5010 Health Care Claim: Professional [X0]


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
03STHDR_ST03_IMP_GUID_VERS_NMStringImplementation Guide Version Name
STHDRBHTBeginning of Hierarchical Transaction
01STHDR_BHT01_HIER_STRUC_CDStringHierarchical Structure Code
02STHDR_BHT02_TS_PURP_CDStringTransaction Set Purpose Code
03STHDR_BHT03_ORIG_APP_TRANS_IDStringOriginator Application Transaction Identifier
04STHDR_BHT04_TS_CRTN_D8Date/TimeTransaction Set Creation Date
05STHDR_BHT05_TS_CRTN_TMTimeTransaction Set Creation Time
06STHDR_BHT06_CLM_ENC_IDStringClaim or Encounter Identifier
L1000A - SUBMITTER NAME
L1000ANM1Submitter Name
03L1000A_NM103_PERSN_LNMStringPerson Last Name
03L1000A_NM103_NONPSNENT_NMStringNon-Person Entity Name
04L1000A_NM104_SBM_FNMStringSubmitter First Name
05L1000A_NM105_SBM_MNMStringSubmitter Middle Name or Initial
09L1000A_NM109_SBM_IDStringSubmitter Identifier
L1000APERSubmitter EDI Contact Information Iterated: [01-02]
02L1000A_nnPER02_SBM_CON_NMStringSubmitter Contact Name
04L1000A_nnPER04_EMAILStringElectronic Mail
04L1000A_nnPER04_FAXStringFacsimile
04L1000A_nnPER04_PHN_NRStringTelephone
06L1000A_nnPER06_EMAILStringElectronic Mail
06L1000A_nnPER06_PHN_EXTStringTelephone Extension
06L1000A_nnPER06_FAXStringFacsimile
06L1000A_nnPER06_PHN_NRStringTelephone
08L1000A_nnPER08_EMAILStringElectronic Mail
08L1000A_nnPER08_PHN_EXTStringTelephone Extension
08L1000A_nnPER08_FAXStringFacsimile
08L1000A_nnPER08_PHN_NRStringTelephone
L1000B - RECEIVER NAME
L1000BNM1Receiver Name
03L1000B_NM103_RCV_NMStringReceiver Name
09L1000B_NM109_RCV_PRI_IDStringReceiver Primary Identifier
L2000A - BILLING PROVIDER HIERARCHICAL LEVEL
L2000AHLBilling Provider Hierarchical Level
01L2000A_HL01_HIER_ID_NRStringHierarchical ID Number
L2000APRVBilling Provider Specialty Information
03L2000A_PRV03_PVR_TAX_CDStringProvider Taxonomy Code
L2000ACURForeign Currency Information
02L2000A_CUR02_CURRNCY_CDStringCurrency Code
L2010AA - BILLING PROVIDER NAME
L2010AANM1Billing Provider Name
03L2010AA_NM103_PERSN_LNMStringPerson Last Name
03L2010AA_NM103_NONPSNENT_NMStringNon-Person Entity Name
04L2010AA_NM104_BILL_PVR_FNMStringBilling Provider First Name
05L2010AA_NM105_BILL_PVR_MNMStringBilling Provider Middle Name or Initial
07L2010AA_NM107_BILL_PVR_SFXStringBilling Provider Name Suffix
09L2010AA_NM109_BILL_PVR_IDStringBilling Provider Identifier
L2010AAN3Billing Provider Address
01L2010AA_N301_BILL_PROV_ADDRStringBilling Provider Address Line
02L2010AA_N302_BILL_PROV_ADDRStringBilling Provider Address Line
L2010AAN4Billing Provider City, State, ZIP Code
01L2010AA_N401_BILL_PVR_CITYStringBilling Provider City Name
02L2010AA_N402_BILL_PVR_STATStringBilling Provider State or Province Code
03L2010AA_N403_BILL_PVR_ZIPStringBilling Provider Postal Zone or ZIP Code
04L2010AA_N404_CNTRY_CDStringCountry Code
07L2010AA_N407_CNTRY_SUBDV_CDStringCountry Subdivision Code
L2010AAREFBilling Provider Tax Identification
02L2010AA_REF_EMPLR_ID_NRStringEmployer?s Identification Number
02L2010AA_REF_SSNStringSocial Security Number
L2010AAREFBilling Provider UPIN/License Information
02L2010AA_REF_STAT_LIC_NRStringState License Number
02L2010AA_REF_UPINStringProvider UPIN Number
L2010AAPERBilling Provider Contact Information Iterated: [01-02]
02L2010AA_nnPER02_BL_PVR_CONT_NMStringBilling Provider Contact Name
04L2010AA_nnPER04_EMAILStringElectronic Mail
04L2010AA_nnPER04_FAXStringFacsimile
04L2010AA_nnPER04_PHN_NRStringTelephone
06L2010AA_nnPER06_EMAILStringElectronic Mail
06L2010AA_nnPER06_PHN_EXTStringTelephone Extension
06L2010AA_nnPER06_FAXStringFacsimile
06L2010AA_nnPER06_PHN_NRStringTelephone
08L2010AA_nnPER08_EMAILStringElectronic Mail
08L2010AA_nnPER08_PHN_EXTStringTelephone Extension
08L2010AA_nnPER08_FAXStringFacsimile
08L2010AA_nnPER08_PHN_NRStringTelephone
L2010AB - PAY-TO ADDRESS NAME
L2010ABNM1Pay-to Address Name
02L2010AB_NM102_ENT_TYP_QUALStringEntity Type Qualifier
L2010ABN3Pay-to Address - ADDRESS
01L2010AB_N301_PAY2_ADDRStringPay-To Address Line
02L2010AB_N302_PAY2_ADDRStringPay-To Address Line
L2010ABN4Pay-To Address City, State, ZIP Code
01L2010AB_N401_PAY2_CITYStringPay-to Address City Name
02L2010AB_N402_PAY2_STATStringPay-to Address State Code
03L2010AB_N403_PAY2_ZIPStringPay-to Address Postal Zone or ZIP Code
04L2010AB_N404_CNTRY_CDStringCountry Code
07L2010AB_N407_CNTRY_SUBDV_CDStringCountry Subdivision Code
L2010AC - PAY-TO PLAN NAME
L2010ACNM1Pay-To Plan Name
03L2010AC_NM103_PAY2_PLN_ORG_NMStringPay-To Plan Organizational Name
09L2010AC_NM109_PAYR_IDStringPayor Identification
09L2010AC_NM109_HCFA_PLAN_IDStringCenters for Medicare and Medicaid Services PlanID
L2010ACN3Pay-to Plan Address
01L2010AC_N301_PAY2_PLN_ADDRStringPay-To Plan Address Line
02L2010AC_N302_PAY2_PLN_ADDRStringPay-To Plan Address Line
L2010ACN4Pay-To Plan City, State, ZIP Code
01L2010AC_N401_PAY2_PLN_CITYStringPay-To Plan City Name
02L2010AC_N402_PAY2_PLN_STATStringPay-To Plan State or Province Code
03L2010AC_N403_PAY2_PLN_ZIPStringPay-To Plan Postal Zone or ZIP Code
04L2010AC_N404_CNTRY_CDStringCountry Code
07L2010AC_N407_CNTRY_SUBDV_CDStringCountry Subdivision Code
L2010ACREFPay-to Plan Secondary Identification
02L2010AC_REF_PYR_IDStringPayer Identification Number
02L2010AC_REF_CLM_OFC_NRStringClaim Office Number
02L2010AC_REF_NAICStringNational Association of Insurance Commissioners (NAIC) Code
L2010ACREFPay-To Plan Tax Identification Number
02L2010AC_REF_EMPLR_ID_NRStringEmployer?s Identification Number
L2000B - SUBSCRIBER HEIRARCHICAL LEVEL
L2000BHLSubscriber Hierarchical Level
01L2000B_HL01_HIER_ID_NRStringHierarchical ID Number
02L2000B_HL02_HIER_PARNT_ID_NRStringHierarchical Parent ID Number
04L2000B_HL04_HL_CHLD_CDStringHierarchical Child Code
L2000BSBRSubscriber Information
01L2000B_SBR01_PYR_RESP_SEQ_NRStringPayer Responsibility Sequence Number Code
02L2000B_SBR02_IND_RELAT_CDStringIndividual Relationship Code
03L2000B_SBR03_SBR_POLCY_NRStringSubscriber Group or Policy Number
04L2000B_SBR04_SBR_GRP_NMStringSubscriber Group Name
05L2000B_SBR05_INS_TYP_CDStringInsurance Type Code
09L2000B_SBR09_CLM_FIL_IND_CDStringClaim Filing Indicator Code
L2000BPATPatient Information
06L2000B_PAT06_PT_DEATH_D8Date/TimePatient Death Date
08L2000B_PAT08_PT_WGTDecimalPatient Weight
09L2000B_PAT09_PREG_INDStringPregnancy Indicator
L2010BA - SUBSCRIBER NAME
L2010BANM1Subscriber Name
03L2010BA_NM103_PERSN_LNMStringPerson Last Name
03L2010BA_NM103_NONPSNENT_NMStringNon-Person Entity Name
04L2010BA_NM104_SBR_FNMStringSubscriber First Name
05L2010BA_NM105_SBR_MNMStringSubscriber Middle Name or Initial
07L2010BA_NM107_SBR_SFXStringSubscriber Name Suffix
09L2010BA_NM109_UNQ_HLTH_IDStringStandard Unique Health Identifier for each Individual in the United States
09L2010BA_NM109_MEM_ID_NRStringMember Identification Number
L2010BAN3Subscriber Address
01L2010BA_N301_SBR_ADDRStringSubscriber Address Line
02L2010BA_N302_SBR_ADDRStringSubscriber Address Line
L2010BAN4Subscriber City, State, ZIP Code
01L2010BA_N401_SBR_CITYStringSubscriber City Name
02L2010BA_N402_SBR_STATStringSubscriber State Code
03L2010BA_N403_SBR_ZIPStringSubscriber Postal Zone or ZIP Code
04L2010BA_N404_CNTRY_CDStringCountry Code
07L2010BA_N407_CNTRY_SUBDV_CDStringCountry Subdivision Code
L2010BADMGSubscriber Demographic Information
02L2010BA_DMG02_SBR_DOB_D8Date/TimeSubscriber Birth Date
03L2010BA_DMG03_SUB_GENDR_CDStringSubscriber Gender Code
L2010BAREFSubscriber Secondary Identification
02L2010BA_REF_SSNStringSocial Security Number
L2010BAREFProperty and Casualty Claim Number
02L2010BA_REF_AGNCY_CLM_NRStringAgency Claim Number
L2010BAPERProperty and Casualty Subscriber Contact Information
02L2010BA_PER02_NMStringName
04L2010BA_PER04_COMM_NRStringCommunication Number
06L2010BA_PER06_COMM_NRStringCommunication Number
L2010BB - PAYER NAME
L2010BBNM1Payer Name
03L2010BB_NM103_PYR_NMStringPayer Name
09L2010BB_NM109_PAYR_IDStringPayor Identification
09L2010BB_NM109_HCFA_PLAN_IDStringCenters for Medicare and Medicaid Services PlanID
L2010BBN3Payer Address
01L2010BB_N301_PYR_ADDR_LNStringPayer Address Line
02L2010BB_N302_PYR_ADDR_LNStringPayer Address Line
L2010BBN4Payer City, State, ZIP Code
01L2010BB_N401_PYR_CITY_NMStringPayer City Name
02L2010BB_N402_PYR_STATStringPayer State or Province Code
03L2010BB_N403_PYR_ZIPStringPayer Postal Zone or ZIP Code
04L2010BB_N404_CNTRY_CDStringCountry Code
07L2010BB_N407_CNTRY_SUBDV_CDStringCountry Subdivision Code
L2010BBREFPayer Secondary Identification Iterated: [01-03]
02L2010BB_nnREF_PYR_IDStringPayer Identification Number
02L2010BB_nnREF_EMPLR_ID_NRStringEmployer?s Identification Number
02L2010BB_nnREF_CLM_OFC_NRStringClaim Office Number
02L2010BB_nnREF_NAICStringNational Association of Insurance Commissioners (NAIC) Code
L2010BBREFBilling Provider Secondary Identification
02L2010BB_REF_PVR_COMM_NRStringProvider Commercial Number
02L2010BB_REF_LOC_NRStringLocation Number
L2000C - PATIENT HIERARCHICAL LEVEL
L2000CHLPatient Hierarchical Level
01L2000C_HL01_HIER_ID_NRStringHierarchical ID Number
02L2000C_HL02_HIER_PARNT_ID_NRStringHierarchical Parent ID Number
L2000CPATPatient Information
01L2000C_PAT01_IND_RELAT_CDStringIndividual Relationship Code
06L2000C_PAT06_PT_DEATH_D8Date/TimePatient Death Date
08L2000C_PAT08_PT_WGTDecimalPatient Weight
09L2000C_PAT09_PREG_INDStringPregnancy Indicator
L2010CA - PATIENT NAME
L2010CANM1Patient Name
03L2010CA_NM103_PT_LNMStringPatient Last Name
04L2010CA_NM104_PT_FNMStringPatient First Name
05L2010CA_NM105_PT_MNMStringPatient Middle Name or Initial
07L2010CA_NM107_PT_SFXStringPatient Name Suffix
L2010CAN3Patient Address
01L2010CA_N301_PT_ADDRStringPatient Address Line
02L2010CA_N302_PT_ADDRStringPatient Address Line
L2010CAN4Patient City, State, ZIP Code
01L2010CA_N401_PT_CITYStringPatient City Name
02L2010CA_N402_PT_STATStringPatient State Code
03L2010CA_N403_PT_ZIPStringPatient Postal Zone or ZIP Code
04L2010CA_N404_CNTRY_CDStringCountry Code
07L2010CA_N407_CNTRY_SUBDV_CDStringCountry Subdivision Code
L2010CADMGPatient Demographic Information
02L2010CA_DMG02_PT_DOB_D8Date/TimePatient Birth Date
03L2010CA_DMG03_PAT_GNDR_CDStringPatient Gender Code
L2010CAREFProperty and Casualty Claim Number
02L2010CA_REF_AGNCY_CLM_NRStringAgency Claim Number
L2010CAPERProperty and Casualty Patient Contact Information
02L2010CA_PER02_NMStringName
04L2010CA_PER04_COMM_NRStringCommunication Number
06L2010CA_PER06_COMM_NRStringCommunication Number
L2300 - CLAIM INFORMATION
L2300CLMClaim Information
01L2300_CLM01_PT_CTL_NRStringPatient Control Number
02L2300_CLM02_TOT_CLM_CHG_AMTDecimalTotal Claim Charge Amount
0501L2300_CLM0501_POS_CDStringPlace of Service Code
0503L2300_CLM0503_CLM_FREQ_CDStringClaim Frequency Code
06L2300_CLM06_PVD_SUPP_SIG_INDStringProvider or Supplier Signature Indicator
07L2300_CLM07_PLAN_PART_CDStringAssignment or Plan Participation Code
08L2300_CLM08_BEN_ASGT_CRT_INDStringBenefits Assignment Certification Indicator
09L2300_CLM09_RELS_NFO_CDStringRelease of Information Code
10L2300_CLM10_PAT_SIG_SRC_CDStringPatient Signature Source Code
1101L2300_CLM1101_RELTD_CAUS_CDStringRelated Causes Code
1102L2300_CLM1102_RELTD_CAUS_CDStringRelated Causes Code
1104L2300_CLM1104_AUTO_ACC_STATStringAuto Accident State or Province Code
1105L2300_CLM1105_CNTRY_CDStringCountry Code
12L2300_CLM12_SPC_PRG_INDStringSpecial Program Indicator
20L2300_CLM20_DELAY_RSN_CDStringDelay Reason Code
L2300DTPDate - Onset of Current Illness or Symptom
03L2300_DTP_ONST_CURR_SYMPTM_D8Start DateOnset of Current Symptoms or Illness (D8)
L2300DTPDate - Initial Treatment Date
03L2300_DTP_INIT_TRTMT_D8Start DateInitial Treatment (D8)
L2300DTPDate - Last Seen Date
03L2300_DTP_LAST_VST_D8Start DateLatest Visit or Consultation (D8)
L2300DTPDate - Acute Manifestation
03L2300_DTP_ACUTE_D8Start DateAcute Manifestation of a Chronic Condition (D8)
L2300DTPDate - Accident
03L2300_DTP_ACCDNT_D8Start DateAccident (D8)
L2300DTPDate - Last Menstrual Period
03L2300_DTP_MENS_PERD_D8Start DateLast Menstrual Period (D8)
L2300DTPDate - Last X-ray Date
03L2300_DTP_XRAY_D8Start DateLast X-Ray (D8)
L2300DTPDate - Hearing and Vision Prescription Date
03L2300_DTP_RX_D8Start DatePrescription (D8)
L2300DTPDate - Disability Dates
03L2300_DTP_DISBLTY_D8Start DateDisability (D8)
03L2300_DTP_DISBLTY_RD8_1Start DateDisability (D8)
03L2300_DTP_DISBLTY_RD8_2End DateDisability (D8)
03L2300_DTP_DIS_BGN_D8Start DateInitial Disability Period Start (D8)
03L2300_DTP_DIS_BGN_RD8_1Start DateInitial Disability Period Start (D8)
03L2300_DTP_DIS_BGN_RD8_2End DateInitial Disability Period Start (D8)
03L2300_DTP_DIS_END_D8Start DateInitial Disability Period End (D8)
03L2300_DTP_DIS_END_RD8_1Start DateInitial Disability Period End (D8)
03L2300_DTP_DIS_END_RD8_2End DateInitial Disability Period End (D8)
L2300DTPDate - Last Worked
03L2300_DTP_LST_WRK_D8Start DateInitial Disability Period Last Day Worked (D8)
L2300DTPDate - Authorized Return to Work
03L2300_DTP_DIS_RET_WRK_D8Start DateInitial Disability Period Return To Work (D8)
L2300DTPDate - Admission
03L2300_DTP_ADMSN_D8Start DateAdmission (D8)
L2300DTPDate - Discharge
03L2300_DTP_DISCHG_D8Start DateDischarge (D8)
L2300DTPDate - Assumed and Relinquished Care Dates
03L2300_DTP_RPT_STRT_D8Start DateReport Start (D8)
03L2300_DTP_RPT_END_D8Start DateReport End (D8)
L2300DTPDate - Property and Casualty Date of First Contact
03L2300_DTP_1ST_VST_D8Start DateFirst Visit or Consultation (D8)
L2300DTPDate - Repricer Received Date
03L2300_DTP_RCVD_D8Start DateReceived (D8)
L2300PWKClaim Supplemental Information Iterated: [01-10]
01L2300_nnPWK01_ATT_REP_TYP_CDStringAttachment Report Type Code
02L2300_nnPWK02_ATT_TRANS_CDStringAttachment Transmission Code
06L2300_nnPWK06_ATTACH_CTL_NRStringAttachment Control Number
L2300CN1Contract Information
01L2300_CN101_CNTRCT_TYP_CDStringContract Type Code
02L2300_CN102_CONTRCT_AMTDecimalContract Amount
03L2300_CN103_CONTRCT_PERCDecimalContract Percentage
04L2300_CN104_CONTRCT_CDStringContract Code
05L2300_CN105_TERMS_DISCT_PERCDecimalTerms Discount Percentage
06L2300_CN106_CONTRCT_VERS_IDStringContract Version Identifier
L2300AMTPatient Amount Paid
02L2300_AMT02_PT_AMT_PDDate TimestampPatient Amount Paid
L2300REFService Authorization Exception Code
02L2300_REF_SP_PMT_REF_NRStringSpecial Payment Reference Number
L2300REFMandatory Medicare (Section 4081) Crossover Indicator
02L2300_REF_MDCR_VRS_CDStringMedicare Version Code
L2300REFMammography Certification Number
02L2300_REF_MAMM_CERTStringMammography Certification Number
L2300REFReferral Number
02L2300_REF_REFRL_NRStringReferral Number
L2300REFPrior Authorization
02L2300_REF_PRIOR_AUTHStringPrior Authorization Number
L2300REFPayer Claim Control Number
02L2300_REF_ORIG_REF_NRStringOriginal Reference Number
L2300REFClinical Laboratory Improvement Amendment (CLIA) Number
02L2300_REF_LAB_IMP_AMDStringClinical Laboratory Improvement Amendment Number
L2300REFRepriced Claim Number
02L2300_REF_REP_CLM_IDStringRepriced Claim Reference Number
L2300REFAdjusted Repriced Claim Number
02L2300_REF_ADJ_REP_CLM_IDStringAdjusted Repriced Claim Reference Number
L2300REFInvestigational Device Exemption Number
02L2300_REF_QUAL_PRD_LSTStringQualified Products List
L2300REFClaim Identifier For Transmission Intermediaries
02L2300_REF_CLM_NRStringClaim Number
L2300REFMedical Record Number
02L2300_REF_MED_REC_IDStringMedical Record Identification Number
L2300REFDemonstration Project Identifier
02L2300_REF_PROJCT_CDStringProject Code
L2300REFCare Plan Oversight
02L2300_REF_FAC_IDStringFacility ID Number
L2300K3File Information Iterated: [01-10]
01L2300_nnK301_FIXD_FMT_NFOStringFixed Format Information
L2300NTEClaim Note
02L2300_NTE02_ADDL_NFOStringAdditional Information
02L2300_NTE02_CERT_NARRStringCertification Narrative
02L2300_NTE02_GOALS_DISCHG_PLNStringGoals, Rehabilitation Potential, or Discharge Plans
02L2300_NTE02_DIAG_DESCStringDiagnosis Description
02L2300_NTE02_TPO_NOTEStringThird Party Organization Notes
L2300CR1Ambulance Transport Information
02L2300_CR102_PT_WGTDecimalPatient Weight
04L2300_CR104_AMB_TRANS_RSN_CDStringAmbulance Transport Reason Code
06L2300_CR106_TRANSPT_DISTDecimalTransport Distance
09L2300_CR109_RNDTRP_PRPS_DESCStringRound Trip Purpose Description
10L2300_CR110_STRTCHR_PURP_DESCStringStretcher Purpose Description
L2300CR2Spinal Manipulation Service Information
08L2300_CR208_PAT_COND_CDStringPatient Condition Code
10L2300_CR210_PT_COND_DESCStringPatient Condition Description
11L2300_CR211_PT_COND_DESCStringPatient Condition Description
L2300CRCAmbulance Certification Segment Suffix:
Iterated: [01-03]
02L2300_nnCRCA02_CERT_COND_INDStringCertification Condition Indicator
03L2300_nnCRCA03_CONDTN_CDStringCondition Code
04L2300_nnCRCA04_CONDTN_CDStringCondition Code
05L2300_nnCRCA05_CONDTN_CDStringCondition Code
06L2300_nnCRCA06_CONDTN_CDStringCondition Code
07L2300_nnCRCA07_CONDTN_CDStringCondition Code
L2300CRCPatient Condition Information: Vision Segment Suffix:
Iterated: [01-03]
01L2300_nnCRCB01_CD_CATStringCode Category
02L2300_nnCRCB02_CERT_COND_INDStringCertification Condition Indicator
03L2300_nnCRCB03_CONDTN_CDStringCondition Code
04L2300_nnCRCB04_CONDTN_CDStringCondition Code
05L2300_nnCRCB05_CONDTN_CDStringCondition Code
06L2300_nnCRCB06_CONDTN_CDStringCondition Code
07L2300_nnCRCB07_CONDTN_CDStringCondition Code
L2300CRCHomebound Indicator Segment Suffix:
03L2300_CRCC03_HOMBND_INDStringHomebound Indicator
L2300CRCEPSDT Referral Segment Suffix:
02L2300_CRCD02_CERT_COND_CD_INDStringCertification Condition Code Applies Indicator
03L2300_CRCD03_CONDTN_INDStringCondition Indicator
04L2300_CRCD04_CONDTN_INDStringCondition Indicator
05L2300_CRCD05_CONDTN_INDStringCondition Indicator
L2300HIHealth Care Diagnosis Code
0102L2300_HI0102_ICD10_PRIN_DIAGStringInternational Classification of Diseases Clinical Modification (ICD-10-CM) Principal Diagnosis
0102L2300_HI0102_ICD9_PRIN_DIAGStringInternational Classification of Diseases Clinical Modification (ICD-9-CM) Principal Diagnosis
0202L2300_HI0202_ICD10_DIAGStringInternational Classification of Diseases Clinical Modification (ICD-10-CM) Diagnosis
0202L2300_HI0202_ICD9_DIAGStringInternational Classification of Diseases Clinical Modification (ICD-9-CM) Diagnosis
0302L2300_HI0302_ICD10_DIAGStringInternational Classification of Diseases Clinical Modification (ICD-10-CM) Diagnosis
0302L2300_HI0302_ICD9_DIAGStringInternational Classification of Diseases Clinical Modification (ICD-9-CM) Diagnosis
0402L2300_HI0402_ICD10_DIAGStringInternational Classification of Diseases Clinical Modification (ICD-10-CM) Diagnosis
0402L2300_HI0402_ICD9_DIAGStringInternational Classification of Diseases Clinical Modification (ICD-9-CM) Diagnosis
0502L2300_HI0502_ICD10_DIAGStringInternational Classification of Diseases Clinical Modification (ICD-10-CM) Diagnosis
0502L2300_HI0502_ICD9_DIAGStringInternational Classification of Diseases Clinical Modification (ICD-9-CM) Diagnosis
0602L2300_HI0602_ICD10_DIAGStringInternational Classification of Diseases Clinical Modification (ICD-10-CM) Diagnosis
0602L2300_HI0602_ICD9_DIAGStringInternational Classification of Diseases Clinical Modification (ICD-9-CM) Diagnosis
0702L2300_HI0702_ICD10_DIAGStringInternational Classification of Diseases Clinical Modification (ICD-10-CM) Diagnosis
0702L2300_HI0702_ICD9_DIAGStringInternational Classification of Diseases Clinical Modification (ICD-9-CM) Diagnosis
0802L2300_HI0802_ICD10_DIAGStringInternational Classification of Diseases Clinical Modification (ICD-10-CM) Diagnosis
0802L2300_HI0802_ICD9_DIAGStringInternational Classification of Diseases Clinical Modification (ICD-9-CM) Diagnosis
0902L2300_HI0902_ICD10_DIAGStringInternational Classification of Diseases Clinical Modification (ICD-10-CM) Diagnosis
0902L2300_HI0902_ICD9_DIAGStringInternational Classification of Diseases Clinical Modification (ICD-9-CM) Diagnosis
1002L2300_HI1002_ICD10_DIAGStringInternational Classification of Diseases Clinical Modification (ICD-10-CM) Diagnosis
1002L2300_HI1002_ICD9_DIAGStringInternational Classification of Diseases Clinical Modification (ICD-9-CM) Diagnosis
1102L2300_HI1102_ICD10_DIAGStringInternational Classification of Diseases Clinical Modification (ICD-10-CM) Diagnosis
1102L2300_HI1102_ICD9_DIAGStringInternational Classification of Diseases Clinical Modification (ICD-9-CM) Diagnosis
1202L2300_HI1202_ICD10_DIAGStringInternational Classification of Diseases Clinical Modification (ICD-10-CM) Diagnosis
1202L2300_HI1202_ICD9_DIAGStringInternational Classification of Diseases Clinical Modification (ICD-9-CM) Diagnosis
L2300HIAnesthesia Related Procedure
0102L2300_HI0102_HCPCS_CDStringHealth Care Financing Administration Common
0202L2300_HI0202_HCPCS_CDStringHealth Care Financing Administration Common Procedural Coding System
L2300HICondition Information Iterated: [01-02]
0102L2300_nnHI0102_CONDStringCondition
0202L2300_nnHI0202_CONDStringCondition
0302L2300_nnHI0302_CONDStringCondition
0402L2300_nnHI0402_CONDStringCondition
0502L2300_nnHI0502_CONDStringCondition
0602L2300_nnHI0602_CONDStringCondition
0702L2300_nnHI0702_CONDStringCondition
0802L2300_nnHI0802_CONDStringCondition
0902L2300_nnHI0902_CONDStringCondition
1002L2300_nnHI1002_CONDStringCondition
1102L2300_nnHI1102_CONDStringCondition
1202L2300_nnHI1202_CONDStringCondition
L2300HCPClaim Pricing/Repricing Information
01L2300_HCP01_PRIC_METHDStringPricing Methodology
02L2300_HCP02_REPRCD_ALLWD_AMTDecimalRepriced Allowed Amount
03L2300_HCP03_REPRCD_SAVNG_AMTDecimalRepriced Saving Amount
04L2300_HCP04_REPRCNG_ORG_IDStringRepricing Organization Identifier
05L2300_HCP05_REPRCD_PERDIEM_AMTDecimalRepricing Per Diem or Flat Rate Amount
06L2300_HCP06_REP_AMB_PT_GRPStringRepriced Approved Ambulatory Patient Group
07L2300_HCP07_REP_AMB_PT_GRPDecimalRepriced Approved Ambulatory Patient Group
13L2300_HCP13_REJ_RSN_CDStringReject Reason Code
14L2300_HCP14_POLCY_COMP_CDStringPolicy Compliance Code
15L2300_HCP15_EXCPTN_CDStringException Code
L2310A - REFERRING PROVIDER NAME (Value Qualified)
Mapping Prefix: L2310A_DN - Referring Provider
Mapping Prefix: L2310A_P3 - Primary Care Provider
L2310ANM1Referring Provider Name
03L2310A_yy_NM103_REF_PVR_LNMStringReferring Provider Last Name
04L2310A_yy_NM104_REF_PVR_FNMStringReferring Provider First Name
05L2310A_yy_NM105_REF_PVR_MNMStringReferring Provider Middle Name or Initial
07L2310A_yy_NM107_REF_PVR_SFXStringReferring Provider Name Suffix
09L2310A_yy_NM109_REF_PVR_IDStringReferring Provider Identifier
L2310AREFReferring Provider Secondary Identification
02L2310A_yy_REF_STAT_LIC_NRStringState License Number
02L2310A_yy_REF_UPINStringProvider UPIN Number
02L2310A_yy_REF_PVR_COMM_NRStringProvider Commercial Number
L2310B - RENDERING PROVIDER NAME
L2310BNM1Rendering Provider Name
03L2310B_NM103_PERSN_LNMStringPerson Last Name
03L2310B_NM103_NONPSNENT_NMStringNon-Person Entity Name
04L2310B_NM104_REND_PVR_FNMStringRendering Provider First Name
05L2310B_NM105_REND_PVR_MNMStringRendering Provider Middle Name or Initial
07L2310B_NM107_REND_PROV_SFXStringRendering Provider Name Suffix
09L2310B_NM109_REND_PROV_IDStringRendering Provider Identifier
L2310BPRVRendering Provider Specialty Information
03L2310B_PRV03_PVR_TAX_CDStringProvider Taxonomy Code
L2310BREFRendering Provider Secondary Identification
02L2310B_REF_STAT_LIC_NRStringState License Number
02L2310B_REF_UPINStringProvider UPIN Number
02L2310B_REF_PVR_COMM_NRStringProvider Commercial Number
02L2310B_REF_LOC_NRStringLocation Number
L2310C - SERVICE FACILITY LOCATION NAME
L2310CNM1Service Facility Location Name
03L2310C_NM103_LAB_FAC_NMStringLaboratory or Facility Name
09L2310C_NM109_LAB_FAC_PRI_IDStringLaboratory or Facility Primary Identifier
L2310CN3Service Facility Location Address
01L2310C_N301_LAB_FAC_ADDRStringLaboratory or Facility Address Line
02L2310C_N302_LAB_FAC_ADDRStringLaboratory or Facility Address Line
L2310CN4Service Facility Location City, State, ZIP Code
01L2310C_N401_LAB_FAC_CITYStringLaboratory or Facility City Name
02L2310C_N402_LAB_FAC_STATStringLaboratory or Facility State or Province Code
03L2310C_N403_LAB_ZIPStringLaboratory or Facility Postal Zone or ZIP Code
04L2310C_N404_CNTRY_CDStringCountry Code
07L2310C_N407_CNTRY_SUBDV_CDStringCountry Subdivision Code
L2310CREFService Facility Location Secondary Identification
02L2310C_REF_STAT_LIC_NRStringState License Number
02L2310C_REF_PVR_COMM_NRStringProvider Commercial Number
02L2310C_REF_LOC_NRStringLocation Number
L2310CPERService Facility Contact Information
02L2310C_PER02_NMStringName
04L2310C_PER04_COMM_NRStringCommunication Number
06L2310C_PER06_COMM_NRStringCommunication Number
L2310D - SUPERVISING PROVIDER NAME
L2310DNM1Supervising Provider Name
03L2310D_NM103_SUP_PVR_LNMStringSupervising Provider Last Name
04L2310D_NM104_SUP_PVR_FNMStringSupervising Provider First Name
05L2310D_NM105_SUP_PVR_MNMStringSupervising Provider Middle Name or Initial
07L2310D_NM107_SUP_PVR_SFXStringSupervising Provider Name Suffix
09L2310D_NM109_SUP_PVR_IDStringSupervising Provider Identifier
L2310DREFSupervising Provider Secondary Identification
02L2310D_REF_STAT_LIC_NRStringState License Number
02L2310D_REF_UPINStringProvider UPIN Number
02L2310D_REF_PVR_COMM_NRStringProvider Commercial Number
02L2310D_REF_LOC_NRStringLocation Number
L2310E - AMBULANCE PICK-UP LOCATION
L2310ENM1Ambulance Pick-up Location
L2310EN3Ambulance Pick-up Location Address
01L2310E_N301_AMB_PU_ADDRStringAmbulance Pick-up Address Line
02L2310E_N302_AMB_PU_ADDRStringAmbulance Pick-up Address Line
L2310EN4Ambulance Pick-up Location City, State, ZIP Code
01L2310E_N401_AMB_PCKUP_CITYStringAmbulance Pick-up City Name
02L2310E_N402_AMB_PKUP_STATStringAmbulance Pick-up State or Province Code
03L2310E_N403_AMB_PCKUP_ZIPStringAmbulance Pick-up Postal Zone or ZIP Code
04L2310E_N404_CNTRY_CDStringCountry Code
07L2310E_N407_CNTRY_SUBDV_CDStringCountry Subdivision Code
L2310F - AMBULANCE DROP-OFF LOCATION
L2310FNM1Ambulance Drop-off Location
03L2310F_NM103_AMB_DROPOFF_LOCStringAmbulance Drop-off Location
L2310FN3Ambulance Drop-off Location Address
01L2310F_N301_AMB_DROPOFF_ADDRStringAmbulance Drop-off Address Line
02L2310F_N302_AMB_DROPOFF_ADDRStringAmbulance Drop-off Address Line
L2310FN4Ambulance Drop-off Location City, State, ZIP Code
01L2310F_N401_AMB_DRPOFF_CITYStringAmbulance Drop-off City Name
02L2310F_N402_AMB_DRPOFF_STATStringAmbulance Drop-off State or Province Code
03L2310F_N403_AMB_DROPOFF_ZIPStringAmbulance Drop-off Postal Zone or ZIP Code
04L2310F_N404_CNTRY_CDStringCountry Code
07L2310F_N407_CNTRY_SUBDV_CDStringCountry Subdivision Code
L2320 - OTHER SUBSCRIBER INFORMATION (Single Iteration)
L2320SBROther Subscriber Information
01L2320_xx_SBR01_PYR_RESP_SEQ_NRStringPayer Responsibility Sequence Number Code
02L2320_xx_SBR02_IND_RELAT_CDStringIndividual Relationship Code
03L2320_xx_SBR03_INS_GRP_PLCY_NRStringInsured Group or Policy Number
04L2320_xx_SBR04_OINS_GRP_NMStringOther Insured Group Name
05L2320_xx_SBR05_INS_TYP_CDStringInsurance Type Code
09L2320_xx_SBR09_CLM_FIL_IND_CDStringClaim Filing Indicator Code
L2320CASClaim Level Adjustments Iterated: [01-05]
01L2320_xx_nnCAS01_CLMADJ_GRP_CDStringClaim Adjustment Group Code
02L2320_xx_nnCAS02_ADJ_RSN_CDStringAdjustment Reason Code
03L2320_xx_nnCAS03_ADJ_AMTDecimalAdjustment Amount
04L2320_xx_nnCAS04_ADJ_QTYDecimalAdjustment Quantity
05L2320_xx_nnCAS05_ADJ_RSN_CDStringAdjustment Reason Code
06L2320_xx_nnCAS06_ADJ_AMTDecimalAdjustment Amount
07L2320_xx_nnCAS07_ADJ_QTYDecimalAdjustment Quantity
08L2320_xx_nnCAS08_ADJ_RSN_CDStringAdjustment Reason Code
09L2320_xx_nnCAS09_ADJ_AMTDecimalAdjustment Amount
10L2320_xx_nnCAS10_ADJ_QTYDecimalAdjustment Quantity
11L2320_xx_nnCAS11_ADJ_RSN_CDStringAdjustment Reason Code
12L2320_xx_nnCAS12_ADJ_AMTDecimalAdjustment Amount
13L2320_xx_nnCAS13_ADJ_QTYDecimalAdjustment Quantity
14L2320_xx_nnCAS14_ADJ_RSN_CDStringAdjustment Reason Code
15L2320_xx_nnCAS15_ADJ_AMTDecimalAdjustment Amount
16L2320_xx_nnCAS16_ADJ_QTYDecimalAdjustment Quantity
17L2320_xx_nnCAS17_ADJ_RSN_CDStringAdjustment Reason Code
18L2320_xx_nnCAS18_ADJ_AMTDecimalAdjustment Amount
19L2320_xx_nnCAS19_ADJ_QTYDecimalAdjustment Quantity
L2320AMTCoordination of Benefits (COB) Payer Paid Amount
02L2320_xx_AMT02_PAYR_AMT_PDDate TimestampPayor Amount Paid
L2320AMTCoordination of Benefits (COB) Total Non-Covered Amount
02L2320_xx_AMT02_NONCVD_CHG_ACTLDate TimestampNoncovered Charges - Actual
L2320AMTRemaining Patient Liability
02L2320_xx_AMT02_AMT_OWEDDate TimestampAmount Owed
L2320OIOther Insurance Coverage Information
03L2320_xx_OI03_BEN_ASGT_CRT_INDStringBenefits Assignment Certification Indicator
04L2320_xx_OI04_PAT_SIG_SRC_CDStringPatient Signature Source Code
06L2320_xx_OI06_RELS_NFO_CDStringRelease of Information Code
L2320MOAOutpatient Adjudication Information
01L2320_xx_MOA01_REIMBRSMT_RTDecimalReimbursement Rate
02L2320_xx_MOA02_HCPCS_PAYBL_AMTDecimalHCPCS Payable Amount
03L2320_xx_MOA03_CLM_PMT_RMK_CDStringClaim Payment Remark Code
04L2320_xx_MOA04_CLM_PMT_RMK_CDStringClaim Payment Remark Code
05L2320_xx_MOA05_CLM_PMT_RMK_CDStringClaim Payment Remark Code
06L2320_xx_MOA06_CLM_PMT_RMK_CDStringClaim Payment Remark Code
07L2320_xx_MOA07_CLM_PMT_RMK_CDStringClaim Payment Remark Code
08L2320_xx_MOA08_ESRD_PMT_AMTDecimalEnd Stage Renal Disease Payment Amount
09L2320_xx_MOA09_NONPAY_PROF_BLLStringNon-Payable Professional Component Billed
L2330A - OTHER SUBSCRIBER NAME (Inherited Loop Iteration)
L2330ANM1Other Subscriber Name
03L2330A_xx_NM103_PERSN_LNMStringPerson Last Name
03L2330A_xx_NM103_NONPSNENT_NMStringNon-Person Entity Name
04L2330A_xx_NM104_OINS_FNMStringOther Insured First Name
05L2330A_xx_NM105_OINS_MNMStringOther Insured Middle Name
07L2330A_xx_NM107_OINS_SFXStringOther Insured Name Suffix
09L2330A_xx_NM109_UNQ_HLTH_IDStringStandard Unique Health Identifier for each Individual in the United States
09L2330A_xx_NM109_MEM_ID_NRStringMember Identification Number
L2330AN3Other Subscriber Address
01L2330A_xx_N301_OSBR_ADDRStringOther Subscriber Address Line
02L2330A_xx_N302_OINS_ADDRStringOther Insured Address Line
L2330AN4Other Subscriber City, State, ZIP Code
01L2330A_xx_N401_OSBR_CITYStringOther Subscriber City Name
02L2330A_xx_N402_OSBR_STATStringOther Subscriber State or Province Code
03L2330A_xx_N403_OSBR_ZIPStringOther Subscriber Postal Zone or ZIP Code
04L2330A_xx_N404_CNTRY_CDStringCountry Code
07L2330A_xx_N407_CNTRY_SUBDV_CDStringCountry Subdivision Code
L2330AREFOther Subscriber Secondary Identification
02L2330A_xx_REF_SSNStringSocial Security Number
L2330B - OTHER PAYER NAME (Inherited Loop Iteration)
L2330BNM1Other Payer Name
03L2330B_xx_NM103_OPYR_ORG_NMStringOther Payer Organization Name
09L2330B_xx_NM109_PAYR_IDStringPayor Identification
09L2330B_xx_NM109_HCFA_PLAN_IDStringCenters for Medicare and Medicaid Services PlanID
L2330BN3Other Payer Address
01L2330B_xx_N301_OPYR_ADDRStringOther Payer Address Line
02L2330B_xx_N302_OPYR_ADDRStringOther Payer Address Line
L2330BN4Other Payer City, State, ZIP Code
01L2330B_xx_N401_OPYR_CITY_NMStringOther Payer City Name
02L2330B_xx_N402_OPYR_STATStringOther Payer State or Province Code
03L2330B_xx_N403_OPYR_POSTL_ZIPStringOther Payer Postal Zone or ZIP Code
04L2330B_xx_N404_CNTRY_CDStringCountry Code
07L2330B_xx_N407_CNTRY_SUBDV_CDStringCountry Subdivision Code
L2330BDTPClaim Check or Remittance Date
03L2330B_xx_DTP_CLM_PD_D8Start DateDate Claim Paid (D8)
L2330BREFOther Payer Secondary Identifier Iterated: [01-02]
02L2330B_xx_nnREF_PYR_IDStringPayer Identification Number
02L2330B_xx_nnREF_EMPLR_ID_NRStringEmployer?s Identification Number
02L2330B_xx_nnREF_CLM_OFC_NRStringClaim Office Number
02L2330B_xx_nnREF_NAICStringNational Association of Insurance Commissioners (NAIC) Code
L2330BREFOther Payer Prior Authorization Number
02L2330B_xx_REF_PRIOR_AUTHStringPrior Authorization Number
L2330BREFOther Payer Referral Number
02L2330B_xx_REF_REFRL_NRStringReferral Number
L2330BREFOther Payer Claim Adjustment Indicator
02L2330B_xx_REF_SIGNL_CDStringSignal Code
L2330BREFOther Payer Claim Control Number
02L2330B_xx_REF_ORIG_REF_NRStringOriginal Reference Number
L2330C - OTHER PAYER REFERRING PROVIDER (Inherited Loop Iteration & Value Qualified)
Mapping Prefix: L2330C_xxDN - Referring Provider
Mapping Prefix: L2330C_xxP3 - Primary Care Provider
L2330CNM1Other Payer Referring Provider
L2330CREFOther Payer Referring Provider Secondary Identification
02L2330C_xxyy_REF_STAT_LIC_NRStringState License Number
02L2330C_xxyy_REF_UPINStringProvider UPIN Number
02L2330C_xxyy_REF_PVR_COMM_NRStringProvider Commercial Number
L2330D - OTHER PAYER RENDERING PROVIDER (Inherited Loop Iteration)
L2330DNM1Other Payer Rendering Provider
02L2330D_xx_NM102_ENT_TYP_QUALStringEntity Type Qualifier
L2330DREFOther Payer Rendering Provider Secondary Identification Iterated: [01-03]
02L2330D_xx_nnREF_STAT_LIC_NRStringState License Number
02L2330D_xx_nnREF_UPINStringProvider UPIN Number
02L2330D_xx_nnREF_PVR_COMM_NRStringProvider Commercial Number
02L2330D_xx_nnREF_LOC_NRStringLocation Number
L2330E - OTHER PAYER SERVICE FACILITY LOCATION (Inherited Loop Iteration)
L2330ENM1Other Payer Service Facility Location
L2330EREFOther Payer Service Facility Location Secondary Identification
02L2330E_xx_REF_STAT_LIC_NRStringState License Number
02L2330E_xx_REF_PVR_COMM_NRStringProvider Commercial Number
02L2330E_xx_REF_LOC_NRStringLocation Number
L2330F - OTHER PAYER SUPERVISING PROVIDER (Inherited Loop Iteration)
L2330FNM1Other Payer Supervising Provider
L2330FREFOther Payer Supervising Provider Secondary Identification Iterated: [01-03]
02L2330F_xx_nnREF_STAT_LIC_NRStringState License Number
02L2330F_xx_nnREF_UPINStringProvider UPIN Number
02L2330F_xx_nnREF_PVR_COMM_NRStringProvider Commercial Number
02L2330F_xx_nnREF_LOC_NRStringLocation Number
L2330G - OTHER PAYER BILLING PROVIDER (Inherited Loop Iteration)
L2330GNM1Other Payer Billing Provider
02L2330G_xx_NM102_ENT_TYP_QUALStringEntity Type Qualifier
L2330GREFOther Payer Billing Provider Secondary Identification
02L2330G_xx_REF_PVR_COMM_NRStringProvider Commercial Number
02L2330G_xx_REF_LOC_NRStringLocation Number
L2400 - SERVICE LINE NUMBER
L2400LXService Line Number
01L2400_LX01_ASSGD_NRIntegerAssigned Number
L2400SV1Professional Service
0102L2400_SV10102_JS_PRC_SPY_CDStringJurisdiction Specific Procedure and Supply Codes
0102L2400_SV10102_HCPCS_CDStringHealth Care Financing Administration Common Procedural Coding System (HCPCS) Codes
0102L2400_SV10102_HIC_PRD_SVCCDStringHome Infusion EDI Coalition (HIEC) Product/Service Code
0102L2400_SV10102_ABC_CDStringAdvanced Billing Concepts (ABC) Codes
0103L2400_SV10103_PROC_MODStringProcedure Modifier
0104L2400_SV10104_PROC_MODStringProcedure Modifier
0105L2400_SV10105_PROC_MODStringProcedure Modifier
0106L2400_SV10106_PROC_MODStringProcedure Modifier
0107L2400_SV10107_DESCRStringDescription
02L2400_SV102_LIN_ITM_CHG_AMTDecimalLine Item Charge Amount
04L2400_SV104_MINDecimalMinutes
04L2400_SV104_UNDecimalUnit
05L2400_SV105_POS_CDStringPlace of Service Code
0701L2400_SV10701_DIAG_CD_PTRIntegerDiagnosis Code Pointer
0702L2400_SV10702_DIAG_CD_PTRIntegerDiagnosis Code Pointer
0703L2400_SV10703_DIAG_CD_PTRIntegerDiagnosis Code Pointer
0704L2400_SV10704_DIAG_CD_PTRIntegerDiagnosis Code Pointer
09L2400_SV109_EMGNCY_INDStringEmergency Indicator
11L2400_SV111_EPSDT_INDStringEPSDT Indicator
12L2400_SV112_FAM_PLAN_INDStringFamily Planning Indicator
15L2400_SV115_COPAY_STAT_CDStringCo-Pay Status Code
L2400SV5Durable Medical Equipment Service
0102L2400_SV50102_PROC_CDStringProcedure Code
03L2400_SV503_LEN_MED_NECCDecimalLength of Medical Necessity
04L2400_SV504_DME_RENTL_PRICDecimalDME Rental Price
05L2400_SV505_DME_PURCH_PRCDecimalDME Purchase Price
06L2400_SV506_RENTL_PRIC_INDStringRental Unit Price Indicator
L2400PWKLine Supplemental Information Iterated: [01-10]
01L2400_nnPWK01_ATT_REP_TYP_CDStringAttachment Report Type Code
02L2400_nnPWK02_ATT_TRANS_CDStringAttachment Transmission Code
06L2400_nnPWK06_ATTACH_CTL_NRStringAttachment Control Number
L2400PWKDurable Medical Equipment Certificate of Medical Necessity Indicator Segment Suffix:
02L2400_PWKB02_ATT_TRANS_CDStringAttachment Transmission Code
L2400CR1Ambulance Transport Information
02L2400_CR102_PT_WGTDecimalPatient Weight
04L2400_CR104_AMB_TRANS_RSN_CDStringAmbulance Transport Reason Code
06L2400_CR106_TRANSPT_DISTDecimalTransport Distance
09L2400_CR109_RNDTRP_PRPS_DESCStringRound Trip Purpose Description
10L2400_CR110_STRTCHR_PURP_DESCStringStretcher Purpose Description
L2400CR3Durable Medical Equipment Certification
01L2400_CR301_CERT_TYP_CDStringCertification Type Code
03L2400_CR303_DME_DURATNDecimalDurable Medical Equipment Duration
L2400CRCAmbulance Certification Iterated: [01-03]
02L2400_nnCRC02_CERT_COND_INDStringCertification Condition Indicator
03L2400_nnCRC03_CONDTN_CDStringCondition Code
04L2400_nnCRC04_CONDTN_CDStringCondition Code
05L2400_nnCRC05_CONDTN_CDStringCondition Code
06L2400_nnCRC06_CONDTN_CDStringCondition Code
07L2400_nnCRC07_CONDTN_CDStringCondition Code
L2400CRCHospice Employee Indicator Segment Suffix:
02L2400_CRCA02_HOSPC_EMP_PRV_INDStringHospice Employed Provider Indicator
L2400CRCCondition Indicator/Durable Medical Equipment Segment Suffix:
02L2400_CRCB02_CERT_COND_INDStringCertification Condition Indicator
03L2400_CRCB03_CONDTN_INDStringCondition Indicator
04L2400_CRCB04_CONDTN_INDStringCondition Indicator
L2400DTPDate - Service Date
03L2400_DTP_SVC_D8Start DateService (D8)
03L2400_DTP_SVC_RD8_1Start DateService (D8)
03L2400_DTP_SVC_RD8_2End DateService (D8)
L2400DTPDate - Prescription Date
03L2400_DTP_RX_D8Start DatePrescription (D8)
L2400DTPDATE - Certification Revision/Recertification Date
03L2400_DTP_CERT_RVSN_D8Start DateCertification Revision (D8)
L2400DTPDate - Begin Therapy Date
03L2400_DTP_BGN_THRPY_D8Start DateBegin Therapy (D8)
L2400DTPDate - Last Certification Date
03L2400_DTP_LAST_CERT_D8Start DateLast Certification (D8)
L2400DTPDate - Last Seen Date
03L2400_DTP_LAST_VST_D8Start DateLatest Visit or Consultation (D8)
L2400DTPDate - Test Date
03L2400_DTP_HEMOHEMA_D8Start DateMost Recent Hemoglobin or Hematocrit or Both (D8)
03L2400_DTP_CREATINE_D8Start DateMost Recent Serum Creatine (D8)
L2400DTPDate - Shipped Date
03L2400_DTP_SHPD_D8Start DateShipped (D8)
L2400DTPDate - Last X-ray Date
03L2400_DTP_XRAY_D8Start DateLast X-Ray (D8)
L2400DTPDate - Initial Treatment Date
03L2400_DTP_INIT_TRTMT_D8Start DateInitial Treatment (D8)
L2400QTYAmbulance Patient Count
02L2400_QTY02_PATDate TimestampPatients
L2400QTYObstetric Anesthesia Additional Units
02L2400_QTY02_UNDate TimestampUnits
L2400MEATest Result Iterated: [01-05]
01L2400_nnMEA01_MSMT_REF_IDStringMeasurement Reference Identification Code
03L2400_nnMEA03_HGTDecimalHeight
03L2400_nnMEA03_HEMOGLOBDecimalHemoglobin
03L2400_nnMEA03_HEMATOCRITDecimalHematocrit
03L2400_nnMEA03_EPOTN_STRT_DSGDecimalEpoetin Starting Dosage
03L2400_nnMEA03_CREATININEDecimalCreatinine
L2400CN1Contract Information
01L2400_CN101_CNTRCT_TYP_CDStringContract Type Code
02L2400_CN102_CONTRCT_AMTDecimalContract Amount
03L2400_CN103_CONTRCT_PERCDecimalContract Percentage
04L2400_CN104_CONTRCT_CDStringContract Code
05L2400_CN105_TERMS_DISCT_PERCDecimalTerms Discount Percentage
06L2400_CN106_CONTRCT_VERS_IDStringContract Version Identifier
L2400REFRepriced Line Item Reference Number
02L2400_REF_REP_LIN_ITMStringRepriced Line Item Reference Number
L2400REFAdjusted Repriced Line Item Reference Number
02L2400_REF_ADJ_REP_LIN_ITMStringAdjusted Repriced Line Item Reference Number
L2400REFPrior Authorization Iterated: [01-05]
02L2400_nnREF_PRIOR_AUTHStringPrior Authorization Number
0402L2400_nnREF0402_PYR_IDStringPayer Identification Number
L2400REFLine Item Control Number
02L2400_REF_PRV_CTL_NRStringProvider Control Number
L2400REFMammography Certification Number
02L2400_REF_MAMM_CERTStringMammography Certification Number
L2400REFClinical Laboratory Improvement Amendment (CLIA) Number
02L2400_REF_LAB_IMP_AMDStringClinical Laboratory Improvement Amendment Number
L2400REFReferring Clinical Laboratory Improvement Amendment (CLIA) Facility Identification
02L2400_REF_FAC_CERT_IDStringFacility Certification Number
L2400REFImmunization Batch Number
02L2400_REF_BATCH_NRStringBatch Number
L2400REFReferral Number Segment Suffix:
Iterated: [01-05]
02L2400_nnREFB_REFRL_NRStringReferral Number
0402L2400_nnREFB0402_PYR_IDStringPayer Identification Number
L2400AMTSales Tax Amount
02L2400_AMT02_TAXDate TimestampTax
L2400AMTPostage Claimed Amount
02L2400_AMT02_POSTG_CLMDDate TimestampPostage Claimed
L2400K3File Information Iterated: [01-10]
01L2400_nnK301_FIXD_FMT_NFOStringFixed Format Information
L2400NTELine Note
02L2400_NTE02_ADDL_NFOStringAdditional Information
02L2400_NTE02_GOALS_DISCHG_PLNStringGoals, Rehabilitation Potential, or Discharge Plans
L2400NTEThird Party Organization Notes Segment Suffix:
02L2400_NTED02_LIN_NOT_TXTStringLine Note Text
L2400PS1Purchased Service Information
01L2400_PS101_PURCH_SVC_PVR_IDStringPurchased Service Provider Identifier
02L2400_PS102_PURCH_SVC_CHG_AMTDecimalPurchased Service Charge Amount
L2400HCPLine Pricing/Repricing Information
01L2400_HCP01_PRIC_METHDStringPricing Methodology
02L2400_HCP02_REPRCD_ALLWD_AMTDecimalRepriced Allowed Amount
03L2400_HCP03_REPRCD_SAVNG_AMTDecimalRepriced Saving Amount
04L2400_HCP04_REPRCNG_ORG_IDStringRepricing Organization Identifier
05L2400_HCP05_REPRCD_PERDIEM_AMTDecimalRepricing Per Diem or Flat Rate Amount
06L2400_HCP06_REP_AMB_PT_GRPStringRepriced Approved Ambulatory Patient Group
07L2400_HCP07_REP_AMB_PT_GRPDecimalRepriced Approved Ambulatory Patient Group
10L2400_HCP10_JS_PRC_SPY_CDStringJurisdiction Specific Procedure and Supply Codes
10L2400_HCP10_HCPCS_CDStringHealth Care Financing Administration Common Procedural Coding System (HCPCS) Codes
10L2400_HCP10_HIC_PRD_SVCCDStringHome Infusion EDI Coalition (HIEC) Product/Service Code
10L2400_HCP10_ABC_CDStringAdvanced Billing Concepts (ABC) Codes
12L2400_HCP12_MINDecimalMinutes
12L2400_HCP12_UNDecimalUnit
13L2400_HCP13_REJ_RSN_CDStringReject Reason Code
14L2400_HCP14_POLCY_COMP_CDStringPolicy Compliance Code
15L2400_HCP15_EXCPTN_CDStringException Code
L2410 - DRUG IDENTIFICATION
L2410LINDrug Identification
03L2410_LIN03_NDCStringNational Drug Code
L2410CTPDrug Quantity
04L2410_CTP04_NATL_DRG_UNIT_CTDecimalNational Drug Unit Count
0501L2410_CTP0501_CD_QUALStringCode Qualifier
L2410REFPrescription or Compound Drug Association Number
02L2410_REF_LNK_SEQ_NRStringLink Sequence Number
02L2410_REF_PHRM_RX_NRStringPharmacy Prescription Number
L2420A - RENDERING PROVIDER NAME
L2420ANM1Rendering Provider Name
03L2420A_NM103_PERSN_LNMStringPerson Last Name
03L2420A_NM103_NONPSNENT_NMStringNon-Person Entity Name
04L2420A_NM104_REND_PVR_FNMStringRendering Provider First Name
05L2420A_NM105_REND_PVR_MNMStringRendering Provider Middle Name or Initial
07L2420A_NM107_REND_PROV_SFXStringRendering Provider Name Suffix
09L2420A_NM109_REND_PROV_IDStringRendering Provider Identifier
L2420APRVRendering Provider Specialty Information
03L2420A_PRV03_PVR_TAX_CDStringProvider Taxonomy Code
L2420AREFRendering Provider Secondary Identification Iterated: [01-20]
02L2420A_nnREF_STAT_LIC_NRStringState License Number
02L2420A_nnREF_UPINStringProvider UPIN Number
02L2420A_nnREF_PVR_COMM_NRStringProvider Commercial Number
02L2420A_nnREF_LOC_NRStringLocation Number
0402L2420A_nnREF0402_PYR_IDStringPayer Identification Number
L2420B - PURCHASED SERVICE PROVIDER NAME
L2420BNM1Purchased Service Provider Name
02L2420B_NM102_ENT_TYP_QUALStringEntity Type Qualifier
09L2420B_NM109_PURCH_SVC_PVR_IDStringPurchased Service Provider Identifier
L2420BREFPurchased Service Provider Secondary Identification Iterated: [01-20]
02L2420B_nnREF_STAT_LIC_NRStringState License Number
02L2420B_nnREF_UPINStringProvider UPIN Number
02L2420B_nnREF_PVR_COMM_NRStringProvider Commercial Number
0402L2420B_nnREF0402_PYR_IDStringPayer Identification Number
L2420C - SERVICE FACILITY LOCATION NAME
L2420CNM1Service Facility Location Name
03L2420C_NM103_LAB_FAC_NMStringLaboratory or Facility Name
09L2420C_NM109_LAB_FAC_PRI_IDStringLaboratory or Facility Primary Identifier
L2420CN3Service Facility Location Address
01L2420C_N301_LAB_FAC_ADDRStringLaboratory or Facility Address Line
02L2420C_N302_LAB_FAC_ADDRStringLaboratory or Facility Address Line
L2420CN4Service Facility Location City, State, ZIP Code
01L2420C_N401_LAB_FAC_CITYStringLaboratory or Facility City Name
02L2420C_N402_LAB_FAC_STATStringLaboratory or Facility State or Province Code
03L2420C_N403_LAB_ZIPStringLaboratory or Facility Postal Zone or ZIP Code
04L2420C_N404_CNTRY_CDStringCountry Code
07L2420C_N407_CNTRY_SUBDV_CDStringCountry Subdivision Code
L2420CREFService Facility Location Secondary Identification Iterated: [01-03]
02L2420C_nnREF_PVR_COMM_NRStringProvider Commercial Number
02L2420C_nnREF_LOC_NRStringLocation Number
02L2420C_nnREF_STAT_LIC_NRStringState License Number
02L2420C_nnREF_UPINStringProvider UPIN Number
0402L2420C_nnREF0402_PYR_IDStringPayer Identification Number
L2420D - SUPERVISING PROVIDER NAME
L2420DNM1Supervising Provider Name
03L2420D_NM103_SUP_PVR_LNMStringSupervising Provider Last Name
04L2420D_NM104_SUP_PVR_FNMStringSupervising Provider First Name
05L2420D_NM105_SUP_PVR_MNMStringSupervising Provider Middle Name or Initial
07L2420D_NM107_SUP_PVR_SFXStringSupervising Provider Name Suffix
09L2420D_NM109_SUP_PVR_IDStringSupervising Provider Identifier
L2420DREFSupervising Provider Secondary Identification Iterated: [01-20]
02L2420D_nnREF_STAT_LIC_NRStringState License Number
02L2420D_nnREF_UPINStringProvider UPIN Number
02L2420D_nnREF_PVR_COMM_NRStringProvider Commercial Number
02L2420D_nnREF_LOC_NRStringLocation Number
0402L2420D_nnREF0402_PYR_IDStringPayer Identification Number
L2420E - ORDERING PROVIDER NAME
L2420ENM1Ordering Provider Name
03L2420E_NM103_ORD_PVR_LNMStringOrdering Provider Last Name
04L2420E_NM104_ORD_PVR_FNMStringOrdering Provider First Name
05L2420E_NM105_ORD_PVR_MNMStringOrdering Provider Middle Name or Initial
07L2420E_NM107_ORD_PVR_SFXStringOrdering Provider Name Suffix
09L2420E_NM109_ORD_PVR_IDStringOrdering Provider Identifier
L2420EN3Ordering Provider Address
01L2420E_N301_ORD_PVR_ADDRStringOrdering Provider Address Line
02L2420E_N302_ORD_PVR_ADDRStringOrdering Provider Address Line
L2420EN4Ordering Provider City, State, ZIP Code
01L2420E_N401_ORD_PVR_CITYStringOrdering Provider City Name
02L2420E_N402_ORD_PVR_STATStringOrdering Provider State or Province Code
03L2420E_N403_ORD_PVR_ZIPStringOrdering Provider Postal Zone or ZIP Code
04L2420E_N404_CNTRY_CDStringCountry Code
07L2420E_N407_CNTRY_SUBDV_CDStringCountry Subdivision Code
L2420EREFOrdering Provider Secondary Identification Iterated: [01-20]
02L2420E_nnREF_STAT_LIC_NRStringState License Number
02L2420E_nnREF_UPINStringProvider UPIN Number
02L2420E_nnREF_PVR_COMM_NRStringProvider Commercial Number
0402L2420E_nnREF0402_PYR_IDStringPayer Identification Number
L2420EPEROrdering Provider Contact Information
02L2420E_PER02_ORD_PVR_CON_NMStringOrdering Provider Contact Name
04L2420E_PER04_EMAILStringElectronic Mail
04L2420E_PER04_FAXStringFacsimile
04L2420E_PER04_PHN_NRStringTelephone
06L2420E_PER06_EMAILStringElectronic Mail
06L2420E_PER06_PHN_EXTStringTelephone Extension
06L2420E_PER06_FAXStringFacsimile
06L2420E_PER06_PHN_NRStringTelephone
08L2420E_PER08_EMAILStringElectronic Mail
08L2420E_PER08_PHN_EXTStringTelephone Extension
08L2420E_PER08_FAXStringFacsimile
08L2420E_PER08_PHN_NRStringTelephone
L2420F - REFERRING PROVIDER NAME (Value Qualified)
Mapping Prefix: L2420F_DN - Referring Provider
Mapping Prefix: L2420F_P3 - Primary Care Provider
L2420FNM1Referring Provider Name
03L2420F_yy_NM103_REF_PVR_LNMStringReferring Provider Last Name
04L2420F_yy_NM104_REF_PVR_FNMStringReferring Provider First Name
05L2420F_yy_NM105_REF_PVR_MNMStringReferring Provider Middle Name or Initial
07L2420F_yy_NM107_REF_PVR_SFXStringReferring Provider Name Suffix
09L2420F_yy_NM109_REF_PVR_IDStringReferring Provider Identifier
L2420FREFReferring Provider Secondary Identification Iterated: [01-20]
02L2420F_yy_nnREF_STAT_LIC_NRStringState License Number
02L2420F_yy_nnREF_UPINStringProvider UPIN Number
02L2420F_yy_nnREF_PVR_COMM_NRStringProvider Commercial Number
0402L2420F_yy_nnREF0402_PYR_IDStringPayer Identification Number
L2420G - AMBULANCE PICK-UP LOCATION
L2420GNM1Ambulance Pick-up Location
L2420GN3Ambulance Pick-up Location Address
01L2420G_N301_AMB_PU_ADDRStringAmbulance Pick-up Address Line
02L2420G_N302_AMB_PU_ADDRStringAmbulance Pick-up Address Line
L2420GN4Ambulance Pick-up Location City, State, ZIP Code
01L2420G_N401_AMB_PCKUP_CITYStringAmbulance Pick-up City Name
02L2420G_N402_AMB_PKUP_STATStringAmbulance Pick-up State or Province Code
03L2420G_N403_AMB_PCKUP_ZIPStringAmbulance Pick-up Postal Zone or ZIP Code
04L2420G_N404_CNTRY_CDStringCountry Code
07L2420G_N407_CNTRY_SUBDV_CDStringCountry Subdivision Code
L2420H - AMBULANCE DROP-OFF LOCATION
L2420HNM1Ambulance Drop-off Location
03L2420H_NM103_AMB_DROPOFF_LOCStringAmbulance Drop-off Location
L2420HN3Ambulance Drop-off Location Address
01L2420H_N301_AMB_DROPOFF_ADDRStringAmbulance Drop-off Address Line
02L2420H_N302_AMB_DROPOFF_ADDRStringAmbulance Drop-off Address Line
L2420HN4Ambulance Drop-off Location City, State, ZIP Code
01L2420H_N401_AMB_DRPOFF_CITYStringAmbulance Drop-off City Name
02L2420H_N402_AMB_DRPOFF_STATStringAmbulance Drop-off State or Province Code
03L2420H_N403_AMB_DROPOFF_ZIPStringAmbulance Drop-off Postal Zone or ZIP Code
04L2420H_N404_CNTRY_CDStringCountry Code
07L2420H_N407_CNTRY_SUBDV_CDStringCountry Subdivision Code
L2430 - LINE ADJUDICATION INFORMATION (Single Iteration)
L2430SVDLine Adjudication Information
01L2430_xx_SVD01_OPYR_PRI_IDStringOther Payer Primary Identifier
02L2430_xx_SVD02_SVC_LIN_PD_AMTDecimalService Line Paid Amount
0302L2430_xx_SVD0302_JS_PRC_SPY_CDStringJurisdiction Specific Procedure and Supply Codes
0302L2430_xx_SVD0302_HCPCS_CDStringHealth Care Financing Administration Common Procedural Coding System (HCPCS) Codes
0302L2430_xx_SVD0302_HIC_PRD_SVCCDStringHome Infusion EDI Coalition (HIEC) Product/Service Code
0302L2430_xx_SVD0302_ABC_CDStringAdvanced Billing Concepts (ABC) Codes
0303L2430_xx_SVD0303_PROC_MODStringProcedure Modifier
0304L2430_xx_SVD0304_PROC_MODStringProcedure Modifier
0305L2430_xx_SVD0305_PROC_MODStringProcedure Modifier
0306L2430_xx_SVD0306_PROC_MODStringProcedure Modifier
0307L2430_xx_SVD0307_PROC_CD_DESCStringProcedure Code Description
05L2430_xx_SVD05_PD_SVC_UN_CTDecimalPaid Service Unit Count
06L2430_xx_SVD06_BND_UNBND_LN_NRIntegerBundled or Unbundled Line Number
L2430CASLine Adjustment Iterated: [01-05]
01L2430_xx_nnCAS01_CLMADJ_GRP_CDStringClaim Adjustment Group Code
02L2430_xx_nnCAS02_ADJ_RSN_CDStringAdjustment Reason Code
03L2430_xx_nnCAS03_ADJ_AMTDecimalAdjustment Amount
04L2430_xx_nnCAS04_ADJ_QTYDecimalAdjustment Quantity
05L2430_xx_nnCAS05_ADJ_RSN_CDStringAdjustment Reason Code
06L2430_xx_nnCAS06_ADJ_AMTDecimalAdjustment Amount
07L2430_xx_nnCAS07_ADJ_QTYDecimalAdjustment Quantity
08L2430_xx_nnCAS08_ADJ_RSN_CDStringAdjustment Reason Code
09L2430_xx_nnCAS09_ADJ_AMTDecimalAdjustment Amount
10L2430_xx_nnCAS10_ADJ_QTYDecimalAdjustment Quantity
11L2430_xx_nnCAS11_ADJ_RSN_CDStringAdjustment Reason Code
12L2430_xx_nnCAS12_ADJ_AMTDecimalAdjustment Amount
13L2430_xx_nnCAS13_ADJ_QTYDecimalAdjustment Quantity
14L2430_xx_nnCAS14_ADJ_RSN_CDStringAdjustment Reason Code
15L2430_xx_nnCAS15_ADJ_AMTDecimalAdjustment Amount
16L2430_xx_nnCAS16_ADJ_QTYDecimalAdjustment Quantity
17L2430_xx_nnCAS17_ADJ_RSN_CDStringAdjustment Reason Code
18L2430_xx_nnCAS18_ADJ_AMTDecimalAdjustment Amount
19L2430_xx_nnCAS19_ADJ_QTYDecimalAdjustment Quantity
L2430DTPLine Check or Remittance Date
03L2430_xx_DTP_CLM_PD_D8Start DateDate Claim Paid (D8)
L2430AMTRemaining Patient Liability
02L2430_xx_AMT02_AMT_OWEDDate TimestampAmount Owed
L2440 - FORM IDENTIFICATION CODE
L2440LQForm Identification Code
02L2440_LQ02_FORM_TYP_CDStringForm Type Code
02L2440_LQ02_CMS_DME_REG_CARRStringCenters for Medicare and Medicaid Services (CMS) Durable Medical Equipment Regional Carrier
L2440FRMSupporting Documentation Iterated: [01-99]
01L2440_nnFRM01_QUESTN_NR_LTRStringQuestion Number/Letter
02L2440_nnFRM02_QUESTN_RESPStringQuestion Response
03L2440_nnFRM03_QUESTN_RESPStringQuestion Response
04L2440_nnFRM04_QUESTN_RESP_D8Date/TimeQuestion Response
05L2440_nnFRM05_QUESTN_RESPDecimalQuestion Response

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