(C) Copyright 2012 Chiapas EDI Technologies, Inc.
5010_277CA 5010 Health Care Claim Acknowledgment - Code:P5
ISA - ISA
| 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 | Function 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 | ST02 | Transaction Set Control Number | STHDR_S01_ST02_CONTRL_NR |
| STHDR | ST03 | Implementation Convention Reference | STHDR_S01_ST03_IMPLMNTN_CONVNTN_REFNC |
| 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 | Reference Identification | STHDR_S02_BHT03_REF_ID |
| STHDR | BHT04 | Transaction Set Creation Date | STHDR_S02_BHT04_TS_CREATN_DT |
| STHDR | BHT05 | Transaction Set Creation Time | STHDR_S02_BHT05_TS_CREATN_TIM |
| 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 - INFORMATION SOURCE NAME
| Loop | Segment | Segment Name | Chiapas Gate Mapping |
| 2100A | Qualified Loop | ||
| L2100A | Clearinghouse | L2100A_AY | |
| L2100A | Payer | L2100A_PR | |
| L2100A | NM1 | Information Source Name | |
| L2100A | NM103 | Non-Person Entity | L2100A_XX_S01_NM103_NFO_SOURC_LAST_ORG_NM_OVL_NON_PERSN_ENTY |
| L2100A | NM109 | Electronic Transmitter Identification Number | L2100A_XX_S01_NM109_NFO_SOURC_PRIMRY_ID_OVL_ETIN |
| L2100A | NM109 | Federal Taxpayer's Identification Number | L2100A_XX_S01_NM109_NFO_SOURC_PRIMRY_ID_OVL_FEDRL_TAX_ID_NR |
| L2100A | NM109 | Payor Identification | L2100A_XX_S01_NM109_NFO_SOURC_PRIMRY_ID_OVL_PAYR_ID |
| L2100A | NM109 | Centers for Medicare abd Medicaid Services PlanID | L2100A_XX_S01_NM109_NFO_SOURC_PRIMRY_ID_OVL_MEDCR_MEDCD_SVCS_PLANID |
2200A - TRANSMISSION RECEIPT CONTROL IDENTIFIER
| Loop | Segment | Segment Name | Chiapas Gate Mapping |
| L2200A | TRN | Transmission Receipt Control Identifier | |
| L2200A | TRN02 | Information Source Application Trace Identifier | L2200A_S01_TRN02_NFO_SRC_APPLCTN_TRAC_ID |
| L2200A | DTP | Information Source Receipt Date | |
| L2200A | DTP03 | Received (D8) | L2200A_S02_DTP03_DT_TM_PERD_OVL_RECVD_D8 |
| L2200A | DTP | Information Source Process Date | |
| L2200A | DTP03 | Process (D8) | L2200A_S03_DTP03_NFO_SRC_PROCSS_DT_OVL_PROCSS_D8 |
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_NON_PERSN_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 | NM109 | Electronic Transmitter Identification Number (ETIN) | L2100B_S01_NM109_NFO_SOURC_PRIMRY_ID_OVL_ETIN |
2200B - INFORMATION RECEIVER APPLICATION TRACE IDENTIFIER
| Loop | Segment | Segment Name | Chiapas Gate Mapping |
| L2200B | TRN | Information Receiver Application Trace Identifier | |
| L2200B | TRN02 | Claim Transaction Batch Number | L2200B_S01_TRN02_CLM_TRANSCTN_BATCH_NR |
| L2200B | TRN04 | Reference Identification | L2200B_S01_TRN04_REF_ID |
| L2200B | STC | Information Receiver Status Information | |
| L2200B | STC01-01 | Health Care Claim Status Category Code | L2200B_S02_STC01_01_HLTH_CR_CLM_STATS_CAT_CD |
| L2200B | STC01-02 | Health Care Claim Status Code | L2200B_S02_STC01_02_HLTH_CR_CLM_STATS_CD |
| L2200B | STC01-03 | Entity Identifier Code | L2200B_S02_STC01_03_ENTY_ID_CD |
| L2200B | STC02 | Status Information Effective Date | L2200B_S02_STC02_STATS_NFO_EFF_DT |
| L2200B | STC03 | Action Code | L2200B_S02_STC03_ACTN_CD |
| L2200B | STC04 | Total Submitted Charges for Work | L2200B_S02_STC04_TOTL_SUBMTD_CHGS_WORK |
| L2200B | STC10-01 | Health Care Claim Status Category Code | L2200B_S02_STC10_01_HLTH_CR_CLM_STATS_CAT_CD |
| L2200B | STC10-02 | Health Care Claim Status Code | L2200B_S02_STC10_02_HLTH_CR_CLM_STATS_CD |
| L2200B | STC10-03 | Entity Identifier Code | L2200B_S02_STC10_03_ENTY_ID_CD |
| L2200B | STC11-01 | Health Care Claim Status Category Code | L2200B_S02_STC11_01_HLTH_CR_CLM_STATS_CAT_CD |
| L2200B | STC11-02 | Health Care Claim Status Code | L2200B_S02_STC11_02_HLTH_CR_CLM_STATS_CD |
| L2200B | STC11-03 | Entity Identifier Code | L2200B_S02_STC11_03_ENTY_ID_CD |
| L2200B | QTY | Total Accepted Quantity | |
| L2200B | QTY01 | Quantity Qualifier | L2200B_S03_QTY01_QTY_QUAL |
| L2200B | QTY02 | Total Accepted Quantity | L2200B_S03_QTY02_TOTL_ACCPTD_QTY |
| L2200B | QTY | Total Rejected Quantity | |
| L2200B | QTY01 | Quantity Qualifier | L2200B_S04_QTY01_QTY_QUAL |
| L2200B | QTY02 | Total Rejected Quantity | L2200B_S04_QTY02_TOTL_REJECTD_QTY |
| L2200B | AMT | Total Accepted Amount | |
| L2200B | AMT01 | Amount Qualifier Code | L2200B_S05_AMT01_AMT_QUAL_CD |
| L2200B | AMT02 | Total Accepted Amount | L2200B_S05_AMT02_TOTL_ACCPTD_AMT |
| L2200B | AMT | Total Rejected Amount | |
| L2200B | AMT01 | Amount Qualifier Code | L2200B_S06_AMT01_AMT_QUAL_CD |
| L2200B | AMT02 | Total Rejected Amount | L2200B_S06_AMT02_TOTL_REJCTD_AMT |
2000C - BILLING PROVIDER OF SERVICE LEVEL
| Loop | Segment | Segment Name | Chiapas Gate Mapping |
| L2000C | HL | Billing Provider of Service 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 - BILLING PROVIDER NAME
| Loop | Segment | Segment Name | Chiapas Gate Mapping |
| L2100C | NM1 | Billing Provider Name | |
| L2100C | NM103 | Person | L2100C_S01_NM103_PROV_LAST_ORG_NM_OVL_PERSN |
| L2100C | NM103 | Non-Person Entity | L2100C_S01_NM103_PROV_LAST_ORG_NM_OVL_NON_PERSN_ENTY |
| L2100C | NM104 | Provider First Name | L2100C_S01_NM104_PROV_FNAME |
| L2100C | NM105 | Provider Middle Name | L2100C_S01_NM105_PROV_MNAME |
| L2100C | NM107 | Provider Name Suffix | L2100C_S01_NM107_PROV_NM_SUFX |
| L2100C | NM109 | Federal Taxpayer's Identification Number | L2100C_S01_NM109_BILNG_PROV_ID_OVL_FED_TAX_ID_NR |
| L2100C | NM109 | Centers for Medicare and Medicaid Services National Provider Identifier | L2100C_S01_NM109_BILNG_PROV_ID_OVL_NPI |
2200C - PROVIDER OF SERVICE INFORMATION TRACE IDENTIFIER
| Loop | Segment | Segment Name | Chiapas Gate Mapping |
| L2200C | TRN | Provider of Service Information Trace Identifier | |
| L2200C | TRN02 | Provider of Service Information Trace Identifier | L2200C_S01_TRN02_PROV_SVC_NFO_TRAC_ID |
| L2200C | STC | Billing Provider Status Information | |
| L2200C | STC01-01 | Health Care Claim Status Category Code | L2200C_S02_STC01_01_HLTH_CR_CLM_STATS_CAT_CD |
| L2200C | STC01-02 | Health Care Claim Status Code | L2200C_S02_STC01_02_HLTH_CR_CLM_STATS_CD |
| L2200C | STC01-03 | Entity Identifier Code | L2200C_S02_STC01_03_ENTY_ID_CD |
| L2200C | STC03 | Action Code | L2200C_S02_STC03_ACTN_CD |
| L2200C | STC04 | Total Submitted Charges for Unit Work | L2200C_S02_STC04_MONTRY_AMTTOTL_SUBMTD_CHGS_UNT_WORK |
| L2200C | STC10-01 | Health Care Claim Status Category Code | L2200C_S02_STC10_01_HLTH_CR_CLM_STATS_CAT_CD |
| L2200C | STC10-02 | Health Care Claim Status Code | L2200C_S02_STC10_02_HLTH_CR_CLM_STATS_CD |
| L2200C | STC10-03 | Entity Identifier Code | L2200C_S02_STC10_03_ENTY_ID_CD |
| L2200C | STC11-01 | Health Care Claim Status Category Code | L2200C_S02_STC11_01_HLTH_CR_CLM_STATS_CAT_CD |
| L2200C | STC11-02 | Health Care Claim Status Code | L2200C_S02_STC11_02_HLTH_CR_CLM_STATS_CD |
| L2200C | STC11-03 | Entity Identifier Code | L2200C_S02_STC11_03_ENTY_ID_CD |
| L2200C | REF | Provider Secondary Identifier | |
| L2200C | REF02 | State License Number | L2200C_S03_REF02_BILLNG_PROV_ADDTL_ID_OVL_STAT_LICNS_NR |
| L2200C | REF02 | Provider UPIN Number | L2200C_S03_REF02_BILLNG_PROV_ADDTL_ID_OVL_PROV_UPIN |
| L2200C | REF02 | Provider Commercial Number | L2200C_S03_REF02_BILLNG_PROV_ADDTL_ID_OVL_PROV_COMMRCL_NR |
| L2200C | REF02 | Location Number | L2200C_S03_REF02_BILLNG_PROV_ADDTL_ID_OVL_LOCTN_NR |
| L2200C | REF02 | Social Security Number | L2200C_S03_REF02_BILLNG_PROV_ADDTL_ID_OVL_SSN |
| L2200C | REF02 | Federal Taxpayer's Identification Number | L2200C_S03_REF02_BILLNG_PROV_ADDTL_ID_OVL_FED_TAX_ID |
| L2200C | QTY | Total Accepted Quantity | |
| L2200C | QTY01 | Quantity Qualifier | L2200C_S04_QTY01_QTY_QUAL |
| L2200C | QTY02 | Total Accepted Quantity | L2200C_S04_QTY02_TOTL_ACCPTD_QTY |
| L2200C | QTY | Total Rejected Quantity | |
| L2200C | QTY01 | Quantity Qualifier | L2200C_S05_QTY01_QTY_QUAL |
| L2200C | QTY02 | Total Rejected Quantity | L2200C_S05_QTY02_TOTL_REJCTD_QTY |
| L2200C | AMT | Total Accepted Amount | |
| L2200C | AMT01 | Amount Qualifier Code | L2200C_S06_AMT01_AMT_QUAL_CD |
| L2200C | AMT02 | Total Accepted Amount | L2200C_S06_AMT02_TOTL_ACCPTD_AMT |
| L2200C | AMT | Total Rejected Amount | |
| L2200C | AMT01 | Amount Qualifier Code | L2200C_S07_AMT01_AMT_QUAL_CD |
| L2200C | AMT02 | Total Rejected Amount | L2200C_S07_AMT02_TOTL_REJCTD_AMT |
2000D - PATIENT LEVEL
| Loop | Segment | Segment Name | Chiapas Gate Mapping |
| L2000D | HL | Patient 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 |
2100D - PATIENT NAME
| Loop | Segment | Segment Name | Chiapas Gate Mapping |
| L2100D | NM1 | Patient Name | |
| L2100D | NM103 | Person | L2100D_S01_NM103_PATNT_LAST_NM_OVL_PERSN |
| L2100D | NM104 | Patient First Name | L2100D_S01_NM104_PATNT_FIRST_NM |
| L2100D | NM105 | Patient Middle Name or Initial | L2100D_S01_NM105_PATNT_MNAME |
| L2100D | NM107 | Patient Name Suffix | L2100D_S01_NM107_PATNT_NM_SUFX |
| L2100D | NM109 | Standard Unique Health Identifier for each Individual in the United States | L2100D_S01_NM109_PATNT_ID_NR_OVL_UNQ_HLTH_ID |
| L2100D | NM109 | Member Identification Number | L2100D_S01_NM109_PATNT_ID_NR_OVL_MEM_ID_NR |
2200D - CLAIM STATUS TRACKING NUMBER
| Loop | Segment | Segment Name | Chiapas Gate Mapping |
| L2200D | TRN | Claim Status Tracking Number | |
| L2200D | TRN02 | Patient Control Number | L2200D_S01_TRN02_PATNT_CONTRL_NR |
| L2200D | TRN04 | Trace Assigning Entity Additional Identifier | L2200D_S01_TRN04_TRAC_ASGNG_ENTY_ADDL_ID |
| L2200D | STC | Claim Level Status Information | |
| L2200D | STC01-01 | Health Care Claim Status Category Code | L2200D_S02_STC01_01_HLTH_CR_CLM_STATS_CAT_CD |
| L2200D | STC01-02 | Health Care Claim Status Code | L2200D_S02_STC01_02_HLTH_CR_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 | STC03 | Action Code | L2200D_S02_STC03_ACTN_CD |
| L2200D | STC04 | Total Claim Charge Amount | L2200D_S02_STC04_TOTL_CLM_CHG_AMT |
| L2200D | STC10-01 | Health Care Claim Status Category Code | L2200D_S02_STC10_01_HLTH_CR_CLM_STATS_CAT_CD |
| L2200D | STC10-02 | Health Care Claim Status Code | L2200D_S02_STC10_02_HLTH_CR_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_HLTH_CR_CLM_STATS_CAT_CD |
| L2200D | STC11-02 | Health Care Claim Status Code | L2200D_S02_STC11_02_HLTH_CR_CLM_STATS_CD |
| L2200D | STC11-03 | Entity Identifier Code | L2200D_S02_STC11_03_ENTY_ID_CD |
| L2200D | STC12 | Free-form Message Text | L2200D_S02_STC12_FREFM_MESG_TEXT |
| L2200D | REF | Payer Claim Control Number | |
| L2200D | REF02 | Payor's Claim Number | L2200D_S03_REF02_PAYR_CLM_CTL_NR_OVL_PAYR_CLM_NR |
| L2200D | REF | Claim Identifier Number For Clearinghouse and Other Transmission Intermediaries | |
| L2200D | REF01 | Reference Identification Qualifier | L2200D_S04_REF01_REF_ID_QUAL |
| L2200D | REF02 | Clearinghouse Trace Number | L2200D_S04_REF02_CLEARNGHS_TRAC_NR |
| L2200D | REF | Institutional Bill Type Identification | |
| L2200D | REF01 | Reference Identification Qualifier | L2200D_S05_REF01_REF_ID_QUAL |
| L2200D | REF02 | Bill Type Identifier | L2200D_S05_REF02_BILL_TYP_ID |
| L2200D | DTP | Claim Level Service Date | |
| L2200D | DTP03 | Service (D8) | L2200D_S06_DTP03_CLM_SVC_PERD_OVL_SERVC_D8 |
| L2200D | DTP03 | Service (RD8) | L2200D_S06_DTP03_CLM_SVC_PERD_OVL_SERVC_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_PROC_CD_OVL_ADA_CD |
| L2220D | SVC01-02 | Jurisdiction Specific Procedure and Supply Codes | L2220D_S01_SVC01_02_PROC_CD_OVL_JURIS_SPEC_PROC_SPLY_CD |
| L2220D | SVC01-02 | Health Care Financing Administration Common Procedural Coding System (HCPCS) Codes | L2220D_S01_SVC01_02_PROC_CD_OVL_HCPCS |
| L2220D | SVC01-02 | Health Insurance Prospective Payment System (HIPPS) Skill Nursing Facility Rate Code | L2220D_S01_SVC01_02_PROC_CD_OVL_HIPPS |
| L2220D | SVC01-02 | National Uniform Billing Committe (NUBC) UB92 Codes | L2220D_S01_SVC01_02_PROC_CD_OVL_UB92 |
| L2220D | SVC01-02 | Advanced Billing Concepts (ABC) Codes | L2220D_S01_SVC01_02_PROC_CD_OVL_ABC |
| L2220D | SVC01-03 | Procedure Modifier | L2220D_S01_SVC01_03_MOD_CD |
| L2220D | SVC01-04 | Procedure Modifier | L2220D_S01_SVC01_04_MOD_CD |
| L2220D | SVC01-05 | Procedure Modifier | L2220D_S01_SVC01_05_MOD_CD |
| L2220D | SVC01-06 | Procedure Modifier | L2220D_S01_SVC01_06_MOD_CD |
| L2220D | SVC02 | Line Item Charge Amount | L2220D_S01_SVC02_LIN_ITM_CHG_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 Level Status Information | |
| L2220D | STC01-01 | Health Care Claim Status Category Code | L2220D_S02_STC01_01_HLTH_CR_CLM_STS_CAT_CD |
| L2220D | STC01-02 | Health Care Claim Status Code | L2220D_S02_STC01_02_HLTH_CR_CLM_STS_CD |
| L2220D | STC01-03 | Entity Identifier Code | L2220D_S02_STC01_03_ENTY_ID_CD |
| L2220D | STC03 | Action Code | L2220D_S02_STC03_ACTN_CD |
| L2220D | STC10-01 | Health Care Claim Status Category Code | L2220D_S02_STC10_01_HLTH_CR_CLM_STS_CAT_CD |
| L2220D | STC10-02 | Health Care Claim Status Code | L2220D_S02_STC10_02_HLTH_CR_CLM_STS_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_HLTH_CR_CLM_STS_CAT_CD |
| L2220D | STC11-02 | Health Care Claim Status Code | L2220D_S02_STC11_02_HLTH_CR_CLM_STS_CD |
| L2220D | STC11-03 | Entity Identifier Code | L2220D_S02_STC11_03_ENTY_ID_CD |
| L2220D | STC12 | Free-form Message Text | L2220D_S02_STC12_FREFM_MESG_TEXT |
| L2220D | REF | Service Line Item Identification | |
| L2220D | REF02 | Line Item Control Number | L2220D_S03_REF02_LIN_ITM_CTL_NR_OVL_LIN_ITM_CONTRL_NR |
| L2220D | REF | Pharmacy Prescription Number | |
| L2220D | REF01 | Reference Identification Qualifier | L2220D_S04_REF01_REF_ID_QUAL |
| L2220D | REF02 | Pharmacy Prescription Number | L2220D_S04_REF02_PHARMCY_RX_NR |
| L2220D | REF03 | Information Receiver Additional Identifier State | L2220D_S04_REF03_NFO_RECVR_ADDL_ID_STAT |
| L2220D | DTP | Service Line Date | |
| L2220D | DTP03 | Service (D8) | L2220D_S05_DTP03_SVC_LIN_DT_OVL_SERVC_D8 |
| L2220D | DTP03 | Service (RD8) | L2220D_S05_DTP03_SVC_LIN_DT_OVL_SERVC_RD8 |