CLM

Claim Information

Pos: 130

Max: 1

Detail - Optional

Loop: 2300

Elements: 12

User Option (Usage): Required

To specify basic data about the claim

Element Summary:

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 NSF Reference: CA0-03.0, CB0-03.0, DA0-03.0, DA1-03.0, DA2-03.0, EA0-03.0, EA1- 03.0, EA2-03.0, FA0-03.0, FB0-03.0, FB1-03.0, FB2-03.0, FD0-03.0, FE0-03.0, GA0-03.0, GC0-03.0, GX0-03.0, GX2-03.0, XA0-03.0, CA1-03. 0, GU0-03.0, HA0-03.0 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 submitter’s patient management system. The developers of this implementation guide strongly recommend that submitters use completely unique numbers for this field for each individual claim. 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 837-receiving system.	M	AN	1/38	Required
CLM02	782	Monetary Amount Description: Monetary amount Industry: Total Claim Charge Amount Alias: Total Submitted Charges NSF Reference: XA0-12.0 For encounter transmissions, zero (0) 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: Place of Service Code NSF Reference: FA0-07.0 CLM05 applies to all service lines unless it is over written at the line level.	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 Use this element for codes identifying a place of service from code source 237. As a courtesy, the codes are listed below, however, the code list is thought to be complete at the time of publication of this implementation guideline. Since this list is subject to change, only codes contained in the document available from code source 237 are to be supported in this transaction and take precedence over any and all codes listed here. 11 Office 12 Home 21 Inpatient Hospital 22 Outpatient Hospital 23 Emergency Room - Hospital 24 Ambulatory Surgical Center 25 Birthing Center 26 Military Treatment Facility 31 Skilled Nursing Facility 32 Nursing Facility 33 Custodial Care Facility 34 Hospice 41 Ambulance - Land 42 Ambulance - Air or Water 51 Inpatient Psychiatric Facility 52 Psychiatric Facility Partial Hospitalization 53 Community Mental Health Center 54 Intermediate Care Facility/Mentally Retarded 55 Residential Substance Abuse Treatment Facility 56 Psychiatric Residential Treatment Center 50 Federally Qualified Health Center 60 Mass Immunization Center 61 Comprehensive Inpatient Rehabilitation Facility 62 Comprehensive Outpatient Rehabilitation Facility 65 End Stage Renal Disease Treatment Facility 71 State or Local Public Health Clinic 72 Rural Health Clinic 81 Independent Laboratory 99 Other Unlisted Facility	M	AN	1/2	Required

	ExternalCodeList
	Name: 237
	Description: Place of Service from Health Care Financing Administration Claim Form

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
Alias: Claim Submission Reason Code
CODE SOURCE: 235: Claim Frequency Type Code

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
NSF Reference: EA0-37.0

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. The NSF mapping to FA0-59.0 occurs only in payer-to-payer COB situations. All valid standard codes are used.	O	ID	1/1	Required
	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 NSF Reference: DA0-15.0	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 Alias: Release of Information Code NSF Reference: EA0-13.0 All valid standard codes are used.	O	ID	1/1	Required
CLM10	1351	Patient Signature Source Code Description: Code indicating how the patient or subscriber authorization signatures were obtained and how they are being retained by the provider Alias: Patient Signature Source Code NSF Reference: DA0-16.0 CLM10 is required except in cases where code ‘‘N’’ is used in CLM09. All valid standard codes are used.	O	ID	1/1	Situational
CLM11	C024	Related Causes Information Description: To identify one or more related causes and associated state or country information Alias: Accident/Employment/Related Causes CLM11-1, CLM11-2, or CLM11-3 are required when the condition being reported is accident or employment related. If CLM11-1, CLM11-2, or CLM11-3 equals AP, then map Yes to EA0-09.0. 2440 If DTP - Date of Accident (DTP01=439) is used, then CLM11 is required.	O	Comp		Situational
	1362	Related-Causes Code Description: Code identifying an accompanying cause of an illness, injury or an accident Industry: Related Causes Code NSF Reference: EA0-05.0 - Auto Accident or Other Accident, EA0-04.0 -Employment, EA0-09.0 - Responsibility Indicator	M	ID	2/3	Required

	Code	Name
	AA	Auto Accident
	AP	Another Party Responsible
	EM	Employment
	OA	Other Accident

1362

Related-Causes Code
Description: Code identifying an accompanying cause of an illness, injury or an accident
Industry: Related Causes Code
NSF Reference: EA0-05.0 - Auto Accident or Other Accident, EA0-04.0 -Employment, EA0-09.0 - Responsibility Indicator
Used if more than one code applies.

2/3

Situational

	Code	Name
	AA	Auto Accident
	AP	Another Party Responsible
	EM	Employment
	OA	Other Accident

1362

2/3

Situational

	Code	Name
	AA	Auto Accident
	AP	Another Party Responsible
	EM	Employment
	OA	Other Accident

156

State or Province Code
Description: Code (Standard State/Province) as defined by appropriate government agency
Industry: Auto Accident State or Province Code
CODE SOURCE: 22: States and Outlying Areas of the U.S.
NSF Reference: EA0-10.0
Required if CLM11-1, -2, or -3 = AA to identify the state in which the automobile accident occurred. Use state postal code (CA = California, UT = Utah, etc).

2/2

Situational

	ExternalCodeList
	Name: 22
	Description: States and Outlying Areas of the U.S.

Country Code
Description: Code identifying the country
CODE SOURCE: 5: Countries, Currencies and Funds
Required if the automobile accident occurred out of the United States to identify the country in which the accident occurred.

2/3

Situational

	ExternalCodeList
	Name: 5
	Description: Countries, Currencies and Funds

CLM12

1366

Special Program Code
Description: Code indicating the Special Program under which the services rendered to the patient were performed
Industry: Special Program Indicator
Alias: Special Program Code
NSF Reference: EA0-43.0
Required if the services were rendered under one of the following circumstances/programs/projects.

2/3

Situational

Code

Name

Early & Periodic Screening, Diagnosis, and Treatment (EPSDT) or Child Health Assessment Program (CHAP)

Physically Handicapped Children's Program

Special Federal Funding

This code is used for Medicaid claims only.

Disability

This code is used for Medicaid claims only.

Induced Abortion - Danger to Life

This code is used for Medicaid claims only.

Induced Abortion - Rape or Incest

This code is used for Medicaid claims only.

Second Opinion or Surgery

This code is used for Medicaid claims only.

CLM16

1360

Provider Agreement Code
Description: Code indicating the type of agreement under which the provider is submitting this claim
Industry: Participation Agreement
Required if a non-participating (non-par) provider is submitting a participating (par) claim/encounter. Sending the “P” code indicates that a non-par provider is sending a par claim as allowed under certain plans.

1/1

Situational

	Code	Name
	P	Participation Agreement

CLM20

1514

Delay Reason Code
Description: Code indicating the reason why a request was delayed
Alias: 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.

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. Because this is a required segment, this is a required loop. See Appendix A for further details on ASC X12 syntax rules.
2. 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.
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 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*A37YH556*500***11::1*Y*A*Y*Y*C~