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HIPAAHandbook for Health Care ClaimStatus Request and Response

(276/277) for Decision Support 2000+

DRAFT 5/20/02

DRAFT

HIPAA

Handbook for

Health Care Claim Status Requestand Response Transactions (276/277)

Decision Support 2000+

May 20, 2002

Survey and Analysis BranchDivision of State and Community Systems Development

Center for Mental Health ServicesSubstance Abuse and Mental Health Services Administration

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Table of Contents

I. Introduction ........................................................................................... 3

II. Overview of the Transactions .............................................................. 4

III. Health Care Claim Status Request (276) Data Check List ................. 13

IV. Health Care Claim Status Notification (277) Data Check List............ 20

V. Health Care Claim Status Request (276) Data Element Tables......... 28

VI. Health Care Claim Status Notification (277) Data ElementTables..................................................................................................... 55

VII. Key Terms and Important Issues.........................................................115

VIII. List of External Code Sources Needed for the Transactions............120

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HIPAA Handbook forHealth Care Claim Status Request

and Response Transactions (276/277)Decision Support 2000+

I

I. Introduction

The Health Care Claim Status Request (276) and the Health Care Claim StatusResponse (277) transaction set is used to request the status of a health careclaim(s) (276) and to respond with the information regarding the specified claim(s)(277).

Entities requesting health care claim status include hospitals, nursing homes,laboratories, physicians, dentists, allied professional groups, employers, andsupplemental (i.e., other than primary payer) health care claims adjudicationprocessors. Organizations sending the 277 Health Care Claim Status Response

include payers, who may be insurance companies; third party administrators; servicecorporations; state and federal agencies and their contractors; plan purchasers; andany other entity that processes health care claims. Other business partners affiliatedwith the 276 and/or the 277 include billing services, consulting services, vendors ofsystems, software and EDI translators; and EDI network intermediaries such asAutomated Clearing Houses (ACHs), Value-Added Networks (VANs), andtelecommunications services.

This Handbook consists of

an overview of the structure of the transaction;

tables of the data elements (including definitions, codes, and attributes) thatconstitute the transaction;

definitions of key terms and explanations of issues for understanding theinformation contained in the master data set; and

a list of external code sources need for the transaction.

The Data Tables define terms, explain usage, and provide technical specificationsfor the data. Section VII defines key terms and elaborates on important issues forthis transaction.

Information in this Handbook is intended to provide a user-friendly summary of the

data contained in the Health Care Claim Status Request and Response (276/277)transaction. When referenced in conjunction with the DS2000+ Master Data Set, thisHandbook will help users construct a transaction. For additional technicalinformation not provided in these documents, users should refer to the full

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Implementation Guide. All information in this Handbook has been taken directly fromthe Health Care Claim Status Request and Response (276/277) transaction. 1

II. Overview of this Transaction

Uses of the Benefit Health Care Claim Status Request and Response (276/277)transaction

The Benefit Health Care Claim Status Request and Response (276/277) is a pairedtransaction set consisting of the Health Care Claim Status Request (276), which isused to request the current status of a specified claim(s), and the Health Care ClaimStatus Response (277) transaction, which is used as a solicited response to a healthcare claim status request (276).

The Health Care Claim Status Response (277) transaction can also be used as anotification about health care claim(s) status, including front end acknowledgments,and as a request for additional information about a health care claim(s). Unlike theHealth Care Claim Status Response (277), the Health Care Claim Status Request(276) has only one usein conjunction with the Health Care Claim Status Response(277). This handbook addresses the paired usage of the 276 as a request for claimstatus and the 277 as a response to that request. Separate handbooks weredeveloped to detail using the 277 Health Care Payer Unsolicited Claim Status andthe 277 Health Care Claim Request for Additional Information.

Claim status requests processed in a real time mode (see Key Terms below) willonly provide a status of a claim that has been accepted by the payers adjudicationsystem within 90 days from the date of the inquiry. Claim status requests that areprocessed in a batch mode, will return claim status information that is available onthe payers adjudication system that has not been purged.

Health Care Claim Status Request (276)

The Health Care Claim Status Request (276) is used to transmit request(s) for statusof specific health care claim(s). Authorized entities involved with processing theclaim need to track the claims current status through the adjudication process. Thepurpose of generating a 276 is to obtain the current status of the claim within theadjudication process. Status information can be requested at the claim and/or linelevel.

1 Health Care Claim Status Request and Response (276/277) transaction, ASCX12N276/277 (004010X093), Washington Publishing Company, May 2000.

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The 276 includes information that is necessary for the payer to identify the specificclaim in question. The primary, or unique, identifying element(s) may be supplied toobtain an exact match. However, when the requester does not know the uniqueelement(s), the claim generally is located by supplying several parameters including

the provider number, patient identifier, date(s) of service, and submitted charge(s)from the original claim.

Health Care Claim Status Response (277)The payer uses the Health Care Claim Status Response (277) to transmit thecurrent status within the adjudication process to the requester. When the 276 doesnot uniquely identify the claim within the payers system, the response may includemultiple claims that meet the identification parameters supplied by the requester.

The claim may be found in a variety of status locations within a payers adjudicationprocess, including the following (which are described in detail in the Key Terms

section below):

pre-adjudication (accepted/rejected claim status)

claim pended for development (incorrect/incomplete claim(s) within adjudicationprocess) or suspended claim(s) requesting additional information

finalized claims

Finalized claims may have various outcomes including finalized rejected claim(s),finalized denied claim(s), finalized approved claim(s) pre-payment, and finalizedapproved claim(s) post-payment.

Information Requirements

The level of information potentially available for a Claim Status Response mayvary drastically from Payer to Payer. In order to make this transaction usable tothe Information Receiver and to give the Information Source a target to which tobuild, minimum theoretical guidelines have been established for the industry. Payersare free to provide a greater level of detail information, but are required tomeet these basic minimums. The primary vehicle for the claim status information inthe 277 transaction is the STC segment and the three iterations of the C043composite.

Information Flow and Interaction with other Transactions

Figure 1, Claim Status Information Flow, illustrates the flow of information related tothe 276 and all uses of the 277 Health Care Claim Status Response. It is importantthat providers differentiate between the multiple uses of the 277 claim status. Forthis transaction set, the third, fourth, and final flows do not apply.

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Submitting a claim, whether by using the Health Care Claim: Professional orInstitutional (837) transaction or by another format, is the first step in the claim statusrequest/response process. Certain data elements (e.g., the patientcontrol number, type of bill, dates of service, insured identifier, service

provider identifier, and claim number when available) found on the claim help locateit within a payers adjudication system. When the provider initiates aclaim status request, as many of these data elements as possible should beforwarded to the payer. With the exception of the claim number, the source of thisinformation is the providers billing system.The Functional Acknowledgment (997) transaction is used upon request by oneof the trading partners to acknowledge receipt of information. A 997 can be used bythe payer to acknowledge claim receipt (837); the provider to acknowledge receipt ofan Health Care Payer Unsolicited Claim Status (277); the provider to acknowledgereceipt of a Health Care Claim Request for Additional Information (277); or theprovider to acknowledge receipt of a Health Care Claim Payment/Advice (835).

The Health Care Claim Request for Additional Information (277) transaction is usedby payers to obtain information on a claim that has been suspended during theadjudication process because it is under medical or utilization review. Thisinformation is needed to supplement or support the providers request for payment ofthe services under review. Although the 277 Health Care Claim Request forAdditional Information is used for this purpose, the 277 Health Care Claim StatusResponse may return similar information if the requested claim happens to be in thisstatus location.

Figure 1. Claim Status Information Flow

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Structure of the Transaction Sets

Under HIPAA, business transactions (such as a group of benefit enrollments sentfrom a sponsor to a payer or a health care claim submitted by a provider to a payer)

are conducted through formal structures called transaction sets. Information istransmitted as discrete data elements grouped together into segments; segmentsare grouped into loops (see Figure 2).

Figure 2. Loops, Segments, and Data Elements

Transaction sets all adhere to the same format: a control segment called the headersegment; loops of data segments, both in specified order; and a control segmentcalled the trailer segment. Within each data segment, the data elements also followa specified order. Similar transaction sets, called functional groups, can be senttogether within a transmission; in this case, each transaction set has its own uniqueidentifier that is transmitted as the first data element of the header segment.

The discussion below on data elements, segments, and loops is intended to helpreaders understand the structure of the transaction and the information presented inthe Data Tables.

Data ElementsA data element corresponds to a data field in data processing terminology. Dataelements are characterized by:

name (e.g., Identification Code)

usage (e.g., required or situational [which means that the element is requiredonly under certain circumstances]);

reference designator (e.g., NM109, which indicates that the element is in theNM1 segment and is the ninth data element in the segment);

number (e.g., 67); and

attributes.

Loop

Segments

DataElements

Segments

DataElements

Loop

Segments

DataElements

Segments

DataElements

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The attributes are the condition designator in the X12 standard (i.e., mandatory [M],optional [O], relational [X]) 2; the type of data element (e.g., Numeric [Nn], Decimal[R], Identifier [ID], String [AN], Date [DT], Time [TM], Binary [B]); and the minimumand maximum length of the data (i.e., the number of character positions used fornumeric, decimal, and binary elements).

For simplicity of presentation, we use the single term attributes in the data tables torefer to allthe characteristics of a data element, i.e., usage, reference designator,number, X12 requirement designator, type, and length. For the data elementsubscriber identification code these attributes are listed sequentially asSITUATIONAL NM109 67 X AN 2/80. In this example, the meaning of the terms isas follows:

SITUATIONAL required only under certain circumstancesNM109 the ninth element in the NM1 segmentX a relational element in the X12 standard

AN a string type of element2/80 a minimum of 2 and a maximum of 80 characters are allowed

SegmentsLogically related data elements are grouped together in units called segments.There are two types of segmentscontrol segments and data segments. Thesesegments have the same structure, but different uses. The control segments areused to convey information about the transaction and the data segments are used toconvey the information that necessitated the transaction. Transaction sets alwaysbegin and end with a control segment between which are the data segments. Thecontrol segment that begins a transaction is called the header (ST) segment and isused to identify the sender and receiver; the control segment that ends a transactionis called the trailer (SE) segment and is used for verification and security purposes.(For more information on control segments, see Section VIII Key Terms)

Each transaction set contains many segments, analogous to a freight train: thesegments are like the trains cars and each one has several data elements just as atrain car might have many crates. The sequence of the data elements within onesegment and the sequence of segments in the transaction set are both specified by

2 The X12 condition designator defines the circumstances under which a data element maybe required to be present or not present in a particular segment. The designation ofmandatory (M) is absolute in the sense that there is no dependency on other data

elements. The designation of optional (O) means that there is no requirement for a dataelement to be in the segment and that its presence is at the option of the sender. Relationalconditions (X) may exist among two or more simple data elements within the same datasegment (e.g., they may be paired or multiple so that if any element specified in therelational condition is present, then all the elements specified must be present).

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the ASC X12 standard. In a more conventional computing environment, thesegments would be equivalent to records, and the data elements equivalent to fields.

Each segment, whether a control or data segment, has its own name and its ownpurpose. A segment always has the same structure: it begins with a unique

identifier, then has one or more logically related data elements, and ends with asegment terminator.

The Data Check List shows all the data elements within each data segment; the datasegments within the transaction by segment ID, name, and usage (required orsituational); and how the segments are grouped into loops.

LoopsLoops are groups of logically related data segments. The segments within a loopoccur in a specified order; the first (beginning) segment in the loop gives the loopits name and establishes whether the loop is required or situational. If the beginning

segment in a loop is required, then the loop is required; if the beginning segment issituational, the loop is situational. Loops themselves are not actually sent in atransactiononly the data segments within the loop are sent. A loop (actually, thedata segments that comprise the loop) may occur once, repeat an unlimited numberof times, or repeat only a specified number of times.

Loop HierarchyThe looping structure is hierarchicali.e., certain loops are subordinated to others.Once the hierarchy is understood, the logic of the data in the transaction becomesapparent.

Figures 3a and 3b show the hierarchical organization of the data in thesetransactions. The 276 and 277 transaction sets are similar in structure but are notduplicates. Both are divided into two levels, or tables. Table 1, Header, containstransaction control information. Table 2, Detail, contains the detail information for thebusiness function of the transaction.

For both the 276 and 277, Table 1, the Header Level, contains the ST and BHTsegments. The ST segment identifies the start of a transaction and the specifictransaction set. The BHT identifies the transactions business purpose and thehierarchical structure. For example, in the BHT segment, a 276 will have a value of13 in the Transaction Set Purpose Code data element to indicate that the transactionis a request and a 277 will have a value of 08 to indicate that the transaction is aresponse. Since the 277 transaction is multi-functional, a Transaction Set TypeCode data element is used, whereas the 276, which has only one function, does notuse that data element.

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Table 2, Detail Level, contains several nested loops. For both transactions, Loop2000 identifies the participant and the relationship to other participants. Nestedwithin Loop 2000 is Loop 2100 which contains the individual or entity name andLoop 2200 which contains specific claim details. It is at Loop 2200 that the 276 and277 transactions begin to differ.

Although Loop 2200 contains segments in the 276 that are different from the 277Health Care Claim Status Response, the intent of the loop is similar in bothtransactions. The specific claim identification parameters are found in Loop 2200.Because the provider and payer identify the claim using different parameters, thesegments used for the request are different from the segments used for theresponse.

When a claim status is requested, the provider supplies parameters that help thepayer locate the claim. Frequently, these parameters are the claim number, dates ofservice, type of bill, and insureds identification number. Similarly, when the claim

status is returned, the payer supplies the parameters that help the provider locatethe claim. Frequently, these parameters are the patientcontrol number, medical record number, type of bill, and dates of service.

In some payers adjudication systems, a request for claim line item status can beaccommodated. Additional parameters must be specified when a specific lineitem status is requested. These parameters are specified in the 276 Health CareClaim Status Request Loop 2210 and in the 277 Health Care Claim StatusResponse Loop 2220.

Note that specific claim detail information is not given a hierarchical level. Thespecific claim(s) in question are described in Loop 2200 and the service informationfollows in Loop 2220. This claim(s) information is said to float and is positioned inthe same hierarchical level that describes its owner-participant, either the Subscriberor the Dependent. That means the claim(s) information is placed at the Subscriberhierarchical level when the patient is the subscriber and placed at the Dependenthierarchical level when the patient is the dependent of the subscriber.

The Data Check List shows the hierarchical levels, the loops within the levels, thesegments within the loops, and the data elements within the segments.

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Figure 3a. Loop Hierarchy for the Health Care Claim Status Request (276)

Table 1 - Header

Transaction Set HeaderBeginning of Hierarchical Transaction

Table 2 Detail, Information Source LevelLOOP ID - 2000A INFORMATION SOURCE LEVEL

LOOP ID - 2100A PAYER NAME

Table 2 Detail, Information Receiver LevelLOOP ID - 2000B INFORMATION RECEIVER LEVEL

LOOP ID - 2100B INFORMATION RECEIVER NAME

Table 2 Detail, Service Provider LevelLOOP ID - 2000C SERVICE PROVIDER LEVEL

LOOP ID - 2100C PROVIDER NAME

Table 2 Detail, Subscriber LevelLOOP ID - 2000D SUBSCRIBER LEVEL

LOOP ID - 2100D SUBSCRIBER NAME

LOOP ID - 2200D CLAIM SUBMITTER TRACE NUMBER

LOOP ID - 2210D SERVICE LINE INFORMATION

Table 2 Detail, Dependent LevelLOOP ID - 2000E DEPENDENT LEVEL

LOOP ID - 2100E DEPENDENT NAME

LOOP ID - 2200E CLAIM SUBMITTER TRACE NUMBER

LOOP ID - 2210E SERVICE LINE INFORMATION

Transaction Set Trailer

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Figure 3b. Loop Hierarchy for the Health Care Claim Status Response (277)transaction set

Table 1 - HeaderTransaction Set Header

Beginning of Hierarchical Transaction

Table 2 Detail, Information Source LevelLOOP ID - 2000A INFORMATION SOURCE LEVEL

LOOP ID - 2100A PAYER NAME

Table 2 Detail, Information Receiver LevelLOOP ID - 2000B INFORMATION RECEIVER LEVEL

LOOP ID - 2100B INFORMATION RECEIVER NAME

Table 2 Detail, Service Provider LevelLOOP ID - 2000C SERVICE PROVIDER LEVEL

LOOP ID - 2100C PROVIDER NAME

Table 2 Detail, Subscriber LevelLOOP ID - 2000D SUBSCRIBER LEVEL

LOOP ID - 2100D SUBSCRIBER NAME

LOOP ID - 2200D CLAIM SUBMITTER TRACE NUMBER

LOOP ID - 2220D SERVICE LINE INFORMATION

Table 2 Detail, Dependent LevelLOOP ID - 2000E DEPENDENT LEVEL

LOOP ID - 2100E DEPENDENT NAME

LOOP ID - 2200E CLAIM SUBMITTER TRACE NUMBER

LOOP ID - 2210E SERVICE LINE INFORMATION

Transaction Set Trailer

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III. Data Check List for the Health Care Claim Status Request (276)

The Data Check List shows the hierarchical levels, the loops within the levels, the segmentswithin the loops, and the data elements within the segments. It helps users ensure that theyhave or collect all the information needed to process the transaction.

Table 1 - Header Information

SEG. ID NAME USAGEST Transaction Set Header R

Transaction Set Identifier Code R

Transaction Set Control Number R

BHT Beginning of Hierarchical Transaction R

Hierarchical Structure Code AGRAM R

Transaction Set Purpose Code R

Date R

Table 2 Detail

LOOP 2000A INFORMATION SOURCE LEVEL

HL Information Source Level R

Hierarchical ID Number R

Hierarchical Level Code RHierarchical Child Code R

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LOOP 2100A PAYER NAME

NM1 Payer Name R

Entity Identifier Code R

Name Last or Organization Name R

Identifier Code Qualifier R

Identification Code R

PER Payer Contact Information S

Contact Function Code R

Name S

Communication Number Qualifier R

Communication Number R

Communication Number Qualifier S

Communication Number S



LOOP 2100B INFORMATION RECEIVER LEVEL

HL Information Receiver Level R

Hierarchical ID Number RHierarchical Parent ID Number R

Hierarchical Level Code R

Hierarchical Child Code R

LOOP 2100B INFORMATION RECEIVER NAME

NM1 Information Receiver Name R


Entity Type Qualifier RName Last or Organization Name R

Name First S

Name Middle S

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Name Suffix S

Identification Code Qualifier R


LOOP 2000C SERVICE PROVIDER LEVEL

HL Service Provider Level R


Hierarchical Parent ID Number R



LOOP 2100C PROVIDER NAME

NM1 Provider Name R


Entity Type Qualifier R


Name First S

Name Middle S

Name Prefix S

Name Suffix S



LOOP 2000D SUBSCRIBER LEVEL

HL Hierarchical Level R





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DMG Subscriber Demographic Information S

Date Time Period Format Qualifier R

Date Time Period RGender Code R

LOOP 2100D SUBSCRIBER NAME

NM1 Subscriber Name S

Entity Identifier Code REntity Type Qualifier RName Last or Organization Name RName First S

Name Middle S

Name Prefix S

Name Suffix S

Identification Code Qualifier RIdentification Code R

LOOP 2200D CLAIM SUBMITTERTRACE NUMBER

TRN Trace R

Trace Type Code R

Reference Identification R

REF Payer Claim Identification Number S

Reference Identification Qualifier R


REF Institutional Bill Type Identification S



REF Medical Record Identification S



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AMT Claim Submitted Charges S

Amount Qualifier Code R

Monetary Amount R

DTP Claim Service Date S

Date/Time Qualifier R


Date Time Period R

LOOP 2210D SERVICE LINE INFORMATION

SVC Service Line Information S

Composite Medical Procedure Identifier R

Product/Service ID Qualifier R

Product/Service ID R

Procedure Modifier S

Procedure Modifier SProcedure Modifier S


Monetary Amount R

Product/Service ID S

Quantity S

REF Service Line Item Identification S



DTP Service Line Date R



Date Time Period R

LOOP 2000E DEPENDENT LEVEL

HL Dependent Level S


Hierarchical Parent ID Level R


DMG Dependent Demographic Information R


Date Time Period R

Gender Code R

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LOOP 2100E DEPENDENT NAME

NM1 Dependent Name R




Name First S

Name Middle S

Name Prefix S

Name Suffix S

Identification Code Qualifier S

Identification Code S

LOOP 2200E CLAIM SUBMITTERTRACE NUMBER

TRN Claim Submitter Trace Number R

Trace Type Code R







Reference Identification RREF Medical Record Identification S



AMT Claim Submitted Charges S

Amount Qualifier Code R

Monetary Amount R




Date Time Period R

LOOP 2210E SERVICE LINE INFORMATION


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Procedure Modifier SProcedure Modifier S

Monetary Amount R


Quantity S




DTP Service Line Date S



Date Time Period R

SE Transaction Set Trailer R

Number of Included Segments R


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IV. Data Check List for Health Care Claim Status Notification (277)

The Data Check List helps ensure that users have or collect all the information they need for thetransaction.

Table 1 Header

ST Transaction Set Header R

Transaction Set Identifier Code R

Transaction set Control Number R

BHT Beginning of Hierarchical Transaction S

Hierarchical Structure Code AGRAM R

Transaction Set Purpose Code R


Date R

Transaction Type Code R

Table 2 Detail

LOOP 2000AINFORMATION SOURCE LEVEL

HL Information Source Level R




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LOOP 2100A PAYER NAME

NM1 Payer Name REntity Identifier Code R





PER Payer Contact Information S

Contact Function Code R

Name SCommunication Number Qualifier R

Communication Number R





LOOP 2000B INFORMATION

RECEIVER LEVEL

HL Information Receiver Level R

Hierarchical ID Number RHierarchical Parent ID Number RHierarchical Level Code RHierarchical Child Code R


NM1 Information Receiver Name REntity Identifier Code REntity Type Qualifier RName Last or Organization Name RName First S

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Name Middle S

Name Prefix S

Name Suffix S




HL Service Provider Level R





NM1 Provider Name S




Name First S

Name Middle S

Name Prefix S

Name Suffix S



LOOP 2100C PROVIDER NAME

NM1 Provider Name R




Name First S

Name Middle S

Name Prefix S

Name Suffix S



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LOOP 2000D SUBSCRIBER LEVEL

HL Hierarchical Level R





DMG Subscriber Demographic Information R


Date Time Period R

Gender Code R

LOOP 2100D SUBSCRIBER NAME

NM1 Subscriber Name R




Name First S

Name Middle S

Name Prefix S

Name Suffix S

Identification Code Qualifier RIdentification Code R

LOOP 2200D CLAIM SUBMITTERTRACE NUMBER

TRN Claim Submitter Trace Number R

Trace Type Code R


STC Claim Level Status Information R

Health Care Claim Status R

Industry Code RIndustry Code R

Entity Identifier Code S

Date R

Monetary Amount R

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Monetary Amount R

Date S

Payment Method Code S

Date S

Check Number S

Health Care Claim Status SIndustry Code R

Industry Code R


Health Care Claim Status S

Industry Code R

Industry Code R





REF Institutional Bill Type Identification SReference Identification Qualifier R


REF Medical Record Identification S






Date Time Period R










Monetary Amount RMonetary Amount R


Quantity S

STC Service Line Status Information S

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Industry Code R

Industry Code R


Date R

Monetary Amount SMonetary Amount S


Industry Code R

Industry Code R



Industry Code R

Industry Code R



Reference Identification Qualifier RReference Identification R




Date Time Period R


HL Dependent Level S


Hierarchical Parent ID Level R


DMG Dependent Demographic Information R


Date Time Period R

Gender Code R


NM1 Dependent Name S




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Name First S

Name Middle S

Name Prefix S

Name Suffix S

Identification Code Qualifier S

Identification Code S

TRN Claim Submitter Trace Number S

Trace Type Code R


STC Claim Level Status Information R


Industry Code R

Industry Code R


Date RMonetary Amount S

Monetary Amount S

Date S

Payment Method Code S

Date S

Check Number S


Industry Code R

Industry Code R


Health Care Claim Status SIndustry Code R

Industry Code R








REF Medical Record Identification SReference Identification Qualifier R




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Date Time Period R




Product/Service ID RProcedure Modifier S




Monetary Amount R


Quantity S

REF Service Line Status Information S


Industry Code R

Industry Code REntity Identifier Code S

Date R

Monetary Amount S

Monetary Amount S


Industry Code R

Industry Code R



Industry Code R

Industry Code REntity Identifier Code S







Date Time Period R

SE Transaction Set Trailer R

Number of Included Segments R


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V. Data Element Tables Health Care Claim Status Request(276)

The Data Element Tables give the purpose and definition, codes, and technicalspecifications for all the data elements in the Benefit Enrollment and Maintenance

Transaction. Section V below explains and defines key terms. Readers should referto the Implementation Guide for additional technical information.

TRANSACTION SET HEADER (ST) REQUIRED

To indicate the start of a transaction set and to assign a control number.

Name Transaction Set Identifier CodePurpose/Definition Identifies this transaction is the 276 Health Care Claim

Status Request.Codes 276 Health Care Claim Status Request

Attributes REQUIRED ST01 143 M ID 3/3

Name Transaction Set Control NumberPurpose/Definition Unique control number for a transaction set assigned by

the originator.CodesAttributes REQUIRED ST02 329 M AN 4/9

BEGINNING OF HIERARCHICAL TRANSACTION (BHT) REQUIRED

Defines the business hierarchical structure of the transaction set and identifies thebusiness application purpose and reference data, i.e., number, date, and time. Thisrequired segment is used to start the transaction set and indicate the sequence ofthe hierarchical levels of information that will follow.

Name Hierarchical Structure CodePurpose/Definition Indicates the hierarchical structure of the transaction set,

i.e. the order of information contained in the transaction.Codes 0010 Information Source, Information Receiver, Provider of

Service, Subscriber, DependentAttributes REQUIRED BHT01 1005 M ID 4/4

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Name Transaction Set Purpose CodePurpose/Definition Identifies the purpose of the transaction set.

Codes 13 RequestAttributes REQUIRED BHT02 353 M ID 2/2

Name DatePurpose/Definition Indicates the date the transaction was created within the

business application system.CodesAttributes REQUIRED BHT04 373 O DT 8/8

LOOP 2000A - INFORMATION SOURCE LEVEL

INFORMATION SOURCE LEVEL (HL) REQUIRED

Identifies the relationship between hierarchically related groups of data segmentsand indicates that the series of segments from this Hierarchical Level (HL) segmentuntil the next HL segment are related to the information source.

Name Hierarchical ID NumberPurpose/Definition Unique number assigned by the sender to identify this data

segment in the hierarchical structure.CodesAttributes REQUIRED HL01 628 M AN 1/12

Name Hierarchical Level Code

Purpose/Definition Indicates the series of segments from this HL segmentuntil the next occurrence of an HL segment are related tothe information source.

Codes 20 Information SourceAttributes REQUIRED HL03 735 M ID 1/2

Name Hierarchical Child CodePurpose/Definition Indicates whether or not there are subordinate (or child)

HL segments related to the current HL segment.Codes 1 Additional Subordinate HL Data Segment in This

Hierarchical Structure.

Attributes REQUIRED HL04 736 O ID 1/1

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LOOP 2100A - PAYER NAME

PAYER NAME (NM1) REQUIRED

Supplies the full name of the payer organization.

Name Entity Identifier CodePurpose/Definition Identifies the organization in NM103 is the payer.Codes PR PayerAttributes REQUIRED NM101 98 M ID 2/3

Name Entity Type QualifierPurpose/Definition Designates the payer in NM103 is an organization.Codes 2 Non-Person EntityAttributes REQUIRED NM102 1065 M ID 1/1

Name Name Last or Organization NamePurpose/Definition Payer organization name.CodesAttributes REQUIRED NM103 1035 O AN 1/35

Name Identification Code QualifierPurpose/Definition Designates the system/method of code structure used for

the Identification Code.Codes 21 Health Industry Number (HIN)

AD Blue Cross Blue Shield Association Plan Code

FI Federal Taxpayers Identification NumberNI National Association of Insurance Commissioners(NAIC) IdentificationPI Payor IdentificationPP Pharmacy Processor NumberXV Health Care Financing Administration National Plan ID

Attributes REQUIRED NM108 66 X ID 1/2

Name Identification CodePurpose/Definition Indicates the Payer ID code.Codes

Attributes REQUIRED NM109 67 X AN 2/80

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PAYER CONTACT INFORMATION (PER) SITUATIONAL

Identifies a person or office to whom administrative communications should bedirected.

Name Contact Function Code

Purpose/Definition Identifies the major duty or responsibility of the person inPER02 is the payer information contact.

Codes IC Information ContactAttributes REQUIRED PER01 366 M ID 2/2

Name NamePurpose/Definition Identifies the payers information contact name.CodesAttributes SITUATIONAL PER02 93 O AN 1/60

Name Communication Number Qualifier

Purpose/Definition Identifies the type of communication number in PER04.Codes ED Electronic Data Interchange Access Number

EM Electronic MailTE Telephone

Attributes REQUIRED PER03 365 X ID 2/2

Name Communication NumberPurpose/Definition Payer contact communication number.CodesAttributes REQUIRED PER04 364 X AN 1/80

Name Communication Number QualifierPurpose/Definition Identifies the type of communication number used in

PER06.Codes EX Telephone ExtensionAttributes SITUATIONAL PER05 365 X ID 2/2

Name Communication NumberPurpose/Definition Complete communications number including country or

area code when applicable.Codes

Attributes SITUATIONAL PER06 364 X AN 1/80

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Name Communication Number QualifierPurpose/Definition Code identifying the type of communication number used

in PER08.Codes EX Telephone Extension

FX Facsimile

Attributes SITUATIONAL PER07 365 X ID 2/2

Name Communication NumberPurpose/Definition Payer contact communication number.CodesAttributes SITUATIONAL PER08 364 X AN 1/80

LOOP 2000B - INFORMATION RECEIVER LEVEL

INFORMATION RECEIVER LEVEL (HL) REQUIRED

Identifies the relationship between hierarchically related groups of data segments inthe information receiver level.

Name Hierarchical ID NumberPurpose/Definition Unique number assigned by the sender to identify this

particular data segment in the hierarchical structure.CodesAttributes REQUIRED HL01 628 M AN 1/12

Name Hierarchical Parent ID Number

Purpose/Definition Identifies the number of the next higher hierarchical datasegment that this data segment is subordinate to.CodesAttributes REQUIRED HL02 734 O AN 1/12

Name Hierarchical Level CodePurpose/Definition Indicates the series of segments following the current HL

segment until the next occurrence of an HL segment in thetransaction are related to the information receiver.

Codes 21 Information ReceiverAttributes REQUIRED HL03 735 M ID 1/2

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Hierarchical Structure.


LOOP 2100 B - INFORMATION RECEIVER NAME

INFORMATION RECEIVER NAME (NM1) REQUIRED

Identifies the individual or organization requesting to receive the status information.

Name Entity Identifier CodePurpose/Definition Identifies the individual or organization in NM103 is the

information receiver.Codes 41 SubmitterAttributes REQUIRED NM101 98 M ID 2/3

Name Entity Type QualifierPurpose/Definition Identifies whether the information receiver is an individual

or an organization.Codes 1 Person

2 Non-Person EntityAttributes REQUIRED NM102 1065 M ID 1/1

Name Name Last or Organization NamePurpose/Definition Information receiver last name or organizational name.CodesAttributes REQUIRED NM103 1035 O AN 1/35

Name Name FirstPurpose/Definition Information receiver first name.CodesAttributes SITUATIONAL NM104 1036 O AN 1/25

Name Name Middle

Purpose/Definition Information receiver middle name or initial.CodesAttributes SITUATIONAL NM105 1037 O AN 1/25

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Name Name SuffixPurpose/Definition Information receiver name suffix.CodesAttributes SITUATIONAL NM107 1039 O AN 1/10

Name Identification Code QualifierPurpose/Definition Code designating the system/method of code structure

used for Identification Code of the information receiver.Codes 46 Electronic Transmitter Identification Number (ETIN)

FI Federal Taxpayers Identification NumberXX Health Care Financing Administration National ProviderIdentifier.


Name Identification CodePurpose/Definition Information receiver identification number.

CodesAttributes REQUIRED NM109 67 X AN 2/80

LOOP 2000C - SERVICE PROVIDER LEVEL

SERVICE PROVIDER LEVEL (HL) REQUIRED

Identifies dependencies among and the content of hierarchically related groups ofdata segments and indicates that the data segments from this HL segment until thenext HL segment are related to the service provider.



Name Hierarchical Parent ID NumberPurpose/Definition Identifies the number of the next higher hierarchical data

segment that this data segment is subordinate to.

CodesAttributes REQUIRED HL02 734 O AN 1/12

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Name Hierarchical Level CodePurpose/Definition Indicates the series of segments following the current HL

segment until the next occurrence of an HL segment arerelated to the service provider.

Codes 19 Provider of Service

Attributes REQUIRED HL03 735 M ID 1/2



Hierarchical Structure.Attributes REQUIRED HL04 736 O ID 1/1

LOOP 2100C - PROVIDER NAME

PROVIDER NAME (NM1) REQUIRED

Supplies the full name of an individual or organizational entity.

Name Entity Identifier CodePurpose/Definition Identifies the organization or individual NM103 is the

provider.Codes 1P ProviderAttributes REQUIRED NM101 98 M ID 2/3

Name Entity Type QualifierPurpose/Definition Indicates whether the provider is an organization or an

individual.Codes 1 Person


Name Name Last or Organization NamePurpose/Definition Provider last name or organization name.CodesAttributes REQUIRED NM103 1035 O AN 1/35

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Name Name FirstPurpose/Definition Provider first name.CodesAttributes SITUATIONAL NM104 1036 O AN 1/25

Name Name MiddlePurpose/Definition Provider middle name or initial.CodesAttributes SITUATIONAL NM105 1037 O AN 1/25

Name Name PrefixPurpose/Definition Provider name prefix.CodesAttributes SITUATIONAL NM106 1038 O AN 1/10

Name Name Suffix

Purpose/Definition Provider name suffix.CodesAttributes SITUATIONAL NM107 1039 O AN 1/10


used for Identification Code of the provider in NM108.Codes FI Federal Taxpayers Identification Number

SV Service Provider NumberXX Health Care Financing Administration National ProviderIdentifier


Name Identification CodePurpose/Definition Code identifying the provider.CodesAttributes REQUIRED NM109 67 X AN 2/80

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SUBSCRIBER LEVEL (HL) REQUIRED

Identifies the relationship between hierarchically related groups of data segmentsand indicates that the series of segments from this hierarchical level (HL) segmentuntil the next HL segment are related to the subscriber.Name Hierarchical ID Number

Purpose/Definition Unique number assigned by the sender to identify aparticular data segment in a hierarchical structure.

CodesAttributes REQUIRED HL01 628 M AN 1/12

Name Hierarchical Parent ID NumberPurpose/Definition Identifies the hierarchical ID number of the HL segment to

which the current HL segment is subordinate.CodesAttributes REQUIRED HL02 734 O AN 1/12

Name Hierarchical Level CodePurpose/Definition Indicates the series of segments from this HL segment

until the next occurrence of an HL segment are related tothe subscriber.

Codes 22 SubscriberAttributes REQUIRED HL03 735 M ID 1/2


HL segments related to the current HL segment.

Codes 0 No Subordinate HL Segment in This HierarchicalStructure.1 Additional Subordinate HL Data Segment in ThisHierarchical Structure.


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SUBSCRIBER DEMOGRAPHIC INFORMATION (DMG) SITUATIONAL

Supplies demographic information for the subscriber when the subscriber is thepatient.

Name Date Time Period Format Qualifier

Purpose/Definition Indicates the date format of the date of birth provided inDMG02.

Codes D8 Date Expressed in Format CCYYMMDDAttributes REQUIRED DMG01 1250 X ID 2/3

Name Date Time PeriodPurpose/Definition Subscriber date of birth.CodesAttributes REQUIRED DMG02 1251 X AN 1/35

Name Gender CodePurpose/Definition Subscriber gender.Codes F Female

M MaleU Unknown

Attributes REQUIRED DMG03 1068 O ID 1/1

LOOP 2100D - SUBSCRIBER NAME

SUBSCRIBER NAME (NM1) REQUIRED

Supplies the full name of the subscriber.

Name Entity Identifier CodePurpose/Definition Identifies whether the subscriber in NM103 is also the

patient.Codes IL Insured or Subscriber

QC PatientAttributes REQUIRED NM101 98 M ID 2/3

Name Entity Type Qualifier

Purpose/Definition Code designating the type of subscriber named in NM103.Codes 1 Person2 Non-Person Entity

Attributes REQUIRED NM102 1065 M ID 1/1

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Name Name Last or Organization NamePurpose/Definition Subscriber last name or organization name.CodesAttributes REQUIRED NM103 1035 O AN 1/35

Name Name FirstPurpose/Definition Subscriber first name.CodesAttributes SITUATIONAL NM104 1036 O AN 1/25

Name Name MiddlePurpose/Definition Subscriber middle name or initial.CodesAttributes SITUATIONAL NM105 1037 O AN 1/25

Name Name PrefixPurpose/Definition Subscriber name prefix.CodesAttributes SITUATIONAL NM106 1038 O AN 1/10

Name Name SuffixPurpose/Definition Subscriber name suffix.CodesAttributes SITUATIONAL NM107 1039 O AN 1/10


used for Identification Code of the subscriber in NM109.Codes 24 Employers Identification Number

MI Member Identification NumberZZ Mutually Defined


Name Identification CodePurpose/Definition Code identifying the subscriber.Codes

Attributes REQUIRED NM109 67 X AN 2/80

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LOOP 2200D CLAIM SUBMITTER TRACE NUMBER

CLAIM SUBMITTER TRACE NUMBER (TRN) REQUIRED

Number assigned by the claim originator intended to allow tracing of a transaction.

Name Trace Type CodePurpose/Definition Code identifying which transaction is being referenced.

Designates the trace number in TRN02.Codes 1 Current Transaction Trace NumbersAttributes REQUIRED TRN01 481 M ID 1/2

Name Reference IdentificationPurpose/Definition Provides a unique trace number as identification for the

transaction.CodesAttributes REQUIRED TRN02 127 M AN 1/30

PAYER CLAIM IDENTIFICATION NUMBER (REF) SITUATIONAL

Identifies the payers assigned control number when the subscriber is the patient.

Name Reference Identification QualifierPurpose/Definition Designates the number in REF02 is the payor claim

number.

Codes 1K Payors Claim NumberAttributes REQUIRED REF01 128 M ID 2/3

Name Reference IdentificationPurpose/Definition Indicates the payor claim number.CodesAttributes REQUIRED REF02 127 X AN 1/30

INSTITUTIONAL BILL TYPE IDENTIFICATION (REF) SITUATIONAL

Identifies the institutional type of bill submitted on the original claim when thesubscriber is the patient.

Name Reference Identification QualifierPurpose/Definition Designates the number in REF02 is the billing type.Codes BLT Billing TypeAttributes REQUIRED REF01 128 M ID 2/3

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Name Reference IdentificationPurpose/Definition Indicates the bill type identifier.CodesAttributes REQUIRED REF02 127 X AN 1/30

MEDICAL RECORD IDENTIFICATION (REF) SITUATIONAL

Identifies the Medical Record number submitted on the original claim when thesubscriber is the patient.

Name Reference Identification QualifierPurpose/Definition Designates the number in REF02 is the Medical Record

identification number.Codes EA Medical Record Identification NumberAttributes REQUIRED REF01 128 M ID 2/3

Name Reference IdentificationPurpose/Definition Identifies the Medical Record number.CodesAttributes REQUIRED REF02 127 X AN 1/30

CLAIM SUBMITTED CHARGES (AMT) SITUATIONAL

Indicates the total monetary amount of the claim charges submitted.

Name Amount Qualifier CodePurpose/Definition Designates the amount in AMT02 is the total submitted

charges.Codes T3 Total Submitted ChargesAttributes REQUIRED AMT01 522 M ID 1/3

Name Monetary AmountPurpose/Definition Identifies the total claim charge amount.CodesAttributes REQUIRED AMT02 782 M R 1/18

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CLAIM SERVICE DATE (DTP) SITUATIONAL

Specifies the claim service period.

Name Date/Time QualifierPurpose/Definition Designates the date in DTP03 is the claim service period.

Codes 232 Claim Statement Period StartAttributes REQUIRED DTP01 374 M ID 3/3

Name Date Time Period Format QualifierPurpose/Definition Designates the format of the claim service period in

DTP03.Codes RD8 Range of Dates Expressed in Format CCYYMMDD-

CCYYMMDDAttributes REQUIRED DTP02 1250 M ID 2/3

Name Date Time PeriodPurpose/Definition Identifies the claim service period.CodesAttributes REQUIRED DTP03 1251 M AN 1/35


SERVICE LINE INFORMATION (SVC) SITUATIONAL

Used to request status information about a service line. Supplies payment andcontrol information to a provider for a particular service.

Name COMPOSITE MEDICAL PROCEDURE IDENTIFIERPurpose/Definition Identifies a medical procedure by its standardized codes

and applicable modifiers.CodesAttributes REQUIRED SVC01 C003 M

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Name Product/Service ID QualifierPurpose/Definition Identifies the type/source of the descriptive number used in

Product/Service ID.Codes AD American Dental Association Codes

CI Common Language Equipment Identifier (CLEI)

HC Health Care Financing Administration CommonProcedural Coding System (HCPCS) CodesID International Classification of Diseases ClinicalModification (ICD-9-CM) - ProcedureIV Home Infusion EDI Coalition (HIEC) Product/ServiceCodeN1 National Drug Code in 4-4-2 FormatN2 National Drug Code in 5-3-2 FormatN3 National Drug Code in 5-4-1 FormatN4 National Drug Code in 5-4-2 FormatND National Drug Code (NDC)

NH National Health Related Item CodeNU National Uniform Billing Committee (NUBC) UB92CodesRB National Uniform Billing Committee (NUBC) UB82Codes

Attributes REQUIRED SVC01 - 1 235 M ID 2/2

Name Product/Service IDPurpose/Definition Identifies the service identification code.CodesAttributes REQUIRED SVC01 - 2 234 ID M AN 1/48

Name Procedure ModifierPurpose/Definition Identifies special circumstances related to the performance

of the service.CodesAttributes SITUATIONAL SVC01 - 3 1339 O AN 2/2


of the service.Codes

Attributes SITUATIONAL SVC01 - 4 1339 O AN 2/2

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of the service.

Codes

Attributes SITUATIONAL SVC01 - 5 1339 O AN 2/2



Name Monetary AmountPurpose/Definition Identifies the original submitted charge.Codes

Attributes REQUIRED SVC02 782 M R 1/18

Name Product/Service IDPurpose/Definition Identifies the National Uniform Billing Code.CodesAttributes SITUATIONAL SVC04 234 O AN 1/48

Name QuantityPurpose/Definition Identifies the original units of service submitted.CodesAttributes SITUATIONAL SVC07 380 O R 1/15

SERVICE LINE ITEM IDENTIFICATION (REF) SITUATIONAL

Specifies the line item control number when the subscriber is the patient.

Name Reference Identification QualifierPurpose/Definition Designates the number in REF02 is the line item control

number.Codes FJ Line Item Control NumberAttributes REQUIRED REF01 128 M ID 2/3

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Name Reference IdentificationPurpose/Definition Identifies the Line Item Control Number.CodesAttributes REQUIRED REF02 127 X AN 1/30

SERVICE LINE DATE (DTP) REQUIREDSpecifies the service line date.

Name Date/Time QualifierPurpose/Definition Designates that the date in DTP03 is the service date.Codes 472 ServiceAttributes REQUIRED DTP01 374 M ID 3/3

Name Date Time Period Format QualifierPurpose/Definition Designates the format of the service line date in DTP03.Codes RD8 Range of Dates Expressed in Format CCYYMMDD-

CCYYMMDDAttributes REQUIRED DTP02 1250 M ID 2/3

Name Date Time PeriodPurpose/Definition Identifies the Service Line Date.CodesAttributes REQUIRED DTP03 1251 M AN 1/35


DEPENDENT LEVEL (HL) SITUATIONAL

Identifies the relationship between hierarchically related groups of data segmentsand indicates that the series of segments from this hierarchical level (HL) segmentuntil the next HL segment are related to the dependent level.

Name Hierarchical ID NumberPurpose/Definition Unique number assigned by the sender to identify this data

segment in the hierarchical structure.CodesAttributes REQUIRED HL01 628 M AN 1/12

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Name Hierarchical Parent ID NumberPurpose/Definition Identifies the number of the next higher hierarchical data

segment that this data segment is subordinate to.CodesAttributes REQUIRED HL02 734 O AN 1/12

Name Hierarchical Level CodePurpose/Definition Indicates the series of segments from this HL segment

until the next occurrence of an HL segment are related tothe dependent level.

Codes 23 DependentAttributes REQUIRED HL03 735 M ID 1/2

DEPENDENT DEMOGRAPHIC INFORMATION (DMG) REQUIRED

Supplies demographic information on the dependent.

Name Date Time Period Format QualifierPurpose/Definition Indicates the date format in DMG02.Codes D8 Date Expressed in Format CCYYMMDDAttributes REQUIRED DMG01 1250 X ID 2/3

Name Date Time PeriodPurpose/Definition Indicates the dependents date of birth.CodesAttributes REQUIRED DMG02 1251 X AN 1/35

Name Gender CodePurpose/Definition Indicates the dependents gender.Codes F Female

M MaleU Unknown

Attributes REQUIRED DMG03 1068 O ID 1/1

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DEPENDENT NAME (NM1) REQUIRED

Supplies the full name of the dependent.

Name Entity Identifier CodePurpose/Definition Identifies that the person named in NM103 is the patient.Codes QC PatientAttributes REQUIRED NM101 98 M ID 2/3

Name Entity Type QualifierPurpose/Definition Code designates the entity in NM103 is an individual.Codes 1 PersonAttributes REQUIRED NM102 1065 M ID 1/1

Name Name Last or Organization NamePurpose/Definition Identifies the dependents last name.CodesAttributes REQUIRED NM103 1035 O AN 1/35

Name Name FirstPurpose/Definition Dependent first name.CodesAttributes SITUATIONAL NM104 1036 O AN 1/25

Name Name Middle

Purpose/Definition Dependent middle name or initial.CodesAttributes SITUATIONAL NM105 1037 O AN 1/25

Name Name PrefixPurpose/Definition Dependent name prefix.CodesAttributes SITUATIONAL NM106 1038 O AN 1/10

Name Name SuffixPurpose/Definition Dependent name suffix.

CodesAttributes SITUATIONAL NM107 1039 O AN 1/10

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Identification Code of the dependent in NM109.Codes MI Member Identification Number

ZZ Mutually Defined

Attributes SITUATIONAL NM108 66 X ID 1/2

Name Identification CodePurpose/Definition Code identifying the dependent.CodesAttributes SITUATIONAL NM109 67 X AN 2/80

LOOP 2200E CLAIM SUBMITTER TRACE NUMBER

CLAIM SUBMITTER TRACE NUMBER (TRN) REQUIRED

Unique number assigned by the claim originator intended to allow tracing of atransaction when the patient is not the subscriber.

Name Trace Type CodePurpose/Definition Code identifying the trace number assigned in TRN02.Codes 1 Current Transaction Trace NumbersAttributes REQUIRED TRN01 481 M ID 1/2

Name Reference IdentificationPurpose/Definition Identifies the transaction trace number.

CodesAttributes REQUIRED TRN02 127 M AN 1/30

PAYER CLAIM IDENTIFICATION NUMBER (REF) SITUATIONAL

Specifies the payer claim control number when the patient is the subscriber.

Name Reference Identification QualifierPurpose/Definition Identifies the number in REF02 is the payer claim control

number (Internal Control Number, Document ControlNumber or Claim Control Number).

Codes 1K Payors Claim Number

Attributes REQUIRED REF01 128 M ID 2/3

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Name Reference IdentificationPurpose/Definition Identifies the payer claim control number.CodesAttributes REQUIRED REF02 127 X AN 1/30

INSTITUTIONAL BILL TYPE IDENTIFICATION (REF) SITUATIONALSpecifies the bill type as submitted on the original claim.

Name Reference Identification QualifierPurpose/Definition Identifies the number in REF02 is the billing type.Codes BLT Billing TypeAttributes REQUIRED REF01 128 M ID 2/3

Name Reference IdentificationPurpose/Definition Identifies the bill type identifier.CodesAttributes REQUIRED REF02 127 X AN 1/30

MEDICAL RECORD IDENTIFICATION (REF) SITUATIONAL

Specifies the medical record number submitted on the original claim.

Name Reference Identification QualifierPurpose/Definition Identifies the number in REF02 is the medical record

number.Codes EA Medical Record Identification NumberAttributes REQUIRED REF01 128 M ID 2/3

Name Reference IdentificationPurpose/Definition Identifies the medical record number submitted on the

original claim.CodesAttributes REQUIRED REF02 127 X AN 1/30

CLAIM SUBMITTED CHARGES (AMT) SITUATIONAL

Specifies the total claim charge amount to assist in identifying the claim.Name Amount Qualifier Code

Purpose/Definition Identifies the amount in AMT02 is the total claim chargeamount.Codes T3 Total Submitted ChargesAttributes REQUIRED AMT01 522 M ID 1/3

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Name Monetary AmountPurpose/Definition Identifies the total charge amount from the original claim.CodesAttributes REQUIRED AMT02 782 M R 1/18

CLAIM SERVICE DATE (DTP) SITUATIONALIdentifies the statement from and through date.

Name Date/Time QualifierPurpose/Definition Identifies the date in DTP03 is the claim service period.Codes 232 Claim Statement Period StartAttributes REQUIRED DTP01 374 M ID 3/3

Name Date Time Period Format QualifierPurpose/Definition Indicates the date format that will appear in DTP03. If the

date is a single date of service, the begin date equals theend date.

Codes RD8 Range of Dates Expressed in Format CCYYMMDD-CCYYMMDD

Attributes REQUIRED DTP02 1250 M ID 2/3

Name Date Time PeriodPurpose/Definition Identifies the service claim period.CodesAttributes REQUIRED DTP03 1251 M AN 1/35

LOOP 2210E SERVICE LINE INFORMATION

SERVICE LINE INFORMATION (SVC) SITUATIONAL

Supplies payment and control information to a provider for a particular service.

Name COMPOSITE MEDICAL PROCEDURE IDENTIFIERPurpose/Definition Identifies the procedure code of the claim.CodesAttributes REQUIRED SVC01 C003 M

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Name Product/Service ID QualifierPurpose/Definition Identifies the type/source of the descriptive number used in

Product/Service ID.Codes AD American Dental Association Codes

CI Common Language Equipment Identifier (CLEI)

HC Health Care Financing Administration CommonProcedural Coding System (HCPCS) CodesID International Classification of Diseases ClinicalModification (ICD-9-CM) ProcedureIV Home Infusion EDI Coalition (HIEC) Product/ServiceCodeN1 National Drug Code in 4-4-2 FormatN2 National Drug Code in 5-3-2 FormatN3 National Drug Code in 5-4-1 FormatN4 National Drug Code in 5-4-2 FormatND National Drug Code (NDC)

NH National Health Related Item CodeNU National Uniform Billing Committee (NUBC) UB92CodesRB National Uniform Billing Committee (NUBC) UB82Codes

Attributes REQUIRED SVC01 - 1 235 M ID 2/2

Name Product/Service IDPurpose/Definition Indicates the service/procedure code.CodesAttributes REQUIRED SVC01 - 2 234 M AN 1/48




of the service.

CodesAttributes SITUATIONAL SVC01 - 4 1339 O AN 2/2

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Name Monetary AmountPurpose/Definition Line item charge amount.CodesAttributes REQUIRED SVC02 782 M R 1/18

Name Product/Service IDPurpose/Definition Revenue Code.CodesAttributes SITUATIONAL SVC04 234 O AN 1/48

Name QuantityPurpose/Definition Identifies the original submitted units of service.CodesAttributes SITUATIONAL SVC07 380 O R 1/15

SERVICE LINE ITEM IDENTIFICATION (REF) SITUATIONAL

Specifies the service line item control number from the original claim.

Name Reference Identification QualifierPurpose/Definition Identifies the number in REF02 is the service line item

control number.Codes FJ Line Item Control NumberAttributes REQUIRED REF01 128 M ID 2/3

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Name Reference IdentificationPurpose/Definition Indicates the line item control number from the original

claim.CodesAttributes REQUIRED REF02 127 X AN 1/30

SERVICE LINE DATE (DTP) SITUATIONAL

Specifies the service date (or statement period for institutional claims).

Name Date/Time QualifierPurpose/Definition Identifies the date in DTP03 is the date of service.Codes 472 ServiceAttributes REQUIRED DTP01 374 M ID 3/3

Name Date Time Period Format Qualifier

Purpose/Definition Indicates the format of the service date in DTP03. If thedate is a single date of service, the begin date equals theend date.

Codes RD8 Range of Dates Expressed in Format CCYYMMDD-CCYYMMDD

Attributes REQUIRED DTP02 1250 M ID 2/3

Name Date Time PeriodPurpose/Definition Identifies the date of service or statement period.CodesAttributes REQUIRED DTP03 1251 M AN 1/35

TRANSACTION SET TRAILER (SE) REQUIRED

Indicates the end of the transaction set and provides the count of the transmittedsegments (including the beginning (ST) and ending (SE) segments).

Name Number of Included SegmentsPurpose/Definition Identifies the total number of segments included in a

transaction set including ST and SE segments.CodesAttributes REQUIRED SE01 96 M N0 1/10

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Name Transaction Set Control NumberPurpose/Definition Identifies a unique control number assigned by the

originator for a transaction set.CodesAttributes REQUIRED SE02 329 M AN 4/9

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VI. Data Element Tables for Health Care Claim StatusNotification (277)

The Data Element Tables give the purpose and definition, codes, and technicalspecifications for all the data elements in the Benefit Enrollment and MaintenanceTransaction. Section V below explains and defines key terms. Readers should referto the Implementation Guide for additional technical information.

TRANSACTION SET HEADER (ST) REQUIREDTo indicate the start of a transaction set and to assign a control number.

Name Transaction Set Identifier Code

Purpose/Definition Identifies this transaction is the 277 Health Care ClaimStatus Notification

Codes 277 Health Care Claim Status Notification

Attributes REQUIRED ST01 143 M ID 3/3

Name Transaction Set Control Number

Purpose/Definition Unique control number assigned by the originator for atransaction set.

CodesAttributes REQUIRED ST02 329 M AN 4/9

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BEGINNING OF HIERARCHICAL TRANSACTION(BHT) REQUIREDDefines the business hierarchical structure of the transaction set and identifies thebusiness application purpose and reference data, i.e., number, date, and time.

Name Hierarchical Structure CodePurpose/Definition Identifies the order of information in the transaction set.

Codes 0010 Information Source, Information Receiver, Providerof Service, Subscriber, Dependent

Attributes REQUIRED BHT01 1005 M ID 4/4

Name Transaction Set Purpose Code

Purpose/Definition Identifies the purpose of transaction set is to provideinformation on the status of a health care claim.

Codes 08 StatusAttributes REQUIRED BHT02 353 M ID 2/2

Name Reference Identification

Purpose/Definition Indicates the number assigned by the originator to identifythe transaction within the originators business applicationsystem.

Codes

Attributes REQUIRED BHT03 127 O AN 1/30

Name Date

Purpose/Definition Identifies the date the transaction was created within thebusiness application system.

CodesAttributes REQUIRED BHT04 373 O DT 8/8

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Name Transaction Type Code

Purpose/Definition Specifies the type of transaction is a response.

Codes DG ResponseAttributes REQUIRED BHT06 640 O ID 2/2

LOOP 2000A INFORMATION SOURCE LEVEL

INFORMATION SOURCE LEVEL (HL) REQUIREDIdentifies the dependencies among, and the content of, the data segments in theinformation source level.



Name Hierarchical Level CodePurpose/Definition Defines that data in this level of the hierarchical structure

refer to the information source.Codes 20 Information SourceAttributes REQUIRED HL03 735 M ID 1/2

Name Hierarchical Child Code

Purpose/Definition Indicates there are dependent (child) data segmentssubordinate to this HL segmentCodes 1 Additional Subordinate HL Data Segment in This


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PAYER NAME (NM1) REQUIREDTo supply the full name of the payer.

Name Entity Identifier CodePurpose/Definition Identifies the organization in NM103 is the payer.

Codes PR PayerAttributes REQUIRED NM101 98 M ID 2/3

Name Entity Type QualifierPurpose/Definition Identifies the payer is an organization.Codes 2 Non-Person EntityAttributes REQUIRED NM102 1065 M ID 1/1

Name Name Last or Organization NamePurpose/Definition Payer name.Codes

Attributes REQUIRED NM103 1035 O AN 1/35


the Payer Identification Code.Codes 21 Health Number (HIN)

AD Blue Cross Blue Shield Association Plan CodeFI Federal Taxpayers Identification NumberNI National Association of Insurance Commissioners(NAIC) IdentificationPI Payor Identification

PP Pharmacy Processor NumberXV Health Care Financing Administration National Plan ID


Name Identification CodePurpose/Definition Payer ID code.CodesAttributes REQUIRED NM109 67 X AN 2/80

PAYER CONTACT INFORMATION (PER) SITUATIONAL

Identifies the person or office to whom administrative communications should bedirected.

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Name Contact Function Code

Purpose/Definition Identifies the major duty or responsibility of the person orgroup named in PER02.

Codes IC Information ContactAttributes REQUIRED PER01 366 M ID 2/2

Name NamePurpose/Definition Payer information contact name.CodesAttributes SITUATIONAL PER02 93 O AN 1/60

Name Communication Number QualifierPurpose/Definition Identifies the type of communication number in PER04.Codes ED Electronic Data Interchange Access Number

EM Electronic MailTE Telephone

Attributes REQUIRED PER03 365 X ID 2/2

Name Communication NumberPurpose/Definition Payer information contact number.CodesAttributes REQUIRED PER04 364 X AN 1/80

Name Communication Number QualifierPurpose/Definition Identifies the type of communication number in PER06 is a

telephone extension.Codes EX Telephone ExtensionAttributes SITUATIONAL PER05 365 X ID 2/2

Name Communication NumberPurpose/Definition Payer information contact telephone extension number.CodesAttributes SITUATIONAL PER06 364 X AN 1/80

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Name Communication Number QualifierPurpose/Definition Identifies the type of communication number in PER08.Codes EX Telephone Extension

FX FacsimileAttributes SITUATIONAL PER07 365 X ID 2/2

Name Communication NumberPurpose/Definition Payer additional extension number or fax number.CodesAttributes SITUATIONAL PER08 364 X AN 1/80

LOOP 2000B INFORMATION RECEIVER LEVEL

INFORMATION RECEIVER LEVEL (HL) REQUIREDIdentifies the dependencies among, and the content of, the data segments in the

information receiver level.



Name Hierarchical Parent ID NumberPurpose/Definition Identifies the ID number of the HL segment to which the

information receiver HL segment is subordinate.

CodesAttributes REQUIRED HL02 734 O AN 1/12

Name Hierarchical Level CodePurpose/Definition Defines that data in this level of the hierarchical structure

refer to the information receiver.Codes 21 Information ReceiverAttributes REQUIRED HL03 735 M ID 1/2

Name Hierarchical Child CodePurpose/Definition Indicates there are dependent (child) data segments

subordinate to this HL segment.Codes 1 Additional Subordinate HL Data Segment in This


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INFORMATION RECEIVER NAME (NM1) REQUIREDSupplies the full name of the individual or organizational entity requesting the status

information.

Name Entity Identifier CodePurpose/Definition Identifies the organization or individual requesting to

receive the status information.Codes 41 SubmitterAttributes REQUIRED NM101 98 M ID 2/3

Name Entity Type QualifierPurpose/Definition Design notes the type of information receiver in NM103.Codes 1 Person


Name Name Last or Organization NamePurpose/Definition Information receiver last name or organization name.CodesAttributes REQUIRED NM103 1035 O AN 1/35

Name Name FirstPurpose/Definition Information receiver first name.Codes

Attributes SITUATIONAL NM104 1036 O AN 1/25

Name Name MiddlePurpose/Definition Information receiver last name.CodesAttributes SITUATIONAL NM105 1037 O AN 1/25

Name Name PrefixPurpose/Definition Information receiver name prefix.CodesAttributes SITUATIONAL NM106 1038 O AN 1/10

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Name Name SuffixPurpose/Definition Information receiver name suffix.CodesAttributes SITUATIONAL NM107 1039 O AN 1/10


the Identification Code.Codes 46 Electronic Transmitter Identification Number (ETIN)

FI Federal Taxpayers Identification NumberXX Health Care Financing Administration NationalProvider Identifier.


Name Identification CodePurpose/Definition Code identifying the information received.

CodesAttributes REQUIRED NM109 67 X AN 2/80


SERVICE PROVIDER LEVE

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