Loop 2300

Pos: 130	Repeat: 100
Optional
Loop: 2300	Elements: N/A

Pos

Id

Segment Name

Req

Max Use

Repeat

Usage

130

CLM

Claim Information

O

1

Required

135

DTP

Date - Admission

O

1

Situational

135

DTP

Date - Discharge

O

1

Situational

135

DTP

Date - Referral

O

1

Situational

135

DTP

Date - Accident

O

1

Situational

135

DTP

Date - Appliance Placement

O

5

Situational

135

DTP

Date - Service

O

1

Situational

145

DN1

Orthodontic Total Months of Treatment

O

1

Situational

150

DN2

Tooth Status

O

35

Situational

155

PWK

Claim Supplemental Information

O

10

Situational

175

AMT

Patient Amount Paid

O

1

Situational

175

AMT

Credit/Debit Card - Maximum Amount

O

1

Situational

180

REF

Predetermination Identification

O

5

Situational

180

REF

Service Authorization Exception Code

O

1

Situational

180

REF

Original Reference Number (ICN/DCN)

O

1

Situational

180

REF

Prior Authorization or Referral Number

O

2

Situational

180

REF

Claim Identification Number for Clearinghouses and Other Transmission Intermediaries

O

1

Situational

190

NTE

Claim Note

O

20

Situational

250

Loop 2310A

O

2

Situational

250

Loop 2310B

O

1

Situational

250

Loop 2310C

O

1

Situational

250

Loop 2310D

O

1

Situational

290

Loop 2320

O

10

Situational

365

Loop 2400

O

50

Required

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. Because this is a required segment, this is a required loop. See Appendix A for further details on ASC X12 nomenclature X12 syntax rules.
2. The developers of this implementation guide recommend that trading partners limit the size of the transaction (SE-ST 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.
3. 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 2010BC 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*013193000001*500***11::1*Y*A*Y*Y~