(C) Copyright 2012 Chiapas EDI Technologies, Inc.
4010_277 4010 Health Care Claim Status Response - Code:D0
ISA - GROUP HEADERS
| Loop | Segment | Segment Name | Chiapas Gate Mapping |
| OEISA | ISA | Interchange Control Header | |
| OEISA | ISA02 | No Authorization Information Present | OEISA_S01_ISA02_AUTH_NFO_OVL_NO_AUTH_NFO |
| OEISA | ISA02 | Additional Data Identification | OEISA_S01_ISA02_AUTH_NFO_OVL_ADDL_ID |
| OEISA | ISA04 | No Security Information Present | OEISA_S01_ISA04_SEC_NFO_OVL_NO_SEC_NFO |
| OEISA | ISA04 | Password | OEISA_S01_ISA04_SEC_NFO_OVL_PASSWD |
| OEISA | ISA06 | Dun and Brandstreet | OEISA_S01_ISA06_SENDR_ID_OVL_DUNS_ID |
| OEISA | ISA06 | Duns Plus Suffix | OEISA_S01_ISA06_SENDR_ID_OVL_DUNS_SUFFX_ID |
| OEISA | ISA06 | Health Industry Number | OEISA_S01_ISA06_SENDR_ID_OVL_HIN_ID |
| OEISA | ISA06 | Carrier Identification Number as assigned by Health Care Financing Administration | OEISA_S01_ISA06_SENDR_ID_OVL_HCFA_CARR_ID |
| OEISA | ISA06 | Fiscal Intermediary Identification Number as assigned by Health Care Financing Administration | OEISA_S01_ISA06_SENDR_ID_OVL_HCFA_FIIN_ID |
| OEISA | ISA06 | Medicare Provider and Supplier Identification Number as assigned by Health Care Financing Administration | OEISA_S01_ISA06_SENDR_ID_OVL_HCFA_MEDCR_ID |
| OEISA | ISA06 | US Federal Tax Identification Number | OEISA_S01_ISA06_SENDR_ID_OVL_TAX_ID |
| OEISA | ISA06 | National Association of Insurance Commissioners Company Code | OEISA_S01_ISA06_SENDR_ID_OVL_NAIC_ID |
| OEISA | ISA06 | Mutually Defined | OEISA_S01_ISA06_SENDR_ID_OVL_MUTLY_DEFND_ID |
| OEISA | ISA08 | Dun and Brandstreet | OEISA_S01_ISA08_RECVR_ID_OVL_DUNS_ID |
| OEISA | ISA08 | Duns Plus Suffix | OEISA_S01_ISA08_RECVR_ID_OVL_DUNS_SUFFX_ID |
| OEISA | ISA08 | Health Industry Number | OEISA_S01_ISA08_RECVR_ID_OVL_HIN_ID |
| OEISA | ISA08 | Carrier Identification Number as assigned by Health Care Financing Administration | OEISA_S01_ISA08_RECVR_ID_OVL_HCFA_CARR_ID |
| OEISA | ISA08 | Fiscal Intermediary Identification Number as assigned by Health Care Financing Administration | OEISA_S01_ISA08_RECVR_ID_OVL_HCFA_FIIN_ID |
| OEISA | ISA08 | Medicare Provider and Supplier Identification Number as assigned by Health Care Financing Administration | OEISA_S01_ISA08_RECVR_ID_OVL_HCFA_MEDCR_ID |
| OEISA | ISA08 | US Federal Tax Identification Number | OEISA_S01_ISA08_RECVR_ID_OVL_TAX_ID |
| OEISA | ISA08 | National Association of Insurance Commissioners Company Code | OEISA_S01_ISA08_RECVR_ID_OVL_NAIC_ID |
| OEISA | ISA08 | Mutually Defined | OEISA_S01_ISA08_RECVR_ID_OVL_MUTLY_DEFND_ID |
| OEISA | ISA09 | Interchange Date | OEISA_S01_ISA09_DT |
| OEISA | ISA10 | Interchange Time | OEISA_S01_ISA10_TM |
| OEISA | ISA11 | Repetition Separator | OEISA_S01_ISA11_REPTN_SEPRTR |
| OEISA | ISA12 | Interchang Control Version Number | OEISA_S01_ISA12_VERSN_NR |
| OEISA | ISA13 | Interchange Control Number | OEISA_S01_ISA13_ICN |
| OEISA | ISA14 | Acknowledgment Requested | OEISA_S01_ISA14_ACK_REQ |
| OEISA | ISA15 | Interchange Usage Indicator | OEISA_S01_ISA15_USG_IND |
| OEISA | ISA16 | Component Element Separator | OEISA_S01_ISA16_SUBELE_SEP |
| OEISA | IEA | Interchange Control Trailer | |
| OEISA | IEA01 | Number of Included Functional Groups | OEISA_S03_IEA01_GS_CT |
| OEISA | IEA02 | Interchange Control Number | OEISA_S03_IEA02_ICN |
GSHDR - GROUP HEADER
| Loop | Segment | Segment Name | Chiapas Gate Mapping |
| GSHDR | GS | Functional Group Header | |
| GSHDR | GS01 | Functional Identifier Code | GSHDR_S01_GS01_FUNCTL_ID_CD |
| GSHDR | GS02 | Application Senders Code | GSHDR_S01_GS02_APP_SENDR_CD |
| GSHDR | GS03 | Application Receivers Code | GSHDR_S01_GS03_APP_RECVR_CD |
| GSHDR | GS04 | Date | GSHDR_S01_GS04_DT |
| GSHDR | GS05 | Time | GSHDR_S01_GS05_TM |
| GSHDR | GS06 | Group Control Number | GSHDR_S01_GS06_GCN |
| GSHDR | GS07 | Responsible Agency Code | GSHDR_S01_GS07_RESP_AGNCY_CD |
| GSHDR | GE | Functional Group Trailer | |
| GSHDR | GE01 | Number of Transaction Sets Included | GSHDR_S03_GE01_TS_CT |
| GSHDR | GE02 | Group Control Number | GSHDR_S03_GE02_GCN |
STHDR - TRANSACTION SET HEADER
| Loop | Segment | Segment Name | Chiapas Gate Mapping |
| STHDR | ST | Transaction Set Header | |
| STHDR | ST01 | Transaction Set Identifier Code | STHDR_S01_ST01_ID_CD |
| STHDR | ST02 | Transaction Set Control Number | STHDR_S01_ST02_CONTRL_NR |
| STHDR | BHT | Beginning of Hierarchical Transaction | |
| STHDR | BHT01 | Hierarchical Structure Code | STHDR_S02_BHT01_STRUCTR_CD |
| STHDR | BHT02 | Transaction Set Purpose Code | STHDR_S02_BHT02_TS_PURPS_CD |
| STHDR | BHT03 | Originator Application Transaction Identifier | STHDR_S02_BHT03_ORGNTR_APLCTN_TRANSCTN_ID |
| STHDR | BHT04 | Transaction Set Creation Date | STHDR_S02_BHT04_TS_CREATN_DT |
| STHDR | BHT06 | Transaction Type Code | STHDR_S02_BHT06_TRANSCTN_TYPE_CD |
| STHDR | SE | Transaction Set Trailer | |
| STHDR | SE01 | Transaction Segment Count | STHDR_S04_SE01_SEG_CT |
| STHDR | SE02 | Transaction Set Control Number | STHDR_S04_SE02_TCN |
2000A - INFORMATION SOURCE LEVEL
| Loop | Segment | Segment Name | Chiapas Gate Mapping |
| L2000A | HL | Information Source Level | |
| L2000A | HL01 | Hierarchical ID Number | L2000A_S01_HL01_HIERCHCL_ID_NR |
| L2000A | HL04 | Hierarchical Child Code | L2000A_S01_HL04_HIERCHCL_CHILD_CD |
2100A - PAYER NAME
| Loop | Segment | Segment Name | Chiapas Gate Mapping |
| L2100A | NM1 | Payer Name | |
| L2100A | NM103 | Non-Person Entity | L2100A_S01_NM103_PAYR_NM_OVL_NONPRSN_ENTY |
| L2100A | NM109 | Health Industry Number (HIN) | L2100A_S01_NM109_PAYR_ID_OVL_HIN |
| L2100A | NM109 | Blue Cross Blue Shield Association Plan Code | L2100A_S01_NM109_PAYR_ID_OVL_BLCRS_BLSHD_ASCTN_PLAN_CD |
| L2100A | NM109 | Federal Taxpayer’s Identification Number | L2100A_S01_NM109_PAYR_ID_OVL_FED_TAX_ID_NR |
| L2100A | NM109 | National Association of Insurance Commissioners | L2100A_S01_NM109_PAYR_ID_OVL_NAIC |
| L2100A | NM109 | Payor Identification | L2100A_S01_NM109_PAYR_ID_OVL_PAYR_ID |
| L2100A | NM109 | Pharmacy Processor Number | L2100A_S01_NM109_PAYR_ID_OVL_PHARMCY_PROCSR_NR |
| L2100A | NM109 | Health Care Financing Administration National PlanID | L2100A_S01_NM109_PAYR_ID_OVL_HCFA_NATNL_PLAND |
| L2100A | PER | Payer Contact Information | |
| L2100A | PER01 | Contact Function Code | L2100A_S02_PER01_FUNCTN_CD |
| L2100A | PER02 | Payer Contact Name | L2100A_S02_PER02_CONTCT_NM |
| L2100A | PER04 | Electronic Data Interchange Access Number | L2100A_S02_PER04_COMM_NR_OVL_EDI_ACS_NR |
| L2100A | PER04 | Electronic Mail | L2100A_S02_PER04_COMM_NR_OVL_EMAIL |
| L2100A | PER04 | Telephone | L2100A_S02_PER04_COMM_NR_OVL_TELPHN |
| L2100A | PER06 | Telephone Extension | L2100A_S02_PER06_COMM_NR_OVL_PHN_EXTNS |
| L2100A | PER08 | Telephone Extension | L2100A_S02_PER08_COMM_NR_OVL_PHN_EXTNS |
| L2100A | PER08 | Facsimile | L2100A_S02_PER08_COMM_NR_OVL_FACSML |
2000B - INFORMATION RECEIVER LEVEL
| Loop | Segment | Segment Name | Chiapas Gate Mapping |
| L2000B | HL | Information Receiver Level | |
| L2000B | HL01 | Hierarchical ID Number | L2000B_S01_HL01_HIERCHCL_ID_NR |
| L2000B | HL02 | Hierarchical Parent ID Number | L2000B_S01_HL02_HIERCHCL_PARNT_ID_NR |
| L2000B | HL04 | Hierarchical Child Code | L2000B_S01_HL04_HIERCHCL_CHILD_CD |
2100B - INFORMATION RECEIVER NAME
| Loop | Segment | Segment Name | Chiapas Gate Mapping |
| L2100B | NM1 | Information Receiver Name | |
| L2100B | NM103 | Person | L2100B_S01_NM103_NFO_RECVR_LAST_ORG_NM_OVL_PERSN |
| L2100B | NM103 | Non-Person Entity | L2100B_S01_NM103_NFO_RECVR_LAST_ORG_NM_OVL_NONPRSN_ENTY |
| L2100B | NM104 | Information Receiver First Name | L2100B_S01_NM104_NFO_RECVR_FNAME |
| L2100B | NM105 | Information Receiver Middle Name | L2100B_S01_NM105_NFO_RECVR_MNAME |
| L2100B | NM106 | Information Receiver Name Prefix | L2100B_S01_NM106_NFO_RECVR_NM_PREFX |
| L2100B | NM107 | Information Receiver Name Suffix | L2100B_S01_NM107_NFO_RECVR_NM_SUFX |
| L2100B | NM109 | Electronic Transmitter Identification Number (ETIN) | L2100B_S01_NM109_NFO_RECVR_ID_NR_OVL_ETN_NR |
| L2100B | NM109 | Federal Taxpayer’s Identification Number | L2100B_S01_NM109_NFO_RECVR_ID_NR_OVL_FED_TAX_ID_NR |
| L2100B | NM109 | Health Care Financing Administration National | L2100B_S01_NM109_NFO_RECVR_ID_NR_OVL_HCFA_NATNL |
2000C - SERVICE PROVIDER LEVEL
| Loop | Segment | Segment Name | Chiapas Gate Mapping |
| L2000C | HL | Service Provider Level | |
| L2000C | HL01 | Hierarchical ID Number | L2000C_S01_HL01_HIERCHCL_ID_NR |
| L2000C | HL02 | Hierarchical Parent ID Number | L2000C_S01_HL02_HIERCHCL_PARNT_ID_NR |
| L2000C | HL04 | Hierarchical Child Code | L2000C_S01_HL04_HIERCHCL_CHILD_CD |
2100C - PROVIDER NAME
| Loop | Segment | Segment Name | Chiapas Gate Mapping |
| L2100C | NM1 | Provider Name | |
| L2100C | NM103 | Non-Person Entity | L2100C_S01_NM103_PROV_LAST_ORG_NM_OVL_NONPRSN_ENTY |
| L2100C | NM104 | Provider First Name | L2100C_S01_NM104_PROV_FNAME |
| L2100C | NM105 | Provider Middle Name | L2100C_S01_NM105_PROV_MNAME |
| L2100C | NM106 | Provider Name Prefix | L2100C_S01_NM106_NM_PREFX |
| L2100C | NM107 | Provider Name Suffix | L2100C_S01_NM107_NM_SUFX |
| L2100C | NM109 | Federal Taxpayer’s Identification Number | L2100C_S01_NM109_PROV_ID_OVL_FED_TAX_ID_NR |
| L2100C | NM109 | Service Provider Number | L2100C_S01_NM109_PROV_ID_OVL_SVC_PROV_NR |
| L2100C | NM109 | Health Care Financing Administration National | L2100C_S01_NM109_PROV_ID_OVL_HCFA_NATNL |
2000D - SUBSCRIBER LEVEL
| Loop | Segment | Segment Name | Chiapas Gate Mapping |
| L2000D | HL | Subscriber Level | |
| L2000D | HL01 | Hierarchical ID Number | L2000D_S01_HL01_HIERCHCL_ID_NR |
| L2000D | HL02 | Hierarchical Parent ID Number | L2000D_S01_HL02_HIERCHCL_PARNT_ID_NR |
| L2000D | HL04 | Hierarchical Child Code | L2000D_S01_HL04_HIERCHCL_CHILD_CD |
| L2000D | DMG | Subscriber Demographic Information | |
| L2000D | DMG02 | Date Expressed in Format CCYYMMDD | L2000D_S02_DMG02_BIRTH_DT_OVL_DT_CCYYMMDD |
| L2000D | DMG03 | Subscriber Gender Code | L2000D_S02_DMG03_GENDR_CD |
2100D - SUBSCRIBER NAME
| Loop | Segment | Segment Name | Chiapas Gate Mapping |
| 2100D | Qualified Loop | ||
| L2100D | Insured or Subscriber | L2100D_IL | |
| L2100D | Patient | L2100D_QC | |
| L2100D | NM1 | Subscriber Name | |
| L2100D | NM103 | Person | L2100D_XX_S01_NM103_SUB_LNAME_OVL_PERSN |
| L2100D | NM103 | Non-Person Entity | L2100D_XX_S01_NM103_SUB_LNAME_OVL_NONPRSN_ENTY |
| L2100D | NM104 | Subscriber First Name | L2100D_XX_S01_NM104_SUB_FNAME |
| L2100D | NM105 | Subscriber Middle Name | L2100D_XX_S01_NM105_SUB_MNAME |
| L2100D | NM106 | Subscriber Name Prefix | L2100D_XX_S01_NM106_NM_PREFX |
| L2100D | NM107 | Subscriber Name Suffix | L2100D_XX_S01_NM107_NM_SUFX |
| L2100D | NM109 | Employer’s Identification Number | L2100D_XX_S01_NM109_SUB_ID_OVL_EMPLYR_ID_NR |
| L2100D | NM109 | Member Identification Number | L2100D_XX_S01_NM109_SUB_ID_OVL_MEM_ID_NR |
| L2100D | NM109 | Mutually Defined | L2100D_XX_S01_NM109_SUB_ID_OVL_MUTLY_DEFND |
2200D - CLAIM SUBMITTER TRACE NUMBER
| Loop | Segment | Segment Name | Chiapas Gate Mapping |
| L2200D | TRN | Claim Submitter Trace Number | |
| L2200D | TRN01 | Trace Type Code | L2200D_S01_TRN01_TYPE_CD |
| L2200D | TRN02 | Trace Number | L2200D_S01_TRN02_TRAC_NR |
| L2200D | STC | Claim Level Status Information | |
| L2200D | STC01-01 | Health Care Claim Status Category Code | L2200D_S02_STC01_01_HLTHCR_CLM_STATS_CATGRY_CD |
| L2200D | STC01-02 | Health Care Claim Status Code | L2200D_S02_STC01_02_HLTHCR_CLM_STATS_CD |
| L2200D | STC01-03 | Entity Identifier Code | L2200D_S02_STC01_03_ENTY_ID_CD |
| L2200D | STC02 | Status Information Effective Date | L2200D_S02_STC02_STATS_NFO_EFF_DT |
| L2200D | STC04 | Total Claim Charge Amount | L2200D_S02_STC04_TOTL_CLM_CHG_AMT |
| L2200D | STC05 | Claim Payment Amount | L2200D_S02_STC05_PMT_AMT |
| L2200D | STC06 | Adjudication or Payment Date | L2200D_S02_STC06_ADJDCTN_PMT_DT |
| L2200D | STC07 | Payment Method Code | L2200D_S02_STC07_PMT_METHD_CD |
| L2200D | STC08 | Check Issue or EFT Effective Date | L2200D_S02_STC08_CHK_IS_EFT_EFF_DT |
| L2200D | STC09 | Check or EFT Trace Number | L2200D_S02_STC09_CHK_EFT_TRAC_NR |
| L2200D | STC10-01 | Health Care Claim Status Category Code | L2200D_S02_STC10_01_HLTHCR_CLM_STATS_CATGRY_CD |
| L2200D | STC10-02 | Health Care Claim Status Code | L2200D_S02_STC10_02_HLTHCR_CLM_STATS_CD |
| L2200D | STC10-03 | Entity Identifier Code | L2200D_S02_STC10_03_ENTY_ID_CD |
| L2200D | STC11-01 | Health Care Claim Status Category Code | L2200D_S02_STC11_01_HLTHCR_CLM_STATS_CATGRY_CD |
| L2200D | STC11-02 | Health Care Claim Status Code | L2200D_S02_STC11_02_HLTHCR_CLM_STATS_CD |
| L2200D | STC11-03 | Entity Identifier Code | L2200D_S02_STC11_03_ENTY_ID_CD |
| L2200D | REF | Payer Claim Identification Number | |
| L2200D | REF02 | Payor’s Claim Number | L2200D_S03_REF02_PAYR_CLM_CONTRL_NR_OVL_PAYR_CLM_NR |
| L2200D | REF | Institutional Bill Type Identification | |
| L2200D | REF02 | Billing Type | L2200D_S04_REF02_TYPE_ID_OVL_BILNG_TYPE |
| L2200D | REF | Medical Record Identification | |
| L2200D | REF02 | Medical Record Identification Number | L2200D_S05_REF02_RECRD_NR_OVL_MEDCL_RECRD_ID_NR |
| L2200D | DTP | Claim Service Date | |
| L2200D | DTP03 | Claim Statement Period Start (RD8) | L2200D_S06_DTP03_SVC_PERD_OVL_CLM_STATMNT_PERD_START_RD8 |
2220D - SERVICE LINE INFORMATION
| Loop | Segment | Segment Name | Chiapas Gate Mapping |
| L2220D | SVC | Service Line Information | |
| L2220D | SVC01-02 | American Dental Association Codes | L2220D_S01_SVC01_02_SVC_ID_CD_OVL_AMRCN_DENTL_ASCTN_CD |
| L2220D | SVC01-02 | Common Language Equipment Identifier (CLEI) | L2220D_S01_SVC01_02_SVC_ID_CD_OVL_CLEI |
| L2220D | SVC01-02 | Health Care Financing Administration Common Procedural Coding System (HCPCS) Codes | L2220D_S01_SVC01_02_SVC_ID_CD_OVL_HCPCS_CD |
| L2220D | SVC01-02 | International Classification of Diseases Clinical Modification (ICD-9-CM) - Procedure | L2220D_S01_SVC01_02_SVC_ID_CD_OVL_ICD9CM_PROC |
| L2220D | SVC01-02 | Home Infusion EDI Coalition (HIEC) Product/Service Code | L2220D_S01_SVC01_02_SVC_ID_CD_OVL_HIEC_PRODCT_SRVC_CD |
| L2220D | SVC01-02 | National Drug Code in 4-4-2 Format | L2220D_S01_SVC01_02_SVC_ID_CD_OVL_NDC_442_FORMT |
| L2220D | SVC01-02 | National Drug Code in 5-3-2 Format | L2220D_S01_SVC01_02_SVC_ID_CD_OVL_NDC_532_FORMT |
| L2220D | SVC01-02 | National Drug Code in 5-4-1 Format | L2220D_S01_SVC01_02_SVC_ID_CD_OVL_NDC_541_FORMT |
| L2220D | SVC01-02 | National Drug Code in 5-4-2 Format | L2220D_S01_SVC01_02_SVC_ID_CD_OVL_NDC_542_FORMT |
| L2220D | SVC01-02 | National Drug Code (NDC) | L2220D_S01_SVC01_02_SVC_ID_CD_OVL_NDC |
| L2220D | SVC01-02 | National Health Related Item Code | L2220D_S01_SVC01_02_SVC_ID_CD_OVL_NATNL_HEALTH_RELTD_ITM_CD |
| L2220D | SVC01-02 | National Uniform Billing Committee (NUBC) UB92 Codes | L2220D_S01_SVC01_02_SVC_ID_CD_OVL_NUBC_UB92_CD |
| L2220D | SVC01-02 | National Uniform Billing Committee (NUBC) UB82 | L2220D_S01_SVC01_02_SVC_ID_CD_OVL_NUBC_UB82 |
| L2220D | SVC01-03 | Procedure Modifier | L2220D_S01_SVC01_03_PROC_MODFR |
| L2220D | SVC01-04 | Procedure Modifier | L2220D_S01_SVC01_04_PROC_MODFR |
| L2220D | SVC01-05 | Procedure Modifier | L2220D_S01_SVC01_05_PROC_MODFR |
| L2220D | SVC01-06 | Procedure Modifier | L2220D_S01_SVC01_06_PROC_MODFR |
| L2220D | SVC02 | Line Item Charge Amount | L2220D_S01_SVC02_LIN_ITM_CHG_AMT |
| L2220D | SVC03 | Line Item Provider Payment Amount | L2220D_S01_SVC03_LIN_ITM_PROV_PMT_AMT |
| L2220D | SVC04 | Revenue Code | L2220D_S01_SVC04_REVN_CD |
| L2220D | SVC07 | Original Units of Service Count | L2220D_S01_SVC07_ORGNL_UNTS_SVC_CT |
| L2220D | STC | Service Line Status Information | |
| L2220D | STC01-01 | Health Care Claim Status Category Code | L2220D_S02_STC01_01_HLTHCR_CLM_STATS_CATGRY_CD |
| L2220D | STC01-02 | Health Care Claim Status Code | L2220D_S02_STC01_02_HLTHCR_CLM_STATS_CD |
| L2220D | STC01-03 | Entity Identifier Code | L2220D_S02_STC01_03_ENTY_ID_CD |
| L2220D | STC02 | Status Information Effective Date | L2220D_S02_STC02_STATS_NFO_EFF_DT |
| L2220D | STC04 | Line Item Charge Amount | L2220D_S02_STC04_LIN_ITM_CHG_AMT |
| L2220D | STC05 | Line Item Provider Payment Amount | L2220D_S02_STC05_LIN_ITM_PROV_PMT_AMT |
| L2220D | STC10-01 | Health Care Claim Status Category Code | L2220D_S02_STC10_01_HLTHCR_CLM_STATS_CATGRY_CD |
| L2220D | STC10-02 | Health Care Claim Status Code | L2220D_S02_STC10_02_HLTHCR_CLM_STATS_CD |
| L2220D | STC10-03 | Entity Identifier Code | L2220D_S02_STC10_03_ENTY_ID_CD |
| L2220D | STC11-01 | Health Care Claim Status Category Code | L2220D_S02_STC11_01_HLTHCR_CLM_STATS_CATGRY_CD |
| L2220D | STC11-02 | Health Care Claim Status Code | L2220D_S02_STC11_02_HLTHCR_CLM_STATS_CD |
| L2220D | STC11-03 | Entity Identifier Code | L2220D_S02_STC11_03_ENTY_ID_CD |
| L2220D | REF | Service Line Item Identification | |
| L2220D | REF02 | Line Item Control Number | L2220D_S03_REF02_LIN_ITM_CONTRL_NR_OVL_LIN_ITM_CONTRL_NR |
| L2220D | DTP | Service Line Date | |
| L2220D | DTP03 | Service (RD8) | L2220D_S04_DTP03_SVC_LIN_DT_OVL_SVC_RD8 |
2000E - DEPENDENT LEVEL
| Loop | Segment | Segment Name | Chiapas Gate Mapping |
| L2000E | HL | Dependent Level | |
| L2000E | HL01 | Hierarchical ID Number | L2000E_S01_HL01_HIERCHCL_ID_NR |
| L2000E | HL02 | Hierarchical Parent ID Number | L2000E_S01_HL02_HIERCHCL_PARNT_ID_NR |
| L2000E | DMG | Dependent Demographic Information | |
| L2000E | DMG02 | Date Expressed in Format CCYYMMDD | L2000E_S02_DMG02_PATNT_BIRTH_DT_OVL_DT_CCYYMMDD |
| L2000E | DMG03 | Patient Gender Code | L2000E_S02_DMG03_PATNT_GENDR_CD |
2100E - DEPENDENT NAME
| Loop | Segment | Segment Name | Chiapas Gate Mapping |
| L2100E | NM1 | Dependent Name | |
| L2100E | NM103 | Person | L2100E_S01_NM103_PATNT_LNAME_OVL_PERSN |
| L2100E | NM104 | Patient First Name | L2100E_S01_NM104_PATNT_FNAME |
| L2100E | NM105 | Patient Middle Name | L2100E_S01_NM105_PATNT_MNAME |
| L2100E | NM106 | Patient Name Prefix | L2100E_S01_NM106_PATNT_NM_PREFX |
| L2100E | NM107 | Patient Name Suffix | L2100E_S01_NM107_PATNT_NM_SUFX |
| L2100E | NM109 | Member Identification Number | L2100E_S01_NM109_PATNT_PRIMRY_ID_OVL_MEM_ID_NR |
| L2100E | NM109 | Mutually Defined | L2100E_S01_NM109_PATNT_PRIMRY_ID_OVL_MUTLY_DEFND |
2200E - CLAIM SUBMITTER TRACE NUMBER
| Loop | Segment | Segment Name | Chiapas Gate Mapping |
| L2200E | TRN | Claim Submitter Trace Number | |
| L2200E | TRN01 | Trace Type Code | L2200E_S01_TRN01_TYPE_CD |
| L2200E | TRN02 | Trace Number | L2200E_S01_TRN02_TRAC_NR |
| L2200E | STC | Claim Level Status Information | |
| L2200E | STC01-01 | Health Care Claim Status Category Code | L2200E_S02_STC01_01_HLTHCR_CLM_STATS_CATGRY_CD |
| L2200E | STC01-02 | Health Care Claim Status Code | L2200E_S02_STC01_02_HLTHCR_CLM_STATS_CD |
| L2200E | STC01-03 | Entity Identifier Code | L2200E_S02_STC01_03_ENTY_ID_CD |
| L2200E | STC02 | Status Information Effective Date | L2200E_S02_STC02_STATS_NFO_EFF_DT |
| L2200E | STC04 | Total Claim Charge Amount | L2200E_S02_STC04_TOTL_CLM_CHG_AMT |
| L2200E | STC05 | Claim Payment Amount | L2200E_S02_STC05_PMT_AMT |
| L2200E | STC06 | Adjudication or Payment Date | L2200E_S02_STC06_ADJDCTN_PMT_DT |
| L2200E | STC07 | Payment Method Code | L2200E_S02_STC07_PMT_METHD_CD |
| L2200E | STC08 | Check Issue or EFT Effective Date | L2200E_S02_STC08_CHK_IS_EFT_EFF_DT |
| L2200E | STC09 | Check or EFT Trace Number | L2200E_S02_STC09_CHK_EFT_TRAC_NR |
| L2200E | STC10-01 | Health Care Claim Status Category Code | L2200E_S02_STC10_01_HLTHCR_CLM_STATS_CATGRY_CD |
| L2200E | STC10-02 | Health Care Claim Status Code | L2200E_S02_STC10_02_HLTHCR_CLM_STATS_CD |
| L2200E | STC10-03 | Entity Identifier Code | L2200E_S02_STC10_03_ENTY_ID_CD |
| L2200E | STC11-01 | Health Care Claim Status Category Code | L2200E_S02_STC11_01_HLTHCR_CLM_STATS_CATGRY_CD |
| L2200E | STC11-02 | Health Care Claim Status Code | L2200E_S02_STC11_02_HLTHCR_CLM_STATS_CD |
| L2200E | STC11-03 | Entity Identifier Code | L2200E_S02_STC11_03_ENTY_ID_CD |
| L2200E | REF | Payer Claim Identification Number | |
| L2200E | REF02 | Payor’s Claim Number | L2200E_S03_REF02_PAYR_CLM_CONTRL_NR_OVL_PAYR_CLM_NR |
| L2200E | REF | Institutional Bill Type Identification | |
| L2200E | REF02 | Billing Type | L2200E_S04_REF02_TYPE_ID_OVL_BILNG_TYPE |
| L2200E | REF | Medical Record Identification | |
| L2200E | REF02 | Medical Record Identification Number | L2200E_S05_REF02_RECRD_NR_OVL_MEDCL_RECRD_ID_NR |
| L2200E | DTP | Claim Service Date | |
| L2200E | DTP03 | Claim Statement Period Start (RD8) | L2200E_S06_DTP03_SVC_PERD_OVL_CLM_STATMNT_PERD_START_RD8 |
2220E - SERVICE LINE INFORMATION
| Loop | Segment | Segment Name | Chiapas Gate Mapping |
| L2220E | SVC | Service Line Information | |
| L2220E | SVC01-02 | American Dental Association Codes | L2220E_S01_SVC01_02_SVC_ID_CD_OVL_AMRCN_DENTL_ASCTN_CD |
| L2220E | SVC01-02 | Common Language Equipment Identifier (CLEI) | L2220E_S01_SVC01_02_SVC_ID_CD_OVL_CLEI |
| L2220E | SVC01-02 | Health Care Financing Administration Common Procedural Coding System (HCPCS) Codes | L2220E_S01_SVC01_02_SVC_ID_CD_OVL_HCPCS_CD |
| L2220E | SVC01-02 | International Classification of Diseases Clinical Modification (ICD-9-CM) - Procedure | L2220E_S01_SVC01_02_SVC_ID_CD_OVL_ICD9CM_PROC |
| L2220E | SVC01-02 | Home Infusion EDI Coalition (HIEC) Product/Service | L2220E_S01_SVC01_02_SVC_ID_CD_OVL_HIEC_PRODCT_SRVC |
| L2220E | SVC01-02 | National Drug Code in 4-4-2 Format | L2220E_S01_SVC01_02_SVC_ID_CD_OVL_NDC_442_FORMT |
| L2220E | SVC01-02 | National Drug Code in 5-3-2 Format | L2220E_S01_SVC01_02_SVC_ID_CD_OVL_NDC_532_FORMT |
| L2220E | SVC01-02 | National Drug Code in 5-4-1 Format | L2220E_S01_SVC01_02_SVC_ID_CD_OVL_NDC_541_FORMT |
| L2220E | SVC01-02 | National Drug Code in 5-4-2 Format | L2220E_S01_SVC01_02_SVC_ID_CD_OVL_NDC_542_FORMT |
| L2220E | SVC01-02 | National Drug Code (NDC) | L2220E_S01_SVC01_02_SVC_ID_CD_OVL_NDC |
| L2220E | SVC01-02 | National Health Related Item Code | L2220E_S01_SVC01_02_SVC_ID_CD_OVL_NATNL_HEALTH_RELTD_ITM_CD |
| L2220E | SVC01-02 | National Uniform Billing Committee (NUBC) UB92 Codes | L2220E_S01_SVC01_02_SVC_ID_CD_OVL_NUBC_UB92_CD |
| L2220E | SVC01-02 | National Uniform Billing Committee (NUBC) UB82 Codes | L2220E_S01_SVC01_02_SVC_ID_CD_OVL_NUBC_UB82_CD |
| L2220E | SVC01-03 | Procedure Modifier | L2220E_S01_SVC01_03_PROC_MODFR |
| L2220E | SVC01-04 | Procedure Modifier | L2220E_S01_SVC01_04_PROC_MODFR |
| L2220E | SVC01-05 | Procedure Modifier | L2220E_S01_SVC01_05_PROC_MODFR |
| L2220E | SVC01-06 | Procedure Modifier | L2220E_S01_SVC01_06_PROC_MODFR |
| L2220E | SVC02 | Line Item Charge Amount | L2220E_S01_SVC02_LIN_ITM_CHG_AMT |
| L2220E | SVC03 | Line Item Provider Payment Amount | L2220E_S01_SVC03_LIN_ITM_PROV_PMT_AMT |
| L2220E | SVC04 | Revenue Code | L2220E_S01_SVC04_REVN_CD |
| L2220E | SVC07 | Original Units of Service Count | L2220E_S01_SVC07_ORGNL_UNTS_SVC_CT |
| L2220E | STC | Service Line Status Information | |
| L2220E | STC01-01 | Health Care Claim Status Category Code | L2220E_S02_STC01_01_HLTHCR_CLM_STATS_CATGRY_CD |
| L2220E | STC01-02 | Health Care Claim Status Code | L2220E_S02_STC01_02_HLTHCR_CLM_STATS_CD |
| L2220E | STC01-03 | Entity Identifier Code | L2220E_S02_STC01_03_ENTY_ID_CD |
| L2220E | STC02 | Status Information Effective Date | L2220E_S02_STC02_STATS_NFO_EFF_DT |
| L2220E | STC04 | Line Item Charge Amount | L2220E_S02_STC04_LIN_ITM_CHG_AMT |
| L2220E | STC05 | Line Item Provider Payment Amount | L2220E_S02_STC05_LIN_ITM_PROV_PMT_AMT |
| L2220E | STC10-01 | Health Care Claim Status Category Code | L2220E_S02_STC10_01_HLTHCR_CLM_STATS_CATGRY_CD |
| L2220E | STC10-02 | Health Care Claim Status Code | L2220E_S02_STC10_02_HLTHCR_CLM_STATS_CD |
| L2220E | STC10-03 | Entity Identifier Code | L2220E_S02_STC10_03_ENTY_ID_CD |
| L2220E | STC11-01 | Health Care Claim Status Category Code | L2220E_S02_STC11_01_HLTHCR_CLM_STATS_CATGRY_CD |
| L2220E | STC11-02 | Health Care Claim Status Code | L2220E_S02_STC11_02_HLTHCR_CLM_STATS_CD |
| L2220E | STC11-03 | Entity Identifier Code | L2220E_S02_STC11_03_ENTY_ID_CD |
| L2220E | REF | Service Line Item Identification | |
| L2220E | REF02 | Line Item Control Number | L2220E_S03_REF02_LIN_ITM_CONTRL_NR_OVL_LIN_ITM_CONTRL_NR |
| L2220E | DTP | Service Line Date | |
| L2220E | DTP03 | Service (RD8) | L2220E_S04_DTP03_SVC_DT_OVL_SVC_RD8 |