GSHDR - GROUP HEADER |
GSHDR | GS | Function 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 |
STHDR | BHT | Beginning of Hierarchical Transaction | ||
03 | STHDR_BHT03_REF_ID | String | Reference Identification | |
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 - INFORMATION SOURCE NAME (Value Qualified) |
Mapping Prefix: L2100A_AY - Clearinghouse |
Mapping Prefix: L2100A_PR - Payer |
L2100A | NM1 | Information Source Name | ||
03 | L2100A_yy_NM103_NFO_SRC_NM | String | Information Source Last or Organization Name | |
09 | L2100A_yy_NM109_ETN_NR | String | Electronic Transmitter Identification Number | |
09 | L2100A_yy_NM109_TAX_ID | String | Federal Taxpayer's Identification Number | |
09 | L2100A_yy_NM109_PAYR_ID | String | Payor Identification | |
09 | L2100A_yy_NM109_HCFA_PLAN_ID | String | Centers for Medicare abd Medicaid Services PlanID |
L2200A - TRANSMISSION RECEIPT CONTROL IDENTIFIER (Inherited Value Qualifier) |
Mapping Prefix: L2200A_AY - Clearinghouse |
Mapping Prefix: L2200A_PR - Payer |
L2200A | TRN | Transmission Receipt Control Identifier | ||
02 | L2200A_yy_TRN02_NFO_SRC_AP_TRC | String | Information Source Application Trace Identifier |
L2200A | DTP | Information Source Receipt Date | ||
03 | L2200A_yy_DTP_RCVD_D8 | Start Date | Received (D8) |
L2200A | DTP | Information Source Process Date | ||
03 | L2200A_yy_DTP_PRCS_D8 | Start Date | Process (D8) |
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 | ||
03 | L2100B_NM103_PERSN_LNM | String | Person Last Name | |
03 | L2100B_NM103_NONPSNENT_NM | String | Non-Person Entity 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_RCV_PRI_ID | String | Information Receiver Primary Identifier |
L2200B - INFORMATION RECEIVER APPLICATION TRACE IDENTIFIER |
L2200B | TRN | Information Receiver Application Trace Identifier | ||
02 | L2200B_TRN02_CLM_TRNS_BAT_NR | String | Claim Transaction Batch Number | |
04 | L2200B_TRN04_REF_ID | String | Reference Identification |
L2200BX - INFORMATION RECEIVER APPLICATION 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_HTCRCLM_STATCD | String | Health Care Claim 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 | |
03 | L2200BX_STC03_ACTN_CD | String | Action Code | |
04 | L2200BX_STC04_TOT_SBR_CHG_WK | Decimal | Total Submitted Charges for Work | |
10 | 01 | L2200BX_STC1001_HTCRCLM_CAT_CD | String | Health Care Claim Status Category Code |
10 | 02 | L2200BX_STC1002_HTCRCLM_STATCD | String | Health Care Claim 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_HTCRCLM_STATCD | String | Health Care Claim Status Code |
11 | 03 | L2200BX_STC1103_ENTY_ID_CD | String | Entity Identifier Code |
L2200B | QTY | Total Accepted Quantity | ||
02 | L2200B_QTY02_ACK_QTY | Date Timestamp | Acknowledged Quantity |
L2200B | QTY | Total Rejected Quantity | ||
02 | L2200B_QTY02_UNACK_QTY | Date Timestamp | Unacknowledged Quantity |
L2200B | AMT | Total Accepted Amount | ||
02 | L2200B_AMT02_IN_PROCS | Date Timestamp | In Process |
L2200B | AMT | Total Rejected Amount | ||
02 | L2200B_AMT02_RETRND | Date Timestamp | Returned |
L2000C - BILLING PROVIDER OF SERVICE LEVEL |
L2000C | HL | Billing Provider of Service 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 - BILLING PROVIDER NAME |
L2100C | NM1 | Billing Provider Name | ||
03 | L2100C_NM103_PERSN_LNM | String | Person Last Name | |
03 | L2100C_NM103_NONPSNENT_NM | String | Non-Person Entity Name | |
04 | L2100C_NM104_PVR_FNM | String | Provider First Name | |
05 | L2100C_NM105_PVR_MNM | String | Provider Middle Name | |
07 | L2100C_NM107_PVR_SFX | String | Provider Name Suffix | |
09 | L2100C_NM109_TAX_ID | String | Federal Taxpayer's Identification Number | |
09 | L2100C_NM109_NPI | String | Centers for Medicare and Medicaid Services National Provider Identifier |
L2200C - PROVIDER OF SERVICE INFORMATION TRACE IDENTIFIER |
L2200C | TRN | Provider of Service Information Trace Identifier | ||
02 | L2200C_TRN02_PVR_SVCNFO_TRC_ID | String | Provider of Service Information Trace Identifier |
L2200CX - PROVIDER OF SERVICE INFORMATION TRACE IDENTIFIER - STC CUTOUT |
L2200CX | STC | Billing Provider Status Information | ||
01 | 01 | L2200CX_STC0101_HTCRCLM_CAT_CD | String | Health Care Claim Status Category Code |
01 | 02 | L2200CX_STC0102_HTCRCLM_STATCD | String | Health Care Claim Status Code |
01 | 03 | L2200CX_STC0103_ENTY_ID_CD | String | Entity Identifier Code |
03 | L2200CX_STC03_ACTN_CD | String | Action Code | |
04 | L2200CX_STC04_TOT_SBR_CHG_WRK | Decimal | Total Submitted Charges for Unit Work | |
10 | 01 | L2200CX_STC1001_HTCRCLM_CAT_CD | String | Health Care Claim Status Category Code |
10 | 02 | L2200CX_STC1002_HTCRCLM_STATCD | String | Health Care Claim 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_HTCRCLM_STATCD | String | Health Care Claim Status Code |
11 | 03 | L2200CX_STC1103_ENTY_ID_CD | String | Entity Identifier Code |
L2200C | REF | Provider Secondary Identifier |
Iterated: [01-03] | |
02 | L2200C_nnREF_STAT_LIC_NR | String | State License Number | |
02 | L2200C_nnREF_UPIN | String | Provider UPIN Number | |
02 | L2200C_nnREF_PVR_COMM_NR | String | Provider Commercial Number | |
02 | L2200C_nnREF_LOC_NR | String | Location Number | |
02 | L2200C_nnREF_SSN | String | Social Security Number | |
02 | L2200C_nnREF_TAX_ID | String | Federal Taxpayer's Identification Number |
L2200C | QTY | Total Accepted Quantity | ||
02 | L2200C_QTY02_QTY_APPR | Date Timestamp | Quantity Approved |
L2200C | QTY | Total Rejected Quantity | ||
02 | L2200C_QTY02_QTY_DSPRVD | Date Timestamp | Quantity Disapproved |
L2200C | AMT | Total Accepted Amount | ||
02 | L2200C_AMT02_IN_PROCS | Date Timestamp | In Process |
L2200C | AMT | Total Rejected Amount | ||
02 | L2200C_AMT02_RETRND | Date Timestamp | Returned |
L2000D - PATIENT LEVEL |
L2000D | HL | Patient Level | ||
01 | L2000D_HL01_HIER_ID_NR | String | Hierarchical ID Number | |
02 | L2000D_HL02_HIER_PARNT_ID_NR | String | Hierarchical Parent ID Number |
L2100D - PATIENT NAME |
L2100D | NM1 | Patient Name | ||
03 | L2100D_NM103_PT_LNM | String | Patient Last Name | |
04 | L2100D_NM104_PT_FNM | String | Patient First Name | |
05 | L2100D_NM105_PT_MNM | String | Patient Middle Name or Initial | |
07 | L2100D_NM107_PT_SFX | String | Patient Name Suffix | |
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_PT_CTL_NR | String | Patient Control Number | |
04 | L2200D_TRN04_TRC_ASS_ADDL_ID | String | Trace Assigning Entity Additional Identifier |
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_HTCRCLM_STATCD | String | Health Care Claim Status Code |
01 | 03 | L2200DX_STC0103_ENTY_ID_CD | String | Entity Identifier Code |
02 | L2200DX_STC02_STMT_NFO_EFF_D8 | Date/Time | Status Information Effective Date | |
03 | L2200DX_STC03_ACTN_CD | String | Action Code | |
04 | L2200DX_STC04_TOT_CLM_CHG_AMT | Decimal | Total Claim Charge Amount | |
10 | 01 | L2200DX_STC1001_HTCRCLM_CAT_CD | String | Health Care Claim Status Category Code |
10 | 02 | L2200DX_STC1002_HTCRCLM_STATCD | String | Health Care Claim Status Code |
10 | 03 | L2200DX_STC1003_ENTY_ID_CD | String | Entity Identifier Code |
11 | 01 | L2200DX_STC1101_HTCRCLM_CAT_CD | String | Health Care Claim Status Category Code |
11 | 02 | L2200DX_STC1102_HTCRCLM_STATCD | String | Health Care Claim Status Code |
11 | 03 | L2200DX_STC1103_ENTY_ID_CD | String | Entity Identifier Code |
12 | L2200DX_STC12_FRFM_MSG_TXT | String | Free-form Message Text |
L2200D | REF | Payer Claim Control Number | ||
02 | L2200D_REF_PYR_CLM_NR | String | Payor's Claim Number |
L2200D | REF | Claim Identifier Number For Clearinghouse and Other Transmission Intermediaries | ||
02 | L2200D_REF_CLM_NR | String | Claim Number |
L2200D | REF | Institutional Bill Type Identification | ||
02 | L2200D_REF_BILL_TYP | String | Billing Type |
L2200D | DTP | Claim Level 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_HIPPS_SNF_RT_CD | String | Health Insurance Prospective Payment System (HIPPS) Skill Nursing Facility Rate Code |
01 | 02 | L2220D_SVC0102_NUBC_UB92_CD | String | National Uniform Billing Committe (NUBC) UB92 Codes |
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 | |
04 | L2220D_SVC04_REV_CD | String | Revenue Code | |
07 | L2220D_SVC07_ORG_UN_SVC_CT | String | Original Units of Service Count |
L2220DX - SERVICE LINE INFORMATION - STC CUTOUT |
L2220DX | STC | Service Line Level Status Information | ||
01 | 01 | L2220DX_STC0101_HTCRCLM_CAT_CD | String | Health Care Claim Status Category Code |
01 | 02 | L2220DX_STC0102_HTCRCLM_STATCD | String | Health Care Claim Status Code |
01 | 03 | L2220DX_STC0103_ENTY_ID_CD | String | Entity Identifier Code |
10 | 01 | L2220DX_STC1001_HTCRCLM_CAT_CD | String | Health Care Claim Status Category Code |
10 | 02 | L2220DX_STC1002_HTCRCLM_STATCD | String | Health Care Claim Status Code |
10 | 03 | L2220DX_STC1003_ENTY_ID_CD | String | Entity Identifier Code |
11 | 01 | L2220DX_STC1101_HTCRCLM_CAT_CD | String | Health Care Claim Status Category Code |
11 | 02 | L2220DX_STC1102_HTCRCLM_STATCD | String | Health Care Claim Status Code |
11 | 03 | L2220DX_STC1103_ENTY_ID_CD | String | Entity Identifier Code |
12 | L2220DX_STC12_FRFM_MSG_TXT | String | Free-form Message Text |
L2220D | REF | Service Line Item Identification | ||
02 | L2220D_REF_LIN_ITM | String | Line Item Control Number |
L2220D | REF | Pharmacy Prescription Number | ||
02 | L2220D_REF_PHRM_RX_NR | String | Pharmacy Prescription Number | |
03 | L2220D_REF03_NFORCV_AD_ID | String | Information Receiver Additional Identifier State |
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) |
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 |