Additional Information to Support Health Care Claim or Encounter [O3]


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
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 - 275 Transaction Set Header
STHDRST275 Transaction Set Header
02STHDR_ST02_TCNStringTransaction Set Control Number
03STHDR_ST03_VERS_REL_IND_IDStringVersion, Release, or Industry Identifier
STHDRBGNBeginning Segment
01STHDR_BGN01_TS_PURP_CDStringTransaction Set Purpose Code
02STHDR_BGN02_TS_REF_NRStringTransaction Set Reference Number
03STHDR_BGN03_TS_CRTN_D8Date (YYYYMMDD)Transaction Set Creation Date
L1000A - Payer Name
L1000ANM1Payer Name
03L1000A_NM103_NONPSN_ENTYStringNon-Person Entity
09L1000A_NM109_PAYR_IDStringPayor Identification
09L1000A_NM109_HCFA_PLAN_IDStringCenters for Medicare and Medicaid Services PlanID
L1000APERPayer Contact Information
02L1000A_PER02_PYR_CON_NMStringPayer Contact Name
04L1000A_PER04_EDI_ACS_NRStringElectronic Data Interchange Access Number
04L1000A_PER04_EMAILStringElectronic Mail
04L1000A_PER04_FAXStringFacsimile
04L1000A_PER04_PHN_NRStringTelephone
06L1000A_PER06_EDI_ACS_NRStringElectronic Data Interchange Access Number
06L1000A_PER06_EMAILStringElectronic Mail
06L1000A_PER06_PHN_EXTStringTelephone Extension
06L1000A_PER06_FAXStringFacsimile
06L1000A_PER06_PHN_NRStringTelephone
08L1000A_PER08_EDI_ACS_NRStringElectronic Data Interchange Access Number
08L1000A_PER08_EMAILStringElectronic Mail
08L1000A_PER08_PHN_EXTStringTelephone Extension
08L1000A_PER08_FAXStringFacsimile
08L1000A_PER08_PHN_NRStringTelephone
L1000B - Submitter Information
L1000BNM1Submitter Information
03L1000B_NM103_PERSNStringPerson
03L1000B_NM103_NONPSN_ENTYStringNon-Person Entity
04L1000B_NM104_SBM_FNMStringSubmitter First Name
05L1000B_NM105_SBM_MNMStringSubmitter Middle Name or Initial
09L1000B_NM109_ETN_NRStringElectronic Transmitter Identification Number (ETIN)
L1000C - Provider Name Information
L1000CNM1Provider Name Information
03L1000C_NM103_PERSNStringPerson
03L1000C_NM103_NONPSN_ENTYStringNon-Person Entity
04L1000C_NM104_PVR_FNMStringProvider First Name
05L1000C_NM105_PVR_MNMStringProvider Middle Name
07L1000C_NM107_PVR_SFXStringProvider Name Suffix
09L1000C_NM109_NPIStringCenters for Medicare and Medicaid Services National Provider Identifier
L1000CPRVProvider Taxonomy Information
03L1000C_PRV03_PVD_TAXNMY_CDStringHealth Care Provider Taxonomy Code
L1000CREFProvider Secondary Identification
02L1000C_REF_PROV_IDStringProvider Identifier
02L1000C_REF_LOC_NRStringLocation Number
L1100C - Provider Identification
L1100CNX1Provider Identification
01L1100C_NX101_ENTY_ID_CDStringEntity Identifier Code
L1100CN3Provider Address
01L1100C_N301_PVR_ADDRStringProvider Address Line
02L1100C_N302_PVR_ADDRStringProvider Address Line
L1100CN4Provider City, State, ZIP Code
01L1100C_N401_PVR_CITYStringProvider City Name
02L1100C_N402_PVR_STATStringProvider State Code
03L1100C_N403_PVR_ZIPStringProvider Postal Zone or ZIP Code
04L1100C_N404_PRV_CTRY_CDStringProvider Country Code
07L1100C_N407_PRV_CTRY_SUBCDStringProvider Country Subdivision Code
L1000D - Patient Name
L1000DNM1Patient Name
03L1000D_NM103_PERSNStringPerson
04L1000D_NM104_PT_FNMStringPatient First Name
05L1000D_NM105_PT_MNMStringPatient Middle Name or Initial
07L1000D_NM107_PT_SFXStringPatient Name Suffix
09L1000D_NM109_UNQ_HLTH_IDStringStandard Unique Health Identifier for each Individual in the United States
09L1000D_NM109_MEM_ID_NRStringMember Identification Number
L1000DREFProvider's Assigned Claim Identifier
02L1000D_REF_PROV_CLM_NRStringProvider Claim Number
L1000DREFInstitutional Type Of Bill
02L1000D_REF_BILL_TYPStringBilling Type
L1000DREFMedical Record Identification Number
02L1000D_REF_MED_REC_IDStringMedical Record Identification Number
L1000DREFClaim Identifier For Transmission Intermediaries
02L1000D_REF_CLM_NRStringClaim Number
L1000DREFProperty & Casualty Claim Number
02L1000D_REF_AGNCY_CLM_NRStringAgency Claim Number
L1000DDTPClaim Service Date
03L1000D_DTP_SVC_D8Date (YYYYMMDD)Service
03L1000D_DTP_SVC_RD8_1Start Date (YYYYMMDD)Service
03L1000D_DTP_SVC_RD8_2End Date (YYYYMMDD)Service
L2000A - Assigned Number
L2000ALXAssigned Number
01L2000A_LX01_ASSGD_NRIntegerAssigned Number
L2000ATRNPayer Claim Control Trace Number/Provider Attachment Control Trace Number
01L2000A_TRN01_TRAC_TYP_CDStringTrace Type Code
02L2000A_TRN02_PYR_CTL_NRStringPayer Claim Control Number or Provider Attachment Control Number
L2000ASTCStatus Information
0101L2000A_STC0101_HTCRCLM_CAT_CDStringHealth Care Claim Status Category Code
0102L2000A_STC0102_ADDL_NFO_CDStringAdditional Information Request Code
0104L2000A_STC0104_CD_LST_QLStringCode List Qualifier Code
1001L2000A_STC1001_HTCRCLM_CAT_CDStringHealth Care Claim Status Category Code
1002L2000A_STC1002_ADDL_NFO_CDStringAdditional Information Request Code
1004L2000A_STC1004_CD_LST_QLStringCode List Qualifier Code
1101L2000A_STC1101_HTCRCLM_CAT_CDStringHealth Care Claim Status Category Code
1102L2000A_STC1102_ADDL_NFO_CDStringAdditional Information Request Code
1104L2000A_STC1104_CD_LST_QLStringCode List Qualifier Code
L2000AREFService Line Item Identification
02L2000A_REF_PRV_CTL_NRStringProvider Control Number
L2000AREFCase Reference Identifier
02L2000A_REF_CASE_NRStringCase Number
L2000AREFAttachment Request Tracking Identifier
02L2000A_REF_INT_CTL_NRStringInternal Control Number
L2000AHIHealth Care Information Codes
0102L2000A_nnHI0102_ICD10_PRIN_DIAGStringInternational Classification of Diseases Clinical Modification (ICD-10-CM) Principal Diagnosis
0102L2000A_nnHI0102_ICD9_PRIN_DIAGStringInternational Classification of Diseases Clinical Modification (ICD-9-CM) Principal Diagnosis
0202L2000A_nnHI0202_ICD10_DIAGStringInternational Classification of Diseases Clinical Modification (ICD-10-CM) Diagnosis
0202L2000A_nnHI0202_ICD10_ADMTG_DIAGStringInternational Classification of Diseases Clinical Modification (ICD-10-CM) Admitting Diagnosis
0202L2000A_nnHI0202_ICD10CM_EXT_CDStringInternational Classification of Diseases Clinical Modification (ICD-10-CM) External Cause of Injury Code
0202L2000A_nnHI0202_ICD9_DIAGStringInternational Classification of Diseases Clinical Modification (ICD-9-CM) Diagnosis
0202L2000A_nnHI0202_ICD9_ADMTG_DIAGStringInternational Classification of Diseases Clinical Modification (ICD-9-CM) Admitting Diagnosis
0202L2000A_nnHI0202_ICD9_ECODEStringInternational Classification of Diseases Clinical Modification (ICD-9-CM) External Cause of Injury Code (E-codes)
0202L2000A_nnHI0202_SNODENTStringSystemized Nomenclature of Dentistry (SNODENT)
0302L2000A_nnHI0302_ICD10_DIAGStringInternational Classification of Diseases Clinical Modification (ICD-10-CM) Diagnosis
0302L2000A_nnHI0302_ICD10CM_EXT_CDStringInternational Classification of Diseases Clinical Modification (ICD-10-CM) External Cause of Injury Code
0302L2000A_nnHI0302_ICD9_DIAGStringInternational Classification of Diseases Clinical Modification (ICD-9-CM) Diagnosis
0302L2000A_nnHI0302_ICD9_ECODEStringInternational Classification of Diseases Clinical Modification (ICD-9-CM) External Cause of Injury Code (E-codes)
0302L2000A_nnHI0302_SNODENTStringSystemized Nomenclature of Dentistry (SNODENT)
0402L2000A_nnHI0402_ICD10_DIAGStringInternational Classification of Diseases Clinical Modification (ICD-10-CM) Diagnosis
0402L2000A_nnHI0402_ICD10CM_EXT_CDStringInternational Classification of Diseases Clinical Modification (ICD-10-CM) External Cause of Injury Code
0402L2000A_nnHI0402_ICD9_DIAGStringInternational Classification of Diseases Clinical Modification (ICD-9-CM) Diagnosis
0402L2000A_nnHI0402_ICD9_ECODEStringInternational Classification of Diseases Clinical Modification (ICD-9-CM) External Cause of Injury Code (E-codes)
0402L2000A_nnHI0402_SNODENTStringSystemized Nomenclature of Dentistry (SNODENT)
0502L2000A_nnHI0502_ICD10_DIAGStringInternational Classification of Diseases Clinical Modification (ICD-10-CM) Diagnosis
0502L2000A_nnHI0502_ICD10CM_EXT_CDStringInternational Classification of Diseases Clinical Modification (ICD-10-CM) External Cause of Injury Code
0502L2000A_nnHI0502_ICD9_DIAGStringInternational Classification of Diseases Clinical Modification (ICD-9-CM) Diagnosis
0502L2000A_nnHI0502_ICD9_ECODEStringInternational Classification of Diseases Clinical Modification (ICD-9-CM) External Cause of Injury Code (E-codes)
0502L2000A_nnHI0502_SNODENTStringSystemized Nomenclature of Dentistry (SNODENT)
0602L2000A_nnHI0602_ICD10_DIAGStringInternational Classification of Diseases Clinical Modification (ICD-10-CM) Diagnosis
0602L2000A_nnHI0602_ICD10CM_EXT_CDStringInternational Classification of Diseases Clinical Modification (ICD-10-CM) External Cause of Injury Code
0602L2000A_nnHI0602_ICD9_DIAGStringInternational Classification of Diseases Clinical Modification (ICD-9-CM) Diagnosis
0602L2000A_nnHI0602_ICD9_ECODEStringInternational Classification of Diseases Clinical Modification (ICD-9-CM) External Cause of Injury Code (E-codes)
0602L2000A_nnHI0602_SNODENTStringSystemized Nomenclature of Dentistry (SNODENT)
0702L2000A_nnHI0702_ICD10_DIAGStringInternational Classification of Diseases Clinical Modification (ICD-10-CM) Diagnosis
0702L2000A_nnHI0702_ICD10CM_EXT_CDStringInternational Classification of Diseases Clinical Modification (ICD-10-CM) External Cause of Injury Code
0702L2000A_nnHI0702_ICD9_DIAGStringInternational Classification of Diseases Clinical Modification (ICD-9-CM) Diagnosis
0702L2000A_nnHI0702_ICD9_ECODEStringInternational Classification of Diseases Clinical Modification (ICD-9-CM) External Cause of Injury Code (E-codes)
0702L2000A_nnHI0702_SNODENTStringSystemized Nomenclature of Dentistry (SNODENT)
0802L2000A_nnHI0802_ICD10_DIAGStringInternational Classification of Diseases Clinical Modification (ICD-10-CM) Diagnosis
0802L2000A_nnHI0802_ICD10CM_EXT_CDStringInternational Classification of Diseases Clinical Modification (ICD-10-CM) External Cause of Injury Code
0802L2000A_nnHI0802_ICD9_DIAGStringInternational Classification of Diseases Clinical Modification (ICD-9-CM) Diagnosis
0802L2000A_nnHI0802_ICD9_ECODEStringInternational Classification of Diseases Clinical Modification (ICD-9-CM) External Cause of Injury Code (E-codes)
0802L2000A_nnHI0802_SNODENTStringSystemized Nomenclature of Dentistry (SNODENT)
0902L2000A_nnHI0902_ICD10_DIAGStringInternational Classification of Diseases Clinical Modification (ICD-10-CM) Diagnosis
0902L2000A_nnHI0902_ICD10CM_EXT_CDStringInternational Classification of Diseases Clinical Modification (ICD-10-CM) External Cause of Injury Code
0902L2000A_nnHI0902_ICD9_DIAGStringInternational Classification of Diseases Clinical Modification (ICD-9-CM) Diagnosis
0902L2000A_nnHI0902_ICD9_ECODEStringInternational Classification of Diseases Clinical Modification (ICD-9-CM) External Cause of Injury Code (E-codes)
0902L2000A_nnHI0902_SNODENTStringSystemized Nomenclature of Dentistry (SNODENT)
1002L2000A_nnHI1002_ICD10_DIAGStringInternational Classification of Diseases Clinical Modification (ICD-10-CM) Diagnosis
1002L2000A_nnHI1002_ICD10CM_EXT_CDStringInternational Classification of Diseases Clinical Modification (ICD-10-CM) External Cause of Injury Code
1002L2000A_nnHI1002_ICD9_DIAGStringInternational Classification of Diseases Clinical Modification (ICD-9-CM) Diagnosis
1002L2000A_nnHI1002_ICD9_ECODEStringInternational Classification of Diseases Clinical Modification (ICD-9-CM) External Cause of Injury Code (E-codes)
1002L2000A_nnHI1002_SNODENTStringSystemized Nomenclature of Dentistry (SNODENT)
1102L2000A_nnHI1102_ICD10_DIAGStringInternational Classification of Diseases Clinical Modification (ICD-10-CM) Diagnosis
1102L2000A_nnHI1102_ICD10CM_EXT_CDStringInternational Classification of Diseases Clinical Modification (ICD-10-CM) External Cause of Injury Code
1102L2000A_nnHI1102_ICD9_DIAGStringInternational Classification of Diseases Clinical Modification (ICD-9-CM) Diagnosis
1102L2000A_nnHI1102_ICD9_ECODEStringInternational Classification of Diseases Clinical Modification (ICD-9-CM) External Cause of Injury Code (E-codes)
1102L2000A_nnHI1102_SNODENTStringSystemized Nomenclature of Dentistry (SNODENT)
1202L2000A_nnHI1202_ICD10_DIAGStringInternational Classification of Diseases Clinical Modification (ICD-10-CM) Diagnosis
1202L2000A_nnHI1202_ICD10CM_EXT_CDStringInternational Classification of Diseases Clinical Modification (ICD-10-CM) External Cause of Injury Code
1202L2000A_nnHI1202_ICD9_DIAGStringInternational Classification of Diseases Clinical Modification (ICD-9-CM) Diagnosis
1202L2000A_nnHI1202_ICD9_ECODEStringInternational Classification of Diseases Clinical Modification (ICD-9-CM) External Cause of Injury Code (E-codes)
1202L2000A_nnHI1202_SNODENTStringSystemized Nomenclature of Dentistry (SNODENT)
L2000ASVCService Information
0102L2000A_SVC0102_ADA_CDStringAmerican Dental Association Codes
0102L2000A_SVC0102_JS_PRC_SPY_CDStringJurisdiction Specific Procedure and Supply Codes
0102L2000A_SVC0102_HCPCS_CDStringHealthcare Common Procedure Coding System (HCPCS) Codes
0102L2000A_SVC0102_HIPPA_SNF_RT_CDStringHealth Insurance Prospective Payment System (HIPPS) Skilled Nursing Facility Rate Code
0102L2000A_SVC0102_NDC542StringNational Drug Code in 5-4-2 Format
0102L2000A_SVC0102_NUBC_UB92_CDStringNational Uniform Billing Committee (NUBC) UB92 Codes
0102L2000A_SVC0102_ABC_CDStringAdvanced Billing Concepts (ABC) Codes
0103L2000A_SVC0103_PROC_MODStringProcedure Modifier
0104L2000A_SVC0104_PROC_MODStringProcedure Modifier
0105L2000A_SVC0105_PROC_MODStringProcedure Modifier
0106L2000A_SVC0106_PROC_MODStringProcedure Modifier
0109L2000A_SVC0109_PROC_MODStringProcedure Modifier
0110L2000A_SVC0110_PROC_MODStringProcedure Modifier
0111L2000A_SVC0111_PROC_MODStringProcedure Modifier
0112L2000A_SVC0112_PROC_MODStringProcedure Modifier
02L2000A_SVC02_MONTRY_AMTNumberMonetary Amount
04L2000A_SVC04_PROD_SVC_IDStringProduct or Service ID
L2100A - Service Line Service Date
L2100ADTPService Line Service Date
03L2100A_DTP_SVC_D8Date (YYYYMMDD)Service
03L2100A_DTP_SVC_RD8_1Start Date (YYYYMMDD)Service
03L2100A_DTP_SVC_RD8_2End Date (YYYYMMDD)Service
L2100B - Additional Information Submitted Date
L2100BDTPAdditional Information Submitted Date
03L2100B_DTP_SUBMTL_D8Date (YYYYMMDD)Submittal
L2100BCATFormat and Version Identifier
02L2100B_CAT02_ADDL_NFO_FMTStringAttachment Information Format Code
03L2100B_CAT03_VERS_ID_CDStringVersion Identification Code
L2110B - Associated Object Type Identification
L2110BOOIAssociated Object Type Identification
01L2110B_OOI01_OBJ_ID_GRPStringObject Identification Group
03L2110B_OOI03_EXT_STD_REQStringExternal Standard Requirement
L2110BBDSBinary Data Segment
01L2110B_BDS01_FLTR_ID_CDStringFilter ID Code
02L2110B_BDS02_MIME_TYPStringMIME Type
02L2110B_BDS02_MIME_DISPStringMIME Disposition
02L2110B_BDS02_ATTCHMNTBinaryBinary Attachment
03L2110B_BDS03_BIN_DATAStringBinary Data
STHDRSE275 Transaction 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