CLM

Claim information

Pos: 130	Max: 1
Detail - Optional
Loop: 2300	Elements: 9

Ref

Id

Element Name

Req

Type

Min/Max

Usage

CLM01

1028

Claim Submitter's Identifier
Description: Identifier used to track a claim from creation by the health care provider through payment
Industry: Patient Account Number
Alias: Patient Control Number
UB-92 Ref. [UB-Name]: 3 [Patient Control Number]
EMC v.6.0 Reference: Record Type 20 Field No. 3
The number that the submitter transmits in this position is echoed back to the submitter in the 835 and other transactions. This permits the submitter to use the value in this field as a key in the submitter’s system to match the claim to the payment information returned in the 835 transaction. The two recommended identifiers are either the patient account number or the claim number in the billing provider’s system.
The MAXIMUM NUMBER OF CHARACTERS to be supported for this field is ’20’. A Provider may submit fewer characters depending upon their needs. However, the HIPAA maximum requirement to be supported by any responding system is ’20’. Characters beyond 20 are not required to be stored nor returned by any receiving system.

M

AN

1/38

Required

CLM02

782

Monetary Amount
Description: Monetary amount
Industry: Total Claim Charge Amount
Alias: Total Claim Charges
UB-92 Ref. [UB-Name]: 47 (Revenue Code 001) This amount is the total of the SV2 segments, with the exception of Revenue Code 001. [Total Charges (by Revenue Code Category)]
EMC v.6.0 Reference: Record Type 90 Field No. 13 (Total of Field No. 13 and Field No. 15. This amount is the total of the SV2 segments, with the exception of Revenue Code 001.)
Use this element to indicate the total amount of all submitted charges of service segments for this claim.
Zero may be a valid amount.

O

R

1/18

Required

CLM05

C023

Health Care Service Location Information
Description: To provide information that identifies the place of service or the type of bill related to the location at which a health care service was rendered
Alias: Type of Bill

O

Comp

Required

1331

Facility Code Value
Description: Code identifying the type of facility where services were performed; the first and second positions of the Uniform Bill Type code or the Place of Service code from the Electronic Media Claims National Standard Format
Industry: Facility Type Code
UB-92 Ref. [UB-Name]: 4, Positions 1-2 [Type of Bill]
EMC v.6.0 Reference: Record Type 40 Field No. 4, Positions 1-2
Record Type 10 Field No. 2, Positions 1-2
Record Type 95 Field No. 5, Position 1-2 (Batch Control)

M

AN

1/2

Required

ExternalCodeList

Name: 236

Description: Uniform Billing Claim Form Bill Type

1332

Facility Code Qualifier
Description: Code identifying the type of facility referenced

O

ID

1/2

Required

Code

Name

A

Uniform Billing Claim Form Bill Type

CODE SOURCE:

236: Uniform Billing Claim Form Bill Type

1325

Claim Frequency Type Code
Description: Code specifying the frequency of the claim; this is the third position of the Uniform Billing Claim Form Bill Type
Industry: Claim Frequency Code
UB-92 Ref. [UB-Name]: 4, Position 3 [Type of Bill]
EMC v.6.0 Reference: Record Type 40 Field No. 4, Position 3
Record Type 10 Field No. 2, Position 3
Record Type 95 Field No. 5, Position 3 (Batch Control)

O

ID

1/1

Required

ExternalCodeList

Name: 235

Description: Claim Frequency Type Code

CLM06

1073

Yes/No Condition or Response Code
Description: Code indicating a Yes or No condition or response
Industry: Provider or Supplier Signature Indicator
Alias: Provider Signature on File

O

ID

1/1

Required

Code

Name

N

No

Y

Yes

CLM07

1359

Provider Accept Assignment Code
Description: Code indicating whether the provider accepts assignment
Industry: Medicare Assignment Code
CLM07 indicates whether the provider accepts Medicare assignment.

O

ID

1/1

Situational

Code

Name

A

Assigned

C

Not Assigned

CLM08

1073

Yes/No Condition or Response Code
Description: Code indicating a Yes or No condition or response
Industry: Benefits Assignment Certification Indicator
Alias: Assignment of Benefits Indicator
UB-92 Ref. [UB-Name]: 53 (A-C) [Assignment of Benefits Certification Indicator]
EMC v.6.0 Reference: Record Type 30 Field No. 17 (Sequence 01-03)
Use this value as an assignment of benefits indicator. Use a “Y” value to indicate that the insured or authorized person authorizes benefits to be assigned to the provider. Use an “N” value to indicate that benefits have not been assigned to the provider.

O

ID

1/1

Required

Code

Name

N

No

Y

Yes

CLM09

1363

Release of Information Code
Description: Code indicating whether the provider has on file a signed statement by the patient authorizing the release of medical data to other organizations
UB-92 Ref. [UB-Name]: 52 (A-C) [Release of Information Certification Indicator]
EMC v.6.0 Reference: Record Type 30 Field No. 16 (Sequence 01-03)

O

ID

1/1

Required

Code

Name

A

Appropriate Release of Information on File at Health Care Service Provider or at Utilization Review Organization

I

Informed Consent to Release Medical Information for Conditions or Diagnoses Regulated by Federal Statutes

M

The Provider has Limited or Restricted Ability to Release Data Related to a Claim

UB-92 Ref. [UB-Name]:

52 Code R [Restricted or Modified Release]

EMC v.6.0 Reference:

Record Type 30 Field No. 16 Code R

N

No, Provider is Not Allowed to Release Data

UB-92 Ref. [UB-Name]:

52 Code N [No Release]

O

On file at Payor or at Plan Sponsor

Y

Yes, Provider has a Signed Statement Permitting Release of Medical Billing Data Related to a Claim

UB-92 Ref. [UB-Name]:

52 Code Y [Yes]

CLM18

1073

Yes/No Condition or Response Code
Description: Code indicating a Yes or No condition or response
Industry: Explanation of Benefits Indicator
Alias: Explanation of Benefits (EOB) Indicator

O

ID

1/1

Required

Code

Name

N

No

Y

Yes

CLM20

1514

Delay Reason Code
Description: Code indicating the reason why a request was delayed
Delay Reason Code
This element may be used if a particular claim is being transmitted in response to a request for information (e.g., a 277), and the response has been delayed.
Required when claim is submitted late (past contracted date of filing limitations) and any of the codes below apply.

O

ID

1/2

Situational

Code

Name

1

Proof of Eligibility Unknown or Unavailable

2

Litigation

3

Authorization Delays

4

Delay in Certifying Provider

5

Delay in Supplying Billing Forms

6

Delay in Delivery of Custom-made Appliances

7

Third Party Processing Delay

8

Delay in Eligibility Determination

9

Original Claim Rejected or Denied Due to a Reason Unrelated to the Billing Limitation Rules

10

Administration Delay in the Prior Approval Process

11

Other

1.

CLM02 is the total amount of all submitted charges of service segments for this claim.

2.

CLM06 is provider signature on file indicator. A "Y" value indicates the provider signature is on file; an "N" value indicates the provider signature is not on file.

3.

CLM08 is assignment of benefits indicator. A "Y" value indicates insured or authorized person authorizes benefits to be assigned to the provider; an "N" value indicates benefits have not been assigned to the provider.

4.

CLM13 is CHAMPUS nonavailability indicator. A "Y" value indicates a statement of non-availability is on file; an "N" value indicates statement of nonavailability is not on file or not necessary.

5.

CLM15 is charges itemized by service indicator. A "Y" value indicates charges are itemized by service; an "N" value indicates charges are summarized by service.

6.

CLM18 is explanation of benefit (EOB) indicator. A "Y" value indicates that a paper EOB is requested; an "N" value indicates that no paper EOB is requested.

Notes:

1. The developers of this implementation guide recommend that trading partners limit the size of the transaction (ST-SE envelope) to a maximum of 5000 CLM segments. There is no recommended limit to the number of ST-SE transactions within a GS-GE or ISA-IEA. Willing trading partners can agree to set limits higher.
2. For purposes of this documentation, the claim detail information is presented only in the dependent level. Specific claim detail information can be given in either the subscriber or the dependent hierarchical level. Because of this the claim information is said to “float.” Claim information is positioned in the same hierarchical level that describes its owner-participant, either the subscriber or the dependent. In other words, the claim information, loop 2300, is placed following loop 2010BD in the subscriber hierarchical level when the patient is the subscriber, or it is placed at the patient/dependent hierarchical level when the patient is the dependent of the subscriber as shown here. When the patient is the subscriber, loops 2000C and 2010CA are not sent. See 2.3.2.1, HL Segment, for details.

Example:

CLM*01319300001*500***11:A:1*Y*A*Y*Y***02******N~