NSF v103 to NSF v301 by liuqingyan

VIEWS: 6 PAGES: 688

									Record type:   AA0
File Header - Submitter Data

                                NSF 1.03 Field Name   Comments


                           1    Record ID “AA0”       AAO record not
                                                      preceded by ZA0
                                                      record - Required
                           2    Submitter ID


                           3    Reserved (AA0.03)
                           4    Submission Type
                           5    Submission Number


                           6    Submitter Name


                           7    Submitter Address1

                           8    Submitter Address2




                           9    Submitter City




                           10   Submitter State



                           11   Submitter Zip




                           12   Submitter Region
13   Submitter Contact




14   Submitter Phone




15   Creation Date




16   Submission Time




17   Receiver ID              ISYS Payer ID




18   Receiver Type Code




19   Version       Code   -
     National
                          20                        Version Code - Local



                          21                        Test/Prod Indicator




                          22                        Password
                          23                        Retransmission Status If Conversion fails
                                                                          on Level 2 Map,
                                                                          issue a system
                                                                          error (11009) and
                                                                          abort
                                                                          transmission.




                          24                        Filler - National      NOT MAPPED
                          25                        Filler - Local         NOT MAPPED




                          24                        Filler - National      NOT MAPPED
                          25                        Filler - Local         NOT MAPPED

Record type:   BA0 (Group Provider # Information)
Batch Header Record - Provider Data 1

                                                    NSF 1.03 Field Name    Comments


                          1                         Record ID “BA0”        BA0 record not
2    EMC Prov ID

3    Batch Type

4    Batch Number
5    Batch ID
6    Provider Tax ID




7    Reserved (BA0.07)

8    Provider Tax ID Type      If Conversion fails
                               on Level 2 Map,
                               issue a system
                               error (11009) and
                               abort
                               transmission.



9    Provider       Medicare
     Number

10   Provider UPIN-USIN ID


11   Reserved (BA0.11)

12   Provider       Medicaid
     Number

13   Provider Champus
14   Provider Blue Shield
     Number

15   Provider     Commercial
     Number

16   Provider Number 1
17   Provider Number 2
18   Provider Org Name         If field present,
                               map     to    2010
                               NM103, otherwise
                               map        Provider
                               Last Name to
                               2010 NM103.
                          19            Provider Last Name            If Provider Org
                                                                      Name = spaces,
                                                                      map    to  2010
                                                                      NM103.


                          20            Provider First Name           If Provider Org
                                                                      Name = spaces,
                                                                      map    to  2010
                                                                      NM104.



                          21            Provider MI                   If Provider Org
                                                                      Name = spaces,
                                                                      map    to  2010
                                                                      NM105.
                          22            Provider Specialty
                          23            Specialty      License
                                        Number
                          24            State License Number


                          25            Dentist             License
                                        Number
                          26            Anesthesia          License
                                        Number

                          27            Filler - National

                          28            Filler - Local

Record type:   BA1
Batch Header Record - Provider Data 2

                                        NSF 1.03 Field Name           Comments


                          1             Record ID “BA1”               BA1 record    not
                                                                      preceeded      by
                                                                      BA0 record.


                          2             EMC Provider ID
3    Batch Type




4    Batch Number




5    Batch ID




6    Provider Type Org
7    Provider        Service NOTE: We may
     Address1                require this field in
                             phase 2.

8    Provider        Service
     Address2
9    Provider Service City   NOTE: We may
                             require this field in
                             phase 2.
10   Provider Service State NOTE: We may
                             require this field in
                             phase 2.
11   Provider Service Zip    NOTE: We may
                             require this field in
                             phase 2.
12   Provider Service Phone NOTE: We may
                             require this field in
                             phase 2.
13   Provider    Pay      To NOTE: We may
     Address1                require this field in
                             phase 2.
14   Provider    Pay      To
     Address2
15   Provider Pay To City    NOTE: We may
                             require this field in
                             phase 2.
16   Provider Pay To State NOTE: We may
                             require this field in
                             phase 2.
17   Provider Pay To Zip     NOTE: We may
                             require this field in
                             phase 2.
                          18         Provider Pay To Phone

                          19         Filler - National

                          20         Filler - Local

Record type:   CA0
Claim Header Record – Patient Data

                                     NSF 1.03 Field Name      Comments


                          1          Record ID “CA0”          CA0 record not
                                                              preceeded     by
                                                              BA0, BA1, XA0 -
                                                              Required Record

                          2          Reserved (CA0-02)

                          3          Patient Control Number

                          4          Patient Last Name




                          5          Patient First Name




                          6          Patient MI




                          7          Patient Generation
8    Patient Date Of Birth




9    Patient Sex




10   Patient    Type         Of
     Residence
11   Patient Address1




12   Patient Address2




13   Patient City




14   Patient State




15   Patient Zip




16   Patient Phone
17   Patient Marital Status    If Conversion fails
                               on Level 2 Map,
                               issue a system
                               error (11009) and
                               abort
                               transmission.

18   Patient Student Status


19   Patient     Employment If Conversion fails
     Status                 on Level 2 Map,
                            issue a system
                            error (11009) and
                            abort
                            transmission.

20   Patient Death Indicator




21   Patient Date Of Death




22   Other         Insurance
     Indicator



23   Claim Editing Indicator
                         24                       Type      Of      Claim If Conversion fails
                                                  Indicator               on Level 2 Map,
                                                                          issue a system
                                                                          error (11009) and
                                                                          abort
                                                                          transmission.




                         25                       Legal Representative
                                                  Indicator




                         26                       Origin Code
                         27                       Payor Claim Control
                                                  Number
                         28                       Provider Number
                         29                       Claim ID Number
                         30                       Filler - National

                         31                       Filler - Local

Record type:   CB0
Claim Header Record - Legal Representative Data

                                                  NSF 1.03 Field Name      Comments


                          1                       Record ID “CB0”


                          2                       Reserved (CB0-02)

                          3                       Patient Control Number
                          4                            Responsible         Person
                                                       Last Name

                          5                            Responsible         Person
                                                       First Name


                          6                            Responsible Person MI

                          7                            Responsible         Person
                                                       Address1


                          8                            Responsible         Person
                                                       Address2




                          9                            Responsible         Person
                                                       City



                          10                           Responsible         Person
                                                       State



                          11                           Responsible         Person
                                                       Zip



                          12                           Responsible         Person
                                                       Phone



                          13                           Filler - National




                          14                           Filler - Local




Record type:   DA0 – SEQUENCE 1
Insurance Information Record - Insurance Information

                                                       NSF 1.03 Field Name          Comments
1   Record ID “DA0”           DA0 record not
                              preceeded     by
                              proper record -
                              Required Record

2   Sequence Number           If Conversion fails
                              on Level 2 Map,
                              issue a system
                              error (11009) and
                              abort
                              transmission.




3   Patient Control Number




4   Claim Filing Indicator




5   Source Of Pay             If Conversion fails
                              on Level 2 Map,
                              issue a system
                              error (11009) and
5   Source    Of        Pay
    Continued
6   Insurance Type Code




7   Payor Organization ID




8   Payor Claim     Office
    Number




9   Payor Name
10   Group Number




11   Group Name




12   PPO/HMO Indicator
13   PPO ID
14   Prior Authorization
15   Assign Of Benefits
16   Patient Signature
17   Patient Relationship To If Conversion fails
     Insured                 on Level 2 Map,
                             issue a system
                             error (11009) and
18   Insured ID Number




19   Insured Last Name




20   Insured First Name

21   Insured MI

22   Insured Generation

23   Insured Sex
24   Insured Date Of Birth
                         25                            Insured    Employment If Conversion fails
                                                       Status                on Level 2 Map,
                                                                             issue a system
                         26                            Supplemental
                                                       Insurance Indicator




                         27                            Insurance Location ID




                         29                            Filler - National

                         30                            Filler - Local

Record type:   DA1 – SEQUENCE 1, 2, 3
Insurance Information Record - Insurance Information
(Payer Data 2)
                                                       NSF 1.03 Field Name      Comments


                         1                             Record ID “DA1”          DA1 record not
                                                                                predeeded   by
                                                                                DA0 record.


                         2                             Sequence Number




                         3                             Patient Control Number
4    Payor Address1



5    Payor Address2
6    Payor City
7    Payor State
8    Payor Zip



9    Disallowed         Cost
     Containment




10   Disallowed Other
11   Allowed Amount




12   Deductible Amount




13   Coinsurance Amount




14   Payor Amount Field



15   Zero Pay Indicator
16   Adjudication Indicator 1

17   Adjudication Indicator 2
18   Adjudication Indicator 3
19   Champus Sponsor
20   Champus Sponsor
21   Champus        Sponsor
     Status
22   Insurance           Card
     Effective Date




23   Insurance        Card
     Termination Date




24   Balance Due




25   Filler - National

26   Filler - Local
                          25            Filler - National
                          26            Filler - Local
Record type:   DA2 – SEQUENCE 1, 2, 3
Insurance Information - Payer Data 3

                                        NSF 1.03 Field Name   Comments


                           1            Record ID “DA2”        DA2 record not
                           2            Sequence Number
                           3            Patient Control Number
                           4            Insured Address1
                           5            Insured Address2
6    Insured City




7    Insured State
8    Insured Zip




 9   Insured Phone
10   Insured    Retirement
     Date




11   Insurance        Spouse
     Retire Date




12   Insured         Employer
     Name
13   Insured         Employer
     Address1
14   Insured         Employer
     Address2
15   Insured Employer City
16   Insured Employer State
17   Insured Employer Zip
18   Employee ID Number
19   Filler - National
20   Filler - Local
Record type:   EA0
If the claim is being submitted for a type of provider that
does not require a principle diagnosis code (i.e. funeral
director) the claim cannot be submitted in the NSF          NSF 1.03 Field Name    Comments


                            1                             Record ID “EA0”          EA0 record not
                            2                             Reserved (EA0.02)        preceeded by

                            3                             Patient Control Number


                            4                             Employment     Related
                                                          Indicator
5   Accident Indicator




6   Symptom Indicator




7   Accident/Symptom
    Date




8   Ext Cause Of Accident
9    Responsibility Indicator




10   Accident State
11   Accident Hour



12   Abuse Indicator
13   Release Of Information
     Indicator




14   Release Of Information
     Date
15   Same/Similar Symptom
     Indicator




16   Same/Similar Symptom
     Date

17   Disability Type


18   Disability-From Date
19   Disability-To Date




20   Referring Provider ID
     Number
21   Reserved (EA0.21)




22   Referring Provider Last

23   Referring      Provider
     First
24   Referring Provider MI

25   Referring     Provider
     State
26   Admission Date-1




27   Discharge Date-1




28   Laboratory Indicator
29   Laboratory Charges



30   Diagnosis Code-1

31   Diagnosis Code-2


32   Diagnosis Code-3



33   Diagnosis Code-4



34   Provider       Assign If Conversion fails
     Indicator             on Level 2 Map,
                           issue a system
                           error (11009) and
                           abort
                           transmission.




35   Provider Signature On
     File
36   Provider      Signature
     Date




37   Facility/Laboratory
     Name
38   Documentation
     Indicator
39   Type               Of
     Documentation




40   Functional Status Code
41   Special      Program
     Indicator




42   Champus Nonavailable
     Indicator
43   Supervising   Provider
     Indicator
44   Resubmission Code
45   Resubmission
     Reference No.


46   Date Last Seen
                            47   Date Document Sent




                            48   Filler - National

                            49   Filler - Local

Record type:   EA1
Claim Record - Claim Data

                                 NSF 1.03 Field Name   Comments


                            1    Record ID “EA1”       EA1 record   not
                                                       preceeded     by
                                                       EA0 record




                            2    Reserved (EA1.02)
3    Patient Control Number




4    Facility/Laboratory ID
     Number
5    Reserved (EA1.05)

6    Facility/Laboratory
     Address1
7    Facility/Laboratory
     Address2
8    Facility/Laboratory City

9    Facility/Laboratory
     State
10   Facility/Laboratory Zip
     Code
11   Medical          Record
     Number
12   Return To Work Date




13   First Consulted Date
                     14   Admission Date-2




                     15   Discharge Date-2




                     16   Supervising Provider ID
                          Number
                     17   Reserved (EA1.17)

                     18   Supervising         Provider
                          Last


                     19   Supervising         Provider
                          First


                     20   Supervising Provider
                          MI
                     21   Supervising Provider
                          State
                     22   EMT/Paramedic Last
                     23   EMT/Paramedic First
                     24   EMT/Paramedic MI




                     25   Filler - National

                     26   Filler - Local

Record type:   EA2
Claim Record – Early Periodic Screening Diagnostic
Testing (EPSDT)
                                                     NSF 1.03 Field Name   Comments
Record type:   FA0
Service Line Detail - Root Segment 99 Fxx records per
claim, only 50 Fxx records allowed for HIPAA-X12 v 4010
                                                          NSF 1.03 Field Name      Comments


                           1                              Record ID “FA0”          FA0 record not
                                                                                   preceeded     by
                                                                                   proper record -
                                                                                   Required Record




                           2                              Sequence Number




                           3                              Patient Control Number




                           4                              Line   Item    Control
                                                          Number
5   Service From Date
6    Service To Date




7    Place Of Service




8    Type Of Service Code


 9   HCPCS Procedure
10   HCPCS Modifier 1
11   HCPCS Modifier 2
12   HCPCS Modifier 3
13   Line Charges
14   Diagnosis          Code
     Pointer1




15   Diagnosis Code
16   Diagnosis Code
17   Diagnosis Code
18   Units Of Service




19   Anesthesia/Oxygen
     Minutes




20   Emergency Indicator




21   COB Indicator
22   HMSA Indicator
23   Rendering Provider ID




24   Referring Provider ID

25   Referring      Provider
     State
26   Purchase        Service
     Indicator
27   Disallowed          Cost
     Containment


28   Disallowed Other



29   Review       By    Code
     Indicator
30   Multiple      Procedure
     Indicator
31   Mammography
     Certification No.
32   Class Findings
33   Podiatry          Service
     Condition
34   Clinical
     Laboratory(CLIA)




35   Primary Paid Amount




36   Filler - National

37   Filler - Local
Record type:   FB0
Service Line Detail - Medical Segment

                                        NSF 1.03 Field Name      Comments


                           1            Record ID "FB0"
                           2            Sequence No

                           3            Patient Control Number
4    Line Item Control No




5    Pur Svc Charge



6    Allowed Amount



7    Deductible Amount



8    Coinsurance Amount



9    Ordering Prov ID

10   Ordering Prov State
11   Pur Svc Prov ID




12   Pur Svc State
13   Pen Grams Of Protein
14   Pen Calories
15   National Drug Code
16   National Drug Units
17   Prescription No
18   Prescription Date




19   Prescript No Of Mos
20   Spec Pricing Ind
21   Copay Status Ind
                          22            EPSDT Ind

                          23            Family Planning Ind




                          24            DME Charge Ind
                          25            HPSA Facility ID
                          26            HPSA Facility Zip
                          27            Pur Svc Name

                          28            Pur Svc Addr1
                          29            Pur Svc Addr2
                          30            Pur Svc City
                          31            Pur Svc Zip
                          32            Pur Svc Phone


                          33            Filler - National

                          34            Filler - Local

Record type:   FB1
Service Line Detail - Medical Segment

                                        NSF 1.03 Field Name      Comments


                           1            Record ID “FB1”          FB1 record   not
                                                                 preceeded     by
                                                                 FA0 or FB0



                           2            Sequence Number
                           3            Patient Control Number
4    Line   Item       Control
     Number




5    Place Of Service Name

6    Ordering Provider Last



7    Ordering Provider First
8    Ordering Provider MI
9    Ordering       Provider
     UPIN
10   Referring Provider Last
11   Referring Provider First
12   Referring Provider MI
13   Referring      Provider
     UPIN


14   Rendering        Provider
     Last



15   Rendering        Provider
     First


16   Rendering Provider MI




17   Rendering         Provider
     UPIN
18   Supervising Provider
19   Supervising Provider
20   Supervising Provider
21   Supervising Provider ID
22   Supervising Provider
23   Filler - National

24   Filler - Local
Record type:   FB2
Service Line Detail - Medical Segment

                                        NSF 1.03 Field Name   Comments




Record type:   FB3
Service Line Detail - Medical Segment

                                        NSF 1.03 Field Name   Comments
Record type:   FD0
Service Line Detail - Dental Segment

                                       NSF 1.03 Field Name      Comments


                           1           Record Id "FD0"




                           2           Sequence No

                           3           Patient Control Number




                           4           Line Item Control No




                            5          Tooth Code Number 1
                            6          Tooth Surface(s) 1
                            7          Tooth Code Number 2
                            8          Tooth Surface(s) 2
                            9          Tooth Code Number 3
                           10          Tooth Surface(s) 3
                           11          Tooth Code Number 4
                           12          Tooth Surface(s) 4
                           13          Initial Place Ind
14   Prior Place Date




15   Impress/Prescript Dt




16   Replacement Reason
17   Ortho Treat Ind
18   Treatment Length
19   Date Appl Inserted




20   Date Appl Removed




21   Reserved (FD0-21.0)
22   Date Appl Replaced




23   Mos Treat Remaining
24   Dt 1st Visit Cur Ser




25   Reserved (FD0-25.0)
26   Pre Determination Id
27   Reserved (FD0-27.0)
28   Missing Primary Teeth

29   Missing Perm   Tooth
30   Missing Perm   Tooth
31   Missing Perm   Tooth
32   Missing Perm   Tooth
33   Missing Perm   Tooth
34   Missing Perm   Tooth
35   Missing Perm   Tooth
36   Missing Perm   Tooth
37   Missing Perm   Tooth
38   Missing Perm   Tooth
39   Missing Perm   Tooth
40   Missing Perm   Tooth
41   Missing Perm   Tooth
42   Missing Perm   Tooth
43   Missing Perm   Tooth
44   Missing Perm   Tooth
45   Missing Perm   Tooth
46   Missing Perm   Tooth
47   Missing Perm   Tooth
48   Missing Perm   Tooth
49   Missing Perm   Tooth
50   Missing Perm   Tooth
51   Missing Perm   Tooth
52   Missing Perm   Tooth
53   Missing Perm   Tooth
54   Missing Perm   Tooth
                          55                          Missing Perm Tooth
                          56                          Missing Perm Tooth
                          57                          Missing Perm Tooth
                          58                          Missing Perm Tooth
                          59                          Missing Perm Tooth
                          60                          Missing Perm Tooth
                          61                          Missing Perm Tooth
                          62                          Quadrant
                          63                          Tooth Pocket Measure

                          64                          Filler - National

Record type:   FE0
Third Party Organization – Third Party Organization
Segment
                                                      NSF 1.03 Field Name    Comments




Record type:   GA0
Ambulance Certification Record - Service Line

                                                      NSF 1.03 Field Name    Comments


                           1                          Record ID "GA0"        GA0 record not
                                                                             preceeded     by
                           2                          Sequence No            proper record
3   Patient Control Number




4   Reserved (GA0-04.0)

5   Patients Weight




6   Hospital Admit
7   Type Of Transport




8   Bed Confined Before




9   Bed Confined After
10   Moved By Stretcher




11   Unconscious/Shock




12   Emergency Situation
13   Physical Restraints




14   Visible Hemorrhaging
15   Transported To/For




16   Medically Necessary
                           17                      Miles




                           18                      Origin Info
                           19                      Destination Info
                           20                      Purpose Of Round Trip




                           21                      Purpose Of Stretcher




                           25                      Filler National

                           26                      Filler Local

Record type:   GC0
Chiropractic Certification Record - Service Line

                                                   NSF 1.03 Field Name     Comments
1   Record ID "GC0"          GC0 record not
                             preceeded     by
                             proper record




2   Sequence No




3   Patient Control Number




4   Reserved (GC0-04.0)

5   Initial Treatment Date
6    Date Of Last X Ray




7    No In Series
8    Level Of Subluxation
9    Treatment
     Months/Years
10   No Treatments Month

11   Nature Of Condition
12   Date Of Manifestation




13   Complication Ind
14   Symptoms Description
                           15   Filler - National     NOT MAPPED
                           16   Filler - Local        NOT MAPPED
Record type:   GD0
DME Certification Record

                                NSF 1.03 Field Name   Comments


                           1    Record ID "GD0"       GD0 record not
                                                      preceded      by
                                                      proper record




                           2    Sequence No
3    Patient Control Number




4    Certification Type
5    Medical Necessity



6    Prognosis
7    HCPCS        Procedure FA0.09 HCPCS
     Code                   Code is defaulted
                            to this field.

 8   Ambulatory
 9   Ambulation/Therapy
10   Confined Bed/Chair
11   Room Confined
12   Ambulation/Mobility
13   Body Positioning
14   Respiratory/Other
15   Breathing Impaired
16   Freq/Immed Changes
17   Operate Controls
18   Siderails Part/Bed
19   Owns Equipment
20   Mattress/Siderails
21   Equipment/Assistance

22   Orthopedic Impair
23   Planned Regimen
24   Decubitus Ulcers
25   Equipment Use
26   Insulin Dependent
27   Diabetic Control
28   Apnea Episodes
29   Surgery Alternative
30   Total Knee Replace
31   Date Surgery




32   Date CPM




33   Lymphedema
34   Ordering Prov Last
35   Ordering Prov First
36   Ordering Prov MI
37   Ordering Prov ID
38   Ordering Prov Phone
39   Date Certification




40   Certification On File
41   Diagnosis Code 1
42   Diagnosis Code 2
43   Diagnosis Code 3
44   Diagnosis Code 4
45   Nursing Home Ind
                        46                             NH From Date




                        47                             NH To Date




                        48                             Respiratory Tract
                        49                             Supv Of Equipment
                                                       Use
                        50                             Propel/Lift Chair
                        51                             Leg Elevation
                        52                             Patient Weight
                        53                             Reclining Wheelchair
                        54                             Manual Operation
                        55                             Side Transfer Chair
                        56                             Filler - National

                        57                             Filler - Local

Record type:   GD1
DME Certification Record - Narrative Information for
DME
                                                       NSF 1.03 Field Name    Comments


                         1                             Record ID "GD1"        GD1 record not
                                                                              preceded      by
                                                                              proper record
                            2                      Sequence No




                            3                      Patient Control Number




                            4                      Narrative
                            5                      Filler - National

                            6                      Filler - Local

Record type:   GE0
Certification Record – Enteral Nutrition Therapy

                                                   NSF 1.03 Field Name      Comments
Record type:   GP0
Certification Record – Parenteral Nutrition Therapy

                                                      NSF 1.03 Field Name   Comments
Record type:   GU0
Certification – Certification Segment

                                        NSF 1.03 Field Name   Comments
Record type:   GX0
Medical Necessity Oxygen – Oxygen Certification
Segment
                                                  NSF 1.03 Field Name   Comments
Record type:   GX1
Narrative Info For Oxygen – Oxygen Narrative Segment

                                                       NSF 1.03 Field Name   Comments




Record type:   GX2
Facility Info For Oxygen – Oxygen Facility Segment

                                                       NSF 1.03 Field Name   Comments




Record type:   HA0
Narrative Record
                                 NSF 1.03 Field Name      Comments


                         1       Record ID "HA0"




                         2       Sequence No




                         3       Patient Control Number




                         4       Line Item Control No




                         5       Extra Narrative Data
Record type:   XA0
Claim Trailer Record – Summary

                                 NSF 1.03 Field Name      Comments


                         1       Record ID “XA0”          XA0 record not
                                                          preceeded     by
                                                          proper record
2   Reserved (XA0.02)

3   Patient Control Number




4   Record CXX Count




5   Record DXX Count




6   Record EXX Count




7   Record FXX Count




8   Record GXX Count
9    Record HXX Count




10   Claim Record Count




11   Reserved (XA0.11)

12   Total Claim Charges




13   Tot Disallowed    Cost
     Containment

14   Total Disallowed Other
     Charges

15   Total Allowed Amount


16   Total       Deductible
     Amount

17   Total     Coinsurance
     Amount

18   Total   Payor   Amount
     Paid

19   Patient Amount Paid




20   Total Purchase Service
     Charges
                       21   Provider        Discount
                            Information
                       22   Remarks
                       23   Filler - National

                       24   Filler - Local

Record type:   YA0
Batch Trailer Record

                            NSF 1.03 Field Name        Comments


                       1    Record ID “YA0”            YA0 record   not
                                                       preceeded     by
                                                       XA0 record


                       2    EMC Provider ID




                       3    Batch Type




                       4    Batch Number




                       5    Batch ID




                       6    Provider Tax ID




                       7    Reserved (YA0.07)
                      8    Batch     Service   Line
                           Count




                      9    Batch Record Count




                      10   Batch Claim Count




                      11   Batch Total Charges




                      12   Filler - National

                      13   Filler - Local

Record type:   ZA0
File Trailer Record

                           NSF 1.03 Field Name        Comments


                      1    Record ID “ZA0”            ZA0 record   not
                                                      preceeded     by
                                                      YA0 record
2   Submitter ID




3   Reserved (ZA0.03)

4   Receiver ID




5   File Service Line Count




6   File Record Count




7   File Claim Count




8   Batch Count
9    File Total Charges




10   Filler - National    NOT MAPPED
11   Filler - Local       NOT MAPPED
              Required
               Record
EDIT       837 837        NSF   IASD   Title   ISYS All
           Loop Element   Req   Req    XIX     Payer
                                       Req     Req
Field will be             R     R      R       R
checked for
value of
Field must 1000 NM109     R     R      R       R
be present.
Value must
NOT                       O
Field must 1000 ZAP02     R     R      R       R
Field must      BGN02     R     R      R       R
be numeric.

Field must 1000 NM103     C     R      R       R
be present.
Title XIX:
Title   XIX: 1000 N301    C            R       C
Field must
Title   XIX: 1000 N302    C            C       C
Hardcoded
to blank.


Title   XIX: 1000 N401    C            R       C
Field must
be present.
Hardcoded
to     "Des
Moines".
Title   XIX: 1000 N402    C            R       C
Field must
be present.
Hardcoded 1000 N403
Title   XIX:              C            R       C
Field must
be present.
Hardcoded
to "50309".
             1000 N406    C            C
Title  XIX: 1000 PER02     C       R
Field must
be present.
Hardcoded
to
"WellMark
Help Desk".

Title    XIX: 1000 PER04   C       R
Field must
be present.
Hardcoded
to
"800407026
7".
Field must         BGN03   R   R   R   R
be a valid
date, must
be          8
numerics.
Zeros and
If present,        BGN04   C       C
must be a
valid time.


Field must 1000 NM109      C   R   R   R
be present.
Value must
be
registered
with ECMS
Trading
Partner
Tables.
Title XIX:
        XIX: 1000 REF02    C       R
Field must
be present
and must
be equal to
a "D" or "Z".

Field must       REF02     R   R   R   R
be present.
Value must
be
registered
with ECMS
Trading
Partner
Tables.
If present,          REF02     C            R
field must
be numeric.

Field must 1000 ZAP02          C     R      R       R
be present.
Value must
be
registered
with ECMS
Trading
Partner
Tables.
             1000 ZAP02        C            C
If present,       BGN01        C            C
must be a
valid value.




                               C            C
                               C            C


                               C            C
                               C            C
                               C
                               C
                               C




                               R
                               C
                               R            R




                   Required
                    Record
EDIT            837 837        NSF   IASD   Title   ISYS All
                Loop Element   Req   Req    XIX     Payer
                                            Req     Req
Field will be                  R     R      R       R
Field must 2010 NM109      R   R   R   R
be present.
Field must 2010 ZAP02      C   R   R   R
be present.
Field must 2010 REF02      R   R   R   R
            2010 REF02     O
Field must 2000 PRV03      C   R   R   R
be present.




NOT                        O
MAPPED
Field must 2010 NM102      C   R   R   R
be present.
Field must
be a valid
value.




           2010 REF02      C   C   C


           2010 REF02      O


NOT                        O
MAPPED
Title    XIX: 2010 REF02   C       R
Field must
be present.
If Claim      2010 REF02   C       C   C
              2010 REF02   C   C   C


           2010 REF02      C       C   C


            2010 REF02     C       C
            2010 REF02     C       C
Title  XIX: 2010 NM103     C       R   C
Field must
be present.
Title  XIX: 2010 NM103         C            R       C
Field must
be present.



Title  XIX: 2010 NM104         C            R       C
Field must
be present.




                2010 NM105     C            C



                2000 PRV06     C            C
                2010 REF02     C            C

                2010 REF02     C            C


                2010 REF02     C            C

                2010 REF02     C            C

                               C
NOT                            R            R
MAPPED
NOT
MAPPED


                   Required
                    Record
EDIT            837 837        NSF   IASD   Title   ISYS All
                Loop Element   Req   Req    XIX     Payer
                                            Req     Req
Field will be                  R     R      R       R
checked for
value      of
"BA1"

Field must                     R     R      R       R
equal BA0-
02.
NOT
MAPPED -
DERIVED
Field must                   C   R   R   R
equal BA0-
03.
NOT
MAPPED -
DERIVED
Field must                   R   R   R   R
equal
BA0.04.
NOT
MAPPED -
DERIVED
If      field                O
present,
must equal
BA0.05.
NOT
MAPPED -
DERIVED
                2010 ZAP02   C       C
                2010 N301    C       C



                2010 N302    C       C

                2010 N401    C       C


                2010 N402    C       C


                2010 N403    C       C


                2010 PER04   C       C


                2010 N301    C       C


                2010 N302    C       C

                2010 N401    C       C


                2010 N402    C       C


                2010 N403    C       C
                2010 PER04     C            C

NOT                            R            R
MAPPED
NOT
MAPPED


                   Required
                    Record
EDIT            837 837        NSF   IASD   Title   ISYS All
                Loop Element   Req   Req    XIX     Payer
                                            Req     Req
Field will be                  R     R      R       R
checked for
value      of
"CA0"

NOT                            O
MAPPED
Field must 2300 CLM01          R     R      R       R
be present.
Field must 2210 NM103          R     R      R       R
be present.




Field must 2210 NM104          R     R      R       R
be present.




                2210 NM105     O     O      O       O




                2210 NM107     C            C
Field must 2210 DMG02   C   R   R   R
be present.
Field must
be a valid
date, must
be        8
numerics.
Zeros and
'0000'  for
the year is
valid.
Field must 2210 DMG03   R   R   R   R
be present.
Field must
be a valid
value.

          2200 PAT02    C       C

Field must 2210 N301    C       R   R
be present.




          2210 N302     C       C   C




Field must 2210 N401    C       R   R
be present.




Field must 2210 N402    C       R   R
be present.




Field must 2210 N403    C       R   R
be present.




          2210 PER04    O
If present, 2210 DMG04        C   C   C   C
must be a
valid value.
(spaces OK
at file level)


If present, 2200 PAT04        C       C   C
must be a
valid value.
If present, 2200 PAT03        C   C   C   C
must be a
valid value.
(spaces OK
at file level)


If present,      2200 ZAP02   C   C   C
must be a
valid value.
Title   XIX:
Field     will
accept
values "N",
"D" or a
"Blank".
If present,      2200 PAT06   C       C
field must
be a valid
date, must
be          8
numerics.
Zeros and
'0000'    for
the year is
valid.
Field must       2200 ZAP02   C   R   R   R
be present.
Field must
be a valid
value.
Field must       2300 CLM03   C   R   R   R
be present.
Field must
be a valid
value.
If present, 2300 CLM04          C     C      C       C
must be a
valid value.
IASD:      If
Batch Type
(BA0.03) =
"200",
CA0.24
must equal
"D".
IASD:      If
Batch Type
(BA0.03) =
"100",
CA0.24 can
not    equal
"D".


                 2200 ZAP02     C            C




                 2200 ZAP02     C            C
                 2200 ZAP02     R     C      R

                 2200 ZAP02     C            C
                 2200 ZAP02     C            C
NOT                             R            R
MAPPED
NOT
MAPPED


                    Required
                     Record
EDIT             837 837        NSF   IASD   Title   ISYS All
                 Loop Element   Req   Req    XIX     Payer
                                             Req     Req
If record is                    R     R      R       R
present,
Field will be
checked for
NOT                             O
MAPPED
Field must                      R     R      R       R
equal     the
CA0-03
value      for
this claim.
NOT
If record is 2210 NM103   R
present,
field must
If record is 2210 NM104   R
present,
field must
be present.
             2210 NM105   R

If record is 2210 N301    R
present,
field must
be present.
             2210 N302    R




If record is 2210 N401    R
present,
field must
be present.
If record is 2210 N402    C
present,
field must
be present.
If record is 2210 N403
present,
field must
be present.
           2210 PER04




NOT
MAPPED



NOT
MAPPED




              Required
               Record
EDIT       837 837        NSF   IASD   Title   ISYS All
           Loop Element   Req   Req    XIX     Payer
                                       Req     Req
Field will be           C   R   R   R
checked for
value      of
"DA0"

Field must 2320 SBR01   C
be present.
Field must
have    the
correct
value and
sequence.
(e.g.   1st
DA0 = 01,
1st FA0 =
01)




Field must              R   R   R   R
equal     the
CA0-03
value      for
this claim.
NOT
MAPPED -
DERIVED 2320 ZAP02
Field must              C   R       R
be present.
Field must
be a valid
value.




Field must 2320 SBR09   C   R       R
be
present(spa
ces OK file
Title XIX: If           O   D       D
field      is
blank then
hardcode to
Field must 2320 SBR05   C   R   R
be present.
Field must
be a valid
value.




Field must 2330 NM109   C   C   C
be present.
Title XIX: If
the    value
comes      in
as 00001-
00005     or
77015 it will
convert
over       to
77015.




          2330 REF02    C   R   R




Field must 2330 NM103   C   R   R
be present.
Title   XIX:
Hardcoded
to    "Iowa
Medicaid".
              2320 SBR03   C   R   R




              2320 SBR04   O




            2320   ZAP02   R
            2320   ZAP02
            2330   REF02
Field must 2320    OI03
Field must 2320    OI04
Field must 2320    SBR02
be present
(spaces OK
file level)
Field must 2330    NM109
be present.



Field must 2320 NM103
be present.




Field must 2320 NM104
be present.
            2320 NM105

              2320 NM107

If present,   2320 DMG03
If present,   2320 DMG02
If present, 2320 SBR08
must be a
valid value.
             2320 ZAP02




                2320 ZAP02




NOT
MAPPED
NOT
MAPPED


                   Required
                    Record
EDIT            837 837        NSF   IASD   Title   ISYS All
                Loop Element   Req   Req    XIX     Payer
                                            Req     Req
Field will be                  R     R      R       R
checked for
value      of
"DA1"

Field must                     R     R      R       R
equal DA0-
02.
NOT
MAPPED -
DERIVED




Field must                     R     R      R       R
          2330 N301      C   C   D



          2330   N302    C   C   D
          2330   N401    C   C   D
          2330   N402    C   C   D
          2330   N403    C   C   D



If present, 2320 AMT02   C   C
field must
be numeric.
(spaces
OK)




If present, 2320 AMT02   C   C
field must
be numeric.
(spaces
OK)
If present, 2320 AMT02   C   C   C
field must
be numeric.
(spaces
OK)




If present, 2320 AMT02   C   C
field must
be numeric.
(spaces
OK)




If present, 2320 AMT02   C   C
field must
be numeric.
(spaces
OK)




If present, 2320 AMT02   C   C   C
field must
be numeric.

          2320 ZAP02     C   C
          2320 ZAP02     C   C

          2320   ZAP02   C   C
          2320   ZAP02   C   C
          2320   ZAP02   C   C
          2320   ZAP02   C   C
          2320   ZAP02   C   C
If present, 2330 DTP03   C   C
field must
be a valid
date, must
be        8
numerics.
Zeros and
'0000'  for
the year is
valid.
If present, 2330 DTP03   C   C
field must
be a valid
date, must
be        8
numerics.
Zeros and
'0000'  for
the year is
valid.
If present, 2320 AMT02   R   R   C
field must
be numeric.
(spaces
OK)

NOT                      C
MAPPED
NOT                      C
MAPPED
                         C




                         C
                         C
                         C




                         C
                         C
                          C




                          C
                          C
                          C
                          R




                          C
NOT                       C            R
NOT


              Required
               Record
EDIT       837 837        NSF   IASD   Title   ISYS All
           Loop Element   Req   Req    XIX     Payer
                                       Req     Req
Field will be             R     R      R       R
Field must                R     R      R       R
Field must                R     R      R       R
Field must 2330 N301      C     C              R
              2330 N302   C                    D
Field must 2330 N401     C   C   R
be present.
IASD: Field
is required
for      1st
occurrence,
but is not
required for
2nd and 3rd
occurrence.



Field must 2330 N402     C   C   R
Field must 2330 N403     C   C   R
be present.
IASD: Field
is required
for      1st
occurrence,
but is not
required for
2nd and 3rd
occurrence.



            2330 PER04   C
If present, 2330 DTP03   C
field must
be a valid
date, must
be        8
numerics.
Zeros and
'0000'  for
the year is
valid.
If present, 2330 DTP03   C
field must
be a valid
date, must
be        8
numerics.
Zeros and
'0000'  for
the year is
valid.
            2330 NM103   C

          2330 N301      C
         2330 N302      C

         2330   N401    C
         2330   N402    C
         2330   N403    C
         2330   NM109   R
NOT                     R
NOT
MAPPED
                   Required
                    Record
EDIT            837 837        NSF   IASD   Title   ISYS All
                Loop Element   Req   Req    XIX     Payer
                                            Req     Req
Field will be                  R     R      R       R
checked for
NOT                            R            R
MAPPED
Field must                     R     R      R       R
equal   the
CA0-03
Field must 2300 ZAP02          R     R      R       R
be present.
Field must
be a valid
value.
Field must 2300 ZAP02      R   R   R   R
be present.
Field must
be a valid
value.




Field must 2300 ZAP02      C       C   R
be present.
If       field
present,
must be a
valid value.
Title    XIX:
Field      will
accept
vaules "0",
"1" or "2".




Field must 2300 DTP03      C       C   C
be present.
If      field
present,
must be a
valid date,
must be 8
numerics.
Zeros and
'0000'    for
the year is
valid.
              2300 ZAP02   C       C
2300 ZAP02   C   C




2300 CLM11   C   C
2300 DTP03   C   C



2300 ZAP02   C   C
Field must 2300 CLM09    C   C   R
be present.
If       field
present,
must be a
valid value.




If present, 2300 DTP03   C   C   D
field must
be a valid
date, must
be        8
numerics.
Zeros and
'0000'  for
the year is
valid.
          2300 ZAP02     C   C




If present, 2300 DTP03   C   C   D
field must
be a valid
If present, 2300 DSB01   C   C
must be a
valid value.
If present, 2300 DTP03   C   C   D
field must
be a valid
date, must
be          8
numerics.
Zeros and
'0000'    for
the year is
valid.
If present, 2300 DTP03   C   C   D
field must
be a valid
date, must
be        8
numerics.
Zeros and
'0000'  for
the year is
valid.
            2310 NM109   C   C

NOT                      C
MAPPED
                         C


                         C
                         C   C




          2310 NM103     C   C

          2310 NM104     C   C

          2310 NM105     C   C

          2310 PRV04     C   C   C

If present, 2300 DTP03   C   C   C
field must
be a valid
date, must
be        8
numerics.
Zeros and
'0000'  for
the year is
valid.
If present, 2300 DTP03   C   C
field must
be a valid
date, must
be        8
numerics.
Zeros and
'0000'  for
the year is
valid.
            2300 ZAP02   C   C   C
If present, 2400 SV108   R   R   R   R
field must
be numeric.

Field must 2300 HI01     C       C
be present.
            2300 HI02    C       C


          2300 HI03      C       C



          2300 HI04      C   R   C   R



Field must 2300 CLM07    C
be
present(spa
ces OK file
level) and a
valid value
at the claim
level.




          2300 CLM06     C
If present, 2300 DTP03   C   C
field must
be a valid
date, must
be        8
numerics.
Zeros and
'0000'  for
the year is
valid.
            2310 NM103   C   C

          2300 ZAP02     C   C
2300 ZAP02   C   C




2300 DSB08   C   C
          2300 CLM12     C   C




          2300 CLM13     C   C

          2300 ZAP02     C   C

          2300 CLM19     C   C
          2300 REF02     C   C



If present, 2300 DTP03   C   C
field must
be a valid
date, must
be        8
numerics.
Zeros and
'0000'  for
the year is
valid.
If present, 2300 DTP03         C            C
field must
be a valid
date, must
be        8
numerics.
Zeros and
'0000'  for
the year is
valid.
                               C




                               C
                               C
                               C

                               R            R

NOT
MAPPED
NOT
MAPPED


                   Required
                    Record
EDIT            837 837        NSF   IASD   Title   ISYS All
                Loop Element   Req   Req    XIX     Payer
                                            Req     Req
If    record                   R     R      R       R
present,
Field will be
checked for
value      of
"EA1"

NOT                            R            R
MAPPED
Field must                    R   R   R   R
equal     the
CA0-03
value      for
this claim.
NOT
MAPPED -
DERIVED
                 2310 NM109   C       C

NOT                           C       C
MAPPED
                 2310 N301    C       C

                 2310 N302    C       C

                 2310 N401    C       C

                 2310 N402    C       C

                 2310 N403    C       C

                 2300 REF02   C       C

If present, 2300 DTP03        C       C   C
field must
be a valid
date, must
be        8
numerics.
Zeros and
'0000'  for
the year is
valid.
If present, 2300 DTP03        C       C
field must
be a valid
date, must
be        8
numerics.
Zeros and
'0000'  for
the year is
valid.
If present, 2300 DTP03   C   C
field must
be a valid
date, must
be        8
numerics.
Zeros and
'0000'  for
the year is
valid.
If present, 2300 DTP03   C   C
field must
be a valid
date, must
be        8
numerics.
Zeros and
'0000'  for
the year is
valid.
            2310 PRV03   C   C

NOT                      C   C
MAPPED
          2310 NM103     C   C



          2310 NM104     C   C



          2310 NM105     C   C

          2310 PRV04     C   C

                         C   C
                         C   C
                         C   C
                         C

                         C
                         C
                         C
                         C
NOT                      R   R
MAPPED
NOT
MAPPED
        No Mappings
       For HIPAA-X12 v
EDIT   837 4010
             837       NSF   IASD   Title   ISYS All
       Loop Element Req      Req    XIX     Payer
                                    Req     Req
                      R      R      R       R



                      R
                      C      R      R       R
                      C
                      R
                      C
                      R
                      C
                      R
                      C
                      R
                      C
                      R
                      C
                      R
                      C
                      R
                      C
                      R
                      C
                      R
                      C
                      R
                      C
                      O
                      C
                      C
                      R
                      C
                      R
                      C
                      R
                      C
                      R
                      C
                      R
                      C
                      O
                      C
                      C
                      O
                      C
                      C
                      C
C
C
C
C
C
C
C
C
C
C
C
C
C
C
C
C
C
C
C
C
C
C
C
C
C
C
C
C
C
C
C
C
C
C
C
C
C
C
C
C
C
C
C
C
C
C
C
O
C
R
                    Required
                     Record
EDIT             837 837        NSF   IASD   Title   ISYS All
                 Loop Element   Req   Req    XIX     Payer
                                             Req     Req
Field will be                   R     R      R       R
checked for
value      of
"FA0"




Field must 2400 LX01            R     R      R       R
be numeric.
Field must
have    the
correct
value and
sequence.
(e.g.   1st
DA0 = 01,
1st FA0 =
01)

Field must                      R     R      R       R
equal     the
CA0-03
value      for
this claim.
NOT
MAPPED -
DERIVED
                 2400 REF02     C            C
Field must 2400 DTP03   R   C   R   R
be present.
Field must
be a valid
date, must
be          8
numerics.
Zeros and
'0000'    for
the year is
valid.
IASD: Field
must      be
present and
a valid date
unless the
payer      is
Delta
Dental
(88851),
then     the
From Date
must      be
numeric.
Title   XIX:
Field must
be present
and         if
CA008-
VAR        is
greater
then then
error.
Field must 2400 DTP03     R   C   R   R
be present.
  Field must
be a valid
date, must
be          8
numerics.
Zeros and
'0000'   for
the year is
valid.
IASD: Field
must      be
present and
a valid date
unless the
payer      is
Delta
Dental
(88851),
then the To
Date must
be numeric.
Title   XIX:
Field must
be present
and must
equal FA0-
05 or will
error.


Field must 2400 SV105     R   R   R   R
be present.
Field must
be a valid
value.




If present, 2400 SV106    C       C   C
must be a
valid value.
Field must 2400 SV101     C   R   R   R
             2400 SV101   C       C
             2400 SV101   C       C
             2400 SV101   C       C
Field must 2400 SV102     R   R   R   R
Field must 2400    SV107   R   R   R   R
be present.
Field must
point to a
non-blank
diagnosis
code, and
value must
be 1 - 4.
            2400   SV107   C       C
            2400   SV107   C       C
            2400   SV107   C       C
If present, 2400   SV103   C   C   R   C
field must
be numeric.
(spaces
OK)

If present, 2400 SV606     C       C   C
field must
be numeric.
(spaces
OK)

Field must 2400 SV109      C           R
be present.
If       field
present,
must be a
valid value.




            2400 ZAP02     C       C
            2400 SV116     C       C
Field must 2420 NM109      C   R   R   R
be present.




           2420 NM109      C       C

           2420 PRV04      C       C

           2400 ZAP02      C       C
If present, 2400 AMT02   C   C
field must
be numeric.

If present, 2400 AMT02   C   C
field must
be numeric.

          2400 SV113     C   C

          2400 SV110     C   C

          2400 REF02     C   C

          2400 ZAP02     C   C
          2400 ZAP02     C   C

          2400 ZAP02     C   C




If present, 2400 AMT02   C   C
field must
be numeric.
(spaces
OK)

NOT                      C   C
MAPPED
NOT                      C   C   D
MAPPED
                         C   C
                         C   C
                         C   C
                         C   C
                         C   C


                         C   C

                         C   C
                         C   C
                         C   C

                         C   C
                         C   C

                         C   C
                         C
                         C
                         C


                         C

                         C
                         C
                         C
                         C
                         C

                         C

                         C

                         C

                         C
                         C
                         C

                         C

                         C




             Required
              Record
EDIT      837 837        NSF   IASD   Title   ISYS All
          Loop Element   Req   Req    XIX     Payer
                                      Req     Req
If     record            R     R      R       R
present,
If     record            R     R      R       R
present,
field must 2400 ZAP02
Field must               R     R      R       R
equal     the
CA0-03
value      for
this claim.
NOT
MAPPED -
DERIVED
If    record 2400 ZAP02    C   C   C   C
present,
field must
equal     the
FA0-04
value      for
this detail.
If present, 2400 PS102     C       C
field must
be numeric.

If present, 2400 AMT02     C       C
field must
be numeric.

If present, 2400 AMT02     C       C
field must
be numeric.

If present, 2400 AMT02     C       C
field must
be numeric.

           2420 NM109      C       C

           2420 PRV04      C       C
           2400 PS101      C       C




            2400   PS103   C       C
            2400   ZAP02   C       C
            2400   ZAP02   C       C
            2400   ZAP02   C       C
            2400   ZAP02   C       C
            2400   ZAP02   C       C
If present, 2400   ZAP02   C       C
field must
be a valid
date, must
be        8
numerics.
Zeros and
'0000'  for
the year is
valid.
            2400   ZAP02   C       C
            2400   ZAP02   C       C
            2400   SV115   C       C
                 2400 SV111     C            C

                 2400 SV112     C            C




                 2400   ZAP02   C            C
                 2400   SV117   C            C
                 2400   SV118   C            C
                 2420   NM103   C            C

                 2420   N301    C            C
                 2420   N302    C            C
                 2420   N401    C            C
                 2420   N403    C            C
                 2420   PER04   C            C
                                C            C
                                C
NOT                             R            R
MAPPED
NOT
MAPPED


                    Required
                     Record
EDIT             837 837        NSF   IASD   Title   ISYS All
                 Loop Element   Req   Req    XIX     Payer
                                             Req     Req
Field will be                   R     R      R       R
checked for
value      of
"FB1"


If     record                   R     R      R       R
present,
Field must                      R     R      R       R
equal     the
CA0-03
value      for
this claim.
NOT
MAPPED -
DERIVED
If    record                    C   C   C   C
present,
field must
equal     the
FA0-04
value      for
this detail.
NOT
MAPPED -
DERIVED
                 2420 NM103     C

                 2420 NM103     C



                 2420 NM104     C
                 2420 NM105     C
                 2420 PRV03     C

                 2420   NM103   C
                 2420   NM104   C
                 2420   NM105   C
                 2420   PRV03   C



Field must 2420 NM103           C           R
be present.



Field must 2420 NM104           C           R
be present.


                 2420 NM105     C           O




                 2420 PRV03     C

                 2420   NM103   C
                 2420   NM104   C
                 2420   NM105   C
                 2420   NM109   C
                 2420   PRV03   C
NOT                             R
MAPPED
NOT
MAPPED
       Optional Record

EDIT   837 837           NSF   IASD   Title   ISYS All
       Loop Element      Req   Req    XIX     Payer
                                      Req     Req
                         R     R      R       R
                         R     R      R       R



                         R     R      R       R
                         C     C      C       C
                         C
                         C
                         C
                         C
                         C
                         C
                         C
                         C
                         C
                         C
                         C
                         C
                         C
                         C
                         C
                         C
                         C
                         C
                         R


         No Mappings
        For X12 v 4010
EDIT   837 837         NSF     IASD   Title   ISYS All
       Loop Element Req        Req    XIX     Payer
                                      Req     Req
                         R     R      R       R


                         R     R      R       R



                         C     R      R       R
                         C     C      C       C

                         C
                         C
                             C
                             C
                             C
                             C
                             C
                             C
                             C
                             C
                             C
                             C
                             C
                             R


            No Mappings for
               X12 v 4010
EDIT        837 837         NSF   IASD   Title   ISYS All
            Loop Element Req      Req    XIX     Payer
                                         Req     Req
If     record 2400 ZAP02     R    R      R       R
present,
field will be
checked for
value        of
"FD0"
If     record 2400 ZAP02     R    R      R       R
present,
Field must                   R    R      R       R
equal     the
CA0-03
value      for
this claim.
NOT
MAPPED -
DERIVED
If     record                C    C      C       C
present,
field must
equal     the
FA0-04
value      for
this detail.
                2400 ZAP02   C
                2400 ZAP02   C
                2400 ZAP02   C
                2400 ZAP02   C
                2400 ZAP02   C
                2400 ZAP02   C
                2400 ZAP02   C
                2400 ZAP02   C
                2400 ZAP02   C
If present, 2400 ZAP02   C
field must
be a valid
date, must
be        8
numerics.
Zeros and
'0000'  for
the year is
valid.
If present, 2400 ZAP02   C
field must
be a valid
date, must
be        8
numerics.
Zeros and
'0000'  for
the year is
valid.
            2400 ZAP02   C
            2400 ZAP02   C
            2400 ZAP02   C
If present, 2400 ZAP02   C
field must
be a valid
date, must
be        8
numerics.
Zeros and
'0000'  for
the year is
valid.
If present, 2400 ZAP02   C
field must
be a valid
date, must
be        8
numerics.
Zeros and
'0000'  for
the year is
valid.
            2400 ZAP02   R
If present, 2400   ZAP02   C
field must
be a valid
date, must
be        8
numerics.
Zeros and
'0000'  for
the year is
valid.
            2400   ZAP02   C
If present, 2400   ZAP02   C
field must
be a valid
date, must
be        8
numerics.
Zeros and
'0000'  for
the year is
valid.
            2400   ZAP02   R
            2400   ZAP02   C
            2400   ZAP02   R
            2400   ZAP02   C

           2400    ZAP02   C
           2400    ZAP02   C
           2400    ZAP02   C
           2400    ZAP02   C
           2400    ZAP02   C
           2400    ZAP02   C
           2400    ZAP02   C
           2400    ZAP02   C
           2400    ZAP02   C
           2400    ZAP02   C
           2400    ZAP02   C
           2400    ZAP02   C
           2400    ZAP02   C
           2400    ZAP02   C
           2400    ZAP02   C
           2400    ZAP02   C
           2400    ZAP02   C
           2400    ZAP02   C
           2400    ZAP02   C
           2400    ZAP02   C
           2400    ZAP02   C
           2400    ZAP02   C
           2400    ZAP02   C
           2400    ZAP02   C
           2400    ZAP02   C
           2400    ZAP02   C
                2400   ZAP02      C
                2400   ZAP02      C
                2400   ZAP02      C
                2400   ZAP02      C
                2400   ZAP02      C
                2400   ZAP02      C
                2400   ZAP02      C
                2400   ZAP02      C
                2400   ZAP02      C

NOT                               R
MAPPED


                Optional Record

EDIT            837 837           NSF   IASD   Title   ISYS All
                Loop Element      Req   Req    XIX     Payer
                                               Req     Req
                                  R     R      R       R
                                  R     R      R       R
                                  R     R      R       R
                                  C     C      C       C
                                  C
                                  C
                                  C
                                  C
                                  C
                                  C
                                  C
                                  C
                                  C
                                  C
                                  C
                                  R


                Optional Record

EDIT            837 837           NSF   IASD   Title   ISYS All
                Loop Element      Req   Req    XIX     Payer
                                               Req     Req
If    record                      R     R      R       R
present,
Field will be
If    record                      R     R      R       R
present,
field must
Field must                    R    R   R   R
equal     the
CA0-03
value      for
this claim.
NOT
MAPPED -
DERIVED
NOT                           O
MAPPED
                 2400 CR102   C




                 2400 CRC03-07 C   C
2400 CR103   C




2400 CRC03-07 C   C




2400 CRC03-07 C   C
2400 CRC03-07 C




2400 CRC03-07 C




2400 CRC03-07 C
2400 CRC03-07 C   C




2400 CRC03-07 C
2400 CR104   C




2400 CRC03-07 C
If    record 2400 CR106      C
present,
field must
be numeric.
(spaces
OK)




           2400 CR107        C     C
           2400 CR108        C     C
           2400 CR109        C




           2400 CR110        C



                             C
                             C     C
                             C

NOT                          R
MAPPED
NOT
MAPPED


           Optional Record

EDIT       837 837           NSF   IASD   Title   ISYS All
           Loop Element      Req   Req    XIX     Payer
                                          Req     Req
If    record            R   R   R   R
present,
Field will be
checked for
value      of
"GC0"

If     record           R   R   R   R
present,
field must
equal      the
FA0-02
value       for
this detail.
NOT
MAPPED -
DERIVED
Field must              C   R   R   R
equal      the
CA0-03
value       for
this claim.
NOT
MAPPED -
DERIVED
NOT                     O
MAPPED
Field must 2400 DTP03   C   R
be present.
If       field
present,
must be a
valid date,
must          8
numerics.
Zeros and
'0000'      for
the year is
valid.
Field must 2400      DTP03   C   R
be present.
If      field
present,
must be a
valid date,
must be a
valid date,
must        8
numerics.
Zeros and
'0000'    for
the year is
valid.
              2400   CR201   C
              2400   CR203   C
              2400   CR205   O

            2400 CR207       O

If    record 2400 CR208      C   R
present,
field must
be present.
Field must 2400 DTP03      C   R
be present.
If      field
present,
must be a
valid date,
must be a
valid date,
must        8
numerics.
Zeros and
'0000'    for
the year is
valid.
              2400 CR209   C
              2400 CR210   C
                               C




                               R



                 No Mappings
                For HIPAA-X12 v
EDIT            837 4010
                      837       NSF   IASD   Title   ISYS All
                Loop Element Req      Req    XIX     Payer
                                             Req     Req
If    record                   R      R      R       R
present,
Field will be
checked for
value      of
"GD0"

If    record                   R      R      R       R
present,
field must
equal    the
FA0-02
value     for
this detail.
NOT
MAPPED -
DERIVED
Field must                         R   R   R   R
equal     the
CA0-03
value      for
this claim.
NOT
MAPPED -
DERIVED
             2400       CR301      C
If    record 2400       CR303      C   R
present,
field must
be present.
             2400       CR305      C
             2400       ZAP02      C



                 2400   CRC03-07   C
                 2400   CRC03-07   C
                 2400   CRC03-07   C
                 2400   CRC03-07   C
                 2400   CRC03-07   C
                 2400   CRC03-07   C
                 2400   CRC03-07   C
                 2400   CRC03-07   C
                 2400   CRC03-07   C
                 2400   CRC03-07   C
                 2400   CRC03-07   C
                 2400   CRC03-07   C
                 2400   CRC03-07   C
                 2400   CRC03-07   C

                 2400   CRC03-07   C
                 2400   CRC03-07   C
                 2400   CRC03-07   C
                 2400   CRC03-07   C
                 2400   ZAP02      C
                 2400   CRC03-07   C
                 2400   CRC03-07   C
                 2400   CRC03-07   C
                 2400   CRC03-07   C
If present, 2400 DTP03        C
field must
be a valid
date, must
be a valid
date, must
8 numerics.
Zeros and
'0000'  for
the year is
valid.

If present, 2400 DTP03        C
field must
be a valid
date, must
be a valid
date, must
8 numerics.
Zeros and
'0000'  for
the year is
valid.

            2400   CRC03-07   C
            2400   ZAP02      C
            2400   ZAP02      C
            2400   ZAP02      C
            2400   ZAP02      C
            2400   ZAP02      C
If present, 2400   DTP03      C
field must
be a valid
date, must
be a valid
date, must
8 numerics.
Zeros and
'0000'  for
the year is
valid.

           2400    CRC03-07   C
           2400    HI01       C
           2400    HI02       C
           2400    HI03       C
           2400    HI04       C
           2400    CRC03-07   C
If present, 2400 DTP03            C
field must
be a valid
date, must
be a valid
date, must
8 numerics.
Zeros and
'0000'  for
the year is
valid.

If present, 2400 DTP03            C
field must
be a valid
date, must
be a valid
date, must
8 numerics.
Zeros and
'0000'  for
the year is
valid.

                2400 CRC03-07 C
                2400 CRC03-07 C

                2400   CRC03-07   C
                2400   CRC03-07   C
                2400   CRC03-07   C
                2400   CRC03-07   C
                2400   CRC03-07   C
                2400   CRC03-07   C
NOT                               R
MAPPED
NOT
MAPPED


                 No Mappings
                For HIPAA-X12 v
EDIT            837 4010
                      837       NSF   IASD   Title   ISYS All
                Loop Element Req      Req    XIX     Payer
                                             Req     Req
If    record                      R   R      R       R
present,
Field will be
checked for
value      of
"GD1"
If     record                   R      R      R       R
present,
field must
equal     the
FA0-02
value      for
this detail.
NOT
MAPPED -
DERIVED
Field must                      R      R      R       R
equal     the
CA0-03
value      for
this claim.
NOT
MAPPED -
DERIVED
                 2400 NTE02     C
NOT                             R
MAPPED
NOT
MAPPED


                  No Mappings
                 For HIPAA-X12 v
EDIT             837 4010
                       837       NSF   IASD   Title   ISYS All
                 Loop Element Req      Req    XIX     Payer
                                              Req     Req
                                C      R      R       R




                                R      R      R       R
                                R      R      R       R
                                C
                                C
                                C
                                C
                                C
                                C
                                C
                                C
                                C
                                C
                                C
                                C
                                C
                                C
                                C
                      C
                      C
                      C
                      C
                      C
                      C
                      C
                      C
                      C
                      C
                      C
                      R


        No Mappings
       For HIPAA-X12 v
EDIT   837 4010
             837       NSF   IASD   Title   ISYS All
       Loop Element Req      Req    XIX     Payer
                                    Req     Req
                      R      R      R       R




                      R      R      R       R
                      R      R      R       R
                      C
                      C
                      C
                      C
                      C
                      C
                      C
                      C
                      C
                      C
                      C
                      C
                      C
                      C
                      C
                      C
                      C
                      C
                      C
                      C
                      C
                      C
                      C
                      C
                      C
                      C
                         C
                         C
                         C
                         R


       Optional Record

EDIT   837 837           NSF   IASD   Title   ISYS All
       Loop Element      Req   Req    XIX     Payer
                                      Req     Req
                         R     R      R       R




                         R     R      R       R



                         R     R      R       R
                         R




                         R
                         C




                         R
                         C
                         C
                         C
                         C
                         R
                         C
C
C
C

C
C
R
C
R
R

R
R
R
C




C
C




C
C
C




C
C




C




C
C




C




C
C




C




C
C
C
C




C




C
C
C
C
C



C



C
C



C
C



C



C




C




C
C
C
C
C
C
C
C
C




C
                         C




                         C




                         C




                         R


       Optional Record

EDIT   837 837           NSF   IASD   Title   ISYS All
       Loop Element      Req   Req    XIX     Payer
                                      Req     Req
                         R     R      R       R




                         R     R      R       R



                         C     R      R       R
C




C




C
C
C
C
C


C


C
C
C

C
C
C
C
C

C
C
C
C
C




C

C




C




C
C
C

C
C
C
C
C
                         R
                         R


        No Mappings
       For HIPAA-X12 v
EDIT   837 4010
             837       NSF     IASD   Title   ISYS All
       Loop Element Req        Req    XIX     Payer
                                      Req     Req
                         R     R      R       R



                         R     R      R       R
                         R     R      R       R
                         C
                         C
                         C
                         R


       Optional Record

EDIT   837 837           NSF   IASD   Title   ISYS All
       Loop Element      Req   Req    XIX     Payer
                                      Req     Req
                         R     R      R       R



                         R     R      R       R
                         R     R      R       R
                         C
                         C
                         C
                         C

                         C

                         C
                         C
                         C
                         C
                         C
                         C
                         R


         Conditional
           Record
EDIT             837 837        NSF   IASD   Title   ISYS All
                 Loop Element   Req   Req    XIX     Payer
                                             Req     Req
If    record                    R     R      R       R
present,
Field will be
checked for
value      of
"HA0"

If     record                   R     R      R       R
present,
field must
equal     the
FA0-02
value      for
this detail.
NOT
MAPPED -
DERIVED
Field must                      R     R      R       R
equal     the
CA0-03
value      for
this claim.
NOT
MAPPED -
DERIVED
If     record                   C     C      C       C
present,
field must
equal     the
FA0-04
value      for
this detail.
NOT
MAPPED -
DERIVED
                 2400 NTE02     C                    C


                    Required
                     Record
EDIT             837 837        NSF   IASD   Title   ISYS All
                 Loop Element   Req   Req    XIX     Payer
                                             Req     Req
Field will be                   R     R      R       R
checked for
value      of
"XA0"
NOT              R       R
MAPPED
Field must       R   R   R   R
equal     the
CA0-03
value      for
this claim.
NOT
MAPPED -
DERIVED
Calculated       R   R   R   R
amount
must equal
amount on
record
NOT
MAPPED -
DERIVED
Calculated       R   R   R   R
amount
must equal
amount on
record
NOT
MAPPED -
DERIVED
Calculated       R   R   R   R
amount
must equal
amount on
record
NOT
MAPPED -
DERIVED
Calculated       R   R   R   R
amount
must equal
amount on
record
NOT
MAPPED -
DERIVED
Calculated       R   R   R   R
amount
must equal
amount on
record
NOT
MAPPED -
DERIVED
Calculated               R   R   R   R
amount
must equal
amount on
record
NOT
MAPPED -
DERIVED
Calculated               R   R   R   R
amount
must equal
amount on
record
NOT
MAPPED -
DERIVED
NOT                      R       R
MAPPED
Calculated 2300 CLM02    R   R   R   R
amount of
FA0.13
must equal
amount on
record
NOT                      R       R
MAPPED -
DERIVED
NOT                      R       R
MAPPED -
DERIVED
NOT                      R       R
MAPPED -
DERIVED
NOT                      R       R
MAPPED -
DERIVED
NOT                      R       R
MAPPED -
DERIVED
NOT                      R       R   C
MAPPED -
DERIVED
If present, 2300 AMT02   R       R
field must
be numeric.
(spaces
OK)

NOT                      R       R
MAPPED -
DERIVED
                2300 ZAP02     C            C

                2300 ZAP02     O
NOT                            R            R
MAPPED
NOT
MAPPED


                   Required
                    Record
EDIT            837 837        NSF   IASD   Title   ISYS All
                Loop Element   Req   Req    XIX     Payer
                                            Req     Req
Field will be                  R     R      R       R
checked for
value      of
"YA0"

Field must                     R     R      R       R
equal
BA0.02.
NOT
MAPPED -
DERIVED
Field must                     R     R      R       R
equal
BA0.03.
NOT
MAPPED -
DERIVED
Field must                     R     R      R       R
be equal to
BA0-04.
NOT
MAPPED -
DERIVED
Field must                     O
equal
BA0.05.
NOT
MAPPED -
DERIVED
Field must                     R     R      R       R
equal
BA0.06.
NOT
MAPPED -
DERIVED
NOT                            R
MAPPED
Calculated                     R     R      R       R
amount of
all   FA0's
must equal
amount on
record.
NOT
MAPPED -
DERIVED
Calculated                     R     R      R       R
amount
must equal
amount on
record.
NOT
MAPPED -
DERIVED
Calculated                     R     R      R       R
amount
must equal
amount on
record.
NOT
MAPPED -
DERIVED
Calculated                     R     R      R       R
amount
must equal
amount on
record
(XA0-12).
NOT
MAPPED -
DERIVED
NOT                            R            R
MAPPED
NOT
MAPPED


                   Required
                    Record
EDIT            837 837        NSF   IASD   Title   ISYS All
                Loop Element   Req   Req    XIX     Payer
                                            Req     Req
Field will be                  R     R      R       R
checked for
value      of
"ZA0"
Field must     R   R   R   R
equal AA0-
02.
NOT
MAPPED -
DERIVED
NOT            R
MAPPED
Field must     C   R   R   R
equal AA0-
17.
NOT
MAPPED -
DERIVED
Calculated     R   R   R   R
amount
must equal
amount on
record (YA0-
08).
NOT
MAPPED -
DERIVED
Calculated     R   R   R   R
amount
must equal
amount on
record (YA0-
09).
NOT
MAPPED -
DERIVED
Calculated     R   R   R   R
amount
must equal
amount on
record (YA0-
10).
NOT
MAPPED -
DERIVED
Calculated     R   R   R   R
amount
must equal
amount on
record.
NOT
MAPPED -
DERIVED
Calculated     R   R   R   R
amount
must equal
amount on
record (YA0-
11).
NOT
MAPPED -
DERIVED
               C
               C
               R       R

ADDITION
AL EDITS
DUPLICAT
E     FILE
HAS BEEN
RECEIVED
Record type:   AA0
File Header - Submitter Data

                         Field #   Field Name           Start Length


                               1   Record ID “AA0”      1     3x


                               2   Submitter ID         4     16x


                               3   Reserved (AA0.03)    20    9x
                               4   Submission Type      29    6x
                               5   Submission Number    35    6x


                               6   Submitter Name       41    33x


                               7   Submitter Address1   74    30x

                               8   Submitter Address2   104   30x




                               9   Submitter City       134   20x




                           10      Submitter State      154   2x



                           11      Submitter Zip        156   9x




                           12      Submitter Region     165   5x
13   Submitter Contact          170   33x




14   Submitter Phone            203   10x




15   Creation Date (CCYYMMDD)   213   8x




16   Submission Time            221   6x




17   Receiver ID                227   16x




18   Receiver Type Code         243   1x




19   Version Code - National    244   5n
                          20                        Version Code - Local      249   5n



                          21                        Test/Prod Indicator       254   4x




                          22                        Password                  258   8x
                          23                        Retransmission Status     266   1x




                          24                        Original Submitter ID     267   16x
                          25                        Vendor App Cat            283   1x


                          26                        Vendor Software Version   284   5x
                          27                        Vendor Software Update    289   2x
                          28                        COB File Indicator        291   1x
                          29                        Process From Date         292   8x
                          30                        Process Thru Date         300   8x




                          31                        Acknowledgment Request    308   1x
                          32                        Date of Receipt           309   8x
                          33                        Filler - National         317   4x


Record type:   BA0 (Group Provider # Information)
Batch Header Record - Provider Data 1

                        Field #                     Field Name                Start Length


                           1                        Record ID “BA0”           1     3x
2    EMC Provider ID               4     15x

3    Batch Type                    19    3x

4    Batch Number                  22    4x
5    Batch ID                      26    6x
6    Provider Tax ID               32    9x




7    Reserved (BA0.07)             41    6x

8    Provider Tax ID Type          47    1X




9    National Provider ID (NPI)    48    15x


10   Provider UPIN-USIN ID         63    6x


11   Reserved (BA0.11)             69    6x

12   Provider Medicaid Number      75    15x


13   Provider Champus Number       90    15x
14   Provider Blue Shield Number   105   15x


15   Provider Commercial Number    120   15x


16   Provider Number 1             135   15x
17   Provider Number 2             150   15x
18   Provider Org Name             165   33x
                          19            Provider Last Name           198   20x




                          20            Provider First Name          218   12x




                          21            Provider MI                  230   1x



                          22            Provider Specialty           231   3x
                          23            Specialty License Number     234   15x

                          24            State License Number         249   15x


                          25            Dentist License Number       264   15x

                          26            Anesthesia License Number    279   15x

                          27            Provider Participation Ind   294   1x
                          28            Filler - National            295   26x




Record type:   BA1
Batch Header Record - Provider Data 2

                        Field #         Field Name                   Start Length


                           1            Record ID “BA1”              1     3x




                          2             EMC Provider ID              4     15x
3    Batch Type                  19    3x




4    Batch Number                22    4x




5    Batch ID                    26    6x




6    Provider Type Org           32    3x
7    Provider Service Address1   35    30x



8    Provider Service Address2   65    30x

9    Provider Service City       95    20x


10   Provider Service State      115   2x


11   Provider Service Zip        117   9x


12   Provider Service Phone      126   10x


13   Provider Pay To Address1    136   30x


14   Provider Pay To Address2    166   30x

15   Provider Pay To City        196   20x


16   Provider Pay To State       216   2x


17   Provider Pay To Zip         218   9x
                          18         Provider Pay To Phone    227   10x

                          19         Filler - National        237   84x




Record type:   CA0
Claim Header Record – Patient Data

                        Field #      Field Name               Start Length


                          1          Record ID “CA0”          1     3x




                          2          Reserved (CA0-02)        4     2x

                          3          Patient Control Number   6     17x

                          4          Patient Last Name        23    20x




                          5          Patient First Name       43    12x




                          6          Patient MI               55    1x




                          7          Patient Generation       56    3x
8    Patient Date        Of      Birth 59   8x
     (CCYYMMDD)




9    Patient Sex                      67    1x




10   Patient Type Of Residence        68    1x

11   Patient Address1                 69    30x




12   Patient Address2                 99    30x




13   Patient City                     129   20x




14   Patient State                    149   2x




15   Patient Zip                      151   9x




16   Patient Phone                    160   10x
17   Patient Marital Status           170    1x




18   Patient Student Status           171    1x


19   Patient Employment Status        172    1x




20   Patient Death Indicator          173    1x




21   Patient Date         Of     Death 174   8n
     (CCYYMMDD)




22   Other Insurance Indicator        182    1x




23   Claim Editing Indicator          183    1x
                          24                      Type Of Claim Indicator          184   2x




                          25                      Legal Representative Indicator   186   1x




                          26                      Origin Code                      187   9x
                          27                      Payer Claim Control Number       196   17x

                          28                      Provider Number                  213   15x
                          29                      Claim ID Number                  228   6x
                          30                      Filler - National                234   87x




Record type:   CB0
Claim Header Record - Legal Representative Data

                        Field #                   Field Name                       Start Length


                          1                       Record ID “CB0”                  1     3x


                          2                       Reserved (CB0-02)                4     2x

                          3                       Patient Control Number           6     17x
                           4                           Responsible Person Last Name    23    20x


                           5                           Responsible Person First Name   43    12x



                           6                           Responsible Person MI           55    1x

                           7                           Responsible Person Address1     56    30x



                           8                           Responsible Person Address2     86    30x




                           9                           Responsible Person City         116   20x




                          10                           Responsible Person State        136   2x




                          11                           Responsible Person Zip          138   9x




                          12                           Responsible Person Phone        147   10x




                          13                           Filler - National               157   164




Record type:   DA0 – SEQUENCE 1
Insurance Information Record - Insurance Information

                        Field #                        Field Name                      Start Length
1   Record ID “DA0”             1    3x




2   Sequence Number             4    2x




3   Patient Control Number      6    17x




4   Claim Filing Indicator      23   1x




5   Source Of Pay               24   1x



5   Source Of Pay (Continued)   25   2x
6   Insurance Type Code         27   5x




7   Payor Organization ID




8   Payor Claim Office Number   32   4x




9   Payor Name                  36   33x
10   Group Number                      69    20x




11   Group Name                        89    33x




12   PPO/HMO Indicator                 122   1x
13   PPO ID                            123   15x
14   Prior Authorization Number        138   15x
15   Assign Of Benefits Indicator      153   1x
16   Patient Signature Source          154   1x
17   Patient Relationship To Insured   155   2x



18   Insured ID Number                 157   25x




19   Insured Last Name                 182   20x




20   Insured First Name                202   12x

21   Insured MI                        214   1x

22   Insured Generation                215   3x

23   Insured Sex                       218   1x
24   Insured Date Of Birth             219   8x
                         25                         Insured Employment Status       227    1x


                         26                         Supplemental Insurance Indicator 228   1x




                         27                         Insurance Location ID           229    7x




                         28                         Medicaid ID NO                  236    25x
                         29                         Supplemental Patient ID         261    25x
                         30                         Assign 4081 Indicator           286    1x

                         31                         COB Routing Indicator           287    1x

                         32                         Filler - National               288    33x




Record type:   DA1 – SEQUENCE 1, 2, 3
Insurance Information Record - Insurance Information
(Payer Data 2)
                       Field #                       Field Name                     Start Length


                         1                          Record ID “DA1”                 1      3x




                         2                          Sequence Number                 4      2x




                         3                          Patient Control Number          6      17x
4    Payor Address1                23    30x



5    Payor Address2                53    30x
6    Payor City                    83    20x
7    Payor State                   103   2x
8    Payor Zip                     105   9x



9    Disallowed Cost Containment   114   n(5)v99




10   Disallowed Other              121   n(5)v99
11   Allowed Amount             128   n(5)v99




12   Deductible Amount          135   n(5)v99




13   Coinsurance Amount         142   n(5)v99




14   Payor Amount Paid          149   n(5)v99



15   Zero Pay Indicator         156   1x
16   Adjudication Indicator 1   157   2x

17   Adjudication Indicator 2   159   2x
18   Adjudication Indicator 3   161   2x
19   Champus Sponsor Branch     163   1x
20   Champus Sponsor Grade      164   2x
21   Champus Sponsor Status     166   1x
22   Insurance Card Effective Date   167   8x




23   Insurance Card Termination Date 175   8x




24   Balance Due                     183   n(5)v99




25   EOMB Date 1                     190   8x

26   EOMB Date 2                     198   8x

27   EOMB Date 3                     206   8x




28   EOMB Date 4                     214   8x
29   Claim Receipt Date              222   8x
30   Amount Paid to Beneficiary      230   n(7)v99




31   Benefit Check/EFT Trace No      239   15x
32   Benefit Check Date              254   8x
                           33           Amount Paid to Provider           262   n(7)v99




                           34           Provider Check/EFT Trace No       271   15x
                           35           Provider Check Date               286   8x
                           36           Interest Paid                     294   n(7)v99
                           37           Approved Amount                   303   n(7)v99




                           38           Contractual Agreement Indicator   312   1x
                           39           Filler - National                 313   8x

Record type:   DA2 – SEQUENCE 1, 2, 3
Insurance Information - Payer Data 3

                         Field #        Field Name                        Start Length


                           1            Record ID “DA2”                   1     3x
                           2            Sequence Number                   4     2x
                           3            Patient Control Number            6     17x
                           4            Insured Address1                  23    30x
                           5            Insured Address2                  53    30x
6    Insured City                   83    20x




7    Insured State                  103   2x
8    Insured Zip                    105   9x




 9   Insured Phone                  114   10x
10   Insured Retirement Date        124   8x




11   Insurance Spouse Retire Date   132   8x




12   Insured Employer Name          140   33x

13   Insured Employer Address1      173   30x
14    Insured Employer Address2   203   30x

15    Insured Employer City       233   20x
16    Insured Employer State      253   2x
17    Insured Employer Zip        255   9x
18    Employee ID Number          264   12x
19    Filler - National           276   45x


DA3
 1    Record ID “DA3”             1     3x
 2    Sequence Number             4     2x




 3    Patient Control Number      6     17x
 4    Claim Reason Code 1         23    6x




 5    Dollar Amount 1             29    n(5)v99




 6    Claim Reason Code 2         36    6x
 7    Dollar Amount 2             42    n(5)v99




 8    Claim Reason Code 3         49    6x
 9    Dollar Amount 3             55    n(5)v99
10    Claim Reason Code 4         62    6x
11   Dollar Amount 4        68    n(5)v99




12   Claim Reason Code 5    75    6x




13   Dollar Amount 5        81    n(5)v99




14   Claim Reason Code 6    88    6x
15   Dollar Amount 6        94    n(5)v99




16   Claim Reason Code 7    101   6x




17   Dollar Amount 7        107   n(5)v99
18   Claim Message Code 1   114   5x
19   Claim Message Code 2   119   5x
20   Claim Message Code 3   124   5x




21   Claim Message Code 4   129   5x
22   Claim Message Code 5      134   5x




23   Claim Detail Line Count   139   2x
24   Claim Adjustment Ind      141   1x




25   Provider Adjustment Amt   142   n(5)v99
                           26                             Beneficiary Adjustment Amt      149   n(5)v99




                           27                             Original Approved Amt           156   n(5)v99
                           28                             Original Paid Amt               163   n(5)v99
                           29                             Original Payor Claim Cont Num   170   17x
                           30                             Filler - National               187   134x
Record type:   EA0
If the claim is being submitted for a type of provider that
does not require a principle diagnosis code (i.e. funeral
                           be submitted in the NSF
director) the claim cannotField #                           Field Name                    Start Length


                            1                             Record ID “EA0”                 1     3x
                            2                             Reserved (EA0.02)               4     2x

                            3                             Patient Control Number          6     17x


                            4                             Employment Related Indicator    23    1x
5   Accident Indicator      24   1x




6   Symptom Indicator       25   1x




7   Accident/Symptom Date   26   8x




8   Ext Cause Of Accident   34   5x
9    Responsibility Indicator   39   1x




10   Accident State             40   2x
11   Accident Hour              42   2x



12   Abuse Indicator            44   1x
13   Release Of Information Indicator   45   1x




14   Release Of Information Date        46   8x
15   Same/Similar Symptom Indicator   54   1x




16   Same/Similar Symptom Date        55   8x


17   Disability Type                  63   1x


18   Disability-From Date             64   8x
19   Disability-To Date               72    8x




20   Referring Provider National ID   80    15x



21   Referring Provider UPIN          95    15x


22   Referring Provider Tax Type      110   1x
23   Referring Provider Tax ID        111   9x




24   Referring Provider Last          120   20x

25   Referring Provider First         140   12x

26   Referring Provider MI            152   1x

27   Referring Provider State         153   2x

28   Admission Date-1                 155   8x




29   Discharge Date-1                 163   8x




30   Laboratory Indicator             171   1x
31   Laboratory Charges           172   n(5)v99



32   Diagnosis Code-1             179   5x

33   Diagnosis Code-2             184   5x


34   Diagnosis Code-3             189   5x



35   Diagnosis Code-4             194   5x



36   Provider Assign Indicator    199   1x




37   Provider Signature On File   200   1x
38   Provider Signature Date    201   8x




39   Facility/Laboratory Name   209   33x

40   Documentation Indicator    242   1x
41   Type Of Documentation    243   1x




42   Functional Status Code   244   2x
43   Special Program Indicator        246   2x




44   Champus Nonavailable Indicator   248   1x

45   Supervising Provider Indicator   249   1x

46   Resubmission Code                250   2x
47   Resubmission Reference No.       252   15x



48   Date Last Seen                   267   8x
                            49    Date Document Sent      275   8x




                            50    Homebound Ind           283   1x




                            51    Blood Units Paid        284   3x
                            52    Blood Units Remaining   287   3x
                            53    CPO Provider Number     290   6x

                            54    IDE Number              296   15x

                            55    Filler - National       311   10x




Record type:   EA1
Claim Record - Claim Data

                        Field #   Field Name              Start Length


                            1     Record ID “EA1”         1     3x




                            2     Reserved (EA1.02)       4     2x
3    Patient Control Number          6     17x




4    Facility/Laboratory ID Number   23    15x

5    Reserved (EA1.05)               38    15x

6    Facility/Laboratory Address1    53    30x

7    Facility/Laboratory Address2    83    30x

8    Facility/Laboratory City        113   20x

9    Facility/Laboratory State       133   2x

10   Facility/Laboratory Zip Code    135   9x

11   Medical Record Number           144   17x

12   Return To Work Date             161   8x




13   Consult/Surgery Date            169   8x
                     14   Admission Date-2                 177   8x




                     15   Discharge Date-2                 185   8x




                     16   Supervising Provider ID Number   193   15x

                     17   Reserved (EA1.17)                208   15x

                     18   Supervising Provider Last        223   20x



                     19   Supervising Provider First       243   12x



                     20   Supervising Provider MI          255   1x

                     21   Supervising Provider State       256   2x

                     22   EMT/Paramedic Last               258   20x
                     23   EMT/Paramedic First              278   12x
                     24   EMT/Paramedic MI                 290   1x
                     25   Date Care Assumed                291   8x

                     26   Diagnosis Code 5                 299   5x
                     27   Diagnosis Code 6                 304   5x
                     28   Diagnosis Code 7                 309   5x
                     29   Diagnosis Code 8                 314   5x
                     30   Filler - National                319   2x




Record type:   EA2
Claim Record – Early Periodic Screening Diagnostic
Testing (EPSDT)
                     Field #                       Field Name                    Start Length


                        1                          Record ID “EA2”               1     3x



                         2                         Reserved (EA2.02)             4     2x
                         3                         Patient Control Number        6     17x
                         4                         Screening Type                23    1x
                         5                         Med History Obtain - Perf     24    1x
                         6                         Med History Obtain - Find     25    1x
                         7                         Physical Exam - Perf          26    1x
                         8                         Physical Exam - Find          27    1x
                         9                         Vision Assess - Perf          28    1x
                        10                         Vision Assess - Find          29    1x
                        11                         Hearing Assess - Perf         30    1x
                        12                         Hearing Assess - Find         31    1x
                        13                         Dental Assess - Perf          32    1x
                        14                         Dental Assess - Find          33    1x
                        15                         Develop Assess - Perf         34    1x
                        16                         Develop Assess - Find         35    1x
                        17                         Nutritional Assess - Perf     36    1x
                        18                         Nutritional Assess - Find     37    1x
                        19                         Cardio Assess - Perf          38    1x
                        20                         Cardio Assess - Find          39    1x
                        21                         Gen/UR Assess - Perf          40    1x
                        22                         Gen/UR Assess - Find          41    1x
                        23                         Diabetes Assess - Perf        42    1x
                        24                         Diabetes Assess - Find        43    1x
                        25                         Other Systems Assess - Perf   44    1x
                        26                         Other Systems Assess - Find   45    1x
                        27                         Other Systmes Assess - Desc   46    20x
                        28                         HBG/HCT Lab Test - Perf       66    1x
                        29                         HBG/HCT Lab Test - Find       67    1x
                        30                         Urinalysis Lab Test - Perf    68    1x
                        31                         Urinalysis Lab Test - Find    69    1x
                        32                         Sickle Cell Lab - Perf        70    1x
                        33                         Sickle Cell Lab - Find        71    1x
                        34                         Blood Lead Lab - Perf         72    1x
                        35                         Blood Lead Lab - Find         73    1x
                        36                         Tine Test - Perf              74    1x
                        37                         Tine Test - Find              75    1x
                        38                         Other Test 1 - Perf           76    1x
                        39                         Other Test 1 - Find           77    1x
                        40                         Other Test 1 - Desc           78    20x
                        41                         Other Test 2 - Perf           98    1x
                        42                         Other Test 2 - Find           99    1x
                        43                         Other Test 2 - Desc           100   20x
                        44                         Treatment Item No 1           120   2x
                     45   Treatment Item No 2      122   2x
                     46   Treatment Item No 3      124   2x
                     47   Treatment Item No 4      126   2x
                     48   Treatment Item No 5      128   2x
                     49   Treatment Item No 6      130   2x
                     50   Treatment Item No 7      132   2x
                     51   Treatment Item No 8      134   2x
                     52   Treatment Item No 9      136   2x
                     53   Treatment Item No 10     138   2x
                     54   Treatment Item No 11     140   2x
                     55   Treatment Item No 12     142   2x
                     56   Treatment Item No 13     144   2x
                     57   Treatment Item No 14     146   2x
                     58   Treatment Item No 15     148   2x
                     59   Treatment Item No 16     150   2x
                     60   Treatment Stat No 1 IN   152   2x
                     61   Treatment Stat No 2 IN   154   2x
                     62   Treatment Stat No 3 IN   156   2x
                     63   Treatment Stat No 4 IN   158   2x
                     64   Treatment Stat No 1 DE   160   2x
                     65   Treatment Stat No 2 DE   162   2x
                     66   Treatment Stat No 3 DE   164   2x
                     67   Treatment Stat No 4 DE   166   2x
                     68   Treatment Stat No1 NR    168   2x
                     69   Treatment Stat No2 NR    170   2x
                     70   Treatment Stat No3 NR    172   2x
                     71   Treatment Stat No4 NR    174   2x
                     72   Referral Item No 1       176   2x
                     73   Referral Item No 2       178   2x
                     74   Referral Item No 3       180   2x
                     75   Referral Item No 4       182   2x
                     76   Referral Item No 5       184   2x
                     77   Referral Item No 6       186   2x
                     78   Referral Item No 7       188   2x
                     79   Referral Item No 8       190   2x
                     80   Immun Polio - Given      192   1x
                     81   Immun Polio - Not        193   1x
                     82   Immun DPT/TD - Given     194   1x
                     83   Immun DPT/TD - Not       195   1x
                     84   Immun Measles - Given    196   1x
                     85   Immun Measles - Not      197   1x
                     86   Immun Mumps - Given      198   1x
                     87   Immun Mumps - Not        199   1x
                     88   Immun Rubella - Given    200   1x
                     89   Immun Rubella - Not      201   1x
                     90   Immun HIB - Given        202   1x
                     91   Immun HIB - Not          203   1x
                     92   Immun Other - Given      204   1x
                     93   Immun Other - Desc       205   20x
                     94   Filler - National        225   96x
Record type:   FA0
Service Line Detail - Root Segment 99 Fxx records per
claim, only 50 Fxx records allowed for HIPAA-X12 v 4010
                         Field #                        Field Name                Start Length


                          1                            Record ID “FA0”            1    3x




                          2                            Sequence Number            4    2x




                          3                            Patient Control Number     6    17x




                          4                            Line Item Control Number   23   17x
5   Service From Date   40   8x
6    Service To Date        48   8x




7    Place Of Service       56   2x




8    Type Of Service Code   58   2x


 9   HCPCS Procedure Code   60   5x
10   HCPCS Modifier 1       65   2x
11   HCPCS Modifier 2       67   2x
12   HCPCS Modifier 3       69   2x
13   Line Charges           71   n(5)v99
14   Diagnosis Code Pointer1      78    1x




15   Diagnosis Code Pointer2      79    1x
16   Diagnosis Code Pointer3      80    1x
17   Diagnosis Code Pointer4      81    1x
18   Units Of Service             82    n(3)v9




19   Anesthesia/Oxygen Minutes    86    4n




20   Emergency Indicator          90    1x




21   COB Indicator                91    1x
22   HPSA Indicator               92    1x
23   Rendering Provider ID        93    15x




24   Referring Provider ID        108   15x

25   Referring Provider State     123   2x

26   Purchase Service Indicator   125   1x
27   Disallowed Cost Containment     126   n(5)v99



28   Disallowed Other                133   n(5)v99



29   Review By Code Indicator        140   1x

30   Multiple Procedure Indicator    141   1x

31   Mammography Certification No.   142   10x

32   Class Findings                  152   9x
33   Podiatry Service Condition      161   3x

34   Clinical Laboratory(CLIA)       164   15x




35   Primary Paid Amount             179   n(5)v99




36   HCPCS Modifier 4                186   2x
37   Provider Specialty              188   3x
38   Podiatry Therapy Ind            191   1x
39   Podiatry Therapy Type           192   1x
40   Hospice Employed Prov Ind       193   1x


41   HGB/HCT Date                    194   8x

42   HGB Result                      202   n(3)
43   HCT Result                      205   n(2)
44   Patient Weight                  207   n(3)

45   EPO Dosage                      210   n(3)
46   Serum Creatine Date             213   8x

47   Creatine Result                 221   n(3)
                           48           Obligated Accept Amt              224   n(5)v99
                           49           Drug Discount Amt                 231   n(5)v99
                           50           Type of Units Indicator           238   1x


                           51           Approved Amount                   239   n(5)v99

                           52           Paid Amount                       246   n(5)v99
                           53           Beneficiary Liability Amount      253   n(5)v99
                           54           Balancing Bill Limiting Charges   260   n(5)v99
                           55           Limiting Charge Percent           267   n(5)v99
                           56           Performing Provider Phone         274   10x

                           57           Performing Provider Tax Type      284   1x

                           58           Performing Provider Tax ID        285   9x

                           59           Performing Provider Assignment    294   1x
                                        Ind
                           60           Pre-Transplant Indicator          295   1x
                           61           ICD-10-PCS                        296   7x
                           62           Universal Product Code (UPC)      303   14x

                           63           Diagnosis Code Pointer 5          317   1x

                           64           Diagnosis Code Pointer 6          318   1x

                           65           Diagnosis Code Pointer 7          319   1x

                           66           Diagnosis Code Pointer 8          320   1x

Record type:   FB0
Service Line Detail - Medical Segment

                        Field #         Field Name                        Start Length


                           1            Record ID "FB0"                   1     3x
                           2            Sequence No                       4     2x

                           3            Patient Control Number            6     17x
4    Line Item Control No   23    17x




5    Pur Svc Charge         40    n(5)v99



6    Allowed Amount         47    n(5)v99



7    Deductible Amount      54    n(5)v99



8    Coinsurance Amount     61    n(5)v99



9    Ordering Prov ID       68    15x

10   Ordering Prov State    83    2x
11   Pur Svc Prov ID        85    15x




12   Pur Svc State          100   2x
13   Pen Grams Of Protein   102   4x
14   Pen Calories           106   4x
15   National Drug Code     110   11x
16   National Drug Units    121   7x
17   Prescription No        128   15x
18   Prescription Date      143   8x




19   Prescript No Of Mos    151   2x
20   Spec Pricing Ind       153   1x
21   Copay Status Ind       154   1x
                           22           EPSDT Ind                155   1x

                           23           Family Planning Ind      156   1x




                           24           DME Charge Ind           157   1x
                           25           HPSA Facility ID         158   15x
                           26           HPSA Facility Zip        173   9x
                           27           Pur Svc Name             182   33x

                           28           Pur Svc Addr1            215   30x
                           29           Pur Svc Addr2            245   30x
                           30           Pur Svc City             275   20x
                           31           Pur Svc Zip              295   9x
                           32           Pur Svc Phone            304   10x
                           33           Drug Days Supply         314   3x
                           34           Payment Type Ind         317   1x
                           35           Filler - National        318   3x




Record type:   FB1
Service Line Detail - Medical Segment

                        Field #         Field Name               Start Length


                           1            Record ID “FB1”          1     3x




                           2            Sequence Number          4     2x
                           3            Patient Control Number   6     17x
4    Line Item Control Number     23    17x




5    Place Of Service Name        40    33x

6    Ordering Provider Last       73    20x



7    Ordering Provider First      93    12x
8    Ordering Provider MI         105   1x
9    Ordering Provider UPIN       106   15x

10   Referring Provider Last      121   20x
11   Referring Provider First     141   12x
12   Referring Provider MI        153   1x
13   Referring Provider UPIN      154   15x



14   Rendering Provider Last      169   20x




15   Rendering Provider First     189   12x




16   Rendering Provider MI        201   1x




17   Rendering Provider UPIN      202   15x

18   Supervising Provider Last    217   20x
19   Supervising Provider First   237   12x
20   Supervising Provider MI      249   1x
21   Supervising Provider ID      250   15x
22   Supervising Provider UPIN    265   15x
23   Filler - National            280   41x
Record type:   FB2
Service Line Detail - Medical Segment

                        Field #         Field Name                 Start Length


                           1            Record Id "FB2"            1     3x
                           2            Sequence Number            4     2x



                            3           Patient Control Number     6     17x
                            4           Line Item Control Number   23    17x
                            5           Provider Type Ind A        40    2x
                            6           Provider A Address 1       42    30x
                            7           Provider A Address 2       72    30x
                            8           Provider A City            102   20x
                            9           Provider A State           122   2x
                           10           Provider A Zip             124   9x
                           11           Provider Type Ind B        133   2x
                           12           Provider B Address 1       135   30x
                           13           Provider B Address 2       165   30x
                           14           Provider B City            195   20x
                           15           Provider B State           215   2x
                           16           Provider B Zip             217   9x
                           17           Provider Type Ind C        226   2x
                           18           Provider C Address 1       228   30x
                           19           Provider C Address 2       258   30x
                           20           Provider C City            288   20x
                           21           Provider C State           308   2x
                           22           Provider C Zip             310   9x
                           23           Filler - National          319   2x
Record type:   FB3
Service Line Detail - Medical Segment

                        Field #         Field Name                 Start Length


                           1            Record Id "FB3"            1     3x


                           2            Sequence Number            4     2x



                           3            Patient Control Number     6     17x
                           4            Line Item Control Number   23    17x
                           5            Reason Code 1              40    6x
                           6            Dollar Amount 1            46    7x
                           7            Reason Code 2              53    6x
                            8          Dollar Amount 2          59    7x
                            9          Reason Code 3            66    6x
                           10          Dollar Amount 3          72    7x
                           11          Reason Code 4            79    6x
                           12          Dollar Amount 4          85    7x
                           13          Reason Code 5            92    6x
                           14          Dollar Amount 5          98    7x
                           15          Reason Code 6            105   6x
                           16          Dollar Amount 6          111   7x
                           17          Reason Code 7            118   6x
                           18          Dollar Amount 7          124   7x
                           19          Filler - National        131   190x
Record type:   FD0
Service Line Detail - Dental Segment

                         Field #       Field Name               Start Length


                           1           Record Id "FD0"          1     3x




                           2           Sequence No              4     2x

                           3           Patient Control Number   6     17x




                           4           Line Item Control No     23    17x




                            5          Tooth Code Number 1      40    2x
                            6          Tooth Surface(s) 1       42    5x
                            7          Tooth Code Number 2      47    2x
                            8          Tooth Surface(s) 2       49    5x
                            9          Tooth Code Number 3      54    2x
                           10          Tooth Surface(s) 3       56    5x
                           11          Tooth Code Number 4      61    2x
                           12          Tooth Surface(s) 4       63    5x
                           13          Initial Place Ind        68    1x
14   Prior Place Date       69    8x




15   Impress/Prescript Dt   77    8x




16   Replacement Reason     85    1x
17   Ortho Treat Ind        86    1x
18   Treatment Length       87    2x
19   Date Appl Inserted     89    8x




20   Date Appl Removed      97    8x




21   Reserved (FD0-21.0)    105   10x
22   Date Appl Replaced      115   8x




23   Mos Treat Remaining     123   2x
24   Dt 1st Visit Cur Ser    125   8x




25   Reserved (FD0-25.0)     133   10x
26   Pre Determination Id    143   20x
27   Reserved (FD0-27.0)     163   10x
28   Missing Primary Teeth   173   20x

29   Missing Perm   Tooth    193   2x
30   Missing Perm   Tooth    195   2x
31   Missing Perm   Tooth    197   2x
32   Missing Perm   Tooth    199   2x
33   Missing Perm   Tooth    201   2x
34   Missing Perm   Tooth    203   2x
35   Missing Perm   Tooth    205   2x
36   Missing Perm   Tooth    207   2x
37   Missing Perm   Tooth    209   2x
38   Missing Perm   Tooth    211   2x
39   Missing Perm   Tooth    213   2x
40   Missing Perm   Tooth    215   2x
41   Missing Perm   Tooth    217   2x
42   Missing Perm   Tooth    219   2x
43   Missing Perm   Tooth    221   2x
44   Missing Perm   Tooth    223   2x
45   Missing Perm   Tooth    225   2x
46   Missing Perm   Tooth    227   2x
47   Missing Perm   Tooth    229   2x
48   Missing Perm   Tooth    231   2x
49   Missing Perm   Tooth    233   2x
50   Missing Perm   Tooth    235   2x
51   Missing Perm   Tooth    237   2x
52   Missing Perm   Tooth    239   2x
53   Missing Perm   Tooth    241   2x
54   Missing Perm   Tooth    243   2x
                          55                       Missing Perm Tooth       245   2x
                          56                       Missing Perm Tooth       247   2x
                          57                       Missing Perm Tooth       249   2x
                          58                       Missing Perm Tooth       251   2x
                          59                       Missing Perm Tooth       253   2x
                          60                       Missing Perm Tooth       255   2x
                          61                       Missing Perm Tooth       257   2x
                          62                       Quadrant                 259   2x
                          63                       Tooth Pocket Measure     261   2x

                          64                       Filler - National        263   58x

Record type:   FE0
Third Party Organization – Third Party Organization
Segment
                       Field #                      Field Name              Start Length


                           1                       Record ID "FE0"          1     3x
                           2                       Sequence No              4     2x
                           3                       Patient Control Number   6     17x
                           4                       Line Item Control No     23    17x
                           5                       TPO ID Number            40    9x
                           6                       TPO Reference Number     49    15x
                           7                       Pricing Methodology      64    2x
                           8                       Allowed Amount           66    n(5)v99
                           9                       Savings Amount           73    n(5)v99
                          10                       Approved HCPCS Code      80    5x
                          11                       Approved Units           85    4x
                          12                       Rejection Message        89    2x
                          13                       Authorization Number     91    20x
                          14                       Policy Compliance Code   111   2x
                          15                       Exception Code           113   2x
                          16                       Filler - National        115   206x
Record type:   GA0
Ambulance Certification Record - Service Line

                        Field #                    Field Name               Start Length


                           1                       Record ID "GA0"          1     3x

                           2                       Sequence No              4     2x
3   Patient Control Number   6    17x




4   Reserved (GA0-04.0)      23   17x

5   Patients Weight          40   3x




6   Hospital Admit           43   1x
7   Type Of Transport     44   1x




8   Bed Confined Before   45   1x




9   Bed Confined After    46   1x
10   Moved By Stretcher    47   1x




11   Unconscious/Shock     48   1x




12   Emergency Situation   49   1x
13   Physical Restraints    50   1x




14   Visible Hemorrhaging   51   1x
15   Transported To/For    52   1x




16   Medically Necessary   53   1x
                            17                     Miles                   54    4x




                            18                     Origin Info             58    40x
                            19                     Destination Info        98    40x
                            20                     Purpose Of Round Trip   138   80x




                            21                     Purpose Of Stretcher    218   80x



                            22                     Patient Discharged      298   1x
                            23                     Patient Admitted        299   1x
                            24                     Services Available      300   1x

                            25                     Filler National         301   20x




Record type:   GC0
Chiropractic Certification Record - Service Line

                         Field #                   Field Name              Start Length
1   Record ID "GC0"          1    3x




2   Sequence No              4    2x




3   Patient Control Number   6    17x




4   Reserved (GC0-04.0)      23   17x

5   Initial Treatment Date   40   8x
6    Date Of Last X Ray       48   8x




7    No In Series             56   7x
8    Level Of Subluxation     63   7x
9    Treatment Months/Years   70   3x

10   No Treatments Month      73   2x

11   Nature Of Condition      75   1x
12   Date Of Manifestation   76   8x




13   Complication Ind        84   1x
14   Symptoms Description    85   160x
                             15      X-Ray Ind           245   1x




                             16      Filler - National   246   75x

Record type:   GD0
DME Certification Record

                           Field #   Field Name          Start Length


                             1       Record ID "GD0"     1     3x




                             2       Sequence No         4     2x
3    Patient Control Number   6    17x




4    Certification Type       23   1x
5    Medical Necessity        24   2x



6    Prognosis                26   20x
7    HCPCS Procedure Code     46   5x



 8   Ambulatory               51   1x
 9   Ambulation/Therapy       52   1x
10   Confined Bed/Chair       53   1x
11   Room Confined            54   1x
12   Ambulation/Mobility      55   1x
13   Body Positioning         56   1x
14   Respiratory/Other        57   1x
15   Breathing Impaired       58   1x
16   Freq/Immed Changes       59   1x
17   Operate Controls         60   1x
18   Siderails Part/Bed       61   1x
19   Owns Equipment           62   1x
20   Mattress/Siderails       63   1x
21   Equipment/Assistance     64   1x

22   Orthopedic Impair        65   1x
23   Planned Regimen          66   1x
24   Decubitus Ulcers         67   1x
25   Equipment Use            68   1x
26   Insulin Dependent        69   3x
27   Diabetic Control         72   1x
28   Apnea Episodes           73   1x
29   Surgery Alternative      74   1x
30   Total Knee Replace       75   1x
31   Date Surgery            76    8x




32   Date CPM                84    8x




33   Lymphedema              92    1x
34   Ordering Prov Last      93    20x
35   Ordering Prov First     113   12x
36   Ordering Prov MI        125   1x
37   Ordering Prov ID        126   15x
38   Ordering Prov Phone     141   10x
39   Date Certification      151   8x




40   Certification On File   159   1x
41   Diagnosis Code 1        160   5x
42   Diagnosis Code 2        165   5x
43   Diagnosis Code 3        170   5x
44   Diagnosis Code 4        175   5x
45   Nursing Home Ind        180   1x
                           46                              NH From Date            181   8x




                           47                              NH To Date              189   8x




                           48                              Respiratory Tract       197   1x
                           49                              Supv Of Equipment Use   198   1x

                           50                              Propel/Lift Chair       199   1x
                           51                              Leg Elevation           200   1x
                           52                              Patient Weight          201   1x
                           53                              Reclining Wheelchair    202   1x
                           54                              Manual Operation        203   1x
                           55                              Side Transfer Chair     204   1x
                           56                              Filler - National       205   116x




Record type:   GD1
DME Certification Record - Narrative Information for DME

                        Field #                            Field Name              Start Length


                           1                               Record ID "GD1"         1     3x
                            2                      Sequence No                   4     2x




                            3                      Patient Control Number        6     17x




                            4                      Narrative                     23    250x
                            5                      Filler - National             273   48x




Record type:   GE0
Certification Record – Enteral Nutrition Therapy

                         Field #                   Field Name                    Start Length


                            1                      Record ID "GE0"               1     3x




                            2                      Sequence No                   4     2x
                            3                      Patient Control Number        6     17x
                            4                      Certification Type            23    1x
                            5                      Onset Date of Therapy         24    8x
                            6                      Therapy Duration              32    2x
                            7                      Last Certification Date       34    8x
                            8                      Number of Months of Cert      42    2x
                            9                      Date Last Seen by Physician   44    8x
                           10                      Non Visit Ind                 52    1x
                           11                      Patient Age                   53    3x
                           12                      Patient Height                56    3x
                           13                      Patient Weight                59    3x
                           14                      Level of Consciousness Ind    62    1x
                           15                      Ambulatory Ind                63    1x
                           16                      Other Forms of Nutrient Ind   64    1x
                           17                      Method of Admin Ind           65    1x
                           18                      Admin Technique Ind           66    1x
                           19                         Total Calories Per Day        67    4x
                           20                         Product Name 1                71    15x
                           21                         Calories Per Product 1        86    4x
                           22                         HCPCS Procedure Code          90    5x
                           23                         HCPCS Modifier 1              95    2x
                           24                         HCPCS Modifier 2              97    2x
                           25                         Enteral Frequency Fed 1       99    3x
                           26                         Narrative Field               102   100x
                           27                         Product Name 2                202   15x
                           28                         Calories Per Product 2        217   4x
                           29                         Enteral Frequency Fed 2       221   3x
                           30                         Filler - National             224   97x
Record type:   GP0
Certification Record – Parenteral Nutrition Therapy

                         Field #                      Field Name                    Start Length


                            1                         Record ID "GP0"               1     3x




                            2                         Sequence Number               4     2x
                            3                         Patient Control Number        6     17x
                            4                         Certification Type            23    1x
                            5                         Onset Date of Therapy         24    8x
                            6                         Therapy Duration              32    2x
                            7                         Last Certification Date       34    8x
                            8                         Number of Months of Cert      42    2x
                            9                         Date Last Seen by Physician   44    8x
                           10                         Non Visit Ind                 52    1x
                           11                         Patient Age                   53    3x
                           12                         Patient Height                56    3x
                           13                         Patient Weight                59    3x
                           14                         Level of Consciousness Ind    62    1x
                           15                         Ambulatory Ind                63    1x
                           16                         Other Forms of Nutrient Ind   64    1x
                           17                         Type of Mix Ind               65    1x
                           18                         Parenteral Frequency Fed      66    3x
                           19                         HCPCS Procedure Code          69    5x
                           20                         HCPCS Modifier 1              74    2x
                           21                         HCPCS Modifier 2              76    2x
                           22                         Amino Acid Name               78    15x
                           23                         Amino Acid Volume             93    4x
                           24                         Amino Acid Concentration      97    5x
                           25                         Amino Acid Weight             102   4x
                           26                         Dextrose Volume               106   4x
                           27                         Dextrose Concentration        110   5x
                           28                         Lipids Volume                 115   4x
                           29                         Lipids Concentration          119   5x
                            30          Lipids Frequency         124   3x
                            31          Narrative Field          127   100x
                            32          Admin Technique Ind      227   1x
                            33          Filler - National        228   93x
Record type:   GU0
Certification – Certification Segment

                         Field #        Field Name               Start Length


                            1           Record ID "GU0"          1     3x




                            2           Sequence Number          4     2x



                            3           Patient Control Number   6     17x
                            4           Certification Type       23    1x




                            5           Place of Service         24    2x
                            6           Replacement Item         26    1x




                             7          HCPCS Procedure Code     27    5x
                             8          HCPCS Modifier           32    2x
                             9          Warranty Reply           34    1x
                            10          Warranty Length          35    2x
                            11          Warranty Type            37    1x
                            12          Diagnosis Code 1         38    5x
                            13          Diagnosis Code 2         43    5x
14   Diagnosis Code 3            48    5x
15   Diagnosis Code 4            53    5x
16   Patient Height              58    n(2)

17   Patient Weight              60    3x
18   Date of Last Medical Exam   63    8x
19   Initial Date                71    8x
20   Revision/Recert Date        79    8x
21   Length of Need              87    n(2)
22   Date Certification Signed   89    8x

23   Ordering Provider Phone     97    10x
24   Certification On File       107   1x
25   Certification Form Number   108   4x
26   Reply ALN L01 N01   112   1x




27   Reply ALN L01 N02   113   1x
28   Reply ALN L01 N03   114   1x




29   Reply ALN L01 N04   115   1x
30   Reply ALN L01 N05   116   1x
31   Reply ALN L01 N06   117   1x




32   Reply ALN L01 N07   118   1x
33   Reply ALN L01 N08    119   1x




34   Reply ALN L01 N09    120   1x




35   Reply ALN L01 N010   121   1x
36   Reply ALN L01 N011   122   1x




37   Reply ALN L01 N012   123   1x




38   Reply ALN L01 N013   124   1x
39   Reply ALN L01 N014   125   1x




40   Reply ALN L01 N015   126   1x




41   Reply ALN L01 N016   127   1x
42   Reply ALN L01 N017   128   1x
43   Reply ALN L01 N018   129   1x
44   Reply ALN L01 N019   130   1x




45   Reply ALN L01 N020   131   1x




46   Reply ALN L01 N021   132   1x
47   Reply ALN L01 N022   133   1x
48   Reply ALN L01 N023   134   1x
49   Reply ALN L01 N024   135   1x
50   Reply ALN L05 N01    136   5x



51   Reply ALN L05 N02    141   5x



52   Reply ALN L05 N03    146   5x
53   Reply ALN L08 N01    151   8x



54   Reply ALN L08 N02    159   8x
55   Reply ALN L08 N03   167   8x



56   Reply ALN L08 N04   175   8x



57   Reply ALN L20 N01   183   20x




58   Reply ALN L60 N01   203   60x




59   Reply NUM L01 N01   263   1x
60   Reply NUM L01 N02   264   1x
61   Reply NUM L01 N03   265   1x
62   Reply NUM L04 N01   266   n(4)
63   Reply NUM L04 N02   270   n(4)
64   Reply NUM L04 N03   274   n(4)
65   Reply NUM L04 N04   278   n(4)
66   Reply NUM L04 N05   282   n(4)
67   Reply NUM L04 N06   286   n(4)




68   Reply NUM L04 N07   290   n(4)
                         69                                Reply PCT L04 N01        294   n(3)v9




                         70                                Reply PCT L04 N02        298   n(3)v9




                         71                                Reply PCT L04 N03        302   n(3)v9




                         72                                Filler - National        306   15x
Record type:   GX0
Medical Necessity    Oxygen   –   Oxygen   Certification
Segment
                       Field #                             Field Name               Start Length


                         1                                 Record ID "GX0"          1     3x




                         2                                 Sequence Number          4     2x



                         3                                 Patient Control Number   6     17x
4    Certification Type        23    1x




5    Oxygen System             24    1x




 6   Length of Need            25    2x
 7   Equipment Type 1          27    1x
 8   Equipment Type 2          28    1x
 9   Equipment Reason          29    64x
10   Prescribed From Date      93    8x


11   Prescribed To Date        101   8x


12   Date Prescribed           109   8x
13   Date Evaluated            117   8x
14   Oxygen Flow Rate          125   3x

15   Frequency of Use          128   2x
16   Duration                  130   2x
17   Arterial Blood Gas 4LPM   132   n(2)v9
18   Oximetry 4LPM             135   n(2)v9
19   Date Tested 4LPM            138   8x

20   Inpatient/Outpatient Ind    146   1x
21   Filler                      147   65x
22   Arterial Blood Gas          212   n(2)v9
23   Oximetry                    215   n(2)v9
24   Date Tested                 218   8x




25   Entity Perf Oximetry Test   226   33x

26   Test Conditions             259   1x




27   Clinical Findings           260   3x




28   Port Oxygen Flow Rate       263   3x
29   Ordering Provider ID        266   15x
30   Ordering Provider Phone     281   10x

31   Diagnosis Code 1            291   5x
32   Diagnosis Code 2            296   5x
33   Diagnosis Code 3            301   5x
34   Diagnosis Code 4            306   5x
35   Certification On File       311   1x
                           36                          Delivery System Type         312   1x
                           37                          Filler - National            313   8x
Record type:   GX1
Narrative Info For Oxygen – Oxygen Narrative Segment

                        Field #                        Field Name                   Start Length


                           1                           Record ID "GX1"              1     3x



                           2                           Sequence Number              4     2x
                           3                           Patient Control Number       6     17x
                           4                           Test Results                 23    90x
                           5                           Medical Findings             113   90x
                           6                           Exercise Routine             203   90x
                           7                           Filler - National            293   28x
Record type:   GX2
Facility Info For Oxygen – Oxygen Facility Segment

                        Field #                        Field Name                   Start Length


                           1                           Record ID "GX2"              1     3x



                           2                           Sequence Number              4     2x
                           3                           Patient Control Number       6     17x
                           4                           Test Facility Address 1      23    30x
                           5                           Test Facility Address 2      53    30x
                           6                           Test Facility City           83    20x
                           7                           Test Facility State          103   2x

                           8                           Test Facility Zip            105   9x

                            9                          Patient Facility Name        114   33x
                           10                          Patient Facility Address 1   147   30x
                           11                          Patient Facility Address 2   177   30x
                           12                          Patient Facility City        207   20x
                           13                          Patient Facility State       227   2x
                           14                          Patient Facility Zip         229   9x
                           15                          Filler - National            238   83x
Record type:   HA0
Narrative Record
                       Field #   Field Name               Start Length


                          1      Record ID "HA0"          1    3x




                          2      Sequence No              4    2x




                          3      Patient Control Number   6    17x




                          4      Line Item Control No     23   17x




                          5      Extra Narrative Data     40   281x
Record type:   XA0
Claim Trailer Record – Summary

                       Field #   Field Name               Start Length


                          1      Record ID “XA0”          1    3x
2   Reserved (XA0.02)        4    2x

3   Patient Control Number   6    17x




4   Record CXX Count         23   2x




5   Record DXX Count         25   2x




6   Record EXX Count         27   2x




7   Record FXX Count         29   2x




8   Record GXX Count         31   2x
9    Record HXX Count                 33    2x




10   Claim Record Count               35    3x




11   Reserved (XA0.11)                38    40x

12   Total Claim Charges              78    n(5)v99




13   Tot Disallowed Cost Containment 85     n(5)v99


14   Total Disallowed Other Charges   92    n(5)v99


15   Total Allowed Amount             99    n(5)v99


16   Total Deductible Amount          106   n(5)v99


17   Total Coinsurance Amount         113   n(5)v99


18   Total Payor Amount Paid          120
                                            n(5)v99

19   Patient Amount Paid              127
                                            n(5)v99




20   Total Purchase Service Charges   134   n(5)v99
                         21      Provider Discount Information   141   16x

                         22      Remarks                         157   103x
                         23      Filler - National               260   61x




Record type:   YA0
Batch Trailer Record

                       Field #   Field Name                      Start Length


                         1       Record ID “YA0”                 1     3x




                         2       EMC Provider ID                 4     15x




                         3       Batch Type                      19    3x




                         4       Batch Number                    22    4x




                         5       Batch ID                        26    6x




                         6       Provider Tax ID                 32    9x




                         7       Reserved (YA0.07)               41    6x
                        8       Batch Service Line Count   47   7x




                        9       Batch Record Count         54   7x




                        10      Batch Claim Count          61   7x




                        11      Batch Total Charges        68   n(7)v99




                        12      Filler - National          77   244x




Record type:   ZA0
File Trailer Record

                      Field #   Field Name                 Start Length


                        1       Record ID “ZA0”            1    3x
2   Submitter ID              4    16x




3   Reserved (ZA0.03)         20   9x

4   Receiver ID               29   16x




5   File Service Line Count   45   7x




6   File Record Count         52   7x




7   File Claim Count          59   7x




8   Batch Count               66   4x
9    File Total Charges          70    n(9)v99




10   File Total Paid Amount      81    n(9)v99
11   File Total Allowed Amount   92    n(9)v99
12   Filler - National           103   218x
                       Required Record

NSF Required   Comments and Values         HIPAA      Notes
Professional

R              Value: AA0   Next record:              Exact Match
               BA0

R              Mapped to NM109 1000A Required         Exact Match
               (NM101=41, NM108=46)

                                                      Exact Match
                                                      Exact Match
S              Mapped to BHT03             Required   Exact Match


S              Mapped to NM103 1000A Required         Exact Match
               (NM101=41,    NM102=2)
               Mapped to PER02 1000A
                                                      Exact Match

                                                      Exact Match




                                                      Exact Match




                                                      Exact Match



                                                      Exact Match




                                                      Exact Match
S   Mapped to PER02 1000A Required   Exact Match
    (PER01=IC, NM101=41)




S   Mapped to PER04 1000A Required   Exact Match
    (PER03=TE, NM101=41)




S   Mapped to BHT04       Required   Exact Match




S   Mapped to BHT05       Required   Exact Match




S   Mapped to NM109 1000B Required   Exact Match
    (NM101=40, NM108=46)




                                     Exact Match




R   301                              Exact Match
                                                    Exact Match



                                                    Exact Match




                                                    Exact Match
S              Original 0 = 00 Non- Required        Exact Match
               Chargeable Retrans 8 = 18
               Chargeable Retrans 9 = 18
               Please note if a blank is
               received nothing will be
               mapped to BHT02 and will
               fail HIPAA
               Mapped to BHT02
               Values are validated in the
               NSF map

                                                    NSF 1.03 NOT MAPPED
                                                    NSF 1.03 NOT MAPPED


                                                    NSF 1.03 NOT MAPPED
                                                    NSF 1.03 NOT MAPPED
               NOT MAPPED                           NOT MAPPED
               NOT MAPPED                           NOT MAPPED
               NOT MAPPED valid date
               Field must be a                      NOT MAPPED
               Field must be a valid date
               must be 8 numerics. Zeros
               and '0000' for the year is
               valid.
               NOT MAPPED                           NOT MAPPED
               NOT MAPPED                           NOT MAPPED
               Field MAPPED valid date
               NOT must be a                        NOT MAPPED
                                                    This field was combined with
                                                    field 33 Filler - National


                         Required Record

NSF Required   Comments and Values          HIPAA   Notes
Professional

R              Value: BA0 Preceded by:              Exact Match
                                        Exact Match

R   100 = All Others 200 =              Exact Match
    Dental
                                        Exact Match
                                        Exact Match
S   If BA0-09 is not present,           Exact Match
    map to NM109 2010AA
    (NM101=85,
    NM108=BA0.08);
    otherwise, map to REF02
    2010AA        (REF01=EI,
    NM101=85)
                                        Exact Match

S   Values: NSF = HIPAA-X12             Exact Match
    v 4010      Employer ID
    Number E = 24 Social
    Security Number S = 34
    Corporate Name, but SSN
    X = 34 Mapped to NM108
    2010AA         (NM101=85)
    Values are validated in the
    NSF map
S   Mapped to NM109 2010AA Required     Exact Match
    (NM101=85, NM108=XX)

S   Mapped to REF02 2010AA Situational Exact Match
    (REF01=1G, NM101=85)

                                        Exact Match

S   Mapped to REF02 2010AA Situational Exact Match
    (REF01=1D, M101=85)

S   Mapped to REF02 2010AA Situational Exact Match
S   Mapped to REF02 2010AA Situational Exact Match
    (REF01=1B, NM101=85)

S   Mapped to REF02 2010AA Situational Exact Match
    (REF01=G2, NM101=85)

                                        Exact Match
                                        Exact Match
S   Either BA0-18 or BA0-19 Situational Exact Match
    must be present. If both
    are present, a failure will
    occur. Mapped to NM103
    2010AA        (NM101=85,
    NM102=2)
S              Either BA0-18 or BA0-19 Situational Exact Match
               must be present. If both
               are present, a failure will
               occur. Mapped to NM103
               2010AA         (NM101=85,
               NM102=1)
S              Mapped to NM104 2010AA Situational Exact Match
               (NM101=85); required if
               BA0-19 is present




S              Mapped to NM105 2010AA Situational Exact Match
               (NM101=85)


                                                   Exact Match
                                                   Exact Match

S              Mapped to REF02 2010AA Situational Exact Match
               (REF01=0B, NM101=85)

                                                   Exact Match

                                                   Exact Match

               NOT MAPPED                          NOT MAPPED
               NOT MAPPED                          NOT MAPPED

                                                   This field was combined with
                                                   field 28 Filler - National


                        Required Record

NSF Required   Comments and Values         HIPAA   Notes
Professional

R              Value: BA1 Preceded by:             Exact Match
               BA0 Next record type: CA0
               One BA1 record per batch.


                                                   Exact Match
                                        Exact Match




                                        Exact Match




                                        Exact Match




                                        Exact Match
S   If BA1.07 is present, then Required Exact Match
    BA1.08 – BA1.11 will be
    mapped. Mapped to N301
    2010AA (NM101=85)
S   Mapped to N302 2010AA Situational Exact Match
    (NM101=85)
S   Mapped to N401 2010AA Required Exact Match
    (NM101=85)

S   Mapped to N402 2010AA Required      Exact Match
    (NM101=85)

S   Mapped to N403 2010AA Required      Exact Match
    (NM101=85)

S   Mapped to PER04 2010AA Situational Exact Match
    (NM101=85)

S                                       Exact Match


S   Mapped to N302 2010AA Situational Exact Match
    (NM101=85)
S   Mapped to N401 2010AA Required Exact Match
    (NM101=85)

S   Mapped to N402 2010AA Required      Exact Match
    (NM101=85)

S   Mapped to N403 2010AA Required      Exact Match
    (NM101=85)
S              Map to PER04 2010AA Situational Exact Match
               (NM101=85)
                                               NSF 1.03 BA1 Field 19
                                               len=42, Field 20 len=42
                                               This field was combined with
                                               field 19 Filler - National


                        Required Record

NSF Required   Comments and Values       HIPAA      Notes
Professional

R              Value: CA0 Preceded by:              Exact Match
               BA0, BA1, or XA0 Next
               record: CA1, CB0 or DA0
               One per claim.

                                                    Exact Match

R              Mapped to CLM01 2300      Required   Exact Match

S              Mapped to NM103 2010BA Required Exact Match
               (NM101=IL, NM102=1), if Situational
               patient is the subscriber
               Mapped to NM103 2010CA
               (NM101=QC, NM102=1) if
               patient is the dependent

S              Mapped to NM104 2010BA Situational Exact Match
               (NM101=IL) if patient is the
               subscriber    Mapped      to
               NM104              2010CA
               (NM101=QC) if patient is
               the dependent
S              Mapped to NM105 2010BA Situational Exact Match
               (NM101=IL) if patient is the
               subscriber    Mapped      to
               NM105              2010CA
               (NM101=QC) if patient is
               the dependent
S              Mapped to NM107 2010BA Situational Exact Match
               (NM101=IL) if patient is the
               subscriber    Mapped      to
               NM107              2010CA
               (NM101=QC) if patient is
               the dependent
S   Mapped to DMG02 2010BA Required Exact Match
    (NM101=IL) if patient is the Situational
    subscriber    Mapped      to
    DMG02              2010CA
    (NM101=QC) if patient is
    the dependent Mapped to
    DMG03              2010CA
    (NM101=QC) if patient is
    the dependent


S   Values: NSF = HIPAA-X12                 Exact Match
    v 4010 Female F = F Male
    M = M Mapped to DMG03
    2010BA       (NM101=IL)   if
    patient is the subscriber

                                            Exact Match

S   Mapped to N301 2010BA          Required Exact Match
    (NM101=IL) if patient is the   Situational
    subscriber    Mapped      to
    N301               2010CA
    (NM101=QC) if patient is
    the dependent
S   Mapped to N302 2010BA          Required Exact Match
    (NM101=IL) if patient is the   Situational
    subscriber    Mapped      to
    N302               2010CA
    (NM101=QC) if patient is
    the dependent
S   Mapped to N401 2010BA          Required Exact Match
    (NM101=IL) if patient is the   Situational
    subscriber    Mapped      to
    N401               2010CA
    (NM101=QC) if patient is
    the dependent
S   Mapped to N402 2010BA          Required Exact Match
    (NM101=IL) if patient is the   Situational
    subscriber    Mapped      to
    N402               2010CA
    (NM101=QC) if patient is
    the dependent
S   Mapped to N403 2010BA          Required Exact Match
    (NM101=IL) if patient is the   Situational
    subscriber    Mapped      to
    N403               2010CA
    (NM101=QC) if patient is
    the dependent
                                            Exact Match
                                      Exact Match




                                      Exact Match


                                      Exact Match




                                      Exact Match




S   Mapped to PAT06 2000B Situational Exact Match
    (NM101=IL) if patient is the
    subscriber    Mapped      to
    PAT06                2000C
    (NM101=QC) if patient is
    the dependent




                                      Exact Match




                                      Exact Match
                                                    Exact Match




S              Values: NSF = HIPAA-X12 Situational Exact Match
               v 4010 Y = QD           N =
               Mapped to NM101 2010BC
               If NSF value is blank or “N”,
               NM1 will not be created
               Values are validated in the
               NSF map
                                                   Exact Match
                                                   Exact Match

                                                    Exact Match
                                                    Exact Match
                                                    NSF 1.03 CA0 Field 30
                                                    len=20, Field 31 len=67
                                                    This field was combined with
                                                    field 30 Filler - National


                        Required Record

NSF Required   Comments and Values       HIPAA      Notes
Professional

               Value: CB0 Preceded by:              Exact Match
               CA0 or CA1 Next record:
               DA0
                                                    Exact Match

                                         Situational Exact Match
               Mapped to NM103 2010BC Situational Exact Match
               (NM101=QD, NM102=1)

               Mapped to NM104 2010BC Situational Exact Match
               (NM101=QD)


               Mapped to NM105 2010BC Situational Exact Match
               (NM101=QD)
               Mapped to N301 2010BC Situational Exact Match
               (NM101=QD)


               Mapped to N302 2010BC Situational Exact Match
               (NM101=QD)




               Mapped to N401 2010BC Situational Exact Match
               (NM101=QD)



               Mapped to N402 2010BC Situational Exact Match
               (NM101=QD)



               Mapped to N403 2010BC              Exact Match
               (NM101=QD)



                                                  Exact Match




                                                  NSF 1.03 CB0 Field 13
                                                  len=82, Field 14 len=82



                                                  This field was combined with
                                                  field 13 Filler - National




                        Required Record

NSF Required   Comments and Values     HIPAA      Notes
Professional
R   Value: DA0                         Exact Match
    Preceded by: CA0, CB0,
    DA0, DA1, DA2 or DA3
    Next record: DA0, DA1,
    DA2, DA3 or EA0
R   Values:                 Required   Exact Match
    NSF =       HIPAA-X12 v
    4010

    Primary Payer 01 = P
    Secondary Payer 02 = S
    Tertiary Payer 03 = T
    DA0 Sequence 01 mapped
    to SBR01=P 2000B
    DA0 Sequence 02 mapped
    to SBR01=S 2320
    DA0 Sequence 03 mapped
    to SBR01=T 2320
    Values are validated in the
    NSF map



                                       Exact Match




                                       Exact Match




R   Values: NSF = HIPAA-X12 Required   Exact Match
    v 4010

    Self Pay A = 09
    Values: NSF = HIPAA-X12            Exact Match
    v 4010

    Self Pay A = 09
S   Values: NSF = HIPAA-X12 Situational Exact Match
    v 4010

    Medigap Policy MG = MG
    Supplemental Policy SP =
    SP
    Individual Policy IP = IP
    Personal Payment PP = PP
    Group Policy GP = GP
    Litigation LT = LT
    Auto Insurance Policy AP =
    AP
    Long Term Policy LT = LT
    Other OT = OT

    Mapped to SBR05 2320
    (SBR01=S)
    Mapped to SBR05 2320
    (SBR01=T)

    DA0 Sequence 01 mapped Required     Exact Match
    to    NM109     2010BB
    (NM101=PR,    NM108=PI,
    SBR01=P 2000B) DA0
    Sequence 02 mapped to
    NM109            2330B
    (NM101=PR,    NM108=PI,
    SBR01=S 2320)
    DA0 Sequence 03 mapped
    to    NM109      2330B
    (NM101=PR,    NM108=PI,
    SBR01=T 2320




S   DA0 Sequence 01 mapped Situational Exact Match
    to    REF02     2010BB
    (REF01=FY, NM101=PR,
    SBR01=P 2000B)



R   DA0 Sequence 01 mapped Required     Exact Match
    to     NM103     2010BB
    (NM101=PR,     SBR01=P
    2000B)              DA0
    Sequence 02 mapped to
    NM103             2330B
    (NM101=PR,     SBR01=S
    2320)
    DA0 Sequence 03 mapped
S   DA0 Sequence 01 mapped Situational Exact Match
    to       SBR03        2000B
    (SBR01=P)
    DA0 Sequence 02 mapped
S   to SBR03 2320 (SBR01=S) Situational Exact Match
    DA0 Sequence 01 mapped
    to       SBR04        2000B
    (SBR01=P)
    DA0 Sequence 02 mapped
    to SBR04 2320 (SBR01=S)
    DA0 Sequence 03 mapped
                                            Exact Match
                                            Exact Match
S   Mapped to REF02 2300        Situational Exact Match
S   Values: NSF = HIPAA-X12 Required Exact Match
S   Values:                     Situational Exact Match
S   Values:                     Required Exact Match
    NSF          =       HIPAA-
    X12 v 4010
    Patient is insured
S   DA0 Sequence 01 mapped Required Exact Match
    to      NM109       2010BA
    (NM101=IL,         SBR01=P
    2000B) if patient is the
    subscriber
S   DA0 Sequence 01 mapped Required Exact Match
    to      NM103       2010BA
    (NM101=IL)
    If patient is the dependent
    DA0 Sequence 02 mapped
    to       NM103        2330A
    (NM101=IL,         SBR01=S
    2320)
    DA0 Sequence 03 mapped
    to       NM103        2330A
    (NM101=IL,         SBR01=T
    2320)




S   DA0 Sequence 01 mapped     Situational Exact Match
    to NM104 2010BA,
S   DA0 Sequence 01 mapped     Situational Exact Match
    to NM105 2010BA
S   DA0 Sequence 01 mapped     Situational Exact Match
    to NM107 2010BA
S   Values: NSF = HIPAA-X12    Required Exact Match
S   DA0 Sequence 01 mapped     Situational Exact Match
                                                        Exact Match


                                                        Exact Match




                                                        Exact Match




                                                   NSF 1.03 NOT MAPPED
                                                   NOT MAPPED
S              Values: NSF = HIPAA-X12 Situational NOT MAPPED
               v 4010
                                                   NOT MAPPED

                                                        NOT MAPPED

                                                        This field was combined with
                                                        1.03 fields 29 & 30 Filler -


                         Required Record

NSF Required   Comments and Values           HIPAA      Notes
Professional

R              Value: DA1                               Exact Match
               Preceded by: DA0
               Next record: DA0, DA2 or
               EA0

S              Values:                       Situational Exact Match
               NSF =        HIPAA-X12 v
               4010

               Primary Payer 01 = P
               Secondary Payer 02 = S
               Tertiary Payer 03 =      T
               Values are validated in the
               NSF map

                                                        Exact Match
S   DA1 Sequence 01 mapped            Situational Exact Match
    to       N301        2010BB
    (NM101=PR,         SBR01=P
    2000B)
S   DA1 Sequence 01 mapped            Situational   Exact Match
S   DA1 Sequence 01 mapped            Situational   Exact Match
S   DA1 Sequence 01 mapped            Situational   Exact Match
S   DA1 Sequence 01 mapped            Situational   Exact Match
    to       N403        2010BB
    (NM101=PR,         SBR01=P
    2000B)
    If any of the following fields                  Exact Match
    are greater than 0, the sum
    of DA1.09 and DA1.10 and
    DA1.11 and DA1.33 and
    DA3.25 and DA3.26 will be
    mapped to the following
    with A2 as the Adjustment
    Reason Code:
    DA1 Sequence 02 mapped
    to CAS03 2320 (SBR01=S)
    DA1 Sequence 03 mapped
    to CAS03 2320 (SBR01=T)



     If any of the following fields                 Exact Match
    are greater than 0, the sum
    of DA1.09 and DA1.10 and
    DA1.11 and DA1.33 and
    DA3.25 and DA3.26 will be
    mapped to the following
    with A2 as the Adjustment
    Reason Code:
    DA1 Sequence 02 mapped
    to CAS03 or CAS06 2320
    (SBR01=S)
    DA1 Sequence 03 mapped
    to CAS03 or CAS06 2320
    (SBR01=T)
 If any of the following fields   Exact Match
are greater than 0, the sum
of DA1.09 and DA1.10 and
DA1.11 and DA1.33 and
DA3.25 and DA3.26 will be
mapped to the following
with A2 as the Adjustment
Reason Code:
DA1 Sequence 02 mapped
to CAS03, CAS06, or
CAS09 2320 (SBR01=S)
DA1 Sequence 03 mapped
to CAS03, CAS06, or
CAS09 2320 (SBR01=T)



  Will be mapped to the           Exact Match
following with 1 as the
Adjustment Reason Code:
DA1 Sequence 02 mapped
to CAS03, CAS06, CAS09,
or CAS12 2320 (SBR01=S)
DA1 Sequence 03 mapped
to CAS03, CAS06, CAS09,
or CAS12 2320 (SBR01=T)



  Will be mapped to the           Exact Match
following with 2 as the
Adjustment Reason Code:
DA1 Sequence 02 mapped
to CAS03 2320 (SBR01=S)
DA1 Sequence 03 mapped
to CAS03 2320 (SBR01=T)



                                  Exact Match



                                  Exact Match
                                  Exact Match

                                  Exact Match
                                  Exact Match
                                  Exact Match
                                  Exact Match
                                  Exact Match
                            Exact Match




                            Exact Match




                            Exact Match




                            NOT MAPPED

                            NOT MAPPED

 DA1 Sequence 02 mapped     NOT MAPPED
to     DTP03      2330B
(DTP01=573, NM101=PR)
DA1 Sequence 03 mapped
to     DTP03      2330B
(DTP01=573, NM101=PR)
                            NOT MAPPED
                            NOT MAPPED
Will be mapped to the       NOT MAPPED
following with 100 as the
Adjustment Reason Code:
DA1 Sequence 02 mapped
to CAS03 2320 (SBR01=S)
DA1 Sequence 03 mapped
to CAS03 2320 (SBR01=T)



                            NOT MAPPED
                            NOT MAPPED
                If any of the following fields           NOT MAPPED
               are greater than 0, the sum
               of DA1.09 and DA1.10 and
               DA1.11 and DA1.33 and
               DA3.25 and DA3.26 will be
               mapped to the following
               with A2 as the Adjustment
               Reason Code:
               DA1 Sequence 02 mapped
               to CAS03 or CAS06 2320
               (SBR01=S)
               DA1 Sequence 03 mapped
               to CAS03 or CAS06 2320
               (SBR01=T)

                                                         NOT MAPPED
                                                         NOT MAPPED
                                                         NOT MAPPED
                DA1 Sequence 02 mapped                   NOT MAPPED
               to     AMT02       2320
               (AMT01=AAE, SBR01=S)
               DA1 Sequence 03 mapped
               to     AMT02       2320
               (AMT01=AAE, SBR01=T)
                                                         NOT MAPPED
                                                         NOT MAPPED
                                                         This field was combined with


                           Required Record

NSF Required   Comments and Values               HIPAA   Notes
Professional

R              Value: DA2                               Exact Match
S              Values:                      Situational Exact Match
                                                        Exact Match
S              DA2 Sequence 01 mapped Situational Exact Match
S              DA2 Sequence 01 mapped Situational Exact Match
               to     N302        2010BA
               (NM101=IL) if patient is the
               dependent
               DA2 Sequence 02 mapped
               to N302 2330A (NM101=IL,
               SBR01=S)
               DA 2 Sequence 03 mapped
               to      N302         2330A
               (NM101=IL, SBR01=T)
S   DA2 Sequence 01 mapped Situational Exact Match
    to     N401        2010BA
    (NM101=IL) if patient is the
    dependent
    DA2 Sequence 02 mapped
    to N401 2330A (NM101=IL,
    SBR01=S)
    DA2 Sequence 03 mapped
    to      N401         2330A
    (NM101=IL, SBR01=T)



S   DA2 Sequence 01 mapped Situational Exact Match
S   DA2 Sequence 01 mapped Situational Exact Match
    to     N403        2010BA
    (NM101=IL) if patient is the
    dependent
    DA2 Sequence 02 mapped
    to N403 2330A (NM101=IL,
    SBR01=S)
    DA2 Sequence 03 mapped
    to      N403         2330A
    (NM101=ILSBR01=T)



                                       Exact Match
                                       Exact Match




                                       Exact Match




                                       Exact Match

                                       Exact Match
                                            Exact Match

                                            Exact Match
                                            Exact Match
                                            Exact Match

                                            NOT MAPPED
                                            This field was combined with
                                            field 19 Filler - National

R   Value: DA3                                NSF 1.03 NOT MAPPED
S   Values:                       Situational NSF 1.03 NOT MAPPED
    NSF =        HIPAA-X12 v
    4010

    Primary Payer 01 = P
    Secondary Payer 02 = S
    Tertiary Payer 03 = T
    Values are validated in the
    NSF map
                                            NSF 1.03 NOT MAPPED
    DA3 Sequence 02 mapped                  NSF 1.03 NOT MAPPED
    to CAS02 2320 (SBR01=S)
    DA3 Sequence 03 mapped
    to CAS02 2320 (SBR01=T)


    DA3 Sequence 02 mapped                  NSF 1.03 NOT MAPPED
    to CAS03 2320 (SBR01=S)
    DA3 Sequence 03 mapped
    to CAS03 2320 (SBR01=T)


    DA3 Sequence 02 mapped                  NSF 1.03 NOT MAPPED
    DA3 Sequence 02 mapped                  NSF 1.03 NOT MAPPED
    to CAS03 or CAS06 2320
    (SBR01=S)
    DA3 Sequence 03 mapped
    to CAS03 or CAS06 2320
    (SBR01=T)
    DA3 Sequence 02 mapped                  NSF 1.03 NOT MAPPED
    DA3 Sequence 02 mapped                  NSF 1.03 NOT MAPPED
     DA3 Sequence 02 mapped                 NSF 1.03 NOT MAPPED
    to CAS02, CAS05, CAS08,
    or CAS11 2320 (SBR01=S)
    DA3 Sequence 03 mapped
    to CAS02, CAS05, CAS08,
    or CAS11 2320 (SBR01=T)
DA3 Sequence 02 mapped    NSF 1.03 NOT MAPPED
to CAS03, CAS06, CAS09,
or CAS12 2320 (SBR01=S)
DA3 Sequence 03 mapped
to CAS03, CAS06, CAS09,
or CAS12 2320 (SBR01=T)


DA3 Sequence 02 mapped    NSF 1.03 NOT MAPPED
to CAS02 2320 (SBR01=S)
DA3 Sequence 03 mapped
to CAS02 2320 (SBR01=T)


DA3 Sequence 02 mapped    NSF 1.03 NOT MAPPED
to CAS03 2320 (SBR01=S)
DA3 Sequence 03 mapped
to CAS03 2320 (SBR01=T)


DA3 Sequence 02 mapped    NSF 1.03 NOT MAPPED
DA3 Sequence 02 mapped    NSF 1.03 NOT MAPPED
to CAS03 or CAS06 2320
(SBR01=S)
DA3 Sequence 03 mapped
to CAS03 or CAS06 2320
(SBR01=T)
DA3 Sequence 02 mapped    NSF 1.03 NOT MAPPED
to CAS02, CAS05, or
CAS08 2320 (SBR01=S)
DA3 Sequence 03 mapped
to CAS02, CAS05, or
CAS08 2320 (SBR01=T)


DA3 Sequence 02 mapped    NSF 1.03 NOT MAPPED
DA3 Sequence 02 mapped    NSF 1.03 NOT MAPPED
DA3 Sequence 02 mapped    NSF 1.03 NOT MAPPED
DA3 Sequence 02 mapped    NSF 1.03 NOT MAPPED
to MOA03, MOA04, or
MOA05 2320 (SBR01=S)
DA3 Sequence 03 mapped
to MOA03, MOA04, or
MOA05 2320 (SBR01=T)


DA3 Sequence 02 mapped    NSF 1.03 NOT MAPPED
DA3 Sequence 02 mapped           NSF 1.03 NOT MAPPED
to   MOA03,     MOA04,
MOA05,    MOA06,     or
MOA07 2320 (SBR01=S)
DA3 Sequence 03 mapped
to   MOA03,     MOA04,
MOA05,    MOA06,     or
MOA07 2320 (SBR01=T)


                                 NSF 1.03 NOT MAPPED
 Values: NSF = HIPAA-X12         NSF 1.03 NOT MAPPED
v 4010

Adjustment to Prior Claim Y
=Y
Not an adjustment to a prior
claim Blank = Not mapped

DA3 Sequence 02 mapped
to     REF02        2330B
(REF01=T4, NM101=PR,
SBR01=S)
DA3 Sequence 03 mapped
to     REF02        2330B
(REF01=T4, NM101=PR,
SBR01=T)
Values are validated in the
NSF map

If any of the following fields   NSF 1.03 NOT MAPPED
are greater than 0, the sum
of DA1.09 and DA1.10 and
DA1.11 and DA1.33 and
DA3.25 and DA3.26 will be
mapped to the following
with A2 as the Adjustment
Reason Code:
DA3 Sequence 02 mapped
to CAS03, CAS06, or
CAS09 2320 (SBR01=S)
DA3 Sequence 03 mapped
to CAS03, CAS06, or
CAS09 2320 (SBR01=T)
                If any of the following fields           NSF 1.03 NOT MAPPED
               are greater than 0, the sum
               of DA1.09 and DA1.10 and
               DA1.11 and DA1.33 and
               DA3.25 and DA3.26 will be
               mapped to the following
               with A2 as the Adjustment
               Reason Code:
               DA3 Sequence 02 mapped
               to CAS03, CAS06, CAS09,
               or CAS12 2320 (SBR01=S)
               DA3 Sequence 03 mapped
               to CAS03, CAS06, CAS09,
               or CAS12 2320 (SBR01=T)



                                                         NSF 1.03 NOT MAPPED
                                                         NSF 1.03 NOT MAPPED
                                                         NSF 1.03 NOT MAPPED
                                                         NSF 1.03 NOT MAPPED


                           Required Record

NSF Required   Comments and Values               HIPAA   Notes
Professional

R              Value: EA0                                Exact Match
               Preceded by: DA0, DA1, or                 NOT MAPPED RESERVED

                                                    Field must equal the CA0-03
                                                    value for this claim.
                                                    NOT MAPPED - DERIVED
S               Values: NSF = HIPAA-X12 Situational Exact Match
               v 4010

               Yes, employment related Y
               = EM
               No, not employment relate
               N=
               Unknown U =

               Mapped to CLM11-1 or
               CLM11-2 2300
               Values are validated in the
               NSF map
S    Values: NSF = HIPAA-X12 Situational
    v 4010

    Auto Accident A = AA
    Other, non-auto accident O
    = OA
    No accident N =

    Mapped to CLM11-1 2300
    Values are validated in the
    NSF map
S   Values:                     Situational Exact Match
    NSF     -    HIPAA-X12 v
    4010 Mapping

    No symptom date in EA0-
    07            0         -
    DTP01=439
    Date of first symptoms of
    illness       1         -
    DTP01=431
    Date         of      LMP
    2       - DTP01=484

    Must be present to map
    EA0-07, or EA0-07 and
    EA0-11
    Values are validated in the
    NSF map
S                                 Situational Exact Match
    If EA0.05 = A or O then
    must be present.
    If present, EA0-06 is
    required.

    Mapped to DTP03 2300
    (DTP01=439), DTP03 2300
    (DTP01=431), or DTP03
    2300 (DTP01=484)


                                             Exact Match
S   Values: NSF = HIPAA-X12 Situational Exact Match
    v 4010

    Accident or illness was
    caused by another party Y
    = AP
    Accident or illness was not
    caused by another party N
    =

    Mapped to CLM11-1 or
    CLM11-2 or CLM11-3 2300
    Values are validated in the
    NSF map

S   Mapped to CLM11-4 2300        Situational Exact Match
S                                 Situational Exact Match
    Field is appended to EA0-
    07 and mapped to DTP03
    (DTP01=439, DTP02=DT)
                                             Exact Match
S     Values:      NSF          = Required
    HIPAA-X12 v 4010              _______
                                  Situational
    Yes, the provider has on file
    a     signed      statement
    permitting the release of
    medical/billing information
    for purposes of claiming
    insurance benefits

    Y        =      Y
    Modified     or   Restricted
    Release, the provider has
    limited      or    restricted
    authority to release some
    medical/billing information
    for purposes of claiming
    insurance benefits.

    M        =       M
    No Release, the provider
    does not have permission
    to       release          any
    medical/billing information

    N        =      N

    Mapped to CLM09 2300
    ______________________
    ______________________
    ____________
    Mapped to OI06 2320
    (SBR01=S)                                   Exact Match
                                      Exact Match




S    Mapped to DTP03 2300 Situational Exact Match
    (DTP01=438)

                                      Exact Match


S    Mapped to DTP03 2300 Situational Exact Match
    (DTP01=360)
S   Mapped to DTP03 2300 Situational Exact Match
    (DTP01=361)




S    Mapped to NM109 2310A Situational Exact Match
    (NM101=DN)


S    Mapped to REF02 2310A Situational NOT MAPPED
    (REF01=1G, NM101=DN) if
    EA0-24 is present
                                        NOT MAPPED
S     If EA0-20 is present, Situational NOT MAPPED
    mapped to NM109 2310A
    (NM101=DN);      otherwise,
    mapped to REF02 2310A
    (REF01=EI, NM101=DN)
S    Mapped to NM103 2310A Situational
    (NM101=DN)
S    Mapped to NM104 2310A Situational
    (NM101=DN)
S    Mapped to NM105 2310A Situational
    (NM101=DN)


S    Mapped to DTP03 2300 Situational
    (DTP01=435)




S    Mapped to DTP03 2300 Situational
    (DTP01=096)
S    Mapped to AMT02 2300 Situational
    (AMT01=NE)


S    Mapped to HI01-2 2300         Situational
    (HI01-1=BK)
S   Mapped to HI02-2 2300          Situational
    (HI02-1=BF)
    EA0-32 must be present
S   Mapped to HI03-2 2300          Situational
    (HI03-1=BF)
    EA0-32 and EA0-33 must
    be present
S    Mapped to HI04-2 2300         Situational
    (HI04-1=BF)
    EA0-32, EA0-33, and EA0-
    34 must be present
S                      Values:     Required
    NSF      = HIPAA-X12 v
    4010

    Assigned A = A
    Not Assigned N = C
    Assignment accepted on
    Clinical Lab services only B
    =B
    Patient Refuses to Assign
    Benefits P = P

    Mapped to CLM07 2300
    Values are validated in the
    NSF map
S      Values:             NSF Required
    = HIPAA-X12 v 4010

    Signature of provider is on
    file         Y        = Y
    Signature of provider is not
    on file          N        =
    N

    Mapped to CLM06 2300
    Values are validated in the
    HIPAA map
S    Mapped to NM103 2310D Situational
    (NM101=FA)
S    Values: NSF = HIPAA-X12 Situational
    v 4010

    In Mail 1 = BM
    Fax 2 = FX
    On file at Provider‟s site 3 =
    AA
    On file at Payer‟s site 4 =
    Cert Record in this claim 5
    =
    Narrative Record included
    in this claim 6 =
    No documentation 9 =

    Mapped to PWK02 2300
    Value “9” will only be
    passed to the HIPAA map if
    EA0-41 contains a value.
    If this field contains value
    “9” and EA0-41 is blank, the
    PWK will not be created.
    PWK05 will contain value
    “AC” when NSF values “1”
    or “2” are used.
    PWK06 will contain value
    “NSF        INPUT       NOT
    AVAILABLE” when NSF
    values “1” or “2” are used.
    Values are validated in the
    NSF map
S    Values: NSF = HIPAA-X12 Situational
    v 4010

    DME Prescription A = B2
    Explanation of benefits
    (MSP or COB) B = EB
    Diagnostic Report C = DG
    Operative note D = OB
    PEN Certification E = CT
    Ambulance Certification F =
    CT
    Physical             Therapy
    Certification G = PZ
    Chiropractic Certification H
    = OZ
    Prosthetics/Orthotic
    Certification I = PO
    Oxygen Prescription J = B2
    Multiple      Documentation
    Items Y = OZ
    Other Z =

    Mapped to PWK01 2300
    This field must be blank if
    field EA0-40 contains NSF
    value “9”
    Values are validated in the
    NSF map
S    Values: NSF = HIPAA-X12 Situational
    v 4010

    Special Federal Funding 03
    = 03
    Disability 05 = 05
    PPV/Medicare         100%
    Payment 06 =
    Induced Abortion – Danger
    to Life 07 = 07
    Induced Abortion – Rape or
    Incest 08 = 08
    Second Opinion/Surgery 09
    = 09
    Medicare Demo Project for
    Lung Volume reduction
    Surgery Study

    30 =
    Champus          Program
    Handicapped-Patient    is
    Sponsor

    A=
    Champus          Program
    Handicapped-Patient    is
    Spouse

    B=
    Champus          Program
    Handicapped-Patient    is
    Widow of Sponsor




S    If present, 2300 CLM05-3 Situational
    will contain a „7‟ and data
    will be mapped to REF02
    2300 (REF01=F8)
S     Mapped to DTP03 2300 Situational
    (DTP01=304)
S               Values: NSF = HIPAA-X12 Situational NOT MAPPED
               v 4010

               Patient is homebound Y =
               IH
               Patient is not homebound N
               =

               Mapped to CRC02 2300
               (CRC01=75, CRC03=IH)
               Values are validated in the
               NSF map
                                                  NOT MAPPED
                                                  NOT MAPPED
S               Mapped to REF02 2310D Situational NOT MAPPED
               (REF01=N5, NM101=FA)
S               Mapped to REF02 2300 Situational NOT MAPPED
               (REF01=LX)
                                                  NOT MAPPED




                         Required Record

NSF Required   Comments and Values           HIPAA   Notes
Professional

R              Value: EA1                            Exact Match
               Preceded by: EA0
               Next record: EA2 or FA0




                                                     NOT MAPPED
                                        NOT MAPPED




S   Mapped to NM109 2310D Situational Exact Match
    (NM101=FA, NM108=XX)
                                      NOT MAPPED

S   Mapped to    N301 2310D Situational Exact Match
    (NM101=FA)
S   Mapped to    N302 2310D Situational Exact Match
    (NM101=FA)
S   Mapped to    N401 2310D Situational Exact Match
    (NM101=FA)
S   Mapped to    N402 2310D Situational Exact Match
    (NM101=FA)
S   Mapped to    N403 2310D Situational Exact Match
    (NM101=FA)
                                        Exact Match

S   Mapped to DTP03 2300 Situational Exact Match
    (DTP01=296)




                                        Exact Match
                                       Exact Match




                                       Exact Match




S   Mapped to NM109 2310E Situational Exact Match
    (NM101=DQ, NM108=XX)
                                      NOT MAPPED

S   Mapped to NM103 2310E Situational Exact Match
    (NM101=DQ)
    Required if EA1-19 is
    present
S   Mapped to NM104 2310E Situational Exact Match
    (NM101=DQ)
    Required if EA1-18 is
    present
S    Mapped to NM105 2310E Situational Exact Match
    (NM101=DQ)
                                       Exact Match

                                      Exact Match
                                      Exact Match
                                      Exact Match
S    Mapped to DTP03 2300 Situational NOT MAPPED
    (DTP01=090)
                                      NOT MAPPED
                                      NOT MAPPED
                                      NOT MAPPED
                                      NOT MAPPED
                                      NOT MAPPED
               No Mappings For HIPAA-X12 v 4010

NSF Required   Comments and Values       HIPAA    Notes
Professional

               Value: EA2
               Preceded by: EA0 or EA1
               Next record: FA0

                                                  NOT MAPPED
                                                  NOT MAPPED
                                                  NOT MAPPED
                                                  NOT MAPPED
                                                  NOT MAPPED
                                                  NOT MAPPED
                                                  NOT MAPPED
                                                  NOT MAPPED
                                                  NOT MAPPED
                                                  NOT MAPPED
                                                  NOT MAPPED
                                                  NOT MAPPED
                                                  NOT MAPPED
                                                  NOT MAPPED
                                                  NOT MAPPED
                                                  NOT MAPPED
                                                  NOT MAPPED
                                                  NOT MAPPED
                                                  NOT MAPPED
                                                  NOT MAPPED
                                                  NOT MAPPED
                                                  NOT MAPPED
                                                  NOT MAPPED
                                                  NOT MAPPED
                                                  NOT MAPPED
                                                  NOT MAPPED
                                                  NOT MAPPED
                                                  NOT MAPPED
                                                  NOT MAPPED
                                                  NOT MAPPED
                                                  NOT MAPPED
                                                  NOT MAPPED
                                                  NOT MAPPED
                                                  NOT MAPPED
                                                  NOT MAPPED
                                                  NOT MAPPED
                                                  NOT MAPPED
                                                  NOT MAPPED
                                                  NOT MAPPED
                                                  NOT MAPPED
                                                  NOT MAPPED
                                                  NOT MAPPED
                                                  NOT MAPPED
NOT MAPPED
NOT MAPPED
NOT MAPPED
NOT MAPPED
NOT MAPPED
NOT MAPPED
NOT MAPPED
NOT MAPPED
NOT MAPPED
NOT MAPPED
NOT MAPPED
NOT MAPPED
NOT MAPPED
NOT MAPPED
NOT MAPPED
NOT MAPPED
NOT MAPPED
NOT MAPPED
NOT MAPPED
NOT MAPPED
NOT MAPPED
NOT MAPPED
NOT MAPPED
NOT MAPPED
NOT MAPPED
NOT MAPPED
NOT MAPPED
NOT MAPPED
NOT MAPPED
NOT MAPPED
NOT MAPPED
NOT MAPPED
NOT MAPPED
NOT MAPPED
NOT MAPPED
NOT MAPPED
NOT MAPPED
NOT MAPPED
NOT MAPPED
NOT MAPPED
NOT MAPPED
NOT MAPPED
NOT MAPPED
NOT MAPPED
NOT MAPPED
NOT MAPPED
NOT MAPPED
NOT MAPPED
NOT MAPPED
NOT MAPPED
                         Required Record

NSF Required   Comments and Values           HIPAA   Notes
Professional

R              Value: FA0                            EXACT MATCH
               Preceded by: EA0, EA1,
               EA2, FA0, FB0, FB1, FB2,
               FB3, FD0, Cert records or
               HA0
               Next record: FB0, FB1,
               FB2, FB3, FD0, FE0, Cert
               records, HA0 or XA0
               Each claim must have at
               least one FA0 record.
               There may be as many as
               99 Fxx records for a claim.

R                Must be present      and            EXACT MATCH
               numeric (00 - 99)




                                                     NOT MAPPED - DERIVED




S               Mapped to REF02 2400 Situational EXACT MATCH
               (REF01=6R)
S    Mapped to DTP03 2400 Required   EXACT MATCH
    (DTP01=472)
S   Mapped to DTP03 2400 Situational EXACT MATCH
    (DTP01=472)
    If present, a hyphen and
    this value are concatenated
    to the value in FA0-05 to
    form the DTP03 2400




S   Mapped to CLM05-1 2300, Required       EXACT MATCH
    first detail
    Mapped to SV105 2400,
    additional detail; mapped if
    not equal to the value in
    CLM05-1 2300
    Valid Values can be found
    at:
    www.hcfa.gov/medicare/po
    scode.htm
                                           EXACT MATCH


S   Mapped to SV101-2 2400   Required      EXACT MATCH
S   Mapped to SV101-3 2400   Situational   EXACT MATCH
S   Mapped to SV101-4 2400   Situational   EXACT MATCH
S   Mapped to SV101-5 2400   Situational   EXACT MATCH
S   Mapped to SV102 2400     Required      EXACT MATCH
S   Mapped to SV107-1 2400        Situational EXACT MATCH




S   Mapped to SV107-2 2400        Situational   EXACT MATCH
S   Mapped to SV107-3 2400        Situational   EXACT MATCH
S   Mapped to SV107-4 2400        Situational   EXACT MATCH
S   Mapped to SV104 2400          Required      EXACT MATCH




S   Mapped to SV104 2400          Required      EXACT MATCH




S    Values: NSF = HIPAA-X12 Situational EXACT MATCH
    v 4010

    Yes, emergency related Y
    =Y
    No, emergency not related
    N=

    Mapped to SV109 2400
    Values are validated in the
    HIPAA map
                                      EXACT MATCH
                                      EXACT MATCH
S   Mapped to NM109 2310B Situational EXACT MATCH
    (NM101=82, NM108=XX),
    NM1 will not map if the
    same as 2010AA
    Mapped to NM109 2420A
    (NM101=82, NM108=XX),
    NM1 will not map if the
    same as 2010AA or 2310B

S    Mapped to REF02 2420F                      EXACT MATCH
    (REF01=1G)
                                  Situational EXACT MATCH

                                  Situational EXACT MATCH
                                                 EXACT MATCH



                                                 EXACT MATCH



                                                 EXACT MATCH

                                                 EXACT MATCH

S    Mapped to REF02 2400                        EXACT MATCH
    (REF01=EW)
                                               EXACT MATCH
                                   Situational EXACT MATCH

S   Mapped to REF02 2300                         EXACT MATCH
    (REF01=X4), first detail
    Mapped to REF02 2400
    (REF01=X4),       additional
    detail; mapped if not equal
    to the value in REF02 2300




S   Mapped to SV101-6 2400         Situational

                                   Situational

S    Values: NSF = HIPAA-X12
    v 4010

S    Mapped to DTP03 2400
    (DTP01=738)
S   Mapped to MEA03 2400           Situational
S   Mapped to MEA03 2400           Situational
S   Mapped to PAT08 2000B, if      Situational
    patient is the subscriber
S   Mapped to MEA03 2400           Situational
S   Mapped to DTP03 2400           Situational
    (DTP01=739)
S    Mapped to MEA03 2400          Situational
    (MEA01=TR, MEA02=R4)
                                               Situational
                                               Situational
S                               Values:                      NOT MAPPED
               NSF        =     HIPAA-
               X12 v 4010
S               Mapped to AMT02 Loop                         NOT MAPPED
               2400 (AMT01=AAE)
                                               Required NOT MAPPED
                                               Situational NOT MAPPED
                                                           NOT MAPPED
                                                           NOT MAPPED
                                                           NOT MAPPED

S                                  Values:                   NOT MAPPED
               NSF              HIPAA-X12
               v4010                                         NOT MAPPED

                                               Situational NOT MAPPED

                                                 NOT MAPPED
                                                 NOT MAPPED
S               Mapped to REF02 2400 Situational NOT MAPPED
               (REF01=OZ)
                                                 NOT MAPPED

                                                             NOT MAPPED

                                                             NOT MAPPED

                                                             NOT MAPPED



                          Required Record

NSF Required   Comments and Values             HIPAA         Notes
Professional

R               Value: FB0                                   EXACT MATCH
               Preceded by: FA0
R              If record present, field must                 EXACT MATCH
               equal the FA0 record, field
               02 value for this service                     NOT MAPPED - DERIVED
                                     EXACT MATCH




S   Mapped to PS102 2400   Situational EXACT MATCH



                                     EXACT MATCH



                                     EXACT MATCH



                                     EXACT MATCH



S    Mapped to NM109 2420E Situational EXACT MATCH
    (NM101=DK, NM108=XX)
                                       EXACT MATCH
S   Mapped to NM109 2420B Situational EXACT MATCH
    (NM101=QB, NM108=XX)
    Mapped to PS101 2400, if
    FB0.05 is present and
    value greater than 0
                                       EXACT MATCH
                                       EXACT MATCH
                                       EXACT MATCH
                                       EXACT MATCH
                                       EXACT MATCH
                                       EXACT MATCH
                                       EXACT MATCH




                                        EXACT MATCH
                                        EXACT MATCH
S                   Values: Situational EXACT MATCH
    NSF    =     HIPAA-
S               Values: NSF = HIPAA-X12 Situational EXACT MATCH
               v 4010
S               Values: NSF = HIPAA-X12 Situational EXACT MATCH
               v 4010

               Yes,     family planning
               involved Y = Y
               No, family planning not
               involved N =

               Mapped to SV112 2400
               Values are validated in the
               HIPAA map
                                                  EXACT MATCH
                                                  EXACT MATCH
                                                  EXACT MATCH
S               Mapped to 2310C NM103 Situational EXACT MATCH
               (NM101=QB, NM102=2)
                                                  EXACT MATCH
                                                  EXACT MATCH
                                                  EXACT MATCH
                                                  EXACT MATCH
                                                  EXACT MATCH
                                                  EXACT MATCH
                                                  EXACT MATCH
                                                  NOT MAPPED




                         Required Record

NSF Required   Comments and Values           HIPAA   Notes
Professional

R              Value: FB1                            EXACT MATCH
               Preceded by: FA0 or FB0
               Next record: FA0, FB2,
               FB3, FD0, FE0, Cert
               records, HA0 or XA0

R               If record present, field             NOT MAPPED
               must equal the FA0 record,
                                                     NOT MAPPED
                                              NOT MAPPED




                                              EXACT MATCH

S   Mapped to NM103 2420E Situational EXACT MATCH
    (NM101=DK, NM102=1)
    Mapped to PER02 2420E
    (NM101=DK)
S   Mapped to NM104 2420E Situational EXACT MATCH
S   Mapped to NM105 2420E Situational EXACT MATCH
                                      EXACT MATCH

S   Mapped to NM103 2420F       Situational   EXACT MATCH
S   Mapped to NM104 2420F       Situational   EXACT MATCH
S   Mapped to NM105 2420F       Situational   EXACT MATCH
S    Mapped to REF02 2420F      Situational   EXACT MATCH
    (REF01=1G); If FA0.24 is
    present, then FB1.13 will
    override FA0.24
S   Mapped to NM103 2310B       Situational EXACT MATCH
    (NM101=82,      NM102=1);
    NM1 will not map if the
    same as 2010AA
S   Mapped to NM103 2420A
    Mapped to NM104 2310B     Situational EXACT MATCH
    (NM101=82); NM1 will not
    map if the same as 2010AA
    Mapped to NM104 2420A
S   (NM101=82);NM105 2310B Situational EXACT MATCH
    Mapped to NM1 will not
    (NM101=82); NM1 will not
    map if the same as 2010AA
    Mapped to NM105 2420A
    (NM101=82); NM1 will not
    map if the same as 2010AA             EXACT MATCH

S   Mapped to NM103 2420D       Situational   EXACT MATCH
S   Mapped to NM104 2420D       Situational   EXACT MATCH
S   Mapped to NM105 2420D       Situational   EXACT MATCH
S   Mapped to NM109 2420D       Situational   EXACT MATCH
S   Mapped to REF02 2420D       Situational   EXACT MATCH
                                              NOT MAPPED

                                              NOT MAPPED
                          Optional Record

NSF Required   Comments and Values             HIPAA         Notes
Professional

R               Value: FB2                                   NSF 1.03 NOT MAPPED
               Preceded by: FA0, FB0,
R                 If record present, field                   NSF 1.03 NOT MAPPED
               must equal the FA0 record,
               field 02 value for this
               service line.
                                                             NSF 1.03 NOT MAPPED
                                                             NSF 1.03 NOT MAPPED
                                                             NSF 1.03 NOT MAPPED
S              Mapped to N301 2420E            Situational   NSF 1.03 NOT MAPPED
S              Mapped to N302 2420E            Situational   NSF 1.03 NOT MAPPED
S              Mapped to N401 2420E            Situational   NSF 1.03 NOT MAPPED
S              Mapped to N402 2420E            Situational   NSF 1.03 NOT MAPPED
S              Mapped to N403 2420E            Situational   NSF 1.03 NOT MAPPED
                                                             NSF 1.03 NOT MAPPED
                                                             NSF 1.03 NOT MAPPED
                                                             NSF 1.03 NOT MAPPED
                                                             NSF 1.03 NOT MAPPED
                                                             NSF 1.03 NOT MAPPED
                                                             NSF 1.03 NOT MAPPED
                                                             NSF 1.03 NOT MAPPED
                                                             NSF 1.03 NOT MAPPED
                                                             NSF 1.03 NOT MAPPED
                                                             NSF 1.03 NOT MAPPED
                                                             NSF 1.03 NOT MAPPED
                                                             NSF 1.03 NOT MAPPED
                                                             NSF 1.03 NOT MAPPED


                    No Mappings For X12 v 4010

NSF Required   Comments and Values             HIPAA         Notes
Professional

                Value: FB3                                   NSF 1.03 NOT MAPPED
               Preceded by: FB2
               Next record: FA0 or XA0
               If record present, field must                 NSF 1.03 NOT MAPPED
               equal the FA0 record, field
               02 value for this service
               line.
                                                             NSF 1.03 NOT MAPPED
                                                             NSF 1.03 NOT MAPPED
                                                             NSF 1.03 NOT MAPPED
                                                             NSF 1.03 NOT MAPPED
                                                             NSF 1.03 NOT MAPPED
                                                    NSF 1.03 NOT MAPPED
                                                    NSF 1.03 NOT MAPPED
                                                    NSF 1.03 NOT MAPPED
                                                    NSF 1.03 NOT MAPPED
                                                    NSF 1.03 NOT MAPPED
                                                    NSF 1.03 NOT MAPPED
                                                    NSF 1.03 NOT MAPPED
                                                    NSF 1.03 NOT MAPPED
                                                    NSF 1.03 NOT MAPPED
                                                    NSF 1.03 NOT MAPPED
                                                    NSF 1.03 NOT MAPPED
                                                    NSF 1.03 NOT MAPPED


                   No Mappings for X12 v 4010

NSF Required   Comments and Values          HIPAA   Notes
Professional

               Value: FD0                           EXACT MATCH
               Preceded by: FA0, FB0,
               FB1, FB2, FB3 or FD0
               Next record: FE0, FA0,
               HA0 or XA0

                If record present, field            EXACT MATCH
               must equal the FA0 record,
                                                    NOT MAPPED - DERIVED




                                                    EXACT MATCH




                                                    EXACT MATCH
                                                    EXACT MATCH
                                                    EXACT MATCH
                                                    EXACT MATCH
                                                    EXACT MATCH
                                                    EXACT MATCH
                                                    EXACT MATCH
                                                    EXACT MATCH
                                                    EXACT MATCH
EXACT MATCH




EXACT MATCH




EXACT MATCH
EXACT MATCH
EXACT MATCH
EXACT MATCH




EXACT MATCH




EXACT MATCH
EXACT MATCH




EXACT MATCH
EXACT MATCH




EXACT MATCH
EXACT MATCH
EXACT MATCH
EXACT MATCH

EXACT MATCH
EXACT MATCH
EXACT MATCH
EXACT MATCH
EXACT MATCH
EXACT MATCH
EXACT MATCH
EXACT MATCH
EXACT MATCH
EXACT MATCH
EXACT MATCH
EXACT MATCH
EXACT MATCH
EXACT MATCH
EXACT MATCH
EXACT MATCH
EXACT MATCH
EXACT MATCH
EXACT MATCH
EXACT MATCH
EXACT MATCH
EXACT MATCH
EXACT MATCH
EXACT MATCH
EXACT MATCH
EXACT MATCH
                                                     EXACT MATCH
                                                     EXACT MATCH
                                                     EXACT MATCH
                                                     EXACT MATCH
                                                     EXACT MATCH
                                                     EXACT MATCH
                                                     EXACT MATCH
                                                     EXACT MATCH
                                                     EXACT MATCH

                                                     NOT MAPPED



                         Optional Record

NSF Required   Comments and Values           HIPAA   Notes
Professional

R                                                    NSF 1.03 NOT MAPPED

R                                                    NOT MAPPED - DERIVED

                                                     NOT MAPPED
S                                                    NOT MAPPED
                                                     NOT MAPPED
                                                     NOT MAPPED
                                                     NOT MAPPED
                                                     NOT MAPPED
                                                     NOT MAPPED
                                                     NOT MAPPED
                                                     NOT MAPPED
                                                     NOT MAPPED
                                                     NOT MAPPED
                                                     NOT MAPPED


                         Optional Record

NSF Required   Comments and Values           HIPAA   Notes
Professional

R              Value: GA0
               Preceded by: FA0, FB0,
R                 If FB2 or present, field
               FB1, record FE0                       NOT MAPPED - DERIVED
               must equal the FA0 record,
               field 02 value for this
                                          NOT MAPPED - DERIVED




                                          NOT MAPPED

S   Mapped to CR102 2300 if Situational
    GA0-07 is present
    Mapped to CR102 2400 if
    GA0-07 is present

    Segment CR1 2400 will not
    map if the information in
    GA0-05, GA0-07, GA0-15,
    GA0-17, GA0-20, and GA0-
    21 (all inclusive) is identical
    to the information mapped
    in CR1 2300

S   Values: NSF = HIPAA-X12 Situational
    v 4010

    Admitted Y = 01
    Not Admitted N =

    Mapped to CRC03 2300
    (CRC01=07) if NSF value =
    Y
    Values are validated in the
    NSF map
S   Values:                           Situational
    NSF       =       HIPAA-X12
    v 4010

    Initial Trip I = I
    Return Trip R = R
    Transfer Trip T = T
    Round Trip X = X

    Mapped to CR103 2300
    Mapped to CR103 2400

    Segment CR1 2400 will not
    map if the information in
    GA0-05, GA0-07, GA0-15,
    GA0-17, GA0-20, and GA0-
    21 (all inclusive) is identical
    to the information mapped
    in CR1 2300

    For NSF value “X”, GA0-20
    should be present
    Values are validated in the
    HIPAA map

S   Values: NSF = HIPAA-X12 Situational
    v 4010

    Patient was bed confined Y
    = 02
    Patient was      not bed
    confined N =

    Mapped to CRC03 or
    CRC04 2300 (CRC01=07)
    if NSF value = Y
    Values are validated in the
    NSF map
S    Values: NSF = HIPAA-X12 Situational
    v 4010

    Patient was bed confined Y
    = 03
    Patient was      not bed
    confined N =

    Mapped to CRC03, CRC04,
    or      CRC05         2300
    (CRC01=07) if NSF value =
    Y
    Values are validated in the
    NSF map
S    Values: NSF = HIPAA-X12 Situational
    v 4010

    Patient was moved by
    stretcher Y = 04
    Patient was not moved by
    stretcher N =

    Mapped to CRC03, CRC04,
    CRC05, or CRC06 2300
    (CRC01=07) if NSF value =
    Y
    Values are validated in the
    NSF map
S    Values: NSF = HIPAA-X12 Situational
    v 4010

    Patient was unconscious or
    in shock Y = 05
    Patient       was      not
    unconscious or in shock N
    =

    Mapped to CRC03, CRC04,
    CRC05, CRC06, or CRC07
    2300 (CRC01=07) if NSF
    value = Y
    Values are validated in the
    NSF map

S    Values: NSF = HIPAA-X12 Situational
    v 4010

    Emergency Situation Y = 06
    Not an emergency situation
    N=

    Mapped to CRC03 2300
    (CRC01=07) if NSF value =
    Y
    Values are validated in the
    NSF map
S    Values: NSF = HIPAA-X12 Situational
    v 4010

    Physical restraints needed
    Y = 07
    No physical restraints used
    N=

    Mapped to CRC03 or
    CRC04 2300 (CRC01=07)
    if NSF value = Y
    Values are validated in the
    NSF map
S   Values: NSF = HIPAA-X12 Situational
    v 4010

    Visible hemorrhaging noted
    Y = 08
    No Visible hemorrhaging
    noted N =

    Mapped to CRC03, CRC04,
    or      CRC05         2300
    (CRC01=07) if NSF value =
    Y
    Values are validated in the
    NSF map
S    Values: NSF = HIPAA-X12 Situational
    v 4010

    To nearest facility for care
    of     symptoms        and/or
    complaints A = A
    For the benefit of a
    preferred physician B = B
    For the nearness of family
    members C = C
    For the care of a specialist
    or    for   availability   of
    specialized
    equipment D         = D

    Mapped to CR104 2300 if
    GA0-07 is present
    Mapped to CR104 2400 if
    GA0-07 is present

    Segment CR1 2400 will not
    map if the information in
    GA0-05, GA0-07, GA0-15,
    GA0-17, GA0-20, and GA0-
    21 (all inclusive) is identical
    to the information mapped
    in CR1 2300

    Values are validated in the
    HIPAA map


S    Values: NSF = HIPAA-X12 Situational
    v 4010

    Medically necessary Y = 09
    Not medically necessary N
    =

    Mapped to CRC03, CRC04,
    CRC05, or CRC06 2300
    (CRC01=07) if NSF value =
    Y
    Values are validated in the
    NSF map
S              Mapped to CR106 2300 if Situational
               GA0-07 is present
               Mapped to CR106 2400 if
               GA0-07 is present

               Segment CR1 2400 will not
               map if the information in
               GA0-05, GA0-07, GA0-15,
               GA0-17, GA0-20, and GA0-
               21 (all inclusive) is identical
               to the information mapped
               in CR1 2300



S              Mapped to CR109 2300 if Situational
               GA0-07 contains NSF value
               “X”
               Mapped to CR109 2400 if
               GA0-07 contains NSF value
               “X”

               Segment CR1 2400 will not
               map if the information in
               GA0-05, GA0-07, GA0-15,
               GA0-17, GA0-20, and GA0-
               21 (all inclusive) is identical
               to the information mapped
               in CR1 2300

S              S Mapped to CR110 2300 Situational
               if GA0-07 is present
               Mapped to CR110 2400 if
               GA0-07 is present                  NSF 1.03 NOT MAPPED
                                                  NSF 1.03 NOT MAPPED
S              S Values: NSF = HIPAA- Situational NSF 1.03 NOT MAPPED
               X12 v 4010
                                                  NOT MAPPED

                                                         NOT MAPPED



                           Optional Record

NSF Required   Comments and Values               HIPAA   Notes
Professional
R   Value: GC0
    Preceded by: FA0, FB0,
    FB1, FB2 or FE0
    Next record: FA0, HA0 or
    XA0


R      If record present, field     NOT MAPPED - DERIVED
    must equal the FA0 record,
    field 02 value for this
    service line.




                                    NOT MAPPED - DERIVED




                                    NOT MAPPED

S    Mapped to DTP03 2300 Situational EXACT MATCH
    (DTP01=454)
    Mapped to DTP03 2400
    (DTP01=454) if value is
    different than DTP03 2300
S    Mapped to DTP03 2300 Situational EXACT MATCH
    (DTP01=455)
    Mapped to DTP03 2400
    (DTP01=455) if value is
    different than DTP03 2300




                                         EXACT MATCH
                                         EXACT MATCH
                                         EXACT MATCH

                                         EXACT MATCH

S                       Values: Situational EXACT MATCH
    NSF       =    HIPAA-X12 v
    4010

    Acute Condition A = A
    Chronic Condition C = C
    Acute Manifestation of a
    Chronic Condition M = M

    Mapped to CR208 2300 if
    GC0-07 is present
    Mapped to CR208 2400 if
    GC0-07 is present

    Segment CR2 2400 will not
    map if the information in
    GC0-11, GC0-14, and GC0-
    15 (all inclusive) is identical
    to the information mapped
    in CR2 2300

    Values are validated in the
    HIPAA map
S   Mapped to DTP03 2300 Situational EXACT MATCH
    (DTP01=453)
    Mapped to DTP03 2400
    (DTP01=453) if value is
    different that DTP03 2300




                                      EXACT MATCH
S   Mapped to CR210 2300, Situational EXACT MATCH
    first 80 bytes if GC0-07 is
    present
    Mapped to CR211 2300,
    second 80 bytes if GC0-07
    is present
    Mapped to CR210 2400,
    first 80 bytes if GC0-07 is
    present
    Mapped to CR211 2400,
    second 80 bytes if GC0-07
    is present

    Segment CR2 2400 will not
    map if the information in
    GC0-11, GC0-14, and GC0-
    15 (all inclusive) is identical
    to the information mapped
    in CR2 2300
S               Values: NSF = HIPAA-X12 Situational EXACT MATCH
               v 4010

               Yes, X-Rays are available Y
               =Y
               No,    X-Rays    are    not
               available N = N

               Mapped to CR212 2300 if
               GC0-07 is present
               Mapped to CR212 2400 if
               GC0-07 is present

               Segment CR2 2400 will not
               map if the information in
               GC0-11, GC0-14, and GC0-
               15 (all inclusive) is identical
               to the information mapped
               in CR2 2300

               Values are validated in the
               HIPAA map

                                                         NOT MAPPED



               No Mappings For HIPAA-X12 v 4010

NSF Required   Comments and Values               HIPAA   Notes
Professional

               Value: GD0                                EXACT MATCH
               Preceded by: FA0, FB0,
               FB1, or FB2
               Next record: FA0, GD1,
               HA0 or XA0


                                                         NOT MAPPED - DERIVED
NOT MAPPED - DERIVED




EXACT MATCH
EXACT MATCH



EXACT MATCH
EXACT MATCH



EXACT MATCH
EXACT MATCH
EXACT MATCH
EXACT MATCH
EXACT MATCH
EXACT MATCH
EXACT MATCH
EXACT MATCH
EXACT MATCH
EXACT MATCH
EXACT MATCH
EXACT MATCH
EXACT MATCH
EXACT MATCH

EXACT MATCH
EXACT MATCH
EXACT MATCH
EXACT MATCH
EXACT MATCH
EXACT MATCH
EXACT MATCH
EXACT MATCH
EXACT MATCH
EXACT MATCH




EXACT MATCH




EXACT MATCH
EXACT MATCH
EXACT MATCH
EXACT MATCH
EXACT MATCH
EXACT MATCH
EXACT MATCH




EXACT MATCH
EXACT MATCH
EXACT MATCH
EXACT MATCH
EXACT MATCH
EXACT MATCH
                                                  EXACT MATCH




                                                  EXACT MATCH




                                                  EXACT MATCH
                                                  EXACT MATCH

                                                  EXACT MATCH
                                                  EXACT MATCH
                                                  EXACT MATCH
                                                  EXACT MATCH
                                                  EXACT MATCH
                                                  EXACT MATCH
                                                  NOT MAPPED

                                                  NOT MAPPED



               No Mappings For HIPAA-X12 v 4010

NSF Required   Comments and Values        HIPAA   Notes
Professional

               Value: GD1                         EXACT MATCH
               Preceded by: GD0
               Next record: FA0, HA0 or
               XA0
                                                  NOT MAPPED - DERIVED




                                                  NOT MAPPED - DERIVED




                                                  EXACT MATCH
                                                  NOT MAPPED




               No Mappings For HIPAA-X12 v 4010

NSF Required   Comments and Values        HIPAA   Notes
Professional

               Value: GE0                         NSF 1.03 NOT MAPPED
               Preceded by: FA0, FB0,
               FB1 or FB2
               Next record: FA0, HA0 or
               XA0
                                                  NOT MAPPED - DERIVED
                                                  NOT MAPPED - DERIVED
                                                  NOT MAPPED
                                                  NOT MAPPED
                                                  NOT MAPPED
                                                  NOT MAPPED
                                                  NOT MAPPED
                                                  NOT MAPPED
                                                  NOT MAPPED
                                                  NOT MAPPED
                                                  NOT MAPPED
                                                  NOT MAPPED
                                                  NOT MAPPED
                                                  NOT MAPPED
                                                  NOT MAPPED
                                                  NOT MAPPED
                                                  NOT MAPPED
                                                  NOT MAPPED
                                                  NOT MAPPED
                                                  NOT MAPPED
                                                  NOT MAPPED
                                                  NOT MAPPED
                                                  NOT MAPPED
                                                  NOT MAPPED
                                                  NOT MAPPED
                                                  NOT MAPPED
                                                  NOT MAPPED
                                                  NOT MAPPED
                                                  NOT MAPPED


               No Mappings For HIPAA-X12 v 4010

NSF Required   Comments and Values        HIPAA   Notes
Professional

               Value: GP0                         NSF 1.03 NOT MAPPED
               Preceded by: FA0, FB0,
               FB1 or FB2
               Next record: FA0, HA0 or
               XA0
                                                  NOT MAPPED - DERIVED
                                                  NOT MAPPED - DERIVED
                                                  NOT MAPPED
                                                  NOT MAPPED
                                                  NOT MAPPED
                                                  NOT MAPPED
                                                  NOT MAPPED
                                                  NOT MAPPED
                                                  NOT MAPPED
                                                  NOT MAPPED
                                                  NOT MAPPED
                                                  NOT MAPPED
                                                  NOT MAPPED
                                                  NOT MAPPED
                                                  NOT MAPPED
                                                  NOT MAPPED
                                                  NOT MAPPED
                                                  NOT MAPPED
                                                  NOT MAPPED
                                                  NOT MAPPED
                                                  NOT MAPPED
                                                  NOT MAPPED
                                                  NOT MAPPED
                                                  NOT MAPPED
                                                  NOT MAPPED
                                                  NOT MAPPED
                                                  NOT MAPPED
                                                  NOT MAPPED
                                                      NOT MAPPED
                                                      NOT MAPPED
                                                      NOT MAPPED
                                                      NOT MAPPED


                              Optional Record

NSF Required   Comments and Values           HIPAA    Notes
Professional

R              Value: GU0                             NSF 1.03 NOT MAPPED
               Preceded by: FA0, FB0,
               FB1, FB2 or FE0
               Next record: FA0, HA0 or
               XA0
                  If record present, field            NOT MAPPED - DERIVED
               must equal the FA0 record,
               field 02 value for this
               service line.
R                                                        NOT MAPPED - DERIVED
                                     Values: Situational NOT MAPPED
               NSF        =       HIPAA-X12
               v 4010

               Initial Certification 1 = I
               Revision 2 = S
               Recertification 3 = R

               Mapped to CR301 2400
               Values are validated in the
               NSF map
S                                                        NOT MAPPED
                                     Values: Situational NOT MAPPED
               NSF        =       HIPAA-X12
               v 4010

               Yes Y = ZV
               No N = ZV


               Mapped to CRC03 2400
               (CRC01=09)
               Values are validated in the
               NSF map
S                                                     NOT MAPPED
                                                      NOT MAPPED
                                                      NOT MAPPED
                                                      NOT MAPPED
                                                      NOT MAPPED
                                                      NOT MAPPED
                                                      NOT MAPPED
                                         NOT MAPPED
                                         NOT MAPPED
    Mapped to MEA03 2400 Situational NOT MAPPED
    (MEA01=TR, MEA02=HT)
S                                        NOT MAPPED
                                         NOT MAPPED
    Mapped to DTP03 2400     Situational NOT MAPPED
S   Mapped to DTP03 2400     Situational NOT MAPPED
S   Mapped to CR303 2400     Situational NOT MAPPED
S   Mapped to DTP03 2400 Situational NOT MAPPED
    (DTP01=461)
S                                        NOT MAPPED
                     Values: Situational NOT MAPPED
    NSF     =     HIPAA-X12
    v 4010

    Yes Y = 38
    No N = 38


    Mapped to CRC03 or
    CRC04 2400 (CRC01=11)
    Values are validated in the
    NSF map
    Will not be mapped if GX0-
    35 contains valid data
S   Values: NSF = HIPAA-X12 Situational NOT MAPPED
    v 4010

    Hospital Bed and Support
    Services 0102 = 0102
    Manual    and    Motorized
    Wheelchairs 0203 = 0203
    Continuous Positive Airway
    Pressure System 0302 =
    0302
    Lymphedema           Pump,
    Osteogenesis     Stimulator
    0403 = 0403
    Reserved for Future Use
    0502 =
    TENS 0602 = 0602
    Seat Lift Mechanisms and
    Power Operated Vehicle
    (POV)

    0702 = 0702
    Immunosuppressive Drugs
    0802 = 0802
    External Infusion Pump
    0902 = 0902
    Parenteral and Enteral
    Nutrition 1002 = 1002

    Mapped to LQ02 2440
    Mapped to FRM01 2440

    The  Certification    Form
    Number specified in this
S     DMERC forms 01.02, Situational NOT MAPPED
    02.03, 04.03, 06.02, 07.02,
    09.02
    Values:
    NSF =        HIPAA-X12 v
    4010

    Yes Y = Y
    No N = N
    Does not apply D = W

    DMERC forms 08.02 &
    10.02
    Values:
    NSF =    HIPAA-X12 v
    4010

    Yes Y = Y
    No N = N

    Mapped to FRM02 2440
    See GU0-25
    Values are validated in the
    NSF map
S     DMERC forms 02.03, Situational NOT MAPPED
    04.03, 06.02 & 07.02
    Values:
    NSF     =    HIPAA-X12 v
    4010

    Yes Y = Y
    No N = N
    Does not apply D = W

    DMERC form 08.02
    Values:
    NSF     =  HIPAA-X12 v
    4010

    Yes Y = Y
    No N = N

    Mapped to FRM02 2440
    See GU0-25
    Values are validated in the
    NSF map
S    Mapped to FRM02 2440       Situational NOT MAPPED
    DMERC       forms    01.02,
    02.03, 04.03 & 07.02
    Values:
    NSF =         HIPAA-X12 v
    4010

    Yes Y = Y
    No N = N
    Does not apply D = W

    Mapped to FRM03 2440.
    DMERC form 06.02
    Values:
    NSF =       HIPAA-X12 v
    4010

    Headache 1 = 1
    Visceral abdominal pain 2 =
    2
    Pelvic pain 3 = 3
    Temporomandibular      joint
    (TMJ) pain 4 = 4
    None of the above 5 = 5

    DMERC form 10.02
    Values:
    NSF =     HIPAA-X12 v
    4010

    Central line 1 = 1
    Hemodialysis Access Line
S   3=3
    DMERC        forms    01.02, Situational NOT MAPPED
    02.03, 04.03, 06.02 and
    07.02
    Values:
    NSF =          HIPAA-X12 v
    4010

    Yes Y = Y
    No N = N
    Does not apply D = W

    Mapped to FRM02 2440
    See GU0-25
    Values are validated in the
    NSF map
S     DMERC forms 01.02, Situational NOT MAPPED
    02.03, 04.03, 06.02 and
    07.02
    Values:
    NSF =       HIPAA-X12 v
    4010

    Yes Y = Y
    No N = N
    Does not apply D = W

    DMERC form 10.02
    Values:
    NSF =      HIPAA-X12 v
    4010
    Yes Y     = Y
    No
    N =     N

    Mapped to FRM02 2440
    See GU0-25
    Values are validated in the
    NSF map
S    Mapped to FRM02 2440       Situational NOT MAPPED
    DMERC       forms    01.02,
    02.03, 04.03 and 07.02
    Values:
    NSF =         HIPAA-X12 v
    4010

    Yes Y = Y
    No N = N
    Does not apply D = W


    DMERC form 10.02
    Values:
    NSF =      HIPAA-X12 v
    4010
    Yes Y     = Y
    No
    N =     N

    Mapped to FRM03 2440
    DMERC form 06.02
    Values:
    NSF =      HIPAA-X12 v
    4010

    Daily 1 = 1
    3 to 6 days per week 2 = 2
    2 or less days per week 3 =
    3

    See GU0-25
S   Values are validated in the Situational NOT MAPPED
      DMERC forms 01.02,
    06.02 and 07.02
    Values:
    NSF =       HIPAA-X12 v
    4010

    Yes Y = Y
    No N = N
    Does      not          apply
    D =     W

    Mapped to FRM02 2440
    See GU0-25
    Values are validated in the
    NSF map
S    Mapped to FRM02 2440   Situational NOT MAPPED
    DMERC form 07.02
    Values:
    NSF     =   HIPAA-X12 v
    4010

    Yes Y = Y
    No N = N
    Does      not          apply
    D =     W

    Mapped to FRM03 2440.
    DMERC form 06.02
    Values:
    NSF =      HIPAA-X12 v
    4010

    2 leads 2 = 2
    4 leads 4 = 4

    DMERC form 10.02
    Values:
    NSF =     HIPAA-X12 v
    4010

    Syringe 1 = 1
    Gravity 2 = 2
    Pump 3 = 3
    Does not apply 4 = 4

    See GU0-25
    Values are validated in the
S   NSF mapforms 10.02
     DMERC                      Situational NOT MAPPED
    Values:
    NSF =       HIPAA-X12 v
    4010

    Yes Y = Y
    No N = N
    Does      not          apply
    D =     W

    Mapped to FRM02 2440
    See GU0-25
    Values are validated in the
    NSF map

S                                       NOT MAPPED
     DMERC form 01.02             Situational NOT MAPPED
    Values:
    NSF =     HIPAA-X12      v
    4010

    Yes Y = Y
    No N = N
    Does      not        apply
    D =     W

    Mapped to FRM02 2440
    See GU0-25
    Values are validated in the
    NSF map

S     DMERC forms 01.02, Situational NOT MAPPED
    03.02 and 07.02
    Values:
    NSF =       HIPAA-X12 v
    4010

    Yes Y = Y
    No N = N
    Does      not        apply
    D =     W

    Mapped to FRM02 2440
    See GU0-25
    Values are validated in the
    NSF map

S    DMERC forms 01.02 and Situational NOT MAPPED
    07.02
    Values:
    NSF =     HIPAA-X12 v
    4010

    Yes Y = Y
    No N = N
    Does      not        apply
    D =     W

    Mapped to FRM02 2440
    See GU0-25
    Values are validated in the
    NSF map
S    DMERC forms 01.02 and Situational NOT MAPPED
    07.02
    Values:
    NSF =     HIPAA-X12 v
    4010

    Yes Y = Y
    No N = N
    Does      not        apply
    D =     W

    Mapped to FRM02 2440
    See GU0-25
    Values are validated in the
    NSF map

S    DMERC form 01.02             Situational NOT MAPPED
    Values:
    NSF =     HIPAA-X12      v
    4010

    Yes Y = Y
    No N = N
    Does      not        apply
    D =     W

    Mapped to FRM02 2440
    See GU0-25
    Values are validated in the
    NSF map

S                                             NOT MAPPED
                                              NOT MAPPED
     DMERC form 01.02             Situational NOT MAPPED
    Values:
    NSF =     HIPAA-X12      v
    4010

    Yes Y = Y
    No N = N
    Does      not        apply
    D =     W

    Mapped to FRM02 2440
    See GU0-25
    Values are validated in the
    NSF map
S    DMERC form 01.02             Situational NOT MAPPED
    Values:
    NSF =     HIPAA-X12      v
    4010

    Yes Y = Y
    No N = N
    Does      not         apply
    D =     W

    Mapped to FRM02 2440
    See GU0-25
    Values are validated in the
    NSF map

S    DMERC form 01.02             Situational NOT MAPPED
    Values:
    NSF =     HIPAA-X12      v
    4010

    Improved 1 = 1
    Remained same 2 = 2
    Worsened
    3      =     3

    Mapped to FRM03 2440
    See GU0-25
    Values are validated in the
    NSF map

S                                             NOT MAPPED
                                              NOT MAPPED
                                              NOT MAPPED
                                              NOT MAPPED
    DMERC form 09.02              Situational NOT MAPPED
    Mapped to FRM03 2440
    See GU0-25

S   DMERC form 08.02              Situational NOT MAPPED
    Mapped to FRM03 2440
    See GU0-25

S                                             NOT MAPPED
    DMERC form 06.02              Situational NOT MAPPED
    Mapped to FRM04 2440
    See GU0-25

S     DMERC forms 06.02, Situational NOT MAPPED
    08.02
    Mapped to FRM04 2440
    See GU0-25
S   DMERC form 06.02            Situational NOT MAPPED
    Mapped to FRM04 2440
    See GU0-25

S   DMERC form 06.02            Situational NOT MAPPED
    Mapped to FRM04 2440
    See GU0-25

S     DMERC forms 08.02, Situational NOT MAPPED
    09.02, 10.02
    Mapped to FRM03 2440
    See GU0-25

S     DMERC forms 08.02, Situational NOT MAPPED
    10.02
    Mapped to FRM03 2440
    See GU0-25

S    DMERC form 01.02      Situational NOT MAPPED
    Values:
    NSF     =  HIPAA-X12 v
    4010

    Stage One 1 = 1
    Stage Two 2 = 2
    Stage Three 3 = 3
    Stage Four 4 = 4
    No Ulcer or Pressure Area
    9 =9

    DMERC form 08.02
    Values:
    NSF     =  HIPAA-X12 v
    4010

    Heart 1 = 1
    Liver 2 = 2
    Kidney 3 = 3
    Bone Marrow 4 = 4
    Lung 5 = 5

    DMERC form 09.02
    Values:
    NSF     =  HIPAA-X12 v
    4010

    External infusion pump
    (non-disposable) 1 = 1
    Implantable infusion pump
    3 =3
    Disposal infusion pump
S    DMERC form 01.02       Situational NOT MAPPED
    Values: 1 through 4 are
    valid in NSF and HIPAA-
    X12 v 4010

    DMERC form 08.02
    Values:
    NSF     =  HIPAA-X12 v
    4010

    Heart 1 = 1
    Liver 2 = 2
    Kidney 3 = 3
    Bone Marrow 4 = 4
    Lung 5 = 5

    DMERC form 09.02
    Values:
    NSF     =  HIPAA-X12 v
    4010

    Intravenous 1 = 1
    Epidural 3 = 3
    Subcutaneous 4 = 4

    DMERC form 10.02
    Values: 1 through 7 are
    valid in NSF and HIPAA-
    X12 v 4010

    Mapped to FRM03 2440
    See GU0-25
    Values are validated in the
S    DMERC form 01.02       Situational NOT MAPPED
    Values: 1 through 4 are
    valid in NSF and HIPAA-
    X12 v 4010

    DMERC form 08.02
    Values:
    NSF     =  HIPAA-X12 v
    4010

    Heart 1 = 1
    Liver 2 = 2
    Kidney 3 = 3
    Bone Marrow 4 = 4
    Lung 5 = 5

    DMERC form 09.02
    Values:
    NSF     =  HIPAA-X12 v
    4010

    Continuous 1 = 1
    Intermittent 3 = 3
    Bolus
    4 =       4

    Mapped to FRM03 2440
    See GU0-25
    Values are validated in the
    NSF map
S    DMERC forms 02.03 and Situational NOT MAPPED
    09.02
    Values: 0001 through 0024
    are valid in NSF and HIPAA-
    X12 v 4010

    DMERC forms 03.02, 08.02
    and 10.02
    Values: 0001 through 9999
    are valid in NSF and HIPAA-
    X12 v 4010

    DMERC form 04.03
    Values: 0001 through 0099
    are valid in NSF and HIPAA-
    X12 v 4010

    DMERC form 06.02
    Values: 0001 through 0099
    are valid in NSF and HIPAA-
    X12 v 4010, if GU0.27=N or
    D, this field must be zero
    filled.

    Mapped to FRM03 2440
    See GU0-25
    Values are validated in the
    NSF map. If this field
    contains data, the only valid
    values are numeric. The
    map will check to ensure
    that all positions in the field
    are numeric. The field may
S    DMERC forms 01.02 and Situational NOT MAPPED
    08.02
    Values: 0000 through 9999
    are valid in NSF and HIPAA-
    X12 v 4010

    DMERC form 10.02
    Values: 0000 through 0999
    are valid in NSF and HIPAA-
    X12 v 4010

    DMERC form 04.03
    Values: 0001 through 0099
    are valid in NSF and HIPAA-
    X12 v 4010

    Mapped to FRM03 2440
    See GU0-25
    Values are validated in the
    NSF map. If this field
    contains data, the only valid
    values are numeric. The
    map will check to ensure
    that all positions in the field
    are numeric. The field may
    contain all blanks if there is
    no data to be sent. In this
    case, the map will not
    check the field value for
    numeric data.
S    DMERC forms 01.02 and Situational NOT MAPPED
    10.02
    Values: 0000 through 0999
    are valid in NSF and HIPAA-
    X12 v 4010

    DMERC form 04.03
    Values: 0001 through 0099
    are valid in NSF and HIPAA-
    X12 v 4010

    Mapped to FRM03 2440
    See GU0-25
    Values are validated in the
    NSF map. If this field
    contains data, the only valid
    values are numeric. The
    map will check to ensure
    that all positions in the field
    are numeric. The field may
    contain all blanks if there is
    no data to be sent. In this
    case, the map will not
    check the field value for
    numeric data.
S    DMERC forms 01.02 and Situational NOT MAPPED
    10.02
    Values: 0000 through 9999
    are valid in NSF and HIPAA-
    X12 v 4010

    DMERC form 04.03
    Values: 0001 through 0099
    are valid in NSF and HIPAA-
    X12 v 4010

    Mapped to FRM03 2440
    See GU0-25
    Values are validated in the
    NSF map. If this field
    contains data, the only valid
    values are numeric. The
    map will check to ensure
    that all positions in the field
    are numeric. The field may
    contain all blanks if there is
    no data to be sent. In this
    case, the map will not
    check the field value for
    numeric data.
S    DMERC form 01.02           Situational NOT MAPPED
    Values: 0000 through 9999
    are valid in NSF and HIPAA-
    X12 v 4010

    DMERC form 04.03
    Values: 0001 through 0099
    are valid in NSF and HIPAA-
    X12 v 4010

    DMERC form 10.02
    Values: 0000 through 0007
    are valid in NSF and HIPAA-
    X12 v 4010

    Mapped to FRM03 2440
    See GU0-25
    Values are validated in the
    NSF map. If this field
    contains data, the only valid
    values are numeric. The
    map will check to ensure
    that all positions in the field
    are numeric. The field may
    contain all blanks if there is
    no data to be sent. In this
    case, the map will not
    check the field value for
    numeric data.
S    DMERC forms 01.02 and Situational NOT MAPPED
    10.02
    Values: 0000 through 9999
    are valid in NSF and HIPAA-
    X12 v 4010

    DMERC form 04.03
    Values: 0001 through 0099
    are valid in NSF and HIPAA-
    X12 v 4010

    Mapped to FRM03 2440
    See GU0-25
    Values are validated in the
    NSF map. If this field
    contains data, the only valid
    values are numeric. The
    map will check to ensure
    that all positions in the field
    are numeric. The field may
    contain all blanks if there is
    no data to be sent. In this
    case, the map will not
    check the field value for
    numeric data.


S    DMERC form 01.02           Situational NOT MAPPED
    Values: 0000 through 9999
    are valid in NSF and HIPAA-
    X12 v 4010

    Mapped to FRM03 2440
    See GU0-25
    Values are validated in the
    NSF map. If this field
    contains data, the only valid
    values are numeric. The
    map will check to ensure
    that all positions in the field
    are numeric. The field may
    contain all blanks if there is
    no data to be sent. In this
    case, the map will not
    check the field value for
    numeric data.
S               DMERC form 10.02       Situational NOT MAPPED
               Values: 000.0% through
               099.9% are valid in NSF
               and HIPAA-X12 v 4010

               Mapped to FRM05 2440
               See GU0-25
               Values are validated in the
               NSF map

S               DMERC form 10.02       Situational NOT MAPPED
               Values: 000.0% through
               099.9% are valid in NSF
               and HIPAA-X12 v 4010

               Mapped to FRM05 2440
               See GU0-25
               Values are validated in the
               NSF map

S               DMERC form 10.02       Situational NOT MAPPED
               Values: 000.0% through
               099.9% are valid in NSF
               and HIPAA-X12 v 4010

               Mapped to FRM05 2440
               See GU0-25
               Values are validated in the
               NSF map

S                                                    NOT MAPPED


                         Optional Record

NSF Required   Comments and Values           HIPAA   Notes
Professional

R              Value: GX0                            NSF 1.03 NOT MAPPED
               Preceded by: FA0, FB0,
               FB1, FB2 or FE0
               Next record: FA0, GX1,
               GX2, HA0 or XA0

                  If record present, field           NOT MAPPED - DERIVED
               must equal the FA0 record,
               field 02 value for this
               service line.
R                                                    NOT MAPPED - DERIVED
                      Values:           NOT MAPPED
    NSF      =   HIPAA-X12 v
    4010

    Initial Certification I = I
    Renewal Certification R = R
    Revised Certification S = S
    Initial Certification 1 = I
    Revised Certification 2 = S
    Renewal Certification 3 = R

    Mapped to CR501 2400
    Values are validated in the
    NSF map




S                      Values: Situational NOT MAPPED
    NSF      =      HIPAA-X12
    v 4010

    Yes Y = AL
    No N = 37
    Does not apply D = 37

    Mapped to CRC03 2400
    (CRC01=11)
    Values are validated in the
    NSF map

S   Mapped to CR502 2400      Situational NOT MAPPED
S                             Situational NOT MAPPED
                                          NOT MAPPED
                                          NOT MAPPED
    Mapped to DTP03 2400                  NOT MAPPED
    (DTP01=463), if GU0-19 is
    not present
S   Mapped to DTP03 2400 Situational NOT MAPPED
    (DTP01=461, if GU0-20 is
    not present
S                             Situational NOT MAPPED
                                          NOT MAPPED
    Mapped to REF02 2400                  NOT MAPPED
    (REF01=TP)
S                             Situational NOT MAPPED
                                          NOT MAPPED
    Mapped to MEA03 2400                  NOT MAPPED
S   Mapped to MEA03 2400 Situational NOT MAPPED
    (MEA01=TR, MEA02=ZO)
S   Mapped to DTP03 2400 Situational     NOT MAPPED
    (DTP01=119)
S    Values:               Situational   NOT MAPPED
S                          Situational   NOT MAPPED
    Mapped to CR510 2400                 NOT MAPPED
S   Mapped to CR511 2400   Situational   NOT MAPPED
S     Mapped to DTP03 2400 Situational   NOT MAPPED
    (DTP01=480)
    Mapped to DTP03 2400
    (DTP01=481)

S    Mapped to NM103 2420C Situational NOT MAPPED
    (NM101=77, NM102=2)
S                   Values: Situational NOT MAPPED
    NSF =      HIPAA-X12 v
    4010

    At Rest 1 = R
    Exercising 2 = E
    Sleeping 3 = S

    Mapped to CR512 2400
    Values are validated in the
    NSF map

S   Position 260 is mapped to Situational NOT MAPPED
    CR513 2400
    Position 261 is mapped to
    CR514 2400
    Position 262 is mapped to
    CR515 2400
S                              Situational NOT MAPPED
                                           NOT MAPPED
     Mapped to PER04 2420E                 NOT MAPPED
    (NM101=DK)
S                              Situational NOT MAPPED
                                           NOT MAPPED
                                           NOT MAPPED
                                           NOT MAPPED
                       Values:             NOT MAPPED
    NSF      =      HIPAA-X12
    v 4010

    Yes Y = 38
    No N = 38


    Mapped to CRC03 or
    CRC04 2400 (CRC01=11)
    Values are validated in the
    NSF map
S                                         Situational NOT MAPPED
                                                      NOT MAPPED


               No Mappings For HIPAA-X12 v 4010

NSF Required   Comments and Values        HIPAA         Notes
Professional

               Value: GX1
               Preceded by: GX0
               Next record: FA0, GX2,
               HA0 or XA0




                        Optional Record

NSF Required   Comments and Values        HIPAA         Notes
Professional

R              Value: GX2                               NSF 1.03 NOT MAPPED
               Preceded by: GX0 or GX1
               Next record: FA0, HA0 or
               XA0
               If record present, field                 NOT MAPPED - DERIVED
R                                                       NOT MAPPED - DERIVED
               Mapped to N301 2420C       Situational   NOT MAPPED
S              Mapped to N302 2420C       Situational   NOT MAPPED
S              Mapped to N401 2420C       Situational   NOT MAPPED
S              Mapped to N402 2420C       Situational   NOT MAPPED
               (NM101=77)
S              Mapped to N403 2420C       Situational NOT MAPPED
               (NM101=77)
S                                                       NOT MAPPED
                                                        NOT MAPPED
                                                        NOT MAPPED
                                                        NOT MAPPED
                                                        NOT MAPPED
                                                        NOT MAPPED
                                                        NOT MAPPED


                       Conditional Record
NSF Required   Comments and Values           HIPAA    Notes
Professional

R              Value: HA0                             EXACT MATCH
               Preceded by: FA0, FB0,
               FB1, FB2, GA0, GD0, or
               GD1
               Next record: FA0 or XA0


R                 If record present, field            NOT MAPPED - DERIVED
               must equal the FA0 record,
               field 02 value for this
               service line.




                Mapped to K301 2400                   NOT MAPPED - DERIVED
               Mapped to NTE02 2400
               (NTE01=ADD)
               Only the first 80 bytes are
               mapped.



                                                      NOT MAPPED - DERIVED




S                                            Situational EXACT MATCH


                         Required Record

NSF Required   Comments and Values           HIPAA    Notes
Professional

R              Value: XA0                             EXACT MATCH
               Preceded by: FA0, FB0,
               FB1, FB2, FD0, GA0, HA0
               Next record: CA0 or YA0
NOT MAPPED

NOT MAPPED - DERIVED




NOT MAPPED - DERIVED




NOT MAPPED - DERIVED




NOT MAPPED - DERIVED




NOT MAPPED - DERIVED




NOT MAPPED - DERIVED
                                        NOT MAPPED - DERIVED




                                        NOT MAPPED - DERIVED




                                        NOT MAPPED - DERIVED

S   Mapped to CLM02 2300    Required    Calculated amount of FA0.13
                                        must equal amount on record




                                        NOT MAPPED - DERIVED


                                        NOT MAPPED - DERIVED


                                        NOT MAPPED - DERIVED


                                        NOT MAPPED - DERIVED


                                        NOT MAPPED - DERIVED


                                        NOT MAPPED - DERIVED


S    Mapped to AMT02 2300 Situational
    (AMT01=F5)




                                        NOT MAPPED - DERIVED
                                                 NOT MAPPED




                        Required Record

NSF Required   Comments and Values       HIPAA   Notes
Professional

R              Value: YA0
               Preceded by: XA0
               Next record: BA0 or ZA0


                                                 NOT MAPPED - DERIVED




                                                 NOT MAPPED - DERIVED




                                                 NOT MAPPED - DERIVED




                                                 NOT MAPPED - DERIVED




                                                 NOT MAPPED - DERIVED




                                                 NOT MAPPED
                                              NOT MAPPED - DERIVED




                                              NOT MAPPED - DERIVED




                                              NOT MAPPED - DERIVED




                                              NOT MAPPED - DERIVED




                                              NOT MAPPED




                        Required Record

NSF Required   Comments and Values    HIPAA   Notes
Professional

R              Value: ZA0
               Preceded by: YA0
NOT MAPPED - DERIVED




NOT MAPPED - DERIVED

NOT MAPPED - DERIVED




NOT MAPPED - DERIVED




NOT MAPPED - DERIVED




NOT MAPPED - DERIVED




NOT MAPPED - DERIVED
NOT MAPPED - DERIVED




NOT MAPPED - DERIVED
NOT MAPPED - DERIVED


ADDITIONAL EDITS

DUPLICATE   FILE   HAS
BEEN RECEIVED
Record type: AA0
File Header - Submitter Data                                                   Required Record
             Field #           Field          Start   Length   NSF           Comment
                               Name                            Required      s and
                                                               Professiona   Values
                                                               l
                1              Record ID        1       3x          R        Value:
                               “AA0”                                         AA0Next
                                                                             record: BA0

                2              Submitter ID     4      16x         R         Mapped to
                                                                             NM109
                                                                             1000A
                                                                             (NM101=41,
                                                                             NM108=46)


                3              Reserved        20       9x
                               (AA0.03)
                4              Submission      29       6x
                               Type
                5              Submission      35       6x          S        Mapped to
                               Number                                        BHT03
                6              Submitter       41      33x          S        Mapped to
                               Name                                          NM103
                                                                             1000A
                                                                             (NM101=41,
                                                                             NM102=2)
                                                                             Mapped to
                                                                             PER02
                                                                             1000A
                                                                             (PER01=IC,
                                                                             NM101=41)
                                                                             if AA0-13 is
                                                                             not present


                7              Submitter       74      30x
                               Address1
                8              Submitter       104     30x
                               Address2
                9              Submitter       134     20x
                               City
               10              Submitter       154      2x
                               State
               11              Submitter       156      9x
                               Zip
               12              Submitter       165      5x
                               Region
               13              Submitter       170     33x          S        Mapped to
                               Contact                                       PER02
                                                                             1000A
                                                                             (PER01=IC,
                                                                             NM101=41)
               14              Submitter       203     10x          S        Mapped to
                               Phone                                         PER04
                                                                             1000A
                                                                             (PER03=TE,
                                                                             NM101=41)
15   Creation       213   8x    S   Mapped to
     Date                           BHT04
     (CCYYMMD
     D)
16   Submission     221   6x    S   Mapped to
     Time                           BHT05
17   Receiver ID    227   16x   S   Mapped to
                                    NM109
                                    1000B
                                    (NM101=40,
                                    NM108=46)


18   Receiver       243   1x
     Type Code
19   Version        244   5n    R             301
     Code -
     National
20   Version        249   5n
     Code - Local

21   Test/Prod      254   4x
     Indicator
22   Password       258   8x
23   Retransmissi   266   1x    S   Values:
     on Status                      NSF     =
                                    HIPAA-X12 v
                                    4010

                                    Original
                                    0        =
                                    Non-
                                    Chargeable
                                    Retrans    8
                                    =     18
                                    Chargeable
                                    Retrans
                                    9        =


                                    Please note
                                    if a blank is
                                    received
                                    nothing will
                                    be mapped
                                    to BHT02
                                    and will fail
                                    HIPAA
                                    Mapped to
                                    BHT02
                                    Values are
                                    validated in
                                    the NSF
                                    map
24   Original       267   16x
     Submitter ID
25   Vendor App     283   1x
     Cat
26   Vendor         284   5x
     Software
     Version
              27               Vendor           289        2x
                               Software
                               Update
              28               COB File         291        1x
                               Indicator
              29               Process          292        8x
                               from Date
                               (CCYYMMD
                               D)
              30               Process thru     300        8x
                               Date
                               (CCYYMMD
                               D)
              31               Acknowledg       308        1x
                               ment
                               Request
              32               Date of          309        8x
                               Receipt
                               (CCYYMMD
                               D)
              33               Filler -         317        4x
                               National




Record type: BA0 (Group Provider          # Information)
Batch Header Record - Provider Data 1                                            Required Record
            Field #            Field           Start   Length        NSF       Comment
                               Name                               Required     s and
                                                                 Professiona   Values
                                                                      l
               1               Record ID         1         3x         R        Value: BA0
                               “BA0”                                           Preceded by:
                                                                               AA0 or YA0
                                                                               Next record:
                                                                               BA1 or CA0
               2               EMC               4         15x
                               Provider ID
               3               Batch Type       19         3x        R         100 = All
                                                                               Others 200
                                                                               = Dental
               4               Batch            22         4x
                               Number
               5               Batch ID         26         6x
               6               Provider Tax     32         9x         S        If BA0-09 is
                               ID                                              not present,
                                                                               map to
                                                                               NM109
                                                                               2010AA
                                                                               (NM101=85,
                                                                               NM108=BA0
                                                                               .08);
                                                                               otherwise,
                                                                               map to
                                                                               REF02
                                                                               2010AA
                                                                               (REF01=EI,
                                                                               NM101=85)
7    Reserved        41    6x
     (BA0.07)
8    Provider Tax    47    1x    S   Values: NSF =
     ID Type                         HIPAA-X12 v
                                     4010
                                     Employer ID
                                     Number E = 24
                                     Social Security
                                     Number S = 34
                                     Corporate
                                     Name, but
                                     SSN X = 34
                                     Mapped to
                                     NM108
                                     2010AA

9    National        48    15x   S   Mapped to
     Provider ID                     NM109
     (NPI)                           2010AA
                                     (NM101=85,
                                     NM108=XX)


10   Provider        63    6x    S   Mapped to
     UPIN-USIN                       REF02
     ID                              2010AA
                                     (REF01=1G,
                                     NM101=85)


11   Reserved        69    6x
     (BA0.11)
12   Provider        75    15x   S   Mapped to
     Medicaid                        REF02
     Number                          2010AA
                                     (REF01=1D,
                                     M101=85)
13   Provider        90    15x   S   Mapped to
     Champus                         REF02
     Number                          2010AA
                                     (REF01=1H,
                                     NM101=85)
14   Provider        105   15x   S   Mapped to
     Blue Shield                     REF02
     Number                          2010AA
                                     (REF01=1B,
                                     NM101=85)
15   Provider        120   15x   S   Mapped to
     Commercial                      REF02
     Number                          2010AA
                                     (REF01=G2,
                                     NM101=85)


16   Provider        135   15x
     Number 1
17   Provider        150   15x
     Number 2
18   Provider Org    165   33x   S   Either BA0-
     Name                            18 or BA0-19
                                     must be
19   Provider Last   198   20x   S   Either BA0-
     Name                            18 or BA0-19
                                     must be
              20               Provider         218     12x          S        Mapped to
                               First Name                                     NM104
                                                                              2010AA
                                                                              (NM101=85);
                                                                              required if
                                                                              BA0-19 is
                                                                              present
              21               Provider MI      230      1x          S        Mapped to
                                                                              NM105
                                                                              2010AA
                                                                              (NM101=85)

              22               Provider         231      3x
                               Specialty
              23               Specialty        234     15x
                               License
                               Number
              24               State            249     15x          S        Mapped to
                               License                                        REF02
                               Number                                         2010AA
                                                                              (REF01=0B,
                                                                              NM101=85)
              25               Dentist          264     15x
                               License
                               Number
              26               Anesthesia       279     15x
                               License
                               Number
              27               Provider         294      1x
                               Participation
                               Ind
              28               Filler -         295     26x
                               National




Record type: BA1
Batch Header Record - Provider Data 2                                                 Required Record
            Field #             Field          Start   Length   NSF
                                Name                            Required
                                                                Professiona
                                                                l
               1               Record ID         1       3x          R
                               “BA1”



               2               EMC               4      15x
                               Provider ID
               3               Batch Type       19       3x
               4               Batch            22       4x
                               Number
               5               Batch ID         26       6x
               6               Provider         32       3x
                               Type Org
               7               Provider         35      30x          S
                               Service
                               Address1
                8    Provider       65    30x   S
                     Service
                     Address2



                9    Provider       95    20x   S
                     Service City




               10    Provider       115   2x    S
                     Service
                     State



               11    Provider       117   9x    S
                     Service Zip




               12    Provider       126   10x   S
                     Service
                     Phone



               13    Provider Pay   136   30x   S
               14    To Address1
                     Provider Pay   166   30x   S
                     To Address2




               15    Provider Pay   196   20x   S
                     To City




               16    Provider Pay   216   2x    S
                     To State




               17    Provider Pay   218   9x    S
                     To Zip




               18    Provider Pay   227   10x   S
                     To Phone




               19    Filler -       237   84x
                     National




Record type:   CA0
Claim Header Record – Patient Data                                            Required Record
            Field #            Field           Start   Length   NSF
                               Name                             Required
                                                                Professiona
                                                                l
               1               Record ID         1       3x          R
               2               “CA0”
                               Reserved          4       2x
                               (CA0-02)
               3               Patient           6      17x         R
                               Control
                               Number
               4               Patient Last     23      20x          S
                               Name




               5               Patient First    43      12x          S
                               Name




               6               Patient MI       55       1x          S
7    Patient        56   3x   S
     Generation




8    Patient Date   59   8x   S
     Of Birth
     (CCYYMMD
     D)




9    Patient Sex    67   1x   S




10   Patient Type   68   1x
     Of
     Residence
11   Patient         69    30x   S
     Address1




12   Patient         99    30x   S
     Address2




13   Patient City    129   20x   S




14   Patient State   149   2x    S
15   Patient Zip    151   9x    S




16   Patient        160   10x
     Phone
17   Patient        170   1x
     Marital
     Status
18   Patient        171   1x
     Student
     Status
19   Patient        172   1x
     Employment
     Status
20   Patient        173   1x
     Death
     Indicator
21   Patient Date   174   8n    S
     Of Death
     (CCYYMMD
     D)




22   Other          182   1x
     Insurance
     Indicator
23   Claim          183   1x
     Editing
     Indicator
24   Type Of        184   2x
     Claim
     Indicator
              25               Legal           186      1x          S
                               Representati
                               ve Indicator




              26               Origin Code     187      9x
              27               Payer Claim     196     17x
                               Control
                               Number
              28               Provider        213     15x
                               Number
              29               Claim ID        228      6x
                               Number
              30               Filler -        234     87x
                               National




Record type: CA1
Claim Header Record – Patient Data                                             Optional Record
            Field #            Field          Start   Length   NSF           Comment
                               Name                            Required      s and
                                                               Professiona   Values
                                                               l
               1               Record ID        1       3x          R        Value: CA1
                               “CA1”                                         Preceded by:
                                                                             CA0
                                                                             Next record:
                                                                             CB0 or DA0

               2               Reserved         4       2x
                               (CA1-02)
               3               Patient          6      17x
                               Control
                               Number
               4               Purchase        23      10x
                               Order
                               Number
               5               Tribe           33       3x          S        Mapped to
                                                                             NM109
                                                                             2010BA
                                                                             (NM101=IL)
               6               Residency       36       7x          S        Mapped to
                               Code                                          NM109
                                                                             2010BA(NM
                                                                             101=IL)
               7               Patient         43       6x
                               Health
                               Record
               8               Auth Fac        49       9x
                               Number
               9               Multi Claim     58       1x
                               Indicator
              10               Filler –        59      262x
                               National




Record type: CB0
Claim Header Record - Legal Representative Data                                Optional Record
            Field #            Field          Start   Length   NSF           Comment
                               Name                            Required      s and
                                                               Professiona   Values
                                                               l
               1               Record ID        1       3x          R        Value: CB0
                               “CB0”
                                                                             Preceded by:
                                                                             CA0 or CA1

                                                                             Next record:
                                                                             DA0

               2               Reserved         4       2x
                               (CB0-02)
               3               Patient          6      17x
                               Control
                               Number
               4               Responsible     23      20x          S        Mapped to
                               Person Last                                   NM103
                               Name                                          2010BC
                                                                             (NM101=QD,
                                                                             NM102=1)


               5               Responsible     43      12x          S        Mapped to
                               Person First                                  NM104
                               Name                                          2010BC
                                                                             (NM101=QD
                                                                             )
               6               Responsible     55       1x          S        Mapped to
                               Person MI                                     NM105
                                                                             2010BC
                                                                             (NM101=QD
                                                                             )
               7               Responsible     56      30x          S        Mapped to
                               Person                                        N301
                               Address1                                      2010BC
                                                                             (NM101=QD
                                                                             )
               8               Responsible     86      30x          S        Mapped to
                               Person                                        N302
                               Address2                                      2010BC
                                                                             (NM101=QD
                                                                             )
               9               Responsible     116     20x          S        Mapped to
                               Person City                                   N401
                                                                             2010BC
                                                                             (NM101=QD
                                                                             )
              10                Responsible     136      2x          S        Mapped to
                                Person State                                  N402
                                                                              2010BC
                                                                              (NM101=QD
                                                                              )
              11                Responsible     138      9x          S        Mapped to
                                Person Zip                                    N403
                                                                              2010BC
                                                                              (NM101=QD
                                                                              )
              12                Responsible     147     10x
                                Person
                                Phone
              13                Filler -        157     164
                                National




Record type: DA0 – SEQUENCE 1
Insurance Information Record - Insurance Information                            Required Record
            Field #             Field          Start   Length   NSF           Comment
                                Name                            Required      s and
                                                                Professiona   Values
                                                                l
               1                Record ID        1       3x          R        Value: DA0
                                “DA0”                                         Preceded by:
                                                                              CA0, CB0,
                                                                              DA0, DA1,
                                                                              DA2 or DA3

                                                                              Next record:
                                                                              DA0, DA1,
                                                                              DA2, DA3 or
                                                                              EA0

               2                Sequence         4       2x         R         Values:
                                Number                                        NSF =
                                                                              HIPAA-X12 v
                                                                              4010


                                                                              Primary Payer
                                                                              01 = P


                                                                              DA0
                                                                              Sequence 01
                                                                              mapped to
                                                                              SBR01=P
                                                                              2000BValue
                                                                              s are
                                                                              validated in
                                                                              the NSF
                                                                              map

               3                Patient          6      17x
                                Control
                                Number
               4                Claim Filing    23       1x
                                Indicator
               5                Source Of       24       1x         R         Values: NSF =
                                Pay                                           HIPAA-X12 v
                                                                              4010
5   Source Of   24   1x   R
    Pay


                              Self Pay A =
                              09
                              Central
                              Certification K
                              = 10
                              Blue Cross
                              Blue Shield G
                              = BL
                              CHAMPUS H =
                              CH
                              Commercial
                              Insurance
                              Company F =
                              CI
                              HMO I = HM
                              Medicare C =
                              MB
                              Medicaid D =
                              MC
                              Other Federal
                              Program E =
                              OF
                              Federal
                              Employee
                              Program (FEP)
                              J = OF
                              Workers‟
                              Compensation
                              B = WC
                              Self
                              Administered
                              Group L = ZZ
                              Family or
                              Friends M = ZZ

                              Managed Care
                              – Non-HMO N
                              = ZZ
                              Indian Health
                              Services O =
                              ZZ
                              Blue Cross P =
                              ZZ
                              Title V T = TV
                              Veteran
                              Administration
                              Plan V = VA
                              Other Z = ZZ


                              DA0
                              Sequence 01
                              mapped to
                              SBR09
                              2000B
                              (SBR01=P))


                              Values are
                              validated in
                              the NSF
                              map
6   Insurance   25   2x
    Type Code
 7      Payer           27    5x    S   DA0
        Organization                    Sequence 01
        ID                              mapped to
                                        NM109
                                        2010BB
                                        (NM101=PR,
                                        NM108=PI,
                                        SBR01=P
                                        2000B)

8-Jul   Redefined as
        National
        Payer ID
 8      Payer Claim     32    4x    S   DA0
        Office                          Sequence 01
        Number                          mapped to
                                        REF02
                                        2010BB
                                        (REF01=FY,
                                        NM101=PR,
                                        SBR01=P
                                        2000B)


 9      Payer Name      36    33x   R   DA0
                                        Sequence 01
                                        mapped to
                                        NM103
                                        2010BB
                                        (NM101=PR,
                                        SBR01=P
                                        2000B)
 10     Group           69    20x   S   DA0
        Number                          Sequence 01
                                        mapped to
                                        SBR03
                                        2000B
                                        (SBR01=P)
 11     Group Name      89    33x   S   DA0
                                        Sequence 01
                                        mapped to
                                        SBR04
                                        2000B
                                        (SBR01=P)
 12     PPO/HMO         122   1x
        Indicator
 13     PPO ID          123   15x
 14     Prior           138   15x   S   Mapped to
        Authorization                   REF02 2300
        Number                          (REF01=G1)



 15     Assign Of       153   1x    S   Values: NSF =
        Benefits                        HIPAA-X12 v
        Indicator                       4010
15   Assign Of   153   1x   S
     Benefits
     Indicator

                                Yes, benefits
                                have been
                                assigned to the
                                provider and a
                                signed form is
                                on file in the
                                provider‟s
                                office. Y = Y

                                No, benefits
                                have not been
                                assigned,
                                insured did not
                                authorize
                                payment to
                                provider.


                                N=N
                                Pay Other
                                Organization/L
                                egal (for NSF
                                COB)

                                O=


                                     DA0
                                     Sequen
                                     ce 01
                                     mapped
                                     to
                                     CLM08
                                     2300
                                     Values
                                     are
                                     validate
                                     d in the
                                     HIPAA
                                     map


16   Patient     154   1x   S   Values:
     Signature                  NSF = HIPAA-
     Source                     X12 v 4010

                                Signed HCFA
                                1500 claim
                                form on file C
                                =C
                                Signed
                                signature
                                authorization
                                form for block
                                12 on file


                                S=S
                                Signed
                                signature
                                authorization
                                form for block
                                13 on file


                                M=M
                                Signed
                                signature
                                authorization
                                form for block
                                12 and 13 on
                                file
                                   B         =   B
                                         Signature
                                         generated
                                         by
                                         provider
                                         because
                                         the
                                         patient
                                         was not
                                         physically
                                         present
                                         for



                                         services
                                         P =     P




                                         DA0
                                         Sequen
                                         ce 01
                                         mapped
                                         to
                                         CLM10
                                         2300
                                         Values
                                         are
                                         validate
                                         d in the
                                         HIPAA
                                         map


17   Patient        155   2x   S   Values:
     Relationship                  NSF        =
     To Insured                    HIPAA-X12 v
                                   4010
                                   Patient is
                                   insured
                                   01           =
                                   18
                                         DA0
                                         Sequen
                                         ce 01
                                         mapped
                                         to
                                         SBR02
                                         2000B
                                   Values:
                                   NSF         =
                                   HIPAA-X12 v
                                   4010
                                   Spouse 02 = 01

                                   Natural
                                   child/insured has
                                   financial
                                   responsibility 03
                                   = 19
                                   Natural
                                   child/insured
                                   does not have
                                   financial
                                   responsibility 04
                                   = 43
                                  Stepchild 05 =
                                  17
                                  Foster child 06 =
                                  10
                                  Ward of the
                                  court 07 = 15
                                  Employee 08 =
                                  20
                                  Unknown 09 =
                                  21
                                  Handicapped
                                  dependent 10 =
                                  22
                                  Organ donor 11
                                  = 39
                                  Cadaver donor
                                  12 = 40
                                  Grandchild 13 =
                                  05
                                  Niece/nephew
                                  14 = 07
                                  Injured plaintiff
                                  15 = 41
                                  Sponsored
                                  dependent 16 =
                                  23
                                  Minor dependent
                                  of a minor
                                  dependent 17 =
                                  24

                                  Parent
                                  18          =
                                  32 or 33
                                  Grandparent 19
                                  = 04


                                        DA0
                                        Sequen
                                        ce 01
                                        mapped
                                        to
                                        PAT01
                                        2000C
                                        Values
                                        are
                                        validate
                                        d in the
                                        NSF
                                        map


18   Insured ID   157   25x   S   DA0
     Number                       Sequence 01
                                  mapped to
                                  NM109
                                  2010BA
                                  (NM101=IL,
                                  SBR01=P
                                  2000B) if
                                  patient is the
                                  subscriber
                                     DA0
                                     Sequence 01
                                     mapped to
                                     NM109
                                     2010CA
                                     (NM101=QC
                                     ), if patient is
                                     the
                                     dependent


19   Insured Last    182   20x   S   DA0
     Name                            Sequence 01
                                     mapped to
                                     NM103
                                     2010BA
                                     (NM101=IL)
                                     If patient is
                                     the
                                     dependent
20   Insured First   202   12x   S   DA0
     Name                            Sequence 01
                                     mapped to
                                     NM104
                                     2010BA,
                                     (NM101=IL)
                                     if patient is
                                     the
                                     dependent
21   Insured MI      214   1x    S   DA0
                                     Sequence 01
                                     mapped to
                                     NM105
                                     2010BA
                                     (NM101=IL)
                                     if patient is
                                     the
                                     dependent

22   Insured         215   3x    S   DA0
     Generation                      Sequence 01
                                     mapped to
                                     NM107
                                     2010BA
                                     (NM101=IL)
                                     if patient is
                                     the
                                     dependent

23   Insured Sex     218   1x    S   Values: NSF =
                                     HIPAA-X12 v
                                     4010


                                     Female F = F
                                     Male M = M
                                     Unknown U =
                                     U
                                    DA0
                                    Sequence 01
                                    mapped to
                                    DMG03
                                    2010BA
                                    (NM101=IL,
                                    SBR02=18
                                    2000B) if
                                    patient is the
                                    dependent


                                    Values are
                                    validated in
                                    the HIPAA
                                    map
24   Insured Date   219   8x    S   DA0
     Of Birth                       Sequence 01
     (CCYYMMD                       mapped to
     D)                             DMG02
                                    2010BA
                                    (NM101=IL)
                                    if patient is
                                    the
                                    dependent
25   Insured        227   1x
     Employment
     Status
26   Supplementa    228   1x
     l Insurance
     Indicator

27   Insurance      229   7x
     Location ID
28   Medicaid ID    236   25x
     NO
29   Supplementa    261   25x
     l Patient Id
30   Assignment     286   1x    S   Values: NSF =
     4081                           HIPAA-X12 v
     Indicator                      4010

                                    4081 1 = Y
                                    Regular
                                    Crossover 2 =
                                    N


                                    Mapped to
                                    REF02 2300
                                    (REF01=F5)

                                    Values are
                                    validated in
                                    the NSF
                                    map
31   COB Routing    287   1x
     Indicator

32   Filler -       288   33x
     National
Record type: DA1 – SEQUENCE 1
Insurance Information Record - Insurance Information (Payer Data 2)              Optional Record

            Field #             Field        Start     Length   NSF           Comment
                                Name                            Required      s and
                                                                Professiona   Values
                                                                l
               1                Record ID      1         3x          R        Value: DA1
                                “DA1”
                                                                              Preceded by:
                                                                              DA0
                                                                              Next record:
                                                                              DA0, DA2 or
                                                                              EA0

               2                Sequence       4         2x           S       Values:
                                Number                                        NSF =
                                                                              HIPAA-X12 v
                                                                              4010


                                                                              Primary Payer
                                                                              01 = P
                                                                              Values are
                                                                              validated in
                                                                              the NSF
                                                                              map
               3                Patient        6         17x
                                Control
                                Number
               4                Payer          23        30x          S       DA1
                                Address1                                      Sequence 01
                                                                              mapped to
                                                                              N301
                                                                              2010BB
                                                                              (NM101=PR,
                                                                              SBR01=P
                                                                              2000B)
               5                Payer          53        30x          S       DA1
                                Address2                                      Sequence 01
                                                                              mapped to
                                                                              N302
                                                                              2010BB
                                                                              (NM101=PR,
                                                                              SBR01=P
                                                                              2000B)
               6                Payer City     83        20x          S       DA1
                                                                              Sequence 01
                                                                              mapped to
                                                                              N401
                                                                              2010BB
                                                                              (NM101=PR,
                                                                              SBR01=P
                                                                              2000B)
7    Payer State    103     2x      S   DA1
                                        Sequence 01
                                        mapped to
                                        N402
                                        2010BB
                                        (NM101=PR,
                                        SBR01=P
                                        2000B)
8    Payer Zip      105     9x      S   DA1
                                        Sequence 01
                                        mapped to
                                        N403
                                        2010BB
                                        (NM101=PR,
                                        SBR01=P
                                        2000B)
9    Disallowed     114   n(5)v99
     Cost
     Containment

10   Disallowed     121   n(5)v99
     Other
11   Allowed        128   n(5)v99
     Amount
12   Deductible     135   n(5)v99
     Amount
13   Coinsurance    142   n(5)v99
     Amount
14   Payer          149   n(5)v99
     Amount
     Field
15   Zero Pay       156     1x
     Indicator
16   Adjudication   157     2x
     Indicator 1

17   Adjudication   159     2x
     Indicator 2

18   Adjudication   161     2x
     Indicator 3

19   Champus        163     1x
     Sponsor
     Branch
20   Champus        164     2x
     Sponsor
     Grade
21   Champus        166     1x
     Sponsor
     Status
22   Insurance      167     8x
     Card
     Effective
     Date
     (CCYYMMD
     D)
23   Insurance       175     8x
     Card
     Termination
     Date
     (CCYYMMD
     D)
24   Balance Due     183   n(5)v99

25   EOMB Date1      190     8x
     (CCYYMMD
     D)

26   EOMB Date2      198     8x
     (CCYYMMD
     D)

27   EOMB Date3      206     8x
     (CCYYMMD
     D)

28   EOMB Date4      214     8x
     (CCYYMMD
     D)

29   Claim           222     8x
     Receipt Date
     (CCYYMMD
     D)

30   Amt Paid to     230   n(7)v99
     Beneficiary
31   Bene            239    15x
     Check/EFT
     Trace No
32   Bene Check      254     8x
     Date
     (CCYYMMD
     D)
33   Amt Paid to     262   n(7)v99
     Provider
34   Prov            271    15x
     Check/EFT
     Trace No
35   Provider        286     8x
     Check Date
     (CCYYMMD
     D)
36   Interest Paid   294   n(7)v99

37   Approved        303   n(7)v99
     Amount
38   Contract        312     1x
     Agreement
     Indicator
39   Filler -        313     8x
     National
Record type: DA2 – SEQUENCE 1
Insurance Information - Payer Data 3                                            Optional Record
            Field #            Field          Start   Length   NSF           Comment
                               Name                            Required      s and
                                                               Professiona   Values
                                                               l
               1               Record ID        1       3x          R        Value: DA2
                               “DA2”                                         Preceded by:
                                                                             DA0 or DA1

                                                                             Next record:
                                                                             DA0, DA3 or
                                                                             EA0

               2               Sequence         4       2x          S        Values:
                               Number                                        NSF =
                                                                             HIPAA-X12 v
                                                                             4010

                                                                             Primary Payer
                                                                             01 = P
                                                                             Values are
                                                                             validated in
                                                                             the NSF
                                                                             map
               3               Patient          6      17x
                               Control
                               Number
               4               Insured         23      30x          S        DA2
                               Address1                                      Sequence 01
                                                                             mapped to
                                                                             N301
                                                                             2010BA
                                                                             (NM101=IL)
                                                                             if patient is
                                                                             the
                                                                             dependent

               5               Insured         53      30x          S        DA2
                               Address2                                      Sequence 01
                                                                             mapped to
                                                                             N302
                                                                             2010BA
                                                                             (NM101=IL)
                                                                             if patient is
                                                                             the
                                                                             dependent

               6               Insured City    83      20x          S        DA2
                                                                             Sequence 01
                                                                             mapped to
                                                                             N401
                                                                             2010BA
                                                                             (NM101=IL)
                                                                             if patient is
                                                                             the
                                                                             dependent
               7               Insured         103      2x         S      DA2
                               State                                      Sequence 01
                                                                          mapped to
                                                                          N402
                                                                          2010BA
                                                                          (NM101=IL)
                                                                          if patient is
                                                                          the
                                                                          dependent

               8               Insured Zip     105      9x         S      DA2
                                                                          Sequence 01
                                                                          mapped to
                                                                          N403
                                                                          2010BA
                                                                          (NM101=IL)
                                                                          if patient is
                                                                          the
                                                                          dependent

               9               Insured         114     10x
                               Phone
              10               Insured         124      8x
                               Retirement
                               Date
                               (CCYYMMD
                               D)
              11               Insurance       132      8x
                               Spouse
                               Retire Date
                               (CCYYMMD
                               D)
              12               Insured         140     33x
                               Employer
                               Name
              13               Insured         173     30x
                               Employer
                               Address1
              14               Insured         203     30x
                               Employer
                               Address2
              15               Insured         233     20x
                               Employer
                               City
              16               Insured         253      2x
                               Employer
                               State
              17               Insured         255      9x
                               Employer Zip

              18               Employee ID     264     12x
                               Number
              19               Filler -        276     45x
                               National




Record type: DA3 – SEQUENCE 1
Insurance Information - Payer Data 4                                        Optional Record
            Field #            Field          Start   Length   NSF        Comment
                               Name                            Required   s and
                                                                          Values
Field #   Field       Start   Length                  Comment
          Name                                        s and
                                        Professiona   Values
                                        l
   1      Record ID     1       3x           R        Value: DA3
          “DA3”                                       Preceded by:
                                                      DA1 or DA2

                                                      Next record:
                                                      DA0 or EA0

   2      Sequence      4       2x           S        Values:
          Number                                      NSF =
                                                      HIPAA-X12 v
                                                      4010


                                                      Primary Payer
                                                      01 = P
                                                      Values are
                                                      validated in
                                                      the NSF
                                                      map
   3      Patient       6      17x
          Control
          Number
   4      Claim        23       6x
          Reason
          Code1
   5      Dollar       29     n(5)v99
          Amount1
   6      Claim        36       6x
          Reason
          Code2
   7      Dollar       42     n(5)v99
          Amount2
   8      Claim        49       6x
          Reason
          Code3
   9      Dollar       55     n(5)v99
          Amount3
  10      Claim        62       6x
          Reason
          Code4
  11      Dollar       68     n(5)v99
          Amount4
  12      Claim        75       6x
          Reason
          Code5
  13      Dollar       81     n(5)v99
          Amount5
  14      Claim        88       6x
          Reason
          Code6
  15      Dollar       94     n(5)v99
          Amount6
  16      Claim        101      6x
          Reason
          Code7
  17      Dollar       107    n(5)v99
          Amount7
              18                Claim           114      5x
                                Message
                                Code1
              19                Claim           119      5x
                                Message
                                Code2
              20                Claim           124      5x
                                Message
                                Code3
              21                Claim           129      5x
                                Message
                                Code4
              22                Claim           134      5x
                                Message
                                Code5
              23                Claim Detail    139      2x
                                Line Count
              24                Claim Adjust    141      1x
                                Indicator

              25                Provider        142    n(5)v99
                                Adjust
                                Amount
              26                Bene Adjust     149    n(5)v99
                                Amount

              27                Orig Approve    156    n(5)v99
                                Amount

              28                Orig Paid       163    n(5)v99
                                Amount
              29                Orig Payor      170     17x
                                Claim
                                Control No
              30                Filler -        187     134x
                                National




Record type: DA0 – SEQUENCE 2 AND 3
Insurance Information Record - Insurance Information                             Required Record
            Field #             Field          Start   Length    NSF           Comment
                                Name                             Required      s and
                                                                 Professiona   Values
                                                                 l
               1                Record ID        1       3x           R        Value: DA0
                                “DA0”                                          Preceded by:
                                                                               CA0, CB0,
                                                                               DA0, DA1,
                                                                               DA2 or DA3

                                                                               Next record:
                                                                               DA0, DA1,
                                                                               DA2, DA3 or
                                                                               EA0

               2                Sequence         4       2x          R         Values:
                                Number                                         NSF =
                                                                               HIPAA-X12 v
                                                                               4010
2   Sequence       4    2x    R
    Number



                                  Secondary
                                  Payer 02 = S
                                  Tertiary Payer
                                  03 = T


                                  DA0
                                  Sequence 02
                                  mapped to
                                  SBR01=S
                                  2320


                                  DA0
                                  Sequence 03
                                  mapped to
                                  SBR01=T
                                  2320


                                  Values are
                                  validated in
                                  the NSF
                                  map
3   Patient        6    17x
    Control
    Number
4   Claim Filing   23   1x
    Indicator
5   Source Of      24   1x    R   Values: NSF =
    Pay                           HIPAA-X12 v
                                  4010

                                  Self Pay A =
                                  09
                                  Central
                                  Certification K
                                  = 10
                                  Blue Cross
                                  Blue Shield G
                                  = BL
                                  CHAMPUS H =
                                  CH
                                  Commercial
                                  Insurance
                                  Company F =
                                  CI
                                  HMO I = HM
                                  Medicare C =
                                  MB
                                  Medicaid D =
                                  MC
                                  Other Federal
                                  Program E =
                                  OF
                                  Federal
                                  Employee
                                  Program (FEP)
                                  J = OF
                                  Workers‟
                                  Compensation
                                  B = WC
                                  Self
                                  Administered
                                  Group L = ZZ
                                  Family or
                                  Friends M = ZZ
                              Managed Care
                              – Non-HMO N
                              = ZZ
                              Indian Health
                              Services O =
                              ZZ
                              Blue Cross P =
                              ZZ
                              Title V T = TV
                              Veteran
                              Administration
                              Plan V = VA
                              Other Z = ZZ


                              DA0
                              Sequence 02
                              mapped to
                              SBR09 2320
                              (SBR01=S)


                              DA0
                              Sequence 03
                              mapped to
                              SBR09 2320
                              (SBR01=T)



                              Values are
                              validated in
                              the NSF
                              map
6   Insurance   25   2x   S   Values: NSF =
    Type Code                 HIPAA-X12 v
                              4010

                              Medigap Policy
                              MG = MG

                              Supplemental
                              Policy SP = SP

                              Individual
                              Policy IP = IP
                              Personal
                              Payment PP =
                              PP
                              Group Policy
                              GP = GP
                              Litigation LT =
                              LT
                              Auto Insurance
                              Policy AP = AP


                              Long Term
                              Policy LT = LT

                              Other OT = OT
                                             Mapp
                                             ed to
                                             SBR0
                                             5
                                             2320
                                             (SBR
                                             01=S)




                                             Mapp
                                             ed to
                                             SBR0
                                             5
                                             2320
                                             (SBR
                                             01=T)




                                      Values are
                                      validated in
                                      the HIPAA
                                      map
 7      Payer          27   5x    S   DA0
        Organization                  Sequence 02
        ID                            mapped to
                                      NM109
                                      2330B
                                      (NM101=PR,
                                      NM108=PI,
                                      SBR01=S
                                      2320)

                                      DA0
                                      Sequence 03
                                      mapped to
                                      NM109
                                      2330B
                                      (NM101=PR,
                                      NM108=PI,
                                      SBR01=T
                                      2320

8-Jul   Redefined as
        National
        Payer ID
 8      Payer Claim    32   4x
        Office
        Number
 9      Payer Name     36   33x   R   DA0
                                      Sequence 02
                                      mapped to
                                      NM103
                                      2330B
                                      (NM101=PR,
                                      SBR01=S
                                      2320)
                                     DA0
                                     Sequence 03
                                     mapped to
                                     NM103
                                     2330B
                                     (NM101=PR,
                                     SBR01=T
                                     2320)
10   Group           69    20x   S   DA0
     Number                          Sequence 02
                                     mapped to
                                     SBR03 2320
                                     (SBR01=S)


                                     DA0
                                     Sequence 03
                                     mapped to
                                     SBR03 2320
                                     (SBR01=T)


11   Group Name      89    33x   S   DA0
                                     Sequence 02
                                     mapped to
                                     SBR04 2320
                                     (SBR01=S)


                                     DA0
                                     Sequence 03
                                     mapped to
                                     SBR04 2320
                                     (SBR01=T)


12   PPO/HMO         122   1x
     Indicator
13   PPO ID          123   15x
14   Prior           138   15x   S   Mapped to
     Authorization                   REF02 2300
     Number                          (REF01=G1)



15   Assign Of       153   1x    S   Values: NSF =
     Benefits                        HIPAA-X12 v
     Indicator                       4010

                                     Yes, benefits
                                     have been
                                     assigned to the
                                     provider and a
                                     signed form is
                                     on file in the
                                     provider‟s
                                     office. Y = Y

                                     No, benefits
                                     have not been
                                     assigned,
                                     insured did not
                                     authorize
                                     payment to
                                     provider.


                                     N=N
                                Pay Other
                                Organization/L
                                egal (for NSF
                                COB)

                                O=


                                     DA0
                                     Sequen
                                     ce 02
                                     mapped
                                     to OI03
                                     2320
                                     (SBR01
                                     =S)


                                     DA0
                                     Sequen
                                     ce 03
                                     mapped
                                     to OI03
                                     2320
                                     (SBR01
                                     =T)


                                     Values
                                     are
                                     validate
                                     d in the
                                     HIPAA
                                     map


16   Patient     154   1x   S   Values:
     Signature                  NSF = HIPAA-
     Source                     X12 v 4010

                                Signed HCFA
                                1500 claim
                                form on file C
                                =C
                                Signed
                                signature
                                authorization
                                form for block
                                12 on file


                                S=S
                                Signed
                                signature
                                authorization
                                form for block
                                13 on file


                                M=M
                                Signed
                                signature
                                authorization
                                form for block
                                12 and 13 on
                                file

                                B       =    B
                                        Signature
                                        generated
                                        by
                                        provider
                                        because
                                        the
                                        patient
                                        was not
                                        physically
                                        present
                                        for



                                        services
                                        P =     P




                                         DA0
                                         Sequen
                                         ce 02
                                         mapped
                                         to OI04
                                         2320
                                         (SBR01
                                         =S)


                                         DA0
                                         Sequen
                                         ce 03
                                         mapped
                                         to OI04
                                         2320
                                         (SBR01
                                         =T)


                                         Values
                                         are
                                         validate
                                         d in the
                                         HIPAA
                                         map


17   Patient        155   2x   S   Values:
     Relationship                  NSF         =
     To Insured                    HIPAA-X12 v
                                   4010
                                   Spouse 02 = 01

                                   Natural
                                   child/insured has
                                   financial
                                   responsibility 03
                                   = 19
                                   Natural
                                   child/insured
                                   does not have
                                   financial
                                   responsibility 04
                                   = 43
                                   Stepchild 05 =
                                   17
                                   Foster child 06 =
                                   10
                                   Ward of the
                                   court 07 = 15
                                  Employee 08 =
                                  20
                                  Unknown 09 =
                                  21
                                  Handicapped
                                  dependent 10 =
                                  22
                                  Organ donor 11
                                  = 39
                                  Cadaver donor
                                  12 = 40
                                  Grandchild 13 =
                                  05
                                  Niece/nephew
                                  14 = 07
                                  Injured plaintiff
                                  15 = 41
                                  Sponsored
                                  dependent 16 =
                                  23
                                  Minor dependent
                                  of a minor
                                  dependent 17 =
                                  24

                                  Parent
                                  18          =
                                  32 or 33
                                  Grandparent 19
                                  = 04


                                        DA0
                                        Sequen
                                        ce 02
                                        mapped
                                        to
                                        SBR02
                                        2320
                                        (SBR01
                                        =S)

                                        DA0
                                        Sequen
                                        ce 03
                                        mapped
                                        to
                                        SBR02
                                        2320
                                        (SBR01
                                        =T)


                                        Values
                                        are
                                        validate
                                        d in the
                                        NSF
                                        map


18   Insured ID   157   25x   S   DA0
     Number                       Sequence 02
                                  mapped to
                                  NM109
                                  2330A
                                  (NM101=IL,
                                  SBR01=S
                                  2320)
     Number




                                     DA0
                                     Sequence 03
                                     mapped to
                                     NM109
                                     2330A
                                     (NM101=IL,
                                     SBR01=T
                                     2320)
19   Insured Last    182   20x   S   DA0
     Name                            Sequence 02
                                     mapped to
                                     NM103
                                     2330A
                                     (NM101=IL,
                                     SBR01=S
                                     2320)
                                     DA0
                                     Sequence 03
                                     mapped to
                                     NM103
                                     2330A
                                     (NM101=IL,
                                     SBR01=T
                                     2320)
20   Insured First   202   12x   S   DA0
     Name                            Sequence 02
                                     mapped to
                                     NM104
                                     2330A
                                     (NM101=IL,
                                     SBR01=S
                                     2320)
                                     DA0
                                     Sequence 03
                                     mapped to
                                     NM104
                                     2330A
                                     (NM101=IL,
                                     SBR01=T
                                     2320)
21   Insured MI      214   1x    S   DA0
                                     Sequence 02
                                     mapped to
                                     NM105
                                     2330A
                                     (NM101=IL,
                                     SBR01=S
                                     2320)
                                     DA0
                                     Sequence 03
                                     mapped to
                                     NM105
                                     2330A
                                     (NM101=IL,
                                     SBR01=T
                                     2320)
22   Insured        215   3x   S   DA0
     Generation                    Sequence 02
                                   mapped to
                                   NM107
                                   2330A
                                   (NM101=IL,
                                   SBR01=S
                                   2320)
                                   DA0
                                   Sequence 03
                                   mapped to
                                   NM107
                                   2330A
                                   (NM101=IL,
                                   SBR01=T
                                   2320)
23   Insured Sex    218   1x   S   Values: NSF =
                                   HIPAA-X12 v
                                   4010


                                   Female F = F
                                   Male M = M
                                   Unknown U =
                                   U



                                   DA0
                                   Sequence 02
                                   mapped to
                                   DMG03
                                   2320
                                   (SBR01=S)
                                   DA0
                                   Sequence 03
                                   mapped to
                                   DMG03
                                   2320
                                   (SBR01=T)
                                   Values are
                                   validated in
                                   the HIPAA
                                   map
24   Insured Date   219   8x   S   DA0
     Of Birth                      Sequence 02
     (CCYYMMD                      mapped to
     D)                            DMG02
                                   2320
                                   (SBR01=S)
                                   DA0
                                   Sequence 03
                                   mapped to
                                   DMG02
                                   2320
                                   (SBR01=T)
25   Insured        227   1x
     Employment
     Status
               26               Supplementa     228      1x
                                l Insurance
                                Indicator

               27               Insurance       229      7x
                                Location ID
               28               Medicaid ID     236      25x
                                NO
               29               Supplementa     261      25x
                                l Patient Id
               30               Assignment      286      1x           S       Values: NSF =
                                4081                                          HIPAA-X12 v
                                Indicator                                     4010

                                                                              4081 1 = Y
                                                                              Regular
                                                                              Crossover 2 =
                                                                              N


                                                                              Mapped to
                                                                              REF02 2300
                                                                              (REF01=F5)

                                                                              Values are
                                                                              validated in
                                                                              the NSF
                                                                              map
               31               COB Routing     287      1x
                                Indicator

               32               Filler -        288      33x
                                National




Record type: DA1 – SEQUENCE 2 AND 3
Insurance Information Record - Insurance Information (Payer Data 2)              Optional Record

            Field #             Field          Start   Length   NSF           Comment
                                Name                            Required      s and
                                                                Professiona   Values
                                                                l
               1                Record ID        1       3x          R        Value: DA1
                                “DA1”
                                                                              Preceded by:
                                                                              DA0
                                                                              Next record:
                                                                              DA0, DA2 or
                                                                              EA0

               2                Sequence         4       2x           S       Values:
                                Number                                        NSF =
                                                                              HIPAA-X12 v
                                                                              4010


                                                                              Secondary
                                                                              Payer 02 = S
                                                                              Tertiary Payer
                                                                              03 =       T
    Number




                                      Values are
                                      validated in
                                      the NSF
                                      map
3   Patient       6      17x
    Control
    Number
4   Payer         23     30x
    Address1
5   Payer         53     30x
    Address2
6   Payer City    83     20x
7   Payer State   103     2x
8   Payer Zip     105     9x
9   Disallowed    114   n(5)v99   S   If any of the
    Cost                              following
    Containment                       fields are
                                      greater than
                                      0, the sum of
                                      DA1.09 and
                                      DA1.10 and
                                      DA1.11 and
                                      DA1.33 and
                                      DA3.25 and
                                      DA3.26 will
                                      be mapped
                                      to the
                                      following
                                      with A2 as
                                      the
                                      Adjustment
                                      Reason
                                      Code:




                                      DA1
                                      Sequence 02
                                      mapped to
                                      CAS03 2320
                                      (SBR01=S)


                                      DA1
                                      Sequence 03
                                      mapped to
                                      CAS03 2320
                                      (SBR01=T)
10   Disallowed   121   n(5)v99   S   If any of the
     Other                            following
                                      fields are
                                      greater than
                                      0, the sum of
                                      DA1.09 and
                                      DA1.10 and
                                      DA1.11 and
                                      DA1.33 and
                                      DA3.25 and
                                      DA3.26 will
                                      be mapped
                                      to the
                                      following
                                      with A2 as
                                      the
                                      Adjustment
                                      Reason
                                      Code:




                                      DA1
                                      Sequence 02
                                      mapped to
                                      CAS03 or
                                      CAS06 2320
                                      (SBR01=S)


                                      DA1
                                      Sequence 03
                                      mapped to
                                      CAS03 or
                                      CAS06 2320
                                      (SBR01=T)


11   Allowed      128   n(5)v99   S   If any of the
     Amount                           following
                                      fields are
                                      greater than
                                      0, the sum of
                                      DA1.09 and
                                      DA1.10 and
                                      DA1.11 and
                                      DA1.33 and
                                      DA3.25 and
                                      DA3.26 will
                                      be mapped
                                      to the
                                      following
                                      with A2 as
                                      the
                                      Adjustment
                                      Reason
                                      Code:
                                       DA1
                                       Sequence 02
                                       mapped to
                                       CAS03,
                                       CAS06, or
                                       CAS09 2320
                                       (SBR01=S)


                                       DA1
                                       Sequence 03
                                       mapped to
                                       CAS03,
                                       CAS06, or
                                       CAS09 2320
                                       (SBR01=T)


12   Deductible    135   n(5)v99   S   Will be
     Amount                            mapped to
                                       the following
                                       with 1 as the
                                       Adjustment
                                       Reason
                                       Code:



                                       DA1
                                       Sequence 02
                                       mapped to
                                       CAS03,
                                       CAS06,
                                       CAS09, or
                                       CAS12 2320
                                       (SBR01=S)


                                       DA1
                                       Sequence 03
                                       mapped to
                                       CAS03,
                                       CAS06,
                                       CAS09, or
                                       CAS12 2320
                                       (SBR01=T)


13   Coinsurance   142   n(5)v99   S   Will be
     Amount                            mapped to
                                       the following
                                       with 2 as the
                                       Adjustment
                                       Reason
                                       Code:



                                       DA1
                                       Sequence 02
                                       mapped to
                                       CAS03 2320
                                       (SBR01=S)
                                        DA1
                                        Sequence 03
                                        mapped to
                                        CAS03 2320
                                        (SBR01=T)


14   Payer          149   n(5)v99
     Amount
     Field
15   Zero Pay       156     1x
     Indicator
16   Adjudication   157     2x
     Indicator 1

17   Adjudication   159     2x
     Indicator 2

18   Adjudication   161     2x
     Indicator 3

19   Champus        163     1x
     Sponsor
     Branch
20   Champus        164     2x
     Sponsor
     Grade
21   Champus        166     1x
     Sponsor
     Status
22   Insurance      167     8x
     Card
     Effective
     Date
     (CCYYMMD
     D)
23   Insurance      175     8x
     Card
     Termination
     Date
     (CCYYMMD
     D)
24   Balance Due    183   n(5)v99

25   EOMB Date1     190     8x
     (CCYYMMD
     D)

26   EOMB Date2     198     8x
     (CCYYMMD
     D)

27   EOMB Date3     206     8x      S   DA1
     (CCYYMMD                           Sequence 02
     D)                                 mapped to
                                        DTP03
                                        2330B
                                        (DTP01=573
                                        ,
                                        NM101=PR)
     (CCYYMMD
     D)




                                        DA1
                                        Sequence 03
                                        mapped to
                                        DTP03
                                        2330B
                                        (DTP01=573
                                        ,
                                        NM101=PR)
28   EOMB Date4     214     8x
     (CCYYMMD
     D)

29   Claim          222     8x
     Receipt Date
     (CCYYMMD
     D)

30   Amt Paid to    230   n(7)v99   S   Will be
     Beneficiary                        mapped to
                                        the following
                                        with 100 as
                                        the
                                        Adjustment
                                        Reason
                                        Code:


                                        DA1
                                        Sequence 02
                                        mapped to
                                        CAS03 2320
                                        (SBR01=S)


                                        DA1
                                        Sequence 03
                                        mapped to
                                        CAS03 2320
                                        (SBR01=T)


31   Bene           239    15x
     Check/EFT
     Trace No
32   Bene Check     254     8x
     Date
     (CCYYMMD
     D)
33   Amt Paid to     262   n(7)v99   S   If any of the
     Provider                            following
                                         fields are
                                         greater than
                                         0, the sum of
                                         DA1.09 and
                                         DA1.10 and
                                         DA1.11 and
                                         DA1.33 and
                                         DA3.25 and
                                         DA3.26 will
                                         be mapped
                                         to the
                                         following
                                         with A2 as
                                         the
                                         Adjustment
                                         Reason
                                         Code:




                                         DA1
                                         Sequence 02
                                         mapped to
                                         CAS03 or
                                         CAS06 2320
                                         (SBR01=S)


                                         DA1
                                         Sequence 03
                                         mapped to
                                         CAS03 or
                                         CAS06 2320
                                         (SBR01=T)


34   Prov            271    15x
     Check/EFT
     Trace No
35   Provider        286     8x
     Check Date
     (CCYYMMD
     D)
36   Interest Paid   294   n(7)v99

37   Approved        303   n(7)v99   S   DA1
     Amount                              Sequence 02
                                         mapped to
                                         AMT02 2320
                                         (AMT01=AA
                                         E,
                                         SBR01=S)
                               Amount




                                                                              DA1
                                                                              Sequence 03
                                                                              mapped to
                                                                              AMT02 2320
                                                                              (AMT01=AA
                                                                              E,
                                                                              SBR01=T)


              38               Contract         312      1x
                               Agreement
                               Indicator
              39               Filler -         313      8x
                               National




Record type: DA2 – SEQUENCE 2          AND 3
Insurance Information - Payer Data 3                                             Optional Record
            Field #            Field           Start   Length   NSF           Comment
                               Name                             Required      s and
                                                                Professiona   Values
                                                                l
               1               Record ID         1       3x          R        Value: DA2
                               “DA2”                                          Preceded by:
                                                                              DA0 or DA1

                                                                              Next record:
                                                                              DA0, DA2 or
                                                                              EA0

               2               Sequence          4       2x          S        Values:
                               Number                                         NSF =
                                                                              HIPAA-X12 v
                                                                              4010

                                                                              Secondary
                                                                              Payer 02 = S
                                                                              Tertiary Payer
                                                                              03 = T
                                                                              Values are
                                                                              validated in
                                                                              the NSF
                                                                              map
               3               Patient           6      17x
                               Control
                               Number
               4               Insured          23      30x          S        DA2
                               Address1                                       Sequence 02
                                                                              mapped to
                                                                              N301 2330A
                                                                              (NM101=IL,
                                                                              SBR01=S)


                                                                              DA2
                                                                              Sequence 03
                                                                              mapped to
                                                                              N301 2330A
                                                                              (NM101=IL,
                                                                              SBR01=T)
5   Insured        53    30x   S   DA2
    Address2                       Sequence 01
                                   mapped to
                                   N302
                                   2010BA
                                   (NM101=IL)
                                   if patient is
                                   the
                                   dependent

                                   DA2
                                   Sequence 02
                                   mapped to
                                   N302 2330A
                                   (NM101=IL,
                                   SBR01=S)


                                   DA 2
                                   Sequence 03
                                   mapped to
                                   N302 2330A
                                   (NM101=IL,
                                   SBR01=T)


6   Insured City   83    20x   S   DA2
                                   Sequence 02
                                   mapped to
                                   N401 2330A
                                   (NM101=IL,
                                   SBR01=S)


                                   DA2
                                   Sequence 03
                                   mapped to
                                   N401 2330A
                                   (NM101=IL,
                                   SBR01=T)


7   Insured        103   2x    S   DA2
    State                          Sequence 02
                                   mapped to
                                   N402 2330A
                                   (NM101=IL,
                                   SBR01=S)


                                   DA2
                                   Sequence 03
                                   mapped to
                                   N402 2330A
                                   T
                                   (NM101=IL,
                                   SBR01=T)
8   Insured Zip    105   9x    S   DA2
                                   Sequence 02
                                   mapped to
                                   N403 2330A
                                   (NM101=IL,
                                   SBR01=S)
               8               Insured Zip      105      9x          S




                                                                              DA2
                                                                              Sequence 03
                                                                              mapped to
                                                                              N403 2330A
                                                                              (NM101=ILS
                                                                              BR01=T)


               9               Insured          114     10x
                               Phone
              10               Insured          124      8x
                               Retirement
                               Date
                               (CCYYMMD
                               D)
              11               Insurance        132      8x
                               Spouse
                               Retire Date
                               (CCYYMMD
                               D)
              12               Insured          140     33x
                               Employer
                               Name
              13               Insured          173     30x
                               Employer
                               Address1
              14               Insured          203     30x
                               Employer
                               Address2
              15               Insured          233     20x
                               Employer
                               City
              16               Insured          253      2x
                               Employer
                               State
              17               Insured          255      9x
                               Employer Zip

              18               Employee ID      264     12x
                               Number
              19               Filler -         276     45x
                               National




Record type: DA3 – SEQUENCE 2          AND 3
Insurance Information - Payer Data 4                                            Optional Record
            Field #            Field           Start   Length   NSF           Comment
                               Name                             Required      s and
                                                                Professiona   Values
                                                                l
               1               Record ID         1       3x          R        Value: DA3
                               “DA3”                                          Preceded by:
                                                                              DA1 or DA2

                                                                              Next record:
                                                                              DA0 or EA0
2   Sequence   4      2x      S   Values:
    Number                        NSF =
                                  HIPAA-X12 v
                                  4010


                                  Secondary
                                  Payer 02 = S
                                  Tertiary Payer
                                  03 =       T
                                  Values are
                                  validated in
                                  the NSF
                                  map
3   Patient    6     17x
    Control
    Number
4   Claim      23     6x      S   DA3
    Reason                        Sequence 02
    Code1                         mapped to
                                  CAS02 2320
                                  (SBR01=S)


                                  DA3
                                  Sequence 03
                                  mapped to
                                  CAS02 2320
                                  (SBR01=T)


5   Dollar     29   n(5)v99   S   DA3
    Amount1                       Sequence 02
                                  mapped to
                                  CAS03 2320
                                  (SBR01=S)


                                  DA3
                                  Sequence 03
                                  mapped to
                                  CAS03 2320
                                  (SBR01=T)


6   Claim      36     6x      S   DA3
    Reason                        Sequence 02
    Code2                         mapped to
                                  CAS02 or
                                  CAS05 2320
                                  (SBR01=S)


                                  DA3
                                  Sequence 03
                                  mapped to
                                  CAS02 or
                                  CAS05 2320
                                  (SBR01=T)
7    Dollar    42   n(5)v99   S   DA3
     Amount2                      Sequence 02
                                  mapped to
                                  CAS03 or
                                  CAS06 2320
                                  (SBR01=S)


                                  DA3
                                  Sequence 03
                                  mapped to
                                  CAS03 or
                                  CAS06 2320
                                  (SBR01=T)


8    Claim     49     6x      S   DA3
     Reason                       Sequence 02
     Code3                        mapped to
                                  CAS02,
                                  CAS05, or
                                  CAS08 2320
                                  (SBR01=S)


                                  DA3
                                  Sequence 03
                                  mapped to
                                  CAS02,
                                  CAS05, or
                                  CAS08 2320
                                  (SBR01=T)


9    Dollar    55   n(5)v99   S   DA3
     Amount3                      Sequence 02
                                  mapped to
                                  CAS03,
                                  CAS06, or
                                  CAS09 2320
                                  (SBR01=S)


                                  DA3
                                  Sequence 03
                                  mapped to
                                  CAS03,
                                  CAS06, or
                                  CAS09 2320


10   Claim     62     6x      S   DA3
     Reason                       Sequence 02
     Code4                        mapped to
                                  CAS02,
                                  CAS05,
                                  CAS08, or
                                  CAS11 2320
                                  (SBR01=S)
     Code4




                                  DA3
                                  Sequence 03
                                  mapped to
                                  CAS02,
                                  CAS05,
                                  CAS08, or
                                  CAS11 2320
                                  (SBR01=T)


11   Dollar    68   n(5)v99   S   DA3
     Amount4                      Sequence 02
                                  mapped to
                                  CAS03,
                                  CAS06,
                                  CAS09, or
                                  CAS12 2320
                                  (SBR01=S)


                                  DA3
                                  Sequence 03
                                  mapped to
                                  CAS03,
                                  CAS06,
                                  CAS09, or
                                  CAS12 2320
                                  (SBR01=T)


12   Claim     75     6x      S   DA3
     Reason                       Sequence 02
     Code5                        mapped to
                                  CAS02 2320
                                  (SBR01=S)


                                  DA3
                                  Sequence 03
                                  mapped to
                                  CAS02 2320
                                  (SBR01=T)


13   Dollar    81   n(5)v99   S   DA3
     Amount5                      Sequence 02
                                  mapped to
                                  CAS03 2320
                                  (SBR01=S)


                                  DA3
                                  Sequence 03
                                  mapped to
                                  CAS03 2320
                                  (SBR01=T)


14   Claim     88     6x      S   DA3
     Reason                       Sequence 02
     Code6                        mapped to
                                  CAS02 or
                                  CAS05 2320
                                  (SBR01=S)
14   Claim     88      6x      S
     Reason
     Code6




                                   DA3
                                   Sequence 03
                                   mapped to
                                   CAS02 or
                                   CAS05 2320
                                   (SBR01=T)


15   Dollar    94    n(5)v99   S   DA3
     Amount6                       Sequence 02
                                   mapped to
                                   CAS03 or
                                   CAS06 2320
                                   (SBR01=S)


                                   DA3
                                   Sequence 03
                                   mapped to
                                   CAS03 or
                                   CAS06 2320
                                   (SBR01=T)


16   Claim     101     6x      S   DA3
     Reason                        Sequence 02
     Code7                         mapped to
                                   CAS02,
                                   CAS05, or
                                   CAS08 2320
                                   (SBR01=S)


                                   DA3
                                   Sequence 03
                                   mapped to
                                   CAS02,
                                   CAS05, or
                                   CAS08 2320
                                   (SBR01=T)


17   Dollar    107   n(5)v99   S   DA3
     Amount7                       Sequence 02
                                   mapped to
                                   CAS03,
                                   CAS06, or
                                   CAS09 2320
                                   (SBR01=S)


                                   DA3
                                   Sequence 03
                                   mapped to
                                   CAS03,
                                   CAS06, or
                                   CAS09 2320
                                   (SBR01=T)


18   Claim     114     5x      S   DA3
     Message                       Sequence 02
     Code1                         mapped to
                                   MOA03 2320
                                   (SBR01=S)
18   Claim     114   5x   S
     Message
     Code1




                              DA3
                              Sequence 03
                              mapped to
                              MOA03 2320
                              (SBR01=T)


19   Claim     119   5x   S   DA3
     Message                  Sequence 02
     Code2                    mapped to
                              MOA03 or
                              MOA04 2320
                              (SBR01=S)


                              DA3
                              Sequence 03
                              mapped to
                              MOA03 or
                              MOA04 2320
                              (SBR01=T)


20   Claim     124   5x   S   DA3
     Message                  Sequence 02
     Code3                    mapped to
                              MOA03,
                              MOA04, or
                              MOA05 2320
                              (SBR01=S)


                              DA3
                              Sequence 03
                              mapped to
                              MOA03,
                              MOA04, or
                              MOA05 2320
                              (SBR01=T)


21   Claim     129   5x   S   DA3
     Message                  Sequence 02
     Code4                    mapped to
                              MOA03,
                              MOA04,
                              MOA05, or
                              MOA06 2320
                              (SBR01=S)


                              DA3
                              Sequence 03
                              mapped to
                              MOA03,
                              MOA04,
                              MOA05, or
                              MOA06 2320
                              (SBR01=T)
22   Claim          134   5x   S   DA3
     Message                       Sequence 02
     Code5                         mapped to
                                   MOA03,
                                   MOA04,
                                   MOA05,
                                   MOA06, or
                                   MOA07 2320
                                   (SBR01=S)


                                   DA3
                                   Sequence 03
                                   mapped to
                                   MOA03,
                                   MOA04,
                                   MOA05,
                                   MOA06, or
                                   MOA07 2320
                                   (SBR01=T)


23   Claim Detail   139   2x
     Line Count
24   Claim Adjust   141   1x   S   Values: NSF =
     Indicator                     HIPAA-X12 v
                                   4010
                                   Adjustment to
                                   Prior Claim Y =
                                   Y
                                   Not an
                                   adjustment to a
                                   prior claim
                                   Blank = Not
                                   mapped

                                   DA3
                                   Sequence 02
                                   mapped to
                                   REF02
                                   2330B
                                   (REF01=T4,
                                   NM101=PR,
                                   SBR01=S)
                                   DA3
                                   Sequence 03
                                   mapped to
                                   REF02
                                   2330B
                                   (REF01=T4,
                                   NM101=PR,
                                   SBR01=T)
                                   Values are
                                   validated in
                                   the NSF
                                   map
25   Provider      142   n(5)v99   S   If any of the
     Adjust                            following
     Amount                            fields are
                                       greater than
                                       0, the sum of
                                       DA1.09 and
                                       DA1.10 and
                                       DA1.11 and
                                       DA1.33 and
                                       DA3.25 and
                                       DA3.26 will
                                       be mapped
                                       to the
                                       following
                                       with A2 as
                                       the
                                       Adjustment
                                       Reason
                                       Code:




                                       DA3
                                       Sequence 02
                                       mapped to
                                       CAS03,
                                       CAS06, or
                                       CAS09 2320
                                       (SBR01=S)


                                       DA3
                                       Sequence 03
                                       mapped to
                                       CAS03,
                                       CAS06, or
                                       CAS09 2320
                                       (SBR01=T)


26   Bene Adjust   149   n(5)v99   S   If any of the
     Amount                            following
                                       fields are
                                       greater than
                                       0, the sum of
                                       DA1.09 and
                                       DA1.10 and
                                       DA1.11 and
                                       DA1.33 and
                                       DA3.25 and
                                       DA3.26 will
                                       be mapped
                                       to the
                                       following
                                       with A2 as
                                       the
                                       Adjustment
                                       Reason
                                       Code:
                                                                                           DA3
                                                                                           Sequence 02
                                                                                           mapped to
                                                                                           CAS03,
                                                                                           CAS06,
                                                                                           CAS09, or
                                                                                           CAS12 2320
                                                                                           (SBR01=S)


                                                                                           DA3
                                                                                           Sequence 03
                                                                                           mapped to
                                                                                           CAS03,
                                                                                           CAS06,
                                                                                           CAS09, or
                                                                                           CAS12 2320
                                                                                           (SBR01=T)


               27                 Orig Approve    156     n(5)v99
                                  Amount

               28                 Orig Paid       163     n(5)v99
                                  Amount
               29                 Orig Payor      170      17x
                                  Claim
                                  Control No
               30                 Filler -        187      134x
                                  National




Record type: EA0
Claim Record – Claim Data                                                                    Required Record
If the claim is being submitted for a type of provider that does not require a principle
diagnosis code (i.e. funeral director) the claim cannot be submitted in the NSF format.
The HIPAA Professional Implementation Guide requires a principle diagnosis code.


             Field #              Field          Start   Length     NSF                    Comment
                                  Name                              Required               s and
                                                                    Professiona            Values
                                                                    l
                1                 Record ID        1        3x           R                 Value: EA0
                                  “EA0”                                                    Preceded by:
                                                                                           DA0, DA1, or
                                                                                           DA2, DA3?

                                                                                           Next record:
                                                                                           EA1, EA2 or
                                                                                           FA0

                2                 Reserved         4        2x
                                  (EA0.02)
                3                 Patient          6       17x
                                  Control
                                  Number
                4                 Employment      23        1x           S                 Values: NSF =
                                  Related                                                  HIPAA-X12 v
                                  Indicator                                                4010
4   Employment   23   1x   S
    Related
    Indicator
                               Yes,
                               employment
                               related Y = EM

                               No, not
                               employment
                               relate N =
                               Unknown U =


                               Mapped to
                               CLM11-1 or
                               CLM11-2
                               2300
                               Values are
                               validated in
                               the NSF
                               map
5   Accident     24   1x   S   Values: NSF =
    Indicator                  HIPAA-X12 v
                               4010
                               Auto Accident
                               A = AA

                               Other, non-
                               auto accident
                               O = OA
                               No accident N
                               =


                               Mapped to
                               CLM11-1
                               2300
                               Values are
                               validated in
                               the NSF
                               map
6   Symptom      25   1x   S   Values:
    Indicator                  NSF     -
                               HIPAA-X12 v
                               4010 Mapping



                               No symptom
                               date in EA0-07
                               0       -
                               DTP01=439
                               Date of first
                               symptoms of
                               illness 1
                               -
                               DTP01=431
                               Date of LMP
                               2        -
                               DTP01=484


                                Must be
                               present to
                               map EA0-07,
                               or EA0-07
                               and EA0-11


                               Values are
                               validated in
                               the NSF
                               map
7    Accident/Sy     26   8x   S
     mptom Date                    If EA0.05 =
     (CCYYMMD                      A or O then
     D)                            must be
                                   present.
                                   If present,
                                   EA0-06 is
                                   required.


                                   Mapped to
                                   DTP03 2300
                                   (DTP01=439
                                   ), DTP03
                                   2300
                                   (DTP01=431
                                   ), or DTP03
                                   2300
                                   (DTP01=484
                                   )



8    Ext Cause       34   5x
     Of Accident

9    Responsibilit   39   1x   S   Values: NSF =
     y Indicator                   HIPAA-X12 v
                                   4010
                                   Accident or
                                   illness was
                                   caused by
                                   another party Y
                                   = AP
                                   Accident or
                                   illness was not
                                   caused by
                                   another party N
                                   =

                                   Mapped to
                                   CLM11-1 or
                                   CLM11-2 or
                                   CLM11-3
                                   2300
                                   Values are
                                   validated in
                                   the NSF
                                   map
10   Accident        40   2x   S   Mapped to
     State                         CLM11-4
                                   2300
11   Accident        42   2x   S
     Hour                          Field is
                                   appended to
                                   EA0-07 and
                                   mapped to
                                   DTP03
                                   (DTP01=439
                                   ,
                                   DTP02=DT)
12   Abuse         44   1x
     Indicator
13   Release Of    45   1x   S   Values:
     Information                 NSF =
     Indicator                   HIPAA-X12 v
                                 4010
                                 Yes, the
                                 provider has on
                                 file a signed
                                 statement
                                 permitting the
                                 release of
                                 medical/billing
                                 information for
                                 purposes of
                                 claiming
                                 insurance
                                 benefits


                                 Y         =
                                 Modified or
                                 Restricted
                                 Release, the
                                 provider has
                                 limited or
                                 restricted
                                 authority to
                                 release some
                                 medical/billing
                                 information for
                                 purposes of
                                 claiming
                                 insurance
                                 benefits.
                                 M         =
                                 M
                                 No Release,
                                 the provider
                                 does not have
                                 permission to
                                 release any
                                 medical/billing
                                 information


                                 N        =
                                 N


                                      Mapped
                                      to
                                      CLM09
                                      2300
                                      ______
                                      ______
                                      ______
                                      ______
                                      ______
                                      ______
                                      ______
                                      ______
                                      ______
                                      __
                                        Mapped
                                        to OI06
                                        2320
                                        (SBR01
                                        =S)


                                        Mapped
                                        to OI06
                                        2320
                                        (SBR01
                                        =T)


                                        Values
                                        are
                                        validate
                                        d in the
                                        HIPAA
                                        map


14   Release Of      46   8x
     Information
     Date
     (CCYYMMD
     D)
15   Same/Simila     54   1x
     r Symptom
     Indicator
16   Same/Simila     55   8x    S   Mapped to
     r Symptom                      DTP03 2300
     Date                           (DTP01=438
     (CCYYMMD                       )
     D)
17   Disability      63   1x
     Type
18   Disability-     64   8x    S   Mapped to
     From Date                      DTP03 2300
     (CCYYMMD                       (DTP01=360
     D)                             )

19   Disability-To   72   8x    S   Mapped to
     Date                           DTP03 2300
     (CCYYMMD                       (DTP01=361
     D)                             )

20   Referring       80   15x   S   Mapped to
     Provider NPI                   NM109
                                    2310A
                                    (NM101=DN)

21   Referring       95   15x   S   Mapped to
     Provider                       REF02
     UPIN                           2310A
                                    (REF01=1G,
                                    NM101=DN)
                                    if EA0-24 is
                                    present
22   Referring       110     1x
     Prov Tax
     Type
23   Referring       111     9x      S   If EA0-20 is
     Prov Tax ID                         present,
                                         mapped to
                                         NM109
                                         2310A
                                         (NM101=DN)
                                         ; otherwise,
                                         mapped to
                                         REF02
                                         2310A
                                         (REF01=EI,
                                         NM101=DN)


24   Referring       120    20x      S   Mapped to
     Provider Last                       NM103
                                         2310A
                                         (NM101=DN)

25   Referring       140    12x      S   Mapped to
     Provider                            NM104
     First                               2310A
                                         (NM101=DN)

26   Referring       152     1x      S   Mapped to
     Provider MI                         NM105
                                         2310A
                                         (NM101=DN)

27   Referring       153     2x
     Provider
     State
28   Admission       155     8x      S   Mapped to
     Date-1                              DTP03 2300
     (CCYYMMD                            (DTP01=435
     D)                                  )

29   Discharge       163     8x      S   Mapped to
     Date-1                              DTP03 2300
     (CCYYMMD                            (DTP01=096
     D)                                  )

30   Laboratory      171     1x
     Indicator
31   Laboratory      172   n(5)v99   S   Mapped to
     Charges                             AMT02 2300
                                         (AMT01=NE)



32   Diagnosis       179     5x      S   Mapped to
     Code-1                              HI01-2 2300
                                         (HI01-1=BK)

33   Diagnosis       184     5x      S   Mapped to
     Code-2                              HI02-2 2300
                                         (HI02-1=BF)
33   Diagnosis      184   5x   S
     Code-2



                                   EA0-32 must
                                   be present

34   Diagnosis      189   5x   S   Mapped to
     Code-3                        HI03-2 2300
                                   (HI03-1=BF)

                                   EA0-32 and
                                   EA0-33 must
                                   be present

35   Diagnosis      194   5x   S   Mapped to
     Code-4                        HI04-2 2300
                                   (HI04-1=BF)

                                   EA0-32, EA0-
                                   33, and EA0-
                                   34 must be
                                   present

36   Provider       199   1x   S   Values:
     Assign Ind                    NSF     =
                                   HIPAA-X12 v
                                   4010
                                   Assigned A = A

                                   Not Assigned
                                   N=C
                                   Assignment
                                   accepted on
                                   Clinical Lab
                                   services only B
                                   =B
                                   Patient
                                   Refuses to
                                   Assign Benefits
                                   P=P



                                   Mapped to
                                   CLM07 2300

                                   Values are
                                   validated in
                                   the NSF
                                   map
37   Provider       200   1x   S   Values:
     Signature On                  NSF         =
     File                          HIPAA-X12 v
                                   4010
                                   Signature of
                                   provider is on
                                   file          Y
                                   = Y
                                   Signature of
                                   provider is not
                                   on file
                                   N         = N

                                   Mapped to
                                   CLM06 2300
                                     Values are
                                     validated in
                                     the HIPAA
                                     map
38   Provider        201   8x
     Signature
     Date
     (CCYYMMD
     D)
39   Facility/Labo   209   33x   S   Mapped to
     ratory Name                     NM103
                                     2310D
                                     (NM101=FA)

40   Documentati     242   1x    S   Values: NSF =
     on Indicator                    HIPAA-X12 v
                                     4010
                                     In Mail 1 = BM
                                     Fax 2 = FX
                                     On file at
                                     Provider‟s site
                                     3 = AA
                                     On file at
                                     Payer‟s site 4 =

                                     Cert Record in
                                     this claim 5 =

                                     Narrative
                                     Record
                                     included in this
                                     claim 6 =
                                     No
                                     documentation
                                     9=


                                          Mapped
                                          to
                                          PWK02
                                          2300
                                          Value
                                          “9” will
                                          only be
                                          passed
                                          to the
                                          HIPAA
                                          map if
                                          EA0-41
                                          contains
                                          a value.
If this
field
contains
value
“9” and
EA0-41
is blank,
the
PWK
will not
be
created.




PWK05
will
contain
value
“AC”
when
NSF
values
“1” or
“2” are
used.


  PWK
  06 will
  contai
  n
  value
  “NSF
  INPU
  T
  NOT
  AVAI
  LABL
  E”
  when
  NSF
  value
  s “1”
  or “2”
  are
  used.
                                           Value
                                           s are
                                           valida
                                           ted in
                                           the
                                           NSF
                                           map



41   Type Of       243   1x   S   Values: NSF =
     Documentati                  HIPAA-X12 v
     on                           4010
                                  DME
                                  Prescription A
                                  = B2
                                  Explanation of
                                  benefits (MSP
                                  or COB) B =
                                  EB
                                  Diagnostic
                                  Report C = DG

                                  Operative note
                                  D = OB
                                  PEN
                                  Certification E
                                  = CT
                                  Ambulance
                                  Certification F
                                  = CT
                                  Physical
                                  Therapy
                                  Certification G
                                  = PZ
                                  Chiropractic
                                  Certification H
                                  = OZ
                                  Prosthetics/Ort
                                  hotic
                                  Certification I =
                                  PO
                                  Oxygen
                                  Prescription J
                                  = B2
                                  Multiple
                                  Documentation
                                  Items Y = OZ

                                  Other Z =


                                        Mapped
                                        to
                                        PWK01
                                        2300
                                       This
                                       field
                                       must be
                                       blank if
                                       field
                                       EA0-40
                                       contains
                                       NSF
                                       value
                                       “9”




                                       Values
                                       are
                                       validate
                                       d in the
                                       NSF
                                       map


42   Functional    244   2x
     Status Code

43   Special       246   2x   S   Values: NSF =
     Program                      HIPAA-X12 v
     Indicator                    4010
                                  Special
                                  Federal
                                  Funding 03 =
                                  03
                                  Disability 05 =
                                  05
                                  PPV/Medicare
                                  100% Payment
                                  06 =
                                  Induced
                                  Abortion –
                                  Danger to Life
                                  07 = 07
                                  Induced
                                  Abortion –
                                  Rape or Incest
                                  08 = 08
                                  Second
                                  Opinion/Surger
                                  y 09 = 09
                                  Medicare
                                  Demo Project
                                  for Lung
                                  Volume
                                  reduction
                                  Surgery Study

                                  30 =
                                  Champus
                                  Program
                                  Handicapped-
                                  Patient is
                                  Sponsor

                                  A=
                                  Champus
                                  Program
                                  Handicapped-
                                  Patient is
                                  Spouse

                                  B=
Champus
Program
Handicapped-
Patient is
Widow of
Sponsor

D=
Champus
Program
Handicapped-
Patient is a
Child; PFTH
Suffix is
unknown

W=
Champus
Program
Handicapped-
Patient is a
Child; PFTH
Suffix is known


C1 =
Champus
Program
Handicapped-
Patient is a
Child; PFTH
Suffix is known

C2 =
Champus
Program
Handicapped-
Patient is a
Child; PFTH
Suffix is known

C3 =
Champus
Program
Handicapped-
Patient is a
Child; PFTH
Suffix is known

C4 =
Champus
Program
Handicapped-
Patient is a
Child; PFTH
Suffix is known

C5 =
Champus
Program
Handicapped-
Patient is a
Child; PFTH
Suffix is known

C6 =
                                   Champus
                                   Program
                                   Handicapped-
                                   Patient is a
                                   Child; PFTH
                                   Suffix is known

                                   C7 =
                                   Champus
                                   Program
                                   Handicapped-
                                   Patient is a
                                   Child; PFTH
                                   Suffix is known

                                   C8 =
                                   Champus
                                   Program
                                   Handicapped-
                                   Patient is a
                                   Child; PFTH
                                   Suffix is known

                                   C9 =
                                   Mapped to
                                   CLM12 2300



                                   Values are
                                   validated in
                                   the HIPAA
                                   map
44   Champus       248   1x
     Non-
     available
     Indicator
45   Supervising   249   1x
     Provider
     Indicator
46   Sub/Resubm    250   2x
     ission Code

47   Resubmissio   252   15x   S   If present,
     n Reference                   2300 CLM05-
     No.                           3 will contain
                                   a „7‟ and
                                   data will be
                                   mapped to
                                   REF02 2300
                                   (REF01=F8)



48   Date Last     267   8x    S   Mapped to
     Seen                          DTP03 2300
     (CCYYMMD                      (DTP01=304
     D)                            )

49   Date          275   8x
     Document
     Sent
     (CCYYMMD
     D)
              50            Homebound      283      1x          S        Values: NSF =
                            Ind                                          HIPAA-X12 v
                                                                         4010
                                                                         Patient is
                                                                         homebound Y
                                                                         = IH
                                                                         Patient is not
                                                                         homebound N
                                                                         =


                                                                         Mapped to
                                                                         CRC02 2300
                                                                         (CRC01=75,
                                                                         CRC03=IH)



                                                                         Values are
                                                                         validated in
                                                                         the NSF
                                                                         map
              51            Blood Units    284      3x
                            Paid
              52            Blood Units    287      3x
                            Remaining
              53            CPO            290      6x          S        Mapped to
                            Provider                                     REF02
                            Number                                       2310D
                                                                         (REF01=N5,
                                                                         NM101=FA)
              54            IDE Number     296     15x          S        Mapped to
                                                                         REF02 2300
                                                                         (REF01=LX)



              55            Filler -       311     10x
                            National




Record type: EA1
Claim Record - Claim Data                                                   Optional Record
            Field #         Field         Start   Length   NSF           Comment
                            Name                           Required      s and
                                                           Professiona   Values
                                                           l
               1            Record ID       1       3x          R        Value: EA1
                            “EA1”                                        Preceded by:
                                                                         EA0
                                                                         Next record:
                                                                         EA2 or FA0

               2            Reserved        4       2x
                            (EA1.02)
               3            Patient         6      17x
                            Control
                            Number
4    Facility/Labo   23    15x   S   Mapped to
     ratory NPI                      NM109
                                     2310D
                                     (NM101=FA,
                                     NM108=XX)


5    Reserved        38    15x
     (EA1.05)
6    Facility/Labo   53    30x   S   Mapped to
     ratory                          N301 2310D
     Address1                        (NM101=FA)



7    Facility/Labo   83    30x   S   Mapped to
     ratory                          N302 2310D
     Address2                        (NM101=FA)



8    Facility/Labo   113   20x   S   Mapped to
     ratory City                     N401 2310D
                                     (NM101=FA)



9    Facility/Labo   133   2x    S   Mapped to
     ratory State                    N402 2310D
                                     (NM101=FA)



10   Facility/Labo   135   9x    S   Mapped to
     ratory Zip                      N403 2310D
     Code                            (NM101=FA)



11   Medical         144   17x
     Record
     Number
12   Return To       161   8x    S   Mapped to
     Work Date                       DTP03 2300
     (CCYYMMD                        (DTP01=296
     D)                              )

13   Consult/Surg    169   8x
     ery Date
     (CCYYMMD
     D)
14   Admission       177   8x
     Date-2
     (CCYYMMD
     D)
15   Discharge       185   8x
     Date-2
     (CCYYMMD
     D)
16   Supervising     193   15x   S   Mapped to
     Provider NPI                    NM109
                                     2310E
                                     (NM101=DQ,
                                     NM108=XX)
              17               Reserved         208     15x
                               (EA1.17)
              18               Supervising      223     20x          S        Mapped to
                               Provider Last                                  NM103
                                                                              2310E
                                                                              (NM101=DQ
                                                                              )
                                                                              Required if
                                                                              EA1-19 is
                                                                              present
              19               Supervising      243     12x          S        Mapped to
                               Provider                                       NM104
                               First                                          2310E
                                                                              (NM101=DQ
                                                                              )
                                                                              Required if
                                                                              EA1-18 is
                                                                              present
              20               Supervising      255      1x          S        Mapped to
                               Provider MI                                    NM105
                                                                              2310E
                                                                              (NM101=DQ
                                                                              )
              21               Supervising      256      2x
                               Provider
                               State
              22               EMT/Parame       258     20x
                               dic Last
              23               EMT/Parame       278     12x
                               dic First
              24               EMT/Parame       290      1x
                               dic MI
              25               Date Care        291      8x          S        Mapped to
                               Assumed                                        DTP03 2300
                               (CCYYMMD                                       (DTP01=090
                               D)                                             )
              26               Diagnosis        299      5x
                               Code 5
              27               Diagnosis        304      5x
                               Code 6
              28               Diagnosis        309      5x
                               Code 7
              29               Diagnosis        314      5x
                               Code 8
              30               Filler -         319      2x
                               National




Record type: EA2
Claim Record – Early Periodic Screening Diagnostic Testing (EPSDT)             No Mappings For
                                                                               HIPAA-X12 v 4010
            Field #            Field           Start   Length   NSF           Comment
                               Name                             Required      s and
                                                                Professiona   Values
                                                                l
               1               Record ID         1       3x                   Value: EA2
                               “EA2”
1    Record ID     1    3x
     “EA2”                    Preceded by:
                              EA0 or EA1

                              Next record:
                              FA0

2    Reserved      4    2x
     (EA2.02)
3    Patient       6    17x
     Control
     Number
4    Screening     23   1x
     Type
5    Med Hist      24   1x
     Obtain Perf
6    Med Hist      25   1x
     Obtain Find
7    Physical      26   1x
     Exam Perf
8    Physical      27   1x
     Exam Find
9    Vision        28   1x
     Assess Perf

10   Vision        29   1x
     Assess Find

11   Hearing       30   1x
     Assess Perf

12   Hearing       31   1x
     Assess Find

13   Dental        32   1x
     Assess Perf

14   Dental        33   1x
     Assess Find

15   Develop       34   1x
     Assess Perf

16   Develop       35   1x
     Assess Find

17   NUT Assess    36   1x
     Perf

18   NUT Assess    37   1x
     Find

19   Card Assess   38   1x
     Perf

20   Card Assess   39   1x
     Find
21   GEN/UR         40    1x
     Assess Perf

22   GEN/UR         41    1x
     Assess Find

23   Diabetes       42    1x
     Assess Perf

24   Diabetes       43    1x
     Assess Find

25   Oth. Sys.      44    1x
     Assess Perf

26   Oth. Sys.      45    1x
     Assess Find

27   Oth. Sys.      46    20x
     Assess Desc

28   HBG/HCT        66    1x
     Lab Test
     Perf
29   HBG/HCT        67    1x
     Lab Test
     Find
30   Urinaly Lab    68    1x
     Test Perf
31   Urinaly Lab    69    1x
     Test Find
32   Sickle Cell    70    1x
     Lab Perf
33   Sickle Cell    71    1x
     Lab Find
34   Blood Lead     72    1x
     Lab Perf
35   Blood Lead     73    1x
     Lab Find
36   Tine Test      74    1x
     Perf
37   Tine Test      75    1x
     Find
38   Other Test 1   76    1x
     Perf
39   Other Test 1   77    1x
     Find
40   Other Test 1   78    20x
     Desc
41   Other Test 2   98    1x
     Perf
42   Other Test 2   99    1x
     Find
43   Other Test 2   100   20x
     Desc
44   Treatment      120   2x
     Item No 1
45   Treatment      122   2x
     Item No 2
46   Treatment      124   2x
     Item No 3
47   Treatment      126   2x
     Item No 4
48   Treatment      128   2x
     Item No 5
49   Treatment      130   2x
     Item No 6
50   Treatment      132   2x
     Item No 7
51   Treatment      134   2x
     Item No 8
52   Treatment      136   2x
     Item No 9
53   Treatment      138   2x
     Item No 10
54   Treatment      140   2x
     Item No 11
55   Treatment      142   2x
     Item No 12
56   Treatment      144   2x
     Item No 13
57   Treatment      146   2x
     Item No 14
58   Treatment      148   2x
     Item No 15
59   Treatment      150   2x
     Item No 16
60   Treatment      152   2x
     Stat No 1 IN
61   Treatment      154   2x
     Stat No 2 IN
62   Treatment      156   2x
     Stat No 3 IN
63   Treatment      158   2x
     Stat No 4 IN
64   Treatment      160   2x
     Stat No 1 DE

65   Treatment      162   2x
     Stat No 2 DE

66   Treatment      164   2x
     Stat No 3 DE

67   Treatment      166   2x
     Stat No 4 DE

68   Treatment      168   2x
     Stat No 1 NR

69   Treatment      170   2x
     Stat No 2 NR

70   Treatment      172   2x
     Stat No 3 NR
               71               Treatment       174   2x
                                Stat No4 NR

               72               Referral Item   176   2x
                                No 1
               73               Referral Item   178   2x
                                No 2
               74               Referral Item   180   2x
                                No 3
               75               Referral Item   182   2x
                                No 4
               76               Referral Item   184   2x
                                No 5
               77               Referral Item   186   2x
                                No 6
               78               Referral Item   188   2x
                                No 7
               79               Referral Item   190   2x
                                No 8
               80               Immun Polio     192   1x
                                Given
               81               Immun Polio     193   1x
                                Not
               82               Immun           194   1x
                                DPT/TD
                                Given
               83               Immun           195   1x
                                DPT/TD Not
               84               Immun Meas      196   1x
                                Given
               85               Immun Meas      197   1x
                                Not
               86               Immun           198   1x
                                Mumps
                                Given
               87               Immun           199   1x
                                Mumps Not
               88               Immun           200   1x
                                Rubella
                                Given
               89               Immun           201   1x
                                Rubella Not
               90               Immun HIB       202   1x
                                Given
               91               Immun HIB       203   1x
                                Not
               92               Immun Other     204   1x
                                Given

               93               Immun Other     205   20x
                                Desc
               94               Filler –        225   96x
                                National




Record type: FA0
Service Line Detail - Root Segment                          Required Record
99 Fxx records per claim, only 50 Fxx records allowed for HIPAA-X12 v 4010

            Field #             Field        Start     Length   NSF
                                Name                            Required
                                                                Professiona
                                                                l
               1                Record ID      1         3x          R
                                “FA0”




               2                Sequence       4         2x         R
                                Number




               3                Patient        6         17x
                                Control
                                Number
               4                Line Item      23        17x         S
                                Control
                                Number



               5                Service        40        8x          S
                                From Date
                                (CCYYMMD
                                D)

               6                Service To     48        8x          S
                                Date
                                (CCYYMMD
                                D)
6    Service To   48     8x      S
     Date
     (CCYYMMD
     D)




7    Place Of     56     2x      S
     Service




8    Type Of      58     2x
     Service
     Code
9    HCPCS        60     5x      S
     Procedure
     Code
10   HCPCS        65     2x      S
     Modifier 1

11   HCPCS        67     2x      S
     Modifier 2

12   HCPCS        69     2x      S
     Modifier 3

13   Line         71   n(5)v99   S
     Charges

14   Diagnosis    78     1x      S
     Code
     Pointer1
15   Diagnosis    79     1x      S
     Code
     Pointer2
16   Diagnosis      80     1x      S
     Code
     Pointer3
17   Diagnosis      81     1x      S
     Code
     Pointer4
18   Units Of       82    n(3)v9   S
     Service

19   Anesthesia/    86     4n      S
     Oxygen
     Minutes
20   Emergency      90     1x      S
     Indicator




21   COB            91     1x
     Indicator
22   HPSA           92     1x
     Indicator
23   Rendering      93     15x     S
     Provider NPI




24   Referring      108    15x     S
     Provider NPI
25   Referring       123     2x
     Provider
     State
26   Purchase        125     1x
     Service
     Indicator
27   Disallowed      126   n(5)v99
     Cost
     Containment

28   Disallowed      133   n(5)v99
     Other
29   Review By       140     1x
     Code
     Indicator
30   Multiple        141     1x
     Procedure
     Indicator
31   Mammograp       142    10x      S
     hy
     Certification
     No.

32   Class           152     9x
     Findings
33   Podiatry        161     3x
     Service
     Condition
34   Clinical        164    15x      S
     Laboratory
     (CLIA)




35   Primary Paid    179   n(5)v99
     Amount

36   HCPCS           186     2x      S
     Modifier 4

37   Provider        188     3x
     Specialty
38   Podiatry        191     1x
     Therapy Ind
39   Podiatry        192     1x
     Therapy
     Type
40   Hospice         193     1x      S
     Employed
     Prov Ind
40   Hospice      193   1x     S
     Employed
     Prov Ind




41   HGB/HCT      194   8x     S
     Date
     (CCYYMMD
     D)

42   HGB Result   202   n(3)   S




43   HCT Result   205   n(2)   S




44   Patient      207   n(3)   S
     Weight
45   EPO Dosage      210    n(3)     S




46   Serum           213     8x      S
     Creatine
     Date
     (CCYYMMD
     D)
47   Creatine        221    n(3)     S
     Result




48   Obligated       224   n(5)v99
     Accept Amt
49   Drug            231   n(5)v99
     Discount
     Amt
50   Type of Units   238     1x      S
     Indicator




51   Approved        239   n(5)v99   S
     Amount




52   Paid Amount     246   n(5)v99

53   Beneficiary     253   n(5)v99
     Liability Amt
54   Balance Bill    260   n(5)v99
     Limit Charge

55   Limiting        267   n(5)v99
     Charge
     Percent
               56    Performing    274   10x
                     Provider
                     Phone
               57    Performing    284   1x    S
                     Prov Tax
                     Type




               58    Performing    285   9x
                     Prov Tax ID
               59    Performing    294   1x
                     Prov Assign
                     Indicator

               60    Pre-          295   1x
                     transplant
                     Indicator
               61    ICD-10-PCS    296   7x
               62    Universal     303   14x   S
                     Product
                     Code



               63    Diag Code     317   1x
                     Pointer5
               64    Diag Code     318   1x
                     Pointer6
               65    Diag Code     319   1x
                     Pointer7
               66    Diag Code     320   1x
                     Pointer8




Record type:   FB0
Service Line Detail - Medical Segment                                          Optional Record
            Field #             Field          Start   Length    NSF
                                Name                             Required
                                                                 Professiona
                                                                 l
               1                Record ID        1       3x           R
                                "FB0"




               2                Sequence         4       2x          R
                                No




               3                Patient          6      17x
                                Control
                                Number
               4                Line Item       23      17x
                                Control No
               5                Pur Svc         40     n(5)v99        S
                                Charge

               6                Allowed         47     n(5)v99
                                Amount
               7                Deductible      54     n(5)v99
                                Amount
               8                Coinsurance     61     n(5)v99
                                Amount
               9                Ordering        68      15x           S
                                Prov NPI




               10               Ordering        83       2x
                                Prov State
               11               Pur Svc Prov    85      15x           S
                                NPI
11   Pur Svc Prov   85    15x   S
     NPI




12   Pur Svc        100   2x
     State
13   PEN Grams      102   4x
     Of Protein
14   PEN            106   4x
     Calories
15   National       110   11x
     Drug Code
16   National       121   7x
     Drug Units
17   Prescription   128   15x
     No
18   Prescription   143   8x
     Date
     (CCYYMMD
     D)
19   Prescript No   151   2x
     Of Mos
20   Spec Pricing   153   1x
     Ind
21   Copay          154   1x    S
     Status Ind




22   EPSDT Ind      155   1x    S
               23               Family         156   1x    S
                                Planning Ind




               24               DME Charge     157   1x
                                Ind
               25               HPSA           158   15x
                                Facility ID
               26               HPSA           173   9x
                                Facility Zip
               27               Pur Svc        182   33x   S
                                Name




               28               Pur Svc        215   30x
                                Addr1
               29               Pur Svc        245   30x
                                Addr2
               30               Pur Svc City   275   20x

               31               Pur Svc Zip    295   9x
               32               Pur Svc        304   10x
                                Phone
               33               Drug Days      314   3x
                                Supply
               34               Payment        317   1x
                                Type
                                Indicator
               35               Filler -       318   3x
                                National




Record type: FB1
Service Line Detail - Medical Segment                          Optional Record
Field #   Field           Start   Length   NSF
          Name                             Required
                                           Professiona
                                           l
   1      Record ID         1       3x          R
          “FB1”




   2      Sequence          4       2x         R
          Number




   3      Patient           6      17x
          Control
          Number
   4      Line Item        23      17x
          Control
          Number
   5      Place Of         40      33x
          Service
          Name
   6      Ordering         73      20x          S
          Provider Last




   7      Ordering         93      12x          S
          Provider
          First



   8      Ordering         105      1x          S
          Provider MI



   9      Ordering         106     15x
          Provider
          UPIN
10   Referring       121   20x   S
     Provider Last




11   Referring       141   12x   S
     Provider
     First



12   Referring       153   1x    S
     Provider MI




13   Referring       154   15x   S
     Provider
     UPIN




14   Rendering       169   20x   S
     Provider Last




15   Rendering       189   12x   S
     Provider
     First
     Provider
     First




16   Rendering       201   1x    S
     Provider MI




17   Rendering       202   15x
     Provider
     UPIN
18   Supervising     217   20x   S
     Provider Last




19   Supervising     237   12x   S
     Provider
     First



20   Supervising     249   1x    S
     Provider MI




21   Supervising     250   15x   S
     Provider ID




22   Supervising     265   15x   S
     Provider
     UPIN




23   Filler -        280   41x
     National
Record type: FB2
Service Line Detail - Medical Segment                                            Optional Record
             Field #            Field Name     Start   Length   NSF           Comments
                                                                Required      and Values
                                                                Professiona
                                                                l
                1               Record ID        1       3x          R        Value: FB2
                                “FB2”                                         Preceded by:
                                                                              FA0, FB0,
                                                                              FB1 or FB3

                                                                              Next record:
                                                                              FA0, FD0,
                                                                              FE0, Cert
                                                                              records, HA0
                                                                              or XA0



                2               Sequence         4       2x         R         If record
                                Number                                        present, field
                                                                              must equal
                                                                              the FA0
                                                                              record, field
                                                                              02 value for
                                                                              this service
                                                                              line.



                3               Patient          6      17x
                                Control
                                Number
                4               Line Item       23      17x
                                Control
                                Number
                5               Provider        40       2x
                                Type
                                Indicator A
                6               Provider “A”    42      30x          S        Mapped to
                                Address 1                                     N301 2420E
                                                                              (NM101=DK)



                7               Provider “A”    72      30x          S        Mapped to
                                Address 2                                     N302 2420E
                                                                              (NM101=DK)



                8               Provider “A”   102      20x          S        Mapped to
                                City                                          N401 2420E
                                                                              (NM101=DK)
               9                Provider “A”    122      2x          S        Mapped to
                                State                                         N402 2420E
                                                                              (NM101=DK)



               10               Provider “A”    124      9x          S        Mapped to
                                Zip Code                                      N403 2420E
                                                                              (NM101=DK)



               11               Provider        133      2x
                                Type
                                Indicator B
               12               Provider “B”    135     30x
                                Address 1

               13               Provider “B”    165     30x
                                Address 2

               14               Provider “B”    195     20x
                                City
               15               Provider “B”    215      2x
                                State
               16               Provider “B”    217      9x
                                Zip Code

               17               Provider        226      2x
                                Type
                                Indicator C
               18               Provider “C”    228     30x
                                Address 1

               19               Provider “C”    258     30x
                                Address 2

               20               Provider “C”    288     20x
                                City
               21               Provider “C”    308      2x
                                State
               22               Provider “C”    310      9x
                                Zip Code

               23               Filler –        319      2x
                                National




Record type: FB3
Service Line Detail - Medical Segment                                           No Mappings For
                                                                                  X12 v 4010
            Field #             Field          Start   Length   NSF           Comment
                                Name                            Required      s and
                                                                Professiona   Values
                                                                l
               1                Record ID        1       3x                   Value: FB3
                                “FB3                                          Preceded by:
                                                                              FB2
               1                 Record ID     1       3x
                                 “FB3

                                                                         Next record:
                                                                         FA0 or XA0

               2                 Sequence      4       2x                If record
                                 Number                                  present, field
                                                                         must equal
                                                                         the FA0
                                                                         record, field
                                                                         02 value for
                                                                         this service
                                                                         line.



               3                 Patient       6      17x
                                 Control
                                 Number
               4                 Line Item    23      17x
                                 Control
                                 Number
               5                 Reason       40       6x
                                 Code 1
               6                 Dollar       46       7x
                                 Amount 1
               7                 Reason       53       6x
                                 Code 2
               8                 Dollar       59       7x
                                 Amount 2
               9                 Reason       66       6x
                                 Code 3
               10                Dollar       72       7x
                                 Amount 3
               11                Reason       79       6x
                                 Code 4
               12                Dollar       85       7x
                                 Amount 4
               13                Reason       92       6x
                                 Code 5
               14                Dollar       98       7x
                                 Amount 5
               15                Reason       105      6x
                                 Code 6
               16                Dollar       111      7x
                                 Amount 6
               17                Reason       118      6x
                                 Code 7
               18                Dollar       124      7x
                                 Amount 7
               19                Filler –     131     190x
                                 National




Record type: FD0
Service Line Detail - Dental Segment                                       No Mappings for
                                                                             X12 v 4010
            Field #              Field       Start   Length   NSF        Comment
                                 Name                         Required   s and
                                                                         Values
1    Record ID       1    3x    Value: FD0
     "FD0"                      Preceded by:
                                FA0, FB0,
                                FB1, FB2,
                                FB3 or FD0

                                Next record:
                                FE0, FA0,
                                HA0 or XA0



2    Sequence        4    2x    If record
     No                         present, field
                                must equal
                                the FA0
                                record, field
                                02 value for
                                this service
                                line.



3    Patient         6    17x
     Control
     Number
4    Line Item       23   17x
     Control No
5    Tooth Code      40   2x
     Number 1
6    Tooth           42   5x
     Surface(s) 1

7    Tooth Code      47   2x
     Number 2
8    Tooth           49   5x
     Surface(s) 2

9    Tooth Code      54   2x
     Number 3
10   Tooth           56   5x
     Surface(s) 3

11   Tooth Code      61   2x
     Number 4
12   Tooth           63   5x
     Surface(s) 4

13   Initial Place   68   1x
     Ind
14   Prior Place     69   8x
     Date
     (CCYYMMD
     D)
15   Impress/Pre     77   8x
     script DT
     (CCYYMMD
     D)
16   Replacement     85   1x
     Reason
17   Ortho Treat    86    1x
     Ind
18   Treatment      87    2x
     Length
19   Date Appl      89    8x
     Inserted
     (CCYYMMD
     D)
20   Date Appl      97    8x
     Removed
     (CCYYMMD
     D)
21   Reserved       105   10x
     (FD0-21.0)
22   Date Appl      115   8x
     Replaced
     (CCYYMMD
     D)
23   Mos Treat      123   2x
     Remaining
24   Dt 1st Visit   125   8x
     Cur Ser
     (CCYYMMD
     D)
25   Reserved       133   10x
     (FD0-25.0)
26   Pre            143   20x
     Determinatio
     n Id
27   Reserved       163   10x
     (FD0-27.0)
28   Missing        173   20x
     Primary
     Teeth
29   Missing        193   2x
     Perm Tooth
30   Missing        195   2x
     Perm Tooth
31   Missing        197   2x
     Perm Tooth
32   Missing        199   2x
     Perm Tooth
33   Missing        201   2x
     Perm Tooth
34   Missing        203   2x
     Perm Tooth
35   Missing        205   2x
     Perm Tooth
36   Missing        207   2x
     Perm Tooth
37   Missing        209   2x
     Perm Tooth
38   Missing        211   2x
     Perm Tooth
39   Missing        213   2x
     Perm Tooth
40   Missing        215   2x
     Perm Tooth
              41                Missing       217        2x
                                Perm Tooth
              42                Missing       219        2x
                                Perm Tooth
              43                Missing       221        2x
                                Perm Tooth
              44                Missing       223        2x
                                Perm Tooth
              45                Missing       225        2x
                                Perm Tooth
              46                Missing       227        2x
                                Perm Tooth
              47                Missing       229        2x
                                Perm Tooth
              48                Missing       231        2x
                                Perm Tooth
              49                Missing       233        2x
                                Perm Tooth
              50                Missing       235        2x
                                Perm Tooth
              51                Missing       237        2x
                                Perm Tooth
              52                Missing       239        2x
                                Perm Tooth
              53                Missing       241        2x
                                Perm Tooth
              54                Missing       243        2x
                                Perm Tooth
              55                Missing       245        2x
                                Perm Tooth
              56                Missing       247        2x
                                Perm Tooth
              57                Missing       249        2x
                                Perm Tooth
              58                Missing       251        2x
                                Perm Tooth
              59                Missing       253        2x
                                Perm Tooth
              60                Missing       255        2x
                                Perm Tooth
              61                Missing       257        2x
                                Perm Tooth
              62                Quadrant      259        2x
              63                Tooth         261        2x
                                Pocket
                                Measure
              64                Filler -      263       58x
                                National




Record type: FE0
Third Party Organization – Third Party Organization Segment                    Optional Record

            Field #             Field        Start    Length   NSF           Comment
                                Name                           Required      s and
                                                               Professiona   Values
                                                               l
               1                Record ID      1         3x         R        Value: FE0
                                “FE0”
1    Record ID       1       3x      R
     “FE0”                               Preceded by:
                                         FA0, FB0,
                                         FB1, FB2, or
                                         FD0
                                         Next record:
                                         FA0, Cert
                                         records, HA0
                                         or XA0




2    Sequence        4       2x      R   If record
     Number                              present, field
                                         must equal
                                         the FA0
                                         record, field
                                         02 value for
                                         this service
                                         line.



3    Patient         6      17x
     Control
     Number
4    Line Item       23     17x
     Control
     Number
5    TPO ID          40      9x
     Number
6    TPO             49     15x      S   Mapped to
     Reference                           REF02 2300
     Number                              (REF01=9A)



7    Pricing         64      2x
     Methodology

8    Allowed         66    n(5)v99
     Amount
9    Savings         73    n(5)v99
     Amount
10   Approved        80      5x
     HCPCS
11   Approved        85      4x
     Units
12   Rejection       89      2x
     Message
13   Authorization   91     20x
     Number
14   Policy          111     2x
     Compliance
     Code
15   Exception       113     2x
     Code
16   Filler –        115    206x
     National
Record type: GA0
Ambulance Certification Record - Service Line                                     Optional Record
            Field #             Field           Start   Length   NSF           Comment
                                Name                             Required      s and
                                                                 Professiona   Values
                                                                 l
               1                Record ID         1       3x          R        Value: GA0
                                "GA0"                                          Preceded by:
                                                                               FA0, FB0,
                                                                               FB1, FB2 or
                                                                               FE0
                                                                               Next record:
                                                                               FA0, HA0 or
                                                                               XA0

               2                Sequence          4       2x         R         If record
                                No                                             present, field
                                                                               must equal
                                                                               the FA0
                                                                               record, field
                                                                               02 value for
                                                                               this service
                                                                               line.



               3                Patient           6      17x
                                Control
                                Number
               4                Reserved         23      17x
                                (GA0-04.0)
               5                Patients         40       3x          S        Mapped to
                                Weight                                         CR102 2300
                                                                               if GA0-07 is
                                                                               present

                                                                               Mapped to
                                                                               CR102 2400
                                                                               if GA0-07 is
                                                                               present
                              Segment
                              CR1 2400
                              will not map
                              if the
                              information
                              in GA0-05,
                              GA0-07,
                              GA0-15,
                              GA0-17,
                              GA0-20, and
                              GA0-21 (all
                              inclusive) is
                              identical to
                              the
                              information
                              mapped in
                              CR1 2300



6   Hospital    43   1x   S   Values: NSF =
    Admit                     HIPAA-X12 v
                              4010
                              Admitted Y =
                              01
                              Not Admitted N
                              =


                              Mapped to
                              CRC03 2300
                              (CRC01=07)
                              if NSF value
                              =Y


                              Values are
                              validated in
                              the NSF
                              map
7   Type Of     44   1x   S   Values:
    Transport                 NSF     =
                              HIPAA-X12 v
                              4010

                              Initial Trip I = I
                              Return Trip R =
                              R
                              Transfer Trip T
                              =T
                              Round Trip X =
                              X


                              Mapped to
                              CR103 2300

                              Mapped to
                              CR103 2400
                             Segment
                             CR1 2400
                             will not map
                             if the
                             information
                             in GA0-05,
                             GA0-07,
                             GA0-15,
                             GA0-17,
                             GA0-20, and
                             GA0-21 (all
                             inclusive) is
                             identical to
                             the
                             information
                             mapped in
                             CR1 2300




                             For NSF
                             value “X”,
                             GA0-20
                             should be
                             present
                             Values are
                             validated in
                             the HIPAA
                             map
8   Bed        45   1x   S   Values: NSF =
    Confined                 HIPAA-X12 v
    Before                   4010
                             Patient was
                             bed confined Y
                             = 02
                             Patient was not
                             bed confined N
                             =


                             Mapped to
                             CRC03 or
                             CRC04 2300
                             (CRC01=07)
                             if NSF value
                             =Y


                             Values are
                             validated in
                             the NSF
                             map
9   Bed        46   1x   S   Values: NSF =
    Confined                 HIPAA-X12 v
    After                    4010
                             Patient was
                             bed confined Y
                             = 03
                             Patient was not
                             bed confined N
                             =
     After




                                 Mapped to
                                 CRC03,
                                 CRC04, or
                                 CRC05 2300
                                 (CRC01=07)
                                 if NSF value
                                 =Y


                                 Values are
                                 validated in
                                 the NSF
                                 map
10   Moved By      47   1x   S   Values: NSF =
     Stretcher                   HIPAA-X12 v
                                 4010
                                 Patient was
                                 moved by
                                 stretcher Y =
                                 04
                                 Patient was not
                                 moved by
                                 stretcher N =


                                 Mapped to
                                 CRC03,
                                 CRC04,
                                 CRC05, or
                                 CRC06 2300
                                 (CRC01=07)
                                 if NSF value
                                 =Y


                                 Values are
                                 validated in
                                 the NSF
                                 map
11   Unconscious   48   1x   S   Values: NSF =
     /Shock                      HIPAA-X12 v
                                 4010
                                 Patient was
                                 unconscious or
                                 in shock Y = 05

                                 Patient was not
                                 unconscious or
                                 in shock N =




                                 Mapped to
                                 CRC03,
                                 CRC04,
                                 CRC05,
                                 CRC06, or
                                 CRC07 2300
                                 (CRC01=07)
                                 if NSF value
                                 =Y


                                 Values are
                                 validated in
                                 the NSF
                                 map
12   Emergency     49   1x   S   Values: NSF =
     Situation                   HIPAA-X12 v
                                 4010
                                 Emergency
                                 Situation Y =
                                 06
                                 Not an
                                 emergency
                                 situation N =


                                 Mapped to
                                 CRC03 2300
                                 (CRC01=07)
                                 if NSF value
                                 =Y


                                 Values are
                                 validated in
                                 the NSF
                                 map
13   Physical      50   1x   S   Values: NSF =
     Restraints                  HIPAA-X12 v
                                 4010
                                 Physical
                                 restraints
                                 needed Y = 07
                                 No physical
                                 restraints used
                                 N=


                                 Mapped to
                                 CRC03 or
                                 CRC04 2300
                                 (CRC01=07)
                                 if NSF value
                                 =Y


                                 Values are
                                 validated in
                                 the NSF
                                 map
14   Visible       51   1x   S   Values: NSF =
     Hemorrhagin                 HIPAA-X12 v
     g                           4010
                                 Visible
                                 hemorrhaging
                                 noted Y = 08
                                 No Visible
                                 hemorrhaging
                                 noted N =


                                 Mapped to
                                 CRC03,
                                 CRC04, or
                                 CRC05 2300
                                 (CRC01=07)
                                 if NSF value
                                 =Y


                                 Values are
                                 validated in
                                 the NSF
                                 map
15   Transported   52   1x   S   Values: NSF =
     To/For                      HIPAA-X12 v
                                 4010
                                 To nearest
                                 facility for care
                                 of symptoms
                                 and/or
                                 complaints A =
                                 A

                                 For the benefit
                                 of a preferred
                                 physician B = B


                                 For the
                                 nearness of
                                 family
                                 members C =
                                 C
                                 For the care of
                                 a specialist or
                                 for availability
                                 of specialized

                                 equipment D
                                 = D


                                 Mapped to
                                 CR104 2300
                                 if GA0-07 is
                                 present

                                 Mapped to
                                 CR104 2400
                                 if GA0-07 is
                                 present



                                 Segment
                                 CR1 2400
                                 will not map
                                 if the
                                 information
                                 in GA0-05,
                                 GA0-07,
                                 GA0-15,
                                 GA0-17,
                                 GA0-20, and
                                 GA0-21 (all
                                 inclusive) is
                                 identical to
                                 the
                                 information
                                 mapped in
                                 CR1 2300




                                 Values are
                                 validated in
                                 the HIPAA
                                 map
16   Medically     53   1x    S   Values: NSF =
     Necessary                    HIPAA-X12 v
                                  4010
                                  Medically
                                  necessary Y =
                                  09
                                  Not medically
                                  necessary N =



                                  Mapped to
                                  CRC03,
                                  CRC04,
                                  CRC05, or
                                  CRC06 2300
                                  (CRC01=07)
                                  if NSF value
                                  =Y


                                  Values are
                                  validated in
                                  the NSF
                                  map
17   Miles         54   4x    S   Mapped to
                                  CR106 2300
                                  if GA0-07 is
                                  present

                                  Mapped to
                                  CR106 2400
                                  if GA0-07 is
                                  present



                                  Segment
                                  CR1 2400
                                  will not map
                                  if the
                                  information
                                  in GA0-05,
                                  GA0-07,
                                  GA0-15,
                                  GA0-17,
                                  GA0-20, and
                                  GA0-21 (all
                                  inclusive) is
                                  identical to
                                  the
                                  information
                                  mapped in
                                  CR1 2300



18   Origin Info   58   40x
19   Destination   98   40x
     Info
20   Purpose Of   138   80x   S   Mapped to
     Round Trip                   CR109 2300
                                  if GA0-07
                                  contains
                                  NSF value
                                  “X”


                                  Mapped to
                                  CR109 2400
                                  if GA0-07
                                  contains
                                  NSF value
                                  “X”



                                  Segment
                                  CR1 2400
                                  will not map
                                  if the
                                  information
                                  in GA0-05,
                                  GA0-07,
                                  GA0-15,
                                  GA0-17,
                                  GA0-20, and
                                  GA0-21 (all
                                  inclusive) is
                                  identical to
                                  the
                                  information
                                  mapped in
                                  CR1 2300



21   Purpose Of   218   80x   S   Mapped to
     Stretcher                    CR110 2300
                                  if GA0-07 is
                                  present

                                  Mapped to
                                  CR110 2400
                                  if GA0-07 is
                                  present
                                                                                Segment
                                                                                CR1 2400
                                                                                will not map
                                                                                if the
                                                                                information
                                                                                in GA0-05,
                                                                                GA0-07,
                                                                                GA0-15,
                                                                                GA0-17,
                                                                                GA0-20, and
                                                                                GA0-21 (all
                                                                                inclusive) is
                                                                                identical to
                                                                                the
                                                                                information
                                                                                mapped in
                                                                                CR1 2300



               22                Patient           298     1x
                                 Discharged
               23                Patient           299     1x
                                 Admitted
               24                Services          300     1x          S        Values: NSF =
                                 Available                                      HIPAA-X12 v
                                                                                4010
                                                                                Yes, services
                                                                                were available
                                                                                at first facility Y
                                                                                = 60
                                                                                No, services
                                                                                were not
                                                                                available at
                                                                                first facility N =



                                                                                Mapped to
                                                                                CRC03,
                                                                                CRC04,
                                                                                CRC05,
                                                                                CRC06, or
                                                                                CRC07 2300
                                                                                (CRC01=07)
                                                                                if NSF value
                                                                                =Y


                                                                                Values are
                                                                                validated in
                                                                                the NSF
                                                                                map
               25                Filler            301    20x
                                 National




Record type: GC0
Chiropractic Certification Record - Service Line                                    Optional Record
             Field #             Field         Start     Length       NSF       Comment
                                 Name                              Required     s and
                                                                  Professiona   Values
                                                                       l
1   Record ID      1    3x    R   Value: GC0
    "GC0"
                                  Preceded by:
                                  FA0, FB0,
                                  FB1, FB2 or
                                  FE0
                                  Next record:
                                  FA0, HA0 or
                                  XA0

2   Sequence       4    2x    R   If record
    No                            present, field
                                  must equal
                                  the FA0
                                  record, field
                                  02 value for
                                  this service
                                  line.



3   Patient        6    17x
    Control
    Number
4   Reserved       23   17x
    (GC0-04.0)
5   Initial        40   8x    S   Mapped to
    Treatment                     DTP03 2300
    Date                          (DTP01=454
                                  )

    (CCYYMMD                      Mapped to
    D)                            DTP03 2400
                                  (DTP01=454
                                  ) if value is
                                  different than
                                  DTP03 2300



6   Date Of Last   48   8x    S   Mapped to
    X Ray                         DTP03 2300
                                  (DTP01=455
                                  )

    (CCYYMMD                      Mapped to
    D)                            DTP03 2400
                                  (DTP01=455
                                  ) if value is
                                  different than
                                  DTP03 2300



7   No In Series   56   7x

8   Level Of       63   7x
    Subluxation
9   Treatment      70   3x
    Months/Year
    s
10   No           73   2x
     Treatments
     Month
11   Nature Of    75   1x   S   Values:
     Condition                  NSF     =
                                HIPAA-X12 v
                                4010

                                Acute
                                Condition A =
                                A
                                Chronic
                                Condition C =
                                C
                                Acute
                                Manifestation
                                of a Chronic
                                Condition M =
                                M



                                     Mapped
                                     to
                                     CR208
                                     2300 if
                                     GC0-07
                                     is
                                     present


                                     Mapped
                                     to
                                     CR208
                                     2400 if
                                     GC0-07
                                     is
                                     present



                                Segment
                                CR2 2400
                                will not map
                                if the
                                information
                                in GC0-11,
                                GC0-14, and
                                GC0-15 (all
                                inclusive) is
                                identical to
                                the
                                information
                                mapped in
                                CR2 2300




                                     Values
                                     are
                                     validate
                                     d in the
                                     HIPAA
                                     map
12   Date Of        76    8x    S   Mapped to
     Manifestatio                   DTP03 2300
     n                              (DTP01=453
                                    )

     (CCYYMMD                       Mapped to
     D)                             DTP03 2400
                                    (DTP01=453
                                    ) if value is
                                    different that
                                    DTP03 2300



13   Complication   84    1x
     Ind
14   Symptoms       85   160x   S   Mapped to
     Description                    CR210 2300,
                                    first 80 bytes
                                    if GC0-07 is
                                    present


                                    Mapped to
                                    CR211 2300,
                                    second 80
                                    bytes if GC0-
                                    07 is present



                                    Mapped to
                                    CR210 2400,
                                    first 80 bytes
                                    if GC0-07 is
                                    present


                                    Mapped to
                                    CR211 2400,
                                    second 80
                                    bytes if GC0-
                                    07 is present




                                    Segment
                                    CR2 2400
                                    will not map
                                    if the
                                    information
                                    in GC0-11,
                                    GC0-14, and
                                    GC0-15 (all
                                    inclusive) is
                                    identical to
                                    the
                                    information
                                    mapped in
                                    CR2 2300
              15           X-Ray Ind    245      1x          S        Values: NSF =
                                                                      HIPAA-X12 v
                                                                      4010
                                                                      Yes, X-Rays
                                                                      are available Y
                                                                      =Y
                                                                      No, X-Rays are
                                                                      not available N
                                                                      =N



                                                                      Mapped to
                                                                      CR212 2300
                                                                      if GC0-07 is
                                                                      present

                                                                      Mapped to
                                                                      CR212 2400
                                                                      if GC0-07 is
                                                                      present



                                                                      Segment
                                                                      CR2 2400
                                                                      will not map
                                                                      if the
                                                                      information
                                                                      in GC0-11,
                                                                      GC0-14, and
                                                                      GC0-15 (all
                                                                      inclusive) is
                                                                      identical to
                                                                      the
                                                                      information
                                                                      mapped in
                                                                      CR2 2300




                                                                      Values are
                                                                      validated in
                                                                      the HIPAA
                                                                      map
              16           Filler -     246     75x
                           National




Record type: GD0
DME Certification Record                                                No Mappings For
                                                                        HIPAA-X12 v 4010
            Field #        Field       Start   Length   NSF           Comment
                           Name                         Required      s and
                                                        Professiona   Values
                                                        l
               1           Record ID     1       3x                   Value: GD0
                           "GD0"
                                                                      Preceded by:
                                                                      FA0, FB0,
                                                                      FB1, or FB2
1    Record ID       1    3x
     "GD0"




                                Next record:
                                FA0, GD1,
                                HA0 or XA0



2    Sequence        4    2x
     No
3    Patient         6    17x
     Control
     Number
4    Certification   23   1x
     Type
5    Medical         24   2x
     Necessity
6    Prognosis       26   20x
7    HCPCS           46   5x
     Procedure
     Code
8    Ambulatory      51   1x
9    Ambulation/     52   1x
     Therapy
10   Confined        53   1x
     Bed/Chair
11   Room            54   1x
     Confined
12   Ambulation/     55   1x
     Mobility
13   Body            56   1x
     Positioning
14   Respiratory/    57   1x
     Other
15   Breathing       58   1x
     Impaired
16   Freq/Immed      59   1x
     Changes
17   Operate         60   1x
     Controls
18   Siderails       61   1x
     Part/Bed
19   Owns            62   1x
     Equipment
20   Mattress/Sid    63   1x
     erails
21   Equipment/A     64   1x
     ssistance
22   Orthopedic      65   1x
     Impair
23   Planned         66   1x
     Regimen
24   Decubitus       67   1x
     Ulcers
25   Equipment       68   1x
     Use
26   Insulin         69   3x
     Dependent
27   Diabetic        72   1x
     Control
28   Apnea           73    1x
     Episodes
29   Surgery         74    1x
     Alternative
30   Total Knee      75    1x
     Replace
31   Date Surgery    76    8x

     (CCYYMMD
     D)
32   Date CPM        84    8x
     (CCYYMMD
     D)
33   Lymphedem       92    1x
     a
34   Ordering        93    20x
     Prov Last
35   Ordering        113   12x
     Prov First
36   Ordering        125   1x
     Prov MI
37   Ordering        126   15x
     Prov ID
38   Ordering        141   10x
     Prov Phone
39   Date            151   8x
     Certification
     (CCYYMMD
     D)
40   Certification   159   1x
     On File
41   Diagnosis       160   5x
     Code 1
42   Diagnosis       165   5x
     Code 2
43   Diagnosis       170   5x
     Code 3
44   Diagnosis       175   5x
     Code 4
45   Nursing         180   1x
     Home Ind
46   NH From         181   8x
     Date
     (CCYYMMD
     D)
47   NH To Date      189   8x
     (CCYYMMD
     D)
48   Respiratory     197   1x
     Tract
49   Supv Of         198   1x
     Equipment
     Use
50   Propel/Lift     199   1x
     Chair
51   Leg             200   1x
     Elevation
52   Patient         201   1x
     Weight
               53                Reclining      202         1x
                                 Wheelchair
               54                Manual         203         1x
                                 Operation
               55                Side           204         1x
                                 Transfer
                                 Chair
               56                Filler -       205        116x
                                 National




Record type: GD1
DME Certification Record - Narrative Information for DME                         No Mappings For
                                                                                 HIPAA-X12 v 4010
             Field #             Field         Start    Length    NSF           Comment
                                 Name                             Required      s and
                                                                  Professiona   Values
                                                                  l
                1                Record ID         1        3x                  Value: GD1
                                 "GD1"
                                                                                Preceded by:
                                                                                GD0
                                                                                Next record:
                                                                                FA0, HA0 or
                                                                                XA0

                2                Sequence          4        2x
                                 No
                3                Patient           6       17x
                                 Control
                                 Number
                4                Narrative         23      250x
                5                Filler -       273        48x
                                 National




Record type: GE0
Certification Record – Enteral Nutrition Therapy                                 No Mappings For
                                                                                 HIPAA-X12 v 4010
             Field #             Field         Start    Length    NSF           Comment
                                 Name                             Required      s and
                                                                  Professiona   Values
                                                                  l
                1                Record ID         1        3x                  Value: GE0
                                 "GE0"                                          Preceded by:
                                                                                FA0, FB0,
                                                                                FB1 or FB2

                                                                                Next record:
                                                                                FA0, HA0 or
                                                                                XA0

                2                Sequence          4        2x
                                 No
                3                Patient           6       17x
                                 Control
                                 Number
4    Certification   23     1x
     Type
5    Onset DT of     24     8x
     Therapy
6    Therapy         32     2x
     Duration
7    Last Cert       34     8x
     Date
     (CCYYMMD
     D)
8    No of           42     2x
     Months Cert

9    DT Last         44     8x
     Seen By Phy

     (CCYYMMD
     D)
10   Non Visit Ind   52     1x

11   Pat Age         53     3x
12   Pat Height      56     3x
13   Pat Weight      59     3x
14   Level of        62     1x
     Cons Ind
15   Ambulatory      63     1x
     Ind
16   Other Forms     64     1x
     of Nutr Ind

17   Method          65     1x
     Admin Ind
18   Admin Tech      66     1x
     Ind
19   Total Cal Per   67     4x
     Day
20   Product         71    15x
     Name 1
21   Cal Per         86     4x
     Product 1
22   HCPCS           90     5x
     Procedure
     Code
23   HCPCS           95     2x
     Modifier 1
24   HCPCS           97     2x
     Modifier 2
25   Enteral Freq    99     3x
     Fed 1
26   Narrative       102   100x
     Field
27   Product         202   15x
     Name 2
28   Cal Per         217    4x
     Product 2
29   Enteral Freq    221    3x
     Fed 2
               30                Filler -         224     97x
                                 National




Record type: GP0
Certification Record – Parenteral Nutrition Therapy                              No Mappings For
                                                                                 HIPAA-X12 v 4010
             Field #             Field           Start   Length   NSF           Comment
                                 Name                             Required      s and
                                                                  Professiona   Values
                                                                  l
                1                Record ID         1       3x                   Value: GP0
                                 "GP0"                                          Preceded by:
                                                                                FA0, FB0,
                                                                                FB1 or FB2

                                                                                Next record:
                                                                                FA0, HA0 or
                                                                                XA0

                2                Sequence          4       2x
                                 No
                3                Patient           6      17x
                                 Control
                                 Number
                4                Certification    23       1x
                                 Type
                5                Onset DT of      24       8x
                                 Therapy
                6                Therapy          32       2x
                                 Duration
                7                Last Cert        34       8x
                                 Date
                                 (CCYYMMD
                                 D)
                8                No of            42       2x
                                 Months Cert

                9                DT Last          44       8x
                                 Seen By Phy

                                 (CCYYMMD
                                 D)
               10                Non Visit Ind    52       1x

               11                Pat Age          53       3x
               12                Pat Height       56       3x
               13                Pat Weight       59       3x
               14                Level of         62       1x
                                 Cons Ind
               15                Ambulatory       63       1x
                                 Ind
               16                Other Forms      64       1x
                                 of Nutr Ind

               17                Type of Mix      65       1x
                                 Ind
               18                 Parenteral     66       3x
                                  Freq Fed
               19                 HCPCS          69       5x
                                  Procedure
                                  Code
               20                 HCPCS          74       2x
                                  Modifier 1
               21                 HCPCS          76       2x
                                  Modifier 2
               22                 Amino Acid     78      15x
                                  Name
               23                 Amino Acid     93       4x
                                  Volume
               24                 Amino Acid     97       5x
                                  Conc
               25                 Amino Acid     102      4x
                                  Weight
               26                 Dextrose       106      4x
                                  Volume
               27                 Dextrose       110      5x
                                  Conc
               28                 Lipids         115      4x
                                  Volume
               29                 Lipids Conc    119      5x
               30                 Lipids Freq    124      3x
               31                 Narrative      127     100x
                                  Field
               32                 Admin Tech     227      1x
                                  Ind
               33                 Filler -       228     93x
                                  National




Record type: GU0
Certification – Certification Segment                                            Optional Record
             Field #              Field         Start   Length   NSF           Comment
                                  Name                           Required      s and
                                                                 Professiona   Values
                                                                 l
                1                 Record ID       1       3x          R        Value: GU0
                                  “GU0”                                        Preceded by:
                                                                               FA0, FB0,
                                                                               FB1, FB2 or
                                                                               FE0
                                                                               Next record:
                                                                               FA0, HA0 or
                                                                               XA0
2   Sequence        4    2x    R   If record
    Number                         present, field
                                   must equal
                                   the FA0
                                   record, field
                                   02 value for
                                   this service
                                   line.



3   Patient         6    17x
    Control
    Number
4   Certification   23   1x    S   Values:
    Type                           NSF     =
                                   HIPAA-X12 v
                                   4010


                                   Initial
                                   Certification 1
                                   =I
                                   Revision 2 = S

                                   Recertification
                                   3=R


                                   Mapped to
                                   CR301 2400

                                   Values are
                                   validated in
                                   the NSF
                                   map
5   Place of        24   2x
    Service
6   Replacement     26   1x    S   Values:
    Item                           NSF     =
                                   HIPAA-X12 v
                                   4010


                                   Yes Y = ZV
                                   No N = ZV




                                   Mapped to
                                   CRC03 2400
                                   (CRC01=09)



                                   Values are
                                   validated in
                                   the NSF
                                   map
7   HCPCS           27   5x
    Procedure
    Code
8   HCPCS           32   2x
    Modifier
9   Warranty        34   1x
    Reply
10   Warranty        35    2x
     Length
11   Warranty        37    1x
     Type
12   Diagnosis       38    5x
     Code 1
13   Diagnosis       43    5x
     Code 2
14   Diagnosis       48    5x
     Code 3
15   Diagnosis       53    5x
     Code 4
16   Patient         58    n(2)   S   Mapped to
     Height                           MEA03 2400
                                      (MEA01=TR,
                                      MEA02=HT)



17   Patient         60    3x
     Weight
18   Date of Last    63    8x
     Medical
     Exam
     (CCYYMMD
     D)


19   Initial Date    71    8x     S   Mapped to
     (CCYYMMD                         DTP03 2400
     D)                               (DTP01=463
                                      )

20   Revision or     79    8x     S   Mapped to
     Recert Date                      DTP03 2400
     (CCYYMMD                         (DTP01=607
     D)                               )
21   Length of       87    n(2)   S   Mapped to
     Need                             CR303 2400

22   Date Cert       89    8x     S   Mapped to
     Signed                           DTP03 2400
     (CCYYMMD                         (DTP01=461
     D)                               )
23   Ordering        97    10x
     Provider
     Phone
24   Certification   107   1x     S   Values:
     on File                          NSF     =
                                      HIPAA-X12 v
                                      4010


                                      Yes Y = 38
                                      No N = 38
                                  Mapped to
                                  CRC03 or
                                  CRC04 2400
                                  (CRC01=11)



                                  Values are
                                  validated in
                                  the NSF
                                  map
                                  Will not be
                                  mapped if
                                  GX0-35
                                  contains
                                  valid data
25   Certificate   108   4x   S   Values: NSF =
     Form                         HIPAA-X12 v
     Number                       4010
                                  Hospital Bed
                                  and Support
                                  Services 0102
                                  = 0102
                                  Manual and
                                  Motorized
                                  Wheelchairs
                                  0203 = 0203
                                  Continuous
                                  Positive Airway
                                  Pressure
                                  System 0302 =
                                  0302

                                  Lymphedema
                                  Pump,
                                  Osteogenesis
                                  Stimulator
                                  0403 = 0403
                                  Reserved for
                                  Future Use
                                  0502 =
                                  TENS 0602 =
                                  0602
                                  Seat Lift
                                  Mechanisms
                                  and Power
                                  Operated
                                  Vehicle (POV)


                                  0702 = 0702
                                  Immunosuppre
                                  ssive Drugs
                                  0802 = 0802
                                  External
                                  Infusion Pump
                                  0902 = 0902

                                  Parenteral and
                                  Enteral
                                  Nutrition 1002
                                  = 1002

                                  Mapped to
                                  LQ02 2440
                                  Mapped to
                                  FRM01 2440
                                The
                                Certification
                                Form
                                Number
                                specified in
                                this field will
                                cause the
                                associated
                                fields in the
                                GU0 record
                                to map.
                                Review the
                                following
                                fields to
                                determine
                                which will
                                map for a
                                given form
                                number:
                                GU0-26,
                                GU0-27,
                                GU0-28,
                                GU0-29,
                                GU0-30,
                                GU0-31,
                                GU0-32,
                                GU0-33,
                                GU0-34,
                                GU0-35,
                                GU0-36,
                                GU0-37,
                                GU0-38,
                                GU0-39,
                                GU0-40,
                                GU0-43,
                                GU0-44,
                                GU0-45,
                                GU0-50,
                                GU0-51,
                                Values are
                                validated in
                                the NSF
                                map
26   Reply ALN   112   1x   S   DMERC
     L01-N01                    forms 01.02,
                                02.03, 04.03,
                                06.02, 07.02,
                                09.02




                                Values:
                                NSF =
                                HIPAA-X12 v
                                4010


                                Yes Y = Y
                                No N = N
                                Does not apply
                                D=W
                                DMERC
                                forms 08.02
                                & 10.02

                                Values:
                                NSF =
                                HIPAA-X12 v
                                4010


                                Yes Y = Y
                                No N = N


                                Mapped to
                                FRM02
                                2440
                                See GU0-25

                                Values are
                                validated in
                                the NSF
                                map
27   Reply ALN   113   1x   S   DMERC
     L01-N02                    forms 02.03,
                                04.03, 06.02
                                & 07.02



                                Values:
                                NSF =
                                HIPAA-X12 v
                                4010


                                Yes Y = Y
                                No N = N
                                Does not apply
                                D=W


                                DMERC
                                form 08.02
                                Values:
                                NSF     =
                                HIPAA-X12 v
                                4010


                                Yes Y = Y
                                No N = N


                                Mapped to
                                FRM02 2440

                                See GU0-25

                                Values are
                                validated in
                                the NSF
                                map
28   Reply ALN   114   1x   S   Mapped to
     LO1-NO3                    FRM02 2440
28   Reply ALN   114   1x   S
     LO1-NO3

                                DMERC
                                forms 01.02,
                                02.03, 04.03
                                & 07.02



                                Values:
                                NSF =
                                HIPAA-X12 v
                                4010


                                Yes Y = Y
                                No N = N
                                Does not apply
                                D=W


                                Mapped to
                                FRM03
                                2440.
                                DMERC
                                form 06.02
                                Values:
                                NSF =
                                HIPAA-X12 v
                                4010


                                Headache 1 =
                                1
                                Visceral
                                abdominal pain
                                2=2
                                Pelvic pain 3 =
                                3
                                Temporomandi
                                bular joint
                                (TMJ) pain 4 =
                                4
                                None of the
                                above 5 = 5


                                DMERC
                                form 10.02
                                Values:
                                NSF =
                                HIPAA-X12 v
                                4010


                                Central line 1 =
                                1
                                Hemodialysis
                                Access Line 3
                                =3
                                Peripherally
                                Inserted
                                Catheter (PIC)
                                line 7 = 7



                                See GU0-25

                                Values are
                                validated in
                                the NSF
                                map
29   Reply ALN   115   1x   S   DMERC
     L01-N04                    forms 01.02,
                                02.03, 04.03,
                                06.02 and
                                07.02



                                Values:
                                NSF =
                                HIPAA-X12 v
                                4010


                                Yes Y = Y
                                No N = N
                                Does not apply
                                D=W


                                Mapped to
                                FRM02 2440

                                See GU0-25

                                Values are
                                validated in
                                the NSF
                                map
30   Reply ALN   116   1x   S   DMERC
     L01-NO5                    forms 01.02,
                                02.03, 04.03,
                                06.02 and
                                07.02



                                Values:
                                NSF =
                                HIPAA-X12 v
                                4010


                                Yes Y = Y
                                No N = N
                                Does not apply
                                D=W


                                DMERC
                                form 10.02
                                Values:
                                NSF =
                                HIPAA-X12 v
                                4010
                                Yes Y     =
                                Y
                                No
                                N =     N


                                Mapped to
                                FRM02 2440

                                See GU0-25
                                Values are
                                validated in
                                the NSF
                                map
31   Reply ALN   117   1x   S   Mapped to
     L01-N06                    FRM02 2440

                                DMERC
                                forms 01.02,
                                02.03, 04.03
                                and 07.02



                                Values:
                                NSF =
                                HIPAA-X12 v
                                4010


                                Yes Y = Y
                                No N = N
                                Does not apply
                                D=W



                                DMERC
                                form 10.02
                                Values:
                                NSF =
                                HIPAA-X12 v
                                4010
                                Yes Y     =
                                Y
                                No
                                N =     N


                                Mapped to
                                FRM03 2440

                                DMERC
                                form 06.02
                                Values:
                                NSF =
                                HIPAA-X12 v
                                4010


                                Daily 1 = 1
                                3 to 6 days per
                                week 2 = 2
                                2 or less days
                                per week 3 = 3


                                See GU0-25

                                Values are
                                validated in
                                the NSF
                                map
32   Reply ALN   118   1x   S   DMERC
     L01-N07                    forms 01.02,
                                06.02 and
                                07.02
32   Reply ALN   118   1x   S
     L01-N07




                                Values:
                                NSF =
                                HIPAA-X12 v
                                4010


                                Yes Y = Y
                                No N = N
                                Does not apply
                                D =     W



                                Mapped to
                                FRM02 2440

                                See GU0-25

                                Values are
                                validated in
                                the NSF
                                map
33   Reply ALN   119   1x   S   Mapped to
     L01-N08                    FRM02 2440

                                DMERC
                                form 07.02
                                Values:
                                NSF =
                                HIPAA-X12 v
                                4010


                                Yes Y = Y
                                No N = N
                                Does not apply
                                D =     W



                                Mapped to
                                FRM03
                                2440.
                                DMERC
                                form 06.02
                                Values:
                                NSF =
                                HIPAA-X12 v
                                4010


                                2 leads 2 = 2
                                4 leads 4 = 4


                                DMERC form
                                10.02
                                Values:
                                NSF =
                                HIPAA-X12 v
                                4010


                                Syringe 1 = 1
                                Gravity 2 = 2
                                Pump 3 = 3
                                Does not apply
                                4=4


                                See GU0-25

                                Values are
                                validated in
                                the NSF
                                map
34   Reply ALN   120   1x   S   DMERC
     L01-N09                    forms 10.02

                                Values:
                                NSF =
                                HIPAA-X12 v
                                4010


                                Yes Y = Y
                                No N = N
                                Does not apply
                                D =     W



                                Mapped to
                                FRM02 2440

                                See GU0-25

                                Values are
                                validated in
                                the NSF
                                map
35   Reply ALN   121   1x
     L01-N10
36   Reply ALN   122   1x   S   DMERC
     L01-N11                    form 01.02
                                Values:
                                NSF =
                                HIPAA-X12 v
                                4010


                                Yes Y = Y
                                No N = N
                                Does not apply
                                D =     W



                                Mapped to
                                FRM02 2440

                                See GU0-25

                                Values are
                                validated in
                                the NSF
                                map
37   Reply ALN   123   1x   S   DMERC
     L01-N12                    forms 01.02,
                                03.02 and
                                07.02

                                Values:
                                NSF =
                                HIPAA-X12 v
                                4010


                                Yes Y = Y
                                No N = N
                                Does not apply
                                D =     W



                                Mapped to
                                FRM02 2440

                                See GU0-25

                                Values are
                                validated in
                                the NSF
                                map
38   Reply ALN   124   1x   S   DMERC
     L01-N13                    forms 01.02
                                and 07.02

                                Values:
                                NSF =
                                HIPAA-X12 v
                                4010


                                Yes Y = Y
                                No N = N
                                Does not apply
                                D =     W



                                Mapped to
                                FRM02 2440

                                See GU0-25

                                Values are
                                validated in
                                the NSF
                                map
39   Reply ALN   125   1x   S   DMERC
     L01-N13                    forms 01.02
                                and 07.02

                                Values:
                                NSF =
                                HIPAA-X12 v
                                4010


                                Yes Y = Y
                                No N = N
                                Does not apply
                                D =     W



                                Mapped to
                                FRM02 2440

                                See GU0-25

                                Values are
                                validated in
                                the NSF
                                map
40   Reply ALN   126   1x   S   DMERC
     L01-N15                    form 01.02
                                Values:
                                NSF =
                                HIPAA-X12 v
                                4010


                                Yes Y = Y
                                No N = N
                                Does not apply
                                D =     W



                                Mapped to
                                FRM02 2440

                                See GU0-25

                                Values are
                                validated in
                                the NSF
                                map
41   Reply ALN   127   1x
     L01-N16
42   Reply ALN   128   1x
     L01-N17
43   Reply ALN   129   1x   S   DMERC
     L01-N18                    form 01.02
                                Values:
                                NSF =
                                HIPAA-X12 v
                                4010


                                Yes Y = Y
                                No N = N
                                Does not apply
                                D =     W



                                Mapped to
                                FRM02 2440

                                See GU0-25
                                Values are
                                validated in
                                the NSF
                                map
44   Reply ALN   130   1x   S   DMERC
     L01-N19                    form 01.02
                                Values:
                                NSF =
                                HIPAA-X12 v
                                4010


                                Yes Y = Y
                                No N = N
                                Does not apply
                                D =     W



                                Mapped to
                                FRM02 2440

                                See GU0-25

                                Values are
                                validated in
                                the NSF
                                map
45   Reply ALN   131   1x   S   DMERC
     L01-N20                    form 01.02
                                Values:
                                NSF =
                                HIPAA-X12 v
                                4010


                                Improved 1 = 1
                                Remained
                                same 2 = 2
                                Worsened
                                3      =


                                Mapped to
                                FRM03 2440

                                See GU0-25

                                Values are
                                validated in
                                the NSF
                                map
46   Reply ALN   132   1x
     L01-N21
47   Reply ALN   133   1x
     L01-N22
48   Reply ALN   134   1x
     L01-N23
49   Reply ALN   135   1x
     L01-N24
50   Reply ALN   136   5x   S   DMERC
     L05-N01                    form 09.02
50   Reply ALN   136   5x    S
     L05-N01
                                 Mapped to
                                 FRM03 2440

                                 See GU0-25

51   Reply ALN   141   5x    S   DMERC
     L05-N02                     form 08.02
                                 Mapped to
                                 FRM03 2440

                                 See GU0-25

52   Reply ALN   146   5x
     L05-N03
53   Reply ALN   151   8x    S   DMERC
     L08-N01                     form 06.02
     (CCYYMMD                    Mapped to
     D)                          FRM04 2440

                                 See GU0-25

54   Reply ALN   159   8x    S   DMERC
     L08-N02                     forms 06.02,
     (CCYYMMD                    08.02
     D)
                                 Mapped to
                                 FRM04 2440

                                 See GU0-25

55   Reply ALN   167   8x    S   DMERC
     L08-N03                     form 06.02
     (CCYYMMD                    Mapped to
     D)                          FRM04 2440

                                 See GU0-25

56   Reply ALN   175   8x    S   DMERC
     L08-N04                     form 06.02
     (CCYYMMD                    Mapped to
     D)                          FRM04 2440

                                 See GU0-25

57   Reply ALN   183   20x   S   DMERC
     L20-N01                     forms 08.02,
                                 09.02, 10.02



                                 Mapped to
                                 FRM03 2440

                                 See GU0-25

58   Reply ALN   203   60x   S   DMERC
     L60-N01                     forms 08.02,
                                 10.02
58   Reply ALN   203   60x   S
     L60-N01



                                 Mapped to
                                 FRM03 2440

                                 See GU0-25

59   Reply NUM   263   1x    S   DMERC
     L01-N01                     form 01.02
                                 Values:
                                 NSF =
                                 HIPAA-X12 v
                                 4010


                                 Stage One 1
                                 =1
                                 Stage Two 2
                                 =2
                                 Stage Three 3
                                 =3
                                 Stage Four 4
                                 =4
                                 No Ulcer or
                                 Pressure Area
                                 9 =9


                                 DMERC
                                 form 08.02
                                 Values:
                                 NSF =
                                 HIPAA-X12 v
                                 4010


                                 Heart 1 = 1
                                 Liver 2 = 2
                                 Kidney 3 = 3
                                 Bone Marrow
                                 4 =4
                                 Lung 5 = 5


                                 DMERC
                                 form 09.02
                                 Values:
                                 NSF =
                                 HIPAA-X12 v
                                 4010


                                 External
                                 infusion pump
                                 (non-
                                 disposable) 1
                                 =1
                                 Implantable
                                 infusion pump
                                 3 =3
                                 Disposal
                                 infusion pump
                                 (e.g.
                                 elastomeric) 4
                                 =4


                                 DMERC
                                 form
                                 10.02
                                Values: 1
                                through 7 are
                                valid in NSF
                                and HIPAA-
                                X12 v 4010

                                Mapped to
                                FRM03 2440

                                See GU0-25

                                Values are
                                validated in
                                the NSF
                                map
60   Reply NUM   264   1x   S   DMERC
     L01-N02                    form 01.02
                                Values: 1
                                through 4 are
                                valid in NSF
                                and HIPAA-
                                X12 v 4010



                                DMERC
                                form 08.02
                                Values:
                                NSF =
                                HIPAA-X12 v
                                4010


                                Heart 1 = 1
                                Liver 2 = 2
                                Kidney 3 = 3
                                Bone Marrow
                                4 =4
                                Lung 5 = 5


                                DMERC
                                form 09.02
                                Values:
                                NSF =
                                HIPAA-X12 v
                                4010


                                Intravenous 1
                                =1
                                Epidural 3 =
                                3
                                Subcutaneous
                                4 =4


                                DMERC
                                form 10.02
                                Values: 1
                                through 7 are
                                valid in NSF
                                and HIPAA-
                                X12 v 4010
                                  Mapped to
                                  FRM03 2440

                                  See GU0-25

                                  Values are
                                  validated in
                                  the NSF
                                  map
61   Reply NUM   265   1x     S   DMERC
     L01-N03                      form 01.02
                                  Values: 1
                                  through 4 are
                                  valid in NSF
                                  and HIPAA-
                                  X12 v 4010



                                  DMERC
                                  form 08.02
                                  Values:
                                  NSF =
                                  HIPAA-X12 v
                                  4010


                                  Heart 1 = 1
                                  Liver 2 = 2
                                  Kidney 3 = 3
                                  Bone Marrow
                                  4 =4
                                  Lung 5 = 5


                                  DMERC
                                  form 09.02
                                  Values:
                                  NSF =
                                  HIPAA-X12 v
                                  4010


                                  Continuous 1
                                  =1
                                  Intermittent 3
                                  =3
                                  Bolus
                                  4 =       4


                                  Mapped to
                                  FRM03 2440

                                  See GU0-25

                                  Values are
                                  validated in
                                  the NSF
                                  map
62   Reply NUM   266   n(4)   S   DMERC
     L04-N01                      forms 02.03
                                  and 09.02
62   Reply NUM   266   n(4)   S
     L04-N01



                                  Values: 0001
                                  through 0024
                                  are valid in
                                  NSF and
                                  HIPAA-X12 v
                                  4010

                                  DMERC
                                  forms 03.02,
                                  08.02 and
                                  10.02

                                  Values: 0001
                                  through 9999
                                  are valid in
                                  NSF and
                                  HIPAA-X12 v
                                  4010

                                  DMERC
                                  form 04.03
                                  Values: 0001
                                  through 0099
                                  are valid in
                                  NSF and
                                  HIPAA-X12 v
                                  4010

                                  DMERC
                                  form 06.02
                                  Values: 0001
                                  through 0099
                                  are valid in
                                  NSF and
                                  HIPAA-X12 v
                                  4010, if
                                  GU0.27=N or
                                  D, this field
                                  must be zero
                                  filled.

                                  Mapped to
                                  FRM03 2440

                                  See GU0-25
                                  Values are
                                  validated in
                                  the NSF
                                  map. If this
                                  field contains
                                  data, the
                                  only valid
                                  values are
                                  numeric. The
                                  map will
                                  check to
                                  ensure that
                                  all positions
                                  in the field
                                  are numeric.
                                  The field
                                  may contain
                                  all blanks if
                                  there is no
                                  data to be
                                  sent. In this
                                  case, the
                                  map will not
                                  check the
                                  field value
                                  for numeric
                                  data.




63   Reply NUM   270   n(4)   S   DMERC
     L04-N02                      forms 01.02
                                  and 08.02

                                  Values: 0000
                                  through 9999
                                  are valid in
                                  NSF and
                                  HIPAA-X12 v
                                  4010

                                  DMERC
                                  form 10.02
                                  Values: 0000
                                  through 0999
                                  are valid in
                                  NSF and
                                  HIPAA-X12 v
                                  4010

                                  DMERC
                                  form 04.03
                                  Values: 0001
                                  through 0099
                                  are valid in
                                  NSF and
                                  HIPAA-X12 v
                                  4010
                                  Mapped to
                                  FRM03 2440

                                  See GU0-25

                                  Values are
                                  validated in
                                  the NSF
                                  map. If this
                                  field contains
                                  data, the
                                  only valid
                                  values are
                                  numeric. The
                                  map will
                                  check to
                                  ensure that
                                  all positions
                                  in the field
                                  are numeric.
                                  The field
                                  may contain
                                  all blanks if
                                  there is no
                                  data to be
                                  sent. In this
                                  case, the
                                  map will not
                                  check the
                                  field value
                                  for numeric
                                  data.




64   Reply NUM   274   n(4)   S   DMERC
     L04-N03                      forms 01.02
                                  and 10.02

                                  Values: 0000
                                  through 0999
                                  are valid in
                                  NSF and
                                  HIPAA-X12 v
                                  4010

                                  DMERC
                                  form 04.03
                                  Values: 0001
                                  through 0099
                                  are valid in
                                  NSF and
                                  HIPAA-X12 v
                                  4010

                                  Mapped to
                                  FRM03 2440

                                  See GU0-25
                                  Values are
                                  validated in
                                  the NSF
                                  map. If this
                                  field contains
                                  data, the
                                  only valid
                                  values are
                                  numeric. The
                                  map will
                                  check to
                                  ensure that
                                  all positions
                                  in the field
                                  are numeric.
                                  The field
                                  may contain
                                  all blanks if
                                  there is no
                                  data to be
                                  sent. In this
                                  case, the
                                  map will not
                                  check the
                                  field value
                                  for numeric
                                  data.




65   Reply NUM   278   n(4)   S   DMERC
     L04-N04                      forms 01.02
                                  and 10.02

                                  Values: 0000
                                  through 9999
                                  are valid in
                                  NSF and
                                  HIPAA-X12 v
                                  4010

                                  DMERC
                                  form 04.03
                                  Values: 0001
                                  through 0099
                                  are valid in
                                  NSF and
                                  HIPAA-X12 v
                                  4010

                                  Mapped to
                                  FRM03 2440

                                  See GU0-25
                                  Values are
                                  validated in
                                  the NSF
                                  map. If this
                                  field contains
                                  data, the
                                  only valid
                                  values are
                                  numeric. The
                                  map will
                                  check to
                                  ensure that
                                  all positions
                                  in the field
                                  are numeric.
                                  The field
                                  may contain
                                  all blanks if
                                  there is no
                                  data to be
                                  sent. In this
                                  case, the
                                  map will not
                                  check the
                                  field value
                                  for numeric
                                  data.




66   Reply NUM   282   n(4)   S   DMERC
     L04-N05                      form 01.02
                                  Values: 0000
                                  through 9999
                                  are valid in
                                  NSF and
                                  HIPAA-X12 v
                                  4010

                                  DMERC
                                  form 04.03
                                  Values: 0001
                                  through 0099
                                  are valid in
                                  NSF and
                                  HIPAA-X12 v
                                  4010

                                  DMERC
                                  form 10.02
                                  Values: 0000
                                  through 0007
                                  are valid in
                                  NSF and
                                  HIPAA-X12 v
                                  4010

                                  Mapped to
                                  FRM03 2440
                                  See GU0-25

                                  Values are
                                  validated in
                                  the NSF
                                  map. If this
                                  field contains
                                  data, the
                                  only valid
                                  values are
                                  numeric. The
                                  map will
                                  check to
                                  ensure that
                                  all positions
                                  in the field
                                  are numeric.
                                  The field
                                  may contain
                                  all blanks if
                                  there is no
                                  data to be
                                  sent. In this
                                  case, the
                                  map will not
                                  check the
                                  field value
                                  for numeric
                                  data.




67   Reply NUM   286   n(4)   S   DMERC
     L04-N06                      forms 01.02
                                  and 10.02

                                  Values: 0000
                                  through 9999
                                  are valid in
                                  NSF and
                                  HIPAA-X12 v
                                  4010

                                  DMERC
                                  form 04.03
                                  Values: 0001
                                  through 0099
                                  are valid in
                                  NSF and
                                  HIPAA-X12 v
                                  4010

                                  Mapped to
                                  FRM03 2440

                                  See GU0-25
                                  Values are
                                  validated in
                                  the NSF
                                  map. If this
                                  field contains
                                  data, the
                                  only valid
                                  values are
                                  numeric. The
                                  map will
                                  check to
                                  ensure that
                                  all positions
                                  in the field
                                  are numeric.
                                  The field
                                  may contain
                                  all blanks if
                                  there is no
                                  data to be
                                  sent. In this
                                  case, the
                                  map will not
                                  check the
                                  field value
                                  for numeric
                                  data.




68   Reply NUM   290   n(4)   S   DMERC
     L04-N07                      form 01.02
                                  Values: 0000
                                  through 9999
                                  are valid in
                                  NSF and
                                  HIPAA-X12 v
                                  4010

                                  Mapped to
                                  FRM03 2440

                                  See GU0-25
                                    Values are
                                    validated in
                                    the NSF
                                    map. If this
                                    field contains
                                    data, the
                                    only valid
                                    values are
                                    numeric. The
                                    map will
                                    check to
                                    ensure that
                                    all positions
                                    in the field
                                    are numeric.
                                    The field
                                    may contain
                                    all blanks if
                                    there is no
                                    data to be
                                    sent. In this
                                    case, the
                                    map will not
                                    check the
                                    field value
                                    for numeric
                                    data.




69   Reply PCT   294   n(3)v9   S   DMERC
     L04-N01                        form 10.02
                                    Values:
                                    000.0%
                                    through
                                    099.9% are
                                    valid in NSF
                                    and HIPAA-
                                    X12 v 4010

                                    Mapped to
                                    FRM05 2440

                                    See GU0-25

                                    Values are
                                    validated in
                                    the NSF
                                    map
70   Reply PCT   298   n(3)v9   S   DMERC
     L04-N02                        form 10.02
                                    Values:
                                    000.0%
                                    through
                                    099.9% are
                                    valid in NSF
                                    and HIPAA-
                                    X12 v 4010
                                                                             Mapped to
                                                                             FRM05 2440

                                                                             See GU0-25

                                                                             Values are
                                                                             validated in
                                                                             the NSF
                                                                             map
              71               Reply PCT    302      n(3)v9         S        DMERC
                               L04-N03                                       form 10.02
                                                                             Values:
                                                                             000.0%
                                                                             through
                                                                             099.9% are
                                                                             valid in NSF
                                                                             and HIPAA-
                                                                             X12 v 4010

                                                                             Mapped to
                                                                             FRM05 2440

                                                                             See GU0-25

                                                                             Values are
                                                                             validated in
                                                                             the NSF
                                                                             map
              72               Filler –     306       15x
                               National




Record type: GX0
Medical Necessity Oxygen – Oxygen Certification Segment                         Optional Record
            Field #            Field       Start    Length     NSF           Comment
                               Name                            Required      s and
                                                               Professiona   Values
                                                               l
               1               Record ID     1            3x        R        Value: GX0
                               “GX0”                                         Preceded by:
                                                                             FA0, FB0,
                                                                             FB1, FB2 or
                                                                             FE0
                                                                             Next record:
                                                                             FA0, GX1,
                                                                             GX2, HA0 or
                                                                             XA0



               2               Sequence      4            2x       R         If record
                               Number                                        present, field
                                                                             must equal
                                                                             the FA0
                                                                             record, field
                                                                             02 value for
                                                                             this service
                                                                             line.
3   Patient         6    17x
    Control
    Number
4   Certification   23   1x    S   Values:
    Type                           NSF     =
                                   HIPAA-X12 v
                                   4010


                                   Initial
                                   Certification I =
                                   I
                                   Renewal
                                   Certification R
                                   =R
                                   Revised
                                   Certification S
                                   =S
                                   Initial
                                   Certification 1
                                   =I
                                   Revised
                                   Certification 2
                                   =S
                                   Renewal
                                   Certification 3
                                   =R


                                   Mapped to
                                   CR501 2400

                                   Values are
                                   validated in
                                   the NSF
                                   map
5   Oxygen          24   1x    S   Values:
    System                         NSF     =
                                   HIPAA-X12 v
                                   4010


                                   Yes Y = AL
                                   No N = 37
                                   Does not apply
                                   D = 37


                                   Mapped to
                                   CRC03 2400
                                   (CRC01=11)



                                   Values are
                                   validated in
                                   the NSF
                                   map
6   Length of       25   2x    S   Mapped to
    Need                           CR502 2400

7   Equipment       27   1x
    Type 1
8   Equipment       28   1x
    Type 2
9   Equipment       29   64x
    Reason
10   Prescribed      93     8x      S   Mapped to
     From Date                          DTP03 2400
                                        (DTP01=463
                                        ), if GU0-19
     (CCYYMMD                           is not
     D)                                 present
11   Prescribed      101    8x      S   Mapped to
     To Date                            DTP03 2400
                                        (DTP01=461
                                        , if GU0-20 is
     (CCYYMMD                           not present
     D)
12   Date            109    8x
     Prescribed
     (CCYYMMD
     D)
13   Date            117    8x
     Evaluated
     (CCYYMMD
     D)
14   Oxygen Flow     125    3x      S   Mapped to
     Rate                               REF02 2400
                                        (REF01=TP)

15   Frequency of    128    2x
     Use
16   Duration        130    2x
17   Arterial        132   n(2)v9   S   Mapped to
     Blood Gas                          MEA03 2400
     4LPM                               (MEA01=TR,
                                        MEA02=GR
                                        A)



18   Oximetry        135   n(2)v9   S   Mapped to
     4PLM                               MEA03 2400
                                        (MEA01=TR,
                                        MEA02=ZO)




19   Date Tested     138    8x      S   Mapped to
     4LPM                               DTP03 2400
                                        (DTP01=119
     (CCYYMMD                           )
     D)
20   Inpatient/Out   146    1x      S   Values:
     patient Ind                        NSF     =
                                        HIPAA-X12 v
                                        4010


                                        Yes Y = P1
                                        No N = P1
                                      Mapped to
                                      CRC03,
                                      CRC04, or
                                      CRC04 2400
                                      (CRC01=11)



                                      Values are
                                      validated in
                                      the NSF
                                      map
21   Filler        147    65x
22   Arterial      212   n(2)v9   S   Mapped to
     Blood Gas                        CR510 2400

23   Oximetry      215   n(2)v9   S   Mapped to
                                      CR511 2400

24   Date Tested   218    8x      S   Mapped to
     (CCYYMMD                         DTP03 2400
     D)                               (DTP01=480
                                      )

                                      Mapped to
                                      DTP03 2400
                                      (DTP01=481
                                      )

25   Entity Perf   226    33x     S   Mapped to
     Oximetry                         NM103
     Test                             2420C
                                      (NM101=77,
                                      NM102=2)
26   Test          259    1x      S   Values:
     Conditions                       NSF =
                                      HIPAA-X12 v
                                      4010


                                      At Rest 1 = R
                                      Exercising 2 =
                                      E
                                      Sleeping 3 = S


                                      Mapped to
                                      CR512 2400

                                      Values are
                                      validated in
                                      the NSF
                                      map
27   Clinical      260    3x      S   Position 260
     Findings 1                       is mapped to
                                      CR513 2400
              27               Clinical        260     3x    S
                               Findings 1




                                                                 Position 261
                                                                 is mapped to
                                                                 CR514 2400



                                                                 Position 262
                                                                 is mapped to
                                                                 CR515 2400



              28               Port Oxygen     263     3x
                               Flow Rate

              29               Ordering        266     15x
                               Provider ID
              30               Ordering        281     10x   S   Mapped to
                               Provider                          PER04
                               Phone                             2420E
                               Number                            (NM101=DK)

              31               Diagnosis       291     5x
                               Code 1
              32               Diagnosis       296     5x
                               Code 2
              33               Diagnosis       301     5x
                               Code 3
              34               Diagnosis       306     5x
                               Code 4
              35               Certification   311     1x    S   Values:
                               on File                           NSF     =
                                                                 HIPAA-X12 v
                                                                 4010


                                                                 Yes Y = 38
                                                                 No N = 38




                                                                 Mapped to
                                                                 CRC03 or
                                                                 CRC04 2400
                                                                 (CRC01=11)



                                                                 Values are
                                                                 validated in
                                                                 the NSF
                                                                 map
              36               Delivery        312     1x
                               System Type

              37               Filler –        313     8x
                               National




Record type: GX1
Narrative Info For Oxygen – Oxygen Narrative Segment               No Mappings For
                                                                   HIPAA-X12 v 4010
            Field #             Field          Start   Length   NSF           Comment
                                Name                            Required      s and
                                                                Professiona   Values
                                                                l
               1                Record ID        1       3x                   Value: GX1
                                “GX1”                                         Preceded by:
                                                                              GX0
                                                                              Next record:
                                                                              FA0, GX2,
                                                                              HA0 or XA0




               2                Sequence         4       2x
                                Number
               3                Patient          6      17x
                                Control
                                Number
               4                Test Results    23      90x

               5                Medical         113     90x
                                Findings
               6                Exercise        203     90x
                                Routine
               7                Filler -        293     28x
                                National




Record type: GX2
Facility Info For Oxygen – Oxygen Facility Segment                               Optional Record
            Field #             Field          Start   Length   NSF           Comment
                                Name                            Required      s and
                                                                Professiona   Values
                                                                l
               1                Record ID        1       3x          R        Value: GX2
                                “GX2”                                         Preceded by:
                                                                              GX0 or GX1

                                                                              Next record:
                                                                              FA0, HA0 or
                                                                              XA0



               2                Sequence         4       2x         R         If record
                                Number                                        present, field
                                                                              must equal
                                                                              the FA0
                                                                              record, field
                                                                              02 value for
                                                                              this service
                                                                              line.



               3                Patient          6      17x
                                Control
                                Number
              4      Test Facility     23      30x          S        Mapped to
                     Address 1                                       N301 2420C
                                                                     (NM101=77)



              5      Test Facility     53      30x          S        Mapped to
                     Address 2                                       N302 2420C
                                                                     (NM101=77)



              6      Test Facility     83      20x          S        Mapped to
                     City                                            N401 2420C
                                                                     (NM101=77)



              7      Test Facility     103      2x          S        Mapped to
                     State                                           N402 2420C
                                                                     (NM101=77)



              8      Test Facility     105      9x          S        Mapped to
                     Zip Code                                        N403 2420C
                                                                     (NM101=77)



              9      Patient           114     33x
                     Facility
                     Name
             10      Patient           147     30x
                     Facility
                     Address 1
             11      Patient           177     30x
                     Facility
                     Address 2
             12      Patient           207     20x
                     Facility City
             13      Patient           227      2x
                     Facility State

             14      Patient           229      9x
                     Facility Zip
                     Code
             15      Filler –          238     83x
                     National




Record type: HA0
Narrative Record                                                     Conditional Record
           Field #   Field            Start   Length   NSF           Comment
                     Name                              Required      s and
                                                       Professiona   Values
                                                       l
              1      Record ID          1       3x          R        Value: HA0
                     "HA0"
               1                 Record ID      1       3x         R
                                 "HA0"
                                                                             Preceded by:
                                                                             FA0, FB0,
                                                                             FB1, FB2,
                                                                             GA0, GD0,
                                                                             or GD1


                                                                             Next record:
                                                                             FA0 or XA0

               2                 Sequence       4       2x         R         If record
                                 No                                          present, field
                                                                             must equal
                                                                             the FA0
                                                                             record, field
                                                                             02 value for
                                                                             this service
                                                                             line.



               3                 Patient        6      17x
                                 Control
                                 Number
               4                 Line Item     23      17x
                                 Control No
               5                 Extra         40      281x         S        Mapped to
                                 Narrative                                   K301 2400
                                 Data                                        Mapped to
                                                                             NTE02 2400
                                                                             (NTE01=AD
                                                                             D)

                                                                             Only the first
                                                                             80 bytes are
                                                                             mapped.




Record type: XA0
Claim Trailer Record – Summary                                                 Required Record
            Field #              Field        Start   Length   NSF           Comment
                                 Name                          Required      s and
                                                               Professiona   Values
                                                               l
               1                 Record ID      1       3x          R        Value: XA0
                                 “XA0”
                                                                             Preceded by:
                                                                             FA0, FB0,
                                                                             FB1, FB2,
                                                                             FD0, GA0,
                                                                             HA0
                                                                             Next record:
                                                                             CA0 or YA0



               2                 Reserved       4       2x
                                 (XA0.02)
3    Patient       6      17x
     Control
     Number
4    Record Cxx    23      2x
     Count
5    Record Dxx    25      2x
     Count
6    Record Exx    27      2x
     Count
7    Record Fxx    29      2x
     Count
8    Record Gxx    31      2x
     Count
9    Record Hxx    33      2x
     Count
10   Claim         35      3x
     Record
     Count
11   Reserved      38     40x
     (XA0.11)
12   Total Claim   78    n(5)v99   S   Mapped to
     Charges                           CLM02 2300

13   Tot           85    n(5)v99
     Disallowed
     Cost
     Containment

14   Total         92    n(5)v99
     Disallowed
     Other
     Charges
15   Total         99    n(5)v99
     Allowed
     Amount
16   Total         106   n(5)v99
     Deductible
     Amount
17   Total         113   n(5)v99
     Coinsurance
     Amount
18   Total Payer   120   n(5)v99
     Amount Paid

19   Patient       127   n(5)v99   S   Mapped to
     Amount Paid                       AMT02 2300
                                       (AMT01=F5)



20   Total         134   n(5)v99
     Purchase
     Service
     Charges
21   Provider      141    16x
     Discount
     Information
22   Remarks       157    103x
23   Filler -      260    61x
     National
Record type: YA0
Batch Trailer Record                                                    Required Record
             Field #   Field          Start   Length    NSF           Comment
                       Name                             Required      s and
                                                        Professiona   Values
                                                        l
                1      Record ID        1       3x           R        Value: YA0
                       “YA0”
                                                                      Preceded by:
                                                                      XA0
                                                                      Next record:
                                                                      BA0 or ZA0



                2      EMC              4      15x
                       Provider ID
                3      Batch Type      19       3x
                4      Batch           22       4x
                       Number
                5      Batch ID        26       6x
                6      Provider Tax    32       9x
                       ID
                7      Reserved        41       6x
                       (YA0.07)
                8      Batch           47       7x
                       Service Line
                       Count
                9      Batch           54       7x
                       Record
                       Count
               10      Batch Claim     61       7x
                       Count
               11      Batch Total     68     n(7)v99
                       Charges
               12      Filler -        77      244x
                       National




Record type: ZA0
File Trailer Record                                                     Required Record
             Field #   Field          Start   Length    NSF           Comment
                       Name                             Required      s and
                                                        Professiona   Values
                                                        l
                1      Record ID        1       3x           R        Value: ZA0
                       “ZA0”
                                                                      Preceded by:
                                                                      YA0
                2      Submitter ID     4      16x
                3      Reserved        20       9x
                       (ZA0.03)
                4      Receiver ID     29      16x
                5      File Service    45       7x
                       Line Count
6    File Record   52      7x
     Count
7    File Claim    59      7x
     Count
8    Batch Count   66      4x

9    File Total    70    n(9)v99
     Charges
10   File Total    81    n(9)v99
     Paid Amount

11   File Total    92    n(9)v99
     Allowed
     Amount
12   Filler -      103    218x
     National
Required Record
       HIPAA




       Required




       Required

       Required




       Required




       Required
Required




Required

Required




Required
Required Record
       HIPAA




       Situational
Required
_______
Situational




Required




Situational




Situational




Situational




Situational




Situational




Situational


Situational
   Situational




   Situational




   Situational




Required Record
   Comment HIPAA
   s and
   Values
   Value: BA1
   Preceded by:
   BA0 Next
   record type:
   CA0 One




   If BA1.07 is    Required
   present, then
   BA1.08 –
Mapped to      Situational
N302
2010AA
(NM101=85)

Mapped to      Required
N401
2010AA
(NM101=85)

Mapped to      Required
N402
2010AA
(NM101=85)

Mapped to      Required
N403
2010AA
(NM101=85)

Mapped to      Situational
PER04
2010AA
(NM101=85)

If BA1.07 is   Required
not present,
Mapped to      Situational
N302
2010AA
(NM101=85)

Mapped to      Required
N401
2010AA
(NM101=85)

Mapped to      Required
N402
2010AA
(NM101=85)

Mapped to      Required
N403
2010AA
(NM101=85)

Map to         Situational
PER04
2010AA
(NM101=85)
Required Record
   Comment HIPAA
   s and
   Values
   Value: CA0
   Preceded by:

   Mapped to  Required
   CLM01 2300

   Mapped to      Required
   NM103          Situational
   2010BA
   (NM101=IL,
   NM102=1), if
   patient is the
   subscriber
   Mapped to
   NM103
   2010CA
   (NM101=QC,
   NM102=1) if
   patient is the
   dependent




   Mapped to       Situational
   NM104
   2010BA
   (NM101=IL)
   if patient is
   the
   subscriber
   Mapped to
   NM104
   2010CA
   (NM101=QC
   ) if patient is
   the
   dependent

   Mapped to       Situational
   NM105
   2010BA
   (NM101=IL)
   if patient is
   the
   subscriber
   Mapped to
   NM105
   2010CA
   (NM101=QC
   ) if patient is
   the
   dependent
Mapped to       Situational
NM107
2010BA
(NM101=IL)
if patient is
the
subscriber
Mapped to
NM107
2010CA
(NM101=QC
) if patient is
the
dependent

Mapped to       Required
DMG02           Situational
2010BA
(NM101=IL)
if patient is
the
subscriber
Mapped to
DMG02
2010CA
(NM101=QC
) if patient is
the
dependent
Mapped to
DMG03
2010CA
(NM101=QC
) if patient is
the
dependent

Values: NSF =
HIPAA-X12 v
4010 Female
F = F Male M
= M Mapped
to DMG03
2010BA
(NM101=IL) if
patient is the
subscriber
Mapped to       Required
N301            Situational
2010BA
(NM101=IL)
if patient is
the
subscriber
Mapped to
N301
2010CA
(NM101=QC
) if patient is
the
dependent

Mapped to       Required
N302            Situational
2010BA
(NM101=IL)
if patient is
the
subscriber
Mapped to
N302
2010CA
(NM101=QC
) if patient is
the
dependent

Mapped to       Required
N401            Situational
2010BA
(NM101=IL)
if patient is
the
subscriber
Mapped to
N401
2010CA
(NM101=QC
) if patient is
the
dependent

Mapped to       Required
N402            Situational
2010BA
(NM101=IL)
if patient is
the
subscriber
Mapped to
N402
2010CA
(NM101=QC
) if patient is
the
dependent
Mapped to       Required
N403            Situational
2010BA
(NM101=IL)
if patient is
the
subscriber
Mapped to
N403
2010CA
(NM101=QC
) if patient is
the
dependent




Mapped to       Situational
PAT06
2000B
(NM101=IL)
if patient is
the
subscriber
Mapped to
PAT06
2000C
(NM101=QC
) if patient is
the
dependent
       Values: NSF = Situational
       HIPAA-X12 v
       4010 Y = QD
       N = Mapped
       to NM101
       2010BC If
       NSF value is
       blank or “N”,
       NM1 will not
       be created
       Values are
       validated in the
       NSF map




Optional Record
       HIPAA




       Situational




       Situational
Optional Record
       HIPAA




       Situational




       Situational




       Situational




       Situational




       Situational




       Situational
       Situational




       Situational




Required Record
       HIPAA




       Required
Required
Required




Situational




Required




Situational




Situational




Situational




Required
Required




Situational
Required
Situational




Required
Required




Situational




Situational




Situational




Required
Situational




Situational
Optional Record

       HIPAA




       Situational




       Situational




       Situational




       Situational
Situational




Situational
Optional Record
       HIPAA




       Situational




       Situational




       Situational




       Situational
       Situational




       Situational




Optional Record
       HIPAA
HIPAA




Situational
Required Record
       HIPAA
Situational
Situational




Situational
Situational




Required
Situational




Situational




Situational




Required
Situational
Situational




Required
Required




Situational




Situational
Situational




Situational




Situational
       Situational




Optional Record

       HIPAA




       Situational
Situational
Situational




Situational
Situational




Situational
Situational
Situational
Situational




Situational
Optional Record
       HIPAA




       Situational




       Situational
Situational




Situational




Situational




Situational
       Situational




Optional Record
       HIPAA
Situational




Situational




Situational




Situational
Situational




Situational




Situational




Situational
Situational




Situational




Situational




Situational
Situational




Situational




Situational




Situational




Situational
Situational




Situational




Situational




Situational
Situational




Situational
Situational




Situational
Required Record




       HIPAA




       Situational
Situational




Situational




Situational
Situational




Situational




Situational



Situational
Required




_______
Situational




Situational




Situational




Situational




Situational




Situational
Situational




Situational




Situational




Situational




Situational




Situational




Situational




Situational




Situational
Situational




Situational




Situational




Required




Required
Situational




Situational
Situational
Situational
Situational




Situational
       Situational




       Situational




       Situational




Optional Record
       HIPAA
Situational




Situational




Situational




Situational




Situational




Situational




Situational




Situational
        Situational




        Situational




        Situational




        Situational




No Mappings For
HIPAA-X12 v 4010
        HIPAA
Required Record
Comment HIPAA
s and
Values
Value: FA0
Preceded by:
EA0, EA1,
EA2, FA0,
FB0, FB1,
FB2, FB3,
FD0, Cert
records or
HA0


Next record:
FB0, FB1,
FB2, FB3,
FD0, FE0,
Cert records,
HA0 or XA0




Each claim
must have at
least one
FA0 record.
There may
be as many
as 99 Fxx
records for a
claim.


Must be
present and
numeric (00 -
99)




Mapped to  Situational
REF02 2400
(REF01=6R)



Mapped to  Required
DTP03 2400
(DTP01=472
)

Mapped to  Situational
DTP03 2400
(DTP01=472
)
                Situational




If present, a
hyphen and
this value
are
concatenate
d to the
value in FA0-
05 to form
the DTP03
2400


Mapped to       Required
CLM05-1
2300, first
detail
Mapped to
SV105 2400,
additional
detail;
mapped if
not equal to
the value in
CLM05-1
2300


Valid
Values
can be
found at:
www.hcfa.
gov/medic
are/posco
de.htm



Mapped to       Required
SV101-2
2400
Mapped to       Situational
SV101-3
2400
Mapped to       Situational
SV101-4
2400
Mapped to       Situational
SV101-5
2400
Mapped to  Required
SV102 2400

Mapped to       Situational
SV107-1
2400
Mapped to       Situational
SV107-2
2400
Mapped to      Situational
SV107-3
2400
Mapped to      Situational
SV107-4
2400
Mapped to  Required
SV104 2400

Mapped to  Required
SV104 2400

Values: NSF = Situational
HIPAA-X12 v
4010
Yes,
emergency
related Y = Y
No, emergency
not related N =




Mapped to
SV109 2400

Values are
validated in
the HIPAA
map




Mapped to    Situational
NM109
2310B
(NM101=82,
NM108=XX),
NM1 will not
map if the
same as
2010AA


Mapped to
NM109
2420A
(NM101=82,
NM108=XX),
NM1 will not
map if the
same as
2010AA or
2310B


               Situational
Mapped to  Situational
REF02
2420F
(REF01=1G)
Mapped to  Situational
REF02 2400
(REF01=EW
)




Mapped to    Situational
REF02 2300
(REF01=X4),
first detail

Mapped to
REF02 2400
(REF01=X4),
additional
detail;
mapped if
not equal to
the value in
REF02 2300




Mapped to      Situational
SV101-6
2400




Values: NSF = Situational
HIPAA-X12 v
4010
                 Situational


Yes, Physician
employed by
Hospice Y = Y


No, Physician
not employed
by Hospice N =
N

Mapped to
CRC02 2400
(CRC01=70)



Values are
validated in
the HIPAA
map
Mapped to  Situational
DTP03 2400
(DTP01=738
)

Mapped to  Situational
MEA03 2400
(MEA01=TR,
MEA02=R1)



Mapped to  Situational
MEA03 2400
(MEA01=TR,
MEA02=R2)



Mapped to      Situational
PAT08
2000B, if
patient is the
subscriber


Mapped to
PAT08
2000C, if
patient is the
dependent



The value in
this field is
originally
reported as
kilograms
and will be
converted to
pounds for
x12
Mapped to  Situational
MEA03 2400
(MEA01=OG
,
MEA02=R3)


Mapped to  Situational
DTP03 2400
(DTP01=739
)

Mapped to  Situational
MEA03 2400
(MEA01=TR,
MEA02=R4)




Values:           Required
NSF     =
HIPAA-X12 v
4010


Transportation
miles 1 =
Anesthesia
Time 2 = MJ
Number of
Services 3 =
UN
Oxygen volume
unites 4 = UN

Blood units 5 =
F2


Mapped to
SV103 2400

Values are
validated in
the NSF
map
Mapped to  Situational
AMT02 Loop
2400
(AMT01=AA
E)
Values:        Situational
NSF
HIPAA-X12
v4010



SS Number
S
34
TIN Number
T
24


Mapped to
NM108
2310B
(NM101=82)

Mapped to
NM108
2420A
(NM101=82)

Values are
validated in
the NSF
map




Mapped to  Situational
REF02 2400
(REF01=OZ)
Optional Record
  Comment HIPAA
  s and
  Values
  Value: FB0
  Preceded by:
  FA0
  Next record:
  FA0, FB1,
  FB2, FB3,
  FD0, FE0,
  Cert records,
  HA0 or XA0




  If record
  present, field
  must equal
  the FA0
  record, field
  02 value for
  this service
  line.




  Mapped to  Situational
  PS102 2400




  Mapped to  Situational
  NM109
  2420E
  (NM101=DK,
  NM108=XX)




  Mapped to  Situational
  NM109
  2420B
  (NM101=QB,
  NM108=XX)
                Situational




Mapped to
PS101 2400,
if FB0.05 is
present and
value greater
than 0




Values:         Situational
NSF     =
HIPAA-X12 v
4010


Copay exempt
0=0
Recipient did
not pay when
asked 1 =
Recipient did
pay when
asked 2 =
Recipient was
not asked 3 =


Mapped to
SV115 2400

Values are
validated in
the HIPAA
map
Values: NSF = Situational
HIPAA-X12 v
4010
Yes, EPSDT
involvement Y
=Y
No, EPSDT
involvement N
=
  Mapped to
  SV111 2400

  Values are
  validated in
  the HIPAA
  map
  Values: NSF = Situational
  HIPAA-X12 v
  4010
  Yes, family
  planning
  involved Y = Y

  No, family
  planning not
  involved N =


  Mapped to
  SV112 2400

  Values are
  validated in
  the HIPAA
  map




  Mapped to Situational
  2310C
  NM103
  (NM101=Q
  B,
  NM102=2)




Optional Record
Comment HIPAA
s and
Values
Value: FB1
Preceded by:
FA0 or FB0

Next record:
FA0, FB2,
FB3, FD0,
FE0, Cert
records, HA0
or XA0



If record
present, field
must equal
the FA0
record, field
02 value for
this service
line.




Mapped to  Situational
NM103
2420E
(NM101=DK,
NM102=1)
Mapped to
PER02
2420E
(NM101=DK)

Mapped to  Situational
NM104
2420E
(NM101=DK)

Mapped to        Situational
NM105
2420E
(NM101DK)
Mapped to  Situational
NM103
2420F
(NM101=DN,
NM102=1)
Mapped to  Situational
NM104
2420F
(NM101=DN)

Mapped to  Situational
NM105
2420F
(NM101=DN)

Mapped to      Situational
REF02
2420F
(REF01=1G)
; If FA0.24 is
present, then
FB1.13 will
override
FA0.24


Mapped to    Situational
NM103
2310B
(NM101=82,
NM102=1);
NM1 will not
map if the
same as
2010AA


Mapped to
NM103
2420A
(NM101=82,
NM102=1);
NM1 will not
map if the
same as
2010AA or
2310B


Mapped to    Situational
NM104
2310B
(NM101=82);
NM1 will not
map if the
same as
2010AA
Mapped to
NM104
2420A
(NM101=82);
NM1 will not
map if the
same as
2010AA or
2310B

Mapped to    Situational
NM105
2310B
(NM101=82);
NM1 will not
map if the
same as
2010AA
Mapped to
NM105
2420A
(NM101=82);
NM1 will not
map if the
same as
2010AA or
2310B




Mapped to  Situational
NM103
2420D
(NM101=DQ,
NM102=1)


Mapped to Situational
NM104
2420D
(NM101=DQ
)
Mapped to Situational
NM105
2420D
(NM101=DQ
)
Mapped to Situational
NM109
2420D
(NM101=DQ
)
Mapped to  Situational
REF02
2420D
(REF01=1G,
NM101=DQ)
Optional Record
       HIPAA




       Situational




       Situational




       Situational
       Situational




       Situational




No Mappings For
  X12 v 4010
       HIPAA
No Mappings for
  X12 v 4010
       HIPAA
Optional Record

       HIPAA
Situational
Optional Record
       HIPAA




       Situational
Situational




Situational
Situational




Situational
Situational




Situational
Situational




Situational




Situational
Situational
Situational




Situational
Situational




Situational
       Situational




Optional Record
       HIPAA
Situational




Situational
Situational
Situational




Situational
        Situational




No Mappings For
HIPAA-X12 v 4010
        HIPAA
No Mappings For
HIPAA-X12 v 4010
        HIPAA




No Mappings For
HIPAA-X12 v 4010
        HIPAA
No Mappings For
HIPAA-X12 v 4010
        HIPAA
Optional Record
       HIPAA
Situational




Situational
Situational




Situational




Situational




Situational



Situational




Situational
Situational
Situational
Situational




Situational
Situational
Situational




Situational
Situational




Situational
Situational




Situational
Situational




Situational
Situational




Situational




Situational
Situational




Situational
Situational




Situational




Situational
Situational




Situational




Situational




Situational




Situational




Situational




Situational




Situational
Situational




Situational
Situational
Situational




Situational
Situational
Situational
Situational
Situational
Situational
Situational
Situational
Situational




Situational
       Situational




Optional Record
       HIPAA
Situational




Situational




Situational
Situational




Situational




Situational




Situational




Situational




Situational




Situational
Situational



Situational



Situational




Situational




Situational




Situational
        Situational




        Situational




        Situational




No Mappings For
HIPAA-X12 v 4010
       HIPAA




Optional Record
       HIPAA
         Situational




         Situational




         Situational




         Situational




         Situational




Conditional Record
         HIPAA
       Situational




Required Record
       HIPAA
Required




Situational
Required Record
       HIPAA




Required Record
       HIPAA

								
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