5010 Health Care Claim Payment/Advice [U0]


Loop Qualifiers
xx - Loop Iteration Prefix
xxyy - Outer Loop Iteration and Inner Loop Iteration
yy / yyy - Loop Value Qualifier
xxyy / xxyyy - Loop Iteration and Value Qualifier
Segment Modifiers:
X - Distinguishing Identifier Suffix
nn - Segment Iteration (only after first iterartion)
nn - Element Repeat Iteration (only after first iterartion)

GSHDR - GROUP HEADER
GSHDRGSFunctional Group Header
02GSHDR_GS02_APP_SNDR_CDStringApplication Senders Code
03GSHDR_GS03_APP_RCV_CDStringApplication Receivers Code
04GSHDR_GS04_D8Date/TimeDate
05GSHDR_GS05_TMTimeTime
06GSHDR_GS06_GCNIntegerGroup Control Number
STHDR - TRANSACTION SET HEADER
STHDRSTTransaction Set Header
02STHDR_ST02_TCNStringTransaction Set Control Number
STHDRBPRFinancial Information
01STHDR_BPR01_TRANS_HANDL_CDStringTransaction Handling Code
02STHDR_BPR02_TOT_ACTL_PVR_PMTDecimalTotal Actual Provider Payment Amount
03STHDR_BPR03_CRED_DEB_FLG_CDStringCredit or Debit Flag Code
04STHDR_BPR04_PMT_METHD_CDStringPayment Method Code
05STHDR_BPR05_PMT_FMT_CDStringPayment Format Code
07STHDR_BPR07_ABA_RT_NRStringABA Transit Routing Number Including Check Digits (9 digits)
07STHDR_BPR07_CAN_BNK_NRStringCanadian Bank Branch and Institution Number
09STHDR_BPR09_SNDR_BNK_ACT_NRStringSender Bank Account Number
10STHDR_BPR10_PYR_IDStringPayer Identifier
11STHDR_BPR11_ORG_CO_SUPP_CDStringOriginating Company Supplemental Code
13STHDR_BPR13_ABA_RT_NRStringABA Transit Routing Number Including Check Digits (9 digits)
13STHDR_BPR13_CAN_BNK_NRStringCanadian Bank Branch and Institution Number
15STHDR_BPR15_DEMND_DEPSTStringDemand Deposit
15STHDR_BPR15_SAVNGSStringSavings
16STHDR_BPR16_CHK_EFT_EFDT_D8Date/TimeCheck Issue or EFT Effective Date
STHDRTRNReassociation Trace Number
02STHDR_TRN02_CHK_EFT_TRC_NRStringCheck or EFT Trace Number
03STHDR_TRN03_PYR_IDStringPayer Identifier
04STHDR_TRN04_ORG_CO_SUPP_CDStringOriginating Company Supplemental Code
STHDRCURForeign Currency Information
02STHDR_CUR02_CURRNCY_CDStringCurrency Code
STHDRREFReceiver Identification
02STHDR_REF_REC_ID_NRStringReceiver Identification Number
STHDRREFVersion Identification
02STHDR_REF_VERS_CDStringVersion Code - Local
STHDRDTMProduction Date
02STHDR_DTM02_PRODCTN_D8Date TimestampProduction
L1000A - PAYER IDENTIFICATION
L1000AN1Payer Identification
02L1000A_N102_PYR_NMStringPayer Name
04L1000A_N104_PYR_IDStringPayer Identifier
L1000AN3Payer Address
01L1000A_N301_PYR_ADDR_LNStringPayer Address Line
02L1000A_N302_PYR_ADDR_LNStringPayer Address Line
L1000AN4Payer City, State, ZIP Code
01L1000A_N401_PYR_CITY_NMStringPayer City Name
02L1000A_N402_PYR_STATStringPayer State Code
03L1000A_N403_PYR_ZIPStringPayer Postal Zone or ZIP Code
04L1000A_N404_CNTRY_CDStringCountry Code
07L1000A_N407_CNTRY_SUBDV_CDStringCountry Subdivision Code
L1000AREFAdditional Payer Identification
02L1000A_REF_PYR_IDStringPayer Identification Number
02L1000A_REF_SUB_ID_NRStringSubmitter Identification Number
02L1000A_REF_HINStringHealth Industry Number (HIN)
02L1000A_REF_NAICStringNational Association of Insurance Commissioners
L1000APERPayer Business Contact Information
02L1000A_PER02_PYR_CON_NMStringPayer Contact Name
04L1000A_PER04_EMAILStringElectronic Mail
04L1000A_PER04_FAXStringFacsimile
04L1000A_PER04_PHN_NRStringTelephone
06L1000A_PER06_EMAILStringElectronic Mail
06L1000A_PER06_PHN_EXTStringTelephone Extension
06L1000A_PER06_FAXStringFacsimile
06L1000A_PER06_PHN_NRStringTelephone
08L1000A_PER08_PYR_CON_COMM_NRStringPayer Contact Communication Number
L1000APERPayer Technical Contact Information Segment Suffix:
Iterated: [01-99]
02L1000A_nnPERB02_PYR_CON_NMStringPayer Technical Contact Name
04L1000A_nnPERB04_EMAILStringElectronic Mail
04L1000A_nnPERB04_PHN_NRStringTelephone
04L1000A_nnPERB04_URLStringUniform Resource Locator (URL)
06L1000A_nnPERB06_EMAILStringElectronic Mail
06L1000A_nnPERB06_PHN_EXTStringTelephone Extension
06L1000A_nnPERB06_FAXStringFacsimile
06L1000A_nnPERB06_PHN_NRStringTelephone
06L1000A_nnPERB06_URLStringUniform Resource Locator (URL)
08L1000A_nnPERB08_EMAILStringElectronic Mail
08L1000A_nnPERB08_PHN_EXTStringTelephone Extension
08L1000A_nnPERB08_FAXStringFacsimile
08L1000A_nnPERB08_URLStringUniform Resource Locator (URL)
L1000APERPayer WEB Site Segment Suffix:
04L1000A_PERC04_COMM_NRStringCommunication Number
L1000B - PAYEE IDENTIFICATION
L1000BN1Payee Identification
02L1000B_N102_PAYEE_NMStringPayee Name
04L1000B_N104_TAX_IDStringFederal Taxpayer?s Identification Number
04L1000B_N104_CMS_PLANIDStringCenters for Medicare and Medicaid Services PlanID
04L1000B_N104_NPIStringCenters for Medicare and Medicaid Services National Provider Identifier
L1000BN3Payee Address
01L1000B_N301_PAYEE_ADDRStringPayee Address Line
02L1000B_N302_PAYEE_ADDRStringPayee Address Line
L1000BN4Payee City, State, ZIP Code
01L1000B_N401_PAYEE_CITYStringPayee City Name
02L1000B_N402_PAYEE_STATStringPayee State Code
03L1000B_N403_PAYEE_ZIPStringPayee Postal Zone or ZIP Code
04L1000B_N404_CNTRY_CDStringCountry Code
07L1000B_N407_CNTRY_SUBDV_CDStringCountry Subdivision Code
L1000BREFPayee Additional Identification Iterated: [01-99]
02L1000B_nnREF_STAT_LIC_NRStringState License Number
02L1000B_nnREF_NABP_NRStringNational Council for Prescription Drug Programs
02L1000B_nnREF_PAYEE_IDStringPayee Identification
02L1000B_nnREF_TAX_IDStringFederal Taxpayer?s Identification Number
L1000BRDMRemittance Delivery Method
01L1000B_RDM01_REPT_TRNS_CDStringReport Transmission Code
02L1000B_RDM02_NMStringName
03L1000B_RDM03_COMM_NRStringCommunication Number
L2000 - HEADER NUMBER
L2000LXHeader Number
01L2000_LX01_ASSGD_NRIntegerAssigned Number
L2000TS3Provider Summary Information
01L2000_TS301_PVR_IDStringProvider Identifier
02L2000_TS302_FAC_TYP_CDStringFacility Type Code
03L2000_TS303_FISCL_PERD_D8Date/TimeFiscal Period Date
04L2000_TS304_TOT_CLM_CTDecimalTotal Claim Count
05L2000_TS305_TOT_CLM_CHG_AMTDecimalTotal Claim Charge Amount
13L2000_TS313_TOT_MSP_PYR_AMTDecimalTotal MSP Payer Amount
15L2000_TS315_TOT_NONLAB_CHG_AMTDecimalTotal Non-Lab Charge Amount
17L2000_TS317_TOT_HCPCS_CHG_AMTDecimalTotal HCPCS Reported Charge Amount
18L2000_TS318_TOT_HCPCS_PYBL_AMTDecimalTotal HCPCS Payable Amount
20L2000_TS320_TOT_PROF_COMP_AMTDecimalTotal Professional Component Amount
21L2000_TS321_TOT_MSP_LIAB_METDecimalTotal MSP Patient Liability Met Amount
22L2000_TS322_TOT_PT_REIM_AMTDecimalTotal Patient Reimbursement Amount
23L2000_TS323_TOT_PIP_CLM_CTDecimalTotal PIP Claim Count
24L2000_TS324_TOT_PIP_ADJ_AMTDecimalTotal PIP Adjustment Amount
L2000TS2Provider Supplemental Summary Information
01L2000_TS201_TOT_DRG_AMTDecimalTotal DRG Amount
02L2000_TS202_TOT_FED_SPEC_AMTDecimalTotal Federal Specific Amount
03L2000_TS203_TOT_HSP_SPEC_AMTDecimalTotal Hospital Specific Amount
04L2000_TS204_TOT_DISP_SHAR_AMTDecimalTotal Disproportionate Share Amount
05L2000_TS205_TOT_CAP_AMTDecimalTotal Capital Amount
06L2000_TS206_IND_MED_EDU_AMTDecimalTotal Indirect Medical Education Amount
07L2000_TS207_TOT_OUTLR_DAYSDecimalTotal Outlier Day Count
08L2000_TS208_TOT_DAY_OUTLR_AMTDecimalTotal Day Outlier Amount
09L2000_TS209_TOT_CST_OUTLR_AMTDecimalTotal Cost Outlier Amount
10L2000_TS210_AVG_DRG_LENOFSTAYDecimalAverage DRG Length of Stay
11L2000_TS211_TOT_DISCHG_AMTDecimalTotal Discharge Count
12L2000_TS212_TOT_CST_REP_DY_CTDecimalTotal Cost Report Day Count
13L2000_TS213_TOT_COVD_DAY_CTDecimalTotal Covered Day Count
14L2000_TS214_TOT_NONCD_DAY_CTDecimalTotal Noncovered Day Count
15L2000_TS215_TOT_MSP_AMTDecimalTotal MSP Pass-Through Amount
16L2000_TS216_AVG_DRG_WGTDecimalAverage DRG weight
17L2000_TS217_PPSCAPFSP_DRG_AMTDecimalTotal PPS Capital FSP DRG Amount
18L2000_TS218_TOT_CAP_DRG_AMTDecimalTotal PPS Capital HSP DRG Amount
19L2000_TS219_PPS_DSH_DRG_AMTDecimalTotal PPS DSH DRG Amount
L2100 - CLAIM PAYMENT INFORMATION
L2100CLPClaim Payment Information
01L2100_CLP01_PT_CTL_NRStringPatient Control Number
02L2100_CLP02_CLM_STAT_CDStringClaim Status Code
03L2100_CLP03_TOT_CLM_CHG_AMTDecimalTotal Claim Charge Amount
04L2100_CLP04_CLM_PMT_AMTDecimalClaim Payment Amount
05L2100_CLP05_PT_RESP_AMTDecimalPatient Responsibility Amount
06L2100_CLP06_CLM_FIL_IND_CDStringClaim Filing Indicator Code
07L2100_CLP07_PYR_CLM_CTL_NRStringPayer Claim Control Number
08L2100_CLP08_FAC_TYP_CDStringFacility Type Code
09L2100_CLP09_CLM_FREQ_CDStringClaim Frequency Code
11L2100_CLP11_DRG_CDStringDiagnosis Related Group (DRG) Code
12L2100_CLP12_DRG_WGTDecimalDiagnosis Related Group (DRG) Weight
13L2100_CLP13_DISCHG_FRACTNDecimalDischarge Fraction
L2100X - CLAIM PAYMENT INFORMATION - CAS CUTOUT
L2100XCASClaim Adjustment
01L2100X_CAS01_CLMADJ_GRP_CDStringClaim Adjustment Group Code
02L2100X_CAS02_ADJ_RSN_CDStringAdjustment Reason Code
03L2100X_CAS03_ADJ_AMTDecimalAdjustment Amount
04L2100X_CAS04_ADJ_QTYDecimalAdjustment Quantity
05L2100X_CAS05_ADJ_RSN_CDStringAdjustment Reason Code
06L2100X_CAS06_ADJ_AMTDecimalAdjustment Amount
07L2100X_CAS07_ADJ_QTYDecimalAdjustment Quantity
08L2100X_CAS08_ADJ_RSN_CDStringAdjustment Reason Code
09L2100X_CAS09_ADJ_AMTDecimalAdjustment Amount
10L2100X_CAS10_ADJ_QTYDecimalAdjustment Quantity
11L2100X_CAS11_ADJ_RSN_CDStringAdjustment Reason Code
12L2100X_CAS12_ADJ_AMTDecimalAdjustment Amount
13L2100X_CAS13_ADJ_QTYDecimalAdjustment Quantity
14L2100X_CAS14_ADJ_RSN_CDStringAdjustment Reason Code
15L2100X_CAS15_ADJ_AMTDecimalAdjustment Amount
16L2100X_CAS16_ADJ_QTYDecimalAdjustment Quantity
17L2100X_CAS17_ADJ_RSN_CDStringAdjustment Reason Code
18L2100X_CAS18_ADJ_AMTDecimalAdjustment Amount
19L2100X_CAS19_ADJ_QTYDecimalAdjustment Quantity

L2100NM1Patient Name Segment Suffix:
03L2100_NM1B03_PT_LNMStringPatient Last Name
04L2100_NM1B04_PT_FNMStringPatient First Name
05L2100_NM1B05_PT_MNMStringPatient Middle Name or Initial
07L2100_NM1B07_PT_SFXStringPatient Name Suffix
09L2100_NM1B09_SSNStringSocial Security Number
09L2100_NM1B09_HIC_NRStringHealth Insurance Claim (HIC) Number
09L2100_NM1B09_UNQ_HLTH_IDStringStandard Unique Health Identifier for each Individual in the United States
09L2100_NM1B09_MEM_ID_NRStringMember Identification Number
09L2100_NM1B09_MDCD_RECPNT_IDStringMedicaid Recipient Identification Number
L2100NM1Insured Name Segment Suffix:
02L2100_NM1C02_ENT_TYP_QUALStringEntity Type Qualifier
03L2100_NM1C03_SBR_LNMStringSubscriber Last Name
04L2100_NM1C04_SBR_FNMStringSubscriber First Name
05L2100_NM1C05_SBR_MNMStringSubscriber Middle Name or Initial
07L2100_NM1C07_SBR_SFXStringSubscriber Name Suffix
09L2100_NM1C09_TAX_IDStringFederal Taxpayer?s Identification Number
09L2100_NM1C09_UNQ_HLTH_IDStringStandard Unique Health Identifier for each Individual in the United States
09L2100_NM1C09_MEM_ID_NRStringMember Identification Number
L2100NM1Corrected Patient/Insured Name Segment Suffix:
02L2100_NM1D02_ENT_TYP_QUALStringEntity Type Qualifier
03L2100_NM1D03_CORR_PT_INS_LNMStringCorrected Patient or Insured Last Name
04L2100_NM1D04_CORR_PT_INS_FNMStringCorrected Patient or Insured First Name
05L2100_NM1D05_CORR_PT_INS_MNMStringCorrected Patient or Insured Middle Name
07L2100_NM1D07_CORR_PT_INS_SFXStringCorrected Patient or Insured Name Suffix
09L2100_NM1D09_CORR_INS_ID_INDStringCorrected Insured Identification Indicator
L2100NM1Service Provider Name Segment Suffix:
02L2100_NM1E02_ENT_TYP_QUALStringEntity Type Qualifier
03L2100_NM1E03_RND_PVR_LNMStringRendering Provider Last or Organization Name
04L2100_NM1E04_REND_PVR_FNMStringRendering Provider First Name
05L2100_NM1E05_REND_PVR_MNMStringRendering Provider Middle Name or Initial
07L2100_NM1E07_REND_PROV_SFXStringRendering Provider Name Suffix
09L2100_NM1E09_BLCS_PROV_NRStringBlue Cross Provider Number
09L2100_NM1E09_BLSH_PROV_NRStringBlue Shield Provider Number
09L2100_NM1E09_TAX_IDStringFederal Taxpayer?s Identification Number
09L2100_NM1E09_MDCD_PROV_NRStringMedicaid Provider Number
09L2100_NM1E09_PROV_COMRCL_NRStringProvider Commercial Number
09L2100_NM1E09_STAT_LICNS_NRStringState License Number
09L2100_NM1E09_UNQ_PHYS_ID_NRStringUnique Physician Identification Number (UPIN)
09L2100_NM1E09_NPIStringCenters for Medicare and Medicaid Services National Provider Identifier
L2100NM1Crossover Carrier Name Segment Suffix:
03L2100_NM1F03_COB_CARR_NMStringCoordination of Benefits Carrier Name
09L2100_NM1F09_BLCSBLSH_PLN_CDStringBlue Cross Blue Shield Association Plan Code
09L2100_NM1F09_TAX_IDStringFederal Taxpayer?s Identification Number
09L2100_NM1F09_NAIC_IDStringNational Association of Insurance Commissioners (NAIC) Identification
09L2100_NM1F09_PAYR_IDStringPayor Identification
09L2100_NM1F09_PHM_PRCSR_NRStringPharmacy Processor Number
09L2100_NM1F09_HCFA_PLAN_IDStringCenters for Medicare and Medicaid Services PlanID
L2100NM1Corrected Priority Payer Name Segment Suffix:
03L2100_NM1G03_CORR_PRI_PYR_NMStringCorrected Priority Payer Name
09L2100_NM1G09_BLCSBLSH_PLN_CDStringBlue Cross Blue Shield Association Plan Code
09L2100_NM1G09_TAX_IDStringFederal Taxpayer?s Identification Number
09L2100_NM1G09_NAIC_IDStringNational Association of Insurance Commissioners (NAIC) Identification
09L2100_NM1G09_PAYR_IDStringPayor Identification
09L2100_NM1G09_PHM_PRCSR_NRStringPharmacy Processor Number
09L2100_NM1G09_HCFA_PLAN_IDStringCenters for Medicare and Medicaid Services PlanID
L2100NM1Other Subscriber Name Segment Suffix:
02L2100_NM1H02_ENT_TYP_QUALStringEntity Type Qualifier
03L2100_NM1H03_OSBR_LNMStringOther Subscriber Last Name
04L2100_NM1H04_OSBR_FNMStringOther Subscriber First Name
05L2100_NM1H05_OSBR_MNMStringOther Subscriber Middle Name or Initial
07L2100_NM1H07_OSBR_SFXStringOther Subscriber Name Suffix
09L2100_NM1H09_TAX_IDStringFederal Taxpayer?s Identification Number
09L2100_NM1H09_UNQ_HLTH_IDStringStandard Unique Health Identifier for each Individual
09L2100_NM1H09_MEM_ID_NRStringMember Identification Number
L2100MIAInpatient Adjudication Information
01L2100_MIA01_COV_DAYS_VST_CTDecimalCovered Days or Visits Count
02L2100_MIA02_PPS_OPR_OUTLR_AMTDecimalPPS Operating Outlier Amount
03L2100_MIA03_LFTM_PSYCH_DAYSDecimalLifetime Psychiatric Days Count
04L2100_MIA04_CLM_DRG_AMTDecimalClaim DRG Amount
05L2100_MIA05_CLM_PMT_RMK_CDStringClaim Payment Remark Code
06L2100_MIA06_CLM_DIS_SHR_AMTDecimalClaim Disproportionate Share Amount
07L2100_MIA07_CLM_MSP_PSS_AMTDecimalClaim MSP Pass-through Amount
08L2100_MIA08_CLM_PPS_CAP_AMTDecimalClaim PPS Capital Amount
09L2100_MIA09_PPS_FSP_DRG_AMTDecimalPPS-Capital FSP DRG Amount
10L2100_MIA10_PPS_HSP_DRG_AMTDecimalPPS-Capital HSP DRG Amount
11L2100_MIA11_PPS_DSH_DRG_AMTDecimalPPS-Capital DSH DRG Amount
12L2100_MIA12_OLD_CAP_AMTDecimalOld Capital Amount
13L2100_MIA13_PPS_CAP_IME_AMTDecimalPPS-Capital IME amount
14L2100_MIA14_PPS_OPRS_DRGAMTDecimalPPS-Operating Hospital Specific DRG Amount
15L2100_MIA15_COST_RPT_DAY_CTDecimalCost Report Day Count
16L2100_MIA16_PPS_FED_DRG_AMTDecimalPPS-Operating Federal Specific DRG Amount
17L2100_MIA17_CLM_CAP_OUT_AMTDecimalClaim PPS Capital Outlier Amount
18L2100_MIA18_CLM_IND_TCH_AMTDecimalClaim Indirect Teaching Amount
19L2100_MIA19_NONPAY_PROF_AMTDecimalNonpayable Professional Component Amount
20L2100_MIA20_CLM_PMT_RMK_CDStringClaim Payment Remark Code
21L2100_MIA21_CLM_PMT_RMK_CDStringClaim Payment Remark Code
22L2100_MIA22_CLM_PMT_RMK_CDStringClaim Payment Remark Code
23L2100_MIA23_CLM_PMT_RMK_CDStringClaim Payment Remark Code
24L2100_MIA24_PPS_EXCPTN_AMTDecimalPPS-Capital Exception Amount
L2100MOAOutpatient Adjudication Information
01L2100_MOA01_REIMBRSMT_RTDecimalReimbursement Rate
02L2100_MOA02_CLMHCPCS_PY_AMTDecimalClaim HCPCS Payable Amount
03L2100_MOA03_CLM_PMT_RMK_CDStringClaim Payment Remark Code
04L2100_MOA04_CLM_PMT_RMK_CDStringClaim Payment Remark Code
05L2100_MOA05_CLM_PMT_RMK_CDStringClaim Payment Remark Code
06L2100_MOA06_CLM_PMT_RMK_CDStringClaim Payment Remark Code
07L2100_MOA07_CLM_PMT_RMK_CDStringClaim Payment Remark Code
08L2100_MOA08_CLMESRD_PMT_AMTDecimalClaim ESRD Payment Amount
09L2100_MOA09_NONPAY_PROF_AMTStringNonpayable Professional Component Amount
L2100REFOther Claim Related Identification Iterated: [01-05]
02L2100_nnREF_GRP_POLCY_NRStringGroup or Policy Number
02L2100_nnREF_MEM_IDStringMember Identification Number
02L2100_nnREF_EMPLE_ID_NRStringEmployee Identification Number
02L2100_nnREF_GRP_NRStringGroup Number
02L2100_nnREF_REP_CLM_IDStringRepriced Claim Reference Number
02L2100_nnREF_ADJ_REP_CLM_IDStringAdjusted Repriced Claim Reference Number
02L2100_nnREF_AUTH_NRStringAuthorization Number
02L2100_nnREF_CLSS_CONTStringClass of Contract Code
02L2100_nnREF_MED_REC_IDStringMedical Record Identification Number
02L2100_nnREF_ORIG_REF_NRStringOriginal Reference Number
02L2100_nnREF_PRIOR_AUTHStringPrior Authorization Number
02L2100_nnREF_PREF_BEN_ID_NRStringPredetermination of Benefits Identification Number
02L2100_nnREF_INS_PLCY_NRStringInsurance Policy Number
02L2100_nnREF_SSNStringSocial Security Number
L2100REFRendering Provider Identification Iterated: [01-10]
02L2100_nnREF_STAT_LIC_NRStringState License Number
02L2100_nnREF_BLCS_PVR_NRStringBlue Cross Provider Number
02L2100_nnREF_BLSH_PROV_NRStringBlue Shield Provider Number
02L2100_nnREF_MDCR_PVR_NRStringMedicare Provider Number
02L2100_nnREF_MDCD_PVR_NRStringMedicaid Provider Number
02L2100_nnREF_UPINStringProvider UPIN Number
02L2100_nnREF_CHAMPUS_IDStringCHAMPUS Identification Number
02L2100_nnREF_FAC_IDStringFacility ID Number
02L2100_nnREF_NABP_NRStringNational Council for Prescription Drug Programs Pharmacy Number
02L2100_nnREF_PVR_COMM_NRStringProvider Commercial Number
02L2100_nnREF_LOC_NRStringLocation Number
L2100DTMStatement From or To Date
02L2100_DTM02_CLM_PRD_STRT_D8Date TimestampClaim Statement Period Start
02L2100_DTM02_CLM_PRD_END_D8Date TimestampClaim Statement Period End
L2100DTMCoverage Expiration Date Segment Suffix:
02L2100_DTMB02_EXP_D8Date TimestampExpiration
L2100DTMClaim Received Date Segment Suffix:
02L2100_DTMC02_RCVD_D8Date TimestampReceived
L2100PERClaim Contact Information Iterated: [01-02]
02L2100_nnPER02_CLM_CON_NMStringClaim Contact Name
04L2100_nnPER04_EMAILStringElectronic Mail
04L2100_nnPER04_FAXStringFacsimile
04L2100_nnPER04_PHN_NRStringTelephone
06L2100_nnPER06_EMAILStringElectronic Mail
06L2100_nnPER06_PHN_EXTStringTelephone Extension
06L2100_nnPER06_FAXStringFacsimile
06L2100_nnPER06_PHN_NRStringTelephone
08L2100_nnPER08_COMM_NR_EXTStringCommunication Number Extension
L2100AMTClaim Supplemental Information
02L2100_AMT02_COVG_AMTDate TimestampCoverage Amount
02L2100_AMT02_DISCT_AMTDate TimestampDiscount Amount
02L2100_AMT02_PER_DAY_LIMDate TimestampPer Day Limit
02L2100_AMT02_PT_AMT_PDDate TimestampPatient Amount Paid
02L2100_AMT02_INTRSTDate TimestampInterest
02L2100_AMT02_NEG_LEDGR_BALDate TimestampNegative Ledger Balance
02L2100_AMT02_TAXDate TimestampTax
02L2100_AMT02_TOT_CLM_B4_TAXDate TimestampTotal Claim Before Taxes
02L2100_AMT02_MDCRMDCD_PMTCAT1Date TimestampFederal Medicare or Medicaid Payment Mandate - Category 1
02L2100_AMT02_MDCRMDCD_PMTCAT2Date TimestampFederal Medicare or Medicaid Payment Mandate - Category 2
02L2100_AMT02_MDCRMDCD_PMTCAT3Date TimestampFederal Medicare or Medicaid Payment Mandate - Category 3
02L2100_AMT02_MDCRMDCD_PMTCAT4Date TimestampFederal Medicare or Medicaid Payment Mandate - Category 4
02L2100_AMT02_MCRMCD_PMTCAT5Date TimestampFederal Medicare or Medicaid Payment Mandate - Category 5
L2100QTYClaim Supplemental Information Quantity
02L2100_QTY02_COVD_ACTLDate TimestampCovered - Actual
02L2100_QTY02_COINS_ACTLDate TimestampCo-insured - Actual
02L2100_QTY02_LFTM_RSRV_ACTLDate TimestampLife-time Reserve - Actual
02L2100_QTY02_LFTM_RSRV_ESTDate TimestampLife-time Reserve - Estimated
02L2100_QTY02_NONCOV_ESTDate TimestampNon-Covered - Estimated
02L2100_QTY02_NOTREP_BLD_UNDate TimestampNot Replaced Blood Units
02L2100_QTY02_OUTLIER_DYSDate TimestampOutlier Days
02L2100_QTY02_RXDate TimestampPrescription
02L2100_QTY02_VISTDate TimestampVisits
02L2100_QTY02_MDCRMDCD_PMTCAT1Date TimestampFederal Medicare or Medicaid Payment Mandate - Category 1
02L2100_QTY02_MDCRMDCD_PMTCAT2Date TimestampFederal Medicare or Medicaid Payment Mandate - Category 2
02L2100_QTY02_MDCRMDCD_PMTCAT3Date TimestampFederal Medicare or Medicaid Payment Mandate - Category 3
02L2100_QTY02_MDCRMDCD_PMTCAT4Date TimestampFederal Medicare or Medicaid Payment Mandate - Category 4
02L2100_QTY02_MCRMCD_PMTCAT5Date TimestampFederal Medicare or Medicaid Payment Mandate - Category 5
L2110 - SERVICE PAYMENT INFORMATION
L2110SVCService Payment Information
0102L2110_SVC0102_ADA_CDStringAmerican Dental Association Codes
0102L2110_SVC0102_JS_PRC_SPY_CDStringJurisdiction Specific Procedure and Supply Codes
0102L2110_SVC0102_HCPCS_CDStringHealth Care Financing Administration Common Procedural Coding System (HCPCS) Codes
0102L2110_SVC0102_HIPPA_SNF_RT_CDStringHealth Insurance Prospective Payment System (HIPPS) Skilled Nursing Facility Rate Code
0102L2110_SVC0102_HIC_PRD_SVCCDStringHome Infusion EDI Coalition (HIEC) Product/Service
0102L2110_SVC0102_NDC542StringNational Drug Code in 5-4-2 Format
0102L2110_SVC0102_NATLHLTH_46StringNational Health Related Item Code in 4-6 Format
0102L2110_SVC0102_NUBC_UB92_CDStringNational Uniform Billing Committee (NUBC) UB92 Codes
0102L2110_SVC0102_UP_CD_155StringU.P.C. Consumer Package Code (1-5-5)
0102L2110_SVC0102_ABC_CDStringAdvanced Billing Concepts (ABC) Codes
0103L2110_SVC0103_PROC_MODStringProcedure Modifier
0104L2110_SVC0104_PROC_MODStringProcedure Modifier
0105L2110_SVC0105_PROC_MODStringProcedure Modifier
0106L2110_SVC0106_PROC_MODStringProcedure Modifier
02L2110_SVC02_LIN_ITM_CHG_AMTDecimalLine Item Charge Amount
03L2110_SVC03_LINITM_PV_PMT_AMTDecimalLine Item Provider Payment Amount
04L2110_SVC04_NUBC_REV_CDStringNational Uniform Billing Committee Revenue
05L2110_SVC05_UN_SVC_PD_CTDecimalUnits of Service Paid Count
0602L2110_SVC0602_ADA_CDStringAmerican Dental Association Codes
0602L2110_SVC0602_JS_PRC_SPY_CDStringJurisdiction Specific Procedure and Supply Codes
0602L2110_SVC0602_HCPCS_CDStringHealth Care Financing Administration Common Procedural Coding System (HCPCS) Codes
0602L2110_SVC0602_HPPSStringHealth Insurance Prospective Payment System
0602L2110_SVC0602_HIC_PRD_SVCCDStringHome Infusion EDI Coalition (HIEC) Product/Service Code
0602L2110_SVC0602_NDC542StringNational Drug Code in 5-4-2 Format
0602L2110_SVC0602_NUBC_UB92_CDStringNational Uniform Billing Committee (NUBC) UB92 Codes
0602L2110_SVC0602_ABC_CDStringAdvanced Billing Concepts (ABC) Codes
0603L2110_SVC0603_PROC_MODStringProcedure Modifier
0604L2110_SVC0604_PROC_MODStringProcedure Modifier
0605L2110_SVC0605_PROC_MODStringProcedure Modifier
0606L2110_SVC0606_PROC_MODStringProcedure Modifier
0607L2110_SVC0607_PROC_CD_DESCStringProcedure Code Description
07L2110_SVC07_ORG_UN_SVC_CTDecimalOriginal Units of Service Count
L2110DTMService Date
02L2110_DTM02_SVC_PER_STRT_D8Date TimestampService Period Start
02L2110_DTM02_SVC_PER_END_D8Date TimestampService Period End
02L2110_DTM02_SVC_D8Date TimestampService
L2110X - SERVICE PAYMENT INFORMATION - CAS CUTOUT
L2110XCASService Adjustment
01L2110X_CAS01_CLMADJ_GRP_CDStringClaim Adjustment Group Code
02L2110X_CAS02_ADJ_RSN_CDStringAdjustment Reason Code
03L2110X_CAS03_ADJ_AMTDecimalAdjustment Amount
04L2110X_CAS04_ADJ_QTYDecimalAdjustment Quantity
05L2110X_CAS05_ADJ_RSN_CDStringAdjustment Reason Code
06L2110X_CAS06_ADJ_AMTDecimalAdjustment Amount
07L2110X_CAS07_ADJ_QTYDecimalAdjustment Quantity
08L2110X_CAS08_ADJ_RSN_CDStringAdjustment Reason Code
09L2110X_CAS09_ADJ_AMTDecimalAdjustment Amount
10L2110X_CAS10_ADJ_QTYDecimalAdjustment Quantity
11L2110X_CAS11_ADJ_RSN_CDStringAdjustment Reason Code
12L2110X_CAS12_ADJ_AMTDecimalAdjustment Amount
13L2110X_CAS13_ADJ_QTYDecimalAdjustment Quantity
14L2110X_CAS14_ADJ_RSN_CDStringAdjustment Reason Code
15L2110X_CAS15_ADJ_AMTDecimalAdjustment Amount
16L2110X_CAS16_ADJ_QTYDecimalAdjustment Quantity
17L2110X_CAS17_ADJ_RSN_CDStringAdjustment Reason Code
18L2110X_CAS18_ADJ_AMTDecimalAdjustment Amount
19L2110X_CAS19_ADJ_QTYDecimalAdjustment Quantity

L2110REFService Identification
02L2110_REF_APG_NRStringAmbulatory Patient Group (APG) Number
02L2110_REF_AMB_PMT_CLSStringAmbulatory Payment Classification
02L2110_REF_AUTH_NRStringAuthorization Number
02L2110_REF_ATTCH_CDStringAttachment Code
02L2110_REF_PRIOR_AUTHStringPrior Authorization Number
02L2110_REF_PREF_BEN_ID_NRStringPredetermination of Benefits Identification Number
02L2110_REF_LOC_NRStringLocation Number
02L2110_REF_RAT_CD_NRStringRate code number
L2110REFLine Item Control Number
02L2110_REF_PRV_CTL_NRStringProvider Control Number
L2110REFRendering Provider Information Iterated: [01-10]
02L2110_nnREF_STAT_LIC_NRStringState License Number
02L2110_nnREF_BLCS_PVR_NRStringBlue Cross Provider Number
02L2110_nnREF_BLSH_PROV_NRStringBlue Shield Provider Number
02L2110_nnREF_MDCR_PVR_NRStringMedicare Provider Number
02L2110_nnREF_MDCD_PVR_NRStringMedicaid Provider Number
02L2110_nnREF_UPINStringProvider UPIN Number
02L2110_nnREF_CHAMPUS_IDStringCHAMPUS Identification Number
02L2110_nnREF_FAC_IDStringFacility ID Number
02L2110_nnREF_NABP_NRStringNational Council for Prescription Drug Programs Pharmacy Number
02L2110_nnREF_PVR_COMM_NRStringProvider Commercial Number
02L2110_nnREF_MDCR_MDCDStringCenters for Medicare and Medicaid Services National Provider Identifier
02L2110_nnREF_SSNStringSocial Security Number
02L2110_nnREF_TAX_IDStringFederal Taxpayer?s Identification Number
L2110REFHealthCare Policy Identification Iterated: [01-05]
02L2110_nnREF_POLCY_IDStringPolicy Form Identifying Number
L2110AMTService Supplemental Amount
02L2110_AMT02_ALLWD_ACTLDate TimestampAllowed - Actual
02L2110_AMT02_DDCTN_AMTDate TimestampDeduction Amount
02L2110_AMT02_TAXDate TimestampTax
02L2110_AMT02_TOT_CLM_B4_TAXDate TimestampTotal Claim Before Taxes
02L2110_AMT02_MDCRMDCD_PMTCAT1Date TimestampFederal Medicare or Medicaid Payment Mandate - Category 1
02L2110_AMT02_MDCRMDCD_PMTCAT2Date TimestampFederal Medicare or Medicaid Payment Mandate - Category 2
02L2110_AMT02_MDCRMDCD_PMTCAT3Date TimestampFederal Medicare or Medicaid Payment Mandate - Category 3
02L2110_AMT02_MDCRMDCD_PMTCAT4Date TimestampFederal Medicare or Medicaid Payment Mandate - Category 4
02L2110_AMT02_MCRMCD_PMTCAT5Date TimestampFederal Medicare or Medicaid Payment Mandate - Category 5
L2110QTYService Supplemental Quantity
02L2110_QTY02_MDCRMDCD_PMTCAT1Date TimestampFederal Medicare or Medicaid Payment Mandate - Category 1
02L2110_QTY02_MDCRMDCD_PMTCAT2Date TimestampFederal Medicare or Medicaid Payment Mandate - Category 2
02L2110_QTY02_MDCRMDCD_PMTCAT3Date TimestampFederal Medicare or Medicaid Payment Mandate - Category 3
02L2110_QTY02_MDCRMDCD_PMTCAT4Date TimestampFederal Medicare or Medicaid Payment Mandate - Category 4
02L2110_QTY02_MCRMCD_PMTCAT5Date TimestampFederal Medicare or Medicaid Payment Mandate - Category 5
L2110Y - SERVICE PAYMENT INFORMATION - LQ CUTOUT
L2110YLQHealth Care Remark Codes
02L2110Y_LQ02_CLM_PMT_REM_CDStringClaim Payment Remark Codes
02L2110Y_LQ02_NCPCP_REJPMT_CDStringNational Council for Prescription Drug Programs Reject/Payment Codes
STHDRX - TRANSACTION SET HEADER - PLB CUTOUT
STHDRXPLBProvider Adjustment
01STHDRX_PLB01_PVR_IDStringProvider Identifier
02STHDRX_PLB02_FISCL_PERD_D8Date/TimeFiscal Period Date
0301STHDRX_PLB0301_ADJ_RSN_CDStringAdjustment Reason Code
0302STHDRX_PLB0302_PVR_ADJ_IDStringProvider Adjustment Identifier
04STHDRX_PLB04_PVR_ADJ_AMTDecimalProvider Adjustment Amount
0501STHDRX_PLB0501_ADJ_RSN_CDStringAdjustment Reason Code
0502STHDRX_PLB0502_PVR_ADJ_IDStringProvider Adjustment Identifier
06STHDRX_PLB06_PVR_ADJ_AMTDecimalProvider Adjustment Amount
0701STHDRX_PLB0701_ADJ_RSN_CDStringAdjustment Reason Code
0702STHDRX_PLB0702_PVR_ADJ_IDStringProvider Adjustment Identifier
08STHDRX_PLB08_PVR_ADJ_AMTDecimalProvider Adjustment Amount
0901STHDRX_PLB0901_ADJ_RSN_CDStringAdjustment Reason Code
0902STHDRX_PLB0902_PVR_ADJ_IDStringProvider Adjustment Identifier
10STHDRX_PLB10_PVR_ADJ_AMTDecimalProvider Adjustment Amount
1101STHDRX_PLB1101_ADJ_RSN_CDStringAdjustment Reason Code
1102STHDRX_PLB1102_PVR_ADJ_IDStringProvider Adjustment Identifier
12STHDRX_PLB12_PVR_ADJ_AMTDecimalProvider Adjustment Amount
1301STHDRX_PLB1301_ADJ_RSN_CDStringAdjustment Reason Code
1302STHDRX_PLB1302_PVR_ADJ_IDStringProvider Adjustment Identifier
14STHDRX_PLB14_PVR_ADJ_AMTDecimalProvider Adjustment Amount

STHDRSETransaction Set Trailer
01STHDR_SE01_TS_SEG_CTIntegerTransaction Segment Count
02STHDR_SE02_TCNStringTransaction Set Control Number

GSHDRGEFunctional Group Trailer
01GSHDR_GE01_NR_TS_INCLUDEDIntegerNumber of Transaction Sets Included
02GSHDR_GE02_GCNIntegerGroup Control Number