GSHDR - GROUP HEADER |
GSHDR | GS | Functional Group Header | ||
02 | GSHDR_GS02_APP_SNDR_CD | String | Application Senders Code | |
03 | GSHDR_GS03_APP_RCV_CD | String | Application Receivers Code | |
04 | GSHDR_GS04_D8 | Date/Time | Date | |
05 | GSHDR_GS05_TM | Time | Time | |
06 | GSHDR_GS06_GCN | Integer | Group Control Number |
STHDR - TRANSACTION SET HEADER |
STHDR | ST | Transaction Set Header | ||
02 | STHDR_ST02_TCN | String | Transaction Set Control Number | |
03 | STHDR_ST03_VERS_REL_IND_ID | String | Version, Release, or Industry Identifier |
STHDR | BHT | Beginning of Hierarchical Transaction | ||
01 | STHDR_BHT01_HIER_STRUC_CD | String | Hierarchical Structure Code | |
03 | STHDR_BHT03_ORIG_APP_TRANS_ID | String | Originator Application Transaction Identifier | |
04 | STHDR_BHT04_TS_CRTN_D8 | Date/Time | Transaction Set Creation Date | |
05 | STHDR_BHT05_TS_CRTN_TM | Time | Transaction Set Creation Time |
L2000A - INFORMATION SOURCE LEVEL |
L2000A | HL | Information Source Level | ||
01 | L2000A_HL01_HIER_ID_NR | String | Hierarchical ID Number |
L2100A - PAYER NAME |
L2100A | NM1 | Payer Name | ||
03 | L2100A_NM103_PYR_NM | String | Payer Name | |
09 | L2100A_NM109_PAYR_ID | String | Payor Identification | |
09 | L2100A_NM109_CMS_PLANID | String | Centers for Medicare and Medicaid Services PlanID |
L2100A | PER | Payer Contact Information | ||
02 | L2100A_PER02_PYR_CON_NM | String | Payer Contact Name | |
04 | L2100A_PER04_EDI_ACS_NR | String | Electronic Data Interchange Access Number | |
04 | L2100A_PER04_EMAIL | String | Electronic Mail | |
04 | L2100A_PER04_FAX | String | Facsimile | |
04 | L2100A_PER04_PHN_NR | String | Telephone | |
06 | L2100A_PER06_EDI_ACS_NR | String | Electronic Data Interchange Access Number | |
06 | L2100A_PER06_EMAIL | String | Electronic Mail | |
06 | L2100A_PER06_PHN_EXT | String | Telephone Extension | |
06 | L2100A_PER06_FAX | String | Facsimile | |
06 | L2100A_PER06_PHN_NR | String | Telephone | |
08 | L2100A_PER08_EDI_ACS_NR | String | Electronic Data Interchange Access Number | |
08 | L2100A_PER08_EMAIL | String | Electronic Mail | |
08 | L2100A_PER08_PHN_EXT | String | Telephone Extension | |
08 | L2100A_PER08_FAX | String | Facsimile | |
08 | L2100A_PER08_PHN_NR | String | Telephone |
L2000B - INFORMATION RECEIVER LEVEL |
L2000B | HL | Information Receiver Level | ||
01 | L2000B_HL01_HIER_ID_NR | String | Hierarchical ID Number | |
02 | L2000B_HL02_HIER_PARNT_ID_NR | String | Hierarchical Parent ID Number | |
04 | L2000B_HL04_HL_CHLD_CD | String | Hierarchical Child Code |
L2100B - INFORMATION RECEIVER NAME |
L2100B | NM1 | Information Receiver Name | ||
02 | L2100B_NM102_ENT_TYP_QUAL | String | Entity Type Qualifier | |
03 | L2100B_NM103_NFO_RCV_NM | String | Information Receiver Last or Organization Name | |
04 | L2100B_NM104_NFO_REC_FNM | String | Information Receiver First Name | |
05 | L2100B_NM105_NFO_REC_MNM | String | Information Receiver Middle Name | |
09 | L2100B_NM109_NFO_REC_ID_NR | String | Information Receiver Identification Number |
L2200B - INFORMATION RECEIVER TRACE IDENTIFIER |
L2200B | TRN | Information Receiver Trace Identifier | ||
02 | L2200B_TRN02_CLM_TRNS_BAT_NR | String | Claim Transaction Batch Number |
L2200BX - INFORMATION RECEIVER TRACE IDENTIFIER - STC CUTOUT |
L2200BX | STC | Information Receiver Status Information | ||
01 | 01 | L2200BX_STC0101_HTCRCLM_CAT_CD | String | Health Care Claim Status Category Code |
01 | 02 | L2200BX_STC0102_STATS_CD | String | Status Code |
01 | 03 | L2200BX_STC0103_ENTY_ID_CD | String | Entity Identifier Code |
02 | L2200BX_STC02_STMT_NFO_EFF_D8 | Date/Time | Status Information Effective Date | |
10 | 01 | L2200BX_STC1001_HTCRCLM_CAT_CD | String | Health Care Claim Status Category Code |
10 | 02 | L2200BX_STC1002_STATS_CD | String | Status Code |
10 | 03 | L2200BX_STC1003_ENTY_ID_CD | String | Entity Identifier Code |
11 | 01 | L2200BX_STC1101_HTCRCLM_CAT_CD | String | Health Care Claim Status Category Code |
11 | 02 | L2200BX_STC1102_STATS_CD | String | Status Code |
11 | 03 | L2200BX_STC1103_ENTY_ID_CD | String | Entity Identifier Code |
L2000C - SERVICE PROVIDER LEVEL |
L2000C | HL | Service Provider Level | ||
01 | L2000C_HL01_HIER_ID_NR | String | Hierarchical ID Number | |
02 | L2000C_HL02_HIER_PARNT_ID_NR | String | Hierarchical Parent ID Number | |
04 | L2000C_HL04_HL_CHLD_CD | String | Hierarchical Child Code |
L2100C - PROVIDER NAME (Single Iteration) |
L2100C | NM1 | Provider Name | ||
02 | L2100C_xx_NM102_ENT_TYP_QUAL | String | Entity Type Qualifier | |
03 | L2100C_xx_NM103_PVR_LNM | String | Provider Last or Organization Name | |
04 | L2100C_xx_NM104_PVR_FNM | String | Provider First Name | |
05 | L2100C_xx_NM105_PVR_MNM | String | Provider Middle Name | |
07 | L2100C_xx_NM107_PVR_SFX | String | Provider Name Suffix | |
09 | L2100C_xx_NM109_TAX_ID | String | Federal Taxpayer?s Identification Number | |
09 | L2100C_xx_NM109_SVC_PROV_NR | String | Service Provider Number | |
09 | L2100C_xx_NM109_NPI | String | Centers for Medicare and Medicaid Services National Provider Identifier |
L2200C - PROVIDER OF SERVICE TRACE IDENTIFIER |
L2200C | TRN | Provider of Service Trace Identifier | ||
02 | L2200C_TRN02_PVR_SVCNFO_TRC_ID | String | Provider of Service Information Trace Identifier |
L2200CX - PROVIDER OF SERVICE TRACE IDENTIFIER - STC CUTOUT |
L2200CX | STC | Provider Status Information | ||
01 | 01 | L2200CX_STC0101_HTCRCLM_CAT_CD | String | Health Care Claim Status Category Code |
01 | 02 | L2200CX_STC0102_STATS_CD | String | Status Code |
01 | 03 | L2200CX_STC0103_ENTY_ID_CD | String | Entity Identifier Code |
02 | L2200CX_STC02_STMT_NFO_EFF_D8 | Date/Time | Status Information Effective Date | |
10 | 01 | L2200CX_STC1001_HTCRCLM_CAT_CD | String | Health Care Claim Status Category Code |
10 | 02 | L2200CX_STC1002_STATS_CD | String | Status Code |
10 | 03 | L2200CX_STC1003_ENTY_ID_CD | String | Entity Identifier Code |
11 | 01 | L2200CX_STC1101_HTCRCLM_CAT_CD | String | Health Care Claim Status Category Code |
11 | 02 | L2200CX_STC1102_STATS_CD | String | Status Code |
11 | 03 | L2200CX_STC1103_ENTY_ID_CD | String | Entity Identifier Code |
L2000D - SUBSCRIBER LEVEL |
L2000D | HL | Subscriber Level | ||
01 | L2000D_HL01_HIER_ID_NR | String | Hierarchical ID Number | |
02 | L2000D_HL02_HIER_PARNT_ID_NR | String | Hierarchical Parent ID Number | |
04 | L2000D_HL04_HL_CHLD_CD | String | Hierarchical Child Code |
L2100D - SUBSCRIBER NAME |
L2100D | NM1 | Subscriber Name | ||
03 | L2100D_NM103_PERSN_LNM | String | Person Last Name | |
03 | L2100D_NM103_NONPSNENT_NM | String | Non-Person Entity Name | |
04 | L2100D_NM104_SBR_FNM | String | Subscriber First Name | |
05 | L2100D_NM105_SBR_MNM | String | Subscriber Middle Name or Initial | |
07 | L2100D_NM107_SBR_SFX | String | Subscriber Name Suffix | |
09 | L2100D_NM109_EMPLYR_ID | String | Employer?s Identification Number | |
09 | L2100D_NM109_UNQ_HLTH_ID | String | Standard Unique Health Identifier for each Individual in the United States | |
09 | L2100D_NM109_MEM_ID_NR | String | Member Identification Number |
L2200D - CLAIM STATUS TRACKING NUMBER |
L2200D | TRN | Claim Status Tracking Number | ||
02 | L2200D_TRN02_REF_TRAN_TRAC_NR | String | Referenced Transaction Trace Number |
L2200DX - CLAIM STATUS TRACKING NUMBER - STC CUTOUT |
L2200DX | STC | Claim Level Status Information | ||
01 | 01 | L2200DX_STC0101_HTCRCLM_CAT_CD | String | Health Care Claim Status Category Code |
01 | 02 | L2200DX_STC0102_STATS_CD | String | Status Code |
01 | 03 | L2200DX_STC0103_ENTY_ID_CD | String | Entity Identifier Code |
01 | 04 | L2200DX_STC0104_CD_LST_QL_CD | String | Code List Qualifier Code |
02 | L2200DX_STC02_STMT_NFO_EFF_D8 | Date/Time | Status Information Effective Date | |
04 | L2200DX_STC04_TOT_CLM_CHG_AMT | Decimal | Total Claim Charge Amount | |
05 | L2200DX_STC05_CLM_PMT_AMT | Decimal | Claim Payment Amount | |
06 | L2200DX_STC06_ADJ_FINAL_D8 | Date/Time | Adjudication Finalized Date | |
08 | L2200DX_STC08_REMTC_D8 | Date/Time | Remittance Date | |
09 | L2200DX_STC09_REMTC_TRAC_NR | String | Remittance Trace Number | |
10 | 01 | L2200DX_STC1001_HTCRCLM_CAT_CD | String | Health Care Claim Status Category Code |
10 | 02 | L2200DX_STC1002_STATS_CD | String | Status Code |
10 | 03 | L2200DX_STC1003_ENTY_ID_CD | String | Entity Identifier Code |
10 | 04 | L2200DX_STC1004_CD_LST_QL_CD | String | Code List Qualifier Code |
11 | 01 | L2200DX_STC1101_HTCRCLM_CAT_CD | String | Health Care Claim Status Category Code |
11 | 02 | L2200DX_STC1102_STATS_CD | String | Status Code |
11 | 03 | L2200DX_STC1103_ENTY_ID_CD | String | Entity Identifier Code |
11 | 04 | L2200DX_STC1104_CD_LST_QL_CD | String | Code List Qualifier Code |
L2200D | REF | Payer Claim Control Number | ||
02 | L2200D_REF_PYR_CLM_NR | String | Payor?s Claim Number |
L2200D | REF | Institutional Bill Type Identification | ||
02 | L2200D_REF_BILL_TYP | String | Billing Type |
L2200D | REF | Patient Control Number | ||
02 | L2200D_REF_PATNT_ACCT_NR | String | Patient Account Number |
L2200D | REF | Pharmacy Prescription Number | ||
02 | L2200D_REF_PHRM_RX_NR | String | Pharmacy Prescription Number |
L2200D | REF | Voucher Identifier | ||
02 | L2200D_REF_VOUCHR | String | Voucher |
L2200D | REF | Claim Identification Number For Clearinghouses and Other Transmission Intermediaries | ||
02 | L2200D_REF_CLM_NR | String | Claim Number |
L2200D | DTP | Claim Service Date | ||
03 | L2200D_DTP_SVC_D8 | Start Date | Service (D8) | |
03 | L2200D_DTP_SVC_RD8_1 | Start Date | Service (D8) | |
03 | L2200D_DTP_SVC_RD8_2 | End Date | Service (D8) |
L2220D - SERVICE LINE INFORMATION |
L2220D | SVC | Service Line Information | ||
01 | 02 | L2220D_SVC0102_ADA_CD | String | American Dental Association Codes |
01 | 02 | L2220D_SVC0102_JS_PRC_SPY_CD | String | Jurisdiction Specific Procedure and Supply Codes |
01 | 02 | L2220D_SVC0102_HCPCS_CD | String | Health Care Financing Administration Common Procedural Coding System (HCPCS) Codes |
01 | 02 | L2220D_SVC0102_HIPPA_SNF_RT_CD | String | Health Insurance Prospective Payment System (HIPPS) Skilled Nursing Facility Rate Code |
01 | 02 | L2220D_SVC0102_HIC_PRD_SVCCD | String | Home Infusion EDI Coalition (HIEC) Product/Service |
01 | 02 | L2220D_SVC0102_NDC542 | String | National Drug Code in 5-4-2 Format |
01 | 02 | L2220D_SVC0102_NUBC_UB92_CD | String | National Uniform Billing Committee (NUBC) UB92 |
01 | 02 | L2220D_SVC0102_ABC_CD | String | Advanced Billing Concepts (ABC) Codes |
01 | 03 | L2220D_SVC0103_PROC_MOD | String | Procedure Modifier |
01 | 04 | L2220D_SVC0104_PROC_MOD | String | Procedure Modifier |
01 | 05 | L2220D_SVC0105_PROC_MOD | String | Procedure Modifier |
01 | 06 | L2220D_SVC0106_PROC_MOD | String | Procedure Modifier |
02 | L2220D_SVC02_LIN_ITM_CHG_AMT | Decimal | Line Item Charge Amount | |
03 | L2220D_SVC03_LIN_ITM_PMT_AMT | Decimal | Line Item Payment Amount | |
04 | L2220D_SVC04_REV_CD | String | Revenue Code | |
07 | L2220D_SVC07_UN_SVC_CT | Decimal | Units of Service Count |
L2220DX - SERVICE LINE INFORMATION - STC CUTOUT |
L2220DX | STC | Service Line Status Information | ||
01 | 01 | L2220DX_STC0101_HTCRCLM_CAT_CD | String | Health Care Claim Status Category Code |
01 | 02 | L2220DX_STC0102_STATS_CD | String | Status Code |
01 | 03 | L2220DX_STC0103_ENTY_ID_CD | String | Entity Identifier Code |
01 | 04 | L2220DX_STC0104_CD_LST_QL_CD | String | Code List Qualifier Code |
02 | L2220DX_STC02_STMT_NFO_EFF_D8 | Date/Time | Status Information Effective Date | |
10 | 01 | L2220DX_STC1001_HTCRCLM_CAT_CD | String | Health Care Claim Status Category Code |
10 | 02 | L2220DX_STC1002_STATS_CD | String | Status Code |
10 | 03 | L2220DX_STC1003_ENTY_ID_CD | String | Entity Identifier Code |
10 | 04 | L2220DX_STC1004_CD_LST_QL_CD | String | Code List Qualifier Code |
11 | 01 | L2220DX_STC1101_HTCRCLM_CAT_CD | String | Health Care Claim Status Category Code |
11 | 02 | L2220DX_STC1102_STATS_CD | String | Status Code |
11 | 03 | L2220DX_STC1103_ENTY_ID_CD | String | Entity Identifier Code |
11 | 04 | L2220DX_STC1104_CD_LST_QL_CD | String | Code List Qualifier Code |
L2220D | REF | Service Line Item Identification | ||
02 | L2220D_REF_LIN_ITM | String | Line Item Control Number |
L2220D | DTP | Service Line Date | ||
03 | L2220D_DTP_SVC_D8 | Start Date | Service (D8) | |
03 | L2220D_DTP_SVC_RD8_1 | Start Date | Service (D8) | |
03 | L2220D_DTP_SVC_RD8_2 | End Date | Service (D8) |
L2000E - DEPENDENT LEVEL |
L2000E | HL | Dependent Level | ||
01 | L2000E_HL01_HIER_ID_NR | String | Hierarchical ID Number | |
02 | L2000E_HL02_HIER_PARNT_ID_NR | String | Hierarchical Parent ID Number |
L2100E - DEPENDENT NAME |
L2100E | NM1 | Dependent Name | ||
03 | L2100E_NM103_PT_LNM | String | Patient Last Name | |
04 | L2100E_NM104_PT_FNM | String | Patient First Name | |
05 | L2100E_NM105_PT_MNM | String | Patient Middle Name or Initial | |
07 | L2100E_NM107_PT_SFX | String | Patient Name Suffix |
L2200E - CLAIM STATUS TRACKING NUMBER |
L2200E | TRN | Claim Status Tracking Number | ||
02 | L2200E_TRN02_REF_TRAN_TRAC_NR | String | Referenced Transaction Trace Number |
L2200EX - CLAIM STATUS TRACKING NUMBER - STC CUTOUT |
L2200EX | STC | Claim Level Status Information | ||
01 | 01 | L2200EX_STC0101_HTCRCLM_CAT_CD | String | Health Care Claim Status Category Code |
01 | 02 | L2200EX_STC0102_STATS_CD | String | Status Code |
01 | 03 | L2200EX_STC0103_ENTY_ID_CD | String | Entity Identifier Code |
01 | 04 | L2200EX_STC0104_CD_LST_QL_CD | String | Code List Qualifier Code |
02 | L2200EX_STC02_STMT_NFO_EFF_D8 | Date/Time | Status Information Effective Date | |
04 | L2200EX_STC04_TOT_CLM_CHG_AMT | Decimal | Total Claim Charge Amount | |
05 | L2200EX_STC05_CLM_PMT_AMT | Decimal | Claim Payment Amount | |
06 | L2200EX_STC06_ADJ_FINAL_D8 | Date/Time | Adjudication Finalized Date | |
08 | L2200EX_STC08_REMTC_D8 | Date/Time | Remittance Date | |
09 | L2200EX_STC09_REMTC_TRAC_NR | String | Remittance Trace Number | |
10 | 01 | L2200EX_STC1001_HTCRCLM_CAT_CD | String | Health Care Claim Status Category Code |
10 | 02 | L2200EX_STC1002_STATS_CD | String | Status Code |
10 | 03 | L2200EX_STC1003_ENTY_ID_CD | String | Entity Identifier Code |
10 | 04 | L2200EX_STC1004_CD_LST_QL_CD | String | Code List Qualifier Code |
11 | 01 | L2200EX_STC1101_HTCRCLM_CAT_CD | String | Health Care Claim Status Category Code |
11 | 02 | L2200EX_STC1102_STATS_CD | String | Status Code |
11 | 03 | L2200EX_STC1103_ENTY_ID_CD | String | Entity Identifier Code |
11 | 04 | L2200EX_STC1104_CD_LST_QL_CD | String | Code List Qualifier Code |
L2200E | REF | Payer Claim Control Number | ||
02 | L2200E_REF_PYR_CLM_NR | String | Payor?s Claim Number |
L2200E | REF | Institutional Bill Type Identification | ||
02 | L2200E_REF_BILL_TYP | String | Billing Type |
L2200E | REF | Patient Control Number | ||
02 | L2200E_REF_PATNT_ACCT_NR | String | Patient Account Number |
L2200E | REF | Pharmacy Prescription Number | ||
02 | L2200E_REF_PHRM_RX_NR | String | Pharmacy Prescription Number |
L2200E | REF | Voucher Identifier | ||
02 | L2200E_REF_VOUCHR | String | Voucher |
L2200E | REF | Claim Identification Number For Clearinghouses and Other Transmission Intermediaries | ||
02 | L2200E_REF_CLM_NR | String | Claim Number |
L2200E | DTP | Claim Service Date | ||
03 | L2200E_DTP_SVC_D8 | Start Date | Service (D8) | |
03 | L2200E_DTP_SVC_RD8_1 | Start Date | Service (D8) | |
03 | L2200E_DTP_SVC_RD8_2 | End Date | Service (D8) |
L2220E - SERVICE LINE INFORMATION |
L2220E | SVC | Service Line Information | ||
01 | 02 | L2220E_SVC0102_ADA_CD | String | American Dental Association Codes |
01 | 02 | L2220E_SVC0102_JS_PRC_SPY_CD | String | Jurisdiction Specific Procedure and Supply Codes |
01 | 02 | L2220E_SVC0102_HCPCS_CD | String | Health Care Financing Administration Common |
01 | 02 | L2220E_SVC0102_HIPPA_SNF_RT_CD | String | Health Insurance Prospective Payment System (HIPPS) Skilled Nursing Facility Rate Code |
01 | 02 | L2220E_SVC0102_HIC_PRD_SVCCD | String | Home Infusion EDI Coalition (HIEC) Product/Service Code |
01 | 02 | L2220E_SVC0102_NDC542 | String | National Drug Code in 5-4-2 Format |
01 | 02 | L2220E_SVC0102_NUBC_UB92_CD | String | National Uniform Billing Committee (NUBC) UB92 Codes |
01 | 02 | L2220E_SVC0102_ABC_CD | String | Advanced Billing Concepts (ABC) Codes |
01 | 03 | L2220E_SVC0103_PROC_MOD | String | Procedure Modifier |
01 | 04 | L2220E_SVC0104_PROC_MOD | String | Procedure Modifier |
01 | 05 | L2220E_SVC0105_PROC_MOD | String | Procedure Modifier |
01 | 06 | L2220E_SVC0106_PROC_MOD | String | Procedure Modifier |
02 | L2220E_SVC02_LIN_ITM_CHG_AMT | Decimal | Line Item Charge Amount | |
03 | L2220E_SVC03_LIN_ITM_PMT_AMT | Decimal | Line Item Payment Amount | |
04 | L2220E_SVC04_REV_CD | String | Revenue Code | |
07 | L2220E_SVC07_UN_SVC_CT | Decimal | Units of Service Count |
L2220EX - SERVICE LINE INFORMATION - STC CUTOUT |
L2220EX | STC | Service Line Status Information | ||
01 | 01 | L2220EX_STC0101_HTCRCLM_CAT_CD | String | Health Care Claim Status Category Code |
01 | 02 | L2220EX_STC0102_STATS_CD | String | Status Code |
01 | 03 | L2220EX_STC0103_ENTY_ID_CD | String | Entity Identifier Code |
01 | 04 | L2220EX_STC0104_CD_LST_QL_CD | String | Code List Qualifier Code |
02 | L2220EX_STC02_STMT_NFO_EFF_D8 | Date/Time | Status Information Effective Date | |
10 | 01 | L2220EX_STC1001_HTCRCLM_CAT_CD | String | Health Care Claim Status Category Code |
10 | 02 | L2220EX_STC1002_STATS_CD | String | Status Code |
10 | 03 | L2220EX_STC1003_ENTY_ID_CD | String | Entity Identifier Code |
10 | 04 | L2220EX_STC1004_CD_LST_QL_CD | String | Code List Qualifier Code |
11 | 01 | L2220EX_STC1101_HTCRCLM_CAT_CD | String | Health Care Claim Status Category Code |
11 | 02 | L2220EX_STC1102_STATS_CD | String | Status Code |
11 | 03 | L2220EX_STC1103_ENTY_ID_CD | String | Entity Identifier Code |
11 | 04 | L2220EX_STC1104_CD_LST_QL_CD | String | Code List Qualifier Code |
L2220E | REF | Service Line Item Identification | ||
02 | L2220E_REF_LIN_ITM | String | Line Item Control Number |
L2220E | DTP | Service Line Date | ||
03 | L2220E_DTP_SVC_D8 | Start Date | Service (D8) | |
03 | L2220E_DTP_SVC_RD8_1 | Start Date | Service (D8) | |
03 | L2220E_DTP_SVC_RD8_2 | End Date | Service (D8) |
STHDR | SE | Transaction Set Trailer | ||
01 | STHDR_SE01_TS_SEG_CT | Integer | Transaction Segment Count | |
02 | STHDR_SE02_TCN | String | Transaction Set Control Number |
GSHDR | GE | Functional Group Trailer | ||
01 | GSHDR_GE01_NR_TS_INCLUDED | Integer | Number of Transaction Sets Included | |
02 | GSHDR_GE02_GCN | Integer | Group Control Number |