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 |
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 (YYYYMMDD) | Transaction Set Creation Date |
05 | | STHDR_BHT05_TS_CRTN_TM | Time (HHMM) | Transaction Set Creation Time |
05 | | STHDR_BHT05_TS_CRTN_TM8 | Time (HHMMSSCC) | Transaction Set Creation Time |
06 | | STHDR_BHT06_CLM_ENC_ID | String | Claim or Encounter Identifier |
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_ETN_NR | String | Electronic Transmitter Identification Number (ETIN) |
L1000A | PER | Submitter EDI Contact Information | | |
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 |
03 | | L1000B_NM103_NONPSNENT_NM | String | Non-Person Entity Name |
09 | | L1000B_NM109_ETN_NR | String | Electronic Transmitter Identification Number (ETIN) |
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_PVD_TAXNMY_CD | String | Health Care 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_NPI | String | Centers for Medicare and Medicaid Services |
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 | | |
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 or Province 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_NONPSNENT_NM | String | Non-Person Entity 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 HIERARCHICAL 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 |
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_D8 | DateTime | 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 |
03 | | L2010BB_NM103_NONPSNENT_NM | String | Non-Person Entity Name |
09 | | L2010BB_NM109_PAYR_ID | String | Payor Identification |
09 | | L2010BB_NM109_HCFA_PLAN_ID | String | Centers for Medicare and Medicaid Services PlanID |
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 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 | | |
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 |
03 | | L2010CA_NM103_PERSN_LNM | String | Person 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 |
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_D8 | DateTime | 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 |
L2300 - CLAIM INFORMATION |
L2300 | CLM | Claim Information | | |
01 | | L2300_CLM01_PT_CTL_NR | String | Patient Control Number |
02 | | L2300_CLM02_TOT_CLM_CHG_AMT | Number | 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 |
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 |
19 | | L2300_CLM19_PRE_BEN_CD | String | Predetermination of Benefits Code |
20 | | L2300_CLM20_DELAY_RSN_CD | String | Delay Reason Code |
03 | | L2300_DTP_ACCDNT_D8 | Date (YYYYMMDD) | Accident Date |
L2300 | DTP | Date - Appliance Placement | | |
03 | | L2300_DTP_APPL_PLCMT_D8 | Date (YYYYMMDD) | Appliance Placement Date |
L2300 | DTP | Date - Service Date | | |
03 | | L2300_DTP_SVC_D8 | Date (YYYYMMDD) | Service Date |
03 | | L2300_DTP_SVC_RD8_1 | Start Date (YYYYMMDD) | Service Date |
03 | | L2300_DTP_SVC_RD8_2 | End Date (YYYYMMDD) | Service Date |
L2300 | DTP | Date - Repricer Received Date | | |
03 | | L2300_DTP_RCVD_D8 | Date (YYYYMMDD) | Received Date |
L2300 | DN1 | Orthodontic Total Months of Treatment | | |
01 | | L2300_DN101_ORTHO_TRT_MO_CT | Number | Orthodontic Treatment Months Count |
02 | | L2300_DN102_ORTHO_MON_REM_CT | Number | Orthodontic Treatment Months Remaining Count |
04 | | L2300_DN104_ORTHO_TMT_IND | String | Orthodontic Treatment Indicator |
L2300X - CLAIM INFORMATION - DN2 CUTOUT |
01 | | L2300X_DN201_TOOTH_NR | String | Tooth Number |
02 | | L2300X_DN202_TTH_STAT_CD | String | Tooth Status Code |
L2300 | PWK | Claim Supplemental Information | | |
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 | Number | Contract Amount |
03 | | L2300_CN103_CONTRCT_PERC | Number | Contract Percentage |
04 | | L2300_CN104_CONTRCT_CD | String | Contract Code |
05 | | L2300_CN105_TERMS_DISCT_PERC | Number | Terms Discount Percentage |
06 | | L2300_CN106_CONTRCT_VERS_ID | String | Contract Version Identifier |
L2300 | AMT | Patient Amount Paid | | |
02 | | L2300_AMT02_PT_AMT_PD | Number | Patient Amount Paid |
L2300 | REF | Predetermination Identification | | |
02 | | L2300_REF_PREF_BEN_ID_NR | String | Predetermination of Benefits Identification Number |
L2300 | REF | Service Authorization Exception Code | | |
02 | | L2300_REF_SP_PMT_REF_NR | String | Special Payment Reference Number |
L2300 | REF | Payer Claim Control Number | | |
02 | | L2300_REF_ORIG_REF_NR | String | Original Reference Number |
02 | | L2300_REF_REFRL_NR | String | Referral Number |
L2300 | REF | Prior Authorization | | |
02 | | L2300_REF_PRIOR_AUTH | String | Prior Authorization 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 | Claim Identifier For Transmission Intermediaries | | |
02 | | L2300_REF_CLM_NR | String | Claim Number |
01 | | L2300_nnK301_FIXD_FMT_NFO | String | Fixed Format Information |
02 | | L2300_nnNTE02_ADDL_NFO | String | Additional Information |
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 |
01 | 02 | L2300_HI0102_SNODENT | String | Systemized Nomenclature of Dentistry (SNODENT) |
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 |
02 | 02 | L2300_HI0202_SNODENT | String | Systemized Nomenclature of Dentistry (SNODENT) |
03 | 01 | L2300_HI0301_CD_LST_QL_CD | String | Code List Qualifier Code |
03 | 02 | L2300_HI0302_DIAG_CD | String | Diagnosis Code |
04 | 01 | L2300_HI0401_CD_LST_QL_CD | String | Code List Qualifier Code |
04 | 02 | L2300_HI0402_DIAG_CD | String | Diagnosis Code |
L2300 | HCP | Claim Pricing/Repricing Information | | |
01 | | L2300_HCP01_PRIC_METHD | String | Pricing Methodology |
02 | | L2300_HCP02_REPRCD_ALLWD_AMT | Number | Repriced Allowed Amount |
03 | | L2300_HCP03_REPRCD_SAVNG_AMT | Number | Repriced Saving Amount |
04 | | L2300_HCP04_REPRCNG_ORG_ID | String | Repricing Organization Identifier |
05 | | L2300_HCP05_REPRCD_PERDIEM_AMT | Number | Repricing Per Diem or Flat Rate Amount |
06 | | L2300_HCP06_REP_AMB_PT_GRP | String | 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_PERSN_LNM | String | Person 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_NPI | String | Centers for Medicare and Medicaid Services National Provider Identifier |
L2310A | PRV | Referring Provider Specialty Information | | |
03 | | L2310A_yy_PRV03_PVD_TAXNMY_CD | String | Health Care Provider Taxonomy Code |
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_NPI | String | Centers for Medicare and Medicaid Services National Provider Identifier |
L2310B | PRV | Rendering Provider Specialty Information | | |
03 | | L2310B_PRV03_PVD_TAXNMY_CD | String | Health Care 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_NONPSNENT_NM | String | Non-Person Entity Name |
09 | | L2310C_NM109_NPI | String | Centers for Medicare and Medicaid Services National Provider 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 |
L2310D - ASSISTANT SURGEON NAME |
L2310D | NM1 | Assistant Surgeon Name | | |
03 | | L2310D_NM103_PERSN_LNM | String | Person Last Name |
04 | | L2310D_NM104_ASST_SRG_FNM | String | Assistant Surgeon First Name |
05 | | L2310D_NM105_ASST_SRG_MNM | String | Assistant Surgeon Middle Name or Initial |
07 | | L2310D_NM107_ASST_SRG_SFX | String | Assistant Surgeon Name Suffix |
09 | | L2310D_NM109_NPI | String | Centers for Medicare and Medicaid Services National Provider Identifier |
L2310D | PRV | Assistant Surgeon Specialty Information | | |
03 | | L2310D_PRV03_PVD_TAXNMY_CD | String | Health Care Provider Taxonomy Code |
L2310D | REF | Assistant Surgeon 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 - SUPERVISING PROVIDER NAME |
L2310E | NM1 | Supervising Provider Name | | |
03 | | L2310E_NM103_PERSN_LNM | String | Person Last Name |
04 | | L2310E_NM104_SUP_PVR_FNM | String | Supervising Provider First Name |
05 | | L2310E_NM105_SUP_PVR_MNM | String | Supervising Provider Middle Name or Initial |
07 | | L2310E_NM107_SUP_PVR_SFX | String | Supervising Provider Name Suffix |
09 | | L2310E_NM109_NPI | String | Centers for Medicare and Medicaid Services National Provider Identifier |
L2310E | REF | Supervising Provider Secondary Identification | | |
02 | | L2310E_REF_STAT_LIC_NR | String | State License Number |
02 | | L2310E_REF_UPIN | String | Provider UPIN Number |
02 | | L2310E_REF_PVR_COMM_NR | String | Provider Commercial Number |
02 | | L2310E_REF_LOC_NR | String | Location Number |
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 | | |
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 | Number | Adjustment Amount |
04 | | L2320_xx_nnCAS04_ADJ_QTY | Number | Adjustment Quantity |
05 | | L2320_xx_nnCAS05_ADJ_RSN_CD | String | Adjustment Reason Code |
06 | | L2320_xx_nnCAS06_ADJ_AMT | Number | Adjustment Amount |
07 | | L2320_xx_nnCAS07_ADJ_QTY | Number | Adjustment Quantity |
08 | | L2320_xx_nnCAS08_ADJ_RSN_CD | String | Adjustment Reason Code |
09 | | L2320_xx_nnCAS09_ADJ_AMT | Number | Adjustment Amount |
10 | | L2320_xx_nnCAS10_ADJ_QTY | Number | Adjustment Quantity |
11 | | L2320_xx_nnCAS11_ADJ_RSN_CD | String | Adjustment Reason Code |
12 | | L2320_xx_nnCAS12_ADJ_AMT | Number | Adjustment Amount |
13 | | L2320_xx_nnCAS13_ADJ_QTY | Number | Adjustment Quantity |
14 | | L2320_xx_nnCAS14_ADJ_RSN_CD | String | Adjustment Reason Code |
15 | | L2320_xx_nnCAS15_ADJ_AMT | Number | Adjustment Amount |
16 | | L2320_xx_nnCAS16_ADJ_QTY | Number | Adjustment Quantity |
17 | | L2320_xx_nnCAS17_ADJ_RSN_CD | String | Adjustment Reason Code |
18 | | L2320_xx_nnCAS18_ADJ_AMT | Number | Adjustment Amount |
19 | | L2320_xx_nnCAS19_ADJ_QTY | Number | Adjustment Quantity |
L2320 | AMT | Coordination of Benefits (COB) Payer Paid Amount | | |
02 | | L2320_xx_AMT02_PAYR_AMT_PD | Number | Payor Amount Paid |
L2320 | AMT | Remaining Patient Liability | | |
02 | | L2320_xx_AMT02_AMT_OWED | Number | Amount Owed |
L2320 | AMT | Coordination of Benefits (COB) Total Non-Covered Amount | | |
02 | | L2320_xx_AMT02_NONCVD_CHG_ACTL | Number | Noncovered Charges - Actual |
L2320 | OI | Other Insurance Coverage Information | | |
03 | | L2320_xx_OI03_BEN_ASGT_CRT_IND | String | Benefits Assignment Certification Indicator |
06 | | L2320_xx_OI06_RELS_NFO_CD | String | Release of Information Code |
L2320 | MOA | Outpatient Adjudication Information | | |
01 | | L2320_xx_MOA01_REIMBRSMT_RT | Number | Reimbursement Rate |
02 | | L2320_xx_MOA02_HCPCS_PAYBL_AMT | Number | 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 |
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_OINS_ADDR | String | Other Insured 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_OINS_CITY | String | Other Insured City Name |
02 | | L2330A_xx_N402_OINS_STAT | String | Other Insured State Code |
03 | | L2330A_xx_N403_OINS_ZIP | String | Other Insured 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_nnREF_SSN | String | Social Security Number |
L2330B - OTHER PAYER NAME (Inherited Loop Iteration) |
L2330B | NM1 | Other Payer Name | | |
03 | | L2330B_xx_NM103_NONPSNENT_NM | String | Non-Person Entity 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 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 | Date (YYYYMMDD) | Date Claim Paid Date |
L2330B | REF | Other Payer Secondary Identifier | | |
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 Predetermination Identification | | |
02 | | L2330B_xx_REF_PREF_BEN_ID_NR | String | Predetermination of Benefits Identification Number |
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 | | |
L2330D | REF | Other Payer Rendering Provider Secondary Identification | | |
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 SUPERVISING PROVIDER (Inherited Loop Iteration) |
L2330E | NM1 | Other Payer Supervising Provider | | |
L2330E | REF | Other Payer Supervising Provider Secondary Identification | | |
02 | | L2330E_xx_nnREF_STAT_LIC_NR | String | State License Number |
02 | | L2330E_xx_nnREF_UPIN | String | Provider UPIN Number |
02 | | L2330E_xx_nnREF_PVR_COMM_NR | String | Provider Commercial Number |
02 | | L2330E_xx_nnREF_LOC_NR | String | Location Number |
L2330F - OTHER PAYER BILLING PROVIDER (Inherited Loop Iteration) |
L2330F | NM1 | Other Payer Billing Provider | | |
02 | | L2330F_xx_NM102_ENT_TYP_QUAL | String | Entity Type Qualifier |
L2330F | REF | Other Payer Billing Provider Secondary Identification | | |
02 | | L2330F_xx_REF_PVR_COMM_NR | String | Provider Commercial Number |
02 | | L2330F_xx_REF_LOC_NR | String | Location Number |
L2330G - OTHER PAYER SERVICE FACILITY LOCATION (Inherited Loop Iteration) |
L2330G | NM1 | Other Payer Service Facility Location | | |
L2330G | REF | Other Payer Service Facility Location Secondary Identification | | |
02 | | L2330G_xx_REF_STAT_LIC_NR | String | State License Number |
02 | | L2330G_xx_REF_PVR_COMM_NR | String | Provider Commercial Number |
02 | | L2330G_xx_REF_LOC_NR | String | Location Number |
L2330H - OTHER PAYER ASSISTANT SURGEON (Inherited Loop Iteration) |
L2330H | NM1 | Other Payer Assistant Surgeon | | |
02 | | L2330H_xx_NM102_ENT_TYP_QUAL | String | Entity Type Qualifier |
L2330H | REF | Other Payer Assistant Surgeon Secondary Identifier | | |
02 | | L2330H_xx_nnREF_STAT_LIC_NR | String | State License Number |
02 | | L2330H_xx_nnREF_UPIN | String | Provider UPIN Number |
02 | | L2330H_xx_nnREF_PVR_COMM_NR | String | Provider Commercial Number |
02 | | L2330H_xx_nnREF_LOC_NR | String | Location Number |
L2400 - SERVICE LINE NUMBER |
L2400 | LX | Service Line Number | | |
01 | | L2400_LX01_ASSGD_NR | Integer | Assigned Number |
01 | 02 | L2400_SV30102_PROC_CD | String | American Dental Association Codes |
01 | 03 | L2400_SV30103_PROC_MOD | String | Procedure Modifier |
01 | 04 | L2400_SV30104_PROC_MOD | String | Procedure Modifier |
01 | 05 | L2400_SV30105_PROC_MOD | String | Procedure Modifier |
01 | 06 | L2400_SV30106_PROC_MOD | String | Procedure Modifier |
01 | 07 | L2400_SV30107_PROC_CD_DESC | String | Procedure Code Description |
02 | | L2400_SV302_LIN_ITM_CHG_AMT | Number | Line Item Charge Amount |
03 | | L2400_SV303_POS_CD | String | Place of Service Code |
04 | 01 | L2400_SV30401_ORAL_CAV_DES_CD | String | Oral Cavity Designation Code |
04 | 02 | L2400_SV30402_ORAL_CAV_DES_CD | String | Oral Cavity Designation Code |
04 | 03 | L2400_SV30403_ORAL_CAV_DES_CD | String | Oral Cavity Designation Code |
04 | 04 | L2400_SV30404_ORAL_CAV_DES_CD | String | Oral Cavity Designation Code |
04 | 05 | L2400_SV30405_ORAL_CAV_DES_CD | String | Oral Cavity Designation Code |
05 | | L2400_SV305_PROS_CWN_INLY_CD | String | Prosthesis, Crown, or Inlay Code |
06 | | L2400_SV306_PROC_CT | Number | Procedure Count |
11 | 01 | L2400_SV31101_DIAG_CD_PTR | Integer | Diagnosis Code Pointer |
11 | 02 | L2400_SV31102_DIAG_CD_PTR | Integer | Diagnosis Code Pointer |
11 | 03 | L2400_SV31103_DIAG_CD_PTR | Integer | Diagnosis Code Pointer |
11 | 04 | L2400_SV31104_DIAG_CD_PTR | Integer | Diagnosis Code Pointer |
L2400X - SERVICE LINE NUMBER - TOO CUTOUT |
L2400X | TOO | Tooth Information | | |
02 | | L2400X_TOO02_NTL_TTH_DES_SYS | String | Universal National Tooth Designation System |
03 | 01 | L2400X_TOO0301_TOOTH_SURF_CD | String | Tooth Surface Code |
03 | 02 | L2400X_TOO0302_TOOTH_SURF_CD | String | Tooth Surface Code |
03 | 03 | L2400X_TOO0303_TOOTH_SURF_CD | String | Tooth Surface Code |
03 | 04 | L2400X_TOO0304_TOOTH_SURF_CD | String | Tooth Surface Code |
03 | 05 | L2400X_TOO0305_TOOTH_SURF_CD | String | Tooth Surface Code |
L2400 | DTP | Date - Service Date | | |
03 | | L2400_DTP_SVC_D8 | Date (YYYYMMDD) | Service Date |
L2400 | DTP | Date - Prior Placement | | |
03 | | L2400_DTP_EST_D8 | Date (YYYYMMDD) | Estimated Date |
03 | | L2400_DTP_PRIOR_PCMT_D8 | Date (YYYYMMDD) | Prior Placement Date |
L2400 | DTP | Date - Appliance Placement | | |
03 | | L2400_DTP_APPL_PLCMT_D8 | Date (YYYYMMDD) | Appliance Placement Date |
L2400 | DTP | Date - Replacement | | |
03 | | L2400_DTP_REPLCMT_D8 | Date (YYYYMMDD) | Replacement Date |
L2400 | DTP | Date - Treatment Start | | |
03 | | L2400_DTP_STRT_D8 | Date (YYYYMMDD) | Start Date |
L2400 | DTP | Date - Treatment Completion | | |
03 | | L2400_DTP_CMPLTN_D8 | Date (YYYYMMDD) | Completion Date |
L2400 | CN1 | Contract Information | | |
01 | | L2400_CN101_CNTRCT_TYP_CD | String | Contract Type Code |
02 | | L2400_CN102_CONTRCT_AMT | Number | Contract Amount |
03 | | L2400_CN103_CONTRCT_PERC | Number | Contract Percentage |
04 | | L2400_CN104_CONTRCT_CD | String | Contract Code |
05 | | L2400_CN105_TERMS_DISCT_PERC | Number | Terms Discount Percentage |
06 | | L2400_CN106_CONTRCT_VERS_ID | String | Contract Version Identifier |
L2400 | REF | Service Predetermination Identification | | |
02 | | L2400_nnREF_PREF_BEN_ID_NR | String | Predetermination of Benefits Identification Number |
04 | 02 | L2400_nnREF0402_OPYR_PRI_ID | String | Payer Identification Number |
L2400 | REF | Prior Authorization | Segment Suffix: B
| |
02 | | L2400_nnREFB_PRIOR_AUTH | String | Prior Authorization Number |
04 | 02 | L2400_nnREFB0402_OPYR_PRI_ID | String | Payer Identification Number |
L2400 | REF | Line Item Control Number | | |
02 | | L2400_REF_PRV_CTL_NR | String | Provider Control Number |
L2400 | REF | Repriced Claim Number | | |
02 | | L2400_REF_REP_CLM_ID | String | Repriced Claim Reference Number |
L2400 | REF | Adjusted Repriced Claim Number | | |
02 | | L2400_REF_ADJ_REP_CLM_ID | String | Adjusted Repriced Claim Reference Number |
L2400 | REF | Referral Number | Segment Suffix: C
| |
02 | | L2400_nnREFC_REFRL_NR | String | Referral Number |
04 | 02 | L2400_nnREFC0402_OPYR_PRI_ID | String | Payer Identification Number |
02 | | L2400_AMT02_TAX | Number | Tax |
01 | | L2400_nnK301_FIXD_FMT_NFO | String | Fixed Format Information |
L2400 | HCP | Line Pricing/Repricing Information | | |
01 | | L2400_HCP01_PRIC_METHD | String | Pricing Methodology |
02 | | L2400_HCP02_REPRCD_ALLWD_AMT | Number | Repriced Allowed Amount |
03 | | L2400_HCP03_REPRCD_SAVNG_AMT | Number | Repriced Saving Amount |
04 | | L2400_HCP04_REPRCNG_ORG_ID | String | Repricing Organization Identifier |
05 | | L2400_HCP05_REPRCD_PERDIEM_AMT | Number | Repricing Per Diem or Flat Rate Amount |
10 | | L2400_HCP10_ADA_CD | String | American Dental Association Codes |
12 | | L2400_HCP12_UN | Number | 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 |
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_NPI | String | Centers for Medicare and Medicaid Services National Provider Identifier |
L2420A | PRV | Rendering Provider Specialty Information | | |
03 | | L2420A_PRV03_PVD_TAXNMY_CD | String | Health Care Provider Taxonomy Code |
L2420A | REF | Rendering Provider Secondary Identification | | |
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_OPYR_PRI_ID | String | Payer Identification Number |
L2420B - ASSISTANT SURGEON NAME |
L2420B | NM1 | Assistant Surgeon Name | | |
03 | | L2420B_NM103_PERSN_LNM | String | Person Last Name |
04 | | L2420B_NM104_ASST_SRG_FNM | String | Assistant Surgeon First Name |
05 | | L2420B_NM105_ASST_SRG_MNM | String | Assistant Surgeon Middle Name or Initial |
07 | | L2420B_NM107_ASST_SRG_SFX | String | Assistant Surgeon Name Suffix |
09 | | L2420B_NM109_NPI | String | Centers for Medicare and Medicaid Services National Provider Identifier |
L2420B | PRV | Assistant Surgeon Specialty Information | | |
03 | | L2420B_PRV03_PVD_TAXNMY_CD | String | Health Care Provider Taxonomy Code |
L2420B | REF | Assistant Surgeon Secondary Identification | | |
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 |
02 | | L2420B_nnREF_LOC_NR | String | Location Number |
04 | 02 | L2420B_nnREF0402_OPYR_PRI_ID | String | Payer Identification Number |
L2420C - SUPERVISING PROVIDER NAME |
L2420C | NM1 | Supervising Provider Name | | |
03 | | L2420C_NM103_PERSN_LNM | String | Person Last Name |
04 | | L2420C_NM104_SUP_PVR_FNM | String | Supervising Provider First Name |
05 | | L2420C_NM105_SUP_PVR_MNM | String | Supervising Provider Middle Name or Initial |
07 | | L2420C_NM107_SUP_PVR_SFX | String | Supervising Provider Name Suffix |
09 | | L2420C_NM109_NPI | String | Centers for Medicare and Medicaid Services National Provider Identifier |
L2420C | REF | Supervising Provider Secondary Identification | | |
02 | | L2420C_nnREF_STAT_LIC_NR | String | State License Number |
02 | | L2420C_nnREF_UPIN | String | Provider UPIN Number |
02 | | L2420C_nnREF_PVR_COMM_NR | String | Provider Commercial Number |
02 | | L2420C_nnREF_LOC_NR | String | Location Number |
04 | 02 | L2420C_nnREF0402_OPYR_PRI_ID | String | Payer Identification Number |
L2420D - SERVICE FACILITY LOCATION NAME |
L2420D | NM1 | Service Facility Location Name | | |
03 | | L2420D_NM103_NONPSNENT_NM | String | Non-Person Entity Name |
09 | | L2420D_NM109_NPI | String | Centers for Medicare and Medicaid Services National Provider Identifier |
L2420D | N3 | Service Facility Location Address | | |
01 | | L2420D_N301_LAB_FAC_ADDR | String | Laboratory or Facility Address Line |
02 | | L2420D_N302_LAB_FAC_ADDR | String | Laboratory or Facility Address Line |
L2420D | N4 | Service Facility Location City, State, ZIP Code | | |
01 | | L2420D_N401_LAB_FAC_CITY | String | Laboratory or Facility City Name |
02 | | L2420D_N402_LAB_FAC_STAT | String | Laboratory or Facility State or Province Code |
03 | | L2420D_N403_LAB_ZIP | String | Laboratory or Facility Postal Zone or ZIP Code |
04 | | L2420D_N404_CNTRY_CD | String | Country Code |
07 | | L2420D_N407_CNTRY_SUBDV_CD | String | Country Subdivision Code |
L2420D | REF | Service Facility Location Secondary Identification | | |
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_OPYR_PRI_ID | String | Payer Identification Number |
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 | Number | Service Line Paid Amount |
03 | 02 | L2430_xx_SVD0302_ADA_CD | String | American Dental Association Codes |
03 | 02 | L2430_xx_SVD0302_JS_PRC_SPY_CD | String | Jurisdiction Specific Procedure and Supply 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 | Number | Paid Service Unit Count |
06 | | L2430_xx_SVD06_BND_UNBND_LN_NR | Integer | Bundled or Unbundled Line Number |
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 | Number | Adjustment Amount |
04 | | L2430_xx_nnCAS04_ADJ_QTY | Number | Adjustment Quantity |
05 | | L2430_xx_nnCAS05_ADJ_RSN_CD | String | Adjustment Reason Code |
06 | | L2430_xx_nnCAS06_ADJ_AMT | Number | Adjustment Amount |
07 | | L2430_xx_nnCAS07_ADJ_QTY | Number | Adjustment Quantity |
08 | | L2430_xx_nnCAS08_ADJ_RSN_CD | String | Adjustment Reason Code |
09 | | L2430_xx_nnCAS09_ADJ_AMT | Number | Adjustment Amount |
10 | | L2430_xx_nnCAS10_ADJ_QTY | Number | Adjustment Quantity |
11 | | L2430_xx_nnCAS11_ADJ_RSN_CD | String | Adjustment Reason Code |
12 | | L2430_xx_nnCAS12_ADJ_AMT | Number | Adjustment Amount |
13 | | L2430_xx_nnCAS13_ADJ_QTY | Number | Adjustment Quantity |
14 | | L2430_xx_nnCAS14_ADJ_RSN_CD | String | Adjustment Reason Code |
15 | | L2430_xx_nnCAS15_ADJ_AMT | Number | Adjustment Amount |
16 | | L2430_xx_nnCAS16_ADJ_QTY | Number | Adjustment Quantity |
17 | | L2430_xx_nnCAS17_ADJ_RSN_CD | String | Adjustment Reason Code |
18 | | L2430_xx_nnCAS18_ADJ_AMT | Number | Adjustment Amount |
19 | | L2430_xx_nnCAS19_ADJ_QTY | Number | Adjustment Quantity |
L2430 | DTP | Line Check or Remittance Date | | |
03 | | L2430_xx_DTP_CLM_PD_D8 | Date (YYYYMMDD) | Date Claim Paid Date |
L2430 | AMT | Remaining Patient Liability | | |
02 | | L2430_xx_AMT02_AMT_OWED | Number | Amount Owed |
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 |