5010 Health Care Claim Status Request [O0]


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)

ISA - GROUP HEADERS
ISAISAInterchange Control Header
02ISA_ISA02_NO_AUTH_NFOStringNo Authorization Information Present
02ISA_ISA02_ADDL_DATA_IDStringAdditional Data Identification
04ISA_ISA04_NO_SEC_NFOStringNo Security Information Present
04ISA_ISA04_PSSWDStringPassword
06ISA_ISA06_DUN_BRDSTStringDun and Brandstreet
06ISA_ISA06_DUN_BRDST_SFXStringDuns Plus Suffix
06ISA_ISA06_HINStringHealth Industry Number
06ISA_ISA06_CARR_IDStringCarrier Identification Number as assigned by Health Care Financing Administration
06ISA_ISA06_HCFA_FIINStringFiscal Intermediary Identification Number as assigned by Health Care Financing Administration
06ISA_ISA06_HCFA_IDStringMedicare Provider and Supplier Identification Number as assigned by Health Care Financing Administration
06ISA_ISA06_TAX_IDStringUS Federal Tax Identification Number
06ISA_ISA06_NAIC_CDStringNational Association of Insurance Commissioners Company Code
06ISA_ISA06_MUTLY_DEFStringMutually Defined
08ISA_ISA08_DUN_BRDSTStringDun and Brandstreet
08ISA_ISA08_DUN_BRDST_SFXStringDuns Plus Suffix
08ISA_ISA08_HINStringHealth Industry Number
08ISA_ISA08_CARR_IDStringCarrier Identification Number as assigned by Health Care Financing Administration
08ISA_ISA08_HCFA_FIINStringFiscal Intermediary Identification Number as assigned by Health Care Financing Administration
08ISA_ISA08_HCFA_IDStringMedicare Provider and Supplier Identification Number as assigned by Health Care Financing Administration
08ISA_ISA08_TAX_IDStringUS Federal Tax Identification Number
08ISA_ISA08_NAIC_CDStringNational Association of Insurance Commissioners Company Code
08ISA_ISA08_MUTLY_DEFStringMutually Defined
09ISA_ISA09_INTCHG_DTDate (YYMMDD)Interchange Date
10ISA_ISA10_INTCHG_TMTime (HHMM)Interchange Time
11ISA_ISA11_REPTN_SEPStringRepetition Separator
12ISA_ISA12_ICN_VERS_NRStringInterchang Control Version Number
13ISA_ISA13_ICNIntegerInterchange Control Number
14ISA_ISA14_ACK_REQStringAcknowledgment Requested
15ISA_ISA15_ICN_USG_INDStringInterchange Usage Indicator
16ISA_ISA16_COMP_ELE_SEPStringComponent Element Separator
GSHDR - GROUP HEADER
GSHDRGSFunctional Group Header
02GSHDR_GS02_APP_SNDR_CDStringApplication Senders Code
03GSHDR_GS03_APP_RCV_CDStringApplication Receivers Code
04GSHDR_GS04_D8Date (YYYYMMDD)Date
05GSHDR_GS05_TMTime (HHMM)Time
05GSHDR_GS05_TM8Time (HHMMSSCC)Time
06GSHDR_GS06_GCNIntegerGroup Control Number
STHDR - TRANSACTION SET HEADER
STHDRSTTransaction Set Header
02STHDR_ST02_TCNStringTransaction Set Control Number
03STHDR_ST03_VERS_REL_IND_IDStringVersion, Release, or Industry Identifier
STHDRBHTBeginning of Hierarchical Transaction
01STHDR_BHT01_HIER_STRUC_CDStringHierarchical Structure Code
03STHDR_BHT03_REF_IDStringReference Identification
04STHDR_BHT04_TS_CRTN_D8Date (YYYYMMDD)Transaction Set Creation Date
05STHDR_BHT05_TS_CRTN_TMTime (HHMM)Transaction Set Creation Time
05STHDR_BHT05_TS_CRTN_TM8Time (HHMMSSCC)Transaction Set Creation Time
L2000A - INFORMATION SOURCE LEVEL
L2000AHLInformation Source Level
01L2000A_HL01_HIER_ID_NRStringHierarchical ID Number
L2100A - PAYER NAME
L2100ANM1Payer Name
03L2100A_NM103_NONPSNENT_NMStringNon-Person Entity Name
09L2100A_NM109_PAYR_IDStringPayor Identification
09L2100A_NM109_HCFA_PLAN_IDStringCenters for Medicare and Medicaid Services PlanID
L2000B - INFORMATION RECEIVER LEVEL
L2000BHLInformation Receiver Level
01L2000B_HL01_HIER_ID_NRStringHierarchical ID Number
02L2000B_HL02_HIER_PARNT_ID_NRStringHierarchical Parent ID Number
L2100B - INFORMATION RECEIVER NAME
L2100BNM1Information Receiver Name
02L2100B_NM102_ENT_TYP_QUALStringEntity Type Qualifier
03L2100B_NM103_NFO_RCV_NMStringInformation Receiver Last or Organization Name
04L2100B_NM104_NFO_REC_FNMStringInformation Receiver First Name
05L2100B_NM105_NFO_REC_MNMStringInformation Receiver Middle Name
09L2100B_NM109_ETN_NRStringElectronic Transmitter Identification Number (ETIN)
L2000C - SERVICE PROVIDER LEVEL
L2000CHLService Provider Level
01L2000C_HL01_HIER_ID_NRStringHierarchical ID Number
02L2000C_HL02_HIER_PARNT_ID_NRStringHierarchical Parent ID Number
L2100C - PROVIDER NAME (Single Iteration)
L2100CNM1Provider Name
02L2100C_xx_NM102_ENT_TYP_QUALStringEntity Type Qualifier
03L2100C_xx_NM103_PVR_LNMStringProvider Last or Organization Name
04L2100C_xx_NM104_PVR_FNMStringProvider First Name
05L2100C_xx_NM105_PVR_MNMStringProvider Middle Name
07L2100C_xx_NM107_PVR_SFXStringProvider Name Suffix
09L2100C_xx_NM109_TAX_IDStringFederal Taxpayer's Identification Number
09L2100C_xx_NM109_SVC_PROV_NRStringService Provider Number
09L2100C_xx_NM109_NPIStringCenters for Medicare and Medicaid Services National Provider Identifier
L2000D - SUBSCRIBER LEVEL
L2000DHLSubscriber Level
01L2000D_HL01_HIER_ID_NRStringHierarchical ID Number
02L2000D_HL02_HIER_PARNT_ID_NRStringHierarchical Parent ID Number
04L2000D_HL04_HL_CHLD_CDStringHierarchical Child Code
L2000DDMGSubscriber Demographic Information
02L2000D_DMG02_D8DateTimeSubscriber Birth Date
03L2000D_DMG03_SUB_GENDR_CDStringSubscriber Gender Code
L2100D - SUBSCRIBER NAME
L2100DNM1Subscriber Name
03L2100D_NM103_PERSN_LNMStringPerson Last Name
03L2100D_NM103_NONPSNENT_NMStringNon-Person Entity Name
04L2100D_NM104_SBR_FNMStringSubscriber First Name
05L2100D_NM105_SBR_MNMStringSubscriber Middle Name or Initial
07L2100D_NM107_SBR_SFXStringSubscriber Name Suffix
09L2100D_NM109_EMPLYR_IDStringEmployer's Identification Number
09L2100D_NM109_UNQ_HLTH_IDStringStandard Unique Health Identifier for each Individual in the United States
09L2100D_NM109_MEM_ID_NRStringMember Identification Number
L2200D - CLAIM STATUS TRACKING NUMBER
L2200DTRNClaim Status Tracking Number
02L2200D_TRN02_CUR_TRANS_TRAC_NRStringCurrent Transaction Trace Number
L2200DREFPayer Claim Control Number
02L2200D_REF_PYR_CLM_NRStringPayor's Claim Number
L2200DREFInstitutional Bill Type Identification
02L2200D_REF_BILL_TYPStringBilling Type
L2200DREFApplication or Location System Identifier
02L2200D_REF_LOC_NRStringLocation Number
L2200DREFGroup Number
02L2200D_REF_GRP_NRStringGroup Number
L2200DREFPatient Control Number
02L2200D_REF_PATNT_ACCT_NRStringPatient Account Number
L2200DREFPharmacy Prescription Number
02L2200D_REF_PHRM_RX_NRStringPharmacy Prescription Number
L2200DREFClaim Identification Number For Clearinghouses and Other Transmission Intermediaries
02L2200D_REF_CLM_NRStringClaim Number
L2200DAMTClaim Submitted Charges
02L2200D_AMT02_TOT_SUB_CHGSNumberTotal Submitted Charges
L2200DDTPClaim Service Date
03L2200D_DTP_SVC_D8Date (YYYYMMDD)Service Date
03L2200D_DTP_SVC_RD8_1Start Date (YYYYMMDD)Service Date
03L2200D_DTP_SVC_RD8_2End Date (YYYYMMDD)Service Date
L2210D - SERVICE LINE INFORMATION
L2210DSVCService Line Information
0102L2210D_SVC0102_ADA_CDStringAmerican Dental Association Codes
0102L2210D_SVC0102_JS_PRC_SPY_CDStringJurisdiction Specific Procedure and Supply Codes
0102L2210D_SVC0102_HCPCS_CDStringHealth Care Financing Administration Common Procedural Coding System (HCPCS) Codes
0102L2210D_SVC0102_HIPPA_SNF_RT_CDStringHealth Insurance Prospective Payment System (HIPPS) Skilled Nursing Facility Rate Code
0102L2210D_SVC0102_HIC_PRD_SVCCDStringHome Infusion EDI Coalition (HIEC) Product/Service
0102L2210D_SVC0102_NDC542StringNational Drug Code in 5-4-2 Format
0102L2210D_SVC0102_NUBC_UB92_CDStringNational Uniform Billing Committee (NUBC) UB92
0102L2210D_SVC0102_ABC_CDStringAdvanced Billing Concepts (ABC) Codes
0103L2210D_SVC0103_PROC_MODStringProcedure Modifier
0104L2210D_SVC0104_PROC_MODStringProcedure Modifier
0105L2210D_SVC0105_PROC_MODStringProcedure Modifier
0106L2210D_SVC0106_PROC_MODStringProcedure Modifier
02L2210D_SVC02_LIN_ITM_CHG_AMTNumberLine Item Charge Amount
04L2210D_SVC04_REV_CDStringRevenue Code
07L2210D_SVC07_UN_SVC_CTNumberUnits of Service Count
L2210DREFService Line Item Identification
02L2210D_REF_LIN_ITMStringLine Item Control Number
L2210DDTPService Line Date
03L2210D_DTP_SVC_D8Date (YYYYMMDD)Service Date
03L2210D_DTP_SVC_RD8_1Start Date (YYYYMMDD)Service Date
03L2210D_DTP_SVC_RD8_2End Date (YYYYMMDD)Service Date
L2000E - DEPENDENT LEVEL
L2000EHLDependent Level
01L2000E_HL01_HIER_ID_NRStringHierarchical ID Number
02L2000E_HL02_HIER_PARNT_ID_NRStringHierarchical Parent ID Number
L2000EDMGDependent Demographic Information
02L2000E_DMG02_D8DateTimePatient Birth Date
03L2000E_DMG03_PAT_GNDR_CDStringPatient Gender Code
L2100E - DEPENDENT NAME
L2100ENM1Dependent Name
03L2100E_NM103_PERSN_LNMStringPerson Last Name
04L2100E_NM104_PT_FNMStringPatient First Name
05L2100E_NM105_PT_MNMStringPatient Middle Name or Initial
07L2100E_NM107_PT_SFXStringPatient Name Suffix
L2200E - CLAIM STATUS TRACKING NUMBER
L2200ETRNClaim Status Tracking Number
02L2200E_TRN02_CUR_TRANS_TRAC_NRStringCurrent Transaction Trace Number
L2200EREFPayer Claim Control Number
02L2200E_REF_PYR_CLM_NRStringPayor's Claim Number
L2200EREFInstitutional Bill Type Identification
02L2200E_REF_BILL_TYPStringBilling Type
L2200EREFApplication or Location System Identifier
02L2200E_REF_LOC_NRStringLocation Number
L2200EREFGroup Number
02L2200E_REF_GRP_NRStringGroup Number
L2200EREFPatient Control Number
02L2200E_REF_PATNT_ACCT_NRStringPatient Account Number
L2200EREFPharmacy Prescription Number
02L2200E_REF_PHRM_RX_NRStringPharmacy Prescription Number
L2200EREFClaim Identification Number For Clearinghouses and Other Transmission Intermediaries
02L2200E_REF_CLM_NRStringClaim Number
L2200EAMTClaim Submitted Charges
02L2200E_AMT02_TOT_SUB_CHGSNumberTotal Submitted Charges
L2200EDTPClaim Service Date
03L2200E_DTP_SVC_D8Date (YYYYMMDD)Service Date
03L2200E_DTP_SVC_RD8_1Start Date (YYYYMMDD)Service Date
03L2200E_DTP_SVC_RD8_2End Date (YYYYMMDD)Service Date
L2210E - SERVICE LINE INFORMATION
L2210ESVCService Line Information
0102L2210E_SVC0102_ADA_CDStringAmerican Dental Association Codes
0102L2210E_SVC0102_JS_PRC_SPY_CDStringJurisdiction Specific Procedure and Supply Codes
0102L2210E_SVC0102_HCPCS_CDStringHealth Care Financing Administration Common Procedural Coding System (HCPCS) Codes
0102L2210E_SVC0102_HIPPA_SNF_RT_CDStringHealth Insurance Prospective Payment System (HIPPS) Skilled Nursing Facility Rate Code
0102L2210E_SVC0102_HIC_PRD_SVCCDStringHome Infusion EDI Coalition (HIEC) Product/Service
0102L2210E_SVC0102_NDC542StringNational Drug Code in 5-4-2 Format
0102L2210E_SVC0102_NUBC_UB92_CDStringNational Uniform Billing Committee (NUBC) UB92
0102L2210E_SVC0102_ABC_CDStringAdvanced Billing Concepts (ABC) Codes
0103L2210E_SVC0103_PROC_MODStringProcedure Modifier
0104L2210E_SVC0104_PROC_MODStringProcedure Modifier
0105L2210E_SVC0105_PROC_MODStringProcedure Modifier
0106L2210E_SVC0106_PROC_MODStringProcedure Modifier
02L2210E_SVC02_LIN_ITM_CHG_AMTNumberLine Item Charge Amount
04L2210E_SVC04_REV_CDStringRevenue Code
07L2210E_SVC07_UN_SVC_CTNumberUnits of Service Count
L2210EREFService Line Item Identification
02L2210E_REF_LIN_ITMStringLine Item Control Number
L2210EDTPService Line Date
03L2210E_DTP_SVC_D8Date (YYYYMMDD)Service Date
03L2210E_DTP_SVC_RD8_1Start Date (YYYYMMDD)Service Date
03L2210E_DTP_SVC_RD8_2End Date (YYYYMMDD)Service Date
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
ISAIEAInterchange Control Trailer
01ISA_IEA01_NR_INC_FUNC_GRPIntegerNumber of Included Functional Groups
02ISA_IEA02_ICNIntegerInterchange Control Number