTP02      1250   2330B M   ID   2/3    D8
                                                                                                  DATE TIME PERIOD                     DTP03      1251   2330B M   AN   1/35
                                                             OTHER PAYER SECONDARY
                                                             IDENTIFICATION AND REFERENCE
                                                   416 414   NUMBER                                                                    REF               2330B                         S          2
                                                                                                  REFERENCE IDENTIFICATION QUALIFIER   REF01       128   2330B M   ID   2/3    2U


                                                                                                  REFERENCE IDENTIFICATION             REF02       127   2330B X   AN   1/30
                                                             OTHER PAYER PRIOR AUTHORIZATION OR
                                                   418 416   REFERRAL NUMBER                                                           REF               2330B                         S          1
                                                                                                  REFERENCE IDENTIFICATION QUALIFIER   REF01       128   2330B M   ID   2/3
                                                                                                  REFERENCE IDENTIFICATION             REF02       127   2330B X   AN   1/30

                                                             LOOP ID 2330C OTHER PAYER PATIENT INFORMATION                                                                                        1
                                                   420 418   OTHER PAYER PATIENT INFORMATION                                           NM1                                             S          1
                                                                                                  ENTITY IDENTIFIER CODE               NM101        98   2330C M   ID   2/3    QC
                                                                                                  ENTITY TYPE QUALIFIER                NM102      1065   2330C M   ID   1/1    1
                                                                                                  IDENTIFICATION CODE QUALIFIER        NM108        66   2330C X   ID   1/2
                                                                                                  IDENTIFICATION CODE                  NM109        67   2330C X   AN   2/80

                                                             OTHER PAYER PATIENT IDENTIFICATION
                                                   422 420   NUMBER                                                                    REF               2330C                         S          3
                                                                                                  REFERENCE IDENTIFICATION QUALIFIER   REF01       128   2330C M   ID   2/3
                                                                                                  REFERENCE IDENTIFICATION             REF02       127   2330C X   AN   1/30
                                                             LOOP ID 2330D - OTHER PAYER ATTENDING PROVIDER                                                                                       1
                                                   424 422   OTHER PAYER ATTENDING PROVIDER                                            NM1                                             S          1


                                                                                                         103
                                                                                                                                                                                                Policy Memorandum 2004 - 37
                                                                                                                                                                                                Exhibit 2L



                                                               837 - HEALTH CLAIMS AND ENCOUNTERS (INSTITUTIONAL)
INTERNAL    TABLE  /   FIELD               FIELD   Old                                                                                 REF     ELEMENT
RECORD ID   DATABASE   LENGTH   FIELD TYPE NAME    PG A1 PG SEGMENT NAME                          ELEMENT NAME                         DES.     NUMBER   LOOP ATTRIBUTES       NOTES            USE     REPEAT
                                                                                                  ENTITY IDENTIFIER CODE               NM101        98   2330D M   ID   2/3
                                                                                                  ENTITY TYPE QUALIFIER                NM102      1065   2330D M   ID   1/1
                                                             OTHER PAYER ATTENDING PROVIDER
                                                   426 424   IDENTIFICATION                                                            REF               2330D                                  R          3


                                                                                                  REFERENCE IDENTIFICATION QUALIFIER   REF01       128   2330D M   ID   2/3
                                                                                                  REFERENCE IDENTIFICATION             REF02       127   2330D X   AN   1/30
                                                             LOOP ID 2330E - OTHER PAYER OPERATING PROVIDER                                                                                                1
                                                   428 426   OTHER PAYER OPERATING PROVIDER                                            NM1                                                      S          1
                                                                                                  ENTITY IDENTIFIER CODE               NM101        98   2330E M   ID   2/3
                                                                                                  ENTITY TYPE QUALIFIER                NM102      1065   2330E M   ID   1/1
                                                             OTHER PAYER OPERATING PROVIDER
                                                   430 428   IDENTIFICATION                                                            REF               2330E                                  R          3
                                                                                                  REFERENCE IDENTIFICATION QUALIFIER   REF01       128   2330E M   ID   2/3
                                                                                                  REFERENCE IDENTIFICATION             REF02       127   2330E X   AN   1/30
                                                             LOOP ID 2330F - OTHER PAYER OTHER PROVIDER                                                                                                    1
                                                   432 430   OTHER PAYER OTHER PROVIDER                                                NM1                                                      S          1
                                                                                                  ENTITY IDENTIFIER CODE               NM101        98   2330F M   ID   2/3
                                                                                                  ENTITY TYPE QUALIFIER                NM102      1065   2330F M   ID   1/1

                                                             OTHER PAYER OTHER PROVIDER
                                                   434 432   IDENTIFICATION                                                            REF               2330F                                  R          3



                                                                                                  REFERENCE IDENTIFICATION QUALIFIER   REF01       128   2330F M   ID   2/3
                                                                                                  REFERENCE IDENTIFICATION             REF02       127   2330F X   AN   1/30
                                                             LOOP ID 2330H - OTHER PAYER SERVICE FACILITY PROVIDER                                                                                         1

                                                             OTHER PAYER SERVICE FACILITY
                                                   440 434   PROVIDER                                                                  NM1                                                      S          1
                                                                                                  ENTITY IDENTIFIER CODE               NM101        98   2330H M   ID   2/3

                                                                                                  ENTITY TYPE QUALIFIER                NM102      1065   2330H M   ID   1/1
                                                             OTHER PAYER SERVICE FACILITY
                                                   442 436   PROVIDER IDENTIFICATION                                                   REF               2330H                                  R          3
                                                                                                  REFERENCE IDENTIFICATION QUALIFIER   REF01       128   2330H M   ID   2/3
                                                                                                  REFERENCE IDENTIFICATION             REF02       127   2330H X   AN   1/30
                                                             LOOP ID - 2400 SERVICE LINE NUMBER                                                                                                           999


                                                   444 438   SERVICE LINE NUMBER                                                       LX                                                       R          1
                                                                                                                                                                               BEGIN WITH 1,
                                                                                                  ASSIGNED NUMBER                      LX01        554    2400 M   NO   1/6    INCREMENT BY 1




                                                                                                          104
                                                                                                                                                                                         Policy Memorandum 2004 - 37
                                                                                                                                                                                         Exhibit 2L



                                                               837 - HEALTH CLAIMS AND ENCOUNTERS (INSTITUTIONAL)
INTERNAL    TABLE  /   FIELD               FIELD   Old                                                                       REF       ELEMENT
RECORD ID   DATABASE   LENGTH   FIELD TYPE NAME    PG A1 PG SEGMENT NAME                     ELEMENT NAME                    DES.       NUMBER   LOOP ATTRIBUTES      NOTES              USE     REPEAT



                                                   445 439   INSTITUTIONAL SERVICE LINE                                      SV2                 2400                                    R          1
                                                                                                                                                                      SERVICE LINE
                                                                                             PRODUCT/SERVICE ID              SV201         234   2400 X   AN   1/48   REVENUE CODE
                                                                                             COMPOSITE MEDICAL PROCEDURE
                                                                                             IDENTIFIER                      SV202        C003   2400 M
                                                                                             PRODUCT/SERVICE ID QUALIFIER    SV202-1       235   2400 M   ID   2/2
                                                                                             PRODUCT/SERVICE ID              SV202-2       234   2400 M   AN   1/48
                                                                                             PROCEDURE MODIFIER              SV202-3      1339   2400 O   AN   2/2
                                                                                             PROCEDURE MODIFIER              SV202-4      1339   2400 O   AN   2/2



                                                                                             PROCEDURE MODIFIER              SV202-5      1339   2400 O   AN   2/2
                                                                                             PROCEDURE MODIFIER              SV202-6      1339   2400 O   AN   2/2
                                                                                             MONETARY AMOUNT                 SV203         782   2400 O   R    1/18   LINE ITEM CHARGE
                                                                                             UNIT OR BASIS FOR MEASUREMENT
                                                                                             CODE                            SV204         355   2400 X   ID   2/2
                                                                                             QUANTITY                        SV205         380   2400 X   R    1/15   UNITS OF SERVICE
                                                                                             UNIT RATE                       SV206        1371   2400 O   R    1/10



                                                                                             MONETARY AMOUNT                 SV207         782   2400 O   R    1/18



                                                   452 444   LINE SUPPLEMENTAL INFORMATION                                   PWK                 2400                                    S          5
                                                                                             REPORT TYPE CODE                PWK01         755   2400 M   ID   2/2
                                                                                             REPORT TRANSMISSION CODE        PWK02         756   2400 O   ID   1/2
                                                                                             ID CODE QUALIFIER               PWK05          66   2400 X   ID   1/2
                                                                                             IDENTIFICATION CODE             PWK06          67   2400 X   AN   2/80
                                                   456 448   SERVICE LINE DATE                                               DTP                 2400                                    S          1
                                                                                             DATE/TIME QUALIFIER             DTP01         374   2400 M   ID   3/3    472



                                                                                             DATE/TIME FORMAT QUALIFIER      DTP02        1250   2400 M   ID   2/3
                                                                                             DATE TIME PERIOD                DTP03        1251   2400 M   AN   1/35
                                                   458 450   ASSESSMENT DATE                                                 DTP                 2400                                    S          1
                                                                                             DATE/TIME QUALIFIER             DTP01         374   2400 M   ID   3/3    866
                                                                                             DATE/TIME FORMAT QUALIFIER      DTP02        1250   2400 M   ID   2/3
                                                                                             DATE TIME PERIOD                DTP03        1251   2400 M   AN   1/35
                                                   460 452   SERVICE TAX AMOUNT                                              AMT                 2400                                    S          1



                                                                                             AMOUNT QUALIFIER CODE           AMT01         522   2400 M   ID   1/3    GT


                                                                                                    105
                                                                                                                                                                                      Policy Memorandum 2004 - 37
                                                                                                                                                                                      Exhibit 2L



                                                               837 - HEALTH CLAIMS AND ENCOUNTERS (INSTITUTIONAL)
INTERNAL    TABLE  /   FIELD               FIELD   Old                                                                               REF       ELEMENT
RECORD ID   DATABASE   LENGTH   FIELD TYPE NAME    PG A1 PG SEGMENT NAME                          ELEMENT NAME                       DES.       NUMBER   LOOP ATTRIBUTES      NOTES   USE     REPEAT
                                                                                                  MONETARY AMOUNT                    AMT02         782   2400 M   R    1/18
                                                   461 453   FACILITY TAX AMOUNT                                                     AMT                                              S          1
                                                                                                  AMOUNT QUALIFIER CODE              AMT01         522   2400 M   ID   1/3    N8
                                                                                                  MONETARY AMOUNT                    AMT02         782   2400 M   R    1/18
                                                       454   LINE PRICING/REPRICING INFORMATION                                      HCP                                              S          1

                                                                                                  PRICING/REPRICING METHODOLOGY      HCP01        1473   2400 X   ID   2/2

                                                                                                  PRICING/REPRICING ALLOWED AMOUNT   HCP02         782   2400 O   R    1/18
                                                                                                  PRICING/REPRICING SAVINGS AMOUNT   HCP03         782   2400 O   R    1/18
                                                                                                  PRICING/REPRICING ORGANIZATIONAL
                                                                                                  IDENTIFNER                         HCP04         127   2400 O   AN   1/30
                                                                                                  PRICING/REPRICING RATE             HCP05         118   2400 O   R    1/9
                                                                                                  APPROVED APG CODE, PRICING         HCP06         127   2400 O   AN   1/30
                                                                                                  APPROVED APG AMOUNT, PRICING       HCP07         782   2400 O   R    1/18
                                                                                                  APPROVED REVENUE CODE              HCP08         234   2400 O   AN   1/48
                                                                                                  PRODUCT/SERVICE ID QUALIFIER       HCP09         235   2400 X   ID   2/2
                                                                                                  PRICING/REPRICING APPROVED
                                                                                                  PROCEDURE CODE                     HCP10         234   2400 X   AN   1/48
                                                                                                  UNIT OR BASIS FOR MEASUREMENT
                                                                                                  CODE                               HCP11         355   2400 X   ID   2/2
                                                                                                  PRICING/REPRICING APPROVED UNITS
                                                                                                  OR INPATIENT DAYS                  HCP12         380   2400 X   R    1/15
                                                                                                  REJECT REASON CODE                 HCP13         901   2400 X   ID   2/2
                                                                                                  POLICY COMPLIANCE CODE             HCP14        1526   2400 O   ID   1/2
                                                                                                  EXCEPTION CODE                     HCP15        1527   2400 O   ID   1/2
                                                             LOOP ID - 2410 DRUG IDENTIFICATION                                                                                                  25
                                                       459   DRUG IDENTIFICATION                                                     LIN                                              S          1

                                                                                                  PRODUCT/SERVICE ID QUALIFIER       LIN02         235   2410 M   ID   2/2
                                                                                                  PRODUCE/SERVICE ID                 LIN03         234   2410 M   AN   1/48
                                                       462   DRUG PRICING                                                            CTP                                              S          1
                                                                                                  DRUG UNIT PRICE                    CTP03         212   2410 X   R    1/17
                                                                                                  NATIONAL DRUG UNIT COUNT           CTP04         380   2410 X   R    1/15
                                                                                                  UNIT/BASIS OF MEASUREMENT          CTP05        C001      X
                                                                                                  CODE QUALIFIER                     CTP05-1       355   2410 M   ID   2/2
                                                       465   PRESCRIPTION NUMBER                                                     REF                                              S          1
                                                                                                  CODE QUALIFIER                     REF01         128   2410 M   ID   2/3
                                                                                                  PRESCRIPTION NUMBER                REF02         127   2410 X   AN   1/30           S          1
                                                             LOOP ID - 2420A ATTENDING PHYSICIAN NAME                                                                                            1

                                                                                                        106
                                                                                                                                                                                                    Policy Memorandum 2004 - 37
                                                                                                                                                                                                    Exhibit 2L



                                                               837 - HEALTH CLAIMS AND ENCOUNTERS (INSTITUTIONAL)
INTERNAL    TABLE  /   FIELD               FIELD   Old                                                                                  REF     ELEMENT
RECORD ID   DATABASE   LENGTH   FIELD TYPE NAME    PG A1 PG SEGMENT NAME                           ELEMENT NAME                         DES.     NUMBER   LOOP ATTRIBUTES       NOTES               USE     REPEAT
                                                                                                                                                                                REQ. IF DIFFERENT
                                                   462 467   ATTENDING PHYSICIAN NAME                                                   NM1               2420A                 FROM 2310A LOOP     S          1
                                                                                                   ENTITY IDENTIFIER CODE               NM101        98   2420A M   ID   2/3    71
                                                                                                   ENTITY TYPE QUALIFIER                NM102      1065   2420A M   ID   1/1
                                                                                                   NAME LAST OR ORGANIZATION NAME       NM103      1035   2420A O   AN   1/35
                                                                                                   NAME FIRST                           NM104      1036   2420A O   AN   1/25
                                                                                                   NAME MIDDLE                          NM105      1037   2420A O   AN   1/25
                                                                                                   NAME SUFFIX                          NM107      1039   2420A O   AN   1/10
                                                                                                   IDENTIFICATION CODE QUALIFIER        NM108        66   2420A X   ID   1/2
                                                                                                   IDENTIFICATION CODE                  NM109        67   2420A X   AN   2/80
                                                             ATTENDING PHYSICIAN SECONDARY
                                                   467 472   IDENTIFICATION                                                             REF               2420A                                     S          1
                                                                                                   REFERENCE IDENTIFICATION QUALIFIER   REF01       128   2420A M   ID   2/3
                                                                                                   REFERENCE IDENTIFICATION             REF02       127   2420A X   AN   1/30
                                                             LOOP ID - 2420B OPERATING PHYSICIAN NAME                                                                                                          1
                                                   469 474   OPERATING PHYSICIAN NAME                                                   NM1                                                         S          1
                                                                                                   ENTITY IDENTIFIER CODE               NM101        98   2420B M   ID   2/3    QB
                                                                                                   ENTITY TYPE QUALIFIER                NM102      1065   2420B M   ID   1/1
                                                                                                   NAME LAST OR ORGANIZATION NAME       NM103      1035   2420B O   AN   1/35
                                                                                                   NAME FIRST                           NM104      1036   2420B O   AN   1/25
                                                                                                   NAME MIDDLE                          NM105      1037   2420B O   AN   1/25
                                                                                                   NAME SUFFIX                          NM107      1039   2420B O   AN   1/10
                                                                                                   ID CODE QUALIFIER                    NM108        66   2420B X   ID   1/2
                                                                                                   ID CODE                              NM109        67   2420B X   AN   2/80
                                                             OPERATING PHYSICIAN SECONDARY
                                                   474 479   IDENTIFICATION                                                             REF               2420B                                     S          1
                                                                                                   REFERENCE IDENTIFICATION QUALIFIER   REF01       128   2420B M   ID   2/3
                                                                                                   REFERENCE IDENTIFICATION             REF02       127   2420B X   AN   1/30
                                                             LOOP ID - 2420C OTHER PROVIDER NAME                                                                                                    S          1
                                                                                                                                                                                REQ. IF DIFFERENT
                                                   476 481   OTHER PROVIDER NAME                                                        NM1                                     FROM 2310C LOOP     S          1
                                                                                                   ENTITY IDENTIFIER CODE               NM101        98   2420C M   ID   2/3    73
                                                                                                   ENTITY TYPE QUALIFIER                NM102      1065   2420C M   ID   1/1
                                                                                                   NAME LAST OR ORGANIZATION NAME       NM103      1035   2420C O   AN   1/35
                                                                                                   NAME FIRST                           NM104      1036   2420C O   AN   1/25
                                                                                                   NAME MIDDLE                          NM105      1037   2420C O   AN   1/25
                                                                                                   NAME SUFFIX                          NM107      1039   2420C O   AN   1/10
                                                                                                   IDENTIFICATION CODE QUALIFIER        NM108        66   2420C X   ID   1/2
                                                                                                   IDENTIFICATION CODE                  NM109        67   2420C X   AN   2/80
                                                             OTHER PROVIDER SECONDARY
                                                   481 486   INFORMATION                                                                REF               2420C                                     S          1
                                                                                                   REFERENCE IDENTIFICATION QUALIFIER   REF01       128   2420C M   ID   2/3
                                                                                                   REFERENCE IDENTIFICATION             REF02       127   2420C X   AN   1/30


                                                                                                          107
                                                                                                                                                                                     Policy Memorandum 2004 - 37
                                                                                                                                                                                     Exhibit 2L



                                                               837 - HEALTH CLAIMS AND ENCOUNTERS (INSTITUTIONAL)
INTERNAL    TABLE  /   FIELD               FIELD   Old                                                                  REF       ELEMENT
RECORD ID   DATABASE   LENGTH   FIELD TYPE NAME    PG A1 PG SEGMENT NAME                 ELEMENT NAME                   DES.       NUMBER   LOOP ATTRIBUTES      NOTES               USE     REPEAT
                                                                                                                                                                 COB; TO SHOW
                                                             SERVICE LINE ADJUDICATION                                                                           UNBUNDLED SVC
                                                   490 488   INFORMATION                                                SVD                                      LINES               S          1
                                                                                                                                                                 MUST MATCH
                                                                                         ID CODE                        SVD01          67   2430 M   AN   2/80   2010BC OR 2330B
                                                                                                                                                                 SERVICE LINE PAID
                                                                                         MONETARY AMOUNT PROCEDURE
                                                                                         COMPOSITE MEDICAL              SVD02         782   2430 M   R    1/18   AMT
                                                                                         IDENTIFIER                     SVD03        C003   2430 O
                                                                                         PRODUCT/SERVICE ID QUALIFIER   SVD03-1       235   2430 M   ID   2/2


                                                                                         PRODUCT/SERVICE ID             SVD03-2       234   2430 M   AN   1/48
                                                                                         PROCEDURE MODIFIER             SVD03-3      1339   2430 O   AN   2/2
                                                                                         PROCEDURE MODIFIER             SVD03-4      1339   2430 O   AN   2/2
                                                                                         PROCEDURE MODIFIER             SVD03-5      1339   2430 O   AN   2/2
                                                                                         PROCEDURE MODIFIER             SVD03-6      1339   2430 O   AN   2/2
                                                                                         DESCRIPTION                    SVD03-7       352   2430 O   AN   1/80


                                                                                         PRODUCT / SERVICE ID           SVD04         234   2430 O   AN   1/48

                                                                                         QUANTITY                       SVD05         380   2430 O   R    1/15   ADJUSTMENT QTY
                                                                                         ASSIGNED NUMBER                SVD06         554   2430 O   NO   1/6
                                                   494 492   SERVICE LINE ADJUSTMENT                                    CAS                 2430                 SEE USAGE NOTES     S          99
                                                                                         CLAIM ADJUSTMENT GROUP CODE    CAS01        1033   2430 M   ID   1/2
                                                                                         CLAIM ADJUSTMENT REASON CODE   CAS02        1034   2430 M   ID   1/5
                                                                                         MONETARY AMOUNT                CAS03         782   2430 M   R    1/18



                                                                                         QUANTITY                       CAS04         380   2430 O   R    1/15
                                                                                         CLAIM ADJUSTMENT REASON CODE   CAS05        1034   2430 M   ID   1/5
                                                                                         MONETARY AMOUNT                CAS06         782   2430 M   R    1/18
                                                                                         QUANTITY                       CAS07         380   2430 O   R    1/15
                                                                                         CLAIM ADJUSTMENT REASON CODE   CAS08        1034   2430 M   ID   1/5
                                                                                         MONETARY AMOUNT                CAS09         782   2430 M   R    1/18

                                                                                         QUANTITY                       CAS10         380   2430 O   R    1/15
                                                                                         CLAIM ADJUSTMENT REASON CODE   CAS11        1034   2430 M   ID   1/5
                                                                                         MONETARY AMOUNT                CAS12         782   2430 M   R    1/18
                                                                                         QUANTITY                       CAS13         380   2430 O   R    1/15
                                                                                         CLAIM ADJUSTMENT REASON CODE   CAS14        1034   2430 M   ID   1/5
                                                                                         MONETARY AMOUNT                CAS15         782   2430 M   R    1/18
                                                                                         QUANTITY                       CAS16         380   2430 O   R    1/15
                                                                                         CLAIM ADJUSTMENT REASON CODE   CAS17        1034   2430 M   ID   1/5
                                                                                         MONETARY AMOUNT                CAS18         782   2430 M   R    1/18
                                                                                         QUANTITY                       CAS19         380   2430 O   R    1/15

                                                                                                108
                                                                                                                                                                                                                                             Policy Memorandum 2004 - 37
                                                                                                                                                                                                                                             Exhibit 2L



                                                                            837 - HEALTH CLAIMS AND ENCOUNTERS (INSTITUTIONAL)
INTERNAL    TABLE  /   FIELD               FIELD           Old                                                                                                      REF             ELEMENT
RECORD ID   DATABASE   LENGTH   FIELD TYPE NAME            PG A1 PG SEGMENT NAME                                       ELEMENT NAME                                 DES.             NUMBER        LOOP ATTRIBUTES         NOTES             USE     REPEAT
                                                           502 500       SERVICE ADJUDICATION DATE                                                                  DTP                              2430                                    S          1
                                                                                                                       DATE/TIME QUALIFIER                          DTP01                  374       2430 M    ID   3/3    573
                                                                                                                       DATE/TIME FORMAT QUALIFIER                   DTP02                1250        2430 M    ID   2/3    D8
                                                                                                                       DATE TIME PERIOD                             DTP03                1251        2430 M    AN   1/35


                                                           503 501       TRANSACTION SET TRAILER                                                                    SE                           TRAILER                                     R          1
                                                                                                                       NUMBER OF INCLUDED SEGMENTS                  SE01                    96   TRAILER M     NO   1/10
                                                                                                                       TRANSACTION SET CONTROL NUMBER               SE02                   329   TRAILER M     AN   4/9    MUST MATCH ST02
                                                                    4010 with Addenda                                     Revised April 10, 2003
                                The tools and templates provided in CalOHI Policy and Information Memoranda have generally been authored by HIPAA workgroups. Users should view the information presented in
                                the context of their own organizations and environments. Legal opinions and/or decision documentation may be needed when interpreting and/or applying this information.




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