837 |
|
|
Pos |
Id |
Segment Name |
Req |
Max Use |
Repeat |
Notes |
Usage |
|
|
|
|
|
|
Interchange Control Header |
M |
1 |
|
|
Required |
|||||
|
|
Functional Group Header |
M |
1 |
|
|
Required |
|
Pos |
Id |
Segment Name |
Req |
Max Use |
Repeat |
Notes |
Usage |
|
|
|
|
|
005 |
Transaction Set Header |
M |
1 |
|
|
Required |
|||||
|
010 |
Beginning of Hierarchical Transaction |
M |
1 |
|
|
Required |
|||||
|
015 |
Transmission Type Identification |
O |
1 |
|
|
Required |
|||||
|
|
1 |
N1/020L |
|
|
|
|
|
||||
|
020 |
Submitter Name |
O |
1 |
|
N1/020 |
Required |
|||||
|
045 |
Submitter Contact Information |
O |
2 |
|
|
Required |
|||||
|
|
1 |
N1/020L |
|
|
|
|
|
||||
|
020 |
Receiver Name |
O |
1 |
|
N1/020 |
Required |
|||||
|
Pos |
Id |
Segment Name |
Req |
Max Use |
Repeat |
Notes |
Usage |
|
|
|
|
|
|
>1 |
|
|
|
|
|
|
||||
|
001 |
Billing/Pay-to Provider Hierarchical Level |
M |
1 |
|
|
Required |
|||||
|
003 |
Billing/Pay-to Provider Specialty Information |
O |
1 |
|
|
Situational |
|||||
|
010 |
Foreign Currency Information |
O |
1 |
|
|
Situational |
|||||
|
|
1 |
N2/015L |
|
|
|
|
|
||||
|
015 |
Billing Provider Name |
O |
1 |
|
N2/015 |
Required |
|||||
|
020 |
Additional Billing Provider Name Information |
O |
1 |
|
|
Situational |
|||||
|
025 |
Billing Provider Address |
O |
1 |
|
|
Required |
|||||
|
030 |
Billing Provider City/State/ZIP Code |
O |
1 |
|
|
Required |
|||||
|
035 |
Billing Provider Secondary Identification Number |
O |
5 |
|
|
Situational |
|||||
|
035 |
Claim Submitter Credit/Debit Card Information |
O |
8 |
|
|
Situational |
|||||
|
|
1 |
N2/015L |
|
|
|
|
|
||||
|
015 |
Pay-to Provider’s Name |
O |
1 |
|
N2/015 |
Situational |
|||||
|
020 |
Additional Pay-to Provider Name Information |
O |
1 |
|
|
Situational |
|||||
|
025 |
Pay-to Provider’s Address |
O |
1 |
|
|
Required |
|||||
|
030 |
Pay-to Provider City/State/Zip |
O |
1 |
|
|
Required |
|||||
|
035 |
Pay-to Provider Secondary Identification Number |
O |
5 |
|
|
Situational |
|||||
|
|
>1 |
|
|
|
|
|
|
||||
|
001 |
Subscriber Hierarchical Level |
M |
1 |
|
|
Required |
|||||
|
005 |
Subscriber Information |
O |
1 |
|
|
Required |
|||||
|
|
1 |
N2/015L |
|
|
|
|
|
||||
|
015 |
Subscriber Name |
O |
1 |
|
N2/015 |
Required |
|||||
|
025 |
Subscriber Address |
O |
1 |
|
|
Situational |
|||||
|
030 |
Subscriber City/State/ZIP Code |
O |
1 |
|
|
Situational |
|||||
|
032 |
Subscriber Demographic Information |
O |
1 |
|
|
Situational |
|||||
|
035 |
Subscriber Secondary Identification |
O |
4 |
|
|
Situational |
|||||
|
035 |
Property and Casualty Claim Number |
O |
1 |
|
|
Situational |
|||||
|
|
1 |
N2/015L |
|
|
|
|
|
||||
|
015 |
Payer Name |
O |
1 |
|
N2/015 |
Required |
|||||
|
025 |
Payer Address |
O |
1 |
|
|
Situational |
|||||
|
030 |
Payer City/State/ZIP Code |
O |
1 |
|
|
Situational |
|||||
|
035 |
Payer Secondary Identification Number |
O |
3 |
|
|
Situational |
|||||
|
|
1 |
N2/015L |
|
|
|
|
|
||||
|
015 |
Credit/Debit Card Holder Name |
O |
1 |
|
N2/015 |
Situational |
|||||
|
035 |
Credit/Debit Card Information |
O |
3 |
|
|
Situational |
|||||
|
|
100 |
|
|
|
|
|
|
||||
|
130 |
Claim Information |
O |
1 |
|
|
Required |
|||||
|
135 |
Date - Admission |
O |
1 |
|
|
Situational |
|||||
|
135 |
Date - Discharge |
O |
1 |
|
|
Situational |
|||||
|
135 |
Date - Referral |
O |
1 |
|
|
Situational |
|||||
|
135 |
Date - Accident |
O |
1 |
|
|
Situational |
|||||
|
135 |
Date - Appliance Placement |
O |
5 |
|
|
Situational |
|||||
|
135 |
Date - Service |
O |
1 |
|
|
Situational |
|||||
|
145 |
Orthodontic Total Months of Treatment |
O |
1 |
|
|
Situational |
|||||
|
150 |
Tooth Status |
O |
35 |
|
|
Situational |
|||||
|
155 |
Claim Supplemental Information |
O |
10 |
|
|
Situational |
|||||
|
175 |
Patient Amount Paid |
O |
1 |
|
|
Situational |
|||||
|
175 |
Credit/Debit Card - Maximum Amount |
O |
1 |
|
|
Situational |
|||||
|
180 |
Predetermination Identification |
O |
5 |
|
|
Situational |
|||||
|
180 |
Service Authorization Exception Code |
O |
1 |
|
|
Situational |
|||||
|
180 |
Original Reference Number (ICN/DCN) |
O |
1 |
|
|
Situational |
|||||
|
180 |
Prior Authorization or Referral Number |
O |
2 |
|
|
Situational |
|||||
|
180 |
Claim Identification Number for Clearinghouses and Other Transmission Intermediaries |
O |
1 |
|
|
Situational |
|||||
|
190 |
Claim Note |
O |
20 |
|
|
Situational |
|||||
|
|
2 |
N2/250L |
|
|
|
|
|
||||
|
250 |
Referring Provider Name |
O |
1 |
|
N2/250 |
Situational |
|||||
|
255 |
Referring Provider Specialty Information |
O |
1 |
|
|
Situational |
|||||
|
271 |
Referring Provider Secondary Identification |
O |
5 |
|
|
Situational |
|||||
|
|
1 |
N2/250L |
|
|
|
|
|
||||
|
250 |
Rendering Provider Name |
O |
1 |
|
N2/250 |
Situational |
|||||
|
255 |
Rendering Provider Specialty Information |
O |
1 |
|
|
Situational |
|||||
|
271 |
Rendering Provider Secondary Identification |
O |
5 |
|
|
Situational |
|||||
|
|
1 |
N2/250L |
|
|
|
|
|
||||
|
250 |
Service Facility Location |
O |
1 |
|
N2/250 |
Situational |
|||||
|
271 |
Service Facility Location Secondary Identification |
O |
5 |
|
|
Situational |
|||||
|
|
1 |
N2/250L |
|
|
|
|
|
||||
|
250 |
Assistant Surgeon Name |
O |
1 |
|
N2/250 |
Situational |
|||||
|
255 |
Assistant Surgeon Specialty Information |
O |
1 |
|
|
Situational |
|||||
|
271 |
Assistant Surgeon Secondary Identification |
O |
1 |
|
|
Situational |
|||||
|
|
10 |
N2/290L |
|
|
|
|
|
||||
|
290 |
Other Subscriber Information |
O |
1 |
|
N2/290 |
Situational |
|||||
|
295 |
Claim Adjustment |
O |
5 |
|
|
Situational |
|||||
|
300 |
Coordination of Benefits (COB) Payer Paid Amount |
O |
1 |
|
|
Situational |
|||||
|
300 |
Coordination of Benefits (COB) Approved Amount |
O |
1 |
|
|
Situational |
|||||
|
300 |
Coordination of Benefits (COB) Allowed Amount |
O |
1 |
|
|
Situational |
|||||
|
300 |
Coordination of Benefits (COB) Patient Responsibility Amount |
O |
1 |
|
|
Situational |
|||||
|
300 |
Coordination of Benefits (COB) Covered Amount |
O |
1 |
|
|
Situational |
|||||
|
300 |
Coordination of Benefits (COB) Discount Amount |
O |
1 |
|
|
Situational |
|||||
|
300 |
Coordination of Benefits (COB) Patient Paid Amount |
O |
1 |
|
|
Situational |
|||||
|
305 |
Other Insured Demographic Information |
O |
1 |
|
|
Situational |
|||||
|
310 |
Other Insurance Coverage Information |
O |
1 |
|
|
Required |
|||||
|
|
1 |
N2/325L |
|
|
|
|
|
||||
|
325 |
Other Subscriber Name |
O |
1 |
|
N2/325 |
Required |
|||||
|
332 |
Other Subscriber Address |
O |
1 |
|
|
Situational |
|||||
|
340 |
Other Subscriber City/State/Zip Code |
O |
1 |
|
|
Situational |
|||||
|
355 |
Other Subscriber Secondary Identification |
O |
3 |
|
|
Situational |
|||||
|
|
1 |
N2/325L |
|
|
|
|
|
||||
|
325 |
Other Payer Name |
O |
1 |
|
N2/325 |
Required |
|||||
|
345 |
Other Payer Contact Information |
O |
2 |
|
|
Situational |
|||||
|
350 |
Claim Paid Date |
O |
1 |
|
|
Situational |
|||||
|
355 |
Other Payer Secondary Identifier |
O |
3 |
|
|
Situational |
|||||
|
355 |
Other Payer Prior Authorization or Referral Number |
O |
2 |
|
|
Situational |
|||||
|
355 |
Other Payer Claim Adjustment Indicator |
O |
1 |
|
|
Situational |
|||||
|
|
1 |
N2/325L |
|
|
|
|
|
||||
|
325 |
Other Payer Patient Information |
O |
1 |
|
N2/325 |
Situational |
|||||
|
355 |
Other Payer Patient Identification |
O |
3 |
|
|
Situational |
|||||
|
|
1 |
N2/325L |
|
|
|
|
|
||||
|
325 |
Other Payer Referring Provider |
O |
1 |
|
N2/325 |
Situational |
|||||
|
355 |
Other Payer Referring Provider Identification |
O |
3 |
|
|
Situational |
|||||
|
|
1 |
N2/325L |
|
|
|
|
|
||||
|
325 |
Other Payer Rendering Provider |
O |
1 |
|
N2/325 |
Situational |
|||||
|
355 |
Other Payer Rendering Provider Identification |
O |
3 |
|
|
Situational |
|||||
|
|
50 |
N2/365L |
|
|
|
|
|
||||
|
365 |
Line Counter |
O |
1 |
|
N2/365 |
Required |
|||||
|
380 |
Dental Service |
O |
1 |
|
|
Required |
|||||
|
382 |
Tooth Information |
O |
32 |
|
|
Situational |
|||||
|
455 |
Date - Service |
O |
1 |
|
|
Situational |
|||||
|
455 |
Date - Prior Placement |
O |
1 |
|
|
Situational |
|||||
|
455 |
Date - Appliance Placement |
O |
1 |
|
|
Situational |
|||||
|
455 |
Date - Replacement |
O |
1 |
|
|
Situational |
|||||
|
460 |
Anesthesia Quantity |
O |
5 |
|
|
Situational |
|||||
|
470 |
Service Predetermination Identification |
O |
1 |
|
|
Situational |
|||||
|
470 |
Prior Authorization or Referral Number |
O |
2 |
|
|
Situational |
|||||
|
470 |
Line Item Control Number |
O |
1 |
|
|
Situational |
|||||
|
475 |
Approved Amount |
O |
1 |
|
|
Situational |
|||||
|
475 |
Sales Tax Amount |
O |
1 |
|
|
Situational |
|||||
|
485 |
Line Note |
O |
10 |
|
|
Situational |
|||||
|
|
1 |
N2/500L |
|
|
|
|
|
||||
|
500 |
Rendering Provider Name |
O |
1 |
|
N2/500 |
Situational |
|||||
|
505 |
Rendering Provider Specialty Information |
O |
1 |
|
|
Situational |
|||||
|
525 |
Rendering Provider Secondary Identification |
O |
5 |
|
|
Situational |
|||||
|
|
1 |
N2/500L |
|
|
|
|
|
||||
|
500 |
Other Payer Prior Authorization or Referral Number |
O |
1 |
|
N2/500 |
Situational |
|||||
|
525 |
Other Payer Prior Authorization or Referral Number |
O |
2 |
|
|
Situational |
|||||
|
|
1 |
N2/500L |
|
|
|
|
|
||||
|
500 |
Assistant Surgeon Name |
O |
1 |
|
N2/500 |
Situational |
|||||
|
505 |
Assistant Surgeon Specialty Information |
O |
1 |
|
|
Situational |
|||||
|
525 |
Assistant Surgeon Secondary Identification |
O |
1 |
|
|
Situational |
|||||
|
|
25 |
N2/540L |
|
|
|
|
|
||||
|
540 |
Line Adjudication Information |
O |
1 |
|
N2/540 |
Situational |
|||||
|
545 |
Service Adjustment |
O |
99 |
|
|
Situational |
|||||
|
550 |
Line Adjudication Date |
O |
1 |
|
|
Required |
|||||
|
|
>1 |
|
|
|
|
|
|
||||
|
001 |
Patient Hierarchical Level |
O |
1 |
|
|
Situational |
|||||
|
007 |
Patient Information |
O |
1 |
|
|
Required |
|||||
|
|
1 |
N2/015L |
|
|
|
|
|
||||
|
015 |
Patient Name |
O |
1 |
|
N2/015 |
Required |
|||||
|
025 |
Patient Address |
O |
1 |
|
|
Required |
|||||
|
030 |
Patient City/State/ZIP Code |
O |
1 |
|
|
Required |
|||||
|
032 |
Patient Demographic Information |
O |
1 |
|
|
Required |
|||||
|
035 |
Patient Secondary Identification |
O |
5 |
|
|
Situational |
|||||
|
035 |
Property and Casualty Claim Number |
O |
1 |
|
|
Situational |
|||||
|
|
100 |
|
|
|
|
|
|
||||
|
130 |
Claim Information |
O |
1 |
|
|
Required |
|||||
|
135 |
Date - Admission |
O |
1 |
|
|
Situational |
|||||
|
135 |
Date - Discharge |
O |
1 |
|
|
Situational |
|||||
|
135 |
Date - Referral |
O |
1 |
|
|
Situational |
|||||
|
135 |
Date - Accident |
O |
1 |
|
|
Situational |
|||||
|
135 |
Date - Appliance Placement |
O |
5 |
|
|
Situational |
|||||
|
135 |
Date - Service |
O |
1 |
|
|
Situational |
|||||
|
145 |
Orthodontic Total Months of Treatment |
O |
1 |
|
|
Situational |
|||||
|
150 |
Tooth Status |
O |
35 |
|
|
Situational |
|||||
|
155 |
Claim Supplemental Information |
O |
10 |
|
|
Situational |
|||||
|
175 |
Patient Amount Paid |
O |
1 |
|
|
Situational |
|||||
|
175 |
Credit/Debit Card - Maximum Amount |
O |
1 |
|
|
Situational |
|||||
|
180 |
Predetermination Identification |
O |
5 |
|
|
Situational |
|||||
|
180 |
Service Authorization Exception Code |
O |
1 |
|
|
Situational |
|||||
|
180 |
Original Reference Number (ICN/DCN) |
O |
1 |
|
|
Situational |
|||||
|
180 |
Prior Authorization or Referral Number |
O |
2 |
|
|
Situational |
|||||
|
180 |
Claim Identification Number for Clearinghouses and Other Transmission Intermediaries |
O |
1 |
|
|
Situational |
|||||
|
190 |
Claim Note |
O |
20 |
|
|
Situational |
|||||
|
|
2 |
N2/250L |
|
|
|
|
|
||||
|
250 |
Referring Provider Name |
O |
1 |
|
N2/250 |
Situational |
|||||
|
255 |
Referring Provider Specialty Information |
O |
1 |
|
|
Situational |
|||||
|
271 |
Referring Provider Secondary Identification |
O |
5 |
|
|
Situational |
|||||
|
|
1 |
N2/250L |
|
|
|
|
|
||||
|
250 |
Rendering Provider Name |
O |
1 |
|
N2/250 |
Situational |
|||||
|
255 |
Rendering Provider Specialty Information |
O |
1 |
|
|
Situational |
|||||
|
271 |
Rendering Provider Secondary Identification |
O |
5 |
|
|
Situational |
|||||
|
|
1 |
N2/250L |
|
|
|
|
|
||||
|
250 |
Service Facility Location |
O |
1 |
|
N2/250 |
Situational |
|||||
|
271 |
Service Facility Location Secondary Identification |
O |
5 |
|
|
Situational |
|||||
|
|
1 |
N2/250L |
|
|
|
|
|
||||
|
250 |
Assistant Surgeon Name |
O |
1 |
|
N2/250 |
Situational |
|||||
|
255 |
Assistant Surgeon Specialty Information |
O |
1 |
|
|
Situational |
|||||
|
271 |
Assistant Surgeon Secondary Identification |
O |
1 |
|
|
Situational |
|||||
|
|
10 |
N2/290L |
|
|
|
|
|
||||
|
290 |
Other Subscriber Information |
O |
1 |
|
N2/290 |
Situational |
|||||
|
295 |
Claim Adjustment |
O |
5 |
|
|
Situational |
|||||
|
300 |
Coordination of Benefits (COB) Payer Paid Amount |
O |
1 |
|
|
Situational |
|||||
|
300 |
Coordination of Benefits (COB) Approved Amount |
O |
1 |
|
|
Situational |
|||||
|
300 |
Coordination of Benefits (COB) Allowed Amount |
O |
1 |
|
|
Situational |
|||||
|
300 |
Coordination of Benefits (COB) Patient Responsibility Amount |
O |
1 |
|
|
Situational |
|||||
|
300 |
Coordination of Benefits (COB) Covered Amount |
O |
1 |
|
|
Situational |
|||||
|
300 |
Coordination of Benefits (COB) Discount Amount |
O |
1 |
|
|
Situational |
|||||
|
300 |
Coordination of Benefits (COB) Patient Paid Amount |
O |
1 |
|
|
Situational |
|||||
|
305 |
Other Insured Demographic Information |
O |
1 |
|
|
Situational |
|||||
|
310 |
Other Insurance Coverage Information |
O |
1 |
|
|
Required |
|||||
|
|
1 |
N2/325L |
|
|
|
|
|
||||
|
325 |
Other Subscriber Name |
O |
1 |
|
N2/325 |
Required |
|||||
|
332 |
Other Subscriber Address |
O |
1 |
|
|
Situational |
|||||
|
340 |
Other Subscriber City/State/Zip Code |
O |
1 |
|
|
Situational |
|||||
|
355 |
Other Subscriber Secondary Identification |
O |
3 |
|
|
Situational |
|||||
|
|
1 |
N2/325L |
|
|
|
|
|
||||
|
325 |
Other Payer Name |
O |
1 |
|
N2/325 |
Required |
|||||
|
345 |
Other Payer Contact Information |
O |
2 |
|
|
Situational |
|||||
|
350 |
Claim Paid Date |
O |
1 |
|
|
Situational |
|||||
|
355 |
Other Payer Secondary Identifier |
O |
3 |
|
|
Situational |
|||||
|
355 |
Other Payer Prior Authorization or Referral Number |
O |
2 |
|
|
Situational |
|||||
|
355 |
Other Payer Claim Adjustment Indicator |
O |
1 |
|
|
Situational |
|||||
|
|
1 |
N2/325L |
|
|
|
|
|
||||
|
325 |
Other Payer Patient Information |
O |
1 |
|
N2/325 |
Situational |
|||||
|
355 |
Other Payer Patient Identification |
O |
3 |
|
|
Situational |
|||||
|
|
1 |
N2/325L |
|
|
|
|
|
||||
|
325 |
Other Payer Referring Provider |
O |
1 |
|
N2/325 |
Situational |
|||||
|
355 |
Other Payer Referring Provider Identification |
O |
3 |
|
|
Situational |
|||||
|
|
1 |
N2/325L |
|
|
|
|
|
||||
|
325 |
Other Payer Rendering Provider |
O |
1 |
|
N2/325 |
Situational |
|||||
|
355 |
Other Payer Rendering Provider Identification |
O |
3 |
|
|
Situational |
|||||
|
|
50 |
N2/365L |
|
|
|
|
|
||||
|
365 |
Line Counter |
O |
1 |
|
N2/365 |
Required |
|||||
|
380 |
Dental Service |
O |
1 |
|
|
Required |
|||||
|
382 |
Tooth Information |
O |
32 |
|
|
Situational |
|||||
|
455 |
Date - Service |
O |
1 |
|
|
Situational |
|||||
|
455 |
Date - Prior Placement |
O |
1 |
|
|
Situational |
|||||
|
455 |
Date - Appliance Placement |
O |
1 |
|
|
Situational |
|||||
|
455 |
Date - Replacement |
O |
1 |
|
|
Situational |
|||||
|
460 |
Anesthesia Quantity |
O |
5 |
|
|
Situational |
|||||
|
470 |
Service Predetermination Identification |
O |
1 |
|
|
Situational |
|||||
|
470 |
Prior Authorization or Referral Number |
O |
2 |
|
|
Situational |
|||||
|
470 |
Line Item Control Number |
O |
1 |
|
|
Situational |
|||||
|
475 |
Approved Amount |
O |
1 |
|
|
Situational |
|||||
|
475 |
Sales Tax Amount |
O |
1 |
|
|
Situational |
|||||
|
485 |
Line Note |
O |
10 |
|
|
Situational |
|||||
|
|
1 |
N2/500L |
|
|
|
|
|
||||
|
500 |
Rendering Provider Name |
O |
1 |
|
N2/500 |
Situational |
|||||
|
505 |
Rendering Provider Specialty Information |
O |
1 |
|
|
Situational |
|||||
|
525 |
Rendering Provider Secondary Identification |
O |
5 |
|
|
Situational |
|||||
|
|
1 |
N2/500L |
|
|
|
|
|
||||
|
500 |
Other Payer Prior Authorization or Referral Number |
O |
1 |
|
N2/500 |
Situational |
|||||
|
525 |
Other Payer Prior Authorization or Referral Number |
O |
2 |
|
|
Situational |
|||||
|
|
1 |
N2/500L |
|
|
|
|
|
||||
|
500 |
Assistant Surgeon Name |
O |
1 |
|
N2/500 |
Situational |
|||||
|
505 |
Assistant Surgeon Specialty Information |
O |
1 |
|
|
Situational |
|||||
|
525 |
Assistant Surgeon Secondary Identification |
O |
1 |
|
|
Situational |
|||||
|
|
25 |
N2/540L |
|
|
|
|
|
||||
|
540 |
Line Adjudication Information |
O |
1 |
|
N2/540 |
Situational |
|||||
|
545 |
Service Adjustment |
O |
99 |
|
|
Situational |
|||||
|
550 |
Line Adjudication Date |
O |
1 |
|
|
Required |
|||||
|
555 |
Transaction Set Trailer |
M |
1 |
|
|
Required |
|||||
|
Pos |