Chiapas EDI 2012 Mapping Guide

5010_837P 5010 Health Care Claim: Professional - Code:X0

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	ST03	Implementation Guide Version Name	STHDR_S01_ST03_IMPLMNTN_GUID_VERSN_NM
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	BHT05	Transaction Set Creation Time	STHDR_S02_BHT05_TS_CREATN_TIM
STHDR	BHT06	Claim or Encounter Identifier	STHDR_S02_BHT06_CLM_ENCNTR_ID
STHDR	SE	Transaction Set Trailer
STHDR	SE01	Transaction Segment Count	STHDR_S06_SE01_SEG_CT
STHDR	SE02	Transaction Set Control Number	STHDR_S06_SE02_TCN

1000A - SUBMITTER NAME

Loop	Segment	Segment Name	Chiapas Gate Mapping
L1000A	NM1	Submitter Name
L1000A	NM103	Person	L1000A_S01_NM103_SUBMTR_LAST_ORG_NM_OVL_PERSN
L1000A	NM103	Non-Person Entity	L1000A_S01_NM103_SUBMTR_LAST_ORG_NM_OVL_NONPRSN_ENTY
L1000A	NM104	Submitter First Name	L1000A_S01_NM104_SUBMTR_FNAME
L1000A	NM105	Submitter Middle Name or Initial	L1000A_S01_NM105_MNAME_INTL
L1000A	NM109	Electronic Transmitter Identification Number (ETIN)	L1000A_S01_NM109_SUBMTR_ID_OVL_ETN_NR
L1000A	PER	Submitter EDI Contact Information
L1000A	PER01	Contact Function Code	L1000A_S02_PER01_FUNCTN_CD
L1000A	PER02	Submitter Contact Name	L1000A_S02_PER02_CONTCT_NM
L1000A	PER04	Electronic Mail	L1000A_S02_PER04_COMM_NR_OVL_EMAIL
L1000A	PER04	Facsimile	L1000A_S02_PER04_COMM_NR_OVL_FACSML
L1000A	PER04	Telephone	L1000A_S02_PER04_COMM_NR_OVL_TELPHN
L1000A	PER06	Electronic Mail	L1000A_S02_PER06_COMM_NR_OVL_EMAIL
L1000A	PER06	Telephone Extension	L1000A_S02_PER06_COMM_NR_OVL_PHN_EXTNS
L1000A	PER06	Facsimile	L1000A_S02_PER06_COMM_NR_OVL_FACSML
L1000A	PER06	Telephone	L1000A_S02_PER06_COMM_NR_OVL_TELPHN
L1000A	PER08	Electronic Mail	L1000A_S02_PER08_COMM_NR_OVL_EMAIL
L1000A	PER08	Telephone Extension	L1000A_S02_PER08_COMM_NR_OVL_PHN_EXTNS
L1000A	PER08	Facsimile	L1000A_S02_PER08_COMM_NR_OVL_FACSML
L1000A	PER08	Telephone	L1000A_S02_PER08_COMM_NR_OVL_TELPHN

1000B - RECEIVER NAME

Loop	Segment	Segment Name	Chiapas Gate Mapping
L1000B	NM1	Receiver Name
L1000B	NM103	Non-Person Entity	L1000B_S01_NM103_RECVR_NM_OVL_NONPRSN_ENTY
L1000B	NM109	Electronic Transmitter Identification Number (ETIN)	L1000B_S01_NM109_PRIMRY_ID_OVL_ETN_NR

2000A - BILLING PROVIDER HIERARCHICAL LEVEL

Loop	Segment	Segment Name	Chiapas Gate Mapping
L2000A	HL	Billing Provider Hierarchical Level
L2000A	HL01	Hierarchical ID Number	L2000A_S01_HL01_HIERCHCL_ID_NR
L2000A	HL04	Hierarchical Child Code	L2000A_S01_HL04_HIERCHCL_CHILD_CD
L2000A	PRV	Billing Provider Specialty Information
L2000A	PRV01	Provider Code	L2000A_S02_PRV01_PROV_CD
L2000A	PRV03	Health Care Provider Taxonomy Code	L2000A_S02_PRV03_TAXNMY_CD_OVL_HLTHCR_PROV_TAXNMY_CD
L2000A	CUR	Foreign Currency Information
L2000A	CUR01	Entity Identifier Code	L2000A_S03_CUR01_ENTY_ID_CD
L2000A	CUR02	Currency Code	L2000A_S03_CUR02_CURNCY_CD

2010AA - BILLING PROVIDER NAME

Loop	Segment	Segment Name	Chiapas Gate Mapping
L2010AA	NM1	Billing Provider Name
L2010AA	NM103	Person	L2010AA_S01_NM103_LAST_ORGL_NM_OVL_PERSN
L2010AA	NM103	Non-Person Entity	L2010AA_S01_NM103_LAST_ORGL_NM_OVL_NONPRSN_ENTY
L2010AA	NM104	Billing Provider First Name	L2010AA_S01_NM104_PROV_FNAME
L2010AA	NM105	Billing Provider Middle Name or Initial	L2010AA_S01_NM105_BILNG_PROV_MNAME_INTL
L2010AA	NM107	Billing Provider Name Suffix	L2010AA_S01_NM107_BILNG_PROV_NM_SUFX
L2010AA	NM109	Centers for Medicare and Medicaid Services	L2010AA_S01_NM109_PROV_ID_OVL_CENTRS_MEDCR_MEDCD_SVCS
L2010AA	N3	Billing Provider Address
L2010AA	N301	Billing Provider Address Line	L2010AA_S02_N301_BILNG_PROV_ADRS_LIN
L2010AA	N302	Billing Provider Address Line	L2010AA_S02_N302_BILNG_PROV_ADRS_LIN
L2010AA	N4	Billing Provider City, State, ZIP Code
L2010AA	N401	Billing Provider City Name	L2010AA_S03_N401_BILNG_PROV_CITY_NM
L2010AA	N402	Billing Provider State or Province Code	L2010AA_S03_N402_STAT_PROVNC_CD
L2010AA	N403	Billing Provider Postal Zone or ZIP Code	L2010AA_S03_N403_POSTL_ZON_ZIP_CD
L2010AA	N404	Country Code	L2010AA_S03_N404_CNTRY_CD
L2010AA	N407	Country Subdivision Code	L2010AA_S03_N407_COUNTRY_SUBDVSN_CD
L2010AA	REF	Billing Provider Tax Identification
L2010AA	REF02	Employer’s Identification Number	L2010AA_S04_REF02_ID_NR_OVL_EMPLYR_ID_NR
L2010AA	REF02	Social Security Number	L2010AA_S04_REF02_ID_NR_OVL_SSN
L2010AA	REF	Billing Provider UPIN/License Information
L2010AA	REF02	State License Number	L2010AA_S05_REF02_LICNS_R_UPN_NFO_OVL_STAT_LICNS_NR
L2010AA	REF02	Provider UPIN Number	L2010AA_S05_REF02_LICNS_R_UPN_NFO_OVL_PROV_UPN_NR
L2010AA	PER	Billing Provider Contact Information
L2010AA	PER01	Contact Function Code	L2010AA_S06_PER01_FUNCTN_CD
L2010AA	PER02	Billing Provider Contact Name	L2010AA_S06_PER02_BILNG_PROV_CONTCT_NM
L2010AA	PER04	Electronic Mail	L2010AA_S06_PER04_COMM_NR_OVL_EMAIL
L2010AA	PER04	Facsimile	L2010AA_S06_PER04_COMM_NR_OVL_FACSML
L2010AA	PER04	Telephone	L2010AA_S06_PER04_COMM_NR_OVL_TELPHN
L2010AA	PER06	Electronic Mail	L2010AA_S06_PER06_COMM_NR_OVL_EMAIL
L2010AA	PER06	Telephone Extension	L2010AA_S06_PER06_COMM_NR_OVL_PHN_EXTNS
L2010AA	PER06	Facsimile	L2010AA_S06_PER06_COMM_NR_OVL_FACSML
L2010AA	PER06	Telephone	L2010AA_S06_PER06_COMM_NR_OVL_TELPHN
L2010AA	PER08	Electronic Mail	L2010AA_S06_PER08_COMM_NR_OVL_EMAIL
L2010AA	PER08	Telephone Extension	L2010AA_S06_PER08_COMM_NR_OVL_PHN_EXTNS
L2010AA	PER08	Facsimile	L2010AA_S06_PER08_COMM_NR_OVL_FACSML
L2010AA	PER08	Telephone	L2010AA_S06_PER08_COMM_NR_OVL_TELPHN

2010AB - PAY-TO ADDRESS NAME

Loop	Segment	Segment Name	Chiapas Gate Mapping
L2010AB	NM1	Pay-to Address Name
L2010AB	NM102	Entity Type Qualifier	L2010AB_S01_NM102_ENTY_TYPE_QUAL
L2010AB	N3	Pay-to Address - ADDRESS
L2010AB	N301	Pay-To Address Line	L2010AB_S02_N301_ADRS_LIN
L2010AB	N302	Pay-To Address Line	L2010AB_S02_N302_ADRS_LIN
L2010AB	N4	Pay-To Address City, State, ZIP Code
L2010AB	N401	Pay-to Address City Name	L2010AB_S03_N401_PAYT_ADRS_CITY_NM
L2010AB	N402	Pay-to Address State Code	L2010AB_S03_N402_PAYT_ADRS_STAT_CD
L2010AB	N403	Pay-to Address Postal Zone or ZIP Code	L2010AB_S03_N403_POSTL_ZON_ZIP_CD
L2010AB	N404	Country Code	L2010AB_S03_N404_CNTRY_CD
L2010AB	N407	Country Subdivision Code	L2010AB_S03_N407_COUNTRY_SUBDVSN_CD

2010AC - PAY-TO PLAN NAME

Loop	Segment	Segment Name	Chiapas Gate Mapping
L2010AC	NM1	Pay-To Plan Name
L2010AC	NM103	Non-Person Entity	L2010AC_S01_NM103_PAYT_PLAN_ORGL_NM_OVL_NONPRSN_ENTY
L2010AC	NM109	Payor Identification	L2010AC_S01_NM109_PAYT_PLAN_PRIMRY_ID_OVL_PAYR_ID
L2010AC	NM109	Centers for Medicare and Medicaid Services PlanID	L2010AC_S01_NM109_PAYT_PLAN_PRIMRY_ID_OVL_MDCR_MDCD_SVCS_PLAND
L2010AC	N3	Pay-to Plan Address
L2010AC	N301	Pay-To Plan Address Line	L2010AC_S02_N301_PAYT_PLAN_ADRS_LIN
L2010AC	N302	Pay-To Plan Address Line	L2010AC_S02_N302_PAYT_PLAN_ADRS_LIN
L2010AC	N4	Pay-To Plan City, State, ZIP Code
L2010AC	N401	Pay-To Plan City Name	L2010AC_S03_N401_PAYT_PLAN_CITY_NM
L2010AC	N402	Pay-To Plan State or Province Code	L2010AC_S03_N402_STAT_PROVNC_CD
L2010AC	N403	Pay-To Plan Postal Zone or ZIP Code	L2010AC_S03_N403_POSTL_ZON_ZIP_CD
L2010AC	N404	Country Code	L2010AC_S03_N404_CNTRY_CD
L2010AC	N407	Country Subdivision Code	L2010AC_S03_N407_COUNTRY_SUBDVSN_CD
L2010AC	REF	Pay-to Plan Secondary Identification
L2010AC	REF02	Payer Identification Number	L2010AC_S04_REF02_PAYT_PLAN_2ND_ID_OVL_PAYR_ID_NR
L2010AC	REF02	Claim Office Number	L2010AC_S04_REF02_PAYT_PLAN_2ND_ID_OVL_CLM_OFC_NR
L2010AC	REF02	National Association of Insurance Commissioners (NAIC) Code	L2010AC_S04_REF02_PAYT_PLAN_2ND_ID_OVL_NAIC_CD
L2010AC	REF	Pay-To Plan Tax Identification Number
L2010AC	REF02	Employer’s Identification Number	L2010AC_S05_REF02_NR_OVL_EMPLYR_ID_NR

2000B - SUBSCRIBER HEIRARCHICAL LEVEL

Loop	Segment	Segment Name	Chiapas Gate Mapping
L2000B	HL	Subscriber Hierarchical 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
L2000B	SBR	Subscriber Information
L2000B	SBR01	Payer Responsibility Sequence Number Code	L2000B_S02_SBR01_PAYR_RESP_SEQNC_NR_CD
L2000B	SBR02	Individual Relationship Code	L2000B_S02_SBR02_INDVDL_REL_CD
L2000B	SBR03	Subscriber Group or Policy Number	L2000B_S02_SBR03_SUB_GRP_POLCY_NR
L2000B	SBR04	Subscriber Group Name	L2000B_S02_SBR04_GRP_NM
L2000B	SBR05	Insurance Type Code	L2000B_S02_SBR05_INS_TYPE_CD
L2000B	SBR09	Claim Filing Indicator Code	L2000B_S02_SBR09_CLM_FILNG_IND_CD
L2000B	PAT	Patient Information
L2000B	PAT06	Date Expressed in Format CCYYMMDD	L2000B_S03_PAT06_DEATH_DT_OVL_DT_CCYYMMDD
L2000B	PAT08	Actual Pounds	L2000B_S03_PAT08_PATNT_WEIGHT_OVL_ACTL_POUNDS
L2000B	PAT09	Pregnancy Indicator	L2000B_S03_PAT09_PREGNCY_IND

2010BA - SUBSCRIBER NAME

Loop	Segment	Segment Name	Chiapas Gate Mapping
L2010BA	NM1	Subscriber Name
L2010BA	NM103	Person	L2010BA_S01_NM103_SUB_LNAME_OVL_PERSN
L2010BA	NM103	Non-Person Entity	L2010BA_S01_NM103_SUB_LNAME_OVL_NONPRSN_ENTY
L2010BA	NM104	Subscriber First Name	L2010BA_S01_NM104_SUB_FNAME
L2010BA	NM105	Subscriber Middle Name or Initial	L2010BA_S01_NM105_MNAME_INTL
L2010BA	NM107	Subscriber Name Suffix	L2010BA_S01_NM107_NM_SUFX
L2010BA	NM109	Standard Unique Health Identifier for each Individual in the United States	L2010BA_S01_NM109_PRIMRY_ID_OVL_STANDRD_UNQ_HEALTH_ID
L2010BA	NM109	Member Identification Number	L2010BA_S01_NM109_PRIMRY_ID_OVL_MEM_ID_NR
L2010BA	N3	Subscriber Address
L2010BA	N301	Subscriber Address Line	L2010BA_S02_N301_ADRS_LIN
L2010BA	N302	Subscriber Address Line	L2010BA_S02_N302_ADRS_LIN
L2010BA	N4	Subscriber City, State, ZIP Code
L2010BA	N401	Subscriber City Name	L2010BA_S03_N401_CITY_NM
L2010BA	N402	Subscriber State Code	L2010BA_S03_N402_STAT_CD
L2010BA	N403	Subscriber Postal Zone or ZIP Code	L2010BA_S03_N403_SUB_POSTL_ZON_ZIP_CD
L2010BA	N404	Country Code	L2010BA_S03_N404_CNTRY_CD
L2010BA	N407	Country Subdivision Code	L2010BA_S03_N407_COUNTRY_SUBDVSN_CD
L2010BA	DMG	Subscriber Demographic Information
L2010BA	DMG02	Date Expressed in Format CCYYMMDD	L2010BA_S04_DMG02_BIRTH_DT_OVL_DT_CCYYMMDD
L2010BA	DMG03	Subscriber Gender Code	L2010BA_S04_DMG03_GENDR_CD
L2010BA	REF	Subscriber Secondary Identification
L2010BA	REF02	Social Security Number	L2010BA_S05_REF02_SUPP_ID_OVL_SSN
L2010BA	REF	Property and Casualty Claim Number
L2010BA	REF02	Agency Claim Number	L2010BA_S06_REF02_PROPRTY_CASLTY_CLM_NR_OVL_AGNCY_CLM_NR
L2010BA	PER	Property and Casualty Subscriber Contact Information
L2010BA	PER01	Contact Function Code	L2010BA_S07_PER01_FUNCTN_CD
L2010BA	PER02	Name	L2010BA_S07_PER02_NM
L2010BA	PER04	Telephone	L2010BA_S07_PER04_COMM_NR_OVL_TELPHN
L2010BA	PER06	Telephone Extension	L2010BA_S07_PER06_COMM_NR_OVL_PHN_EXTNS

2010BB - PAYER NAME

Loop	Segment	Segment Name	Chiapas Gate Mapping
L2010BB	NM1	Payer Name
L2010BB	NM103	Non-Person Entity	L2010BB_S01_NM103_PAYR_NM_OVL_NONPRSN_ENTY
L2010BB	NM109	Payor Identification	L2010BB_S01_NM109_PAYR_ID_OVL_PAYR_ID
L2010BB	NM109	Centers for Medicare and Medicaid Services PlanID	L2010BB_S01_NM109_PAYR_ID_OVL_MDCR_MDCD_SVCS_PLAND
L2010BB	N3	Payer Address
L2010BB	N301	Payer Address Line	L2010BB_S02_N301_ADRS_LIN
L2010BB	N302	Payer Address Line	L2010BB_S02_N302_ADRS_LIN
L2010BB	N4	Payer City, State, ZIP Code
L2010BB	N401	Payer City Name	L2010BB_S03_N401_CITY_NM
L2010BB	N402	Payer State or Province Code	L2010BB_S03_N402_PAYR_STAT_PROVNC_CD
L2010BB	N403	Payer Postal Zone or ZIP Code	L2010BB_S03_N403_PAYR_POSTL_ZON_ZIP_CD
L2010BB	N404	Country Code	L2010BB_S03_N404_CNTRY_CD
L2010BB	N407	Country Subdivision Code	L2010BB_S03_N407_COUNTRY_SUBDVSN_CD
L2010BB	REF	Payer Secondary Identification
L2010BB	REF02	Payer Identification Number	L2010BB_S04_REF02_2ND_ID_OVL_PAYR_ID_NR
L2010BB	REF02	Employer’s Identification Number	L2010BB_S04_REF02_2ND_ID_OVL_EMPLYR_ID_NR
L2010BB	REF02	Claim Office Number	L2010BB_S04_REF02_2ND_ID_OVL_CLM_OFC_NR
L2010BB	REF02	National Association of Insurance Commissioners (NAIC) Code	L2010BB_S04_REF02_2ND_ID_OVL_NAIC_CD
L2010BB	REF	Billing Provider Secondary Identification
L2010BB	REF02	Provider Commercial Number	L2010BB_S05_REF02_BILNG_PROV_2ND_ID_OVL_PROV_COMRCL_NR
L2010BB	REF02	Location Number	L2010BB_S05_REF02_BILNG_PROV_2ND_ID_OVL_LOC_NR

2000C - PATIENT HIERARCHICAL LEVEL

Loop	Segment	Segment Name	Chiapas Gate Mapping
L2000C	HL	Patient Hierarchical 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
L2000C	PAT	Patient Information
L2000C	PAT01	Individual Relationship Code	L2000C_S02_PAT01_INDVDL_REL_CD
L2000C	PAT06	Date Expressed in Format CCYYMMDD	L2000C_S02_PAT06_DEATH_DT_OVL_DT_CCYYMMDD
L2000C	PAT08	Actual Pounds	L2000C_S02_PAT08_PATNT_WEIGHT_OVL_ACTL_POUNDS
L2000C	PAT09	Pregnancy Indicator	L2000C_S02_PAT09_PREGNCY_IND

2010CA - PATIENT NAME

Loop	Segment	Segment Name	Chiapas Gate Mapping
L2010CA	NM1	Patient Name
L2010CA	NM103	Person	L2010CA_S01_NM103_PATNT_LNAME_OVL_PERSN
L2010CA	NM104	Patient First Name	L2010CA_S01_NM104_PATNT_FNAME
L2010CA	NM105	Patient Middle Name or Initial	L2010CA_S01_NM105_MNAME_INTL
L2010CA	NM107	Patient Name Suffix	L2010CA_S01_NM107_NM_SUFX
L2010CA	N3	Patient Address
L2010CA	N301	Patient Address Line	L2010CA_S02_N301_ADRS_LIN
L2010CA	N302	Patient Address Line	L2010CA_S02_N302_ADRS_LIN
L2010CA	N4	Patient City, State, ZIP Code
L2010CA	N401	Patient City Name	L2010CA_S03_N401_CITY_NM
L2010CA	N402	Patient State Code	L2010CA_S03_N402_STAT_CD
L2010CA	N403	Patient Postal Zone or ZIP Code	L2010CA_S03_N403_PATNT_POSTL_ZON_ZIP_CD
L2010CA	N404	Country Code	L2010CA_S03_N404_CNTRY_CD
L2010CA	N407	Country Subdivision Code	L2010CA_S03_N407_COUNTRY_SUBDVSN_CD
L2010CA	DMG	Patient Demographic Information
L2010CA	DMG02	Date Expressed in Format CCYYMMDD	L2010CA_S04_DMG02_BIRTH_DT_OVL_DT_CCYYMMDD
L2010CA	DMG03	Patient Gender Code	L2010CA_S04_DMG03_GENDR_CD
L2010CA	REF	Property and Casualty Claim Number
L2010CA	REF02	Agency Claim Number	L2010CA_S05_REF02_PROPRTY_CASLTY_CLM_NR_OVL_AGNCY_CLM_NR
L2010CA	PER	Property and Casualty Patient Contact Information
L2010CA	PER01	Contact Function Code	L2010CA_S06_PER01_FUNCTN_CD
L2010CA	PER02	Name	L2010CA_S06_PER02_NM
L2010CA	PER04	Telephone	L2010CA_S06_PER04_COMM_NR_OVL_TELPHN
L2010CA	PER06	Telephone Extension	L2010CA_S06_PER06_COMM_NR_OVL_PHN_EXTNS

2300 - CLAIM INFORMATION

Loop	Segment	Segment Name	Chiapas Gate Mapping
L2300	CLM	Claim Information
L2300	CLM01	Patient Control Number	L2300_S01_CLM01_PATNT_CONTRL_NR
L2300	CLM02	Total Claim Charge Amount	L2300_S01_CLM02_TOTL_CLM_CHG_AMT
L2300	CLM05-01	Place of Service Code	L2300_S01_CLM05_01_PLAC_SVC_CD
L2300	CLM05-03	Place of Service Codes for Professional or Dental	L2300_S01_CLM05_03_CLM_FREQNCY_CD_OVL_PLAC_SVC_CODS_PROF_DENTL
L2300	CLM06	Provider or Supplier Signature Indicator	L2300_S01_CLM06_PROV_SUPLR_SIGNTR_IND
L2300	CLM07	Assignment or Plan Participation Code	L2300_S01_CLM07_ASGNMNT_PLAN_PARTCPTN_CD
L2300	CLM08	Benefits Assignment Certification Indicator	L2300_S01_CLM08_BENFTS_ASGNMNT_CERT_IND
L2300	CLM09	Release of Information Code	L2300_S01_CLM09_RELS_NFO_CD
L2300	CLM10	Patient Signature Source Code	L2300_S01_CLM10_PATNT_SIGNTR_SOURC_CD
L2300	CLM11-01	Related Causes Code	L2300_S01_CLM11_01_RELTD_CAUS_CD
L2300	CLM11-02	Related Causes Code	L2300_S01_CLM11_02_RELTD_CAUS_CD
L2300	CLM11-04	Auto Accident State or Province Code	L2300_S01_CLM11_04_AUT_ACDNT_STAT_PROVNC_CD
L2300	CLM11-05	Country Code	L2300_S01_CLM11_05_CNTRY_CD
L2300	CLM12	Special Program Indicator	L2300_S01_CLM12_SPECL_PROGRM_IND
L2300	CLM20	Delay Reason Code	L2300_S01_CLM20_DELY_RSN_CD
L2300	DTP	Date - Onset of Current Illness or Symptom
L2300	DTP03	Onset of Current Symptoms or Illness (D8)	L2300_S02_DTP03_INJRY_DT_OVL_ONST_CURNT_SYMPTMS_ILNS_D8
L2300	DTP	Date - Initial Treatment Date
L2300	DTP03	Initial Treatment (D8)	L2300_S03_DTP03_TREATMNT_DT_OVL_INTL_TREATMNT_D8
L2300	DTP	Date - Last Seen Date
L2300	DTP03	Latest Visit or Consultation (D8)	L2300_S04_DTP03_SEN_DT_OVL_LATST_VIST_CONSLTN_D8
L2300	DTP	Date - Acute Manifestation
L2300	DTP03	Acute Manifestation of a Chronic Condition (D8)	L2300_S05_DTP03_MANFSTN_DT_OVL_ACT_MANFSTN_CHRONC_CONDTN_D8
L2300	DTP	Date - Accident
L2300	DTP03	Accident (D8)	L2300_S06_DTP03_ACDNT_DT_OVL_ACDNT_D8
L2300	DTP	Date - Last Menstrual Period
L2300	DTP03	Last Menstrual Period (D8)	L2300_S07_DTP03_LAST_MENSTRL_PERD_DT_OVL_LAST_MENSTRL_PERD_D8
L2300	DTP	Date - Last X-ray Date
L2300	DTP03	Last X-Ray (D8)	L2300_S08_DTP03_XRAY_DT_OVL_LAST_XRAY_D8
L2300	DTP	Date - Hearing and Vision Prescription Date
L2300	DTP03	Prescription (D8)	L2300_S09_DTP03_RX_DT_OVL_RX_D8
L2300	DTP	Date - Disability Dates
L2300	DTP03	Disability (D8)	L2300_S10_DTP03_FROM_DT_OVL_DISBLTY_D8
L2300	DTP03	Initial Disability Period Start (D8)	L2300_S10_DTP03_FROM_DT_OVL_INTL_DISBLTY_PERD_START_D8
L2300	DTP03	Initial Disability Period End (D8)	L2300_S10_DTP03_FROM_DT_OVL_INTL_DISBLTY_PERD_END_D8
L2300	DTP03	Disability (RD8)	L2300_S10_DTP03_FROM_DT_OVL_DISBLTY_RD8
L2300	DTP03	Initial Disability Period Start (RD8)	L2300_S10_DTP03_FROM_DT_OVL_INTL_DISBLTY_PERD_START_RD8
L2300	DTP03	Initial Disability Period End (RD8)	L2300_S10_DTP03_FROM_DT_OVL_INTL_DISBLTY_PERD_END_RD8
L2300	DTP	Date - Last Worked
L2300	DTP03	Initial Disability Period Last Day Worked (D8)	L2300_S11_DTP03_WORKD_DT_OVL_INTL_DISBLTY_PERD_LAST_DAY_WORKD_D8
L2300	DTP	Date - Authorized Return to Work
L2300	DTP03	Initial Disability Period Return To Work (D8)	L2300_S12_DTP03_WORK_RETRN_DT_OVL_INTL_DISBLTY_PERD_RETRN_TO_WORK_D8
L2300	DTP	Date - Admission
L2300	DTP03	Admission (D8)	L2300_S13_DTP03_RELTD_HOSPTLZTN_ADMSN_DT_OVL_ADMSN_D8
L2300	DTP	Date - Discharge
L2300	DTP03	Discharge (D8)	L2300_S14_DTP03_RELTD_HOSPTLZTN_DISCHRG_DT_OVL_DISCHRG_D8
L2300	DTP	Date - Assumed and Relinquished Care Dates
L2300	DTP03	Report Start (D8)	L2300_S15_DTP03_ASMD_RELNQSHD_CAR_DT_OVL_REPRT_START_D8
L2300	DTP03	Report End (D8)	L2300_S15_DTP03_ASMD_RELNQSHD_CAR_DT_OVL_REPRT_END_D8
L2300	DTP	Date - Property and Casualty Date of First Contact
L2300	DTP03	First Visit or Consultation (D8)	L2300_S16_DTP03_TIM_PERD_OVL_1ST_VIST_CONSLTN_D8
L2300	DTP	Date - Repricer Received Date
L2300	DTP03	Received (D8)	L2300_S17_DTP03_RECVD_DT_OVL_RECVD_D8
L2300	PWK	Claim Supplemental Information
L2300	PWK01	Attachment Report Type Code	L2300_S18_PWK01_ATCHMNT_REPRT_TYPE_CD
L2300	PWK02	Attachment Transmission Code	L2300_S18_PWK02_ATCHMNT_TRANSMSN_CD
L2300	PWK06	Attachment Control Number	L2300_S18_PWK06_ATCHMNT_CONTRL_NR_OVL_ATCHMNT_CONTRL_NR
L2300	CN1	Contract Information
L2300	CN101	Contract Type Code	L2300_S19_CN101_TYPE_CD
L2300	CN102	Contract Amount	L2300_S19_CN102_CONTRCT_AMT
L2300	CN103	Contract Percentage	L2300_S19_CN103_CONTRCT_PERCNTG
L2300	CN104	Contract Code	L2300_S19_CN104_CONTRCT_CD
L2300	CN105	Terms Discount Percentage	L2300_S19_CN105_TERMS_DISCNT_PERCNTG
L2300	CN106	Contract Version Identifier	L2300_S19_CN106_VERSN_ID
L2300	AMT	Patient Amount Paid
L2300	AMT01	Amount Qualifier Code	L2300_S20_AMT01_QUAL_CD
L2300	AMT02	Patient Amount Paid	L2300_S20_AMT02_AMT_PD
L2300	REF	Service Authorization Exception Code
L2300	REF02	Special Payment Reference Number	L2300_S21_REF02_SVC_AUTH_EXCPTN_CD_OVL_SPECL_PMT_REF_NR
L2300	REF	Mandatory Medicare (Section 4081) Crossover Indicator
L2300	REF02	Medicare Version Code	L2300_S22_REF02_MEDCR_SECTN_4081_IND_OVL_MEDCR_VERSN_CD
L2300	REF	Mammography Certification Number
L2300	REF02	Mammography Certification Number	L2300_S23_REF02_CERT_NR_OVL_MAMGRPHY_CERT_NR
L2300	REF	Referral Number
L2300	REF02	Referral Number	L2300_S24_REF02_REFL_NR_OVL_REFL_NR
L2300	REF	Prior Authorization
L2300	REF02	Prior Authorization Number	L2300_S25_REF02_AUTH_NR_OVL_PRI_AUTH_NR
L2300	REF	Payer Claim Control Number
L2300	REF02	Original Reference Number	L2300_S26_REF02_PAYR_CLM_CONTRL_NR_OVL_ORGNL_REF_NR
L2300	REF	Clinical Laboratory Improvement Amendment (CLIA) Number
L2300	REF02	Clinical Laboratory Improvement Amendment Number	L2300_S27_REF02_CLINCL_LAB_OVL_CLINCL_LAB_NR
L2300	REF	Repriced Claim Number
L2300	REF02	Repriced Claim Reference Number	L2300_S28_REF02_REPRCD_CLM_REF_NR_OVL_REPRCD_CLM_REF_NR
L2300	REF	Adjusted Repriced Claim Number
L2300	REF02	Adjusted Repriced Claim Reference Number	L2300_S29_REF02_REF_NR_OVL_ADJSTD_REPRCD_CLM_REF_NR
L2300	REF	Investigational Device Exemption Number
L2300	REF02	Qualified Products List	L2300_S30_REF02_INVSTGTNL_DEVC_EXMPTN_ID_OVL_QUALFD_PRODCTS_LIST
L2300	REF	Claim Identifier For Transmission Intermediaries
L2300	REF02	Claim Number	L2300_S31_REF02_VAL_AD_NETWRK_TRAC_NR_OVL_CLM_NR
L2300	REF	Medical Record Number
L2300	REF02	Medical Record Identification Number	L2300_S32_REF02_RECRD_NR_OVL_MEDCL_RECRD_ID_NR
L2300	REF	Demonstration Project Identifier
L2300	REF02	Project Code	L2300_S33_REF02_PROJCT_ID_OVL_PROJCT_CD
L2300	REF	Care Plan Oversight
L2300	REF02	Facility ID Number	L2300_S34_REF02_CAR_PLAN_OVRSGHT_NR_OVL_FACLTY_ID_NR
L2300	K3	File Information
L2300	K301	Fixed Format Information	L2300_S35_K301_FIXD_FORMT_NFO
L2300	NTE	Claim Note
L2300	NTE02	Additional Information	L2300_S36_NTE02_NOT_TEXT_OVL_ADDL_NFO
L2300	NTE02	Certification Narrative	L2300_S36_NTE02_NOT_TEXT_OVL_CERT_NARTV
L2300	NTE02	Goals, Rehabilitation Potential, or Discharge Plans	L2300_S36_NTE02_NOT_TEXT_OVL_GOALS_REHBLTN_POTNTL_DISCHRG_PLANS
L2300	NTE02	Diagnosis Description	L2300_S36_NTE02_NOT_TEXT_OVL_DIAG_DESCRPTN
L2300	NTE02	Third Party Organization Notes	L2300_S36_NTE02_NOT_TEXT_OVL_3RD_PARTY_ORG_NOTS
L2300	CR1	Ambulance Transport Information
L2300	CR102	Pound	L2300_S37_CR102_PATNT_WEIGHT_OVL_POUND
L2300	CR104	Ambulance Transport Reason Code	L2300_S37_CR104_AMBLNC_TRANSPRT_RSN_CD
L2300	CR106	Miles	L2300_S37_CR106_TRANSPRT_DISTNC_OVL_MILS
L2300	CR109	Round Trip Purpose Description	L2300_S37_CR109_ROUND_TRIP_PURPS_DESCRPTN
L2300	CR110	Stretcher Purpose Description	L2300_S37_CR110_STRETCHR_PURPS_DESCRPTN
L2300	CR2	Spinal Manipulation Service Information
L2300	CR208	Patient Condition Code	L2300_S38_CR208_PATNT_CONDTN_CD
L2300	CR210	Patient Condition Description	L2300_S38_CR210_PATNT_CONDTN_DESCRPTN
L2300	CR211	Patient Condition Description	L2300_S38_CR211_PATNT_CONDTN_DESCRPTN
L2300	CRC	Ambulance Certification
L2300	CRC01	Code Category	L2300_S39_CRC01_CD_CATGRY
L2300	CRC02	Certification Condition Indicator	L2300_S39_CRC02_CERT_CONDTN_IND
L2300	CRC03	Condition Code	L2300_S39_CRC03_CONDTN_CD
L2300	CRC04	Condition Code	L2300_S39_CRC04_CONDTN_CD
L2300	CRC05	Condition Code	L2300_S39_CRC05_CONDTN_CD
L2300	CRC06	Condition Code	L2300_S39_CRC06_CONDTN_CD
L2300	CRC07	Condition Code	L2300_S39_CRC07_CONDTN_CD
L2300	CRC	Patient Condition Information: Vision
L2300	CRC01	Code Category	L2300_S40_CRC01_CD_CATGRY
L2300	CRC02	Certification Condition Indicator	L2300_S40_CRC02_CERT_CONDTN_IND
L2300	CRC03	Condition Code	L2300_S40_CRC03_CONDTN_CD
L2300	CRC04	Condition Code	L2300_S40_CRC04_CONDTN_CD
L2300	CRC05	Condition Code	L2300_S40_CRC05_CONDTN_CD
L2300	CRC06	Condition Code	L2300_S40_CRC06_CONDTN_CD
L2300	CRC07	Condition Code	L2300_S40_CRC07_CONDTN_CD
L2300	CRC	Homebound Indicator
L2300	CRC01	Code Category	L2300_S41_CRC01_CD_CATGRY
L2300	CRC02	Certification Condition Indicator	L2300_S41_CRC02_CERT_CONDTN_IND
L2300	CRC03	Homebound Indicator	L2300_S41_CRC03_HOMBND_IND
L2300	CRC	EPSDT Referral
L2300	CRC02	Mutually Defined	L2300_S42_CRC02_CERT_CONDTN_CD_APLS_IND_OVL_MUTLY_DEFND
L2300	CRC03	Condition Indicator	L2300_S42_CRC03_CONDTN_IND
L2300	CRC04	Condition Indicator	L2300_S42_CRC04_CONDTN_IND
L2300	CRC05	Condition Indicator	L2300_S42_CRC05_CONDTN_IND
L2300	HI	Health Care Diagnosis Code
L2300	HI01-02	International Classification of Diseases Clinical Modification (ICD-10-CM) Principal Diagnosis	L2300_S43_HI01_02_DIAG_CD_OVL_ICD10CM_PRINCPL_DIAG
L2300	HI01-02	International Classification of Diseases Clinical Modification (ICD-9-CM) Principal Diagnosis	L2300_S43_HI01_02_DIAG_CD_OVL_ICD9CM_PRINCPL_DIAG
L2300	HI02-02	International Classification of Diseases Clinical Modification (ICD-10-CM) Diagnosis	L2300_S43_HI02_02_DIAG_CD_OVL_ICD10CM_DIAG
L2300	HI02-02	International Classification of Diseases Clinical Modification (ICD-9-CM) Diagnosis	L2300_S43_HI02_02_DIAG_CD_OVL_ICD9CM_DIAG
L2300	HI03-02	International Classification of Diseases Clinical Modification (ICD-10-CM) Diagnosis	L2300_S43_HI03_02_DIAG_CD_OVL_ICD10CM_DIAG
L2300	HI03-02	International Classification of Diseases Clinical Modification (ICD-9-CM) Diagnosis	L2300_S43_HI03_02_DIAG_CD_OVL_ICD9CM_DIAG
L2300	HI04-02	International Classification of Diseases Clinical Modification (ICD-10-CM) Diagnosis	L2300_S43_HI04_02_DIAG_CD_OVL_ICD10CM_DIAG
L2300	HI04-02	International Classification of Diseases Clinical Modification (ICD-9-CM) Diagnosis	L2300_S43_HI04_02_DIAG_CD_OVL_ICD9CM_DIAG
L2300	HI05-02	International Classification of Diseases Clinical Modification (ICD-10-CM) Diagnosis	L2300_S43_HI05_02_DIAG_CD_OVL_ICD10CM_DIAG
L2300	HI05-02	International Classification of Diseases Clinical Modification (ICD-9-CM) Diagnosis	L2300_S43_HI05_02_DIAG_CD_OVL_ICD9CM_DIAG
L2300	HI06-02	International Classification of Diseases Clinical Modification (ICD-10-CM) Diagnosis	L2300_S43_HI06_02_DIAG_CD_OVL_ICD10CM_DIAG
L2300	HI06-02	International Classification of Diseases Clinical Modification (ICD-9-CM) Diagnosis	L2300_S43_HI06_02_DIAG_CD_OVL_ICD9CM_DIAG
L2300	HI07-02	International Classification of Diseases Clinical Modification (ICD-10-CM) Diagnosis	L2300_S43_HI07_02_DIAG_CD_OVL_ICD10CM_DIAG
L2300	HI07-02	International Classification of Diseases Clinical Modification (ICD-9-CM) Diagnosis	L2300_S43_HI07_02_DIAG_CD_OVL_ICD9CM_DIAG
L2300	HI08-02	International Classification of Diseases Clinical Modification (ICD-10-CM) Diagnosis	L2300_S43_HI08_02_DIAG_CD_OVL_ICD10CM_DIAG
L2300	HI08-02	International Classification of Diseases Clinical Modification (ICD-9-CM) Diagnosis	L2300_S43_HI08_02_DIAG_CD_OVL_ICD9CM_DIAG
L2300	HI09-02	International Classification of Diseases Clinical Modification (ICD-10-CM) Diagnosis	L2300_S43_HI09_02_DIAG_CD_OVL_ICD10CM_DIAG
L2300	HI09-02	International Classification of Diseases Clinical Modification (ICD-9-CM) Diagnosis	L2300_S43_HI09_02_DIAG_CD_OVL_ICD9CM_DIAG
L2300	HI10-02	International Classification of Diseases Clinical Modification (ICD-10-CM) Diagnosis	L2300_S43_HI10_02_DIAG_CD_OVL_ICD10CM_DIAG
L2300	HI10-02	International Classification of Diseases Clinical Modification (ICD-9-CM) Diagnosis	L2300_S43_HI10_02_DIAG_CD_OVL_ICD9CM_DIAG
L2300	HI11-02	International Classification of Diseases Clinical Modification (ICD-10-CM) Diagnosis	L2300_S43_HI11_02_DIAG_CD_OVL_ICD10CM_DIAG
L2300	HI11-02	International Classification of Diseases Clinical Modification (ICD-9-CM) Diagnosis	L2300_S43_HI11_02_DIAG_CD_OVL_ICD9CM_DIAG
L2300	HI12-02	International Classification of Diseases Clinical Modification (ICD-10-CM) Diagnosis	L2300_S43_HI12_02_DIAG_CD_OVL_ICD10CM_DIAG
L2300	HI12-02	International Classification of Diseases Clinical Modification (ICD-9-CM) Diagnosis	L2300_S43_HI12_02_DIAG_CD_OVL_ICD9CM_DIAG
L2300	HI	Anesthesia Related Procedure
L2300	HI01-02	Health Care Financing Administration Common	L2300_S44_HI01_02_ANSTHS_RELTD_SURGCL_PROCDR_OVL_HCFA_COMN
L2300	HI02-02	Health Care Financing Administration Common Procedural Coding System	L2300_S44_HI02_02_INDSTRY_CD_OVL_HCPCSTEM
L2300	HI	Condition Information
L2300	HI01-02	Condition	L2300_S45_HI01_02_CONDTN_CD_OVL_CONDTN
L2300	HI02-02	Condition	L2300_S45_HI02_02_CONDTN_CD_OVL_CONDTN
L2300	HI03-02	Condition	L2300_S45_HI03_02_CONDTN_CD_OVL_CONDTN
L2300	HI04-02	Condition	L2300_S45_HI04_02_CONDTN_CD_OVL_CONDTN
L2300	HI05-02	Condition	L2300_S45_HI05_02_CONDTN_CD_OVL_CONDTN
L2300	HI06-02	Condition	L2300_S45_HI06_02_CONDTN_CD_OVL_CONDTN
L2300	HI07-02	Condition	L2300_S45_HI07_02_CONDTN_CD_OVL_CONDTN
L2300	HI08-02	Condition	L2300_S45_HI08_02_CONDTN_CD_OVL_CONDTN
L2300	HI09-02	Condition	L2300_S45_HI09_02_CONDTN_CD_OVL_CONDTN
L2300	HI10-02	Condition	L2300_S45_HI10_02_CONDTN_CD_OVL_CONDTN
L2300	HI11-02	Condition	L2300_S45_HI11_02_CONDTN_CD_OVL_CONDTN
L2300	HI12-02	Condition	L2300_S45_HI12_02_CONDTN_CD_OVL_CONDTN
L2300	HCP	Claim Pricing/Repricing Information
L2300	HCP01	Pricing Methodology	L2300_S46_HCP01_PRICNG_METHDLGY
L2300	HCP02	Repriced Allowed Amount	L2300_S46_HCP02_REPRCD_ALWD_AMT
L2300	HCP03	Repriced Saving Amount	L2300_S46_HCP03_REPRCD_SAVNG_AMT
L2300	HCP04	Repricing Organization Identifier	L2300_S46_HCP04_REPRCNG_ORG_ID
L2300	HCP05	Repricing Per Diem or Flat Rate Amount	L2300_S46_HCP05_REPRCNG_DIEM_FLAT_RT_AMT
L2300	HCP06	Repriced Approved Ambulatory Patient Group	L2300_S46_HCP06_REPRCD_APRVD_AMBLTRY_PATNT_GROUP
L2300	HCP07	Repriced Approved Ambulatory Patient Group	L2300_S46_HCP07_REPRCD_APRVD_AMBLTRY_PATNT_GROUP
L2300	HCP13	Reject Reason Code	L2300_S46_HCP13_REJCT_RSN_CD
L2300	HCP14	Policy Compliance Code	L2300_S46_HCP14_POLCY_COMPLNC_CD
L2300	HCP15	Exception Code	L2300_S46_HCP15_EXCPTN_CD

2310A - REFERRING PROVIDER NAME

Loop	Segment	Segment Name	Chiapas Gate Mapping
2310A		Qualified Loop
L2310A		Referring Provider	L2310A_DN
L2310A		Primary Care Provider	L2310A_P3
L2310A	NM1	Referring Provider Name
L2310A	NM103	Person	L2310A_XX_S01_NM103_PROV_LNAME_OVL_PERSN
L2310A	NM104	Referring Provider First Name	L2310A_XX_S01_NM104_PROV_FNAME
L2310A	NM105	Referring Provider Middle Name or Initial	L2310A_XX_S01_NM105_REFNG_PROV_MNAME_INTL
L2310A	NM107	Referring Provider Name Suffix	L2310A_XX_S01_NM107_REFNG_PROV_NM_SUFX
L2310A	NM109	Centers for Medicare and Medicaid Services National Provider Identifier	L2310A_XX_S01_NM109_PROV_ID_OVL_MDCR_MDCD_SVCS_NATNL_PROV_ID
L2310A	REF	Referring Provider Secondary Identification
L2310A	REF02	State License Number	L2310A_XX_S02_REF02_REFNG_PROV_2ND_ID_OVL_STAT_LICNS_NR
L2310A	REF02	Provider UPIN Number	L2310A_XX_S02_REF02_REFNG_PROV_2ND_ID_OVL_PROV_UPN_NR
L2310A	REF02	Provider Commercial Number	L2310A_XX_S02_REF02_REFNG_PROV_2ND_ID_OVL_PROV_COMRCL_NR

2310B - RENDERING PROVIDER NAME

Loop	Segment	Segment Name	Chiapas Gate Mapping
L2310B	NM1	Rendering Provider Name
L2310B	NM103	Person	L2310B_S01_NM103_LAST_ORG_NM_OVL_PERSN
L2310B	NM103	Non-Person Entity	L2310B_S01_NM103_LAST_ORG_NM_OVL_NONPRSN_ENTY
L2310B	NM104	Rendering Provider First Name	L2310B_S01_NM104_PROV_FNAME
L2310B	NM105	Rendering Provider Middle Name or Initial	L2310B_S01_NM105_RENDRNG_PROV_MNAME_INTL
L2310B	NM107	Rendering Provider Name Suffix	L2310B_S01_NM107_RENDRNG_PROV_NM_SUFX
L2310B	NM109	Centers for Medicare and Medicaid Services National Provider Identifier	L2310B_S01_NM109_PROV_ID_OVL_MDCR_MDCD_SVCS_NATNL_PROV_ID
L2310B	PRV	Rendering Provider Specialty Information
L2310B	PRV01	Provider Code	L2310B_S02_PRV01_PROV_CD
L2310B	PRV03	Health Care Provider Taxonomy Code	L2310B_S02_PRV03_TAXNMY_CD_OVL_HLTHCR_PROV_TAXNMY_CD
L2310B	REF	Rendering Provider Secondary Identification
L2310B	REF02	State License Number	L2310B_S03_REF02_RENDRNG_PROV_2ND_ID_OVL_STAT_LICNS_NR
L2310B	REF02	Provider UPIN Number	L2310B_S03_REF02_RENDRNG_PROV_2ND_ID_OVL_PROV_UPN_NR
L2310B	REF02	Provider Commercial Number	L2310B_S03_REF02_RENDRNG_PROV_2ND_ID_OVL_PROV_COMRCL_NR
L2310B	REF02	Location Number	L2310B_S03_REF02_RENDRNG_PROV_2ND_ID_OVL_LOC_NR

2310C - SERVICE FACILITY LOCATION NAME

Loop	Segment	Segment Name	Chiapas Gate Mapping
L2310C	NM1	Service Facility Location Name
L2310C	NM103	Non-Person Entity	L2310C_S01_NM103_LAB_FACLTY_NM_OVL_NONPRSN_ENTY
L2310C	NM109	Centers for Medicare and Medicaid Services National Provider Identifier	L2310C_S01_NM109_LAB_FACLTY_PRIMRY_ID_OVL_MDCR_MDCD_SVCS_NATNL_PROV_ID
L2310C	N3	Service Facility Location Address
L2310C	N301	Laboratory or Facility Address Line	L2310C_S02_N301_LAB_FACLTY_ADRS_LIN
L2310C	N302	Laboratory or Facility Address Line	L2310C_S02_N302_LAB_FACLTY_ADRS_LIN
L2310C	N4	Service Facility Location City, State, ZIP Code
L2310C	N401	Laboratory or Facility City Name	L2310C_S03_N401_LAB_FACLTY_CITY_NM
L2310C	N402	Laboratory or Facility State or Province Code	L2310C_S03_N402_LAB_FACLTY_STAT_PROVNC_CD
L2310C	N403	Laboratory or Facility Postal Zone or ZIP Code	L2310C_S03_N403_LAB_FACLTY_POSTL_ZON_ZIP_CD
L2310C	N404	Country Code	L2310C_S03_N404_CNTRY_CD
L2310C	N407	Country Subdivision Code	L2310C_S03_N407_COUNTRY_SUBDVSN_CD
L2310C	REF	Service Facility Location Secondary Identification
L2310C	REF02	State License Number	L2310C_S04_REF02_LAB_FACLTY_2ND_ID_OVL_STAT_LICNS_NR
L2310C	REF02	Provider Commercial Number	L2310C_S04_REF02_LAB_FACLTY_2ND_ID_OVL_PROV_COMRCL_NR
L2310C	REF02	Location Number	L2310C_S04_REF02_LAB_FACLTY_2ND_ID_OVL_LOC_NR
L2310C	PER	Service Facility Contact Information
L2310C	PER01	Contact Function Code	L2310C_S05_PER01_FUNCTN_CD
L2310C	PER02	Name	L2310C_S05_PER02_NM
L2310C	PER04	Telephone	L2310C_S05_PER04_COMM_NR_OVL_TELPHN
L2310C	PER06	Telephone Extension	L2310C_S05_PER06_COMM_NR_OVL_PHN_EXTNS

2310D - SUPERVISING PROVIDER NAME

Loop	Segment	Segment Name	Chiapas Gate Mapping
L2310D	NM1	Supervising Provider Name
L2310D	NM103	Person	L2310D_S01_NM103_PROV_LNAME_OVL_PERSN
L2310D	NM104	Supervising Provider First Name	L2310D_S01_NM104_PROV_FNAME
L2310D	NM105	Supervising Provider Middle Name or Initial	L2310D_S01_NM105_SUPER_PROV_MNAME_INTL
L2310D	NM107	Supervising Provider Name Suffix	L2310D_S01_NM107_SUPER_PROV_NM_SUFX
L2310D	NM109	Centers for Medicare and Medicaid Services National Provider Identifier	L2310D_S01_NM109_PROV_ID_OVL_MDCR_MDCD_SVCS_NATNL_PROV_ID
L2310D	REF	Supervising Provider Secondary Identification
L2310D	REF02	State License Number	L2310D_S02_REF02_SUPER_PROV_2ND_ID_OVL_STAT_LICNS_NR
L2310D	REF02	Provider UPIN Number	L2310D_S02_REF02_SUPER_PROV_2ND_ID_OVL_PROV_UPN_NR
L2310D	REF02	Provider Commercial Number	L2310D_S02_REF02_SUPER_PROV_2ND_ID_OVL_PROV_COMRCL_NR
L2310D	REF02	Location Number	L2310D_S02_REF02_SUPER_PROV_2ND_ID_OVL_LOC_NR

2310E - AMBULANCE PICK-UP LOCATION

Loop	Segment	Segment Name	Chiapas Gate Mapping
L2310E	NM1	Ambulance Pick-up Location
L2310E	NM102	Entity Type Qualifier	L2310E_S01_NM102_ENTY_TYPE_QUAL
L2310E	N3	Ambulance Pick-up Location Address
L2310E	N301	Ambulance Pick-up Address Line	L2310E_S02_N301_AMBLNC_PICKP_ADRS_LIN
L2310E	N302	Ambulance Pick-up Address Line	L2310E_S02_N302_AMBLNC_PICKP_ADRS_LIN
L2310E	N4	Ambulance Pick-up Location City, State, ZIP Code
L2310E	N401	Ambulance Pick-up City Name	L2310E_S03_N401_AMBLNC_PICKP_CITY_NM
L2310E	N402	Ambulance Pick-up State or Province Code	L2310E_S03_N402_STAT_PROVNC_CD
L2310E	N403	Ambulance Pick-up Postal Zone or ZIP Code	L2310E_S03_N403_POSTL_ZON_ZIP_CD
L2310E	N404	Country Code	L2310E_S03_N404_CNTRY_CD
L2310E	N407	Country Subdivision Code	L2310E_S03_N407_COUNTRY_SUBDVSN_CD

2310F - AMBULANCE DROP-OFF LOCATION

Loop	Segment	Segment Name	Chiapas Gate Mapping
L2310F	NM1	Ambulance Drop-off Location
L2310F	NM102	Entity Type Qualifier	L2310F_S01_NM102_ENTY_TYPE_QUAL
L2310F	NM103	Ambulance Drop-off Location	L2310F_S01_NM103_DRPOFF_LOC
L2310F	N3	Ambulance Drop-off Location Address
L2310F	N301	Ambulance Drop-off Address Line	L2310F_S02_N301_AMBLNC_DRPOFF_ADRS_LIN
L2310F	N302	Ambulance Drop-off Address Line	L2310F_S02_N302_AMBLNC_DRPOFF_ADRS_LIN
L2310F	N4	Ambulance Drop-off Location City, State, ZIP Code
L2310F	N401	Ambulance Drop-off City Name	L2310F_S03_N401_AMBLNC_DRPOFF_CITY_NM
L2310F	N402	Ambulance Drop-off State or Province Code	L2310F_S03_N402_STAT_PROVNC_CD
L2310F	N403	Ambulance Drop-off Postal Zone or ZIP Code	L2310F_S03_N403_POSTL_ZON_ZIP_CD
L2310F	N404	Country Code	L2310F_S03_N404_CNTRY_CD
L2310F	N407	Country Subdivision Code	L2310F_S03_N407_COUNTRY_SUBDVSN_CD

2320 - OTHER SUBSCRIBER INFORMATION

Loop	Segment	Segment Name	Chiapas Gate Mapping
L2320	SBR	Other Subscriber Information
L2320	SBR01	Payer Responsibility Sequence Number Code	L2320_S01_SBR01_PAYR_RESP_SEQNC_NR_CD
L2320	SBR02	Individual Relationship Code	L2320_S01_SBR02_INDVDL_REL_CD
L2320	SBR03	Insured Group or Policy Number	L2320_S01_SBR03_INSRD_GRP_POLCY_NR
L2320	SBR04	Other Insured Group Name	L2320_S01_SBR04_OTHR_INSRD_GRP_NM
L2320	SBR05	Insurance Type Code	L2320_S01_SBR05_INS_TYPE_CD
L2320	SBR09	Claim Filing Indicator Code	L2320_S01_SBR09_CLM_FILNG_IND_CD
L2320	CAS	Claim Level Adjustments
L2320	CAS01	Claim Adjustment Group Code	L2320_S02_CAS01_CLM_ADJ_GRP_CD
L2320	CAS02	Adjustment Reason Code	L2320_S02_CAS02_RSN_CD
L2320	CAS03	Adjustment Amount	L2320_S02_CAS03_ADJ_AMT
L2320	CAS04	Adjustment Quantity	L2320_S02_CAS04_ADJ_QTY
L2320	CAS05	Adjustment Reason Code	L2320_S02_CAS05_RSN_CD
L2320	CAS06	Adjustment Amount	L2320_S02_CAS06_ADJ_AMT
L2320	CAS07	Adjustment Quantity	L2320_S02_CAS07_ADJ_QTY
L2320	CAS08	Adjustment Reason Code	L2320_S02_CAS08_RSN_CD
L2320	CAS09	Adjustment Amount	L2320_S02_CAS09_ADJ_AMT
L2320	CAS10	Adjustment Quantity	L2320_S02_CAS10_ADJ_QTY
L2320	CAS11	Adjustment Reason Code	L2320_S02_CAS11_RSN_CD
L2320	CAS12	Adjustment Amount	L2320_S02_CAS12_ADJ_AMT
L2320	CAS13	Adjustment Quantity	L2320_S02_CAS13_ADJ_QTY
L2320	CAS14	Adjustment Reason Code	L2320_S02_CAS14_RSN_CD
L2320	CAS15	Adjustment Amount	L2320_S02_CAS15_ADJ_AMT
L2320	CAS16	Adjustment Quantity	L2320_S02_CAS16_ADJ_QTY
L2320	CAS17	Adjustment Reason Code	L2320_S02_CAS17_RSN_CD
L2320	CAS18	Adjustment Amount	L2320_S02_CAS18_ADJ_AMT
L2320	CAS19	Adjustment Quantity	L2320_S02_CAS19_ADJ_QTY
L2320	AMT	Coordination of Benefits (COB) Payer Paid Amount
L2320	AMT02	Payor Amount Paid	L2320_S03_AMT02_PD_AMT_OVL_PAYR_AMT_PAID
L2320	AMT	Coordination of Benefits (COB) Total Non-Covered Amount
L2320	AMT02	Noncovered Charges - Actual	L2320_S04_AMT02_CHG_AMT_OVL_NONCVRD_CHGS_ACTL
L2320	AMT	Remaining Patient Liability
L2320	AMT01	Amount Qualifier Code	L2320_S05_AMT01_AMT_QUAL_CD
L2320	AMT02	Remaining Patient Liability	L2320_S05_AMT02_PATNT_LIABLTY
L2320	OI	Other Insurance Coverage Information
L2320	OI03	Benefits Assignment Certification Indicator	L2320_S06_OI03_BENFTS_ASGNMNT_CERT_IND
L2320	OI04	Patient Signature Source Code	L2320_S06_OI04_PATNT_SIGNTR_SOURC_CD
L2320	OI06	Release of Information Code	L2320_S06_OI06_RELS_NFO_CD
L2320	MOA	Outpatient Adjudication Information
L2320	MOA01	Reimbursement Rate	L2320_S07_MOA01_REIMBRSMNT_RAT
L2320	MOA02	HCPCS Payable Amount	L2320_S07_MOA02_HCPCS_PAYBL_AMT
L2320	MOA03	Claim Payment Remark Code	L2320_S07_MOA03_CLM_PMT_REMRK_CD
L2320	MOA04	Claim Payment Remark Code	L2320_S07_MOA04_CLM_PMT_REMRK_CD
L2320	MOA05	Claim Payment Remark Code	L2320_S07_MOA05_CLM_PMT_REMRK_CD
L2320	MOA06	Claim Payment Remark Code	L2320_S07_MOA06_CLM_PMT_REMRK_CD
L2320	MOA07	Claim Payment Remark Code	L2320_S07_MOA07_CLM_PMT_REMRK_CD
L2320	MOA08	End Stage Renal Disease Payment Amount	L2320_S07_MOA08_END_STAG_RENL_DIS_PMT_AMT
L2320	MOA09	Non-Payable Professional Component Billed	L2320_S07_MOA09_NONPYBL_PROF_COMPNT_BILD

2330A - OTHER SUBSCRIBER NAME

Loop	Segment	Segment Name	Chiapas Gate Mapping
L2330A	NM1	Other Subscriber Name
L2330A	NM103	Person	L2330A_S01_NM103_INSRD_LNAME_OVL_PERSN
L2330A	NM103	Non-Person Entity	L2330A_S01_NM103_INSRD_LNAME_OVL_NONPRSN_ENTY
L2330A	NM104	Other Insured First Name	L2330A_S01_NM104_INSRD_FNAME
L2330A	NM105	Other Insured Middle Name	L2330A_S01_NM105_INSRD_MNAME
L2330A	NM107	Other Insured Name Suffix	L2330A_S01_NM107_OTHR_INSRD_NM_SUFX
L2330A	NM109	Standard Unique Health Identifier for each Individual in the United States	L2330A_S01_NM109_INSRD_ID_OVL_STANDRD_UNQ_HEALTH_ID
L2330A	NM109	Member Identification Number	L2330A_S01_NM109_INSRD_ID_OVL_MEM_ID_NR
L2330A	N3	Other Subscriber Address
L2330A	N301	Other Subscriber Address Line	L2330A_S02_N301_OTHR_SUB_ADRS_LIN
L2330A	N302	Other Insured Address Line	L2330A_S02_N302_OTHR_INSRD_ADRS_LIN
L2330A	N4	Other Subscriber City, State, ZIP Code
L2330A	N401	Other Subscriber City Name	L2330A_S03_N401_OTHR_SUB_CITY_NM
L2330A	N402	Other Subscriber State or Province Code	L2330A_S03_N402_STAT_PROVNC_CD
L2330A	N403	Other Subscriber Postal Zone or ZIP Code	L2330A_S03_N403_POSTL_ZON_ZIP_CD
L2330A	N404	Country Code	L2330A_S03_N404_CNTRY_CD
L2330A	N407	Country Subdivision Code	L2330A_S03_N407_COUNTRY_SUBDVSN_CD
L2330A	REF	Other Subscriber Secondary Identification
L2330A	REF02	Social Security Number	L2330A_S04_REF02_OTHR_INSRD_ADDL_ID_OVL_SSN

2330B - OTHER PAYER NAME

Loop	Segment	Segment Name	Chiapas Gate Mapping
L2330B	NM1	Other Payer Name
L2330B	NM103	Non-Person Entity	L2330B_S01_NM103_OTHR_PAYR_ORG_NM_OVL_NONPRSN_ENTY
L2330B	NM109	Payor Identification	L2330B_S01_NM109_OTHR_PAYR_PRIMRY_ID_OVL_PAYR_ID
L2330B	NM109	Centers for Medicare and Medicaid Services PlanID	L2330B_S01_NM109_OTHR_PAYR_PRIMRY_ID_OVL_MDCR_MDCD_SVCS_PLAND
L2330B	N3	Other Payer Address
L2330B	N301	Other Payer Address Line	L2330B_S02_N301_OTHR_PAYR_ADRS_LIN
L2330B	N302	Other Payer Address Line	L2330B_S02_N302_OTHR_PAYR_ADRS_LIN
L2330B	N4	Other Payer City, State, ZIP Code
L2330B	N401	Other Payer City Name	L2330B_S03_N401_OTHR_PAYR_CITY_NM
L2330B	N402	Other Payer State or Province Code	L2330B_S03_N402_STAT_PROVNC_CD
L2330B	N403	Other Payer Postal Zone or ZIP Code	L2330B_S03_N403_POSTL_ZON_ZIP_CD
L2330B	N404	Country Code	L2330B_S03_N404_CNTRY_CD
L2330B	N407	Country Subdivision Code	L2330B_S03_N407_COUNTRY_SUBDVSN_CD
L2330B	DTP	Claim Check or Remittance Date
L2330B	DTP03	Date Claim Paid (D8)	L2330B_S04_DTP03_ADJDCTN_PMT_DT_OVL_DAT_CLM_PAID_D8
L2330B	REF	Other Payer Secondary Identifier
L2330B	REF02	Payer Identification Number	L2330B_S05_REF02_OTHR_PAYR_2ND_ID_OVL_PAYR_ID_NR
L2330B	REF02	Employer’s Identification Number	L2330B_S05_REF02_OTHR_PAYR_2ND_ID_OVL_EMPLYR_ID_NR
L2330B	REF02	Claim Office Number	L2330B_S05_REF02_OTHR_PAYR_2ND_ID_OVL_CLM_OFC_NR
L2330B	REF02	National Association of Insurance Commissioners (NAIC) Code	L2330B_S05_REF02_OTHR_PAYR_2ND_ID_OVL_NAIC_CD
L2330B	REF	Other Payer Prior Authorization Number
L2330B	REF02	Prior Authorization Number	L2330B_S06_REF02_AUTH_NR_OVL_PRI_AUTH_NR
L2330B	REF	Other Payer Referral Number
L2330B	REF02	Referral Number	L2330B_S07_REF02_PRI_AUTH_REFL_OVL_REFL_NR
L2330B	REF	Other Payer Claim Adjustment Indicator
L2330B	REF02	Signal Code	L2330B_S08_REF02_IND_OVL_SIGNL_CD
L2330B	REF	Other Payer Claim Control Number
L2330B	REF02	Original Reference Number	L2330B_S09_REF02_NR_OVL_ORGNL_REF_NR

2330C - OTHER PAYER REFERRING PROVIDER

Loop	Segment	Segment Name	Chiapas Gate Mapping
2330C		Qualified Loop
L2330C		Referring Provider	L2330C_DN
L2330C		Primary Care Provider	L2330C_P3
L2330C	NM1	Other Payer Referring Provider
L2330C	NM102	Entity Type Qualifier	L2330C_XX_S01_NM102_ENTY_TYPE_QUAL
L2330C	REF	Other Payer Referring Provider Secondary Identification
L2330C	REF02	State License Number	L2330C_XX_S02_REF02_ID_OVL_STAT_LICNS_NR
L2330C	REF02	Provider UPIN Number	L2330C_XX_S02_REF02_ID_OVL_PROV_UPN_NR
L2330C	REF02	Provider Commercial Number	L2330C_XX_S02_REF02_ID_OVL_PROV_COMRCL_NR

2330D - OTHER PAYER RENDERING PROVIDER

Loop	Segment	Segment Name	Chiapas Gate Mapping
L2330D	NM1	Other Payer Rendering Provider
L2330D	NM102	Entity Type Qualifier	L2330D_S01_NM102_ENTY_TYPE_QUAL
L2330D	REF	Other Payer Rendering Provider Secondary Identification
L2330D	REF02	State License Number	L2330D_S02_REF02_2ND_OVL_STAT_LICNS_NR
L2330D	REF02	Provider UPIN Number	L2330D_S02_REF02_2ND_OVL_PROV_UPN_NR
L2330D	REF02	Provider Commercial Number	L2330D_S02_REF02_2ND_OVL_PROV_COMRCL_NR
L2330D	REF02	Location Number	L2330D_S02_REF02_2ND_OVL_LOC_NR

2330E - OTHER PAYER SERVICE FACILITY LOCATION

Loop	Segment	Segment Name	Chiapas Gate Mapping
L2330E	NM1	Other Payer Service Facility Location
L2330E	NM102	Entity Type Qualifier	L2330E_S01_NM102_ENTY_TYPE_QUAL
L2330E	REF	Other Payer Service Facility Location Secondary Identification
L2330E	REF02	State License Number	L2330E_S02_REF02_LOC_2ND_OVL_STAT_LICNS_NR
L2330E	REF02	Provider Commercial Number	L2330E_S02_REF02_LOC_2ND_OVL_PROV_COMRCL_NR
L2330E	REF02	Location Number	L2330E_S02_REF02_LOC_2ND_OVL_LOC_NR

2330F - OTHER PAYER SUPERVISING PROVIDER

Loop	Segment	Segment Name	Chiapas Gate Mapping
L2330F	NM1	Other Payer Supervising Provider
L2330F	NM102	Entity Type Qualifier	L2330F_S01_NM102_ENTY_TYPE_QUAL
L2330F	REF	Other Payer Supervising Provider Secondary Identification
L2330F	REF02	State License Number	L2330F_S02_REF02_ID_OVL_STAT_LICNS_NR
L2330F	REF02	Provider UPIN Number	L2330F_S02_REF02_ID_OVL_PROV_UPN_NR
L2330F	REF02	Provider Commercial Number	L2330F_S02_REF02_ID_OVL_PROV_COMRCL_NR
L2330F	REF02	Location Number	L2330F_S02_REF02_ID_OVL_LOC_NR

2330G - OTHER PAYER BILLING PROVIDER

Loop	Segment	Segment Name	Chiapas Gate Mapping
L2330G	NM1	Other Payer Billing Provider
L2330G	NM102	Entity Type Qualifier	L2330G_S01_NM102_ENTY_TYPE_QUAL
L2330G	REF	Other Payer Billing Provider Secondary Identification
L2330G	REF02	Provider Commercial Number	L2330G_S02_REF02_ID_OVL_PROV_COMRCL_NR
L2330G	REF02	Location Number	L2330G_S02_REF02_ID_OVL_LOC_NR

2400 - SERVICE LINE NUMBER

Loop	Segment	Segment Name	Chiapas Gate Mapping
L2400	LX	Service Line Number
L2400	LX01	Assigned Number	L2400_S01_LX01_ASGND_NR
L2400	SV1	Professional Service
L2400	SV101-02	Jurisdiction Specific Procedure and Supply Codes	L2400_S02_SV101_02_PROC_CD_OVL_JURSDCTN_SPECFC_PROC_SUPLY_CD
L2400	SV101-02	Health Care Financing Administration Common Procedural Coding System (HCPCS) Codes	L2400_S02_SV101_02_PROC_CD_OVL_HCPCS_CD
L2400	SV101-02	Home Infusion EDI Coalition (HIEC) Product/Service Code	L2400_S02_SV101_02_PROC_CD_OVL_HIEC_PRODCT_SRVC_CD
L2400	SV101-02	Advanced Billing Concepts (ABC) Codes	L2400_S02_SV101_02_PROC_CD_OVL_ABC_CD
L2400	SV101-03	Procedure Modifier	L2400_S02_SV101_03_PROC_MODFR
L2400	SV101-04	Procedure Modifier	L2400_S02_SV101_04_PROC_MODFR
L2400	SV101-05	Procedure Modifier	L2400_S02_SV101_05_PROC_MODFR
L2400	SV101-06	Procedure Modifier	L2400_S02_SV101_06_PROC_MODFR
L2400	SV101-07	Description	L2400_S02_SV101_07_DESCRPTN
L2400	SV102	Line Item Charge Amount	L2400_S02_SV102_LIN_ITM_CHG_AMT
L2400	SV104	Minutes	L2400_S02_SV104_SVC_UNT_CT_OVL_MINTS
L2400	SV104	Unit	L2400_S02_SV104_SVC_UNT_CT_OVL_UNT
L2400	SV105	Place of Service Code	L2400_S02_SV105_PLAC_SVC_CD
L2400	SV107-01	Diagnosis Code Pointer	L2400_S02_SV107_01_DIAG_CD_POINTR
L2400	SV107-02	Diagnosis Code Pointer	L2400_S02_SV107_02_DIAG_CD_POINTR
L2400	SV107-03	Diagnosis Code Pointer	L2400_S02_SV107_03_DIAG_CD_POINTR
L2400	SV107-04	Diagnosis Code Pointer	L2400_S02_SV107_04_DIAG_CD_POINTR
L2400	SV109	Emergency Indicator	L2400_S02_SV109_EMRGNCY_IND
L2400	SV111	EPSDT Indicator	L2400_S02_SV111_EPSDT_IND
L2400	SV112	Family Planning Indicator	L2400_S02_SV112_FAMLY_PLANG_IND
L2400	SV115	Co-Pay Status Code	L2400_S02_SV115_COPY_STATS_CD
L2400	SV5	Durable Medical Equipment Service
L2400	SV501-01	Procedure Identifier	L2400_S03_SV501_01_PROC_ID
L2400	SV501-02	Procedure Code	L2400_S03_SV501_02_PROC_CD
L2400	SV503	Days	L2400_S03_SV503_LENGTH_MEDCL_NECSTY_OVL_DAYS
L2400	SV504	DME Rental Price	L2400_S03_SV504_RENTL_PRIC
L2400	SV505	DME Purchase Price	L2400_S03_SV505_PURCHS_PRIC
L2400	SV506	Rental Unit Price Indicator	L2400_S03_SV506_RENTL_UNT_PRIC_IND
L2400	PWK	Line Supplemental Information
L2400	PWK01	Attachment Report Type Code	L2400_S04_PWK01_ATCHMNT_REPRT_TYPE_CD
L2400	PWK02	Attachment Transmission Code	L2400_S04_PWK02_ATCHMNT_TRANSMSN_CD
L2400	PWK06	Attachment Control Number	L2400_S04_PWK06_ATCHMNT_CONTRL_NR_OVL_ATCHMNT_CONTRL_NR
L2400	PWK	Durable Medical Equipment Certificate of Medical Necessity Indicator
L2400	PWK01	Attachment Report Type Code	L2400_S05_PWK01_ATCHMNT_REPRT_TYPE_CD
L2400	PWK02	Attachment Transmission Code	L2400_S05_PWK02_ATCHMNT_TRANSMSN_CD
L2400	CR1	Ambulance Transport Information
L2400	CR102	Pound	L2400_S06_CR102_PATNT_WEIGHT_OVL_POUND
L2400	CR104	Ambulance Transport Reason Code	L2400_S06_CR104_AMBLNC_TRANSPRT_RSN_CD
L2400	CR106	Miles	L2400_S06_CR106_TRANSPRT_DISTNC_OVL_MILS
L2400	CR109	Round Trip Purpose Description	L2400_S06_CR109_ROUND_TRIP_PURPS_DESCRPTN
L2400	CR110	Stretcher Purpose Description	L2400_S06_CR110_STRETCHR_PURPS_DESCRPTN
L2400	CR3	Durable Medical Equipment Certification
L2400	CR301	Certification Type Code	L2400_S07_CR301_CERT_TYPE_CD
L2400	CR303	Months	L2400_S07_CR303_DURBL_MEDCL_EQPMNT_DURTN_OVL_MONTHS
L2400	CRC	Ambulance Certification
L2400	CRC01	Code Category	L2400_S08_CRC01_CD_CATGRY
L2400	CRC02	Certification Condition Indicator	L2400_S08_CRC02_CERT_CONDTN_IND
L2400	CRC03	Condition Code	L2400_S08_CRC03_CONDTN_CD
L2400	CRC04	Condition Code	L2400_S08_CRC04_CONDTN_CD
L2400	CRC05	Condition Code	L2400_S08_CRC05_CONDTN_CD
L2400	CRC06	Condition Code	L2400_S08_CRC06_CONDTN_CD
L2400	CRC07	Condition Code	L2400_S08_CRC07_CONDTN_CD
L2400	CRC	Hospice Employee Indicator
L2400	CRC01	Code Category	L2400_S09_CRC01_CD_CATGRY
L2400	CRC02	Hospice Employed Provider Indicator	L2400_S09_CRC02_HOSPC_EMPLYD_PROV_IND
L2400	CRC03	Condition Indicator	L2400_S09_CRC03_CONDTN_IND
L2400	CRC	Condition Indicator/Durable Medical Equipment
L2400	CRC01	Code Category	L2400_S10_CRC01_CD_CATGRY
L2400	CRC02	Certification Condition Indicator	L2400_S10_CRC02_CERT_CONDTN_IND
L2400	CRC03	Condition Indicator	L2400_S10_CRC03_CONDTN_IND
L2400	CRC04	Condition Indicator	L2400_S10_CRC04_CONDTN_IND
L2400	DTP	Date - Service Date
L2400	DTP03	Service (D8)	L2400_S11_DTP03_SVC_DT_OVL_SVC_D8
L2400	DTP03	Service (RD8)	L2400_S11_DTP03_SVC_DT_OVL_SVC_RD8
L2400	DTP	Date - Prescription Date
L2400	DTP03	Prescription (D8)	L2400_S12_DTP03_RX_DT_OVL_RX_D8
L2400	DTP	DATE - Certification Revision/Recertification Date
L2400	DTP03	Certification Revision (D8)	L2400_S13_DTP03_CERT_REVSN_RECRTFCTN_DT_OVL_CERT_REVSN_D8
L2400	DTP	Date - Begin Therapy Date
L2400	DTP03	Begin Therapy (D8)	L2400_S14_DTP03_THERPY_DT_OVL_BEGN_THERPY_D8
L2400	DTP	Date - Last Certification Date
L2400	DTP03	Last Certification (D8)	L2400_S15_DTP03_CERT_DT_OVL_LAST_CERT_D8
L2400	DTP	Date - Last Seen Date
L2400	DTP03	Latest Visit or Consultation (D8)	L2400_S16_DTP03_TREATMNT_THERPY_DT_OVL_LATST_VIST_CONSLTN_D8
L2400	DTP	Date - Test Date
L2400	DTP03	Most Recent Hemoglobin or Hematocrit or Both (D8)	L2400_S17_DTP03_PERFRMD_DT_OVL_MOST_RECNT_HEMGLBN_HEMTCRT_BOTH_D8
L2400	DTP03	Most Recent Serum Creatine (D8)	L2400_S17_DTP03_PERFRMD_DT_OVL_MOST_RECNT_SERM_CREATN_D8
L2400	DTP	Date - Shipped Date
L2400	DTP03	Shipped (D8)	L2400_S18_DTP03_SHIPD_DT_OVL_SHIPD_D8
L2400	DTP	Date - Last X-ray Date
L2400	DTP03	Last X-Ray (D8)	L2400_S19_DTP03_XRAY_DT_OVL_LAST_XRAY_D8
L2400	DTP	Date - Initial Treatment Date
L2400	DTP03	Initial Treatment (D8)	L2400_S20_DTP03_TREATMNT_DT_OVL_INTL_TREATMNT_D8
L2400	QTY	Ambulance Patient Count
L2400	QTY02	Patients	L2400_S21_QTY02_PATNT_CT_OVL_PATNTS
L2400	QTY	Obstetric Anesthesia Additional Units
L2400	QTY02	Units	L2400_S22_QTY02_ADDL_UNTS_OVL_UNTS
L2400	MEA	Test Result
L2400	MEA01	Measurement Reference Identification Code	L2400_S23_MEA01_MEASRMNT_REF_ID_CD
L2400	MEA03	Height	L2400_S23_MEA03_TEST_RESLTS_OVL_HEIGHT
L2400	MEA03	Hemoglobin	L2400_S23_MEA03_TEST_RESLTS_OVL_HEMGLBN
L2400	MEA03	Hematocrit	L2400_S23_MEA03_TEST_RESLTS_OVL_HEMTCRT
L2400	MEA03	Epoetin Starting Dosage	L2400_S23_MEA03_TEST_RESLTS_OVL_EPTN_STARTNG_DOSG
L2400	MEA03	Creatinine	L2400_S23_MEA03_TEST_RESLTS_OVL_CREATN
L2400	CN1	Contract Information
L2400	CN101	Contract Type Code	L2400_S24_CN101_TYPE_CD
L2400	CN102	Contract Amount	L2400_S24_CN102_CONTRCT_AMT
L2400	CN103	Contract Percentage	L2400_S24_CN103_CONTRCT_PERCNTG
L2400	CN104	Contract Code	L2400_S24_CN104_CONTRCT_CD
L2400	CN105	Terms Discount Percentage	L2400_S24_CN105_TERMS_DISCNT_PERCNTG
L2400	CN106	Contract Version Identifier	L2400_S24_CN106_VERSN_ID
L2400	REF	Repriced Line Item Reference Number
L2400	REF02	Repriced Line Item Reference Number	L2400_S25_REF02_NR_OVL_REPRCD_LIN_ITM_REF_NR
L2400	REF	Adjusted Repriced Line Item Reference Number
L2400	REF02	Adjusted Repriced Line Item Reference Number	L2400_S26_REF02_REF_NR_OVL_ADJSTD_REPRCD_LIN_ITM_REF_NR
L2400	REF	Prior Authorization
L2400	REF02	Prior Authorization Number	L2400_S27_REF02_PRI_AUTH_REFL_NR_OVL_PRI_AUTH_NR
L2400	REF04-02	Payer Identification Number	L2400_S27_REF04_02_OTHR_PAYR_PRIMRY_ID_OVL_PAYR_ID_NR
L2400	REF	Line Item Control Number
L2400	REF02	Provider Control Number	L2400_S28_REF02_LIN_ITM_CONTRL_NR_OVL_PROV_CONTRL_NR
L2400	REF	Mammography Certification Number
L2400	REF02	Mammography Certification Number	L2400_S29_REF02_CERT_NR_OVL_MAMGRPHY_CERT_NR
L2400	REF	Clinical Laboratory Improvement Amendment (CLIA) Number
L2400	REF02	Clinical Laboratory Improvement Amendment Number	L2400_S30_REF02_CLINCL_LAB_OVL_CLINCL_LAB_NR
L2400	REF	Referring Clinical Laboratory Improvement Amendment (CLIA) Facility Identification
L2400	REF02	Facility Certification Number	L2400_S31_REF02_CLIA_NR_OVL_FACLTY_CERT_NR
L2400	REF	Immunization Batch Number
L2400	REF02	Batch Number	L2400_S32_REF02_BATCH_NR_OVL_BATCH_NR
L2400	REF	Referral Number
L2400	REF02	Referral Number	L2400_S33_REF02_REFL_NR_OVL_REFL_NR
L2400	REF04-02	Payer Identification Number	L2400_S33_REF04_02_OTHR_PAYR_PRIMRY_ID_OVL_PAYR_ID_NR
L2400	AMT	Sales Tax Amount
L2400	AMT02	Tax	L2400_S34_AMT02_TAX_AMT_OVL_TAX
L2400	AMT	Postage Claimed Amount
L2400	AMT02	Postage Claimed	L2400_S35_AMT02_CLAIMD_AMT_OVL_POSTG_CLMD
L2400	K3	File Information
L2400	K301	Fixed Format Information	L2400_S36_K301_FIXD_FORMT_NFO
L2400	NTE	Line Note
L2400	NTE02	Additional Information	L2400_S37_NTE02_NOT_TEXT_OVL_ADDL_NFO
L2400	NTE02	Goals, Rehabilitation Potential, or Discharge Plans	L2400_S37_NTE02_NOT_TEXT_OVL_GOALS_REHBLTN_POTNTL_DISCHRG_PLANS
L2400	NTE	Third Party Organization Notes
L2400	NTE02	Third Party Organization Notes	L2400_S38_NTE02_LIN_NOT_TEXT_OVL_3RD_PARTY_ORG_NOTS
L2400	PS1	Purchased Service Information
L2400	PS101	Purchased Service Provider Identifier	L2400_S39_PS101_PURCHSD_SVC_PROV_ID
L2400	PS102	Purchased Service Charge Amount	L2400_S39_PS102_PURCHSD_SVC_CHG_AMT
L2400	HCP	Line Pricing/Repricing Information
L2400	HCP01	Pricing Methodology	L2400_S40_HCP01_PRICNG_METHDLGY
L2400	HCP02	Repriced Allowed Amount	L2400_S40_HCP02_REPRCD_ALWD_AMT
L2400	HCP03	Repriced Saving Amount	L2400_S40_HCP03_REPRCD_SAVNG_AMT
L2400	HCP04	Repricing Organization Identifier	L2400_S40_HCP04_REPRCNG_ORG_ID
L2400	HCP05	Repricing Per Diem or Flat Rate Amount	L2400_S40_HCP05_REPRCNG_DIEM_FLAT_RT_AMT
L2400	HCP06	Repriced Approved Ambulatory Patient Group	L2400_S40_HCP06_REPRCD_APRVD_AMBLTRY_PATNT_GROUP
L2400	HCP07	Repriced Approved Ambulatory Patient Group	L2400_S40_HCP07_REPRCD_APRVD_AMBLTRY_PATNT_GROUP
L2400	HCP10	Jurisdiction Specific Procedure and Supply Codes	L2400_S40_HCP10_REPRCD_APRVD_HCPCS_CD_OVL_JURSDCTN_SPECFC_PROC_SUPLY_CD
L2400	HCP10	Health Care Financing Administration Common Procedural Coding System (HCPCS) Codes	L2400_S40_HCP10_REPRCD_APRVD_HCPCS_CD_OVL_HCPCS_CD
L2400	HCP10	Home Infusion EDI Coalition (HIEC) Product/Service Code	L2400_S40_HCP10_REPRCD_APRVD_HCPCS_CD_OVL_HIEC_PRODCT_SRVC_CD
L2400	HCP10	Advanced Billing Concepts (ABC) Codes	L2400_S40_HCP10_REPRCD_APRVD_HCPCS_CD_OVL_ABC_CD
L2400	HCP12	Minutes	L2400_S40_HCP12_REPRCD_APRVD_SVC_UNT_CT_OVL_MINTS
L2400	HCP12	Unit	L2400_S40_HCP12_REPRCD_APRVD_SVC_UNT_CT_OVL_UNT
L2400	HCP13	Reject Reason Code	L2400_S40_HCP13_REJCT_RSN_CD
L2400	HCP14	Policy Compliance Code	L2400_S40_HCP14_POLCY_COMPLNC_CD
L2400	HCP15	Exception Code	L2400_S40_HCP15_EXCPTN_CD

2410 - DRUG IDENTIFICATION

Loop	Segment	Segment Name	Chiapas Gate Mapping
L2410	LIN	Drug Identification
L2410	LIN03	National Drug Code in 5-4-2 Format	L2410_S01_LIN03_NATNL_DRUG_CD_OVL_NDC_542_FORMT
L2410	CTP	Drug Quantity
L2410	CTP04	National Drug Unit Count	L2410_S02_CTP04_NATNL_DRUG_UNT_CT
L2410	CTP05-01	Code Qualifier	L2410_S02_CTP05_01_CD_QUAL
L2410	REF	Prescription or Compound Drug Association Number
L2410	REF02	Link Sequence Number	L2410_S03_REF02_RX_NR_OVL_LINK_SEQNC_NR
L2410	REF02	Pharmacy Prescription Number	L2410_S03_REF02_RX_NR_OVL_PHARMCY_RX_NR

2420A - RENDERING PROVIDER NAME

Loop	Segment	Segment Name	Chiapas Gate Mapping
L2420A	NM1	Rendering Provider Name
L2420A	NM103	Person	L2420A_S01_NM103_LAST_ORG_NM_OVL_PERSN
L2420A	NM103	Non-Person Entity	L2420A_S01_NM103_LAST_ORG_NM_OVL_NONPRSN_ENTY
L2420A	NM104	Rendering Provider First Name	L2420A_S01_NM104_PROV_FNAME
L2420A	NM105	Rendering Provider Middle Name or Initial	L2420A_S01_NM105_RENDRNG_PROV_MNAME_INTL
L2420A	NM107	Rendering Provider Name Suffix	L2420A_S01_NM107_RENDRNG_PROV_NM_SUFX
L2420A	NM109	Centers for Medicare and Medicaid Services National Provider Identifier	L2420A_S01_NM109_PROV_ID_OVL_MDCR_MDCD_SVCS_NATNL_PROV_ID
L2420A	PRV	Rendering Provider Specialty Information
L2420A	PRV01	Provider Code	L2420A_S02_PRV01_PROV_CD
L2420A	PRV03	Health Care Provider Taxonomy Code	L2420A_S02_PRV03_TAXNMY_CD_OVL_HLTHCR_PROV_TAXNMY_CD
L2420A	REF	Rendering Provider Secondary Identification
L2420A	REF02	State License Number	L2420A_S03_REF02_RENDRNG_PROV_2ND_ID_OVL_STAT_LICNS_NR
L2420A	REF02	Provider UPIN Number	L2420A_S03_REF02_RENDRNG_PROV_2ND_ID_OVL_PROV_UPN_NR
L2420A	REF02	Provider Commercial Number	L2420A_S03_REF02_RENDRNG_PROV_2ND_ID_OVL_PROV_COMRCL_NR
L2420A	REF02	Location Number	L2420A_S03_REF02_RENDRNG_PROV_2ND_ID_OVL_LOC_NR
L2420A	REF04-02	Payer Identification Number	L2420A_S03_REF04_02_OTHR_PAYR_PRIMRY_ID_OVL_PAYR_ID_NR

2420B - PURCHASED SERVICE PROVIDER NAME

Loop	Segment	Segment Name	Chiapas Gate Mapping
L2420B	NM1	Purchased Service Provider Name
L2420B	NM102	Entity Type Qualifier	L2420B_S01_NM102_ENTY_TYPE_QUAL
L2420B	NM109	Centers for Medicare and Medicaid Services National Provider Identifier	L2420B_S01_NM109_PURCHSD_SVC_PROV_ID_OVL_MDCR_MDCD_SVCS_NATNL_PROV_ID
L2420B	REF	Purchased Service Provider Secondary Identification
L2420B	REF02	State License Number	L2420B_S02_REF02_ID_OVL_STAT_LICNS_NR
L2420B	REF02	Provider UPIN Number	L2420B_S02_REF02_ID_OVL_PROV_UPN_NR
L2420B	REF02	Provider Commercial Number	L2420B_S02_REF02_ID_OVL_PROV_COMRCL_NR
L2420B	REF04-02	Payer Identification Number	L2420B_S02_REF04_02_OTHR_PAYR_PRIMRY_ID_OVL_PAYR_ID_NR

2420C - SERVICE FACILITY LOCATION NAME

Loop	Segment	Segment Name	Chiapas Gate Mapping
L2420C	NM1	Service Facility Location Name
L2420C	NM103	Non-Person Entity	L2420C_S01_NM103_LAB_FACLTY_NM_OVL_NONPRSN_ENTY
L2420C	NM109	Centers for Medicare and Medicaid Services National Provider Identifier	L2420C_S01_NM109_LAB_FACLTY_PRIMRY_ID_OVL_MDCR_MDCD_SVCS_NATNL_PROV_ID
L2420C	N3	Service Facility Location Address
L2420C	N301	Laboratory or Facility Address Line	L2420C_S02_N301_LAB_FACLTY_ADRS_LIN
L2420C	N302	Laboratory or Facility Address Line	L2420C_S02_N302_LAB_FACLTY_ADRS_LIN
L2420C	N4	Service Facility Location City, State, ZIP Code
L2420C	N401	Laboratory or Facility City Name	L2420C_S03_N401_LAB_FACLTY_CITY_NM
L2420C	N402	Laboratory or Facility State or Province Code	L2420C_S03_N402_LAB_FACLTY_STAT_PROVNC_CD
L2420C	N403	Laboratory or Facility Postal Zone or ZIP Code	L2420C_S03_N403_LAB_FACLTY_POSTL_ZON_ZIP_CD
L2420C	N404	Country Code	L2420C_S03_N404_CNTRY_CD
L2420C	N407	Country Subdivision Code	L2420C_S03_N407_COUNTRY_SUBDVSN_CD
L2420C	REF	Service Facility Location Secondary Identification
L2420C	REF02	Provider Commercial Number	L2420C_S04_REF02_SVC_FACLTY_LOC_2ND_ID_OVL_PROV_COMRCL_NR
L2420C	REF02	Location Number	L2420C_S04_REF02_SVC_FACLTY_LOC_2ND_ID_OVL_LOC_NR
L2420C	REF04-02	Payer Identification Number	L2420C_S04_REF04_02_OTHR_PAYR_PRIMRY_ID_OVL_PAYR_ID_NR

2420D - SUPERVISING PROVIDER NAME

Loop	Segment	Segment Name	Chiapas Gate Mapping
L2420D	NM1	Supervising Provider Name
L2420D	NM103	Person	L2420D_S01_NM103_PROV_LNAME_OVL_PERSN
L2420D	NM104	Supervising Provider First Name	L2420D_S01_NM104_PROV_FNAME
L2420D	NM105	Supervising Provider Middle Name or Initial	L2420D_S01_NM105_SUPER_PROV_MNAME_INTL
L2420D	NM107	Supervising Provider Name Suffix	L2420D_S01_NM107_SUPER_PROV_NM_SUFX
L2420D	NM109	Centers for Medicare and Medicaid Services National Provider Identifier	L2420D_S01_NM109_PROV_ID_OVL_MDCR_MDCD_SVCS_NATNL_PROV_ID
L2420D	REF	Supervising Provider Secondary Identification
L2420D	REF02	State License Number	L2420D_S02_REF02_SUPER_PROV_2ND_ID_OVL_STAT_LICNS_NR
L2420D	REF02	Provider UPIN Number	L2420D_S02_REF02_SUPER_PROV_2ND_ID_OVL_PROV_UPN_NR
L2420D	REF02	Provider Commercial Number	L2420D_S02_REF02_SUPER_PROV_2ND_ID_OVL_PROV_COMRCL_NR
L2420D	REF02	Location Number	L2420D_S02_REF02_SUPER_PROV_2ND_ID_OVL_LOC_NR
L2420D	REF04-02	Payer Identification Number	L2420D_S02_REF04_02_OTHR_PAYR_PRIMRY_ID_OVL_PAYR_ID_NR

2420E - ORDERING PROVIDER NAME

Loop	Segment	Segment Name	Chiapas Gate Mapping
L2420E	NM1	Ordering Provider Name
L2420E	NM103	Person	L2420E_S01_NM103_PROV_LNAME_OVL_PERSN
L2420E	NM104	Ordering Provider First Name	L2420E_S01_NM104_PROV_FNAME
L2420E	NM105	Ordering Provider Middle Name or Initial	L2420E_S01_NM105_ORDRNG_PROV_MNAME_INTL
L2420E	NM107	Ordering Provider Name Suffix	L2420E_S01_NM107_ORDRNG_PROV_NM_SUFX
L2420E	NM109	Centers for Medicare and Medicaid Services National Provider Identifier	L2420E_S01_NM109_PROV_ID_OVL_MDCR_MDCD_SVCS_NATNL_PROV_ID
L2420E	N3	Ordering Provider Address
L2420E	N301	Ordering Provider Address Line	L2420E_S02_N301_ORDRNG_PROV_ADRS_LIN
L2420E	N302	Ordering Provider Address Line	L2420E_S02_N302_ORDRNG_PROV_ADRS_LIN
L2420E	N4	Ordering Provider City, State, ZIP Code
L2420E	N401	Ordering Provider City Name	L2420E_S03_N401_ORDRNG_PROV_CITY_NM
L2420E	N402	Ordering Provider State or Province Code	L2420E_S03_N402_STAT_PROVNC_CD
L2420E	N403	Ordering Provider Postal Zone or ZIP Code	L2420E_S03_N403_POSTL_ZON_ZIP_CD
L2420E	N404	Country Code	L2420E_S03_N404_CNTRY_CD
L2420E	N407	Country Subdivision Code	L2420E_S03_N407_COUNTRY_SUBDVSN_CD
L2420E	REF	Ordering Provider Secondary Identification
L2420E	REF02	State License Number	L2420E_S04_REF02_ORDRNG_PROV_2ND_ID_OVL_STAT_LICNS_NR
L2420E	REF02	Provider UPIN Number	L2420E_S04_REF02_ORDRNG_PROV_2ND_ID_OVL_PROV_UPN_NR
L2420E	REF02	Provider Commercial Number	L2420E_S04_REF02_ORDRNG_PROV_2ND_ID_OVL_PROV_COMRCL_NR
L2420E	REF04-02	Payer Identification Number	L2420E_S04_REF04_02_OTHR_PAYR_PRIMRY_ID_OVL_PAYR_ID_NR
L2420E	PER	Ordering Provider Contact Information
L2420E	PER01	Contact Function Code	L2420E_S05_PER01_FUNCTN_CD
L2420E	PER02	Ordering Provider Contact Name	L2420E_S05_PER02_ORDRNG_PROV_CONTCT_NM
L2420E	PER04	Electronic Mail	L2420E_S05_PER04_COMM_NR_OVL_EMAIL
L2420E	PER04	Facsimile	L2420E_S05_PER04_COMM_NR_OVL_FACSML
L2420E	PER04	Telephone	L2420E_S05_PER04_COMM_NR_OVL_TELPHN
L2420E	PER06	Electronic Mail	L2420E_S05_PER06_COMM_NR_OVL_EMAIL
L2420E	PER06	Telephone Extension	L2420E_S05_PER06_COMM_NR_OVL_PHN_EXTNS
L2420E	PER06	Facsimile	L2420E_S05_PER06_COMM_NR_OVL_FACSML
L2420E	PER06	Telephone	L2420E_S05_PER06_COMM_NR_OVL_TELPHN
L2420E	PER08	Electronic Mail	L2420E_S05_PER08_COMM_NR_OVL_EMAIL
L2420E	PER08	Telephone Extension	L2420E_S05_PER08_COMM_NR_OVL_PHN_EXTNS
L2420E	PER08	Facsimile	L2420E_S05_PER08_COMM_NR_OVL_FACSML
L2420E	PER08	Telephone	L2420E_S05_PER08_COMM_NR_OVL_TELPHN

2420F - REFERRING PROVIDER NAME

Loop	Segment	Segment Name	Chiapas Gate Mapping
2420F		Qualified Loop
L2420F		Referring Provider	L2420F_DN
L2420F		Primary Care Provider	L2420F_P3
L2420F	NM1	Referring Provider Name
L2420F	NM103	Person	L2420F_XX_S01_NM103_PROV_LNAME_OVL_PERSN
L2420F	NM104	Referring Provider First Name	L2420F_XX_S01_NM104_PROV_FNAME
L2420F	NM105	Referring Provider Middle Name or Initial	L2420F_XX_S01_NM105_REFNG_PROV_MNAME_INTL
L2420F	NM107	Referring Provider Name Suffix	L2420F_XX_S01_NM107_REFNG_PROV_NM_SUFX
L2420F	NM109	Centers for Medicare and Medicaid Services National Provider Identifier	L2420F_XX_S01_NM109_PROV_ID_OVL_MDCR_MDCD_SVCS_NATNL_PROV_ID
L2420F	REF	Referring Provider Secondary Identification
L2420F	REF02	State License Number	L2420F_XX_S02_REF02_REFNG_PROV_2ND_ID_OVL_STAT_LICNS_NR
L2420F	REF02	Provider UPIN Number	L2420F_XX_S02_REF02_REFNG_PROV_2ND_ID_OVL_PROV_UPN_NR
L2420F	REF02	Provider Commercial Number	L2420F_XX_S02_REF02_REFNG_PROV_2ND_ID_OVL_PROV_COMRCL_NR
L2420F	REF04-02	Payer Identification Number	L2420F_XX_S02_REF04_02_OTHR_PAYR_PRIMRY_ID_OVL_PAYR_ID_NR

2420G - AMBULANCE PICK-UP LOCATION

Loop	Segment	Segment Name	Chiapas Gate Mapping
L2420G	NM1	Ambulance Pick-up Location
L2420G	NM102	Entity Type Qualifier	L2420G_S01_NM102_ENTY_TYPE_QUAL
L2420G	N3	Ambulance Pick-up Location Address
L2420G	N301	Ambulance Pick-up Address Line	L2420G_S02_N301_AMBLNC_PICKP_ADRS_LIN
L2420G	N302	Ambulance Pick-up Address Line	L2420G_S02_N302_AMBLNC_PICKP_ADRS_LIN
L2420G	N4	Ambulance Pick-up Location City, State, ZIP Code
L2420G	N401	Ambulance Pick-up City Name	L2420G_S03_N401_AMBLNC_PICKP_CITY_NM
L2420G	N402	Ambulance Pick-up State or Province Code	L2420G_S03_N402_STAT_PROVNC_CD
L2420G	N403	Ambulance Pick-up Postal Zone or ZIP Code	L2420G_S03_N403_POSTL_ZON_ZIP_CD
L2420G	N404	Country Code	L2420G_S03_N404_CNTRY_CD
L2420G	N407	Country Subdivision Code	L2420G_S03_N407_COUNTRY_SUBDVSN_CD

2420H - AMBULANCE DROP-OFF LOCATION

Loop	Segment	Segment Name	Chiapas Gate Mapping
L2420H	NM1	Ambulance Drop-off Location
L2420H	NM102	Entity Type Qualifier	L2420H_S01_NM102_ENTY_TYPE_QUAL
L2420H	NM103	Ambulance Drop-off Location	L2420H_S01_NM103_DRPOFF_LOC
L2420H	N3	Ambulance Drop-off Location Address
L2420H	N301	Ambulance Drop-off Address Line	L2420H_S02_N301_AMBLNC_DRPOFF_ADRS_LIN
L2420H	N302	Ambulance Drop-off Address Line	L2420H_S02_N302_AMBLNC_DRPOFF_ADRS_LIN
L2420H	N4	Ambulance Drop-off Location City, State, ZIP Code
L2420H	N401	Ambulance Drop-off City Name	L2420H_S03_N401_AMBLNC_DRPOFF_CITY_NM
L2420H	N402	Ambulance Drop-off State or Province Code	L2420H_S03_N402_STAT_PROVNC_CD
L2420H	N403	Ambulance Drop-off Postal Zone or ZIP Code	L2420H_S03_N403_POSTL_ZON_ZIP_CD
L2420H	N404	Country Code	L2420H_S03_N404_CNTRY_CD
L2420H	N407	Country Subdivision Code	L2420H_S03_N407_COUNTRY_SUBDVSN_CD

2430 - LINE ADJUDICATION INFORMATION

Loop	Segment	Segment Name	Chiapas Gate Mapping
L2430	SVD	Line Adjudication Information
L2430	SVD01	Other Payer Primary Identifier	L2430_S01_SVD01_OTHR_PAYR_PRIMRY_ID
L2430	SVD02	Service Line Paid Amount	L2430_S01_SVD02_SVC_LIN_PD_AMT
L2430	SVD03-02	Jurisdiction Specific Procedure and Supply Codes	L2430_S01_SVD03_02_PROC_CD_OVL_JURSDCTN_SPECFC_PROC_SUPLY_CD
L2430	SVD03-02	Health Care Financing Administration Common Procedural Coding System (HCPCS) Codes	L2430_S01_SVD03_02_PROC_CD_OVL_HCPCS_CD
L2430	SVD03-02	Home Infusion EDI Coalition (HIEC) Product/Service Code	L2430_S01_SVD03_02_PROC_CD_OVL_HIEC_PRODCT_SRVC_CD
L2430	SVD03-02	Advanced Billing Concepts (ABC) Codes	L2430_S01_SVD03_02_PROC_CD_OVL_ABC_CD
L2430	SVD03-03	Procedure Modifier	L2430_S01_SVD03_03_PROC_MODFR
L2430	SVD03-04	Procedure Modifier	L2430_S01_SVD03_04_PROC_MODFR
L2430	SVD03-05	Procedure Modifier	L2430_S01_SVD03_05_PROC_MODFR
L2430	SVD03-06	Procedure Modifier	L2430_S01_SVD03_06_PROC_MODFR
L2430	SVD03-07	Procedure Code Description	L2430_S01_SVD03_07_PROC_CD_DESCRPTN
L2430	SVD05	Paid Service Unit Count	L2430_S01_SVD05_PD_SVC_UNT_CT
L2430	SVD06	Bundled or Unbundled Line Number	L2430_S01_SVD06_BUNDLD_UNBNDLD_LIN_NR
L2430	CAS	Line Adjustment
L2430	CAS01	Claim Adjustment Group Code	L2430_S02_CAS01_CLM_ADJ_GRP_CD
L2430	CAS02	Adjustment Reason Code	L2430_S02_CAS02_ADJ_RSN_CD
L2430	CAS03	Adjustment Amount	L2430_S02_CAS03_ADJ_AMT
L2430	CAS04	Adjustment Quantity	L2430_S02_CAS04_ADJ_QTY
L2430	CAS05	Adjustment Reason Code	L2430_S02_CAS05_ADJ_RSN_CD
L2430	CAS06	Adjustment Amount	L2430_S02_CAS06_ADJ_AMT
L2430	CAS07	Adjustment Quantity	L2430_S02_CAS07_ADJ_QTY
L2430	CAS08	Adjustment Reason Code	L2430_S02_CAS08_ADJ_RSN_CD
L2430	CAS09	Adjustment Amount	L2430_S02_CAS09_ADJ_AMT
L2430	CAS10	Adjustment Quantity	L2430_S02_CAS10_ADJ_QTY
L2430	CAS11	Adjustment Reason Code	L2430_S02_CAS11_ADJ_RSN_CD
L2430	CAS12	Adjustment Amount	L2430_S02_CAS12_ADJ_AMT
L2430	CAS13	Adjustment Quantity	L2430_S02_CAS13_ADJ_QTY
L2430	CAS14	Adjustment Reason Code	L2430_S02_CAS14_ADJ_RSN_CD
L2430	CAS15	Adjustment Amount	L2430_S02_CAS15_ADJ_AMT
L2430	CAS16	Adjustment Quantity	L2430_S02_CAS16_ADJ_QTY
L2430	CAS17	Adjustment Reason Code	L2430_S02_CAS17_ADJ_RSN_CD
L2430	CAS18	Adjustment Amount	L2430_S02_CAS18_ADJ_AMT
L2430	CAS19	Adjustment Quantity	L2430_S02_CAS19_ADJ_QTY
L2430	DTP	Line Check or Remittance Date
L2430	DTP03	Date Claim Paid (D8)	L2430_S03_DTP03_ADJDCTN_PMT_DT_OVL_DAT_CLM_PAID_D8
L2430	AMT	Remaining Patient Liability
L2430	AMT01	Amount Qualifier Code	L2430_S04_AMT01_AMT_QUAL_CD
L2430	AMT02	Remaining Patient Liability	L2430_S04_AMT02_PATNT_LIABLTY

2440 - FORM IDENTIFICATION CODE

Loop	Segment	Segment Name	Chiapas Gate Mapping
L2440	LQ	Form Identification Code
L2440	LQ02	Form Type Code	L2440_S01_LQ02_FORM_ID_OVL_FORM_TYPE_CD
L2440	LQ02	Centers for Medicare and Medicaid Services (CMS) Durable Medical Equipment Regional Carrier	L2440_S01_LQ02_FORM_ID_OVL_CMS_DME
L2440	FRM	Supporting Documentation
L2440	FRM01	Question Number/Letter	L2440_S02_FRM01_QUESTN_NR_LTR
L2440	FRM02	Question Response	L2440_S02_FRM02_QUESTN_RESPNS
L2440	FRM03	Question Response	L2440_S02_FRM03_QUESTN_RESPNS
L2440	FRM04	Question Response	L2440_S02_FRM04_QUESTN_RESPNS
L2440	FRM05	Question Response	L2440_S02_FRM05_QUESTN_RESPNS