Loop Qualifiersxx - 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 | ISA | Interchange Control Header | | |
02 | | ISA_ISA02_NO_AUTH_NFO | String | No Authorization Information Present |
02 | | ISA_ISA02_ADDL_DATA_ID | String | Additional Data Identification |
04 | | ISA_ISA04_NO_SEC_NFO | String | No Security Information Present |
04 | | ISA_ISA04_PSSWD | String | Password |
06 | | ISA_ISA06_DUN_BRDST | String | Dun and Brandstreet |
06 | | ISA_ISA06_DUN_BRDST_SFX | String | Duns Plus Suffix |
06 | | ISA_ISA06_HIN | String | Health Industry Number |
06 | | ISA_ISA06_CARR_ID | String | Carrier Identification Number as assigned by Health Care Financing Administration |
06 | | ISA_ISA06_HCFA_FIIN | String | Fiscal Intermediary Identification Number as assigned by Health Care Financing Administration |
06 | | ISA_ISA06_HCFA_ID | String | Medicare Provider and Supplier Identification Number as assigned by Health Care Financing Administration |
06 | | ISA_ISA06_TAX_ID | String | US Federal Tax Identification Number |
06 | | ISA_ISA06_NAIC_CD | String | National Association of Insurance Commissioners Company Code |
06 | | ISA_ISA06_MUTLY_DEF | String | Mutually Defined |
08 | | ISA_ISA08_DUN_BRDST | String | Dun and Brandstreet |
08 | | ISA_ISA08_DUN_BRDST_SFX | String | Duns Plus Suffix |
08 | | ISA_ISA08_HIN | String | Health Industry Number |
08 | | ISA_ISA08_CARR_ID | String | Carrier Identification Number as assigned by Health Care Financing Administration |
08 | | ISA_ISA08_HCFA_FIIN | String | Fiscal Intermediary Identification Number as assigned by Health Care Financing Administration |
08 | | ISA_ISA08_HCFA_ID | String | Medicare Provider and Supplier Identification Number as assigned by Health Care Financing Administration |
08 | | ISA_ISA08_TAX_ID | String | US Federal Tax Identification Number |
08 | | ISA_ISA08_NAIC_CD | String | National Association of Insurance Commissioners Company Code |
08 | | ISA_ISA08_MUTLY_DEF | String | Mutually Defined |
09 | | ISA_ISA09_INTCHG_DT | Date (YYMMDD) | Interchange Date |
10 | | ISA_ISA10_INTCHG_TM | Time (HHMM) | Interchange Time |
11 | | ISA_ISA11_REPTN_SEP | String | Repetition Separator |
12 | | ISA_ISA12_ICN_VERS_NR | String | Interchang Control Version Number |
13 | | ISA_ISA13_ICN | Integer | Interchange Control Number |
14 | | ISA_ISA14_ACK_REQ | String | Acknowledgment Requested |
15 | | ISA_ISA15_ICN_USG_IND | String | Interchange Usage Indicator |
16 | | ISA_ISA16_COMP_ELE_SEP | String | Component Element Separator |
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 (YYYYMMDD) | Date |
05 | | GSHDR_GS05_TM | Time (HHMM) | Time |
05 | | GSHDR_GS05_TM8 | Time (HHMMSSCC) | Time |
06 | | GSHDR_GS06_GCN | Integer | Group Control Number |
STHDR - TRANSACTION SET HEADER |
STHDR | ST | Transaction Set Header | | |
02 | | STHDR_ST02_TCN | String | Transaction Set Control Number |
STHDR | BPR | Financial Information | | |
01 | | STHDR_BPR01_TRANS_HANDL_CD | String | Transaction Handling Code |
02 | | STHDR_BPR02_TOT_ACTL_PVR_PMT | Number | Total Actual Provider Payment Amount |
03 | | STHDR_BPR03_CRED_DEB_FLG_CD | String | Credit or Debit Flag Code |
04 | | STHDR_BPR04_PMT_METHD_CD | String | Payment Method Code |
05 | | STHDR_BPR05_PMT_FMT_CD | String | Payment Format Code |
07 | | STHDR_BPR07_ABA_RT_NR | String | ABA Transit Routing Number Including Check Digits (9 digits) |
07 | | STHDR_BPR07_CAN_BNK_NR | String | Canadian Bank Branch and Institution Number |
09 | | STHDR_BPR09_DEMND_DEPST | String | Demand Deposit |
10 | | STHDR_BPR10_PYR_ID | String | Payer Identifier |
11 | | STHDR_BPR11_ORG_CO_SUPP_CD | String | Originating Company Supplemental Code |
13 | | STHDR_BPR13_ABA_RT_NR | String | ABA Transit Routing Number Including Check Digits (9 digits) |
13 | | STHDR_BPR13_CAN_BNK_NR | String | Canadian Bank Branch and Institution Number |
15 | | STHDR_BPR15_DEMND_DEPST | String | Demand Deposit |
15 | | STHDR_BPR15_SAVNGS | String | Savings |
16 | | STHDR_BPR16_CHK_EFT_EFDT_D8 | Date (YYYYMMDD) | Check Issue or EFT Effective Date |
STHDR | TRN | Reassociation Trace Number | | |
02 | | STHDR_TRN02_CHK_EFT_TRC_NR | String | Check or EFT Trace Number |
03 | | STHDR_TRN03_PYR_ID | String | Payer Identifier |
04 | | STHDR_TRN04_ORG_CO_SUPP_CD | String | Originating Company Supplemental Code |
STHDR | CUR | Foreign Currency Information | | |
02 | | STHDR_CUR02_CURRNCY_CD | String | Currency Code |
STHDR | REF | Receiver Identification | | |
02 | | STHDR_REF_REC_ID_NR | String | Receiver Identification Number |
STHDR | REF | Version Identification | | |
02 | | STHDR_REF_VERS_CD | String | Version Code - Local |
02 | | STHDR_DTM02_PRODCTN | DateTime | Production |
L1000A - PAYER IDENTIFICATION |
L1000A | N1 | Payer Identification | | |
02 | | L1000A_N102_PYR_NM | String | Payer Name |
04 | | L1000A_N104_CMS_PLANID | String | Centers for Medicare and Medicaid Services PlanID |
01 | | L1000A_N301_PYR_ADDR_LN | String | Payer Address Line |
02 | | L1000A_N302_PYR_ADDR_LN | String | Payer Address Line |
L1000A | N4 | Payer City, State, ZIP Code | | |
01 | | L1000A_N401_PYR_CITY_NM | String | Payer City Name |
02 | | L1000A_N402_PYR_STAT | String | Payer State Code |
03 | | L1000A_N403_PYR_ZIP | String | Payer Postal Zone or ZIP Code |
04 | | L1000A_N404_CNTRY_CD | String | Country Code |
07 | | L1000A_N407_CNTRY_SUBDV_CD | String | Country Subdivision Code |
L1000A | REF | Additional Payer Identification | | |
02 | | L1000A_REF_PYR_ID | String | Payer Identification Number |
02 | | L1000A_REF_SUB_ID_NR | String | Submitter Identification Number |
02 | | L1000A_REF_HIN | String | Health Industry Number (HIN) |
02 | | L1000A_REF_NAIC | String | National Association of Insurance Commissioners |
L1000A | PER | Payer Business Contact Information | | |
02 | | L1000A_PER02_PYR_CON_NM | String | Payer Contact Name |
04 | | L1000A_PER04_EMAIL | String | Electronic Mail |
04 | | L1000A_PER04_FAX | String | Facsimile |
04 | | L1000A_PER04_PHN_NR | String | Telephone |
06 | | L1000A_PER06_EMAIL | String | Electronic Mail |
06 | | L1000A_PER06_PHN_EXT | String | Telephone Extension |
06 | | L1000A_PER06_FAX | String | Facsimile |
06 | | L1000A_PER06_PHN_NR | String | Telephone |
08 | | L1000A_PER08_PHN_EXT | String | Telephone Extension |
L1000A | PER | Payer Technical Contact Information | Segment Suffix: B
| |
02 | | L1000A_nnPERB02_PYR_CON_NM | String | Payer Technical Contact Name |
04 | | L1000A_nnPERB04_EMAIL | String | Electronic Mail |
04 | | L1000A_nnPERB04_PHN_NR | String | Telephone |
04 | | L1000A_nnPERB04_URL | String | Uniform Resource Locator (URL) |
06 | | L1000A_nnPERB06_EMAIL | String | Electronic Mail |
06 | | L1000A_nnPERB06_PHN_EXT | String | Telephone Extension |
06 | | L1000A_nnPERB06_FAX | String | Facsimile |
06 | | L1000A_nnPERB06_PHN_NR | String | Telephone |
06 | | L1000A_nnPERB06_URL | String | Uniform Resource Locator (URL) |
08 | | L1000A_nnPERB08_EMAIL | String | Electronic Mail |
08 | | L1000A_nnPERB08_PHN_EXT | String | Telephone Extension |
08 | | L1000A_nnPERB08_FAX | String | Facsimile |
08 | | L1000A_nnPERB08_URL | String | Uniform Resource Locator (URL) |
L1000A | PER | Payer WEB Site | Segment Suffix: C
| |
04 | | L1000A_PERC04_URL | String | Uniform Resource Locator (URL) |
L1000B - PAYEE IDENTIFICATION |
L1000B | N1 | Payee Identification | | |
02 | | L1000B_N102_PAYEE_NM | String | Payee Name |
04 | | L1000B_N104_TAX_ID | String | Federal Taxpayer's Identification Number |
04 | | L1000B_N104_CMS_PLANID | String | Centers for Medicare and Medicaid Services PlanID |
04 | | L1000B_N104_NPI | String | Centers for Medicare and Medicaid Services National Provider Identifier |
01 | | L1000B_N301_PAYEE_ADDR | String | Payee Address Line |
02 | | L1000B_N302_PAYEE_ADDR | String | Payee Address Line |
L1000B | N4 | Payee City, State, ZIP Code | | |
01 | | L1000B_N401_PAYEE_CITY | String | Payee City Name |
02 | | L1000B_N402_PAYEE_STAT | String | Payee State Code |
03 | | L1000B_N403_PAYEE_ZIP | String | Payee Postal Zone or ZIP Code |
04 | | L1000B_N404_CNTRY_CD | String | Country Code |
07 | | L1000B_N407_CNTRY_SUBDV_CD | String | Country Subdivision Code |
L1000B | REF | Payee Additional Identification | Iterated: [01-99]
| |
02 | | L1000B_nnREF_STAT_LIC_NR | String | State License Number |
02 | | L1000B_nnREF_NABP_NR | String | National Council for Prescription Drug Programs |
02 | | L1000B_nnREF_PAYEE_ID | String | Payee Identification |
02 | | L1000B_nnREF_TAX_ID | String | Federal Taxpayer's Identification Number |
L1000B | RDM | Remittance Delivery Method | | |
01 | | L1000B_RDM01_REPT_TRNS_CD | String | Report Transmission Code |
02 | | L1000B_RDM02_NM | String | Name |
03 | | L1000B_RDM03_COMM_NR | String | Communication Number |
01 | | L2000_LX01_ASSGD_NR | Integer | Assigned Number |
L2000 | TS3 | Provider Summary Information | | |
01 | | L2000_TS301_PVR_ID | String | Provider Identifier |
02 | | L2000_TS302_FAC_TYP_CD | String | Facility Type Code |
03 | | L2000_TS303_FISCL_PERD_D8 | Date (YYYYMMDD) | Fiscal Period Date |
04 | | L2000_TS304_TOT_CLM_CT | Number | Total Claim Count |
05 | | L2000_TS305_TOT_CLM_CHG_AMT | Number | Total Claim Charge Amount |
13 | | L2000_TS313_TOT_MSP_PYR_AMT | Number | Total MSP Payer Amount |
15 | | L2000_TS315_TOT_NONLAB_CHG_AMT | Number | Total Non-Lab Charge Amount |
17 | | L2000_TS317_TOT_HCPCS_CHG_AMT | Number | Total HCPCS Reported Charge Amount |
18 | | L2000_TS318_TOT_HCPCS_PYBL_AMT | Number | Total HCPCS Payable Amount |
20 | | L2000_TS320_TOT_PROF_COMP_AMT | Number | Total Professional Component Amount |
21 | | L2000_TS321_TOT_MSP_LIAB_MET | Number | Total MSP Patient Liability Met Amount |
22 | | L2000_TS322_TOT_PT_REIM_AMT | Number | Total Patient Reimbursement Amount |
23 | | L2000_TS323_TOT_PIP_CLM_CT | Number | Total PIP Claim Count |
24 | | L2000_TS324_TOT_PIP_ADJ_AMT | Number | Total PIP Adjustment Amount |
L2000 | TS2 | Provider Supplemental Summary Information | | |
01 | | L2000_TS201_TOT_DRG_AMT | Number | Total DRG Amount |
02 | | L2000_TS202_TOT_FED_SPEC_AMT | Number | Total Federal Specific Amount |
03 | | L2000_TS203_TOT_HSP_SPEC_AMT | Number | Total Hospital Specific Amount |
04 | | L2000_TS204_TOT_DISP_SHAR_AMT | Number | Total Disproportionate Share Amount |
05 | | L2000_TS205_TOT_CAP_AMT | Number | Total Capital Amount |
06 | | L2000_TS206_IND_MED_EDU_AMT | Number | Total Indirect Medical Education Amount |
07 | | L2000_TS207_TOT_OUTLR_DAYS | Number | Total Outlier Day Count |
08 | | L2000_TS208_TOT_DAY_OUTLR_AMT | Number | Total Day Outlier Amount |
09 | | L2000_TS209_TOT_CST_OUTLR_AMT | Number | Total Cost Outlier Amount |
10 | | L2000_TS210_AVG_DRG_LENOFSTAY | Number | Average DRG Length of Stay |
11 | | L2000_TS211_TOT_DISCHG_AMT | Number | Total Discharge Count |
12 | | L2000_TS212_TOT_CST_REP_DY_CT | Number | Total Cost Report Day Count |
13 | | L2000_TS213_TOT_COVD_DAY_CT | Number | Total Covered Day Count |
14 | | L2000_TS214_TOT_NONCD_DAY_CT | Number | Total Noncovered Day Count |
15 | | L2000_TS215_TOT_MSP_AMT | Number | Total MSP Pass-Through Amount |
16 | | L2000_TS216_AVG_DRG_WGT | Number | Average DRG weight |
17 | | L2000_TS217_PPSCAPFSP_DRG_AMT | Number | Total PPS Capital FSP DRG Amount |
18 | | L2000_TS218_TOT_CAP_DRG_AMT | Number | Total PPS Capital HSP DRG Amount |
19 | | L2000_TS219_PPS_DSH_DRG_AMT | Number | Total PPS DSH DRG Amount |
L2100 - CLAIM PAYMENT INFORMATION |
L2100 | CLP | Claim Payment Information | | |
01 | | L2100_CLP01_PT_CTL_NR | String | Patient Control Number |
02 | | L2100_CLP02_CLM_STAT_CD | String | Claim Status Code |
03 | | L2100_CLP03_TOT_CLM_CHG_AMT | Number | Total Claim Charge Amount |
04 | | L2100_CLP04_CLM_PMT_AMT | Number | Claim Payment Amount |
05 | | L2100_CLP05_PT_RESP_AMT | Number | Patient Responsibility Amount |
06 | | L2100_CLP06_CLM_FIL_IND_CD | String | Claim Filing Indicator Code |
07 | | L2100_CLP07_PYR_CLM_CTL_NR | String | Payer Claim Control Number |
08 | | L2100_CLP08_FAC_TYP_CD | String | Facility Type Code |
09 | | L2100_CLP09_CLM_FREQ_CD | String | Claim Frequency Code |
11 | | L2100_CLP11_DRG_CD | String | Diagnosis Related Group (DRG) Code |
12 | | L2100_CLP12_DRG_WGT | Number | Diagnosis Related Group (DRG) Weight |
13 | | L2100_CLP13_DISCHG_FRACTN | Number | Discharge Fraction |
L2100X - CLAIM PAYMENT INFORMATION - CAS CUTOUT |
L2100X | CAS | Claim Adjustment | | |
01 | | L2100X_CAS01_CLMADJ_GRP_CD | String | Claim Adjustment Group Code |
02 | | L2100X_CAS02_ADJ_RSN_CD | String | Adjustment Reason Code |
03 | | L2100X_CAS03_ADJ_AMT | Number | Adjustment Amount |
04 | | L2100X_CAS04_ADJ_QTY | Number | Adjustment Quantity |
05 | | L2100X_CAS05_ADJ_RSN_CD | String | Adjustment Reason Code |
06 | | L2100X_CAS06_ADJ_AMT | Number | Adjustment Amount |
07 | | L2100X_CAS07_ADJ_QTY | Number | Adjustment Quantity |
08 | | L2100X_CAS08_ADJ_RSN_CD | String | Adjustment Reason Code |
09 | | L2100X_CAS09_ADJ_AMT | Number | Adjustment Amount |
10 | | L2100X_CAS10_ADJ_QTY | Number | Adjustment Quantity |
11 | | L2100X_CAS11_ADJ_RSN_CD | String | Adjustment Reason Code |
12 | | L2100X_CAS12_ADJ_AMT | Number | Adjustment Amount |
13 | | L2100X_CAS13_ADJ_QTY | Number | Adjustment Quantity |
14 | | L2100X_CAS14_ADJ_RSN_CD | String | Adjustment Reason Code |
15 | | L2100X_CAS15_ADJ_AMT | Number | Adjustment Amount |
16 | | L2100X_CAS16_ADJ_QTY | Number | Adjustment Quantity |
17 | | L2100X_CAS17_ADJ_RSN_CD | String | Adjustment Reason Code |
18 | | L2100X_CAS18_ADJ_AMT | Number | Adjustment Amount |
19 | | L2100X_CAS19_ADJ_QTY | Number | Adjustment Quantity |
L2100 | NM1 | Patient Name | Segment Suffix: B
| |
03 | | L2100_NM1B_PT_LNM | String | Patient Last Name |
04 | | L2100_NM1B_PT_FNM | String | Patient First Name |
05 | | L2100_NM1B_PT_MNM | String | Patient Middle Name or Initial |
07 | | L2100_NM1B_PT_SFX | String | Patient Name Suffix |
09 | | L2100_NM1B_SSN | String | Social Security Number |
09 | | L2100_NM1B_HIC_NR | String | Health Insurance Claim (HIC) Number |
09 | | L2100_NM1B_UNQ_HLTH_ID | String | Standard Unique Health Identifier for each Individual in the United States |
09 | | L2100_NM1B_MEM_ID_NR | String | Member Identification Number |
09 | | L2100_NM1B_MDCD_RECPNT_ID | String | Medicaid Recipient Identification Number |
L2100 | NM1 | Insured Name | Segment Suffix: C
| |
02 | | L2100_NM1C_ENT_TYP_QUAL | String | Entity Type Qualifier |
03 | | L2100_NM1C_SBR_LNM | String | Subscriber Last Name |
04 | | L2100_NM1C_SBR_FNM | String | Subscriber First Name |
05 | | L2100_NM1C_SBR_MNM | String | Subscriber Middle Name or Initial |
07 | | L2100_NM1C_SBR_SFX | String | Subscriber Name Suffix |
09 | | L2100_NM1C_TAX_ID | String | Federal Taxpayer's Identification Number |
09 | | L2100_NM1C_UNQ_HLTH_ID | String | Standard Unique Health Identifier for each Individual in the United States |
09 | | L2100_NM1C_MEM_ID_NR | String | Member Identification Number |
L2100 | NM1 | Corrected Patient/Insured Name | Segment Suffix: D
| |
02 | | L2100_NM1D_ENT_TYP_QUAL | String | Entity Type Qualifier |
03 | | L2100_NM1D_CORR_PT_INS_LNM | String | Corrected Patient or Insured Last Name |
04 | | L2100_NM1D_CORR_PT_INS_FNM | String | Corrected Patient or Insured First Name |
05 | | L2100_NM1D_CORR_PT_INS_MNM | String | Corrected Patient or Insured Middle Name |
07 | | L2100_NM1D_CORR_PT_INS_SFX | String | Corrected Patient or Insured Name Suffix |
09 | | L2100_NM1D_INSRD_CHGD_UNQ_ID | String | Insured's Changed Unique Identification Number |
L2100 | NM1 | Service Provider Name | Segment Suffix: E
| |
02 | | L2100_NM1E_ENT_TYP_QUAL | String | Entity Type Qualifier |
03 | | L2100_NM1E_RND_PVR_LNM | String | Rendering Provider Last or Organization Name |
04 | | L2100_NM1E_REND_PVR_FNM | String | Rendering Provider First Name |
05 | | L2100_NM1E_REND_PVR_MNM | String | Rendering Provider Middle Name or Initial |
07 | | L2100_NM1E_REND_PROV_SFX | String | Rendering Provider Name Suffix |
09 | | L2100_NM1E_BLCS_PROV_NR | String | Blue Cross Provider Number |
09 | | L2100_NM1E_BLSH_PROV_NR | String | Blue Shield Provider Number |
09 | | L2100_NM1E_TAX_ID | String | Federal Taxpayer's Identification Number |
09 | | L2100_NM1E_MDCD_PROV_NR | String | Medicaid Provider Number |
09 | | L2100_NM1E_PROV_COMRCL_NR | String | Provider Commercial Number |
09 | | L2100_NM1E_STAT_LICNS_NR | String | State License Number |
09 | | L2100_NM1E_UNQ_PHYS_ID_NR | String | Unique Physician Identification Number (UPIN) |
09 | | L2100_NM1E_NPI | String | Centers for Medicare and Medicaid Services National Provider Identifier |
L2100 | NM1 | Crossover Carrier Name | Segment Suffix: F
| |
03 | | L2100_NM1F_NONPSNENT_NM | String | Non-Person Entity Name |
09 | | L2100_NM1F_BLCSBLSH_PLN_CD | String | Blue Cross Blue Shield Association Plan Code |
09 | | L2100_NM1F_TAX_ID | String | Federal Taxpayer's Identification Number |
09 | | L2100_NM1F_NAIC_ID | String | National Association of Insurance Commissioners (NAIC) Identification |
09 | | L2100_NM1F_PAYR_ID | String | Payor Identification |
09 | | L2100_NM1F_PHM_PRCSR_NR | String | Pharmacy Processor Number |
09 | | L2100_NM1F_HCFA_PLAN_ID | String | Centers for Medicare and Medicaid Services PlanID |
L2100 | NM1 | Corrected Priority Payer Name | Segment Suffix: G
| |
03 | | L2100_NM1G_NONPSNENT_NM | String | Non-Person Entity Name |
09 | | L2100_NM1G_BLCSBLSH_PLN_CD | String | Blue Cross Blue Shield Association Plan Code |
09 | | L2100_NM1G_TAX_ID | String | Federal Taxpayer's Identification Number |
09 | | L2100_NM1G_NAIC_ID | String | National Association of Insurance Commissioners (NAIC) Identification |
09 | | L2100_NM1G_PAYR_ID | String | Payor Identification |
09 | | L2100_NM1G_PHM_PRCSR_NR | String | Pharmacy Processor Number |
09 | | L2100_NM1G_HCFA_PLAN_ID | String | Centers for Medicare and Medicaid Services PlanID |
L2100 | NM1 | Other Subscriber Name | Segment Suffix: H
| |
02 | | L2100_NM1H_ENT_TYP_QUAL | String | Entity Type Qualifier |
03 | | L2100_NM1H_OSBR_LNM | String | Other Subscriber Last Name |
04 | | L2100_NM1H_OSBR_FNM | String | Other Subscriber First Name |
05 | | L2100_NM1H_OSBR_MNM | String | Other Subscriber Middle Name or Initial |
07 | | L2100_NM1H_OSBR_SFX | String | Other Subscriber Name Suffix |
09 | | L2100_NM1H_TAX_ID | String | Federal Taxpayer's Identification Number |
09 | | L2100_NM1H_UNQ_HLTH_ID | String | Standard Unique Health Identifier for each Individual |
09 | | L2100_NM1H_MEM_ID_NR | String | Member Identification Number |
L2100 | MIA | Inpatient Adjudication Information | | |
01 | | L2100_MIA01_COV_DAYS_VST_CT | Number | Covered Days or Visits Count |
02 | | L2100_MIA02_PPS_OPR_OUTLR_AMT | Number | PPS Operating Outlier Amount |
03 | | L2100_MIA03_LFTM_PSYCH_DAYS | Number | Lifetime Psychiatric Days Count |
04 | | L2100_MIA04_CLM_DRG_AMT | Number | Claim DRG Amount |
05 | | L2100_MIA05_CLM_PMT_RMK_CD | String | Claim Payment Remark Code |
06 | | L2100_MIA06_CLM_DIS_SHR_AMT | Number | Claim Disproportionate Share Amount |
07 | | L2100_MIA07_CLM_MSP_PSS_AMT | Number | Claim MSP Pass-through Amount |
08 | | L2100_MIA08_CLM_PPS_CAP_AMT | Number | Claim PPS Capital Amount |
09 | | L2100_MIA09_PPS_FSP_DRG_AMT | Number | PPS-Capital FSP DRG Amount |
10 | | L2100_MIA10_PPS_HSP_DRG_AMT | Number | PPS-Capital HSP DRG Amount |
11 | | L2100_MIA11_PPS_DSH_DRG_AMT | Number | PPS-Capital DSH DRG Amount |
12 | | L2100_MIA12_OLD_CAP_AMT | Number | Old Capital Amount |
13 | | L2100_MIA13_PPS_CAP_IME_AMT | Number | PPS-Capital IME amount |
14 | | L2100_MIA14_PPS_OPRS_DRGAMT | Number | PPS-Operating Hospital Specific DRG Amount |
15 | | L2100_MIA15_COST_RPT_DAY_CT | Number | Cost Report Day Count |
16 | | L2100_MIA16_PPS_FED_DRG_AMT | Number | PPS-Operating Federal Specific DRG Amount |
17 | | L2100_MIA17_CLM_CAP_OUT_AMT | Number | Claim PPS Capital Outlier Amount |
18 | | L2100_MIA18_CLM_IND_TCH_AMT | Number | Claim Indirect Teaching Amount |
19 | | L2100_MIA19_NONPAY_PROF_AMT | Number | Nonpayable Professional Component Amount |
20 | | L2100_MIA20_CLM_PMT_RMK_CD | String | Claim Payment Remark Code |
21 | | L2100_MIA21_CLM_PMT_RMK_CD | String | Claim Payment Remark Code |
22 | | L2100_MIA22_CLM_PMT_RMK_CD | String | Claim Payment Remark Code |
23 | | L2100_MIA23_CLM_PMT_RMK_CD | String | Claim Payment Remark Code |
24 | | L2100_MIA24_PPS_EXCPTN_AMT | Number | PPS-Capital Exception Amount |
L2100 | MOA | Outpatient Adjudication Information | | |
01 | | L2100_MOA01_REIMBRSMT_RT | Number | Reimbursement Rate |
02 | | L2100_MOA02_CLMHCPCS_PY_AMT | Number | Claim HCPCS Payable Amount |
03 | | L2100_MOA03_CLM_PMT_RMK_CD | String | Claim Payment Remark Code |
04 | | L2100_MOA04_CLM_PMT_RMK_CD | String | Claim Payment Remark Code |
05 | | L2100_MOA05_CLM_PMT_RMK_CD | String | Claim Payment Remark Code |
06 | | L2100_MOA06_CLM_PMT_RMK_CD | String | Claim Payment Remark Code |
07 | | L2100_MOA07_CLM_PMT_RMK_CD | String | Claim Payment Remark Code |
08 | | L2100_MOA08_CLMESRD_PMT_AMT | Number | Claim ESRD Payment Amount |
09 | | L2100_MOA09_NONPAY_PROF_AMT | Number | Nonpayable Professional Component Amount |
L2100 | REF | Other Claim Related Identification | | |
02 | | L2100_nnREF_GRP_POLCY_NR | String | Group or Policy Number |
02 | | L2100_nnREF_MEM_ID | String | Member Identification Number |
02 | | L2100_nnREF_EMPLE_ID_NR | String | Employee Identification Number |
02 | | L2100_nnREF_GRP_NR | String | Group Number |
02 | | L2100_nnREF_REP_CLM_ID | String | Repriced Claim Reference Number |
02 | | L2100_nnREF_ADJ_REP_CLM_ID | String | Adjusted Repriced Claim Reference Number |
02 | | L2100_nnREF_AUTH_NR | String | Authorization Number |
02 | | L2100_nnREF_CLSS_CONT | String | Class of Contract Code |
02 | | L2100_nnREF_MED_REC_ID | String | Medical Record Identification Number |
02 | | L2100_nnREF_ORIG_REF_NR | String | Original Reference Number |
02 | | L2100_nnREF_PRIOR_AUTH | String | Prior Authorization Number |
02 | | L2100_nnREF_PREF_BEN_ID_NR | String | Predetermination of Benefits Identification Number |
02 | | L2100_nnREF_INS_PLCY_NR | String | Insurance Policy Number |
02 | | L2100_nnREF_SSN | String | Social Security Number |
L2100 | REF | Rendering Provider Identification | | |
02 | | L2100_nnREF_STAT_LIC_NR | String | State License Number |
02 | | L2100_nnREF_BLCS_PVR_NR | String | Blue Cross Provider Number |
02 | | L2100_nnREF_BLSH_PROV_NR | String | Blue Shield Provider Number |
02 | | L2100_nnREF_MDCR_PVR_NR | String | Medicare Provider Number |
02 | | L2100_nnREF_MDCD_PVR_NR | String | Medicaid Provider Number |
02 | | L2100_nnREF_UPIN | String | Provider UPIN Number |
02 | | L2100_nnREF_CHAMPUS_ID | String | CHAMPUS Identification Number |
02 | | L2100_nnREF_FAC_ID | String | Facility ID Number |
02 | | L2100_nnREF_NABP_NR | String | National Council for Prescription Drug Programs Pharmacy Number |
02 | | L2100_nnREF_PVR_COMM_NR | String | Provider Commercial Number |
02 | | L2100_nnREF_LOC_NR | String | Location Number |
L2100 | DTM | Statement From or To Date | | |
02 | | L2100_DTM02_CLM_PRD_STRT | DateTime | Claim Statement Period Start |
02 | | L2100_DTM02_CLM_PRD_END | DateTime | Claim Statement Period End |
L2100 | DTM | Coverage Expiration Date | Segment Suffix: B
| |
02 | | L2100_DTMB02_EXP | DateTime | Expiration |
L2100 | DTM | Claim Received Date | Segment Suffix: C
| |
02 | | L2100_DTMC02_RCVD | DateTime | Received |
L2100 | PER | Claim Contact Information | | |
02 | | L2100_nnPER02_CLM_CON_NM | String | Claim Contact Name |
04 | | L2100_nnPER04_EMAIL | String | Electronic Mail |
04 | | L2100_nnPER04_FAX | String | Facsimile |
04 | | L2100_nnPER04_PHN_NR | String | Telephone |
06 | | L2100_nnPER06_EMAIL | String | Electronic Mail |
06 | | L2100_nnPER06_PHN_EXT | String | Telephone Extension |
06 | | L2100_nnPER06_FAX | String | Facsimile |
06 | | L2100_nnPER06_PHN_NR | String | Telephone |
08 | | L2100_nnPER08_PHN_EXT | String | Telephone Extension |
L2100 | AMT | Claim Supplemental Information | | |
02 | | L2100_AMT02_COVG_AMT | Number | Coverage Amount |
02 | | L2100_AMT02_DISCT_AMT | Number | Claim Supplemental Information Amount |
02 | | L2100_AMT02_PER_DAY_LIM | Number | Per Day Limit |
02 | | L2100_AMT02_PT_AMT_PD | Number | Patient Amount Paid |
02 | | L2100_AMT02_INTRST | Number | Interest |
02 | | L2100_AMT02_NEG_LEDGR_BAL | Number | Negative Ledger Balance |
02 | | L2100_AMT02_TAX | Number | Tax |
02 | | L2100_AMT02_TOT_CLM_B4_TAX | Number | Total Claim Before Taxes |
02 | | L2100_AMT02_MDCRMDCD_PMTCAT1 | Number | Federal Medicare or Medicaid Payment Mandate - Category 1 |
02 | | L2100_AMT02_MDCRMDCD_PMTCAT2 | Number | Federal Medicare or Medicaid Payment Mandate - Category 2 |
02 | | L2100_AMT02_MDCRMDCD_PMTCAT3 | Number | Federal Medicare or Medicaid Payment Mandate - Category 3 |
02 | | L2100_AMT02_MDCRMDCD_PMTCAT4 | Number | Federal Medicare or Medicaid Payment Mandate - Category 4 |
02 | | L2100_AMT02_MCRMCD_PMTCAT5 | Number | Federal Medicare or Medicaid Payment Mandate - Category 5 |
L2100 | QTY | Claim Supplemental Information Quantity | | |
02 | | L2100_QTY02_COVD_ACTL | Number | Covered - Actual |
02 | | L2100_QTY02_COINS_ACTL | Number | Co-insured - Actual |
02 | | L2100_QTY02_LFTM_RSRV_ACTL | Number | Life-time Reserve - Actual |
02 | | L2100_QTY02_LFTM_RSRV_EST | Number | Life-time Reserve - Estimated |
02 | | L2100_QTY02_NONCOV_EST | Number | Non-Covered - Estimated |
02 | | L2100_QTY02_NOTREP_BLD_UN | Number | Not Replaced Blood Units |
02 | | L2100_QTY02_OUTLIER_DYS | Number | Outlier Days |
02 | | L2100_QTY02_RX | Number | Prescription |
02 | | L2100_QTY02_VIST | Number | Visits |
02 | | L2100_QTY02_MDCRMDCD_PMTCAT1 | Number | Federal Medicare or Medicaid Payment Mandate - Category 1 |
02 | | L2100_QTY02_MDCRMDCD_PMTCAT2 | Number | Federal Medicare or Medicaid Payment Mandate - Category 2 |
02 | | L2100_QTY02_MDCRMDCD_PMTCAT3 | Number | Federal Medicare or Medicaid Payment Mandate - Category 3 |
02 | | L2100_QTY02_MDCRMDCD_PMTCAT4 | Number | Federal Medicare or Medicaid Payment Mandate - Category 4 |
02 | | L2100_QTY02_MCRMCD_PMTCAT5 | Number | Federal Medicare or Medicaid Payment Mandate - Category 5 |
L2110 - SERVICE PAYMENT INFORMATION |
L2110 | SVC | Service Payment Information | | |
01 | 02 | L2110_SVC0102_ADA_CD | String | American Dental Association Codes |
01 | 02 | L2110_SVC0102_JS_PRC_SPY_CD | String | Jurisdiction Specific Procedure and Supply Codes |
01 | 02 | L2110_SVC0102_HCPCS_CD | String | Health Care Financing Administration Common Procedural Coding System (HCPCS) Codes |
01 | 02 | L2110_SVC0102_HIPPA_SNF_RT_CD | String | Health Insurance Prospective Payment System (HIPPS) Skilled Nursing Facility Rate Code |
01 | 02 | L2110_SVC0102_HIC_PRD_SVCCD | String | Home Infusion EDI Coalition (HIEC) Product/Service |
01 | 02 | L2110_SVC0102_NDC542 | String | National Drug Code in 5-4-2 Format |
01 | 02 | L2110_SVC0102_NATLHLTH_46 | String | National Health Related Item Code in 4-6 Format |
01 | 02 | L2110_SVC0102_NUBC_UB92_CD | String | National Uniform Billing Committee (NUBC) UB92 Codes |
01 | 02 | L2110_SVC0102_UP_CD_155 | String | U.P.C. Consumer Package Code (1-5-5) |
01 | 02 | L2110_SVC0102_ABC_CD | String | Advanced Billing Concepts (ABC) Codes |
01 | 03 | L2110_SVC0103_PROC_MOD | String | Procedure Modifier |
01 | 04 | L2110_SVC0104_PROC_MOD | String | Procedure Modifier |
01 | 05 | L2110_SVC0105_PROC_MOD | String | Procedure Modifier |
01 | 06 | L2110_SVC0106_PROC_MOD | String | Procedure Modifier |
02 | | L2110_SVC02_LIN_ITM_CHG_AMT | Number | Line Item Charge Amount |
03 | | L2110_SVC03_LINITM_PV_PMT_AMT | Number | Line Item Provider Payment Amount |
04 | | L2110_SVC04_NUBC_REV_CD | String | National Uniform Billing Committee Revenue |
05 | | L2110_SVC05_UN_SVC_PD_CT | Number | Units of Service Paid Count |
06 | 02 | L2110_SVC0602_ADA_CD | String | American Dental Association Codes |
06 | 02 | L2110_SVC0602_JS_PRC_SPY_CD | String | Jurisdiction Specific Procedure and Supply Codes |
06 | 02 | L2110_SVC0602_HCPCS_CD | String | Health Care Financing Administration Common Procedural Coding System (HCPCS) Codes |
06 | 02 | L2110_SVC0602_HPPS | String | Health Insurance Prospective Payment System |
06 | 02 | L2110_SVC0602_HIC_PRD_SVCCD | String | Home Infusion EDI Coalition (HIEC) Product/Service Code |
06 | 02 | L2110_SVC0602_NDC542 | String | National Drug Code in 5-4-2 Format |
06 | 02 | L2110_SVC0602_NUBC_UB92_CD | String | National Uniform Billing Committee (NUBC) UB92 Codes |
06 | 02 | L2110_SVC0602_ABC_CD | String | Advanced Billing Concepts (ABC) Codes |
06 | 03 | L2110_SVC0603_PROC_MOD | String | Procedure Modifier |
06 | 04 | L2110_SVC0604_PROC_MOD | String | Procedure Modifier |
06 | 05 | L2110_SVC0605_PROC_MOD | String | Procedure Modifier |
06 | 06 | L2110_SVC0606_PROC_MOD | String | Procedure Modifier |
06 | 07 | L2110_SVC0607_PROC_CD_DESC | String | Procedure Code Description |
07 | | L2110_SVC07_ORG_UN_SVC_CT | Number | Original Units of Service Count |
02 | | L2110_DTM02_SVC_PER_STRT | DateTime | Service Period Start |
02 | | L2110_DTM02_SVC_PER_END | DateTime | Service Period End |
02 | | L2110_DTM02_SVC | DateTime | Service |
L2110X - SERVICE PAYMENT INFORMATION - CAS CUTOUT |
L2110X | CAS | Service Adjustment | | |
01 | | L2110X_CAS01_CLMADJ_GRP_CD | String | Claim Adjustment Group Code |
02 | | L2110X_CAS02_ADJ_RSN_CD | String | Adjustment Reason Code |
03 | | L2110X_CAS03_ADJ_AMT | Number | Adjustment Amount |
04 | | L2110X_CAS04_ADJ_QTY | Number | Adjustment Quantity |
05 | | L2110X_CAS05_ADJ_RSN_CD | String | Adjustment Reason Code |
06 | | L2110X_CAS06_ADJ_AMT | Number | Adjustment Amount |
07 | | L2110X_CAS07_ADJ_QTY | Number | Adjustment Quantity |
08 | | L2110X_CAS08_ADJ_RSN_CD | String | Adjustment Reason Code |
09 | | L2110X_CAS09_ADJ_AMT | Number | Adjustment Amount |
10 | | L2110X_CAS10_ADJ_QTY | Number | Adjustment Quantity |
11 | | L2110X_CAS11_ADJ_RSN_CD | String | Adjustment Reason Code |
12 | | L2110X_CAS12_ADJ_AMT | Number | Adjustment Amount |
13 | | L2110X_CAS13_ADJ_QTY | Number | Adjustment Quantity |
14 | | L2110X_CAS14_ADJ_RSN_CD | String | Adjustment Reason Code |
15 | | L2110X_CAS15_ADJ_AMT | Number | Adjustment Amount |
16 | | L2110X_CAS16_ADJ_QTY | Number | Adjustment Quantity |
17 | | L2110X_CAS17_ADJ_RSN_CD | String | Adjustment Reason Code |
18 | | L2110X_CAS18_ADJ_AMT | Number | Adjustment Amount |
19 | | L2110X_CAS19_ADJ_QTY | Number | Adjustment Quantity |
L2110 | REF | Service Identification | | |
02 | | L2110_REF_APG_NR | String | Ambulatory Patient Group (APG) Number |
02 | | L2110_REF_AMB_PMT_CLS | String | Ambulatory Payment Classification |
02 | | L2110_REF_AUTH_NR | String | Authorization Number |
02 | | L2110_REF_ATTCH_CD | String | Attachment Code |
02 | | L2110_REF_PRIOR_AUTH | String | Prior Authorization Number |
02 | | L2110_REF_PREF_BEN_ID_NR | String | Predetermination of Benefits Identification Number |
02 | | L2110_REF_LOC_NR | String | Location Number |
02 | | L2110_REF_RAT_CD_NR | String | Rate code number |
L2110 | REF | Line Item Control Number | | |
02 | | L2110_REF_PRV_CTL_NR | String | Provider Control Number |
L2110 | REF | Rendering Provider Information | | |
02 | | L2110_nnREF_STAT_LIC_NR | String | State License Number |
02 | | L2110_nnREF_BLCS_PVR_NR | String | Blue Cross Provider Number |
02 | | L2110_nnREF_BLSH_PROV_NR | String | Blue Shield Provider Number |
02 | | L2110_nnREF_MDCR_PVR_NR | String | Medicare Provider Number |
02 | | L2110_nnREF_MDCD_PVR_NR | String | Medicaid Provider Number |
02 | | L2110_nnREF_UPIN | String | Provider UPIN Number |
02 | | L2110_nnREF_CHAMPUS_ID | String | CHAMPUS Identification Number |
02 | | L2110_nnREF_FAC_ID | String | Facility ID Number |
02 | | L2110_nnREF_NABP_NR | String | National Council for Prescription Drug Programs Pharmacy Number |
02 | | L2110_nnREF_PVR_COMM_NR | String | Provider Commercial Number |
02 | | L2110_nnREF_MDCR_MDCD | String | Centers for Medicare and Medicaid Services National Provider Identifier |
02 | | L2110_nnREF_SSN | String | Social Security Number |
02 | | L2110_nnREF_TAX_ID | String | Federal Taxpayer's Identification Number |
L2110 | REF | HealthCare Policy Identification | | |
02 | | L2110_nnREF_POLCY_ID | String | Policy Form Identifying Number |
L2110 | AMT | Service Supplemental Amount | | |
02 | | L2110_AMT02_ALLWD_ACTL | Number | Allowed - Actual |
02 | | L2110_AMT02_DDCTN_AMT | Number | Deduction Amount |
02 | | L2110_AMT02_TAX | Number | Tax |
02 | | L2110_AMT02_TOT_CLM_B4_TAX | Number | Total Claim Before Taxes |
02 | | L2110_AMT02_MDCRMDCD_PMTCAT1 | Number | Federal Medicare or Medicaid Payment Mandate - Category 1 |
02 | | L2110_AMT02_MDCRMDCD_PMTCAT2 | Number | Federal Medicare or Medicaid Payment Mandate - Category 2 |
02 | | L2110_AMT02_MDCRMDCD_PMTCAT3 | Number | Federal Medicare or Medicaid Payment Mandate - Category 3 |
02 | | L2110_AMT02_MDCRMDCD_PMTCAT4 | Number | Federal Medicare or Medicaid Payment Mandate - Category 4 |
02 | | L2110_AMT02_MCRMCD_PMTCAT5 | Number | Federal Medicare or Medicaid Payment Mandate - Category 5 |
L2110 | QTY | Service Supplemental Quantity | | |
02 | | L2110_QTY02_MDCRMDCD_PMTCAT1 | Number | Federal Medicare or Medicaid Payment Mandate - Category 1 |
02 | | L2110_QTY02_MDCRMDCD_PMTCAT2 | Number | Federal Medicare or Medicaid Payment Mandate - Category 2 |
02 | | L2110_QTY02_MDCRMDCD_PMTCAT3 | Number | Federal Medicare or Medicaid Payment Mandate - Category 3 |
02 | | L2110_QTY02_MDCRMDCD_PMTCAT4 | Number | Federal Medicare or Medicaid Payment Mandate - Category 4 |
02 | | L2110_QTY02_MCRMCD_PMTCAT5 | Number | Federal Medicare or Medicaid Payment Mandate - Category 5 |
L2110Y - SERVICE PAYMENT INFORMATION - LQ CUTOUT |
L2110Y | LQ | Health Care Remark Codes | | |
02 | | L2110Y_LQ02_CLM_PMT_REM_CD | String | Claim Payment Remark Codes |
02 | | L2110Y_LQ02_NCPCP_REJPMT_CD | String | National Council for Prescription Drug Programs Reject/Payment Codes |
STHDRX - TRANSACTION SET HEADER - PLB CUTOUT |
STHDRX | PLB | Provider Adjustment | | |
01 | | STHDRX_PLB01_PVR_ID | String | Provider Identifier |
02 | | STHDRX_PLB02_FISCL_PERD_D8 | Date (YYYYMMDD) | Fiscal Period Date |
03 | 01 | STHDRX_PLB0301_ADJ_RSN_CD | String | Adjustment Reason Code |
03 | 02 | STHDRX_PLB0302_PVR_ADJ_ID | String | Provider Adjustment Identifier |
04 | | STHDRX_PLB04_PVR_ADJ_AMT | Number | Provider Adjustment Amount |
05 | 01 | STHDRX_PLB0501_ADJ_RSN_CD | String | Adjustment Reason Code |
05 | 02 | STHDRX_PLB0502_PVR_ADJ_ID | String | Provider Adjustment Identifier |
06 | | STHDRX_PLB06_PVR_ADJ_AMT | Number | Provider Adjustment Amount |
07 | 01 | STHDRX_PLB0701_ADJ_RSN_CD | String | Adjustment Reason Code |
07 | 02 | STHDRX_PLB0702_PVR_ADJ_ID | String | Provider Adjustment Identifier |
08 | | STHDRX_PLB08_PVR_ADJ_AMT | Number | Provider Adjustment Amount |
09 | 01 | STHDRX_PLB0901_ADJ_RSN_CD | String | Adjustment Reason Code |
09 | 02 | STHDRX_PLB0902_PVR_ADJ_ID | String | Provider Adjustment Identifier |
10 | | STHDRX_PLB10_PVR_ADJ_AMT | Number | Provider Adjustment Amount |
11 | 01 | STHDRX_PLB1101_ADJ_RSN_CD | String | Adjustment Reason Code |
11 | 02 | STHDRX_PLB1102_PVR_ADJ_ID | String | Provider Adjustment Identifier |
12 | | STHDRX_PLB12_PVR_ADJ_AMT | Number | Provider Adjustment Amount |
13 | 01 | STHDRX_PLB1301_ADJ_RSN_CD | String | Adjustment Reason Code |
13 | 02 | STHDRX_PLB1302_PVR_ADJ_ID | String | Provider Adjustment Identifier |
14 | | STHDRX_PLB14_PVR_ADJ_AMT | Number | Provider Adjustment Amount |
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 |
ISA | IEA | Interchange Control Trailer | | |
01 | | ISA_IEA01_NR_INC_FUNC_GRP | Integer | Number of Included Functional Groups |
02 | | ISA_IEA02_ICN | Integer | Interchange Control Number |