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_IMP_GUID_VERS_NM | String | Implementation Guide Version Name |
STHDR | BHT | Beginning of Hierarchical Transaction | ||
01 | STHDR_BHT01_HIER_STRUC_CD | String | Hierarchical Structure Code | |
02 | STHDR_BHT02_TS_PURP_CD | String | Transaction Set Purpose 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 | |
06 | STHDR_BHT06_CLM_ENC_ID | String | Claim or Encounter Identifier |
L1000A - SUBMITTER NAME |
L1000A | NM1 | Submitter Name | ||
03 | L1000A_NM103_PERSN_LNM | String | Person Last Name | |
03 | L1000A_NM103_NONPSNENT_NM | String | Non-Person Entity Name | |
04 | L1000A_NM104_SBM_FNM | String | Submitter First Name | |
05 | L1000A_NM105_SBM_MNM | String | Submitter Middle Name or Initial | |
09 | L1000A_NM109_SBM_ID | String | Submitter Identifier |
L1000A | PER | Submitter EDI Contact Information |
Iterated: [01-02] | |
02 | L1000A_nnPER02_SBM_CON_NM | String | Submitter Contact Name | |
04 | L1000A_nnPER04_EMAIL | String | Electronic Mail | |
04 | L1000A_nnPER04_FAX | String | Facsimile | |
04 | L1000A_nnPER04_PHN_NR | String | Telephone | |
06 | L1000A_nnPER06_EMAIL | String | Electronic Mail | |
06 | L1000A_nnPER06_PHN_EXT | String | Telephone Extension | |
06 | L1000A_nnPER06_FAX | String | Facsimile | |
06 | L1000A_nnPER06_PHN_NR | String | Telephone | |
08 | L1000A_nnPER08_EMAIL | String | Electronic Mail | |
08 | L1000A_nnPER08_PHN_EXT | String | Telephone Extension | |
08 | L1000A_nnPER08_FAX | String | Facsimile | |
08 | L1000A_nnPER08_PHN_NR | String | Telephone |
L1000B - RECEIVER NAME |
L1000B | NM1 | Receiver Name | ||
03 | L1000B_NM103_RCV_NM | String | Receiver Name | |
09 | L1000B_NM109_RCV_PRI_ID | String | Receiver Primary Identifier |
L2000A - BILLING PROVIDER HIERARCHICAL LEVEL |
L2000A | HL | Billing Provider Hierarchical Level | ||
01 | L2000A_HL01_HIER_ID_NR | String | Hierarchical ID Number |
L2000A | PRV | Billing Provider Specialty Information | ||
03 | L2000A_PRV03_PVR_TAX_CD | String | Provider Taxonomy Code |
L2000A | CUR | Foreign Currency Information | ||
02 | L2000A_CUR02_CURRNCY_CD | String | Currency Code |
L2010AA - BILLING PROVIDER NAME |
L2010AA | NM1 | Billing Provider Name | ||
03 | L2010AA_NM103_PERSN_LNM | String | Person Last Name | |
03 | L2010AA_NM103_NONPSNENT_NM | String | Non-Person Entity Name | |
04 | L2010AA_NM104_BILL_PVR_FNM | String | Billing Provider First Name | |
05 | L2010AA_NM105_BILL_PVR_MNM | String | Billing Provider Middle Name or Initial | |
07 | L2010AA_NM107_BILL_PVR_SFX | String | Billing Provider Name Suffix | |
09 | L2010AA_NM109_BILL_PVR_ID | String | Billing Provider Identifier |
L2010AA | N3 | Billing Provider Address | ||
01 | L2010AA_N301_BILL_PROV_ADDR | String | Billing Provider Address Line | |
02 | L2010AA_N302_BILL_PROV_ADDR | String | Billing Provider Address Line |
L2010AA | N4 | Billing Provider City, State, ZIP Code | ||
01 | L2010AA_N401_BILL_PVR_CITY | String | Billing Provider City Name | |
02 | L2010AA_N402_BILL_PVR_STAT | String | Billing Provider State or Province Code | |
03 | L2010AA_N403_BILL_PVR_ZIP | String | Billing Provider Postal Zone or ZIP Code | |
04 | L2010AA_N404_CNTRY_CD | String | Country Code | |
07 | L2010AA_N407_CNTRY_SUBDV_CD | String | Country Subdivision Code |
L2010AA | REF | Billing Provider Tax Identification | ||
02 | L2010AA_REF_EMPLR_ID_NR | String | Employer?s Identification Number | |
02 | L2010AA_REF_SSN | String | Social Security Number |
L2010AA | REF | Billing Provider UPIN/License Information | ||
02 | L2010AA_REF_STAT_LIC_NR | String | State License Number | |
02 | L2010AA_REF_UPIN | String | Provider UPIN Number |
L2010AA | PER | Billing Provider Contact Information |
Iterated: [01-02] | |
02 | L2010AA_nnPER02_BL_PVR_CONT_NM | String | Billing Provider Contact Name | |
04 | L2010AA_nnPER04_EMAIL | String | Electronic Mail | |
04 | L2010AA_nnPER04_FAX | String | Facsimile | |
04 | L2010AA_nnPER04_PHN_NR | String | Telephone | |
06 | L2010AA_nnPER06_EMAIL | String | Electronic Mail | |
06 | L2010AA_nnPER06_PHN_EXT | String | Telephone Extension | |
06 | L2010AA_nnPER06_FAX | String | Facsimile | |
06 | L2010AA_nnPER06_PHN_NR | String | Telephone | |
08 | L2010AA_nnPER08_EMAIL | String | Electronic Mail | |
08 | L2010AA_nnPER08_PHN_EXT | String | Telephone Extension | |
08 | L2010AA_nnPER08_FAX | String | Facsimile | |
08 | L2010AA_nnPER08_PHN_NR | String | Telephone |
L2010AB - PAY-TO ADDRESS NAME |
L2010AB | NM1 | Pay-to Address Name | ||
02 | L2010AB_NM102_ENT_TYP_QUAL | String | Entity Type Qualifier |
L2010AB | N3 | Pay-to Address - ADDRESS | ||
01 | L2010AB_N301_PAY2_ADDR | String | Pay-To Address Line | |
02 | L2010AB_N302_PAY2_ADDR | String | Pay-To Address Line |
L2010AB | N4 | Pay-To Address City, State, ZIP Code | ||
01 | L2010AB_N401_PAY2_CITY | String | Pay-to Address City Name | |
02 | L2010AB_N402_PAY2_STAT | String | Pay-to Address State Code | |
03 | L2010AB_N403_PAY2_ZIP | String | Pay-to Address Postal Zone or ZIP Code | |
04 | L2010AB_N404_CNTRY_CD | String | Country Code | |
07 | L2010AB_N407_CNTRY_SUBDV_CD | String | Country Subdivision Code |
L2010AC - PAY-TO PLAN NAME |
L2010AC | NM1 | Pay-To Plan Name | ||
03 | L2010AC_NM103_PAY2_PLN_ORG_NM | String | Pay-To Plan Organizational Name | |
09 | L2010AC_NM109_PAYR_ID | String | Payor Identification | |
09 | L2010AC_NM109_HCFA_PLAN_ID | String | Centers for Medicare and Medicaid Services PlanID |
L2010AC | N3 | Pay-to Plan Address | ||
01 | L2010AC_N301_PAY2_PLN_ADDR | String | Pay-To Plan Address Line | |
02 | L2010AC_N302_PAY2_PLN_ADDR | String | Pay-To Plan Address Line |
L2010AC | N4 | Pay-To Plan City, State, ZIP Code | ||
01 | L2010AC_N401_PAY2_PLN_CITY | String | Pay-To Plan City Name | |
02 | L2010AC_N402_PAY2_PLN_STAT | String | Pay-To Plan State or Province Code | |
03 | L2010AC_N403_PAY2_PLN_ZIP | String | Pay-To Plan Postal Zone or ZIP Code | |
04 | L2010AC_N404_CNTRY_CD | String | Country Code | |
07 | L2010AC_N407_CNTRY_SUBDV_CD | String | Country Subdivision Code |
L2010AC | REF | Pay-to Plan Secondary Identification | ||
02 | L2010AC_REF_PYR_ID | String | Payer Identification Number | |
02 | L2010AC_REF_CLM_OFC_NR | String | Claim Office Number | |
02 | L2010AC_REF_NAIC | String | National Association of Insurance Commissioners (NAIC) Code |
L2010AC | REF | Pay-To Plan Tax Identification Number | ||
02 | L2010AC_REF_EMPLR_ID_NR | String | Employer?s Identification Number |
L2000B - SUBSCRIBER HEIRARCHICAL LEVEL |
L2000B | HL | Subscriber Hierarchical 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 |
L2000B | SBR | Subscriber Information | ||
01 | L2000B_SBR01_PYR_RESP_SEQ_NR | String | Payer Responsibility Sequence Number Code | |
02 | L2000B_SBR02_IND_RELAT_CD | String | Individual Relationship Code | |
03 | L2000B_SBR03_SBR_POLCY_NR | String | Subscriber Group or Policy Number | |
04 | L2000B_SBR04_SBR_GRP_NM | String | Subscriber Group Name | |
05 | L2000B_SBR05_INS_TYP_CD | String | Insurance Type Code | |
09 | L2000B_SBR09_CLM_FIL_IND_CD | String | Claim Filing Indicator Code |
L2000B | PAT | Patient Information | ||
06 | L2000B_PAT06_PT_DEATH_D8 | Date/Time | Patient Death Date | |
08 | L2000B_PAT08_PT_WGT | Decimal | Patient Weight | |
09 | L2000B_PAT09_PREG_IND | String | Pregnancy Indicator |
L2010BA - SUBSCRIBER NAME |
L2010BA | NM1 | Subscriber Name | ||
03 | L2010BA_NM103_PERSN_LNM | String | Person Last Name | |
03 | L2010BA_NM103_NONPSNENT_NM | String | Non-Person Entity Name | |
04 | L2010BA_NM104_SBR_FNM | String | Subscriber First Name | |
05 | L2010BA_NM105_SBR_MNM | String | Subscriber Middle Name or Initial | |
07 | L2010BA_NM107_SBR_SFX | String | Subscriber Name Suffix | |
09 | L2010BA_NM109_UNQ_HLTH_ID | String | Standard Unique Health Identifier for each Individual in the United States | |
09 | L2010BA_NM109_MEM_ID_NR | String | Member Identification Number |
L2010BA | N3 | Subscriber Address | ||
01 | L2010BA_N301_SBR_ADDR | String | Subscriber Address Line | |
02 | L2010BA_N302_SBR_ADDR | String | Subscriber Address Line |
L2010BA | N4 | Subscriber City, State, ZIP Code | ||
01 | L2010BA_N401_SBR_CITY | String | Subscriber City Name | |
02 | L2010BA_N402_SBR_STAT | String | Subscriber State Code | |
03 | L2010BA_N403_SBR_ZIP | String | Subscriber Postal Zone or ZIP Code | |
04 | L2010BA_N404_CNTRY_CD | String | Country Code | |
07 | L2010BA_N407_CNTRY_SUBDV_CD | String | Country Subdivision Code |
L2010BA | DMG | Subscriber Demographic Information | ||
02 | L2010BA_DMG02_SBR_DOB_D8 | Date/Time | Subscriber Birth Date | |
03 | L2010BA_DMG03_SUB_GENDR_CD | String | Subscriber Gender Code |
L2010BA | REF | Subscriber Secondary Identification | ||
02 | L2010BA_REF_SSN | String | Social Security Number |
L2010BA | REF | Property and Casualty Claim Number | ||
02 | L2010BA_REF_AGNCY_CLM_NR | String | Agency Claim Number |
L2010BA | PER | Property and Casualty Subscriber Contact Information | ||
02 | L2010BA_PER02_NM | String | Name | |
04 | L2010BA_PER04_COMM_NR | String | Communication Number | |
06 | L2010BA_PER06_COMM_NR | String | Communication Number |
L2010BB - PAYER NAME |
L2010BB | NM1 | Payer Name | ||
03 | L2010BB_NM103_PYR_NM | String | Payer Name | |
09 | L2010BB_NM109_PAYR_ID | String | Payor Identification | |
09 | L2010BB_NM109_HCFA_PLAN_ID | String | Centers for Medicare and Medicaid Services PlanID |
L2010BB | N3 | Payer Address | ||
01 | L2010BB_N301_PYR_ADDR_LN | String | Payer Address Line | |
02 | L2010BB_N302_PYR_ADDR_LN | String | Payer Address Line |
L2010BB | N4 | Payer City, State, ZIP Code | ||
01 | L2010BB_N401_PYR_CITY_NM | String | Payer City Name | |
02 | L2010BB_N402_PYR_STAT | String | Payer State or Province Code | |
03 | L2010BB_N403_PYR_ZIP | String | Payer Postal Zone or ZIP Code | |
04 | L2010BB_N404_CNTRY_CD | String | Country Code | |
07 | L2010BB_N407_CNTRY_SUBDV_CD | String | Country Subdivision Code |
L2010BB | REF | Payer Secondary Identification |
Iterated: [01-03] | |
02 | L2010BB_nnREF_PYR_ID | String | Payer Identification Number | |
02 | L2010BB_nnREF_EMPLR_ID_NR | String | Employer?s Identification Number | |
02 | L2010BB_nnREF_CLM_OFC_NR | String | Claim Office Number | |
02 | L2010BB_nnREF_NAIC | String | National Association of Insurance Commissioners (NAIC) Code |
L2010BB | REF | Billing Provider Secondary Identification | ||
02 | L2010BB_REF_PVR_COMM_NR | String | Provider Commercial Number | |
02 | L2010BB_REF_LOC_NR | String | Location Number |
L2000C - PATIENT HIERARCHICAL LEVEL |
L2000C | HL | Patient Hierarchical Level | ||
01 | L2000C_HL01_HIER_ID_NR | String | Hierarchical ID Number | |
02 | L2000C_HL02_HIER_PARNT_ID_NR | String | Hierarchical Parent ID Number |
L2000C | PAT | Patient Information | ||
01 | L2000C_PAT01_IND_RELAT_CD | String | Individual Relationship Code | |
06 | L2000C_PAT06_PT_DEATH_D8 | Date/Time | Patient Death Date | |
08 | L2000C_PAT08_PT_WGT | Decimal | Patient Weight | |
09 | L2000C_PAT09_PREG_IND | String | Pregnancy Indicator |
L2010CA - PATIENT NAME |
L2010CA | NM1 | Patient Name | ||
03 | L2010CA_NM103_PT_LNM | String | Patient Last Name | |
04 | L2010CA_NM104_PT_FNM | String | Patient First Name | |
05 | L2010CA_NM105_PT_MNM | String | Patient Middle Name or Initial | |
07 | L2010CA_NM107_PT_SFX | String | Patient Name Suffix |
L2010CA | N3 | Patient Address | ||
01 | L2010CA_N301_PT_ADDR | String | Patient Address Line | |
02 | L2010CA_N302_PT_ADDR | String | Patient Address Line |
L2010CA | N4 | Patient City, State, ZIP Code | ||
01 | L2010CA_N401_PT_CITY | String | Patient City Name | |
02 | L2010CA_N402_PT_STAT | String | Patient State Code | |
03 | L2010CA_N403_PT_ZIP | String | Patient Postal Zone or ZIP Code | |
04 | L2010CA_N404_CNTRY_CD | String | Country Code | |
07 | L2010CA_N407_CNTRY_SUBDV_CD | String | Country Subdivision Code |
L2010CA | DMG | Patient Demographic Information | ||
02 | L2010CA_DMG02_PT_DOB_D8 | Date/Time | Patient Birth Date | |
03 | L2010CA_DMG03_PAT_GNDR_CD | String | Patient Gender Code |
L2010CA | REF | Property and Casualty Claim Number | ||
02 | L2010CA_REF_AGNCY_CLM_NR | String | Agency Claim Number |
L2010CA | PER | Property and Casualty Patient Contact Information | ||
02 | L2010CA_PER02_NM | String | Name | |
04 | L2010CA_PER04_COMM_NR | String | Communication Number | |
06 | L2010CA_PER06_COMM_NR | String | Communication Number |
L2300 - CLAIM INFORMATION |
L2300 | CLM | Claim Information | ||
01 | L2300_CLM01_PT_CTL_NR | String | Patient Control Number | |
02 | L2300_CLM02_TOT_CLM_CHG_AMT | Decimal | Total Claim Charge Amount | |
05 | 01 | L2300_CLM0501_POS_CD | String | Place of Service Code |
05 | 03 | L2300_CLM0503_CLM_FREQ_CD | String | Claim Frequency Code |
06 | L2300_CLM06_PVD_SUPP_SIG_IND | String | Provider or Supplier Signature Indicator | |
07 | L2300_CLM07_PLAN_PART_CD | String | Assignment or Plan Participation Code | |
08 | L2300_CLM08_BEN_ASGT_CRT_IND | String | Benefits Assignment Certification Indicator | |
09 | L2300_CLM09_RELS_NFO_CD | String | Release of Information Code | |
10 | L2300_CLM10_PAT_SIG_SRC_CD | String | Patient Signature Source Code | |
11 | 01 | L2300_CLM1101_RELTD_CAUS_CD | String | Related Causes Code |
11 | 02 | L2300_CLM1102_RELTD_CAUS_CD | String | Related Causes Code |
11 | 04 | L2300_CLM1104_AUTO_ACC_STAT | String | Auto Accident State or Province Code |
11 | 05 | L2300_CLM1105_CNTRY_CD | String | Country Code |
12 | L2300_CLM12_SPC_PRG_IND | String | Special Program Indicator | |
20 | L2300_CLM20_DELAY_RSN_CD | String | Delay Reason Code |
L2300 | DTP | Date - Onset of Current Illness or Symptom | ||
03 | L2300_DTP_ONST_CURR_SYMPTM_D8 | Start Date | Onset of Current Symptoms or Illness (D8) |
L2300 | DTP | Date - Initial Treatment Date | ||
03 | L2300_DTP_INIT_TRTMT_D8 | Start Date | Initial Treatment (D8) |
L2300 | DTP | Date - Last Seen Date | ||
03 | L2300_DTP_LAST_VST_D8 | Start Date | Latest Visit or Consultation (D8) |
L2300 | DTP | Date - Acute Manifestation | ||
03 | L2300_DTP_ACUTE_D8 | Start Date | Acute Manifestation of a Chronic Condition (D8) |
L2300 | DTP | Date - Accident | ||
03 | L2300_DTP_ACCDNT_D8 | Start Date | Accident (D8) |
L2300 | DTP | Date - Last Menstrual Period | ||
03 | L2300_DTP_MENS_PERD_D8 | Start Date | Last Menstrual Period (D8) |
L2300 | DTP | Date - Last X-ray Date | ||
03 | L2300_DTP_XRAY_D8 | Start Date | Last X-Ray (D8) |
L2300 | DTP | Date - Hearing and Vision Prescription Date | ||
03 | L2300_DTP_RX_D8 | Start Date | Prescription (D8) |
L2300 | DTP | Date - Disability Dates | ||
03 | L2300_DTP_DISBLTY_D8 | Start Date | Disability (D8) | |
03 | L2300_DTP_DISBLTY_RD8_1 | Start Date | Disability (D8) | |
03 | L2300_DTP_DISBLTY_RD8_2 | End Date | Disability (D8) | |
03 | L2300_DTP_DIS_BGN_D8 | Start Date | Initial Disability Period Start (D8) | |
03 | L2300_DTP_DIS_BGN_RD8_1 | Start Date | Initial Disability Period Start (D8) | |
03 | L2300_DTP_DIS_BGN_RD8_2 | End Date | Initial Disability Period Start (D8) | |
03 | L2300_DTP_DIS_END_D8 | Start Date | Initial Disability Period End (D8) | |
03 | L2300_DTP_DIS_END_RD8_1 | Start Date | Initial Disability Period End (D8) | |
03 | L2300_DTP_DIS_END_RD8_2 | End Date | Initial Disability Period End (D8) |
L2300 | DTP | Date - Last Worked | ||
03 | L2300_DTP_LST_WRK_D8 | Start Date | Initial Disability Period Last Day Worked (D8) |
L2300 | DTP | Date - Authorized Return to Work | ||
03 | L2300_DTP_DIS_RET_WRK_D8 | Start Date | Initial Disability Period Return To Work (D8) |
L2300 | DTP | Date - Admission | ||
03 | L2300_DTP_ADMSN_D8 | Start Date | Admission (D8) |
L2300 | DTP | Date - Discharge | ||
03 | L2300_DTP_DISCHG_D8 | Start Date | Discharge (D8) |
L2300 | DTP | Date - Assumed and Relinquished Care Dates | ||
03 | L2300_DTP_RPT_STRT_D8 | Start Date | Report Start (D8) | |
03 | L2300_DTP_RPT_END_D8 | Start Date | Report End (D8) |
L2300 | DTP | Date - Property and Casualty Date of First Contact | ||
03 | L2300_DTP_1ST_VST_D8 | Start Date | First Visit or Consultation (D8) |
L2300 | DTP | Date - Repricer Received Date | ||
03 | L2300_DTP_RCVD_D8 | Start Date | Received (D8) |
L2300 | PWK | Claim Supplemental Information |
Iterated: [01-10] | |
01 | L2300_nnPWK01_ATT_REP_TYP_CD | String | Attachment Report Type Code | |
02 | L2300_nnPWK02_ATT_TRANS_CD | String | Attachment Transmission Code | |
06 | L2300_nnPWK06_ATTACH_CTL_NR | String | Attachment Control Number |
L2300 | CN1 | Contract Information | ||
01 | L2300_CN101_CNTRCT_TYP_CD | String | Contract Type Code | |
02 | L2300_CN102_CONTRCT_AMT | Decimal | Contract Amount | |
03 | L2300_CN103_CONTRCT_PERC | Decimal | Contract Percentage | |
04 | L2300_CN104_CONTRCT_CD | String | Contract Code | |
05 | L2300_CN105_TERMS_DISCT_PERC | Decimal | Terms Discount Percentage | |
06 | L2300_CN106_CONTRCT_VERS_ID | String | Contract Version Identifier |
L2300 | AMT | Patient Amount Paid | ||
02 | L2300_AMT02_PT_AMT_PD | Date Timestamp | Patient Amount Paid |
L2300 | REF | Service Authorization Exception Code | ||
02 | L2300_REF_SP_PMT_REF_NR | String | Special Payment Reference Number |
L2300 | REF | Mandatory Medicare (Section 4081) Crossover Indicator | ||
02 | L2300_REF_MDCR_VRS_CD | String | Medicare Version Code |
L2300 | REF | Mammography Certification Number | ||
02 | L2300_REF_MAMM_CERT | String | Mammography Certification Number |
L2300 | REF | Referral Number | ||
02 | L2300_REF_REFRL_NR | String | Referral Number |
L2300 | REF | Prior Authorization | ||
02 | L2300_REF_PRIOR_AUTH | String | Prior Authorization Number |
L2300 | REF | Payer Claim Control Number | ||
02 | L2300_REF_ORIG_REF_NR | String | Original Reference Number |
L2300 | REF | Clinical Laboratory Improvement Amendment (CLIA) Number | ||
02 | L2300_REF_LAB_IMP_AMD | String | Clinical Laboratory Improvement Amendment Number |
L2300 | REF | Repriced Claim Number | ||
02 | L2300_REF_REP_CLM_ID | String | Repriced Claim Reference Number |
L2300 | REF | Adjusted Repriced Claim Number | ||
02 | L2300_REF_ADJ_REP_CLM_ID | String | Adjusted Repriced Claim Reference Number |
L2300 | REF | Investigational Device Exemption Number | ||
02 | L2300_REF_QUAL_PRD_LST | String | Qualified Products List |
L2300 | REF | Claim Identifier For Transmission Intermediaries | ||
02 | L2300_REF_CLM_NR | String | Claim Number |
L2300 | REF | Medical Record Number | ||
02 | L2300_REF_MED_REC_ID | String | Medical Record Identification Number |
L2300 | REF | Demonstration Project Identifier | ||
02 | L2300_REF_PROJCT_CD | String | Project Code |
L2300 | REF | Care Plan Oversight | ||
02 | L2300_REF_FAC_ID | String | Facility ID Number |
L2300 | K3 | File Information |
Iterated: [01-10] | |
01 | L2300_nnK301_FIXD_FMT_NFO | String | Fixed Format Information |
L2300 | NTE | Claim Note | ||
02 | L2300_NTE02_ADDL_NFO | String | Additional Information | |
02 | L2300_NTE02_CERT_NARR | String | Certification Narrative | |
02 | L2300_NTE02_GOALS_DISCHG_PLN | String | Goals, Rehabilitation Potential, or Discharge Plans | |
02 | L2300_NTE02_DIAG_DESC | String | Diagnosis Description | |
02 | L2300_NTE02_TPO_NOTE | String | Third Party Organization Notes |
L2300 | CR1 | Ambulance Transport Information | ||
02 | L2300_CR102_PT_WGT | Decimal | Patient Weight | |
04 | L2300_CR104_AMB_TRANS_RSN_CD | String | Ambulance Transport Reason Code | |
06 | L2300_CR106_TRANSPT_DIST | Decimal | Transport Distance | |
09 | L2300_CR109_RNDTRP_PRPS_DESC | String | Round Trip Purpose Description | |
10 | L2300_CR110_STRTCHR_PURP_DESC | String | Stretcher Purpose Description |
L2300 | CR2 | Spinal Manipulation Service Information | ||
08 | L2300_CR208_PAT_COND_CD | String | Patient Condition Code | |
10 | L2300_CR210_PT_COND_DESC | String | Patient Condition Description | |
11 | L2300_CR211_PT_COND_DESC | String | Patient Condition Description |
L2300 | CRC | Ambulance Certification |
Segment Suffix: Iterated: [01-03] | |
02 | L2300_nnCRCA02_CERT_COND_IND | String | Certification Condition Indicator | |
03 | L2300_nnCRCA03_CONDTN_CD | String | Condition Code | |
04 | L2300_nnCRCA04_CONDTN_CD | String | Condition Code | |
05 | L2300_nnCRCA05_CONDTN_CD | String | Condition Code | |
06 | L2300_nnCRCA06_CONDTN_CD | String | Condition Code | |
07 | L2300_nnCRCA07_CONDTN_CD | String | Condition Code |
L2300 | CRC | Patient Condition Information: Vision |
Segment Suffix: Iterated: [01-03] | |
01 | L2300_nnCRCB01_CD_CAT | String | Code Category | |
02 | L2300_nnCRCB02_CERT_COND_IND | String | Certification Condition Indicator | |
03 | L2300_nnCRCB03_CONDTN_CD | String | Condition Code | |
04 | L2300_nnCRCB04_CONDTN_CD | String | Condition Code | |
05 | L2300_nnCRCB05_CONDTN_CD | String | Condition Code | |
06 | L2300_nnCRCB06_CONDTN_CD | String | Condition Code | |
07 | L2300_nnCRCB07_CONDTN_CD | String | Condition Code |
L2300 | CRC | Homebound Indicator |
Segment Suffix: | |
03 | L2300_CRCC03_HOMBND_IND | String | Homebound Indicator |
L2300 | CRC | EPSDT Referral |
Segment Suffix: | |
02 | L2300_CRCD02_CERT_COND_CD_IND | String | Certification Condition Code Applies Indicator | |
03 | L2300_CRCD03_CONDTN_IND | String | Condition Indicator | |
04 | L2300_CRCD04_CONDTN_IND | String | Condition Indicator | |
05 | L2300_CRCD05_CONDTN_IND | String | Condition Indicator |
L2300 | HI | Health Care Diagnosis Code | ||
01 | 02 | L2300_HI0102_ICD10_PRIN_DIAG | String | International Classification of Diseases Clinical Modification (ICD-10-CM) Principal Diagnosis |
01 | 02 | L2300_HI0102_ICD9_PRIN_DIAG | String | International Classification of Diseases Clinical Modification (ICD-9-CM) Principal Diagnosis |
02 | 02 | L2300_HI0202_ICD10_DIAG | String | International Classification of Diseases Clinical Modification (ICD-10-CM) Diagnosis |
02 | 02 | L2300_HI0202_ICD9_DIAG | String | International Classification of Diseases Clinical Modification (ICD-9-CM) Diagnosis |
03 | 02 | L2300_HI0302_ICD10_DIAG | String | International Classification of Diseases Clinical Modification (ICD-10-CM) Diagnosis |
03 | 02 | L2300_HI0302_ICD9_DIAG | String | International Classification of Diseases Clinical Modification (ICD-9-CM) Diagnosis |
04 | 02 | L2300_HI0402_ICD10_DIAG | String | International Classification of Diseases Clinical Modification (ICD-10-CM) Diagnosis |
04 | 02 | L2300_HI0402_ICD9_DIAG | String | International Classification of Diseases Clinical Modification (ICD-9-CM) Diagnosis |
05 | 02 | L2300_HI0502_ICD10_DIAG | String | International Classification of Diseases Clinical Modification (ICD-10-CM) Diagnosis |
05 | 02 | L2300_HI0502_ICD9_DIAG | String | International Classification of Diseases Clinical Modification (ICD-9-CM) Diagnosis |
06 | 02 | L2300_HI0602_ICD10_DIAG | String | International Classification of Diseases Clinical Modification (ICD-10-CM) Diagnosis |
06 | 02 | L2300_HI0602_ICD9_DIAG | String | International Classification of Diseases Clinical Modification (ICD-9-CM) Diagnosis |
07 | 02 | L2300_HI0702_ICD10_DIAG | String | International Classification of Diseases Clinical Modification (ICD-10-CM) Diagnosis |
07 | 02 | L2300_HI0702_ICD9_DIAG | String | International Classification of Diseases Clinical Modification (ICD-9-CM) Diagnosis |
08 | 02 | L2300_HI0802_ICD10_DIAG | String | International Classification of Diseases Clinical Modification (ICD-10-CM) Diagnosis |
08 | 02 | L2300_HI0802_ICD9_DIAG | String | International Classification of Diseases Clinical Modification (ICD-9-CM) Diagnosis |
09 | 02 | L2300_HI0902_ICD10_DIAG | String | International Classification of Diseases Clinical Modification (ICD-10-CM) Diagnosis |
09 | 02 | L2300_HI0902_ICD9_DIAG | String | International Classification of Diseases Clinical Modification (ICD-9-CM) Diagnosis |
10 | 02 | L2300_HI1002_ICD10_DIAG | String | International Classification of Diseases Clinical Modification (ICD-10-CM) Diagnosis |
10 | 02 | L2300_HI1002_ICD9_DIAG | String | International Classification of Diseases Clinical Modification (ICD-9-CM) Diagnosis |
11 | 02 | L2300_HI1102_ICD10_DIAG | String | International Classification of Diseases Clinical Modification (ICD-10-CM) Diagnosis |
11 | 02 | L2300_HI1102_ICD9_DIAG | String | International Classification of Diseases Clinical Modification (ICD-9-CM) Diagnosis |
12 | 02 | L2300_HI1202_ICD10_DIAG | String | International Classification of Diseases Clinical Modification (ICD-10-CM) Diagnosis |
12 | 02 | L2300_HI1202_ICD9_DIAG | String | International Classification of Diseases Clinical Modification (ICD-9-CM) Diagnosis |
L2300 | HI | Anesthesia Related Procedure | ||
01 | 02 | L2300_HI0102_HCPCS_CD | String | Health Care Financing Administration Common |
02 | 02 | L2300_HI0202_HCPCS_CD | String | Health Care Financing Administration Common Procedural Coding System |
L2300 | HI | Condition Information |
Iterated: [01-02] | |
01 | 02 | L2300_nnHI0102_COND | String | Condition |
02 | 02 | L2300_nnHI0202_COND | String | Condition |
03 | 02 | L2300_nnHI0302_COND | String | Condition |
04 | 02 | L2300_nnHI0402_COND | String | Condition |
05 | 02 | L2300_nnHI0502_COND | String | Condition |
06 | 02 | L2300_nnHI0602_COND | String | Condition |
07 | 02 | L2300_nnHI0702_COND | String | Condition |
08 | 02 | L2300_nnHI0802_COND | String | Condition |
09 | 02 | L2300_nnHI0902_COND | String | Condition |
10 | 02 | L2300_nnHI1002_COND | String | Condition |
11 | 02 | L2300_nnHI1102_COND | String | Condition |
12 | 02 | L2300_nnHI1202_COND | String | Condition |
L2300 | HCP | Claim Pricing/Repricing Information | ||
01 | L2300_HCP01_PRIC_METHD | String | Pricing Methodology | |
02 | L2300_HCP02_REPRCD_ALLWD_AMT | Decimal | Repriced Allowed Amount | |
03 | L2300_HCP03_REPRCD_SAVNG_AMT | Decimal | Repriced Saving Amount | |
04 | L2300_HCP04_REPRCNG_ORG_ID | String | Repricing Organization Identifier | |
05 | L2300_HCP05_REPRCD_PERDIEM_AMT | Decimal | Repricing Per Diem or Flat Rate Amount | |
06 | L2300_HCP06_REP_AMB_PT_GRP | String | Repriced Approved Ambulatory Patient Group | |
07 | L2300_HCP07_REP_AMB_PT_GRP | Decimal | Repriced Approved Ambulatory Patient Group | |
13 | L2300_HCP13_REJ_RSN_CD | String | Reject Reason Code | |
14 | L2300_HCP14_POLCY_COMP_CD | String | Policy Compliance Code | |
15 | L2300_HCP15_EXCPTN_CD | String | Exception Code |
L2310A - REFERRING PROVIDER NAME (Value Qualified) |
Mapping Prefix: L2310A_DN - Referring Provider |
Mapping Prefix: L2310A_P3 - Primary Care Provider |
L2310A | NM1 | Referring Provider Name | ||
03 | L2310A_yy_NM103_REF_PVR_LNM | String | Referring Provider Last Name | |
04 | L2310A_yy_NM104_REF_PVR_FNM | String | Referring Provider First Name | |
05 | L2310A_yy_NM105_REF_PVR_MNM | String | Referring Provider Middle Name or Initial | |
07 | L2310A_yy_NM107_REF_PVR_SFX | String | Referring Provider Name Suffix | |
09 | L2310A_yy_NM109_REF_PVR_ID | String | Referring Provider Identifier |
L2310A | REF | Referring Provider Secondary Identification | ||
02 | L2310A_yy_REF_STAT_LIC_NR | String | State License Number | |
02 | L2310A_yy_REF_UPIN | String | Provider UPIN Number | |
02 | L2310A_yy_REF_PVR_COMM_NR | String | Provider Commercial Number |
L2310B - RENDERING PROVIDER NAME |
L2310B | NM1 | Rendering Provider Name | ||
03 | L2310B_NM103_PERSN_LNM | String | Person Last Name | |
03 | L2310B_NM103_NONPSNENT_NM | String | Non-Person Entity Name | |
04 | L2310B_NM104_REND_PVR_FNM | String | Rendering Provider First Name | |
05 | L2310B_NM105_REND_PVR_MNM | String | Rendering Provider Middle Name or Initial | |
07 | L2310B_NM107_REND_PROV_SFX | String | Rendering Provider Name Suffix | |
09 | L2310B_NM109_REND_PROV_ID | String | Rendering Provider Identifier |
L2310B | PRV | Rendering Provider Specialty Information | ||
03 | L2310B_PRV03_PVR_TAX_CD | String | Provider Taxonomy Code |
L2310B | REF | Rendering Provider Secondary Identification | ||
02 | L2310B_REF_STAT_LIC_NR | String | State License Number | |
02 | L2310B_REF_UPIN | String | Provider UPIN Number | |
02 | L2310B_REF_PVR_COMM_NR | String | Provider Commercial Number | |
02 | L2310B_REF_LOC_NR | String | Location Number |
L2310C - SERVICE FACILITY LOCATION NAME |
L2310C | NM1 | Service Facility Location Name | ||
03 | L2310C_NM103_LAB_FAC_NM | String | Laboratory or Facility Name | |
09 | L2310C_NM109_LAB_FAC_PRI_ID | String | Laboratory or Facility Primary Identifier |
L2310C | N3 | Service Facility Location Address | ||
01 | L2310C_N301_LAB_FAC_ADDR | String | Laboratory or Facility Address Line | |
02 | L2310C_N302_LAB_FAC_ADDR | String | Laboratory or Facility Address Line |
L2310C | N4 | Service Facility Location City, State, ZIP Code | ||
01 | L2310C_N401_LAB_FAC_CITY | String | Laboratory or Facility City Name | |
02 | L2310C_N402_LAB_FAC_STAT | String | Laboratory or Facility State or Province Code | |
03 | L2310C_N403_LAB_ZIP | String | Laboratory or Facility Postal Zone or ZIP Code | |
04 | L2310C_N404_CNTRY_CD | String | Country Code | |
07 | L2310C_N407_CNTRY_SUBDV_CD | String | Country Subdivision Code |
L2310C | REF | Service Facility Location Secondary Identification | ||
02 | L2310C_REF_STAT_LIC_NR | String | State License Number | |
02 | L2310C_REF_PVR_COMM_NR | String | Provider Commercial Number | |
02 | L2310C_REF_LOC_NR | String | Location Number |
L2310C | PER | Service Facility Contact Information | ||
02 | L2310C_PER02_NM | String | Name | |
04 | L2310C_PER04_COMM_NR | String | Communication Number | |
06 | L2310C_PER06_COMM_NR | String | Communication Number |
L2310D - SUPERVISING PROVIDER NAME |
L2310D | NM1 | Supervising Provider Name | ||
03 | L2310D_NM103_SUP_PVR_LNM | String | Supervising Provider Last Name | |
04 | L2310D_NM104_SUP_PVR_FNM | String | Supervising Provider First Name | |
05 | L2310D_NM105_SUP_PVR_MNM | String | Supervising Provider Middle Name or Initial | |
07 | L2310D_NM107_SUP_PVR_SFX | String | Supervising Provider Name Suffix | |
09 | L2310D_NM109_SUP_PVR_ID | String | Supervising Provider Identifier |
L2310D | REF | Supervising Provider Secondary Identification | ||
02 | L2310D_REF_STAT_LIC_NR | String | State License Number | |
02 | L2310D_REF_UPIN | String | Provider UPIN Number | |
02 | L2310D_REF_PVR_COMM_NR | String | Provider Commercial Number | |
02 | L2310D_REF_LOC_NR | String | Location Number |
L2310E - AMBULANCE PICK-UP LOCATION |
L2310E | NM1 | Ambulance Pick-up Location |
L2310E | N3 | Ambulance Pick-up Location Address | ||
01 | L2310E_N301_AMB_PU_ADDR | String | Ambulance Pick-up Address Line | |
02 | L2310E_N302_AMB_PU_ADDR | String | Ambulance Pick-up Address Line |
L2310E | N4 | Ambulance Pick-up Location City, State, ZIP Code | ||
01 | L2310E_N401_AMB_PCKUP_CITY | String | Ambulance Pick-up City Name | |
02 | L2310E_N402_AMB_PKUP_STAT | String | Ambulance Pick-up State or Province Code | |
03 | L2310E_N403_AMB_PCKUP_ZIP | String | Ambulance Pick-up Postal Zone or ZIP Code | |
04 | L2310E_N404_CNTRY_CD | String | Country Code | |
07 | L2310E_N407_CNTRY_SUBDV_CD | String | Country Subdivision Code |
L2310F - AMBULANCE DROP-OFF LOCATION |
L2310F | NM1 | Ambulance Drop-off Location | ||
03 | L2310F_NM103_AMB_DROPOFF_LOC | String | Ambulance Drop-off Location |
L2310F | N3 | Ambulance Drop-off Location Address | ||
01 | L2310F_N301_AMB_DROPOFF_ADDR | String | Ambulance Drop-off Address Line | |
02 | L2310F_N302_AMB_DROPOFF_ADDR | String | Ambulance Drop-off Address Line |
L2310F | N4 | Ambulance Drop-off Location City, State, ZIP Code | ||
01 | L2310F_N401_AMB_DRPOFF_CITY | String | Ambulance Drop-off City Name | |
02 | L2310F_N402_AMB_DRPOFF_STAT | String | Ambulance Drop-off State or Province Code | |
03 | L2310F_N403_AMB_DROPOFF_ZIP | String | Ambulance Drop-off Postal Zone or ZIP Code | |
04 | L2310F_N404_CNTRY_CD | String | Country Code | |
07 | L2310F_N407_CNTRY_SUBDV_CD | String | Country Subdivision Code |
L2320 - OTHER SUBSCRIBER INFORMATION (Single Iteration) |
L2320 | SBR | Other Subscriber Information | ||
01 | L2320_xx_SBR01_PYR_RESP_SEQ_NR | String | Payer Responsibility Sequence Number Code | |
02 | L2320_xx_SBR02_IND_RELAT_CD | String | Individual Relationship Code | |
03 | L2320_xx_SBR03_INS_GRP_PLCY_NR | String | Insured Group or Policy Number | |
04 | L2320_xx_SBR04_OINS_GRP_NM | String | Other Insured Group Name | |
05 | L2320_xx_SBR05_INS_TYP_CD | String | Insurance Type Code | |
09 | L2320_xx_SBR09_CLM_FIL_IND_CD | String | Claim Filing Indicator Code |
L2320 | CAS | Claim Level Adjustments |
Iterated: [01-05] | |
01 | L2320_xx_nnCAS01_CLMADJ_GRP_CD | String | Claim Adjustment Group Code | |
02 | L2320_xx_nnCAS02_ADJ_RSN_CD | String | Adjustment Reason Code | |
03 | L2320_xx_nnCAS03_ADJ_AMT | Decimal | Adjustment Amount | |
04 | L2320_xx_nnCAS04_ADJ_QTY | Decimal | Adjustment Quantity | |
05 | L2320_xx_nnCAS05_ADJ_RSN_CD | String | Adjustment Reason Code | |
06 | L2320_xx_nnCAS06_ADJ_AMT | Decimal | Adjustment Amount | |
07 | L2320_xx_nnCAS07_ADJ_QTY | Decimal | Adjustment Quantity | |
08 | L2320_xx_nnCAS08_ADJ_RSN_CD | String | Adjustment Reason Code | |
09 | L2320_xx_nnCAS09_ADJ_AMT | Decimal | Adjustment Amount | |
10 | L2320_xx_nnCAS10_ADJ_QTY | Decimal | Adjustment Quantity | |
11 | L2320_xx_nnCAS11_ADJ_RSN_CD | String | Adjustment Reason Code | |
12 | L2320_xx_nnCAS12_ADJ_AMT | Decimal | Adjustment Amount | |
13 | L2320_xx_nnCAS13_ADJ_QTY | Decimal | Adjustment Quantity | |
14 | L2320_xx_nnCAS14_ADJ_RSN_CD | String | Adjustment Reason Code | |
15 | L2320_xx_nnCAS15_ADJ_AMT | Decimal | Adjustment Amount | |
16 | L2320_xx_nnCAS16_ADJ_QTY | Decimal | Adjustment Quantity | |
17 | L2320_xx_nnCAS17_ADJ_RSN_CD | String | Adjustment Reason Code | |
18 | L2320_xx_nnCAS18_ADJ_AMT | Decimal | Adjustment Amount | |
19 | L2320_xx_nnCAS19_ADJ_QTY | Decimal | Adjustment Quantity |
L2320 | AMT | Coordination of Benefits (COB) Payer Paid Amount | ||
02 | L2320_xx_AMT02_PAYR_AMT_PD | Date Timestamp | Payor Amount Paid |
L2320 | AMT | Coordination of Benefits (COB) Total Non-Covered Amount | ||
02 | L2320_xx_AMT02_NONCVD_CHG_ACTL | Date Timestamp | Noncovered Charges - Actual |
L2320 | AMT | Remaining Patient Liability | ||
02 | L2320_xx_AMT02_AMT_OWED | Date Timestamp | Amount Owed |
L2320 | OI | Other Insurance Coverage Information | ||
03 | L2320_xx_OI03_BEN_ASGT_CRT_IND | String | Benefits Assignment Certification Indicator | |
04 | L2320_xx_OI04_PAT_SIG_SRC_CD | String | Patient Signature Source Code | |
06 | L2320_xx_OI06_RELS_NFO_CD | String | Release of Information Code |
L2320 | MOA | Outpatient Adjudication Information | ||
01 | L2320_xx_MOA01_REIMBRSMT_RT | Decimal | Reimbursement Rate | |
02 | L2320_xx_MOA02_HCPCS_PAYBL_AMT | Decimal | HCPCS Payable Amount | |
03 | L2320_xx_MOA03_CLM_PMT_RMK_CD | String | Claim Payment Remark Code | |
04 | L2320_xx_MOA04_CLM_PMT_RMK_CD | String | Claim Payment Remark Code | |
05 | L2320_xx_MOA05_CLM_PMT_RMK_CD | String | Claim Payment Remark Code | |
06 | L2320_xx_MOA06_CLM_PMT_RMK_CD | String | Claim Payment Remark Code | |
07 | L2320_xx_MOA07_CLM_PMT_RMK_CD | String | Claim Payment Remark Code | |
08 | L2320_xx_MOA08_ESRD_PMT_AMT | Decimal | End Stage Renal Disease Payment Amount | |
09 | L2320_xx_MOA09_NONPAY_PROF_BLL | String | Non-Payable Professional Component Billed |
L2330A - OTHER SUBSCRIBER NAME (Inherited Loop Iteration) |
L2330A | NM1 | Other Subscriber Name | ||
03 | L2330A_xx_NM103_PERSN_LNM | String | Person Last Name | |
03 | L2330A_xx_NM103_NONPSNENT_NM | String | Non-Person Entity Name | |
04 | L2330A_xx_NM104_OINS_FNM | String | Other Insured First Name | |
05 | L2330A_xx_NM105_OINS_MNM | String | Other Insured Middle Name | |
07 | L2330A_xx_NM107_OINS_SFX | String | Other Insured Name Suffix | |
09 | L2330A_xx_NM109_UNQ_HLTH_ID | String | Standard Unique Health Identifier for each Individual in the United States | |
09 | L2330A_xx_NM109_MEM_ID_NR | String | Member Identification Number |
L2330A | N3 | Other Subscriber Address | ||
01 | L2330A_xx_N301_OSBR_ADDR | String | Other Subscriber Address Line | |
02 | L2330A_xx_N302_OINS_ADDR | String | Other Insured Address Line |
L2330A | N4 | Other Subscriber City, State, ZIP Code | ||
01 | L2330A_xx_N401_OSBR_CITY | String | Other Subscriber City Name | |
02 | L2330A_xx_N402_OSBR_STAT | String | Other Subscriber State or Province Code | |
03 | L2330A_xx_N403_OSBR_ZIP | String | Other Subscriber Postal Zone or ZIP Code | |
04 | L2330A_xx_N404_CNTRY_CD | String | Country Code | |
07 | L2330A_xx_N407_CNTRY_SUBDV_CD | String | Country Subdivision Code |
L2330A | REF | Other Subscriber Secondary Identification | ||
02 | L2330A_xx_REF_SSN | String | Social Security Number |
L2330B - OTHER PAYER NAME (Inherited Loop Iteration) |
L2330B | NM1 | Other Payer Name | ||
03 | L2330B_xx_NM103_OPYR_ORG_NM | String | Other Payer Organization Name | |
09 | L2330B_xx_NM109_PAYR_ID | String | Payor Identification | |
09 | L2330B_xx_NM109_HCFA_PLAN_ID | String | Centers for Medicare and Medicaid Services PlanID |
L2330B | N3 | Other Payer Address | ||
01 | L2330B_xx_N301_OPYR_ADDR | String | Other Payer Address Line | |
02 | L2330B_xx_N302_OPYR_ADDR | String | Other Payer Address Line |
L2330B | N4 | Other Payer City, State, ZIP Code | ||
01 | L2330B_xx_N401_OPYR_CITY_NM | String | Other Payer City Name | |
02 | L2330B_xx_N402_OPYR_STAT | String | Other Payer State or Province Code | |
03 | L2330B_xx_N403_OPYR_POSTL_ZIP | String | Other Payer Postal Zone or ZIP Code | |
04 | L2330B_xx_N404_CNTRY_CD | String | Country Code | |
07 | L2330B_xx_N407_CNTRY_SUBDV_CD | String | Country Subdivision Code |
L2330B | DTP | Claim Check or Remittance Date | ||
03 | L2330B_xx_DTP_CLM_PD_D8 | Start Date | Date Claim Paid (D8) |
L2330B | REF | Other Payer Secondary Identifier |
Iterated: [01-02] | |
02 | L2330B_xx_nnREF_PYR_ID | String | Payer Identification Number | |
02 | L2330B_xx_nnREF_EMPLR_ID_NR | String | Employer?s Identification Number | |
02 | L2330B_xx_nnREF_CLM_OFC_NR | String | Claim Office Number | |
02 | L2330B_xx_nnREF_NAIC | String | National Association of Insurance Commissioners (NAIC) Code |
L2330B | REF | Other Payer Prior Authorization Number | ||
02 | L2330B_xx_REF_PRIOR_AUTH | String | Prior Authorization Number |
L2330B | REF | Other Payer Referral Number | ||
02 | L2330B_xx_REF_REFRL_NR | String | Referral Number |
L2330B | REF | Other Payer Claim Adjustment Indicator | ||
02 | L2330B_xx_REF_SIGNL_CD | String | Signal Code |
L2330B | REF | Other Payer Claim Control Number | ||
02 | L2330B_xx_REF_ORIG_REF_NR | String | Original 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 |
L2330C | NM1 | Other Payer Referring Provider |
L2330C | REF | Other Payer Referring Provider Secondary Identification | ||
02 | L2330C_xxyy_REF_STAT_LIC_NR | String | State License Number | |
02 | L2330C_xxyy_REF_UPIN | String | Provider UPIN Number | |
02 | L2330C_xxyy_REF_PVR_COMM_NR | String | Provider Commercial Number |
L2330D - OTHER PAYER RENDERING PROVIDER (Inherited Loop Iteration) |
L2330D | NM1 | Other Payer Rendering Provider | ||
02 | L2330D_xx_NM102_ENT_TYP_QUAL | String | Entity Type Qualifier |
L2330D | REF | Other Payer Rendering Provider Secondary Identification |
Iterated: [01-03] | |
02 | L2330D_xx_nnREF_STAT_LIC_NR | String | State License Number | |
02 | L2330D_xx_nnREF_UPIN | String | Provider UPIN Number | |
02 | L2330D_xx_nnREF_PVR_COMM_NR | String | Provider Commercial Number | |
02 | L2330D_xx_nnREF_LOC_NR | String | Location Number |
L2330E - OTHER PAYER SERVICE FACILITY LOCATION (Inherited Loop Iteration) |
L2330E | NM1 | Other Payer Service Facility Location |
L2330E | REF | Other Payer Service Facility Location Secondary Identification | ||
02 | L2330E_xx_REF_STAT_LIC_NR | String | State License Number | |
02 | L2330E_xx_REF_PVR_COMM_NR | String | Provider Commercial Number | |
02 | L2330E_xx_REF_LOC_NR | String | Location Number |
L2330F - OTHER PAYER SUPERVISING PROVIDER (Inherited Loop Iteration) |
L2330F | NM1 | Other Payer Supervising Provider |
L2330F | REF | Other Payer Supervising Provider Secondary Identification |
Iterated: [01-03] | |
02 | L2330F_xx_nnREF_STAT_LIC_NR | String | State License Number | |
02 | L2330F_xx_nnREF_UPIN | String | Provider UPIN Number | |
02 | L2330F_xx_nnREF_PVR_COMM_NR | String | Provider Commercial Number | |
02 | L2330F_xx_nnREF_LOC_NR | String | Location Number |
L2330G - OTHER PAYER BILLING PROVIDER (Inherited Loop Iteration) |
L2330G | NM1 | Other Payer Billing Provider | ||
02 | L2330G_xx_NM102_ENT_TYP_QUAL | String | Entity Type Qualifier |
L2330G | REF | Other Payer Billing Provider Secondary Identification | ||
02 | L2330G_xx_REF_PVR_COMM_NR | String | Provider Commercial Number | |
02 | L2330G_xx_REF_LOC_NR | String | Location Number |
L2400 - SERVICE LINE NUMBER |
L2400 | LX | Service Line Number | ||
01 | L2400_LX01_ASSGD_NR | Integer | Assigned Number |
L2400 | SV1 | Professional Service | ||
01 | 02 | L2400_SV10102_JS_PRC_SPY_CD | String | Jurisdiction Specific Procedure and Supply Codes |
01 | 02 | L2400_SV10102_HCPCS_CD | String | Health Care Financing Administration Common Procedural Coding System (HCPCS) Codes |
01 | 02 | L2400_SV10102_HIC_PRD_SVCCD | String | Home Infusion EDI Coalition (HIEC) Product/Service Code |
01 | 02 | L2400_SV10102_ABC_CD | String | Advanced Billing Concepts (ABC) Codes |
01 | 03 | L2400_SV10103_PROC_MOD | String | Procedure Modifier |
01 | 04 | L2400_SV10104_PROC_MOD | String | Procedure Modifier |
01 | 05 | L2400_SV10105_PROC_MOD | String | Procedure Modifier |
01 | 06 | L2400_SV10106_PROC_MOD | String | Procedure Modifier |
01 | 07 | L2400_SV10107_DESCR | String | Description |
02 | L2400_SV102_LIN_ITM_CHG_AMT | Decimal | Line Item Charge Amount | |
04 | L2400_SV104_MIN | Decimal | Minutes | |
04 | L2400_SV104_UN | Decimal | Unit | |
05 | L2400_SV105_POS_CD | String | Place of Service Code | |
07 | 01 | L2400_SV10701_DIAG_CD_PTR | Integer | Diagnosis Code Pointer |
07 | 02 | L2400_SV10702_DIAG_CD_PTR | Integer | Diagnosis Code Pointer |
07 | 03 | L2400_SV10703_DIAG_CD_PTR | Integer | Diagnosis Code Pointer |
07 | 04 | L2400_SV10704_DIAG_CD_PTR | Integer | Diagnosis Code Pointer |
09 | L2400_SV109_EMGNCY_IND | String | Emergency Indicator | |
11 | L2400_SV111_EPSDT_IND | String | EPSDT Indicator | |
12 | L2400_SV112_FAM_PLAN_IND | String | Family Planning Indicator | |
15 | L2400_SV115_COPAY_STAT_CD | String | Co-Pay Status Code |
L2400 | SV5 | Durable Medical Equipment Service | ||
01 | 02 | L2400_SV50102_PROC_CD | String | Procedure Code |
03 | L2400_SV503_LEN_MED_NECC | Decimal | Length of Medical Necessity | |
04 | L2400_SV504_DME_RENTL_PRIC | Decimal | DME Rental Price | |
05 | L2400_SV505_DME_PURCH_PRC | Decimal | DME Purchase Price | |
06 | L2400_SV506_RENTL_PRIC_IND | String | Rental Unit Price Indicator |
L2400 | PWK | Line Supplemental Information |
Iterated: [01-10] | |
01 | L2400_nnPWK01_ATT_REP_TYP_CD | String | Attachment Report Type Code | |
02 | L2400_nnPWK02_ATT_TRANS_CD | String | Attachment Transmission Code | |
06 | L2400_nnPWK06_ATTACH_CTL_NR | String | Attachment Control Number |
L2400 | PWK | Durable Medical Equipment Certificate of Medical Necessity Indicator |
Segment Suffix: | |
02 | L2400_PWKB02_ATT_TRANS_CD | String | Attachment Transmission Code |
L2400 | CR1 | Ambulance Transport Information | ||
02 | L2400_CR102_PT_WGT | Decimal | Patient Weight | |
04 | L2400_CR104_AMB_TRANS_RSN_CD | String | Ambulance Transport Reason Code | |
06 | L2400_CR106_TRANSPT_DIST | Decimal | Transport Distance | |
09 | L2400_CR109_RNDTRP_PRPS_DESC | String | Round Trip Purpose Description | |
10 | L2400_CR110_STRTCHR_PURP_DESC | String | Stretcher Purpose Description |
L2400 | CR3 | Durable Medical Equipment Certification | ||
01 | L2400_CR301_CERT_TYP_CD | String | Certification Type Code | |
03 | L2400_CR303_DME_DURATN | Decimal | Durable Medical Equipment Duration |
L2400 | CRC | Ambulance Certification |
Iterated: [01-03] | |
02 | L2400_nnCRC02_CERT_COND_IND | String | Certification Condition Indicator | |
03 | L2400_nnCRC03_CONDTN_CD | String | Condition Code | |
04 | L2400_nnCRC04_CONDTN_CD | String | Condition Code | |
05 | L2400_nnCRC05_CONDTN_CD | String | Condition Code | |
06 | L2400_nnCRC06_CONDTN_CD | String | Condition Code | |
07 | L2400_nnCRC07_CONDTN_CD | String | Condition Code |
L2400 | CRC | Hospice Employee Indicator |
Segment Suffix: | |
02 | L2400_CRCA02_HOSPC_EMP_PRV_IND | String | Hospice Employed Provider Indicator |
L2400 | CRC | Condition Indicator/Durable Medical Equipment |
Segment Suffix: | |
02 | L2400_CRCB02_CERT_COND_IND | String | Certification Condition Indicator | |
03 | L2400_CRCB03_CONDTN_IND | String | Condition Indicator | |
04 | L2400_CRCB04_CONDTN_IND | String | Condition Indicator |
L2400 | DTP | Date - Service Date | ||
03 | L2400_DTP_SVC_D8 | Start Date | Service (D8) | |
03 | L2400_DTP_SVC_RD8_1 | Start Date | Service (D8) | |
03 | L2400_DTP_SVC_RD8_2 | End Date | Service (D8) |
L2400 | DTP | Date - Prescription Date | ||
03 | L2400_DTP_RX_D8 | Start Date | Prescription (D8) |
L2400 | DTP | DATE - Certification Revision/Recertification Date | ||
03 | L2400_DTP_CERT_RVSN_D8 | Start Date | Certification Revision (D8) |
L2400 | DTP | Date - Begin Therapy Date | ||
03 | L2400_DTP_BGN_THRPY_D8 | Start Date | Begin Therapy (D8) |
L2400 | DTP | Date - Last Certification Date | ||
03 | L2400_DTP_LAST_CERT_D8 | Start Date | Last Certification (D8) |
L2400 | DTP | Date - Last Seen Date | ||
03 | L2400_DTP_LAST_VST_D8 | Start Date | Latest Visit or Consultation (D8) |
L2400 | DTP | Date - Test Date | ||
03 | L2400_DTP_HEMOHEMA_D8 | Start Date | Most Recent Hemoglobin or Hematocrit or Both (D8) | |
03 | L2400_DTP_CREATINE_D8 | Start Date | Most Recent Serum Creatine (D8) |
L2400 | DTP | Date - Shipped Date | ||
03 | L2400_DTP_SHPD_D8 | Start Date | Shipped (D8) |
L2400 | DTP | Date - Last X-ray Date | ||
03 | L2400_DTP_XRAY_D8 | Start Date | Last X-Ray (D8) |
L2400 | DTP | Date - Initial Treatment Date | ||
03 | L2400_DTP_INIT_TRTMT_D8 | Start Date | Initial Treatment (D8) |
L2400 | QTY | Ambulance Patient Count | ||
02 | L2400_QTY02_PAT | Date Timestamp | Patients |
L2400 | QTY | Obstetric Anesthesia Additional Units | ||
02 | L2400_QTY02_UN | Date Timestamp | Units |
L2400 | MEA | Test Result |
Iterated: [01-05] | |
01 | L2400_nnMEA01_MSMT_REF_ID | String | Measurement Reference Identification Code | |
03 | L2400_nnMEA03_HGT | Decimal | Height | |
03 | L2400_nnMEA03_HEMOGLOB | Decimal | Hemoglobin | |
03 | L2400_nnMEA03_HEMATOCRIT | Decimal | Hematocrit | |
03 | L2400_nnMEA03_EPOTN_STRT_DSG | Decimal | Epoetin Starting Dosage | |
03 | L2400_nnMEA03_CREATININE | Decimal | Creatinine |
L2400 | CN1 | Contract Information | ||
01 | L2400_CN101_CNTRCT_TYP_CD | String | Contract Type Code | |
02 | L2400_CN102_CONTRCT_AMT | Decimal | Contract Amount | |
03 | L2400_CN103_CONTRCT_PERC | Decimal | Contract Percentage | |
04 | L2400_CN104_CONTRCT_CD | String | Contract Code | |
05 | L2400_CN105_TERMS_DISCT_PERC | Decimal | Terms Discount Percentage | |
06 | L2400_CN106_CONTRCT_VERS_ID | String | Contract Version Identifier |
L2400 | REF | Repriced Line Item Reference Number | ||
02 | L2400_REF_REP_LIN_ITM | String | Repriced Line Item Reference Number |
L2400 | REF | Adjusted Repriced Line Item Reference Number | ||
02 | L2400_REF_ADJ_REP_LIN_ITM | String | Adjusted Repriced Line Item Reference Number |
L2400 | REF | Prior Authorization |
Iterated: [01-05] | |
02 | L2400_nnREF_PRIOR_AUTH | String | Prior Authorization Number | |
04 | 02 | L2400_nnREF0402_PYR_ID | String | Payer Identification Number |
L2400 | REF | Line Item Control Number | ||
02 | L2400_REF_PRV_CTL_NR | String | Provider Control Number |
L2400 | REF | Mammography Certification Number | ||
02 | L2400_REF_MAMM_CERT | String | Mammography Certification Number |
L2400 | REF | Clinical Laboratory Improvement Amendment (CLIA) Number | ||
02 | L2400_REF_LAB_IMP_AMD | String | Clinical Laboratory Improvement Amendment Number |
L2400 | REF | Referring Clinical Laboratory Improvement Amendment (CLIA) Facility Identification | ||
02 | L2400_REF_FAC_CERT_ID | String | Facility Certification Number |
L2400 | REF | Immunization Batch Number | ||
02 | L2400_REF_BATCH_NR | String | Batch Number |
L2400 | REF | Referral Number |
Segment Suffix: Iterated: [01-05] | |
02 | L2400_nnREFB_REFRL_NR | String | Referral Number | |
04 | 02 | L2400_nnREFB0402_PYR_ID | String | Payer Identification Number |
L2400 | AMT | Sales Tax Amount | ||
02 | L2400_AMT02_TAX | Date Timestamp | Tax |
L2400 | AMT | Postage Claimed Amount | ||
02 | L2400_AMT02_POSTG_CLMD | Date Timestamp | Postage Claimed |
L2400 | K3 | File Information |
Iterated: [01-10] | |
01 | L2400_nnK301_FIXD_FMT_NFO | String | Fixed Format Information |
L2400 | NTE | Line Note | ||
02 | L2400_NTE02_ADDL_NFO | String | Additional Information | |
02 | L2400_NTE02_GOALS_DISCHG_PLN | String | Goals, Rehabilitation Potential, or Discharge Plans |
L2400 | NTE | Third Party Organization Notes |
Segment Suffix: | |
02 | L2400_NTED02_LIN_NOT_TXT | String | Line Note Text |
L2400 | PS1 | Purchased Service Information | ||
01 | L2400_PS101_PURCH_SVC_PVR_ID | String | Purchased Service Provider Identifier | |
02 | L2400_PS102_PURCH_SVC_CHG_AMT | Decimal | Purchased Service Charge Amount |
L2400 | HCP | Line Pricing/Repricing Information | ||
01 | L2400_HCP01_PRIC_METHD | String | Pricing Methodology | |
02 | L2400_HCP02_REPRCD_ALLWD_AMT | Decimal | Repriced Allowed Amount | |
03 | L2400_HCP03_REPRCD_SAVNG_AMT | Decimal | Repriced Saving Amount | |
04 | L2400_HCP04_REPRCNG_ORG_ID | String | Repricing Organization Identifier | |
05 | L2400_HCP05_REPRCD_PERDIEM_AMT | Decimal | Repricing Per Diem or Flat Rate Amount | |
06 | L2400_HCP06_REP_AMB_PT_GRP | String | Repriced Approved Ambulatory Patient Group | |
07 | L2400_HCP07_REP_AMB_PT_GRP | Decimal | Repriced Approved Ambulatory Patient Group | |
10 | L2400_HCP10_JS_PRC_SPY_CD | String | Jurisdiction Specific Procedure and Supply Codes | |
10 | L2400_HCP10_HCPCS_CD | String | Health Care Financing Administration Common Procedural Coding System (HCPCS) Codes | |
10 | L2400_HCP10_HIC_PRD_SVCCD | String | Home Infusion EDI Coalition (HIEC) Product/Service Code | |
10 | L2400_HCP10_ABC_CD | String | Advanced Billing Concepts (ABC) Codes | |
12 | L2400_HCP12_MIN | Decimal | Minutes | |
12 | L2400_HCP12_UN | Decimal | Unit | |
13 | L2400_HCP13_REJ_RSN_CD | String | Reject Reason Code | |
14 | L2400_HCP14_POLCY_COMP_CD | String | Policy Compliance Code | |
15 | L2400_HCP15_EXCPTN_CD | String | Exception Code |
L2410 - DRUG IDENTIFICATION |
L2410 | LIN | Drug Identification | ||
03 | L2410_LIN03_NDC | String | National Drug Code |
L2410 | CTP | Drug Quantity | ||
04 | L2410_CTP04_NATL_DRG_UNIT_CT | Decimal | National Drug Unit Count | |
05 | 01 | L2410_CTP0501_CD_QUAL | String | Code Qualifier |
L2410 | REF | Prescription or Compound Drug Association Number | ||
02 | L2410_REF_LNK_SEQ_NR | String | Link Sequence Number | |
02 | L2410_REF_PHRM_RX_NR | String | Pharmacy Prescription Number |
L2420A - RENDERING PROVIDER NAME |
L2420A | NM1 | Rendering Provider Name | ||
03 | L2420A_NM103_PERSN_LNM | String | Person Last Name | |
03 | L2420A_NM103_NONPSNENT_NM | String | Non-Person Entity Name | |
04 | L2420A_NM104_REND_PVR_FNM | String | Rendering Provider First Name | |
05 | L2420A_NM105_REND_PVR_MNM | String | Rendering Provider Middle Name or Initial | |
07 | L2420A_NM107_REND_PROV_SFX | String | Rendering Provider Name Suffix | |
09 | L2420A_NM109_REND_PROV_ID | String | Rendering Provider Identifier |
L2420A | PRV | Rendering Provider Specialty Information | ||
03 | L2420A_PRV03_PVR_TAX_CD | String | Provider Taxonomy Code |
L2420A | REF | Rendering Provider Secondary Identification |
Iterated: [01-20] | |
02 | L2420A_nnREF_STAT_LIC_NR | String | State License Number | |
02 | L2420A_nnREF_UPIN | String | Provider UPIN Number | |
02 | L2420A_nnREF_PVR_COMM_NR | String | Provider Commercial Number | |
02 | L2420A_nnREF_LOC_NR | String | Location Number | |
04 | 02 | L2420A_nnREF0402_PYR_ID | String | Payer Identification Number |
L2420B - PURCHASED SERVICE PROVIDER NAME |
L2420B | NM1 | Purchased Service Provider Name | ||
02 | L2420B_NM102_ENT_TYP_QUAL | String | Entity Type Qualifier | |
09 | L2420B_NM109_PURCH_SVC_PVR_ID | String | Purchased Service Provider Identifier |
L2420B | REF | Purchased Service Provider Secondary Identification |
Iterated: [01-20] | |
02 | L2420B_nnREF_STAT_LIC_NR | String | State License Number | |
02 | L2420B_nnREF_UPIN | String | Provider UPIN Number | |
02 | L2420B_nnREF_PVR_COMM_NR | String | Provider Commercial Number | |
04 | 02 | L2420B_nnREF0402_PYR_ID | String | Payer Identification Number |
L2420C - SERVICE FACILITY LOCATION NAME |
L2420C | NM1 | Service Facility Location Name | ||
03 | L2420C_NM103_LAB_FAC_NM | String | Laboratory or Facility Name | |
09 | L2420C_NM109_LAB_FAC_PRI_ID | String | Laboratory or Facility Primary Identifier |
L2420C | N3 | Service Facility Location Address | ||
01 | L2420C_N301_LAB_FAC_ADDR | String | Laboratory or Facility Address Line | |
02 | L2420C_N302_LAB_FAC_ADDR | String | Laboratory or Facility Address Line |
L2420C | N4 | Service Facility Location City, State, ZIP Code | ||
01 | L2420C_N401_LAB_FAC_CITY | String | Laboratory or Facility City Name | |
02 | L2420C_N402_LAB_FAC_STAT | String | Laboratory or Facility State or Province Code | |
03 | L2420C_N403_LAB_ZIP | String | Laboratory or Facility Postal Zone or ZIP Code | |
04 | L2420C_N404_CNTRY_CD | String | Country Code | |
07 | L2420C_N407_CNTRY_SUBDV_CD | String | Country Subdivision Code |
L2420C | REF | Service Facility Location Secondary Identification |
Iterated: [01-03] | |
02 | L2420C_nnREF_PVR_COMM_NR | String | Provider Commercial Number | |
02 | L2420C_nnREF_LOC_NR | String | Location Number | |
02 | L2420C_nnREF_STAT_LIC_NR | String | State License Number | |
02 | L2420C_nnREF_UPIN | String | Provider UPIN Number | |
04 | 02 | L2420C_nnREF0402_PYR_ID | String | Payer Identification Number |
L2420D - SUPERVISING PROVIDER NAME |
L2420D | NM1 | Supervising Provider Name | ||
03 | L2420D_NM103_SUP_PVR_LNM | String | Supervising Provider Last Name | |
04 | L2420D_NM104_SUP_PVR_FNM | String | Supervising Provider First Name | |
05 | L2420D_NM105_SUP_PVR_MNM | String | Supervising Provider Middle Name or Initial | |
07 | L2420D_NM107_SUP_PVR_SFX | String | Supervising Provider Name Suffix | |
09 | L2420D_NM109_SUP_PVR_ID | String | Supervising Provider Identifier |
L2420D | REF | Supervising Provider Secondary Identification |
Iterated: [01-20] | |
02 | L2420D_nnREF_STAT_LIC_NR | String | State License Number | |
02 | L2420D_nnREF_UPIN | String | Provider UPIN Number | |
02 | L2420D_nnREF_PVR_COMM_NR | String | Provider Commercial Number | |
02 | L2420D_nnREF_LOC_NR | String | Location Number | |
04 | 02 | L2420D_nnREF0402_PYR_ID | String | Payer Identification Number |
L2420E - ORDERING PROVIDER NAME |
L2420E | NM1 | Ordering Provider Name | ||
03 | L2420E_NM103_ORD_PVR_LNM | String | Ordering Provider Last Name | |
04 | L2420E_NM104_ORD_PVR_FNM | String | Ordering Provider First Name | |
05 | L2420E_NM105_ORD_PVR_MNM | String | Ordering Provider Middle Name or Initial | |
07 | L2420E_NM107_ORD_PVR_SFX | String | Ordering Provider Name Suffix | |
09 | L2420E_NM109_ORD_PVR_ID | String | Ordering Provider Identifier |
L2420E | N3 | Ordering Provider Address | ||
01 | L2420E_N301_ORD_PVR_ADDR | String | Ordering Provider Address Line | |
02 | L2420E_N302_ORD_PVR_ADDR | String | Ordering Provider Address Line |
L2420E | N4 | Ordering Provider City, State, ZIP Code | ||
01 | L2420E_N401_ORD_PVR_CITY | String | Ordering Provider City Name | |
02 | L2420E_N402_ORD_PVR_STAT | String | Ordering Provider State or Province Code | |
03 | L2420E_N403_ORD_PVR_ZIP | String | Ordering Provider Postal Zone or ZIP Code | |
04 | L2420E_N404_CNTRY_CD | String | Country Code | |
07 | L2420E_N407_CNTRY_SUBDV_CD | String | Country Subdivision Code |
L2420E | REF | Ordering Provider Secondary Identification |
Iterated: [01-20] | |
02 | L2420E_nnREF_STAT_LIC_NR | String | State License Number | |
02 | L2420E_nnREF_UPIN | String | Provider UPIN Number | |
02 | L2420E_nnREF_PVR_COMM_NR | String | Provider Commercial Number | |
04 | 02 | L2420E_nnREF0402_PYR_ID | String | Payer Identification Number |
L2420E | PER | Ordering Provider Contact Information | ||
02 | L2420E_PER02_ORD_PVR_CON_NM | String | Ordering Provider Contact Name | |
04 | L2420E_PER04_EMAIL | String | Electronic Mail | |
04 | L2420E_PER04_FAX | String | Facsimile | |
04 | L2420E_PER04_PHN_NR | String | Telephone | |
06 | L2420E_PER06_EMAIL | String | Electronic Mail | |
06 | L2420E_PER06_PHN_EXT | String | Telephone Extension | |
06 | L2420E_PER06_FAX | String | Facsimile | |
06 | L2420E_PER06_PHN_NR | String | Telephone | |
08 | L2420E_PER08_EMAIL | String | Electronic Mail | |
08 | L2420E_PER08_PHN_EXT | String | Telephone Extension | |
08 | L2420E_PER08_FAX | String | Facsimile | |
08 | L2420E_PER08_PHN_NR | String | Telephone |
L2420F - REFERRING PROVIDER NAME (Value Qualified) |
Mapping Prefix: L2420F_DN - Referring Provider |
Mapping Prefix: L2420F_P3 - Primary Care Provider |
L2420F | NM1 | Referring Provider Name | ||
03 | L2420F_yy_NM103_REF_PVR_LNM | String | Referring Provider Last Name | |
04 | L2420F_yy_NM104_REF_PVR_FNM | String | Referring Provider First Name | |
05 | L2420F_yy_NM105_REF_PVR_MNM | String | Referring Provider Middle Name or Initial | |
07 | L2420F_yy_NM107_REF_PVR_SFX | String | Referring Provider Name Suffix | |
09 | L2420F_yy_NM109_REF_PVR_ID | String | Referring Provider Identifier |
L2420F | REF | Referring Provider Secondary Identification |
Iterated: [01-20] | |
02 | L2420F_yy_nnREF_STAT_LIC_NR | String | State License Number | |
02 | L2420F_yy_nnREF_UPIN | String | Provider UPIN Number | |
02 | L2420F_yy_nnREF_PVR_COMM_NR | String | Provider Commercial Number | |
04 | 02 | L2420F_yy_nnREF0402_PYR_ID | String | Payer Identification Number |
L2420G - AMBULANCE PICK-UP LOCATION |
L2420G | NM1 | Ambulance Pick-up Location |
L2420G | N3 | Ambulance Pick-up Location Address | ||
01 | L2420G_N301_AMB_PU_ADDR | String | Ambulance Pick-up Address Line | |
02 | L2420G_N302_AMB_PU_ADDR | String | Ambulance Pick-up Address Line |
L2420G | N4 | Ambulance Pick-up Location City, State, ZIP Code | ||
01 | L2420G_N401_AMB_PCKUP_CITY | String | Ambulance Pick-up City Name | |
02 | L2420G_N402_AMB_PKUP_STAT | String | Ambulance Pick-up State or Province Code | |
03 | L2420G_N403_AMB_PCKUP_ZIP | String | Ambulance Pick-up Postal Zone or ZIP Code | |
04 | L2420G_N404_CNTRY_CD | String | Country Code | |
07 | L2420G_N407_CNTRY_SUBDV_CD | String | Country Subdivision Code |
L2420H - AMBULANCE DROP-OFF LOCATION |
L2420H | NM1 | Ambulance Drop-off Location | ||
03 | L2420H_NM103_AMB_DROPOFF_LOC | String | Ambulance Drop-off Location |
L2420H | N3 | Ambulance Drop-off Location Address | ||
01 | L2420H_N301_AMB_DROPOFF_ADDR | String | Ambulance Drop-off Address Line | |
02 | L2420H_N302_AMB_DROPOFF_ADDR | String | Ambulance Drop-off Address Line |
L2420H | N4 | Ambulance Drop-off Location City, State, ZIP Code | ||
01 | L2420H_N401_AMB_DRPOFF_CITY | String | Ambulance Drop-off City Name | |
02 | L2420H_N402_AMB_DRPOFF_STAT | String | Ambulance Drop-off State or Province Code | |
03 | L2420H_N403_AMB_DROPOFF_ZIP | String | Ambulance Drop-off Postal Zone or ZIP Code | |
04 | L2420H_N404_CNTRY_CD | String | Country Code | |
07 | L2420H_N407_CNTRY_SUBDV_CD | String | Country Subdivision Code |
L2430 - LINE ADJUDICATION INFORMATION (Single Iteration) |
L2430 | SVD | Line Adjudication Information | ||
01 | L2430_xx_SVD01_OPYR_PRI_ID | String | Other Payer Primary Identifier | |
02 | L2430_xx_SVD02_SVC_LIN_PD_AMT | Decimal | Service Line Paid Amount | |
03 | 02 | L2430_xx_SVD0302_JS_PRC_SPY_CD | String | Jurisdiction Specific Procedure and Supply Codes |
03 | 02 | L2430_xx_SVD0302_HCPCS_CD | String | Health Care Financing Administration Common Procedural Coding System (HCPCS) Codes |
03 | 02 | L2430_xx_SVD0302_HIC_PRD_SVCCD | String | Home Infusion EDI Coalition (HIEC) Product/Service Code |
03 | 02 | L2430_xx_SVD0302_ABC_CD | String | Advanced Billing Concepts (ABC) Codes |
03 | 03 | L2430_xx_SVD0303_PROC_MOD | String | Procedure Modifier |
03 | 04 | L2430_xx_SVD0304_PROC_MOD | String | Procedure Modifier |
03 | 05 | L2430_xx_SVD0305_PROC_MOD | String | Procedure Modifier |
03 | 06 | L2430_xx_SVD0306_PROC_MOD | String | Procedure Modifier |
03 | 07 | L2430_xx_SVD0307_PROC_CD_DESC | String | Procedure Code Description |
05 | L2430_xx_SVD05_PD_SVC_UN_CT | Decimal | Paid Service Unit Count | |
06 | L2430_xx_SVD06_BND_UNBND_LN_NR | Integer | Bundled or Unbundled Line Number |
L2430 | CAS | Line Adjustment |
Iterated: [01-05] | |
01 | L2430_xx_nnCAS01_CLMADJ_GRP_CD | String | Claim Adjustment Group Code | |
02 | L2430_xx_nnCAS02_ADJ_RSN_CD | String | Adjustment Reason Code | |
03 | L2430_xx_nnCAS03_ADJ_AMT | Decimal | Adjustment Amount | |
04 | L2430_xx_nnCAS04_ADJ_QTY | Decimal | Adjustment Quantity | |
05 | L2430_xx_nnCAS05_ADJ_RSN_CD | String | Adjustment Reason Code | |
06 | L2430_xx_nnCAS06_ADJ_AMT | Decimal | Adjustment Amount | |
07 | L2430_xx_nnCAS07_ADJ_QTY | Decimal | Adjustment Quantity | |
08 | L2430_xx_nnCAS08_ADJ_RSN_CD | String | Adjustment Reason Code | |
09 | L2430_xx_nnCAS09_ADJ_AMT | Decimal | Adjustment Amount | |
10 | L2430_xx_nnCAS10_ADJ_QTY | Decimal | Adjustment Quantity | |
11 | L2430_xx_nnCAS11_ADJ_RSN_CD | String | Adjustment Reason Code | |
12 | L2430_xx_nnCAS12_ADJ_AMT | Decimal | Adjustment Amount | |
13 | L2430_xx_nnCAS13_ADJ_QTY | Decimal | Adjustment Quantity | |
14 | L2430_xx_nnCAS14_ADJ_RSN_CD | String | Adjustment Reason Code | |
15 | L2430_xx_nnCAS15_ADJ_AMT | Decimal | Adjustment Amount | |
16 | L2430_xx_nnCAS16_ADJ_QTY | Decimal | Adjustment Quantity | |
17 | L2430_xx_nnCAS17_ADJ_RSN_CD | String | Adjustment Reason Code | |
18 | L2430_xx_nnCAS18_ADJ_AMT | Decimal | Adjustment Amount | |
19 | L2430_xx_nnCAS19_ADJ_QTY | Decimal | Adjustment Quantity |
L2430 | DTP | Line Check or Remittance Date | ||
03 | L2430_xx_DTP_CLM_PD_D8 | Start Date | Date Claim Paid (D8) |
L2430 | AMT | Remaining Patient Liability | ||
02 | L2430_xx_AMT02_AMT_OWED | Date Timestamp | Amount Owed |
L2440 - FORM IDENTIFICATION CODE |
L2440 | LQ | Form Identification Code | ||
02 | L2440_LQ02_FORM_TYP_CD | String | Form Type Code | |
02 | L2440_LQ02_CMS_DME_REG_CARR | String | Centers for Medicare and Medicaid Services (CMS) Durable Medical Equipment Regional Carrier |
L2440 | FRM | Supporting Documentation |
Iterated: [01-99] | |
01 | L2440_nnFRM01_QUESTN_NR_LTR | String | Question Number/Letter | |
02 | L2440_nnFRM02_QUESTN_RESP | String | Question Response | |
03 | L2440_nnFRM03_QUESTN_RESP | String | Question Response | |
04 | L2440_nnFRM04_QUESTN_RESP_D8 | Date/Time | Question Response | |
05 | L2440_nnFRM05_QUESTN_RESP | Decimal | Question Response |
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 |