5010 Health Care Claim: Dental [V0]


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_IMP_GUID_VERS_NMStringImplementation Guide Version Name
STHDRBHTBeginning of Hierarchical Transaction
01STHDR_BHT01_HIER_STRUC_CDStringHierarchical Structure Code
02STHDR_BHT02_TS_PURP_CDStringTransaction Set Purpose Code
03STHDR_BHT03_ORIG_APP_TRANS_IDStringOriginator Application Transaction Identifier
04STHDR_BHT04_TS_CRTN_D8Date (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
06STHDR_BHT06_CLM_ENC_IDStringClaim or Encounter Identifier
L1000A - SUBMITTER NAME
L1000ANM1Submitter Name
03L1000A_NM103_PERSN_LNMStringPerson Last Name
03L1000A_NM103_NONPSNENT_NMStringNon-Person Entity Name
04L1000A_NM104_SBM_FNMStringSubmitter First Name
05L1000A_NM105_SBM_MNMStringSubmitter Middle Name or Initial
09L1000A_NM109_ETN_NRStringElectronic Transmitter Identification Number (ETIN)
L1000APERSubmitter EDI Contact Information
02L1000A_nnPER02_SBM_CON_NMStringSubmitter Contact Name
04L1000A_nnPER04_EMAILStringElectronic Mail
04L1000A_nnPER04_FAXStringFacsimile
04L1000A_nnPER04_PHN_NRStringTelephone
06L1000A_nnPER06_EMAILStringElectronic Mail
06L1000A_nnPER06_PHN_EXTStringTelephone Extension
06L1000A_nnPER06_FAXStringFacsimile
06L1000A_nnPER06_PHN_NRStringTelephone
08L1000A_nnPER08_EMAILStringElectronic Mail
08L1000A_nnPER08_PHN_EXTStringTelephone Extension
08L1000A_nnPER08_FAXStringFacsimile
08L1000A_nnPER08_PHN_NRStringTelephone
L1000B - RECEIVER NAME
L1000BNM1Receiver Name
03L1000B_NM103_NONPSNENT_NMStringNon-Person Entity Name
09L1000B_NM109_ETN_NRStringElectronic Transmitter Identification Number (ETIN)
L2000A - BILLING PROVIDER HIERARCHICAL LEVEL
L2000AHLBilling Provider Hierarchical Level
01L2000A_HL01_HIER_ID_NRStringHierarchical ID Number
L2000APRVBilling Provider Specialty Information
03L2000A_PRV03_PVD_TAXNMY_CDStringHealth Care Provider Taxonomy Code
L2000ACURForeign Currency Information
02L2000A_CUR02_CURRNCY_CDStringCurrency Code
L2010AA - BILLING PROVIDER NAME
L2010AANM1Billing Provider Name
03L2010AA_NM103_PERSN_LNMStringPerson Last Name
03L2010AA_NM103_NONPSNENT_NMStringNon-Person Entity Name
04L2010AA_NM104_BILL_PVR_FNMStringBilling Provider First Name
05L2010AA_NM105_BILL_PVR_MNMStringBilling Provider Middle Name or Initial
07L2010AA_NM107_BILL_PVR_SFXStringBilling Provider Name Suffix
09L2010AA_NM109_NPIStringCenters for Medicare and Medicaid Services
L2010AAN3Billing Provider Address
01L2010AA_N301_BILL_PROV_ADDRStringBilling Provider Address Line
02L2010AA_N302_BILL_PROV_ADDRStringBilling Provider Address Line
L2010AAN4Billing Provider City, State, ZIP Code
01L2010AA_N401_BILL_PVR_CITYStringBilling Provider City Name
02L2010AA_N402_BILL_PVR_STATStringBilling Provider State or Province Code
03L2010AA_N403_BILL_PVR_ZIPStringBilling Provider Postal Zone or ZIP Code
04L2010AA_N404_CNTRY_CDStringCountry Code
07L2010AA_N407_CNTRY_SUBDV_CDStringCountry Subdivision Code
L2010AAREFBilling Provider Tax Identification
02L2010AA_REF_EMPLR_ID_NRStringEmployer's Identification Number
02L2010AA_REF_SSNStringSocial Security Number
L2010AAREFBilling Provider UPIN/License Information
02L2010AA_REF_STAT_LIC_NRStringState License Number
02L2010AA_REF_UPINStringProvider UPIN Number
L2010AAPERBilling Provider Contact Information
02L2010AA_nnPER02_BL_PVR_CONT_NMStringBilling Provider Contact Name
04L2010AA_nnPER04_EMAILStringElectronic Mail
04L2010AA_nnPER04_FAXStringFacsimile
04L2010AA_nnPER04_PHN_NRStringTelephone
06L2010AA_nnPER06_EMAILStringElectronic Mail
06L2010AA_nnPER06_PHN_EXTStringTelephone Extension
06L2010AA_nnPER06_FAXStringFacsimile
06L2010AA_nnPER06_PHN_NRStringTelephone
08L2010AA_nnPER08_EMAILStringElectronic Mail
08L2010AA_nnPER08_PHN_EXTStringTelephone Extension
08L2010AA_nnPER08_FAXStringFacsimile
08L2010AA_nnPER08_PHN_NRStringTelephone
L2010AB - PAY-TO ADDRESS NAME
L2010ABNM1Pay-to Address Name
02L2010AB_NM102_ENT_TYP_QUALStringEntity Type Qualifier
L2010ABN3Pay-to Address - ADDRESS
01L2010AB_N301_PAY2_ADDRStringPay-To Address Line
02L2010AB_N302_PAY2_ADDRStringPay-To Address Line
L2010ABN4Pay-To Address City, State, ZIP Code
01L2010AB_N401_PAY2_CITYStringPay-to Address City Name
02L2010AB_N402_PAY2_STATStringPay-To Address State or Province Code
03L2010AB_N403_PAY2_ZIPStringPay-to Address Postal Zone or ZIP Code
04L2010AB_N404_CNTRY_CDStringCountry Code
07L2010AB_N407_CNTRY_SUBDV_CDStringCountry Subdivision Code
L2010AC - PAY-TO PLAN NAME
L2010ACNM1Pay-To Plan Name
03L2010AC_NM103_NONPSNENT_NMStringNon-Person Entity Name
09L2010AC_NM109_PAYR_IDStringPayor Identification
09L2010AC_NM109_HCFA_PLAN_IDStringCenters for Medicare and Medicaid Services PlanID
L2010ACN3Pay-to Plan Address
01L2010AC_N301_PAY2_PLN_ADDRStringPay-To Plan Address Line
02L2010AC_N302_PAY2_PLN_ADDRStringPay-To Plan Address Line
L2010ACN4Pay-To Plan City, State, ZIP Code
01L2010AC_N401_PAY2_PLN_CITYStringPay-To Plan City Name
02L2010AC_N402_PAY2_PLN_STATStringPay-To Plan State or Province Code
03L2010AC_N403_PAY2_PLN_ZIPStringPay-To Plan Postal Zone or ZIP Code
04L2010AC_N404_CNTRY_CDStringCountry Code
07L2010AC_N407_CNTRY_SUBDV_CDStringCountry Subdivision Code
L2010ACREFPay-to Plan Secondary Identification
02L2010AC_REF_PYR_IDStringPayer Identification Number
02L2010AC_REF_CLM_OFC_NRStringClaim Office Number
02L2010AC_REF_NAICStringNational Association of Insurance Commissioners (NAIC) Code
L2010ACREFPay-To Plan Tax Identification Number
02L2010AC_REF_EMPLR_ID_NRStringEmployer's Identification Number
L2000B - SUBSCRIBER HIERARCHICAL LEVEL
L2000BHLSubscriber Hierarchical Level
01L2000B_HL01_HIER_ID_NRStringHierarchical ID Number
02L2000B_HL02_HIER_PARNT_ID_NRStringHierarchical Parent ID Number
04L2000B_HL04_HL_CHLD_CDStringHierarchical Child Code
L2000BSBRSubscriber Information
01L2000B_SBR01_PYR_RESP_SEQ_NRStringPayer Responsibility Sequence Number Code
02L2000B_SBR02_IND_RELAT_CDStringIndividual Relationship Code
03L2000B_SBR03_SBR_POLCY_NRStringSubscriber Group or Policy Number
04L2000B_SBR04_SBR_GRP_NMStringSubscriber Group Name
05L2000B_SBR05_INS_TYP_CDStringInsurance Type Code
09L2000B_SBR09_CLM_FIL_IND_CDStringClaim Filing Indicator Code
L2010BA - SUBSCRIBER NAME
L2010BANM1Subscriber Name
03L2010BA_NM103_PERSN_LNMStringPerson Last Name
03L2010BA_NM103_NONPSNENT_NMStringNon-Person Entity Name
04L2010BA_NM104_SBR_FNMStringSubscriber First Name
05L2010BA_NM105_SBR_MNMStringSubscriber Middle Name or Initial
07L2010BA_NM107_SBR_SFXStringSubscriber Name Suffix
09L2010BA_NM109_UNQ_HLTH_IDStringStandard Unique Health Identifier for each Individual in the United States
09L2010BA_NM109_MEM_ID_NRStringMember Identification Number
L2010BAN3Subscriber Address
01L2010BA_N301_SBR_ADDRStringSubscriber Address Line
02L2010BA_N302_SBR_ADDRStringSubscriber Address Line
L2010BAN4Subscriber City, State, ZIP Code
01L2010BA_N401_SBR_CITYStringSubscriber City Name
02L2010BA_N402_SBR_STATStringSubscriber State Code
03L2010BA_N403_SBR_ZIPStringSubscriber Postal Zone or ZIP Code
04L2010BA_N404_CNTRY_CDStringCountry Code
07L2010BA_N407_CNTRY_SUBDV_CDStringCountry Subdivision Code
L2010BADMGSubscriber Demographic Information
02L2010BA_DMG02_D8DateTimeSubscriber Birth Date
03L2010BA_DMG03_SUB_GENDR_CDStringSubscriber Gender Code
L2010BAREFSubscriber Secondary Identification
02L2010BA_REF_SSNStringSocial Security Number
L2010BAREFProperty and Casualty Claim Number
02L2010BA_REF_AGNCY_CLM_NRStringAgency Claim Number
L2010BB - PAYER NAME
L2010BBNM1Payer Name
03L2010BB_NM103_NONPSNENT_NMStringNon-Person Entity Name
09L2010BB_NM109_PAYR_IDStringPayor Identification
09L2010BB_NM109_HCFA_PLAN_IDStringCenters for Medicare and Medicaid Services PlanID
L2010BBN3Payer Address
01L2010BB_N301_PYR_ADDR_LNStringPayer Address Line
02L2010BB_N302_PYR_ADDR_LNStringPayer Address Line
L2010BBN4Payer City, State, ZIP Code
01L2010BB_N401_PYR_CITY_NMStringPayer City Name
02L2010BB_N402_PYR_STATStringPayer State Code
03L2010BB_N403_PYR_ZIPStringPayer Postal Zone or ZIP Code
04L2010BB_N404_CNTRY_CDStringCountry Code
07L2010BB_N407_CNTRY_SUBDV_CDStringCountry Subdivision Code
L2010BBREFPayer Secondary Identification
02L2010BB_nnREF_PYR_IDStringPayer Identification Number
02L2010BB_nnREF_EMPLR_ID_NRStringEmployer's Identification Number
02L2010BB_nnREF_CLM_OFC_NRStringClaim Office Number
02L2010BB_nnREF_NAICStringNational Association of Insurance Commissioners (NAIC) Code
L2010BBREFBilling Provider Secondary Identification
02L2010BB_REF_PVR_COMM_NRStringProvider Commercial Number
02L2010BB_REF_LOC_NRStringLocation Number
L2000C - PATIENT HIERARCHICAL LEVEL
L2000CHLPatient Hierarchical Level
01L2000C_HL01_HIER_ID_NRStringHierarchical ID Number
02L2000C_HL02_HIER_PARNT_ID_NRStringHierarchical Parent ID Number
L2000CPATPatient Information
01L2000C_PAT01_IND_RELAT_CDStringIndividual Relationship Code
L2010CA - PATIENT NAME
L2010CANM1Patient Name
03L2010CA_NM103_PERSN_LNMStringPerson Last Name
04L2010CA_NM104_PT_FNMStringPatient First Name
05L2010CA_NM105_PT_MNMStringPatient Middle Name or Initial
07L2010CA_NM107_PT_SFXStringPatient Name Suffix
L2010CAN3Patient Address
01L2010CA_N301_PT_ADDRStringPatient Address Line
02L2010CA_N302_PT_ADDRStringPatient Address Line
L2010CAN4Patient City, State, ZIP Code
01L2010CA_N401_PT_CITYStringPatient City Name
02L2010CA_N402_PT_STATStringPatient State Code
03L2010CA_N403_PT_ZIPStringPatient Postal Zone or ZIP Code
04L2010CA_N404_CNTRY_CDStringCountry Code
07L2010CA_N407_CNTRY_SUBDV_CDStringCountry Subdivision Code
L2010CADMGPatient Demographic Information
02L2010CA_DMG02_D8DateTimePatient Birth Date
03L2010CA_DMG03_PAT_GNDR_CDStringPatient Gender Code
L2010CAREFProperty and Casualty Claim Number
02L2010CA_REF_AGNCY_CLM_NRStringAgency Claim Number
L2300 - CLAIM INFORMATION
L2300CLMClaim Information
01L2300_CLM01_PT_CTL_NRStringPatient Control Number
02L2300_CLM02_TOT_CLM_CHG_AMTNumberTotal Claim Charge Amount
0501L2300_CLM0501_POS_CDStringPlace of Service Code
0503L2300_CLM0503_CLM_FREQ_CDStringClaim Frequency Code
06L2300_CLM06_PVD_SUPP_SIG_INDStringProvider or Supplier Signature Indicator
07L2300_CLM07_PLAN_PART_CDStringAssignment or Plan Participation Code
08L2300_CLM08_BEN_ASGT_CRT_INDStringBenefits Assignment Certification Indicator
09L2300_CLM09_RELS_NFO_CDStringRelease of Information Code
1101L2300_CLM1101_RELTD_CAUS_CDStringRelated Causes Code
1102L2300_CLM1102_RELTD_CAUS_CDStringRelated Causes Code
1104L2300_CLM1104_AUTO_ACC_STATStringAuto Accident State or Province Code
1105L2300_CLM1105_CNTRY_CDStringCountry Code
12L2300_CLM12_SPC_PRG_INDStringSpecial Program Indicator
19L2300_CLM19_PRE_BEN_CDStringPredetermination of Benefits Code
20L2300_CLM20_DELAY_RSN_CDStringDelay Reason Code
L2300DTPDate - Accident
03L2300_DTP_ACCDNT_D8Date (YYYYMMDD)Accident Date
L2300DTPDate - Appliance Placement
03L2300_DTP_APPL_PLCMT_D8Date (YYYYMMDD)Appliance Placement Date
L2300DTPDate - Service Date
03L2300_DTP_SVC_D8Date (YYYYMMDD)Service Date
03L2300_DTP_SVC_RD8_1Start Date (YYYYMMDD)Service Date
03L2300_DTP_SVC_RD8_2End Date (YYYYMMDD)Service Date
L2300DTPDate - Repricer Received Date
03L2300_DTP_RCVD_D8Date (YYYYMMDD)Received Date
L2300DN1Orthodontic Total Months of Treatment
01L2300_DN101_ORTHO_TRT_MO_CTNumberOrthodontic Treatment Months Count
02L2300_DN102_ORTHO_MON_REM_CTNumberOrthodontic Treatment Months Remaining Count
04L2300_DN104_ORTHO_TMT_INDStringOrthodontic Treatment Indicator
L2300X - CLAIM INFORMATION - DN2 CUTOUT
L2300XDN2Tooth Status
01L2300X_DN201_TOOTH_NRStringTooth Number
02L2300X_DN202_TTH_STAT_CDStringTooth Status Code
L2300PWKClaim Supplemental Information
01L2300_nnPWK01_ATT_REP_TYP_CDStringAttachment Report Type Code
02L2300_nnPWK02_ATT_TRANS_CDStringAttachment Transmission Code
06L2300_nnPWK06_ATTACH_CTL_NRStringAttachment Control Number
L2300CN1Contract Information
01L2300_CN101_CNTRCT_TYP_CDStringContract Type Code
02L2300_CN102_CONTRCT_AMTNumberContract Amount
03L2300_CN103_CONTRCT_PERCNumberContract Percentage
04L2300_CN104_CONTRCT_CDStringContract Code
05L2300_CN105_TERMS_DISCT_PERCNumberTerms Discount Percentage
06L2300_CN106_CONTRCT_VERS_IDStringContract Version Identifier
L2300AMTPatient Amount Paid
02L2300_AMT02_PT_AMT_PDNumberPatient Amount Paid
L2300REFPredetermination Identification
02L2300_REF_PREF_BEN_ID_NRStringPredetermination of Benefits Identification Number
L2300REFService Authorization Exception Code
02L2300_REF_SP_PMT_REF_NRStringSpecial Payment Reference Number
L2300REFPayer Claim Control Number
02L2300_REF_ORIG_REF_NRStringOriginal Reference Number
L2300REFReferral Number
02L2300_REF_REFRL_NRStringReferral Number
L2300REFPrior Authorization
02L2300_REF_PRIOR_AUTHStringPrior Authorization Number
L2300REFRepriced Claim Number
02L2300_REF_REP_CLM_IDStringRepriced Claim Reference Number
L2300REFAdjusted Repriced Claim Number
02L2300_REF_ADJ_REP_CLM_IDStringAdjusted Repriced Claim Reference Number
L2300REFClaim Identifier For Transmission Intermediaries
02L2300_REF_CLM_NRStringClaim Number
L2300K3File Information
01L2300_nnK301_FIXD_FMT_NFOStringFixed Format Information
L2300NTEClaim Note
02L2300_nnNTE02_ADDL_NFOStringAdditional Information
L2300HIHealth Care Diagnosis Code
0102L2300_HI0102_ICD10_PRIN_DIAGStringInternational Classification of Diseases Clinical Modification (ICD-10-CM) Principal Diagnosis
0102L2300_HI0102_ICD9_PRIN_DIAGStringInternational Classification of Diseases Clinical Modification (ICD-9-CM) Principal Diagnosis
0102L2300_HI0102_SNODENTStringSystemized Nomenclature of Dentistry (SNODENT)
0202L2300_HI0202_ICD10_DIAGStringInternational Classification of Diseases Clinical Modification (ICD-10-CM) Diagnosis
0202L2300_HI0202_ICD9_DIAGStringInternational Classification of Diseases Clinical Modification (ICD-9-CM) Diagnosis
0202L2300_HI0202_SNODENTStringSystemized Nomenclature of Dentistry (SNODENT)
0301L2300_HI0301_CD_LST_QL_CDStringCode List Qualifier Code
0302L2300_HI0302_DIAG_CDStringDiagnosis Code
0401L2300_HI0401_CD_LST_QL_CDStringCode List Qualifier Code
0402L2300_HI0402_DIAG_CDStringDiagnosis Code
L2300HCPClaim Pricing/Repricing Information
01L2300_HCP01_PRIC_METHDStringPricing Methodology
02L2300_HCP02_REPRCD_ALLWD_AMTNumberRepriced Allowed Amount
03L2300_HCP03_REPRCD_SAVNG_AMTNumberRepriced Saving Amount
04L2300_HCP04_REPRCNG_ORG_IDStringRepricing Organization Identifier
05L2300_HCP05_REPRCD_PERDIEM_AMTNumberRepricing Per Diem or Flat Rate Amount
06L2300_HCP06_REP_AMB_PT_GRPStringRepriced Approved Ambulatory Patient Group
13L2300_HCP13_REJ_RSN_CDStringReject Reason Code
14L2300_HCP14_POLCY_COMP_CDStringPolicy Compliance Code
15L2300_HCP15_EXCPTN_CDStringException Code
L2310A - REFERRING PROVIDER NAME (Value Qualified)
Mapping Prefix: L2310A_DN - Referring Provider
Mapping Prefix: L2310A_P3 - Primary Care Provider
L2310ANM1Referring Provider Name
03L2310A_yy_NM103_PERSN_LNMStringPerson Last Name
04L2310A_yy_NM104_REF_PVR_FNMStringReferring Provider First Name
05L2310A_yy_NM105_REF_PVR_MNMStringReferring Provider Middle Name or Initial
07L2310A_yy_NM107_REF_PVR_SFXStringReferring Provider Name Suffix
09L2310A_yy_NM109_NPIStringCenters for Medicare and Medicaid Services National Provider Identifier
L2310APRVReferring Provider Specialty Information
03L2310A_yy_PRV03_PVD_TAXNMY_CDStringHealth Care Provider Taxonomy Code
L2310AREFReferring Provider Secondary Identification
02L2310A_yy_REF_STAT_LIC_NRStringState License Number
02L2310A_yy_REF_UPINStringProvider UPIN Number
02L2310A_yy_REF_PVR_COMM_NRStringProvider Commercial Number
L2310B - RENDERING PROVIDER NAME
L2310BNM1Rendering Provider Name
03L2310B_NM103_PERSN_LNMStringPerson Last Name
03L2310B_NM103_NONPSNENT_NMStringNon-Person Entity Name
04L2310B_NM104_REND_PVR_FNMStringRendering Provider First Name
05L2310B_NM105_REND_PVR_MNMStringRendering Provider Middle Name or Initial
07L2310B_NM107_REND_PROV_SFXStringRendering Provider Name Suffix
09L2310B_NM109_NPIStringCenters for Medicare and Medicaid Services National Provider Identifier
L2310BPRVRendering Provider Specialty Information
03L2310B_PRV03_PVD_TAXNMY_CDStringHealth Care Provider Taxonomy Code
L2310BREFRendering Provider Secondary Identification
02L2310B_REF_STAT_LIC_NRStringState License Number
02L2310B_REF_UPINStringProvider UPIN Number
02L2310B_REF_PVR_COMM_NRStringProvider Commercial Number
02L2310B_REF_LOC_NRStringLocation Number
L2310C - SERVICE FACILITY LOCATION NAME
L2310CNM1Service Facility Location Name
03L2310C_NM103_NONPSNENT_NMStringNon-Person Entity Name
09L2310C_NM109_NPIStringCenters for Medicare and Medicaid Services National Provider Identifier
L2310CN3Service Facility Location Address
01L2310C_N301_LAB_FAC_ADDRStringLaboratory or Facility Address Line
02L2310C_N302_LAB_FAC_ADDRStringLaboratory or Facility Address Line
L2310CN4Service Facility Location City, State, ZIP Code
01L2310C_N401_LAB_FAC_CITYStringLaboratory or Facility City Name
02L2310C_N402_LAB_FAC_STATStringLaboratory or Facility State or Province Code
03L2310C_N403_LAB_ZIPStringLaboratory or Facility Postal Zone or ZIP Code
04L2310C_N404_CNTRY_CDStringCountry Code
07L2310C_N407_CNTRY_SUBDV_CDStringCountry Subdivision Code
L2310CREFService Facility Location Secondary Identification
02L2310C_REF_STAT_LIC_NRStringState License Number
02L2310C_REF_PVR_COMM_NRStringProvider Commercial Number
02L2310C_REF_LOC_NRStringLocation Number
L2310D - ASSISTANT SURGEON NAME
L2310DNM1Assistant Surgeon Name
03L2310D_NM103_PERSN_LNMStringPerson Last Name
04L2310D_NM104_ASST_SRG_FNMStringAssistant Surgeon First Name
05L2310D_NM105_ASST_SRG_MNMStringAssistant Surgeon Middle Name or Initial
07L2310D_NM107_ASST_SRG_SFXStringAssistant Surgeon Name Suffix
09L2310D_NM109_NPIStringCenters for Medicare and Medicaid Services National Provider Identifier
L2310DPRVAssistant Surgeon Specialty Information
03L2310D_PRV03_PVD_TAXNMY_CDStringHealth Care Provider Taxonomy Code
L2310DREFAssistant Surgeon Secondary Identification
02L2310D_REF_STAT_LIC_NRStringState License Number
02L2310D_REF_UPINStringProvider UPIN Number
02L2310D_REF_PVR_COMM_NRStringProvider Commercial Number
02L2310D_REF_LOC_NRStringLocation Number
L2310E - SUPERVISING PROVIDER NAME
L2310ENM1Supervising Provider Name
03L2310E_NM103_PERSN_LNMStringPerson Last Name
04L2310E_NM104_SUP_PVR_FNMStringSupervising Provider First Name
05L2310E_NM105_SUP_PVR_MNMStringSupervising Provider Middle Name or Initial
07L2310E_NM107_SUP_PVR_SFXStringSupervising Provider Name Suffix
09L2310E_NM109_NPIStringCenters for Medicare and Medicaid Services National Provider Identifier
L2310EREFSupervising Provider Secondary Identification
02L2310E_REF_STAT_LIC_NRStringState License Number
02L2310E_REF_UPINStringProvider UPIN Number
02L2310E_REF_PVR_COMM_NRStringProvider Commercial Number
02L2310E_REF_LOC_NRStringLocation Number
L2320 - OTHER SUBSCRIBER INFORMATION (Single Iteration)
L2320SBROther Subscriber Information
01L2320_xx_SBR01_PYR_RESP_SEQ_NRStringPayer Responsibility Sequence Number Code
02L2320_xx_SBR02_IND_RELAT_CDStringIndividual Relationship Code
03L2320_xx_SBR03_INS_GRP_PLCY_NRStringInsured Group or Policy Number
04L2320_xx_SBR04_OINS_GRP_NMStringOther Insured Group Name
05L2320_xx_SBR05_INS_TYP_CDStringInsurance Type Code
09L2320_xx_SBR09_CLM_FIL_IND_CDStringClaim Filing Indicator Code
L2320CASClaim Level Adjustments
01L2320_xx_nnCAS01_CLMADJ_GRP_CDStringClaim Adjustment Group Code
02L2320_xx_nnCAS02_ADJ_RSN_CDStringAdjustment Reason Code
03L2320_xx_nnCAS03_ADJ_AMTNumberAdjustment Amount
04L2320_xx_nnCAS04_ADJ_QTYNumberAdjustment Quantity
05L2320_xx_nnCAS05_ADJ_RSN_CDStringAdjustment Reason Code
06L2320_xx_nnCAS06_ADJ_AMTNumberAdjustment Amount
07L2320_xx_nnCAS07_ADJ_QTYNumberAdjustment Quantity
08L2320_xx_nnCAS08_ADJ_RSN_CDStringAdjustment Reason Code
09L2320_xx_nnCAS09_ADJ_AMTNumberAdjustment Amount
10L2320_xx_nnCAS10_ADJ_QTYNumberAdjustment Quantity
11L2320_xx_nnCAS11_ADJ_RSN_CDStringAdjustment Reason Code
12L2320_xx_nnCAS12_ADJ_AMTNumberAdjustment Amount
13L2320_xx_nnCAS13_ADJ_QTYNumberAdjustment Quantity
14L2320_xx_nnCAS14_ADJ_RSN_CDStringAdjustment Reason Code
15L2320_xx_nnCAS15_ADJ_AMTNumberAdjustment Amount
16L2320_xx_nnCAS16_ADJ_QTYNumberAdjustment Quantity
17L2320_xx_nnCAS17_ADJ_RSN_CDStringAdjustment Reason Code
18L2320_xx_nnCAS18_ADJ_AMTNumberAdjustment Amount
19L2320_xx_nnCAS19_ADJ_QTYNumberAdjustment Quantity
L2320AMTCoordination of Benefits (COB) Payer Paid Amount
02L2320_xx_AMT02_PAYR_AMT_PDNumberPayor Amount Paid
L2320AMTRemaining Patient Liability
02L2320_xx_AMT02_AMT_OWEDNumberAmount Owed
L2320AMTCoordination of Benefits (COB) Total Non-Covered Amount
02L2320_xx_AMT02_NONCVD_CHG_ACTLNumberNoncovered Charges - Actual
L2320OIOther Insurance Coverage Information
03L2320_xx_OI03_BEN_ASGT_CRT_INDStringBenefits Assignment Certification Indicator
06L2320_xx_OI06_RELS_NFO_CDStringRelease of Information Code
L2320MOAOutpatient Adjudication Information
01L2320_xx_MOA01_REIMBRSMT_RTNumberReimbursement Rate
02L2320_xx_MOA02_HCPCS_PAYBL_AMTNumberHCPCS Payable Amount
03L2320_xx_MOA03_CLM_PMT_RMK_CDStringClaim Payment Remark Code
04L2320_xx_MOA04_CLM_PMT_RMK_CDStringClaim Payment Remark Code
05L2320_xx_MOA05_CLM_PMT_RMK_CDStringClaim Payment Remark Code
06L2320_xx_MOA06_CLM_PMT_RMK_CDStringClaim Payment Remark Code
07L2320_xx_MOA07_CLM_PMT_RMK_CDStringClaim Payment Remark Code
09L2320_xx_MOA09_NONPAY_PROF_BLLStringNon-Payable Professional Component Billed
L2330A - OTHER SUBSCRIBER NAME (Inherited Loop Iteration)
L2330ANM1Other Subscriber Name
03L2330A_xx_NM103_PERSN_LNMStringPerson Last Name
03L2330A_xx_NM103_NONPSNENT_NMStringNon-Person Entity Name
04L2330A_xx_NM104_OINS_FNMStringOther Insured First Name
05L2330A_xx_NM105_OINS_MNMStringOther Insured Middle Name
07L2330A_xx_NM107_OINS_SFXStringOther Insured Name Suffix
09L2330A_xx_NM109_UNQ_HLTH_IDStringStandard Unique Health Identifier for each Individual in the United States
09L2330A_xx_NM109_MEM_ID_NRStringMember Identification Number
L2330AN3Other Subscriber Address
01L2330A_xx_N301_OINS_ADDRStringOther Insured Address Line
02L2330A_xx_N302_OINS_ADDRStringOther Insured Address Line
L2330AN4Other Subscriber City, State, ZIP Code
01L2330A_xx_N401_OINS_CITYStringOther Insured City Name
02L2330A_xx_N402_OINS_STATStringOther Insured State Code
03L2330A_xx_N403_OINS_ZIPStringOther Insured Postal Zone or ZIP Code
04L2330A_xx_N404_CNTRY_CDStringCountry Code
07L2330A_xx_N407_CNTRY_SUBDV_CDStringCountry Subdivision Code
L2330AREFOther Subscriber Secondary Identification
02L2330A_xx_nnREF_SSNStringSocial Security Number
L2330B - OTHER PAYER NAME (Inherited Loop Iteration)
L2330BNM1Other Payer Name
03L2330B_xx_NM103_NONPSNENT_NMStringNon-Person Entity Name
09L2330B_xx_NM109_PAYR_IDStringPayor Identification
09L2330B_xx_NM109_HCFA_PLAN_IDStringCenters for Medicare and Medicaid Services PlanID
L2330BN3Other Payer Address
01L2330B_xx_N301_OPYR_ADDRStringOther Payer Address Line
02L2330B_xx_N302_OPYR_ADDRStringOther Payer Address Line
L2330BN4Other Payer City, State, ZIP Code
01L2330B_xx_N401_OPYR_CITY_NMStringOther Payer City Name
02L2330B_xx_N402_OPYR_STATStringOther Payer State Code
03L2330B_xx_N403_OPYR_POSTL_ZIPStringOther Payer Postal Zone or ZIP Code
04L2330B_xx_N404_CNTRY_CDStringCountry Code
07L2330B_xx_N407_CNTRY_SUBDV_CDStringCountry Subdivision Code
L2330BDTPClaim Check or Remittance Date
03L2330B_xx_DTP_CLM_PD_D8Date (YYYYMMDD)Date Claim Paid Date
L2330BREFOther Payer Secondary Identifier
02L2330B_xx_nnREF_PYR_IDStringPayer Identification Number
02L2330B_xx_nnREF_EMPLR_ID_NRStringEmployer's Identification Number
02L2330B_xx_nnREF_CLM_OFC_NRStringClaim Office Number
02L2330B_xx_nnREF_NAICStringNational Association of Insurance Commissioners (NAIC) Code
L2330BREFOther Payer Prior Authorization Number
02L2330B_xx_REF_PRIOR_AUTHStringPrior Authorization Number
L2330BREFOther Payer Referral Number
02L2330B_xx_REF_REFRL_NRStringReferral Number
L2330BREFOther Payer Claim Adjustment Indicator
02L2330B_xx_REF_SIGNL_CDStringSignal Code
L2330BREFOther Payer Predetermination Identification
02L2330B_xx_REF_PREF_BEN_ID_NRStringPredetermination of Benefits Identification Number
L2330BREFOther Payer Claim Control Number
02L2330B_xx_REF_ORIG_REF_NRStringOriginal Reference Number
L2330C - OTHER PAYER REFERRING PROVIDER (Inherited Loop Iteration & Value Qualified)
Mapping Prefix: L2330C_xxDN - Referring Provider
Mapping Prefix: L2330C_xxP3 - Primary Care Provider
L2330CNM1Other Payer Referring Provider
L2330CREFOther Payer Referring Provider Secondary Identification
02L2330C_xxyy_REF_STAT_LIC_NRStringState License Number
02L2330C_xxyy_REF_UPINStringProvider UPIN Number
02L2330C_xxyy_REF_PVR_COMM_NRStringProvider Commercial Number
L2330D - OTHER PAYER RENDERING PROVIDER (Inherited Loop Iteration)
L2330DNM1Other Payer Rendering Provider
L2330DREFOther Payer Rendering Provider Secondary Identification
02L2330D_xx_nnREF_STAT_LIC_NRStringState License Number
02L2330D_xx_nnREF_UPINStringProvider UPIN Number
02L2330D_xx_nnREF_PVR_COMM_NRStringProvider Commercial Number
02L2330D_xx_nnREF_LOC_NRStringLocation Number
L2330E - OTHER PAYER SUPERVISING PROVIDER (Inherited Loop Iteration)
L2330ENM1Other Payer Supervising Provider
L2330EREFOther Payer Supervising Provider Secondary Identification
02L2330E_xx_nnREF_STAT_LIC_NRStringState License Number
02L2330E_xx_nnREF_UPINStringProvider UPIN Number
02L2330E_xx_nnREF_PVR_COMM_NRStringProvider Commercial Number
02L2330E_xx_nnREF_LOC_NRStringLocation Number
L2330F - OTHER PAYER BILLING PROVIDER (Inherited Loop Iteration)
L2330FNM1Other Payer Billing Provider
02L2330F_xx_NM102_ENT_TYP_QUALStringEntity Type Qualifier
L2330FREFOther Payer Billing Provider Secondary Identification
02L2330F_xx_REF_PVR_COMM_NRStringProvider Commercial Number
02L2330F_xx_REF_LOC_NRStringLocation Number
L2330G - OTHER PAYER SERVICE FACILITY LOCATION (Inherited Loop Iteration)
L2330GNM1Other Payer Service Facility Location
L2330GREFOther Payer Service Facility Location Secondary Identification
02L2330G_xx_REF_STAT_LIC_NRStringState License Number
02L2330G_xx_REF_PVR_COMM_NRStringProvider Commercial Number
02L2330G_xx_REF_LOC_NRStringLocation Number
L2330H - OTHER PAYER ASSISTANT SURGEON (Inherited Loop Iteration)
L2330HNM1Other Payer Assistant Surgeon
02L2330H_xx_NM102_ENT_TYP_QUALStringEntity Type Qualifier
L2330HREFOther Payer Assistant Surgeon Secondary Identifier
02L2330H_xx_nnREF_STAT_LIC_NRStringState License Number
02L2330H_xx_nnREF_UPINStringProvider UPIN Number
02L2330H_xx_nnREF_PVR_COMM_NRStringProvider Commercial Number
02L2330H_xx_nnREF_LOC_NRStringLocation Number
L2400 - SERVICE LINE NUMBER
L2400LXService Line Number
01L2400_LX01_ASSGD_NRIntegerAssigned Number
L2400SV3Dental Service
0102L2400_SV30102_PROC_CDStringAmerican Dental Association Codes
0103L2400_SV30103_PROC_MODStringProcedure Modifier
0104L2400_SV30104_PROC_MODStringProcedure Modifier
0105L2400_SV30105_PROC_MODStringProcedure Modifier
0106L2400_SV30106_PROC_MODStringProcedure Modifier
0107L2400_SV30107_PROC_CD_DESCStringProcedure Code Description
02L2400_SV302_LIN_ITM_CHG_AMTNumberLine Item Charge Amount
03L2400_SV303_POS_CDStringPlace of Service Code
0401L2400_SV30401_ORAL_CAV_DES_CDStringOral Cavity Designation Code
0402L2400_SV30402_ORAL_CAV_DES_CDStringOral Cavity Designation Code
0403L2400_SV30403_ORAL_CAV_DES_CDStringOral Cavity Designation Code
0404L2400_SV30404_ORAL_CAV_DES_CDStringOral Cavity Designation Code
0405L2400_SV30405_ORAL_CAV_DES_CDStringOral Cavity Designation Code
05L2400_SV305_PROS_CWN_INLY_CDStringProsthesis, Crown, or Inlay Code
06L2400_SV306_PROC_CTNumberProcedure Count
1101L2400_SV31101_DIAG_CD_PTRIntegerDiagnosis Code Pointer
1102L2400_SV31102_DIAG_CD_PTRIntegerDiagnosis Code Pointer
1103L2400_SV31103_DIAG_CD_PTRIntegerDiagnosis Code Pointer
1104L2400_SV31104_DIAG_CD_PTRIntegerDiagnosis Code Pointer
L2400X - SERVICE LINE NUMBER - TOO CUTOUT
L2400XTOOTooth Information
02L2400X_TOO02_NTL_TTH_DES_SYSStringUniversal National Tooth Designation System
0301L2400X_TOO0301_TOOTH_SURF_CDStringTooth Surface Code
0302L2400X_TOO0302_TOOTH_SURF_CDStringTooth Surface Code
0303L2400X_TOO0303_TOOTH_SURF_CDStringTooth Surface Code
0304L2400X_TOO0304_TOOTH_SURF_CDStringTooth Surface Code
0305L2400X_TOO0305_TOOTH_SURF_CDStringTooth Surface Code
L2400DTPDate - Service Date
03L2400_DTP_SVC_D8Date (YYYYMMDD)Service Date
L2400DTPDate - Prior Placement
03L2400_DTP_EST_D8Date (YYYYMMDD)Estimated Date
03L2400_DTP_PRIOR_PCMT_D8Date (YYYYMMDD)Prior Placement Date
L2400DTPDate - Appliance Placement
03L2400_DTP_APPL_PLCMT_D8Date (YYYYMMDD)Appliance Placement Date
L2400DTPDate - Replacement
03L2400_DTP_REPLCMT_D8Date (YYYYMMDD)Replacement Date
L2400DTPDate - Treatment Start
03L2400_DTP_STRT_D8Date (YYYYMMDD)Start Date
L2400DTPDate - Treatment Completion
03L2400_DTP_CMPLTN_D8Date (YYYYMMDD)Completion Date
L2400CN1Contract Information
01L2400_CN101_CNTRCT_TYP_CDStringContract Type Code
02L2400_CN102_CONTRCT_AMTNumberContract Amount
03L2400_CN103_CONTRCT_PERCNumberContract Percentage
04L2400_CN104_CONTRCT_CDStringContract Code
05L2400_CN105_TERMS_DISCT_PERCNumberTerms Discount Percentage
06L2400_CN106_CONTRCT_VERS_IDStringContract Version Identifier
L2400REFService Predetermination Identification
02L2400_nnREF_PREF_BEN_ID_NRStringPredetermination of Benefits Identification Number
0402L2400_nnREF0402_OPYR_PRI_IDStringPayer Identification Number
L2400REFPrior AuthorizationSegment Suffix: B
02L2400_nnREFB_PRIOR_AUTHStringPrior Authorization Number
0402L2400_nnREFB0402_OPYR_PRI_IDStringPayer Identification Number
L2400REFLine Item Control Number
02L2400_REF_PRV_CTL_NRStringProvider Control Number
L2400REFRepriced Claim Number
02L2400_REF_REP_CLM_IDStringRepriced Claim Reference Number
L2400REFAdjusted Repriced Claim Number
02L2400_REF_ADJ_REP_CLM_IDStringAdjusted Repriced Claim Reference Number
L2400REFReferral NumberSegment Suffix: C
02L2400_nnREFC_REFRL_NRStringReferral Number
0402L2400_nnREFC0402_OPYR_PRI_IDStringPayer Identification Number
L2400AMTSales Tax Amount
02L2400_AMT02_TAXNumberTax
L2400K3File Information
01L2400_nnK301_FIXD_FMT_NFOStringFixed Format Information
L2400HCPLine Pricing/Repricing Information
01L2400_HCP01_PRIC_METHDStringPricing Methodology
02L2400_HCP02_REPRCD_ALLWD_AMTNumberRepriced Allowed Amount
03L2400_HCP03_REPRCD_SAVNG_AMTNumberRepriced Saving Amount
04L2400_HCP04_REPRCNG_ORG_IDStringRepricing Organization Identifier
05L2400_HCP05_REPRCD_PERDIEM_AMTNumberRepricing Per Diem or Flat Rate Amount
10L2400_HCP10_ADA_CDStringAmerican Dental Association Codes
12L2400_HCP12_UNNumberUnit
13L2400_HCP13_REJ_RSN_CDStringReject Reason Code
14L2400_HCP14_POLCY_COMP_CDStringPolicy Compliance Code
15L2400_HCP15_EXCPTN_CDStringException Code
L2420A - RENDERING PROVIDER NAME
L2420ANM1Rendering Provider Name
03L2420A_NM103_PERSN_LNMStringPerson Last Name
03L2420A_NM103_NONPSNENT_NMStringNon-Person Entity Name
04L2420A_NM104_REND_PVR_FNMStringRendering Provider First Name
05L2420A_NM105_REND_PVR_MNMStringRendering Provider Middle Name or Initial
07L2420A_NM107_REND_PROV_SFXStringRendering Provider Name Suffix
09L2420A_NM109_NPIStringCenters for Medicare and Medicaid Services National Provider Identifier
L2420APRVRendering Provider Specialty Information
03L2420A_PRV03_PVD_TAXNMY_CDStringHealth Care Provider Taxonomy Code
L2420AREFRendering Provider Secondary Identification
02L2420A_nnREF_STAT_LIC_NRStringState License Number
02L2420A_nnREF_UPINStringProvider UPIN Number
02L2420A_nnREF_PVR_COMM_NRStringProvider Commercial Number
02L2420A_nnREF_LOC_NRStringLocation Number
0402L2420A_nnREF0402_OPYR_PRI_IDStringPayer Identification Number
L2420B - ASSISTANT SURGEON NAME
L2420BNM1Assistant Surgeon Name
03L2420B_NM103_PERSN_LNMStringPerson Last Name
04L2420B_NM104_ASST_SRG_FNMStringAssistant Surgeon First Name
05L2420B_NM105_ASST_SRG_MNMStringAssistant Surgeon Middle Name or Initial
07L2420B_NM107_ASST_SRG_SFXStringAssistant Surgeon Name Suffix
09L2420B_NM109_NPIStringCenters for Medicare and Medicaid Services National Provider Identifier
L2420BPRVAssistant Surgeon Specialty Information
03L2420B_PRV03_PVD_TAXNMY_CDStringHealth Care Provider Taxonomy Code
L2420BREFAssistant Surgeon Secondary Identification
02L2420B_nnREF_STAT_LIC_NRStringState License Number
02L2420B_nnREF_UPINStringProvider UPIN Number
02L2420B_nnREF_PVR_COMM_NRStringProvider Commercial Number
02L2420B_nnREF_LOC_NRStringLocation Number
0402L2420B_nnREF0402_OPYR_PRI_IDStringPayer Identification Number
L2420C - SUPERVISING PROVIDER NAME
L2420CNM1Supervising Provider Name
03L2420C_NM103_PERSN_LNMStringPerson Last Name
04L2420C_NM104_SUP_PVR_FNMStringSupervising Provider First Name
05L2420C_NM105_SUP_PVR_MNMStringSupervising Provider Middle Name or Initial
07L2420C_NM107_SUP_PVR_SFXStringSupervising Provider Name Suffix
09L2420C_NM109_NPIStringCenters for Medicare and Medicaid Services National Provider Identifier
L2420CREFSupervising Provider Secondary Identification
02L2420C_nnREF_STAT_LIC_NRStringState License Number
02L2420C_nnREF_UPINStringProvider UPIN Number
02L2420C_nnREF_PVR_COMM_NRStringProvider Commercial Number
02L2420C_nnREF_LOC_NRStringLocation Number
0402L2420C_nnREF0402_OPYR_PRI_IDStringPayer Identification Number
L2420D - SERVICE FACILITY LOCATION NAME
L2420DNM1Service Facility Location Name
03L2420D_NM103_NONPSNENT_NMStringNon-Person Entity Name
09L2420D_NM109_NPIStringCenters for Medicare and Medicaid Services National Provider Identifier
L2420DN3Service Facility Location Address
01L2420D_N301_LAB_FAC_ADDRStringLaboratory or Facility Address Line
02L2420D_N302_LAB_FAC_ADDRStringLaboratory or Facility Address Line
L2420DN4Service Facility Location City, State, ZIP Code
01L2420D_N401_LAB_FAC_CITYStringLaboratory or Facility City Name
02L2420D_N402_LAB_FAC_STATStringLaboratory or Facility State or Province Code
03L2420D_N403_LAB_ZIPStringLaboratory or Facility Postal Zone or ZIP Code
04L2420D_N404_CNTRY_CDStringCountry Code
07L2420D_N407_CNTRY_SUBDV_CDStringCountry Subdivision Code
L2420DREFService Facility Location Secondary Identification
02L2420D_nnREF_UPINStringProvider UPIN Number
02L2420D_nnREF_PVR_COMM_NRStringProvider Commercial Number
02L2420D_nnREF_LOC_NRStringLocation Number
0402L2420D_nnREF0402_OPYR_PRI_IDStringPayer Identification Number
L2430 - LINE ADJUDICATION INFORMATION (Single Iteration)
L2430SVDLine Adjudication Information
01L2430_xx_SVD01_OPYR_PRI_IDStringOther Payer Primary Identifier
02L2430_xx_SVD02_SVC_LIN_PD_AMTNumberService Line Paid Amount
0302L2430_xx_SVD0302_ADA_CDStringAmerican Dental Association Codes
0302L2430_xx_SVD0302_JS_PRC_SPY_CDStringJurisdiction Specific Procedure and Supply Codes
0303L2430_xx_SVD0303_PROC_MODStringProcedure Modifier
0304L2430_xx_SVD0304_PROC_MODStringProcedure Modifier
0305L2430_xx_SVD0305_PROC_MODStringProcedure Modifier
0306L2430_xx_SVD0306_PROC_MODStringProcedure Modifier
0307L2430_xx_SVD0307_PROC_CD_DESCStringProcedure Code Description
05L2430_xx_SVD05_PD_SVC_UN_CTNumberPaid Service Unit Count
06L2430_xx_SVD06_BND_UNBND_LN_NRIntegerBundled or Unbundled Line Number
L2430CASLine Adjustment
01L2430_xx_nnCAS01_CLMADJ_GRP_CDStringClaim Adjustment Group Code
02L2430_xx_nnCAS02_ADJ_RSN_CDStringAdjustment Reason Code
03L2430_xx_nnCAS03_ADJ_AMTNumberAdjustment Amount
04L2430_xx_nnCAS04_ADJ_QTYNumberAdjustment Quantity
05L2430_xx_nnCAS05_ADJ_RSN_CDStringAdjustment Reason Code
06L2430_xx_nnCAS06_ADJ_AMTNumberAdjustment Amount
07L2430_xx_nnCAS07_ADJ_QTYNumberAdjustment Quantity
08L2430_xx_nnCAS08_ADJ_RSN_CDStringAdjustment Reason Code
09L2430_xx_nnCAS09_ADJ_AMTNumberAdjustment Amount
10L2430_xx_nnCAS10_ADJ_QTYNumberAdjustment Quantity
11L2430_xx_nnCAS11_ADJ_RSN_CDStringAdjustment Reason Code
12L2430_xx_nnCAS12_ADJ_AMTNumberAdjustment Amount
13L2430_xx_nnCAS13_ADJ_QTYNumberAdjustment Quantity
14L2430_xx_nnCAS14_ADJ_RSN_CDStringAdjustment Reason Code
15L2430_xx_nnCAS15_ADJ_AMTNumberAdjustment Amount
16L2430_xx_nnCAS16_ADJ_QTYNumberAdjustment Quantity
17L2430_xx_nnCAS17_ADJ_RSN_CDStringAdjustment Reason Code
18L2430_xx_nnCAS18_ADJ_AMTNumberAdjustment Amount
19L2430_xx_nnCAS19_ADJ_QTYNumberAdjustment Quantity
L2430DTPLine Check or Remittance Date
03L2430_xx_DTP_CLM_PD_D8Date (YYYYMMDD)Date Claim Paid Date
L2430AMTRemaining Patient Liability
02L2430_xx_AMT02_AMT_OWEDNumberAmount Owed
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