AUC Acknowledgements TAG Meeting Materials 07-29-10

Preliminary Discussion Draft–For Acknowledgements TAG Review 7-29-10 

Meeting Materials 

Acknowledgements TAG Meeting 

July 29, 2010 

1. Acknowledgments TAG 07-29-10 agenda 

2. Acknowledgement_TAG_Minutes071510 

3. Clarification Email Response From Code Committee 

4. Claim Category and Status Codes with homework changes 7-27-10 

Page 1 of 63


AUC – Acknowledgments TAG Agenda 

July 29, 2010 (9:00-11:00 am, CDT) 

Minnesota Room at SOP 

Conference call number is: New call-in line: 213-289-0500 participant code: 337213 

WebEx Instructions-- 

1. Click on this link: https://health-state-mnustraining.webex.com/mw0306l/mywebex/default.do?siteurl=health-state-mn-ustraining&service=7 

2. Click on the link to the AUC Acknowledgments TAG meeting. 

3. Type your name, email address and password into the prompt boxes. The password is: Ack2010! 

1. Minute Taker for Today – 

2. AUC Antitrust Statement 

3. Welcome and Introductions 

a. Take attendance for AUC member organizations 

4. ACTION ITEMS: 

a. Approve Minutes from July 15 meeting 

5. DISCUSSION ITEMS: 

a. Clarification on Claim Status Codes – see email 

b. Review HIR 

QUESTION: 

According to the note, the assigned value of zero or the sender assigned value would not 

be of value to the receiver of the 277CA if the original claim had multiple loops with the 

same billing provider. How does a zero or an assigned value inform the receiver of the 

277CA of where the error is? 

ANSWER: 

This issue is explicitly addressed in guide 005010X214. The note on the 2200C loop TRN 

segment states "Because the TRN segment is syntactically required in order to use Loop 

2200C, TRN02 can either be a sender assigned value or a default value of zero (0)." 

The loop 2200C value in TRN02 is not intended to be of any help in identifying where an 

error is located. It is required syntactically in order to use other parts of the 2200C loop. 

Identification of the specific error, if there is an error, would be in the other parts of the 

2200C loop, like the STC segment, and would apply to all claims from that provider of 

service. 

i. 

c. Continue review of 277CA Status Code Usage 

Page 1 of 1 

Page 2 of 63


6. Other Business – 

a. Future meeting – Flows Best Practice 

7. Next Meeting Information: 

August 19, 9:00-11:00 am, Minnesota Dept of Health, Snelling Office Park, Minnesota 

Room 

Page 2 of 1 

Page 3 of 63

AUC Acknowledgement TAG Workgroup 

July 15, 2010 9:00 AM – 11:00 AM 

WEB EX and PHONE 


Minutes By: Patrice Kuppe 

DRAFT 

Agenda Item Discussion Action 

AUC Antitrust Reminded group we follow anit-trust. None 

Welcome and 

Introductions 

(attendance) 

Approve Minutes 

from June 15, 

2010 Meeting 

Review and 

approve 997 

statement for 

Approved the Approve Minutes from June 15 and July 8 meetings 

Approved 997 statement that AUC should recommend that MDH to not create guide based on X12 

interpretations and that Medicare does not use it. 

None 

Dave post to web. 

Patrice to send 

recommendation to 

Dave to get on AUC 

Ops agenda. 

Continue review 

of 277CA Status 

Code Usage (see 

template) 

See spreadsheet 

We completed through status code 267. 

The group decided to share the burden and each of the following people took a set of codes. Each will research 

whether that data is reported in a claim (P, I, or D) and if so, recommend what category code(s) would be 

appropriate. The results will be sent to Patrice by 7/23 so she can incorporate into one spreadsheet for the group 

to review on 7/29. 

Person 

Numbers 

Chip Evelsizer 600 series 

Allan Klug 301 - 350 

Patrice Kuppe 268 - 300 

Faye Ostroot 700 -742 

Lisa Wichterman. 401- 450 

Steve Williams 451 - 500 

Brian Roy 501- 550 

Sherri Wilson 551-599 

Ed Stroot 351- 400 

TAG volunteers to 

complete assigned 

review and send to 

Patrice by 7/23. 

Page 4 of 63

Agenda Item Discussion Action 

Future meeting – Future meeting. 

Flows Best 

Practice 

Next Meeting July 29, 2010 

9:00 AM-12:00 AM 

MDH – Snelling Office Park, Minnesota Room 


Page 5 of 63


From: Cabral, Michael J. (CMS/OIS) [michael.cabral@cms.hhs.gov] 

Sent: Wednesday, July 14, 2010 6:21 AM 

To: Kuppe, Patrice M 

Cc: Stine, Merri-Lee; Debra Strickland 

Subject: Clarification on Claim Status Codes 

Patrice, 

Per our conversation of last week the two codes in question can fit into separate scenarios but 

the logic can be applied simply as follows: 

Claim Status Code: 

24 Entity not approved as an electronic submitter. 

Note: Changed as of 6/01 

One of the situations where this can be used is when a trading partner is attempting to send a 

transaction to another trading partner. e.g. Clearinghouse sending claims transactions to a 

payer. If the clearinghouse is approved to send a single form of the claim transaction (e.g. 

approved for institutional claims in production but not for professional claim submission in 

production). Using code 24 when the Professional claim transaction is submitted would indicate 

that the transaction is being rejected because the entity (trading Partner) is not approved as an 

electronic submitter. 

In the second scenario discussed a clearinghouse may be servicing several providers. Provider 1 

is approved and registered with the payer as is Provider 3. Provider 2 is not approved to bill the 

payer and the use of this code would require using the data element 98 in the composite data 

element of the STC segment in the 277, which would indicate that the Billing Provider is not 

approved. By indicating that all claims under Provider 2 are being rejected, the payer can 

accept and process claims for Provider 1 and Provider 3 per the payer’s adjudication processes 

without having to reject an entire transaction. 

25 Entity not approved. This change effective 11/1/2010: Entity not approved. 

Note: This code requires use of an Entity Code. 

Start: 01/01/1995 | Last Modified: 02/11/2010 

Hope this helps to clarify our discussion. 

Michael J. Cabral 

Chair - Code Maintenance Committee 

Phone: (410) 786-6168 

Email: michael.cabral@cms.hhs.gov 

From: wedi-acknowledgements-lists@lists.wedi.org [mailto:wedi-acknowledgementslists@lists.wedi.org] 

On Behalf Of Kuppe, Patrice M 

Sent: Tuesday, July 06, 2010 10:49 AM 

To: WEDI-acknowledgements@lists.wedi.org 

Subject: Question for Claim ACK and Status Codes 

Page 6 of 63


Does anyone know if there is a way to get clarification from code committee? 

The MN AUC is hoping to get clarification on this: 

We want to understand how the codes below are expected to be used in a 999 or 

277CA? 

How would the electronic transaction ever get to someone if not approved? 

Also, what is the difference between electronic submitter approval versus entity not 

approved? Not approved for what? Thanks! 

Entity not approved as an electronic submitter. This change 

effective 11/1/2010: Entity not approved as an electronic submitter. 

Note: This code requires use of an Entity 

Code. 

Start: 01/01/1995 | Last 

Modified: 02/11/2010 

Entity not approved. This change effective 11/1/2010: Entity not 

approved. Note: This code requires use of an Entity 

Code. 

Start: 01/01/1995 | Last 


Page 7 of 63


Claim Category Codes 05/10/2010 - Check wpc-edi.com for current list 

Acknowledgement 

Pending 

Finalized 

Requests 

General Questions 

Response not possible 

Data Search Unsuccessful (Not for CA?) 

Correction required (Not for CA?) 

YES OR NO 

COMMENTS 

A0 

Acknowledgement/Forwarded-The claim/encounter has been forwarded to 

another entity. Start: 01/01/1995 

Y 

A1 

Acknowledgement/Receipt-The claim/encounter has been received. This does 

not mean that the claim has been accepted for adjudication. 

Start: 01/01/1995 

Y 

Allow for non-HIPAA covered entities 

A2 

Acknowledgement/Acceptance into adjudication system-The claim/encounter 

has been accepted into the adjudication system. Start: 01/01/1995 

Y 

A3 

Acknowledgement/Returned as unprocessable claim-The claim/encounter has 

been rejected and has not been entered into the adjudication system. 

Start: 01/01/1995 

Y 

Require Claim Status code 

A4 

Acknowledgement/Not Found-The claim/encounter can not be found in the 

adjudication system. Start: 01/01/1995 

N 

A5 

Acknowledgement/Split Claim-The claim/encounter has been split upon 

acceptance into the adjudication system. Start: 02/28/2002 

Y 

A6 

Acknowledgement/Rejected for Missing Information - The claim/encounter is 

missing the information specified in the Status details and has been rejected. 

Start: 10/31/2002 

Y 

A7 

Acknowledgement/Rejected for Invalid Information - The claim/encounter has 

invalid information as specified in the Status details and has been rejected. 

Start: 10/31/2002 

Y 

Page 8 of 63


A8 

P0 

P1 

P2 

Acknowledgement / Rejected for relational field in error. Start: 

10/31/2004 

Pending: Adjudication/Details-This is a generic message about a pended claim. 

A pended claim is one for which no remittance advice has been issued, or only 

part of the claim has been paid. Start: 01/01/1995 

Pending/In Process-The claim or encounter is in the adjudication system. 

Start: 01/01/1995 

Pending/Payer Review-The claim/encounter is suspended and is pending 

review (e.g. medical review, repricing, Third Party Administrator processing). 

Start: 01/01/1995 | Last Modified: 01/27/2008 

Y Example? 

N 

N 

N 

P3 

Pending/Provider Requested Information - The claim or encounter is waiting for 

information that has already been requested from the provider. (Note: A Claim 

Status Code identifying the type of information requested, must be reported) 


N 

P4 

Pending/Patient Requested Information - The claim or encounter is waiting for 

information that has already been requested from the patient. (Note: A status 

code identifying the type of information requested must be sent) 


N 

P5 Pending/Payer Administrative/System hold Start: 10/31/2006 N 

F0 

Finalized-The claim/encounter has completed the adjudication cycle and no 

more action will be taken. Start: 01/01/1995 

F1 Finalized/Payment-The claim/line has been paid. Start: 01/01/1995 N 

F2 Finalized/Denial-The claim/line has been denied. Start: 01/01/1995 N 

N 

F3 

F3F 

Finalized/Revised - Adjudication information has been changed Start: 

02/28/2001 

Finalized/Forwarded-The claim/encounter processing has been completed. Any 

applicable payment has been made and the claim/encounter has been 

forwarded to a subsequent entity as identified on the original claim or in this 

payer's records. Start: 01/01/1995 

N 

N 

Page 9 of 63


F3N 

Finalized/Not Forwarded-The claim/encounter processing has been completed. 

Any applicable payment has been made. The claim/encounter has NOT been 

forwarded to any subsequent entity identified on the original claim. 

Start: 01/01/1995 

N 

F4 

R0 

R1 

R3 

R4 

Finalized/Adjudication Complete - No payment forthcoming-The 

claim/encounter has been adjudicated and no further payment is forthcoming. 

Start: 01/01/1995 

Requests for additional Information/General Requests-Requests that don't fall 

into other R-type categories. Start: 01/01/1995 

Requests for additional Information/Entity Requests-Requests for information 

about specific entities (subscribers, patients, various providers). 

Start: 01/01/1995 

Requests for additional Information/Claim/Line-Requests for information that 

could normally be submitted on a claim. Start: 01/01/1995 | Last 

Modified: 02/28/1998 

Requests for additional Information/Documentation-Requests for additional 

supporting documentation. Examples: certification, x-ray, notes. 


N 

N 

N 

N 

N 

R5 

R6 

R7 

R8 

R9 

Request for additional information/more specific detail-Additional information 

as a follow up to a previous request is needed. The original information was 

received but is inadequate. More specific/detailed information is requested. 


Requests for additional information - Regulatory requirements Start: 

02/28/2007 

Requests for additional information - Confirm care is consistent with Health 

Plan policy coverage. Start: 02/28/2007 

Requests for additional information - Confirm care is consistent with health 

plan coverage exceptions Start: 02/28/2007 

Requests for additional information - Determination of medical necessity. 

Start: 02/28/2007 

N 

N 

N 

N 

N 

Page 10 of 63


R10 

R11 

R12 

R13 

R14 

R15 

Requests for additional information - Support a filed grievance or appeal. 


Requests for additional information - Pre-payment review of claims. Start: 


Requests for additional information - Clarification or justification of use for 

specified procedure code Start: 02/28/2007 

Requests for additional information - Original documents submitted are not 

readable. Used only for subsequent request(s). Start: 


Requests for additional information - Original documents received are not what 

was requested. Used only for subsequent request(s). Start: 


Requests for additional information - Workers Compensation coverage 

determination. Start: 02/28/2007 

N 

N 

N 

N 

N 

N 

R16 

RQ 

E0 

Requests for additional information - Eligibility determination Start: 


General Questions (Yes/No Responses)-Questions that may be answered by a 

simple 'yes' or 'no'. Start: 01/01/1995 | Last 

Modified: 07/09/2007 | Stop: 01/01/2008 

Response not possible - error on submitted request data. Start: 

01/01/1995 | Last Modified: 02/28/2002 

E1 Response not possible - System Status Start: 02/29/2000 N 

N 

N 

N should have denied on 999 

E2 

DO 

E3 

Information Holder is not responding; resubmit at a later time. Start: 

06/30/2003 

Data Search Unsuccessful - The payer is unable to return status on the 

requested claim(s) based on the submitted search criteria. Start: 

01/01/1995 | Last Modified: 09/20/2009 

Correction required - relational fields in error. Start: 


N 

N 

N 

use A8 for acknowledgment 

Page 11 of 63


Health Care Claim Status Codes 5/10/2010 (see WPC-EDI.com for current list) 

Health Care Claim Status Codes convey the status of an entire claim or a specific service line 

(A) Acknowledgement 

(P) Pending 

(F) Finalized 

(R)Requests 

(G) General Questions 

(NP) Response not possible 

4 levels needed? (Patrice has notes) 

Add defn of A0. etc. 

Additional notes 

Claim 

Status 

Code 

Claim Status Code Description 

Claim Cateory 

Codes: A0, A1, 

A2, A3, A5, A6, 

A7, A8 or NA 

COMMENTS 

Entity Codes 

0 Cannot provide further status electronically. Start: 01/01/1995 NA 

1 

For more detailed information, see remittance advice. 

Start: 01/01/1995 

NA 

2 More detailed information in letter. Start: 01/01/1995 NA 

3 

Claim has been adjudicated and is awaiting payment cycle. 

Start: 01/01/1995 

NA 

6 Balance due from the subscriber. Start: 01/01/1995 NA 

12 

One or more originally submitted procedure codes have been combined. 


NA 

shouldn't be using codes for 

ajudication 

15 

One or more originally submitted procedure code have been modified. 


NA 

16 

Claim/encounter has been forwarded to entity. This change effective 11/1/2010: 

Claim/encounter has been forwarded to entity. Note: This code requires use of an 

Entity Code. Start: 01/01/1995 | Last Modified: 


A0 

requires use of 

entity code -- add 

later 

17 

Claim/encounter has been forwarded by third party entity to entity. This change 

effective 11/1/2010: Claim/encounter has been forwarded by third party entity to 

entity. Note: This code requires use of an Entity Code. Start: 

01/01/1995 | Last Modified: 02/11/2010 

A0 



later 

18 

Entity received claim/encounter, but returned invalid status. This change effective 

11/1/2010: Entity received claim/encounter, but returned invalid status. Note: This 

code requires use of an Entity Code. Start: 01/01/1995 | Last Modified: 


NA 

19 

Entity acknowledges receipt of claim/encounter. This change effective 11/1/2010: 

Entity acknowledges receipt of claim/encounter. Note: This code requires use of an 



NA 

20 

Accepted for processing. Start: 01/01/1995 | 

Last Modified: 06/30/2001 

A2 

21 

Missing or invalid information. Note: At least one other status code is required to 

identify the missing or invalid information. Start: 

01/01/1995 | Last Modified: 07/09/2007 

??? 

how does this add value if we have 

to add another reason? 

Page 12 of 63


23 

24 

25 

26 

Returned to Entity. This change effective 11/1/2010: Returned to Entity. Note: This 

code requires use of an Entity Code. Start: 


Entity not approved as an electronic submitter. This change effective 11/1/2010: 

Entity not approved as an electronic submitter. Note: This code requires use of an 



Entity not approved. This change effective 11/1/2010: Entity not approved. Note: 

This code requires use of an Entity Code. Start: 


Entity not found. This change effective 11/1/2010: Entity not found. Note: This code 

requires use of an Entity Code. Start: 01/01/1995 | 

Last Modified: 02/11/2010 

27 Policy canceled. Start: 01/01/1995 | Last Modified: 06/30/2001 A3 

29 

Subscriber and policy number/contract number mismatched. 

Start: 01/01/1995 

30 Subscriber and subscriber id mismatched. Start: 01/01/1995 A3 

31 Subscriber and policyholder name mismatched. Start: 01/01/1995 A3 

32 

Subscriber and policy number/contract number not found. 

Start: 01/01/1995 

33 Subscriber and subscriber id not found. Start: 01/01/1995 A3 

34 Subscriber and policyholder name not found. Start: 01/01/1995 NA 

35 Claim/encounter not found. Start: 01/01/1995 NA 

37 

Predetermination is on file, awaiting completion of services. 

Start: 01/01/1995 

38 Awaiting next periodic adjudication cycle. Start: 01/01/1995 NA 

39 Charges for pregnancy deferred until delivery. Start: 01/01/1995 NA 

A3 

??? 

??? 

??? 

?? 

NA 

NA 

Patrice to follow up with claims 

status code committee -- 7-8-10 

PK rec'd verbal response -- written 

response soon. Diff between #24 

and #25? 25 is for entity not 

enrolled. Patrice to email response 

to TAG 


status code committee 

what entities would this apply to? 

Includes use by non-HIPAA 

covered entities Also for level 

discussion-- 

If policy/contract not required on 

claim, would this be used? 


status code committee re category 

code A8 

If policy/contract not required on 

claim, would this be used? 



later 



later 

HK 

40 Waiting for final approval. Start: 01/01/1995 NA 

41 Special handling required at payer site. Start: 01/01/1995 NA 

42 Awaiting related charges. Start: 01/01/1995 NA 

44 Charges pending provider audit. Start: 01/01/1995 NA 

45 Awaiting benefit determination. Start: 01/01/1995 NA 

46 Internal review/audit. Start: 01/01/1995 NA 

47 Internal review/audit - partial payment made. Start: 01/01/1995 NA 

Perhaps used by non-HIPAA 

covered entities 

48 

Referral/authorization. Start: 01/01/1995 | 


A6, A7, A8 

Page 13 of 63


49 Pending provider accreditation review. Start: 01/01/1995 NA Not for pending 

50 Claim waiting for internal provider verification. Start: 01/01/1995 NA Not for pending 

51 Investigating occupational illness/accident. Start: 01/01/1995 A1 

52 

53 

Investigating existence of other insurance coverage. Start: 

01/01/1995 

Claim being researched for Insured ID/Group Policy Number error. Start: 

01/01/1995 

NA 

NA 

Providers should research 51 -- 

does it help to know that non- 

HIPAA covered payer took in and 

is pended until investigation 

completed 

54 Duplicate of a previously processed claim/line. Start: 01/01/1995 A3 

55 Claim assigned to an approver/analyst. Start: 01/01/1995 NA 

56 Awaiting eligibility determination. Start: 01/01/1995 NA 

57 Pending COBRA information requested. Start: 01/01/1995 NA 

59 Non-electronic request for information. Start: 01/01/1995 NA 

60 Electronic request for information. Start: 01/01/1995 NA 

61 Eligibility for extended benefits. Start: 01/01/1995 NA 

64 Re-pricing information. Start: 01/01/1995 NA 

65 Claim/line has been paid. Start: 01/01/1995 NA 

66 

Payment reflects usual and customary charges. Start: 

01/01/1995 

NA 

72 Claim contains split payment. Start: 01/01/1995 NA 

73 

Payment made to entity, assignment of benefits not on file. This change effective 

11/1/2010: Payment made to entity, assignment of benefits not on file. Note: This 



NA 

78 Duplicate of an existing claim/line, awaiting processing. Start: 01/01/1995 A3 

81 

Contract/plan does not cover pre-existing conditions. Start: 

01/01/1995 

NA 

83 No coverage for newborns. Start: 01/01/1995 NA 

84 Service not authorized. Start: 01/01/1995 NA 

85 

Entity not primary. This change effective 11/1/2010: Entity not primary. Note: This 

code requires use of an Entity Code. Start: 01/01/1995 | Last 


A0 

86 

Diagnosis and patient gender mismatch. Start: 01/01/1995 

| Last Modified: 02/28/2000 

A3 

88 

Entity not eligible for benefits for submitted dates of service. This change effective 

11/1/2010: Entity not eligible for benefits for submitted dates of service. Note: This 



A3 

82, 85 

Page 14 of 63


89 

Entity not eligible for dental benefits for submitted dates of service. This change 

effective 11/1/2010: Entity not eligible for dental benefits for submitted dates of 

service. Note: This code requires use of an Entity Code. Start: 


A3 

90 

Entity not eligible for medical benefits for submitted dates of service. This change 

effective 11/1/2010: Entity not eligible for medical benefits for submitted dates of 

service. Note: This code requires use of an Entity Code. Start: 


A3 

91 

Entity not eligible/not approved for dates of service. This change effective 

11/1/2010: Entity not eligible/not approved for dates of service. Note: This code 

requires use of an Entity Code. Start: 01/01/1995 | Last 


A3 

92 

Entity does not meet dependent or student qualification. This change effective 

11/1/2010: Entity does not meet dependent or student qualification. Note: This code 

requires use of an Entity Code. Start: 01/01/1995 | Last Modified: 


A3 

93 

Entity is not selected primary care provider. This change effective 11/1/2010: Entity 

is not selected primary care provider. Note: This code requires use of an Entity 

Code. Start: 01/01/1995 | Last Modified: 


A3 

94 

Entity not referred by selected primary care provider. This change effective 

11/1/2010: Entity not referred by selected primary care provider. Note: This code 



A3 

95 

Requested additional information not received. Start: 01/01/1995 

| Last Modified: 07/09/2007 

Notes: If known, the payer must report a second claim status code identifying the 

requested information. 

NA 

if asking for addl info, claim must 

have already been taken in 

96 

No agreement with entity. This change effective 11/1/2010: No agreement with 

entity. Note: This code requires use of an Entity Code. Start: 01/01/1995 | 


A3 

97 

Patient eligibility not found with entity. This change effective 11/1/2010: Patient 

eligibility not found with entity. Note: This code requires use of an Entity Code. 


A3 

Examples of entity codes? One 

example -- medical home (health 

care home) 

98 Charges applied to deductible. Start: 01/01/1995 NA 

99 Pre-treatment review. Start: 01/01/1995 NA 

100 Pre-certification penalty taken. Start: 01/01/1995 NA 

101 


Claim was processed as adjustment to previous claim. Start: 

01/01/1995 

Newborn's charges processed on mother's claim. Start: 

01/01/1995 

NA 

NA 

103 Claim combined with other claim(s). Start: 01/01/1995 NA 


Processed according to plan provisions (Plan refers to provisions that exist 

between the Health Plan and the Consumer or Patient) Start: 

01/01/1995 | Last Modified: 06/01/2008 

NA 

105 Claim/line is capitated. Start: 01/01/1995 NA 

Page 15 of 63



107 


This amount is not entity's responsibility. This change effective 11/1/2010: This 

amount is not entity's responsibility. Note: This code requires use of an Entity 

Code. Start: 01/01/1995 | Last 


Processed according to contract provisions (Contract refers to provisions that 

exist between the Health Plan and a Provider of Health Care Services) 


Entity not eligible. This change effective 11/1/2010: Entity not eligible. Note: This 



NA 

NA 

A3 

110 Claim requires pricing information. Start: 01/01/1995 A6 

111 

At the policyholder's request these claims cannot be submitted electronically. 

Start: 01/01/1995 

NA 

114 

Claim/service should be processed by entity. This change effective 11/1/2010: 

Claim/service should be processed by entity. Note: This code requires use of an 



NA 

Use number 16 above 

116 Claim submitted to incorrect payer. Start: 01/01/1995 A3 

117 Claim requires signature-on-file indicator. Start: 01/01/1995 A3 

121 

123 

124 

125 

126 

127 

128 


130 

131 

Service line number greater than maximum allowable for payer. 

Start: 01/01/1995 

Additional information requested from entity. This change effective 11/1/2010: 

Additional information requested from entity. Note: This code requires use of an 



Entity's name, address, phone and id number. This change effective 11/1/2010: 

Entity's name, address, phone and id number. Note: This code requires use of an 



Entity's name. This change effective 11/1/2010: Entity's name. Note: This code 



Entity's address. This change effective 11/1/2010: Entity's address. Note: This code 



Entity's phone number. This change to be effective 7/1/2010: Entity's 

Communication Number. This change effective 11/1/2010: Entity's Communication 

Number. Note: This code requires use of an Entity Code. Start: 


Entity's tax id. This change effective 11/1/2010: Entity's tax id. Note: This code 



Entity's Blue Cross provider id. This change effective 11/1/2010: Entity's Blue Cross 

provider id. Note: This code requires use of an Entity Code. Start: 01/01/1995 

| Last Modified: 02/11/2010 

Entity's Blue Shield provider id. This change effective 11/1/2010: Entity's Blue 

Shield provider id. Note: This code requires use of an Entity Code. Start: 


Entity's Medicare provider id. This change effective 11/1/2010: Entity's Medicare 

provider id. Note: This code requires use of an Entity Code. Start: 01/01/1995 | 


NA 

NA 

A3 or A6 

A3 or A6 

A3 or A6 

A3 or A6 

A3 or A6 

NA 

NA 

NA 

When using A3 have to use in 

combination with another claims 

status code 



status code 



status code 



status code 



status code 

Page 16 of 63


132 

133 

Entity's Medicaid provider id. This change effective 11/1/2010: Entity's Medicaid 



Entity's UPIN. This change effective 11/1/2010: Entity's UPIN. Note: This code 

requires use of an Entity Code. Start: 01/01/1995 | 


Entity's CHAMPUS provider id. This change effective 11/1/2010: Entity's CHAMPUS 



A3 or A6 

NA 



status code (should only be used 

for atypical providers) 82, 85 

134 

NA 

135 

136 

Entity's commercial provider id. This change effective 11/1/2010: Entity's 

commercial provider id. Note: This code requires use of an Entity Code. Start: 


Entity's health industry id number. This change effective 11/1/2010: Entity's health 

industry id number. Note: This code requires use of an Entity Code. 


Entity's plan network id. This change effective 11/1/2010: Entity's plan network id. 

Note: This code requires use of an Entity Code. Start: 01/01/1995 | Last 


Entity's site id . This change effective 11/1/2010: Entity's site id . Note: This code 



Entity's health maintenance provider id (HMO). This change effective 11/1/2010: 

Entity's health maintenance provider id (HMO). Note: This code requires use of an 



Entity's preferred provider organization id (PPO). This change effective 11/1/2010: 

Entity's preferred provider organization id (PPO). Note: This code requires use of an 



Entity's administrative services organization id (ASO). This change effective 

11/1/2010: Entity's administrative services organization id (ASO). Note: This code 



A3 or A6 

NA 



status code (should only be used 

for atypical providers) 

82, 85, DQ 

137 

NA 

138 

NA 

139 

NA 

140 

NA 

141 

NA 

142 

Entity's license/certification number. This change effective 11/1/2010: Entity's 

license/certification number. Note: This code requires use of an Entity Code. 


NA 

143 

Entity's state license number. This change effective 11/1/2010: Entity's state license 

number. Note: This code requires use of an Entity Code. Start: 01/01/1995 | Last 


Entity's specialty license number. This change effective 11/1/2010: Entity's specialty 

license number. Note: This code requires use of an Entity Code. 


NA 

144 

NA 

145 

Entity's specialty/taxonomy code. This change effective 11/1/2010: Entity's 

specialty/taxonomy code. Note: This code requires use of an Entity Code. 


A3 or A6 



status code Invalid Taxonomy 

Code 82, 85 

146 

Entity's anesthesia license number. This change effective 11/1/2010: Entity's 

anesthesia license number. Note: This code requires use of an Entity Code. 


NA 

Page 17 of 63


147 

148 

149 

150 

Entity's qualification degree/designation. (e.g. RN,PhD,MD) This change effective 

11/1/2010: Entity's qualification degree/designation (e.g. RN,PhD,MD). Note: This 



Entity's social security number. This change effective 11/1/2010: Entity's social 

security number. Note: This code requires use of an Entity Code. Start: 


Entity's employer id. This change effective 11/1/2010: Entity's employer id. Note: 

This code requires use of an Entity Code. Start: 01/01/1995 | 


Entity's drug enforcement agency (DEA) number. This change effective 11/1/2010: 

Entity's drug enforcement agency (DEA) number. Note: This code requires use of 

an Entity Code. Start: 01/01/1995 | Last Modified: 


NA 

NA 

NA 

NA 

152 Pharmacy processor number. Start: 01/01/1995 NA 

153 

Entity's id number. This change effective 11/1/2010: Entity's id number. Note: This 



NA 

154 Relationship of surgeon & assistant surgeon. Start: 01/01/1995 NA 

155 

Entity's relationship to patient. This change effective 11/1/2010: Entity's relationship 

to patient. Note: This code requires use of an Entity Code. Start: 01/01/1995 | 


NA 

156 Patient relationship to subscriber. Start: 01/01/1995 A6 or A7 

Use with entity codes (find element 

number for patient relationship in 

837) --stopping point on 7-8-10 -- 

Patrice to fill in through end of 

spreadsheet, to be emailed to 

TAG for review prior to next 

Thursday 

157 

158 

159 

160 

161 

162 

163 

Entity's Gender. This change effective 11/1/2010: Entity's Gender. Note: This code 



Entity's date of birth. This change effective 11/1/2010: Entity's date of birth. Note: 

This code requires use of an Entity Code. Start: 01/01/1995 | Last 


Entity's date of death. This change effective 11/1/2010: Entity's date of death. Note: 



Entity's marital status. This change effective 11/1/2010: Entity's marital status. Note: 



Entity's employment status. This change effective 11/1/2010: Entity's employment 

status. Note: This code requires use of an Entity Code. Start: 01/01/1995 | Last 


Entity's health insurance claim number (HICN). This change effective 11/1/2010: 

Entity's health insurance claim number (HICN). Note: This code requires use of an 



Entity's policy number. This change effective 11/1/2010: Entity's policy number. 



A7 

A7 or A8 

A7 

NA 

NA 

A6 or A7 or A8 


statement dates must be equal to 

or greater than patient's date of 

birth. 

QC 

When CLM Freq Type Cd (CLM05- 

3) indicates claim is a replacement 

or cancel, then this REF segment 

must contain the original payer 

claim number. 85 

2010 BB of 837 SBR03 names this 

equal to group no. 

Page 18 of 63


164 

Entity's contract/member number. This change effective 11/1/2010: Entity's 

contract/member number. Note: This code requires use of an Entity Code. 


A8 

check MN companion guide 

165 

Entity's employer name, address and phone. This change effective 11/1/2010: 

Entity's employer name, address and phone. Note: This code requires use of an 



NA 

166 

Entity's employer name. This change effective 11/1/2010: Entity's employer name. 



NA 

167 

Entity's employer address. This change effective 11/1/2010: Entity's employer 

address. Note: This code requires use of an Entity Code. Start: 01/01/1995 | Last 


NA 

168 

Entity's employer phone number. This change effective 11/1/2010: Entity's employer 

phone number. Note: This code requires use of an Entity Code. 


NA 

170 

Entity's employee id. This change effective 11/1/2010: Entity's employee id. Note: 

This code requires use of an Entity Code. Start: 01/01/1995 | 


NA 

171 

Other insurance coverage information (health, liability, auto, etc.). Start: 

01/01/1995 

A6 or A7 

172 Other employer name, address and telephone number. Start: 01/01/1995 NA 

173 

174 

175 

176 

177 

Entity's name, address, phone, gender, DOB, marital status, employment status and 

relation to subscriber. This change effective 11/1/2010: Entity's name, address, 

phone, gender, DOB, marital status, employment status and relation to subscriber. 



Entity's student status. This change effective 11/1/2010: Entity's student status. 



Entity's school name. This change effective 11/1/2010: Entity's school name. Note: 



Entity's school address. This change effective 11/1/2010: Entity's school address. 



Transplant recipient's name, date of birth, gender, relationship to insured. 


NA 

NA 

NA 

NA 

NA 

178 Submitted charges. Start: 01/01/1995 A6 or A7 

179 Outside lab charges. Start: 01/01/1995 follow -- check to see if in 5010 

180 Hospital s semi-private room rate. Start: 01/01/1995 NA 

181 Hospital s room rate. Start: 01/01/1995 NA 

182 

Allowable/paid from primary coverage. This change to be effective 11/1/2010: 

Allowable/paid from other entities coverage NOTE: This code requires the use of an 

entity code. Start: 01/01/1995 | Last Modified: 


A6 or A7 

for secondary claims 

183 

Amount entity has paid. This change effective 11/1/2010: Amount entity has paid. 



A6 or A7 

patient paid amount must be 

positive value and cannot exceed 

total claim charge amount. 

QC 

Page 19 of 63


184 

Purchase price for the rented durable medical equipment. Start: 

01/01/1995 

A6 or A7 

185 Rental price for durable medical equipment. Start: 01/01/1995 A6 or A7 

186 

Purchase and rental price of durable medical equipment. Start: 

01/01/1995 

187 Date(s) of service. Start: 01/01/1995 A6 or A7 or A8 

188 Statement from-through dates. Start: 01/01/1995 A6 or A7 or A8 

189 Facility admission date. Start: 01/01/1995 | Last Modified: 10/31/2006 A6 or A7 or A8 

190 Facility discharge date. Start: 01/01/1995 | Last Modified: 10/31/2006 A6 or A7 or A8 

191 Date of Last Menstrual Period (LMP) Start: 02/28/1997 A6 or A7 or A8 

192 

Date of first service for current series/symptom/illness. Start: 

01/01/1995 

NA 

ending date of service must be 

greater than or equal to the 

beginning date of service AND 

service line date must be within 

statement date range. (may also 

get this status code when date is 

tied to another reject reason. This 

would always be the second code 

in this case.) 

statement end date must be 

greater than or eequal to statement 

start date. Statement start date 

must be equal to or before 

statement dates. (may also get this 

status code when date is tied to 

another reject reason. This would 

always be the second code in this 

case.) 

Admission date must be equal to or 

before statement dates. 

LMP date can not be greater than 

receipt date. In 837p not in 837I 

NA check to see if in 5010 

193 First consultation/evaluation date. Start: 02/28/1997 check to see if in 5010 

194 Confinement dates. Start: 01/01/1995 NA 

195 

Unable to work dates. This change to be effective 7/1/2010: Unable to work 

dates/Disability Dates. Start: 01/01/1995 | 



196 Return to work dates. Start: 01/01/1995 A6 or A7 or A8 

197 Effective coverage date(s). Start: 01/01/1995 A3 This is patient's coverage 

198 Medicare effective date. Start: 01/01/1995 A3 This is patient's coverage 

199 Date of conception and expected date of delivery. Start: 01/01/1995 NA 

200 Date of equipment return. Start: 01/01/1995 NA 

201 Date of dental appliance prior placement. Start: 01/01/1995 A6 or A7 or A8 

202 

Date of dental prior replacement/reason for replacement. Start: 

01/01/1995 


203 Date of dental appliance placed. Start: 01/01/1995 A6 or A7 or A8 

Page 20 of 63


204 

205 

206 

Date dental canal(s) opened and date service completed. Start: 

01/01/1995 

Date(s) dental root canal therapy previously performed. Start: 

01/01/1995 

Most recent date of curettage, root planing, or periodontal surgery. Start: 

01/01/1995 

NA 

NA 

NA 

207 Dental impression and seating date. Start: 01/01/1995 NA 

208 Most recent date pacemaker was implanted. Start: 01/01/1995 NA no field 

209 Most recent pacemaker battery change date. Start: 01/01/1995 NA 

210 Date of the last x-ray. Start: 01/01/1995 A6 or A7 or A8 

211 Date(s) of dialysis training provided to patient. Start: 01/01/1995 NA 

212 Date of last routine dialysis. Start: 01/01/1995 check 

213 Date of first routine dialysis. Start: 01/01/1995 check 

214 Original date of prescription/orders/referral. Start: 02/28/1997 NA 

215 Date of tooth extraction/evolution. Start: 01/01/1995 A6 or A7 or A8 

216 Drug information. Start: 01/01/1995 A6 missing NDC segment 

217 Drug name, strength and dosage form. Start: 01/01/1995 NA 

218 NDC number. Start: 01/01/1995 A6 or A7 or A8 

219 Prescription number. Start: 01/01/1995 A6 or A7 2410 ref segment 

220 Drug product id number. Start: 01/01/1995 NA 

221 

222 

Drug days supply and dosage. Start: 01/01/1995 

Last Modified: 01/24/2010 | Stop: 01/01/2012 

Drug dispensing units and average wholesale price (AWP). Start: 

01/01/1995 

| Discontinued 01- check 

01-12 

check 

223 Route of drug/myelogram administration. Start: 01/01/1995 NA 

224 Anatomical location for joint injection. Start: 01/01/1995 NA 

225 Anatomical location. Start: 01/01/1995 NA 

226 Joint injection site. Start: 01/01/1995 NA 

227 Hospital information. Start: 01/01/1995 NA 

228 

Type of bill for UB claim Start: 01/01/1995 | 

Last Modified: 10/31/2006 


Invalid type of bill (3 digit 

combination of CLM05-1 and 

CLM05-3) 

229 Hospital admission source. Start: 01/01/1995 A6 or A7 or A8 

230 Hospital admission hour. Start: 01/01/1995 A6 or A7 or A8 

Page 21 of 63


231 Hospital admission type. Start: 01/01/1995 A6 or A7 or A8 

232 Admitting diagnosis. Start: 01/01/1995 A6 or A7 or A8 

233 Hospital discharge hour. Start: 01/01/1995 A6 or A7 or A8 

234 Patient discharge status. Start: 01/01/1995 A6 or A7 or A8 

235 Units of blood furnished. Start: 01/01/1995 NA 

236 Units of blood replaced. Start: 01/01/1995 NA 

237 Units of deductible blood. Start: 01/01/1995 NA 

Admitting diagnosis must be 

present. Admitting diagnosis must 

be a valid value for the admit date, 

dates of service and statement 

from dates submitted. 

238 Separate claim for mother/baby charges. Start: 01/01/1995 A3 

239 Dental information. Start: 01/01/1995 NA 

To be used if mother and baby 

charges are in one claim 

240 Tooth surface(s) involved. Start: 01/01/1995 A6 or A7 or A8 

241 List of all missing teeth (upper and lower). Start: 01/01/1995 NA check 

242 

Tooth numbers, surfaces, and/or quadrants involved. Start: 

01/01/1995 


243 Months of dental treatment remaining. Start: 01/01/1995 A6 or A7 or A8 

244 Tooth number or letter. Start: 01/01/1995 A6 or A7 

245 Dental quadrant/arch. Start: 01/01/1995 A6 or A7 

246 

Total orthodontic service fee, initial appliance fee, monthly fee, length of service. 

Start: 01/01/1995 

NA 

247 Line information. Start: 01/01/1995 NA 

248 

Accident date, state, description and cause. Start: 

01/01/1995 | Last Modified: 01/24/2010 | Stop: 01/01/2012 

249 Place of service. Start: 01/01/1995 A6 or A7 or A8 

250 Type of service. Start: 01/01/1995 NA 

Discontinued 01- check for separate versions of 248 

01-12 

251 Total anesthesia minutes. Start: 01/01/1995 A6 or A7 this is for units 

252 Authorization/certification number. Start: 01/01/1995 A6 or A7 

254 Primary diagnosis code. Start: 01/01/1995 A6 or A7 

255 Diagnosis code. Start: 01/01/1995 A7 

256 DRG code(s). Start: 01/01/1995 A6 or A7 

Diagnosis code must be a valid 

ICD-9-CM Code. 

257 ADSM-III-R code for services rendered. Start: 01/01/1995 NA 

Page 22 of 63


258 Days/units for procedure/revenue code. Start: 01/01/1995 A6 or A7 or A8 

259 Frequency of service. Start: 01/01/1995 A6 or A7 or A8 

260 Length of medical necessity, including begin date. Start: 02/28/1997 NA 

261 Obesity measurements. Start: 01/01/1995 NA 

262 

Type of surgery/service for which anesthesia was administered. Start: 

01/01/1995 

263 Length of time for services rendered. Start: 01/01/1995 NA check 

264 

Number of liters/minute & total hours/day for respiratory support. Start: 

01/01/1995 

265 Number of lesions excised. Start: 01/01/1995 NA 

266 Facility point of origin and destination - ambulance. Start: 01/01/1995 A3 or A8 

267 Number of miles patient was transported. Start: 01/01/1995 A6 or A7 or A8 

NA 

NA 

Unit value billed is inconsistent with 

procedure code. 

CR1 segment is missing or is 

relational to the procedure 

ending point on 7-15-10 -- see 

assignments for individual followup 

KUPPE 268 - 300 

This is not a clear 

enough reason - 

do not use 

268 Location of durable medical equipment use. Start: 01/01/1995 NA Currently, this is 

not sent 

269 Length/size of laceration/tumor. Start: 01/01/1995 NA Currently, this is 

not sent 

270 Subluxation location. Start: 01/01/1995 NA Currently, this is 

not sent 

271 Number of spine segments. Start: 01/01/1995 NA Currently, this is 

not sent 

272 Oxygen contents for oxygen system rental. Start: 01/01/1995 NA 

273 Weight. Start: 01/01/1995 NA Currently, this is 

not sent 

274 Height. Start: 01/01/1995 NA Currently, this is 

not sent 

275 Claim. Start: 01/01/1995 NA 

276 

UB04/HCFA-1450/1500 claim form Start: 01/01/1995 

| Last Modified: 10/31/2006 

277 Paper claim. Start: 01/01/1995 NA 

278 Signed claim form. Start: 01/01/1995 NA 

NA 

85 

Not clear 

279 Itemized claim. Start: 01/01/1995 

PWK Attachment 

Page 23 of 63


280 Itemized claim by provider. Start: 01/01/1995 

281 Related confinement claim. Start: 01/01/1995 

282 Copy of prescription. Start: 01/01/1995 NA 



283 

Medicare entitlement information is required to determine primary coverage 


NA 


284 Copy of Medicare ID card. Start: 01/01/1995 NA 


285 Vouchers/explanation of benefits (EOB). Start: 01/01/1995 NA 

286 

Other payer's Explanation of Benefits/payment information. Start: 

01/01/1995 

A6 

If report type cd (PWK01) = EB 

(EOB) then PWK02 (transmission 

code) must not =AA (available at 

provider's site). 

see 286 


287 Medical necessity for service. Start: 01/01/1995 NA Currently, this is 

not sent 

288 Reason for late hospital charges. Start: 01/01/1995 

289 Reason for late discharge. Start: 01/01/1995 

NA for PB 

NA for PB 

290 Pre-existing information. Start: 01/01/1995 Currently, this is 

not sent 

291 Reason for termination of pregnancy. Start: 01/01/1995 Currently, this is 

not sent 

292 Purpose of family conference/therapy. Start: 01/01/1995 Currently, this is 

not sent 

293 Reason for physical therapy. Start: 01/01/1995 Currently, this is 

not sent 

294 Supporting documentation. Start: 01/01/1995 

295 Attending physician report. Start: 01/01/1995 

296 Nurse's notes. Start: 01/01/1995 

297 Medical notes/report. Start: 02/28/1997 

298 Operative report. Start: 01/01/1995 






Page 24 of 63


299 Emergency room notes/report. Start: 01/01/1995 


300 Lab/test report/notes/results. Start: 02/28/1997 


KLUG 301 - 350 837P 837I Support 

301 MRI report. Start: 01/01/1995 

304 Reports for service. Start: 01/01/1995 

305 X-ray reports/interpretation. Start: 01/01/1995 

306 Detailed description of service. Start: 01/01/1995 

307 Narrative with pocket depth chart. Start: 01/01/1995 

NA ‐ ‐ 

NA ‐ ‐ 

NA ‐ ‐ 

NA ‐ ‐ 

NA ‐ ‐ 

? No 837D 

available 

308 Discharge summary. Start: 01/01/1995 


NA PWK*DS PWK*DS 

Progress notes for the six months prior to statement date. Start: 

01/01/1995 NA ‐ ‐ 

NA‐Best practice 

for PWK indicate 3 

days. TAG agreed 

277CA returned 

within 24 hours of 

receipt from 

provider 

311 Pathology notes/report. Start: 01/01/1995 

312 Dental charting. Start: 01/01/1995 

313 Bridgework information. Start: 01/01/1995 

314 Dental records for this service. Start: 01/01/1995 

315 Past perio treatment history. Start: 01/01/1995 

NA PWK*P4 PWK*P4 

NA ‐ ‐ 

NA ‐ ‐ 

NA ‐ ‐ 

NA ‐ ‐ 

? No 837D 

available 

316 Complete medical history. Start: 01/01/1995 

NA PWK*P5 PWK*P5 






receipt from 

provider 

Page 25 of 63


317 Patient's medical records. Start: 01/01/1995 

NA PWK*M1 PWK*M1 






receipt from 

provider 

318 X-rays. Start: 01/01/1995 

NA PWK*MT PWK*MT 






receipt from 

provider 

319 Pre/post-operative x-rays/photographs. Start: 02/28/1997 

320 Study models. Start: 01/01/1995 

NA PWK*XP PWK*XP 

NA ‐ ‐ 






receipt from 

provider 

321 Radiographs or models. Start: 01/01/1995 

322 Recent fm x-rays. Start: 01/01/1995 

323 Study models, x-rays, and/or narrative. Start: 01/01/1995 

324 Recent x-ray of treatment area and/or narrative. Start: 01/01/1995 

325 Recent fm x-rays and/or narrative. Start: 01/01/1995 

326 Copy of transplant acquisition invoice. Start: 01/01/1995 

NA PWK*MT PWK*MT 

NA ‐ ‐ 

NA ‐ ‐ 

NA ‐ ‐ 

NA ‐ ‐ 

NA ‐ ‐ 






receipt from 

provider 

Page 26 of 63


327 

Periodontal case type diagnosis and recent pocket depth chart with narrative. 

Start: 01/01/1995 

NA ‐ ‐ 

329 Exercise notes. Start: 01/01/1995 

330 Occupational notes. Start: 01/01/1995 

331 History and physical. Start: 01/01/1995 | Last Modified: 08/01/2007 

333 Patient release of information authorization. Start: 01/01/1995 

NA ‐ ‐ 

NA ‐ ‐ 

NA ‐ ‐ 

A6/A7 CLM09 CLM09 

334 Oxygen certification. Start: 01/01/1995 

335 Durable medical equipment certification. Start: 01/01/1995 

NA PWK*OX PWK*OX 

A6/A7 PWK*CT ‐ 






receipt from 

provider 

336 Chiropractic certification. Start: 01/01/1995 

337 Ambulance certification/documentation. Start: 01/01/1995 

NA/A6/A7 CR2 CR2 

NA/A6/A7 CRC CRC 

Required on 

chiropractic claims 

involving spinal 

manipulation 

when the 

information is 

known to impact 

the payer’s 

adjudication 

process. If not 

required by this 

implementation 

guide, do not 

send. 

the claim involves 

ambulance 

339 Enteral/parenteral certification. Start: 01/01/1995 

NA PWK*PE PWK*PE 






receipt from 

provider 

Page 27 of 63


340 Pacemaker certification. Start: 01/01/1995 

341 Private duty nursing certification. Start: 01/01/1995 

342 Podiatric certification. Start: 01/01/1995 

NA ‐ ‐ 

NA ‐ ‐ 

NA ‐ ‐ 

343 

344 

Documentation that facility is state licensed and Medicare approved as a surgical 

facility. Start: 01/01/1995 

Documentation that provider of physical therapy is Medicare Part B approved. 

Start: 01/01/1995 

NA ‐ ‐ 

NA ‐ ‐ 

345 Treatment plan for service/diagnosis Start: 01/01/1995 

NA ‐ ‐ 

346 Proposed treatment plan for next 6 months. Start: 01/01/1995 

STROOT 351 - 400 

352 Duration of treatment plan. Start: 01/01/1995 A6, 

353 Orthodontics treatment plan. Start: 01/01/1995 A6, 

354 

Treatment plan for replacement of remaining missing teeth. Start: 

01/01/1995 

355 Has claim been paid? Start: 01/01/1995 NA 

356 Was blood furnished? Start: 01/01/1995 NA 

357 Has or will blood be replaced? Start: 01/01/1995 NA 

358 Does provider accept assignment of benefits? Start: 01/01/1995 NA 

359 Is there a release of information signature on file? Start: 01/01/1995 NA 

NA ‐ ‐ 

NA 

DN1 segment - Treatment months 

could be missing 

DN1 segment - Treatment months, 

or DN1-04 could be missing. 

360 

Is there an assignment of benefits signature on file? Start: 

01/01/1995 

361 Is there other insurance? Start: 01/01/1995 NA 

362 Is the dental patient covered by medical insurance? Start: 01/01/1995 NA 

363 

364 

Will worker's compensation cover submitted charges? Start: 

01/01/1995 

Is accident/illness/condition employment related? Start: 

01/01/1995 

365 Is service the result of an accident? Start: 01/01/1995 NA 

366 Is injury due to auto accident? Start: 01/01/1995 NA 

367 

Is service performed for a recurring condition or new condition? Start: 

01/01/1995 

NA 

NA 

NA 

NA 

Could this be "A6" missing COB 

information? 

Could this be "A6" missing 

condition information (HI 

segment)? 



segment)? 



segment)? 

368 

Is medical doctor (MD) or doctor of osteopath (DO) on staff of this facility? 

Start: 01/01/1995 

NA 

Page 28 of 63


369 

Does patient condition preclude use of ordinary bed? Start: 

01/01/1995 

370 Can patient operate controls of bed? Start: 01/01/1995 NA 

371 Is patient confined to room? Start: 01/01/1995 NA 

372 Is patient confined to bed? Start: 01/01/1995 NA 

373 Is patient an insulin diabetic? Start: 01/01/1995 NA 

374 Is prescribed lenses a result of cataract surgery? Start: 01/01/1995 NA 

375 Was refraction performed? Start: 01/01/1995 NA 

NA 

376 Was charge for ambulance for a round-trip? Start: 01/01/1995 NA 

377 

Was durable medical equipment purchased new or used? Start: 

01/01/1995 

378 Is pacemaker temporary or permanent? Start: 01/01/1995 NA 

NA 

Could this be "A6" missing CR1-09 

information? 

379 

380 

Were services performed supervised by a physician? Start: 

01/01/1995 

Were services performed by a CRNA under appropriate medical direction? 

Start: 01/01/1995 | Last Modified: 10/31/1999 

NA 

NA 

381 Is drug generic? Start: 01/01/1995 NA 

382 

383 

384 

Did provider authorize generic or brand name dispensing? Start: 

01/01/1995 

Was nerve block used for surgical procedure or pain management? Start: 

01/01/1995 

Is prosthesis/crown/inlay placement an initial placement or a replacement? 

Start: 01/01/1995 

NA 

NA 

NA 

385 

Is appliance upper or lower arch & is appliance fixed or removable? Start: 

01/01/1995 

386 Is service for orthodontic purposes? Start: 01/01/1995 NA 

387 

Date patient last examined by entity. This change effective 11/1/2010: Date patient 

last examined by entity. Note: This code requires use of an Entity Code. 


388 Date post-operative care assumed. Start: 02/28/1997 A8 

389 Date post-operative care relinquished. Start: 02/28/1997 A8 

390 

Date of most recent medical event necessitating service(s). Start: 

02/28/1997 

391 Date(s) dialysis conducted. Start: 02/28/1997 NA 

392 Date(s) of blood transfusion(s) Start: 02/28/1997 NA 

393 Date of previous pacemaker check. Start: 02/28/1997 NA 

NA 

A6, A8 DTP*304 (Last Seen Date) 

?? 

Assume care date may not be 

greater than receipt date. 

Relinquish care date cannot be 

greater than receipt date. 

Is this the same as code 397 

below? 

394 

Date(s) of most recent hospitalization related to service. Start: 

02/28/1997 

NA 

Page 29 of 63


395 

Date entity signed certification/recertification This change effective 11/1/2010: Date 

entity signed certification/recertification Note: This code requires use of an Entity 

Code. Start: 02/28/1997 | Last Modified: 02/11/2010 

NA 

396 Date home dialysis began. Start: 02/28/1997 NA 

397 Date of onset/exacerbation of illness/condition. Start: 02/28/1997 A8 

Onset date of current 

illness/symptom cannot be greater 

than receipt date. 

398 Visual field test results. Start: 02/28/1997 NA 

399 

Report of prior testing related to this service, including dates Start: 

02/28/1997 

NA 

400 Claim is out of balance. Start: 02/28/1997 

WICHTERMAN 401 - 450 

401 Source of payment is not valid. Start: 02/28/1997 NA 

402 

Amount must be greater than zero. Note: At least one other status code is required 

to identify which amount element is in error. Start: 02/28/1997 | Last 

Modified: 09/20/2009 

A3 A6 A7 

403 Entity referral notes/orders/prescription. Start: 02/28/1997 A6 A7 

404 

Specific findings, complaints, or symptoms necessitating service. Start: 

02/28/1997 

A6 

405 Summary of services. Start: 02/28/1997 A6 

406 Brief medical history as related to service(s). Start: 02/28/1997 NA 

407 Complications/mitigating circumstances. Start: 02/28/1997 NA 

408 Initial certification. Start: 02/28/1997 A6 

409 


Medication logs/records (including medication therapy). Start: 

02/28/1997 

Explain differences between treatment plan and patient's condition. Start: 

02/28/1997 

NA 

NA 

411 Medical necessity for non-routine service(s). Start: 02/28/1997 A6 

412 

413 

Medical records to substantiate decision of non-coverage. Start: 

02/28/1997 

Explain/justify differences between treatment plan and services rendered. 

Start: 02/28/1997 

NA 

NA 

414 Need for more than one physician to treat patient. Start: 02/28/1997 A6 

415 Justify services outside composite rate. Start: 02/28/1997 A6 

416 

417 

Verification of patient's ability to retain and use information. Start: 

02/28/1997 

Prior testing, including result(s) and date(s) as related to service(s). Start: 

02/28/1997 

NA 

A6 

418 Indicating why medications cannot be taken orally. Start: 02/28/1997 A6 

419 

Individual test(s) comprising the panel and the charges for each test. Start: 

02/28/1997 

A6 

Page 30 of 63


420 

421 

Name, dosage and medical justification of contrast material used for radiology 

procedure Start: 02/28/1997 

Medical review attachment/information for service(s). Start: 

02/28/1997 

A6 

A6 

422 Homebound status. Start: 02/28/1997 NA 

424 Statement of non-coverage including itemized bill. Start: 02/28/1997 A6 

425 Itemize non-covered services. Start: 02/28/1997 A6 

426 All current diagnoses Start: 02/28/1997 A6 

427 Emergency care provided during transport. Start: 02/28/1997 A6 

428 Reason for transport by ambulance. Start: 02/28/1997 A6 


Loaded miles and charges for transport to nearest facility with appropriate 

services. Start: 02/28/1997 

A6 

430 Nearest appropriate facility. Start: 02/28/1997 A6 

431 

Provide condition/functional status at time of service. Start: 

02/28/1997 

A6 

432 Date benefits exhausted. Start: 02/28/1997 A6 

433 Copy of patient revocation of hospice benefits. Start: 02/28/1997 A6 

434 

Reasons for more than one transfer per entitlement period Start: 

02/28/1997 

A6 

435 Notice of Admission. Start: 02/28/1997 A6 

436 Short term goals. Start: 02/28/1997 A6 

437 Long term goals. Start: 02/28/1997 A6 

438 Number of patients attending session. Start: 02/28/1997 A6 

439 Size, depth, amount, and type of drainage wounds. Start: 02/28/1997 NA 

440 

Why non-skilled caregiver has not been taught procedure. Start: 

02/28/1997 

NA 

441 Entity professional qualification for service(s). Start: 02/28/1997 A6 

442 Modalities of service. Start: 02/28/1997 A6 

443 Initial evaluation report. Start: 02/28/1997 A6 

444 Method used to obtain test sample. Start: 02/28/1997 NA 

445 

446 

Explain why hearing loss not correctable by hearing aid. Start: 

02/28/1997 

Documentation from prior claim(s) related to service(s). Start: 

02/28/1997 

NA 

NA 

447 Plan of teaching. Start: 02/28/1997 NA 

Page 31 of 63


448 

Invalid billing combination. See STC12 for details. This code should only be used to 

indicate an inconsistency between two or more data elements on the claim. A 

detailed explanation is required in STC12 when this code is used. 

Start: 02/28/1997 | Last Modified: 01/24/2010 | Stop: 01/01/2012 

Discontinued 01- 

01-12 

449 Projected date to discontinue service(s). Start: 02/28/1997 A6 

450 Awaiting spend down determination. Start: 02/28/1997 NA 

WILLIAMS 451 - 450 

451 Preoperative and post-operative diagnosis. Start: 02/28/1997 NA 

452 

Total visits in total number of hours/day and total number of hours/week. 

Start: 02/28/1997 

453 Procedure Code Modifier(s) for Service(s) Rendered. Start: 02/28/1997 A6, A7 

454 Procedure code for services rendered. Start: 02/28/1997 A6, A7 

455 Revenue code for services rendered. Start: 02/28/1997 A6, A7 

456 Covered Day(s) Start: 02/28/1997 A7 

457 Non-Covered Day(s) Start: 02/28/1997 NA 

458 Coinsurance Day(s) Start: 02/28/1997 NA 

459 Lifetime Reserve Day(s) Start: 02/28/1997 NA 

460 NUBC Condition Code(s) Start: 02/28/1997 A7 

461 

462 

463 

464 

NUBC Occurrence Code(s) and Date(s) Start: 


NUBC Occurrence Span Code(s) and Date(s) Start: 


NUBC Value Code(s) and/or Amount(s) Start: 02/28/1997 

| Last Modified: 01/24/2010 | Stop: 01/01/2012 

Payer Assigned Claim Control Number Start: 02/28/1997 

| Last Modified: 10/31/2004 

NA 


01-12 


01-12 


01-12 

465 Principal Procedure Code for Service(s) Rendered Start: 02/28/1997 A7, A8 

466 

467 

Entities Original Signature. This change effective 11/1/2010: Entities Original 

Signature. Note: This code requires use of an Entity Code. Start: 02/28/1997 | Last 


Entity Signature Date. This change effective 11/1/2010: Entity Signature Date. Note: 



468 Patient Signature Source. Start: 02/28/1997 NA 

469 Purchase Service Charge. Start: 02/28/1997 

NA 

NA 

NA 

If principal procedure code is 

present then this date is required 

(A8). 

470 

Was service purchased from another entity? This change effective 11/1/2010: Was 

service purchased from another entity? Note: This code requires use of an Entity 


NA 

Page 32 of 63


471 Were services related to an emergency? Start: 02/28/1997 NA 

472 Ambulance Run Sheet. Start: 02/28/1997 NA 

473 Missing or invalid lab indicator. Start: 06/30/1998 A7, A8 

474 

475 

Procedure code and patient gender mismatch. Start: 06/30/1998 

| Last Modified: 02/29/2000 

Procedure code not valid for patient age Start: 

06/30/1998 | Last Modified: 02/29/2000 

476 Missing or invalid units of service. Start: 06/30/1998 A7 

477 Diagnosis code pointer is missing or invalid. Start: 06/30/1998 A8 

478 

Claim submitter's identifier (patient account number) is missing. This change to be 

effective 11/1/2010 - Claim submitter's identifier. Start: 06/30/1998 | Last 


479 Other Carrier payer ID is missing or invalid. Start: 06/30/1998 A6 

A8 

A8 

A6 

Number of services cannot be zero 

or a negative value. 

First diagnosis pointer cannot point 

to "E" diagnosis. 

480 

Other Carrier Claim filing indicator is missing or invalid. Start: 

06/30/1998 

481 Claim/submission format is invalid. Start: 10/31/1998 A3 

482 

483 

Date Error, Century Missing. Start: 02/28/1999 | 

Last Modified: 09/20/2009 | Stop: 10/01/2010 

Maximum coverage amount met or exceeded for benefit period. Start: 

06/30/1999 

484 Business Application Currently Not Available. Start: 02/29/2000 NA 

A6, A7 

A6, A7 

NA 

85 

485 

More information available than can be returned in real time mode. Narrow your 

current search criteria. Start: 02/28/2001 

NA 

486 

Principal Procedure Date. Start: 10/31/2001 | 

Last Modified: 07/01/2009 

A8 

If principal procedure code is 

present then this date is required. 

487 

Claim not found, claim should have been submitted to/through 'entity'. This change 

effective 11/1/2010: Claim not found, claim should have been submitted to/through 

'entity'. Note: This code requires use of an Entity Code. Start: 


A3 

488 Diagnosis code(s) for the services rendered. Start: 06/30/2002 A6, A7 

489 Attachment Control Number. Start: 10/31/2002 A8 

490 Other Procedure Code for Service(s) Rendered. Start: 02/28/2003 A7 

491 

Entity not eligible for encounter submission. This change effective 11/1/2010: Entity 

not eligible for encounter submission. Note: This code requires use of an Entity 


NA 

492 Other Procedure Date. Start: 02/28/2003 A8 

If other procedure code is present, 

then this date is required. 

493 

Version/Release/Industry ID code not currently supported by information holder. 

Start: 02/28/2003 

A3 

Page 33 of 63


494 

495 

Real-Time requests not supported by the information holder, resubmit as batch 

request. Start: 02/28/2003 

Requests for re-adjudication must reference the newly assigned payer claim control 

number for this previously adjusted claim. Correct the payer claim control number 

and re-submit. Start: 10/31/2003 

NA 

A8 

496 

Submitter not approved for electronic claim submissions on behalf of this entity. 

This change effective 11/1/2010: Submitter not approved for electronic claim 

submissions on behalf of this entity. Note: This code requires use of an Entity 

Code. Start: 02/29/2004 | Last Modified: 02/11/2010 

A3 

497 Sales tax not paid. Start: 06/30/2004 NA 

498 Maximum leave days exhausted. Start: 06/30/2004 NA 

499 

500 

501 

502 

503 

504 

505 

No rate on file with the payer for this service for this entity This change effective 

11/1/2010: No rate on file with the payer for this service for this entity Note: This 



Entity's Postal/Zip Code. This change effective 11/1/2010: Entity's Postal/Zip Code. 



ROY 501 - 550 

Entity's State/Province. This change effective 11/1/2010: Entity's State/Province. 



Entity's City. This change effective 11/1/2010: Entity's City. Note: This code requires 

use of an Entity Code. Start: 06/30/2004 | Last 


Entity's Street Address. This change effective 11/1/2010: Entity's Street Address. 



Entity's Last Name. This change effective 11/1/2010: Entity's Last Name. Note: This 



Entity's First Name. This change effective 11/1/2010: Entity's First Name. Note: This 



NA 

A7 

A7 

77, 85, 87, DK, GB, 

HK, PR, QC, SEP 

77, 85, 87, DK, GB, 

HK, PR, QC 

506 

Entity is changing processor/clearinghouse. This claim must be submitted to the 

new processor/clearinghouse. This change effective 11/1/2010: Entity is changing 

processor/clearinghouse. This claim must be submitted to the new 

processor/clearinghouse. Note: This code requires use of an Entity Code. 


NA 

507 HCPCS Start: 10/31/2004 

508 

ICD9 NOTE: At least one other status code is required to identify the related 

procedure code or diagnosis code. Start: 10/31/2004 | Last 

Modified: 07/01/2009 

509 E-Code Start: 10/31/2004 A7, A8 


Future date. This change to be effective 7/1/2010: Future date. Note: At least one 

other status code is required to identify the data element in error. 

Start: 10/31/2004 | Last Modified: 09/20/2009 

??? 

A8 

Similar to code 21, questioning 

value if another more specific code 

is needed. 

First diagnosis pointer cannot point 

to "E" diagnosis (A8). 

LMP date can not be greater than 

receipt date. 

Page 34 of 63


511 

512 

Invalid character. This change to be effective 7/1/2010: Invalid character. Note: At 

least one other status code is required to identify the data element in error. 


Length invalid for receiver's application system. This change to be effective 

7/1/2010: Length invalid for receiver's application system. Note: At least one other 

status code is required to identify the data element in error. 


513 HIPPS Rate Code for services Rendered Start: 10/31/2004 A7 

514 

Entities Middle Name This change effective 11/1/2010: Entities Middle Name Note: 

This code requires use of an Entity Code. Start: 10/31/2004 | Last 


Product or service ID qualifier must 

equal HC or ZZ. 

515 Managed Care review Start: 10/31/2004 

516 

Adjudication or Payment Date. This change to be effective 7/1/2010: Other Entity's 

Adjudication or Payment/Remittance Date. Note: An Entity code is required to 

identify the Other Payer Entity, i.e. primary, secondary. Start: 

10/31/2004 | Last Modified: 11/29/2009 

517 Adjusted Repriced Claim Reference Number Start: 10/31/2004 

518 Adjusted Repriced Line item Reference Number Start: 10/31/2004 

519 Adjustment Amount Start: 10/31/2004 

520 Adjustment Quantity Start: 10/31/2004 

521 Adjustment Reason Code Start: 10/31/2004 A7 

522 Anesthesia Modifying Units Start: 10/31/2004 

523 Anesthesia Unit Count Start: 10/31/2004 

524 Arterial Blood Gas Quantity Start: 10/31/2004 

525 Begin Therapy Date Start: 10/31/2004 

526 Bundled or Unbundled Line Number Start: 10/31/2004 

527 Certification Condition Indicator Start: 10/31/2004 

528 Certification Period Projected Visit Count Start: 10/31/2004 

529 Certification Revision Date Start: 10/31/2004 

530 Claim Adjustment Indicator Start: 10/31/2004 A8 

When CLM Freq Type Cd (CLM05- 

3) indicates claim is a replacement 

or cancel, then this REF segment 

must contain the original payer 

claim number. 85 

531 Claim Disproportinate Share Amount Start: 10/31/2004 

532 Claim DRG Amount Start: 10/31/2004 

Page 35 of 63


533 Claim DRG Outlier Amount Start: 10/31/2004 

534 Claim ESRD Payment Amount Start: 10/31/2004 

535 Claim Frequency Code Start: 10/31/2004 A3, A7 

A3 used when 

original claim is 

medicare crossover 

to indicate that 

Medicare must be 

replaced or 

cancelled first. A7 

is used when the 

value submitted is 

not valid. 

536 Claim Indirect Teaching Amount Start: 10/31/2004 

537 Claim MSP Pass-through Amount Start: 10/31/2004 

538 Claim or Encounter Identifier Start: 10/31/2004 

539 Claim PPS Capital Amount Start: 10/31/2004 

540 Claim PPS Capital Outlier Amount Start: 10/31/2004 

541 Claim Submission Reason Code Start: 10/31/2004 

542 Claim Total Denied Charge Amount Start: 10/31/2004 

543 Clearinghouse or Value Added Network Trace Start: 10/31/2004 

544 Clinical Laboratory Improvement Amendment Start: 10/31/2004 

545 Contract Amount Start: 10/31/2004 

546 Contract Code Start: 10/31/2004 

547 Contract Percentage Start: 10/31/2004 

548 Contract Type Code Start: 10/31/2004 

549 Contract Version Identifier Start: 10/31/2004 

550 Coordination of Benefits Code Start: 10/31/2004 

WILSON 551 - 600 

551 Coordination of Benefits Total Submitted Charge Start: 10/31/2004 A6,A7 ??? Not is 5010 837 

Additiona 837 l 

Comments 

Page 36 of 63


552 Cost Report Day Count Start: 10/31/2004 A6 

553 Covered Amount Start: 10/31/2004 A6 

554 Date Claim Paid Start: 10/31/2004 A6, A7 

555 Delay Reason Code Start: 10/31/2004 A6 

556 Demonstration Project Identifier Start: 10/31/2004 A6 

837I only: Cost Report Day Count 

is missing (A6) 

????? 837 only references the noncovered 

amount 

837 P,I, D: Date Claim Paid is 

missing (A6) Or invalid (A7) 

837 P,I D: Delay Reason Code is 

Missing (A6) 

837 P,& I Demonstration Project 

Identifier is missing (A6) 

CMS Situtiational 

Rule: Required 

when inpatient 

adjudication 


reported in the 

remittance 

advice.OR 

Required when it 

is necessary to 

report remark 

codes. 

2330B DTP*573 

Situational Rules: 

Required when the 

claim is submitted 

late (past 

contracted date of 

filing 

limitations).2300 

CLM20 

Stiuational 

Rule:Required 

when it is 

necessary to 

identify claims 

which are atypical 

in ways such as 

content, purpose, 

and/or payment, 

as could be the 

case for a 

demonstration or 

other special 

project, or a 

clinical trial:. 

Page 37 of 63


557 Diagnosis Date Start: 10/31/2004 A6,A7 

Required for Home HealthCare 

billling. Date of Onset or 

Exacerbation of Principal 

Diagnosis: Diagnosis Date is 

missing (A6) OR invalid (A7) 

Most of the Home 

HealthCare 

segments have 

been removed in 

5010. 837i, Home 

HealthCare 

Information, 

primary is CR605, 

secondary diag 1 

is CR618, diag 2 is 

CR619, diag 3 is 

CR620, diag 4 is 

CR621 

558 Discount Amount Start: 10/31/2004 A6,A7 

837P & D 5010 -Discount Amount 

Section Removed. 837I references 

the term "Discount Percentage ??? 

Discount Percentage Amount is 


837 I Terms 

Discount Percent : 

Terms discount 

percentage, 

expressed as a 

percent, available 

to the purchaser if 

an invoice is paid 

on or before the 

Terms Discount 

Due Date 

SITUATIONAL 

RULE: Required 

when the provider 

is required by 

contract 

to supply this 

information on the 

claim. 

IMPLEMENTATIO 

N NAME: Terms 

Discount 

Percentage 

Page 38 of 63


559 Document Control Identifier Start: 10/31/2004 A6, A7 

837 P&I: Payer document Control 

Number Identifier is missing (A6) 

OR invalid (A7) 

837 P, I: Required 

when CLM05-3 

(Claim Frequency 

Code) indicates 

this claim is a 

replacement or 

void to a 

previously 

adjudicated claim . 

TR3 Note: This 


specific to the 

destination payer 

reported in Loop 

ID-2010BB. 

560 

Entity's Additional/Secondary Identifier. This change effective 11/1/2010: Entity's 

Additional/Secondary Identifier. Note: This code requires use of an Entity Code. 

Start: 10/31/2004 | Last Modified: 02/11/2010 

A6,A7 

837 P,I D : Missing required 

secondary identifier (A6) OR 

Invalid secondary identifier (A7) 

41, FA,HK,82,85, 

DN, 71, 72, DQ, 

73,DD,,DK, PR 

561 

562 

Entity's Contact Name. This change effective 11/1/2010: Entity's Contact Name. 

Note: This code requires use of an Entity Code. Start: 10/31/2004 | Last 


Entity's National Provider Identifier (NPI). This change effective 11/1/2010: Entity's 

National Provider Identifier (NPI). Note: This code requires use of an Entity Code. 


A6, A7 

A3, A6, A7, A8 

837 P, I, D: Submitter or Billing 

Provider Contact Name is missing ( 

A6) OR Invalid ( A7) 

837 P,I,D: NPI has not been 

reported to the payer (A3). OR NPI 

is missing and provider is not 

atypical (A6) OR NPI is invalid 

(A7). OR multiple provider type 

identifiers are not allowed on the 

same claim (A8). 

85 Billing Provider 

41 Submitter 

41, FA,HK,82,85, 

DN, 71, 72, DQ, 

73,DD,DK, PR 

Page 39 of 63


563 

Entity's Tax Amount. This change effective 11/1/2010: Entity's Tax Amount. Note: 

This code requires use of an Entity Code. Start: 10/31/2004 | 


A6 

837, P, I, D : Sales Tax amount is 

missing (A6) 

85 Billing Provider 

Situational 

Rule:Required 

when sales tax 

applies to the 

service line and 

the submitter is 

required to report 

that information to 

the receiver. If not 



guide, do not 

send. TR3 

Note:When 

reporting the Sales 

Tax Amount 

(AMT02), the 

amount reported 

in the Line Item 

Charge Amount 

(SV102) for this 

service line must 

include the 

amount reported in 

the Sales Tax 

Amount. 

564 EPSDT Indicator Start: 10/31/2004 A6 A7 

837 P, I , D: EPSDT Indicator is 


565 Estimated Claim Due Amount Start: 10/31/2004 A6,A7 

837 I: Required when the Patient 

Responsibility Amount is applicable 

to this claim. Estimated Claim Due 

Amount is missing (A6) OR invalid 

(A7) 

QC 

837i only. The 

payer Estimated 

Claim Due Amount 

was removed in 

5010. Only the 

patient claim due 

amount remains. 

2300 loop AMT*F3 

566 Exception Code Start: 10/31/2004 A6 A7 

937 P,I, D: Required when this 

information is deemed necessary 

by the repricer. The segment is not 

completed by providers. The 

information is completed by 

repricers only. Exception Code is 


The only 

esxception code I 

could find, other 

that the service 

authorization 

exception code, is 

th one use in the 

HCP reprising 

information 

segment. 2300 

and 2400 loops in 

HCP15 

Page 40 of 63


567 Facility Code Qualifier Start: 10/31/2004 A6, A7 

568 Family Planning Indicator Start: 10/31/2004 A6, A7 

569 Fixed Format Information Start: 10/31/2004 A6 

837 P, I , D. :Facility Code 

Quallifier is missing (A6) OR 

invalid (A7) 

837 P & I: Required when 

applicable for Medicaid claims; 

Family Planning Indicator is 


837 P, I , D: See TR3 Notes: If K3 

segment is approved for use by 

X12, then the following would 

apply: Fixed Format Informatiion 

missing (A6) 

In 4010 this was 

"NOT USED" in 

the 837p. 2300 

loop CLM05-2 

2400 loop SV112 

TR3 Notes:At the 

time of publication 

of this 

implementation, 

K3 segments have 

no specific use. 

The K3 segment is 

expected to be 

used only when 

necessary to meet 

the unexpected 

data requirement 

of a legislative 

authority. Before 

this segment can 

be used : 

- The X12N Health 

Care Claim 

workgroup must 

conclude there is 

no 

other available 

option in the 


guide to meet the 

emergency 

legislative 

requirement. 

- The requestor 

must submit a 

proposal for 

approval 

accompanied by 

Page 41 of 63


570 Free Form Message Text Start: 10/31/2004 ???? 

571 Frequency Count Start: 10/31/2004 ??? 

572 Frequency Period Start: 10/31/2004 ???? 

573 Functional Limitation Code Start: 10/31/2004 A6 A7 

574 HCPCS Payable Amount Home Health Start: 10/31/2004 ??? 

837 P, I. D: If NTE Segment is 

used, then NTE03 is required. 

Free Form Message Text is 

missing ( A6)OR invalid (A7) 

Formerly in the Home HealthCare 

HSD segment. No longer used in 

5010. HSD04 

Formerly in the Home HealthCare 

HSD segment. No longer used in 

5010. HSD03 

837 P: Functional Limitation Code 

is missing (A6) OR invalid (A7) 

837P & I : Cannot find specifc to 

home heatlh?? 

Situational Rule: to 

substantiate the 

medical treatment 

and is not 

supported 

elsewhere 

within the claim 

data set. OR 

Required when in 

the judgment of 

the provider, 

narrative 

information from 

the forms “Home 

Health 

Certification and 

Plan of Treatment” 

or “Medical 

Update and 

Patient 

Information” is 

needed to 

substantiate home 

health 

services. If not 



guide, do not 

send. 

206 TR3 Notes: 1. 

The developers of 

this 


The only functional 

limitation 

reference is the 

CRC*75 segment 

in the 837p. Not 

sure what the 

code would be. 

Does not 

specifically state 

home health…just 

HCPCS Montary 

Amt. (2320 

HCPCS Payable 

Amount in 

MOA02) 

Page 42 of 63


575 Homebound Indicator Start: 10/31/2004 A6 A7 

576 Immunization Batch Number Start: 10/31/2004 A6 

577 Industry Code Start: 10/31/2004 A6 A7 

578 Insurance Type Code Start: 10/31/2004 A6 A7 

579 Investigational Device Exemption Identifier Start: 10/31/2004 A6 A7 

580 Last Certification Date Start: 10/31/2004 

581 Last Worked Date Start: 10/31/2004 A6 

582 Lifetime Psychiatric Days Count Start: 10/31/2004 A6 

583 Line Item Charge Amount Start: 10/31/2004 A3 A6 

837 P& I :Homebound Indicator is 


837P: Immunization Batch Number 

missing (A6) 

837 P,I, D : Industry Code missing 

(A6) OR invalid ( A7) 

837 P , I , D: Insurance Type Code 

missing (A6) OR invalid ( A7) 

837 P & I : Investigational Device 

Exemption Identifier is missing ( 

A6) OR invalid ( A7) 

837P: Last Certification Date is 


837 P: Last Worked Date is 

missing (A6) 

837I : Lifetime Psychiatric Days 

Count missing ( A6) 

837 P, I, D : Line Item Charge 

Amount was not submitted to the 

payer (A3) OR missing (A6) 

Required for 

Medicare claims 

when an 

independent 

laboratory renders 

an 

EKG tracing or 

obtains a 

specimen from a 

homebound or 

institutionalized 

patient. 2300 loop 

CRC*75 field 

CRC03 

Sum of service 

line charges must 

equal the Total 

Claim Charge 

Amount in Loop 

2300 CLM02 

Page 43 of 63


584 Line Item Control Number Start: 10/31/2004 A6 

837P,I,D: Line Item Control 

Number is missing (A6) 

TR3 NoteS:The 

line item control 

number must be 

unique within a 

patient control 

number (CLM01). 

Payers are 

required to return 

this number in the 

remittance advice 

transaction (835) if 

the provider sends 

it to them in 

the 837 and 

adjudication is 

based upon line 

item detail 

regardless of 

whether bundling 

or unbundling has 

occurred. 2400 

loop REF*6R 

585 

Denied Charge or Non-covered Charge Start: 10/31/2004 

| Last Modified: 07/09/2007 

586 Line Note Text Start: 10/31/2004 A6 A7 

587 Measurement Reference Identification Code Start: 10/31/2004 ?? Cannot find 

588 Medical Record Number Start: 10/31/2004 A6 A7 

A6 

837 P I D: Non Covered Charges 

missing (A6) 

837 P & I: If NTE segment is used 

then NTE02 is required. Line Note 

Text is missing (A6) 

837 P & I : Medical Record Number 

is missing (A6) OR invalid (A7) 

For an 837i, 

Required when the 

TPO/repricer 

needs to forward 

additional 

information to the 

payer. This 

segment is not 

completed by 

providers 

Could not find a 

reference to this 

name 

589 Medicare Assignment Code Start: 10/31/2004 A6 

837 P&I Provider Accept 

Assignment Code: Medicare 

Assignement Code is missing (A6) 

2300 CLM07 

Page 44 of 63


590 Medicare Coverage Indicator Start: 10/31/2004 A6,A7 ??? 

591 Medicare Paid at 100% Amount Start: 10/31/2004 NA 

592 Medicare Paid at 80% Amount Start: 10/31/2004 NA 

593 Medicare Section 4081 Indicator Start: 10/31/2004 A6,A7 

Required when the submitter is 

Medicare and the claim is a 

Medigap or COB crossover claim. 

I am going to 

guess that this is 

SBR09. If the 

destination payer 

in loop 2010BB is 

Medicare the 

claim filing 

indicator should 

indicate the proper 

Medicare 

coverage. 

I am thinking that 

these are 276 

responces as to 

what adjudication 

was used 

I am thinking that 

these are 276 

responces as to 

what adjudication 

was used 

2300 REF*F5 

594 Mental Status Code Start: 10/31/2004 A6,A7 

595 Monthly Treatment Count Start: 10/31/2004 ?? 

596 Non-covered Charge Amount Start: 10/31/2004 A6 A7 

597 Non-payable Professional Component Amount Start: 10/31/2004 ?? 

This segment is required to convey 

Home Health Plan of Treatment 

information when applicable. 

837 P, I, D: Non-covered charge 

amount cannot be greater than 

service line charge amount. Non 

Covered Charge Amount is missing 

(A6) OR invalid 

Most of the Home 

HealthCare 

segments have 

been removed in 

5010. 837i, 2300 

CRC*77 

could not find a 

reference to this 

added to 837p in 


I could only find 

the professional 

component 

BILLED amount 

Page 45 of 63


598 

Non-payable Professional Component Billed Amount Start: 


A7 ????? 

Used when there 

was a prior 

payment and 

required when 

returned in the 

prior remittance 

advice. 2320 

MOA09 and in 

837i 2320 loop 

MIA19 

599 Note Reference Code Start: 10/31/2004 A6,A7 

EVELSIZER 601 - 700 

837 P I D: If NTESegment is used 

then NTE01 is required . Note 

Reference Code is missing (A6) 

OR invalid (A7) 

004010X098A1 CR511 - Entire 

CR5 segment removed in 

005010X222A1 

2300 and 2400 

loops NTE01 

600 Oxygen Saturation Qty Start: 10/31/2004 

A3 or A7? 

999 will report 

005010X223A1 may carry percent 

value using Value Code 59 - 

covered under error code 726 (nonspecific) 

601 Oxygen Test Condition Code Start: 10/31/2004 

602 Oxygen Test Date Start: 10/31/2004 

A3 or A7? 


A3 or A7? 


5010 standard allows CR511 

If element is sent, 277CA with error 

code 684 and A3 may be returned. 




004010X098A1 DTP with DTP01 

481 removed in 005010X222A1 

http://ushik.ahrq.g 

ov/dr.ui.drData_Pa 

ge?system=mdr& 

Search=xxKEYIDx 

x&KeyOrgID=18& 

KeyRID=2662300 

0&Referer=DataEl 

ement 

Page 46 of 63


603 Old Capital Amount Start: 10/31/2004 A7 

604 Originator Application Transaction Identifier Start: 10/31/2004 A6 

005010X223A1 MIA12 - Sit rule 

Required when returned in the 


Destination Payer may not be able 

to determine when this value is 

required. If present must be valid 

monetary amount. No known 

crossedit against other data. 

005010X222A1 BHT03 required 


g 


ge?System=mdr& 

CallingRoutine=& 

ResponsibleOrgan 

ization=&Submittin 

gOrganization=&R 

egistrationAuthorit 

y=&Administrative 

Status=&Registrati 

onStatus=&Criteri 

aDataType=&Com 

ponentName=&Da 

taAgreementID=& 

DefinitionSearchT 

ype=&DefinitionSe 

arch=&valueMeani 

ngSearchType=$v 

alueMeaningSearc 

hType$&valueMea 

ningSearch=$valu 

eMeaningSearch$ 

&valueSearch=$v 

alueSearch$&Nam 

eSearchType=&Se 

arch=O&ModelOrg 

ID=&ModelRegID= 

&InitiativeOrgID=& 

InitiativeRegID=& 

KeyOrgID=3&Key 

RID=26453000&O 

rgID=&DataCollect 

ionID=&RecordOff 

605 Orthodontic Treatment Months Count Start: 10/31/2004 A7 or A8 

606 Paid From Part A Medicare Trust Fund Amount Start: 10/31/2004 

607 Paid From Part B Medicare Trust Fund Amount Start: 10/31/2004 

A3 or A7? 


A3 or A7? 



005010X224A1 DN102 sit required 

004010X096A1 AMT segment 

removed in 005010X223A1 

5010 standard allows AMT 

If segment is sent, 277CA with 

error code 684 and A3 may be 

returned. 

004010X096A1 AMT segment 





returned. 

Page 47 of 63


608 Paid Service Unit Count Start: 10/31/2004 A6 or A7 

609 Participation Agreement Start: 10/31/2004 A7 

005010X222A1 SVD05 



No known crossedit against other 

data. 

005010X222A1 CLM07 



If CLM07 is not 'A', then an error 

may be returned if a Participation 

Agreement exists 

610 Patient Discharge Facility Type Code Start: 10/31/2004 

A3 or A7? 








611 Peer Review Authorization Number Start: 10/31/2004 A6 or A7 

005010X223A1 REF01 = G4 

Crosscheck against REF01 if 

REF02 is blank considered A6 

612 Per Day Limit Amount Start: 10/31/2004 

613 Physician Contact Date Start: 10/31/2004 

A3 or A7? 


A3 or A7? 


004010X096A1 AMT - AMT01 = 

DY segment removed in 





returned. 







614 Physician Order Date Start: 10/31/2004 

A3 or A7? 


615 Policy Compliance Code Start: 10/31/2004 A3 or A7 




005010X222A1 HCP14 



Note: this entire segment, including 

this element is not expected in the 

837 for a provider to payer 

exchange. If received by 

destination payer, rejection may 

occur. (A3) 

Page 48 of 63


616 Policy Name Start: 10/31/2004 N/A 

617 Postage Claimed Amount Start: 10/31/2004 A7 or A8 

618 PPS-Capital DSH DRG Amount Start: 10/31/2004 A7 

619 PPS-Capital Exception Amount Start: 10/31/2004 A7 

620 PPS-Capital FSP DRG Amount Start: 10/31/2004 A7 

621 PPS-Capital HSP DRG Amount Start: 10/31/2004 A7 

622 PPS-Capital IME Amount Start: 10/31/2004 A7 

623 PPS-Operating Federal Specific DRG Amount Start: 10/31/2004 A7 

624 PPS-Operating Hospital Specific DRG Amount Start: 10/31/2004 A7 

625 Predetermination of Benefits Identifier Start: 10/31/2004 A3 

626 Pregnancy Indicator Start: 10/31/2004 A7 

Possible SBR04 Group Plan 

Name. Policy Name listed as 

present in 005010X224A1 in 

reference material, but not found. 

005010X222A1 AMT - AMT01 = 

F4 

Crosscheck against service line 

charge. 










005010X223A1 MIA10 - Sit rule 












predetermination of benefit 

inquiries cannot be submitted 

electronically using the 837 

transaction for this payer. 

005010X223A1 2000B, 2000C 

PAT09 - Sit rule Required when 

mandated by law. 

http://ushik.ahrq.g 


ge?system=mdr& 

KeyRID=2687800 

0&Referer=DataEl 

ement 

627 Pre-Tax Claim Amount Start: 10/31/2004 

A3 or A7? 


004010X098A1 2320 AMT - Entire 

AMT qualifier T2 segment removed 

in 005010X222A1 


If segment T2 is sent, 277CA with 


returned. 

Page 49 of 63


005010X222A1 2300, 2400 HCP01 



628 Pricing Methodology Start: 10/31/2004 A3 or A7 




exchange. Repricers only. If 

received by destination payer, 

rejection may occur. (A3) 

629 Property Casualty Claim Number Start: 10/31/2004 

A3 or A6 or 

A7 or A8 

630 Referring CLIA Number Start: 10/31/2004 A6 

631 Reimbursement Rate Start: 10/31/2004 A7 

005010X222A1 2010BA, 2010CA 

REF01 = Y4 


REF01 = Y4 


REF01 = Y4 

Crosschecks against CLM11, 

SBR09, PER Property and 

Casualty Patient Contact 

Information, PER Property and 

Casualty Subscriber Contact 

Information, Occurrance codes, 

Condition codes, etc. 

005010X222A1 2400 REF01 = F4 

Crosscheck against REF01 if 

REF02 is blank considered A6 

005010X222A1 2320 MOA01 



Sit rule - required when returned in 

the remittance advice 

632 Reject Reason Code Start: 10/31/2004 A3 or A6 or A7 




Syntax crosscheck - HCP01 or 

HCP13 must be present (A6) 







Page 50 of 63


633 Related Causes Code Start: 10/31/2004 A3 or A7 or A8 

005010X222A1 2300 CLM11 


Crosscheck with Date Accident - if 

present CLM11 required 

005010X223A1 2300 CLM11 Not 

used 

5010 standard allows CLM11 



634 Remark Code Start: 10/31/2004 A7 

005010X222A1 2300 MOA03-07 


MIA05 

MIA20-23 


Invalid remittance advice remark 

code. 




635 

Repriced Ambulatory Patient Group. This change effective 11/1/2010: Repriced 

Ambulatory Patient Group Code Start: 10/31/2004 

A3 







005010X222A1 2400 REF-1 = 9B 


636 Repriced Line Item Reference Number Start: 10/31/2004 A3 or A6 








Not Used 

5010 standard allows 2400 REF 



returned. 

Page 51 of 63





637 Repriced Saving Amount Start: 10/31/2004 A3 or A7 










638 Repricing Per Diem or Flat Rate Amount Start: 10/31/2004 A3 or A7 







Assume this represents the Patient 

Responsibility Amount Prof/Dental 

and Patient Estimated Amount Due 

Inst 

639 Responsibility Amount Start: 10/31/2004 A3 or A6 or A7 

005010X223A1 2300 AMT01 = F3 

Patient Estimated Amount Due 

005010X224A1 2300 AMT01 = 

EAF 

Remaining Patient Liability 

004010X098A1 2320 AMT01 = F2 

Entire Patient Responsibility AMT 

segment removed in 


5010 standard allows 2320 AMT 



returned. 

Page 52 of 63


640 Sales Tax Amount Start: 10/31/2004 A6 or A7 

005010X222A1 2400 AMT01 = T 

or 2400 SV102 when SV101-2 = 

S9999 

005010X224A1 2400 AMT01 = T 

Note: ADA procedure codes do not 

have a specific value for Sales Tax 

amount. 

005010X223A1 does not contain 

an AMT where AMT01 = T. There 

is no specific value to represent 

Sales Tax. 2400 SV203 when 

SV202-2 = S9999 

641 

Service Adjudication or Payment Date. Note: Use code 516. Start: 

10/31/2004 | Last Modified: 09/20/2009 | Stop: 10/01/2010 

N/A 

(see code 516 

rules) 

005010X222A1 2330B, 2430 

DTP01 = 573 


DTP01 = 573 


DTP01 = 573 

642 Service Authorization Exception Code Start: 10/31/2004 A6 or A7 

005010X222A1 2300 REF01 = 4N 



Sit rule for segment - Required 

when mandated by government law 

or regulation 

643 Service Line Paid Amount Start: 10/31/2004 A6 or A7 or A8 

005010X222A1 2400 SVD02 




when claim has been previously 

adjudicated by payer in loop 2330B 

Crosscheck against other payer 

2330B Other Payer Name 

644 Service Line Rate Start: 10/31/2004 

A3 or A7? 


004010X098A1 2400 SV206 

005010X223A1 2400 SV206 not 

used 

645 Service Tax Amount Start: 10/31/2004 A7 

005010X223A1 2400 AMT01 = GT 

(Note: X12 N TG2 WG2 could not 

define what tax amount would be 

carried in this data element) 

Page 53 of 63


646 Ship, Delivery or Calendar Pattern Code Start: 10/31/2004 

A3 or A7? 


004010X098A1 2305, 2400 HSD07 

- Entire HSD qualifier VS segment 


004010X096A1 2305 HSD07 - 

Entire HSD qualifier VS segment 


5010 standard allows HSD07 



647 Shipped Date Start: 10/31/2004 A7 

005010X222A1 2400 DTP01 = 011 

date value in DTP03 

648 Similar Illness or Symptom Date Start: 10/31/2004 

649 Skilled Nursing Facility Indicator Start: 10/31/2004 

A3 or A7? 


A3 or A7? 


004010X098A1 2300 DTP - Entire 

DTP qualifier 438 segment 


5010 standard allows DTP 



returned. 

004010X096A1 2300 CR606 

Entire CR6 segment removed in 





returned. 



650 Special Program Indicator Start: 10/31/2004 A3 or A7 

005010X223A1 2300 CLM12 not 

used 

5010 standard allows CLM12 



Page 54 of 63


004010X098A1 Multiple REF 

segments - Qualifier X5 no longer 

included in any REF segment in 






651 State Industrial Accident Provider Number Start: 10/31/2004 A3 

652 Terms Discount Percentage Start: 10/31/2004 A3 or A7 





5010 standard allows REF01 

qualifier of X5 



returned. 

005010X222A1 2300, 2400 CN105 

005010X223A1 2300 CN105 

005010X224A1 2300, 2400 CN105 

CN1 segment is deemed non 

HIPAA use and for post 

adjudicated claims only 

653 Test Performed Date Start: 10/31/2004 A3 or A6 or A7 

005010X222A1 2400 DTP01 = 

738, 739 

5010 standard allows DTP 

If segment is sent with qualifiers 

not allowed by guide, 277CA with 


returned. 

004010X096A1 AMT01 = YT - 

Segment AMT - Qualifier YT no 

longer included in any REF 

segment in 005010X223A1 

654 Total Denied Charge Amount Start: 10/31/2004 A3 

5010 standard allows AMT qual YT 




returned. 

Page 55 of 63


004010X096A1 AMT01 = N1 - 

Segment AMT - Qualifier N1 no 

longer included in any REF 

segment in 005010X223A1 

655 Total Medicare Paid Amount Start: 10/31/2004 A3 

5010 standard allows AMT qual N1 




returned. 

004010X098A1 CR703 - 

Segment CR7 no longer included 


656 Total Visits Projected This Certification Count Start: 10/31/2004 A3 





segment 

If segment is sent and not allowed 

by guide, 277CA with error code 

684 and A3 may be returned. 




657 Total Visits Rendered Count Start: 10/31/2004 A3 

658 Treatment Code Start: 10/31/2004 A7 

659 Unit or Basis for Measurement Code Start: 10/31/2004 

A3 or A6 or 

A7 or A8 


segment 




004010X096A1 2300 HI##-01 = TC 

- 

Value in HI##-02 

Invalid treatment code. 

Code source 359 

Various segments may contain 

D.E. Number 355 

Some segments required 

Some segment sit required 

Some segments not used 

Page 56 of 63


004010X098A1 2400 REF01 = OZ, 

VP - 

Segment REF with qualifier OZ, VP 

no longer included in 


660 Universal Product Number Start: 10/31/2004 A3 

5010 standard allows REF01 

qualifier value of OZ or VP 







661 Visits Prior to Recertification Date Count CR702 Start: 10/31/2004 A3 


segment 




004010X098A1 2400 CR212 - 

Element CR212 Spinal 

Manipulation not used in 


662 X-ray Availability Indicator Start: 10/31/2004 A3 


element 

If element is sent and not allowed 



663 

Entity's Group Name. This change effective 11/1/2010: Entity's Group Name. Note: 

This code requires use of an Entity Code. Start: 10/31/2004 | Last 


N/A 


SBR04 


SBR04 


SBR04 


when SBR03 is not used and the 

group name is available. (External 

condition) 

664 Orthodontic Banding Date Start: 10/31/2004 A6 or A7 

005010X224A1 2300, 2400 DTP01 

= 452 

Page 57 of 63





656 Surgery Date Start: 10/31/2004 A3 

666 Surgical Procedure Code Start: 10/31/2004 A3 

667 

668 

Real-Time requests not supported by the information holder, do not resubmit 

Start: 02/28/2005 

Missing Endodontics treatment history and prognosis Start: 

06/30/2005 

669 Dental service narrative needed. Start: 10/31/2005 N/A 

670 

Funds applied from a consumer spending account such as consumer 

directed/driven health plan (CDHP), Health savings account (H S A) and or other 

similar accounts Start: 06/30/2006 | Last Modified: 02/28/2007 

A3 

N/A 

N/A 




returned. 







returned. 

Coordinate with error code 494 

Possible PWK not present - Not 

related to data within 837 

transaction 

005010X224A1 2300 NTE - 

missing 

Possible PWK not present 

671 

Funds may be available from a consumer spending account such as consumer 

directed/driven health plan (CDHP), Health savings account (H S A) and or other 

similar accounts. Start: 06/30/2006 | Last Modified: 


N/A 

005010X222A1 2320, 2430 

CAS03,06,09,12,15,18 

SVD02 

AMT02 

672 

Other Payer's payment information is out of balance. Start: 


A8 


CAS03,06,09,12,15,18 

SVD02 

AMT02 


CAS03,06,09,12,15,18 

SVD02 

AMT02 

Crosscheck amounts 

Page 58 of 63


673 Patient Reason for Visit Start: 10/31/2006 A6 or A7 or A8 

674 Authorization exceeded Start: 10/31/2006 N/A 

005010X223A1 2300 HI01-01 = 

PR, APR 

Sit rule - Required when claim 

involves outpatient visits. 

Crosscheck CLM05-01 Facility 

Type 


DTP01 = 096 


or HI##-01 = BH and HI##-02 

Occurrence code 42 (discharge) 

675 Facility admission through discharge dates. Start: 10/31/2006 

A3 or A6 or 

A7 or A8 


DTP01 = 096 - 

Segments with DTP01 values 435 

and 096 have been removed from 


676 

677 

Entity possibly compensated by facility. This change effective 11/1/2010: Entity 

possibly compensated by facility. Note: This code requires use of an Entity Code. 


Entity not affiliated. This change effective 11/1/2010: Entity not affiliated. Note: This 

code requires use of an Entity Code. Start: 10/31/2006 | Last 


678 Revenue code and patient gender mismatch. Start: 10/31/2006 A8 

N/A 

A3 

5010 standard allows DTP01 435 

and 096 

If qualifier is sent and not allowed 



Not related to data contained in 

837 requires use of 


later 

Blues use this to indicate that the 

claim must be submitted to the 

local Blue Plan 


DMG03 

2400 SV201 

Crosscheck SV201 against DMG03 

679 Submit newborn services on mother's claim Start: 10/31/2006 A3 

680 

Entity's Country. This change effective 11/1/2010: Entity's Country. Note: This code 

requires use of an Entity Code. Start: 10/31/2006 | Last 


681 Claim currency not supported Start: 10/31/2006 A7 

682 Cosmetic procedure Start: 02/28/2007 A3 

683 Awaiting Associated Hospital Claims Start: 02/28/2007 P1 or P5 

A7 

Possible CL101, Value code 54, 

Revenue Code 017 1-4, DMG02 

005010X222A1 N404 



Validate against Codesource 5 

005010X222A1 2000A CUR02 



005010X222A1 2400 SV101-02 

005010X223A1 2400 SV202-02 

005010X224A1 2400 SV301-02 



later 

Page 59 of 63


684 

685 

Rejected. Syntax error noted for this claim/service/inquiry. See Functional or 

Implementation Acknowledgement for details. (Note: Only for use to reject claims or 

status requests in transactions that were 'accepted with errors' on a 997 or 999 

Acknowledgement.) Start: 11/05/2007 

Claim could not complete adjudication in real time. Claim will continue processing 

in a batch mode. Do not resubmit. Start: 01/27/2008 

N/A or A3 

A3 

Only use 684 when transaction has 

been accepted with syntax errors. 

The syntax errors will be reported 

in 277CA instead of using the 999. 

Optionally, the 999 could be used 

to report the syntax errors and no 

277CA would be returned, thus 

N/A. 


ISA transaction id is assumed to 

indicate batch or real time 

submission. 

686 

The claim/ encounter has completed the adjudication cycle and the entire claim has 

been voided. Start: 01/27/2008 

F0 


837 

687 

688 

Claim estimation can not be completed in real time. Do not resubmit. Start: 

01/27/2008 

Present on Admission Indicator for reported diagnosis code(s). Start: 

01/27/2008 

A3 

A6 or A7 


005010X223A1 2300 HI##-09 

Sit rule - Required as directed by 

the NUBC manual 

689 

690 

691 

692 

Entity was unable to respond within the expected time frame. This change effective 

11/1/2010: Entity was unable to respond within the expected time frame. Note: This 

code requires use of an Entity Code. Start: 06/01/2008 | Last Modified: 02/11/2010 

Multiple claims or estimate requests cannot be processed in real time. Start: 

06/01/2008 

Multiple claim status requests cannot be processed in real time. Start: 

06/01/2008 

Contracted funding agreement-Subscriber is employed by the provider of services. 

Start: 09/21/2008 

A3 

A3 

N/A 

?? 


837 requires use of 


later 


Used for 276/277 Claim Status 

Request 

Crosscheck Subscriber data with 

contract data - external to 837 

693 

Amount must be greater than or equal to zero. Note: At least one other status code 

is required to identify which amount element is in error. Start: 01/25/2009 

A8 

Patient paid amount must be 

positive value and can not exceed 

total claim charge amount. 

694 

695 

Amount must not be equal to zero. Note: At least one other status code is required 

to identify which amount element is in error. Start: 01/25/2009 

Entity's Country Subdivision Code. This change effective 11/1/2010: Entity's 

Country Subdivision Code. Note: This code requires use of an Entity Code. 


A7 

A7 

Any amount included in 837 that is 

deemed by payer to be 

inappropriate as zero (defined by 

guide notes or business practice 

per payer) 

005010X222A1 N407 



Validate against Part 2 of ISO 3166 

696 Claim Adjustment Group Code. Start: 01/25/2009 A6 or A7 

005010X222A1 2320, 2430 CAS01 



Page 60 of 63


697 

Invalid Decimal Precision. Note: At least one other status code is required to 

identify the data element in error. Start: 07/01/2009 

A7 

Relates to any integer defined data 

element (example: monetary 

amounts) 

005010X222A1 2440 LQ02 

(assumed location) 

698 Form Type Identification Start: 07/01/2009 A6 or A7 

005010X223A1 2440 LQ02 not 

included 

005010X224A1 2440 LQ02 not 

included 

5010 standard allows LQ02 



returned. 

699 

Question/Response from Supporting Documentation Form. Start: 


A6 or A7 

005010X222A1 2440 FRM03,04,05 

FRM02 = Freeform text format (A6) 

FRM03 = Date format (A6 or A7) 

FRM04 = Percent decimal format 

(A6 or A7) 

700 

ICD10. Note: At least one other status code is required to identify the related 

procedure code or diagnosis code. Start: 07/01/2009 

OSTROOT 701 - 742 

A6, A7 or A8 

HI 

Same as 508 only this code for 

ICD10 

701 Initial Treatment Date Start: 07/01/2009 A6, A7 or A8 DTP 

702 Repriced Claim Reference Number. Start: 11/01/2009 A6, A7 or A8 REF 

703 Advanced Billing Concepts (ABC) code. Start: 01/24/2010 A6, A7 or A8 

704 Claim Note Text Start: 01/24/2010 A7 

SV101-1 (qualifier WK) and SV101- 

2 

NTE - invalid characters, payer can 

not require NTE submission. 

705 Repriced Allowed Amount. Start: 01/24/2010 A6, A7 or A8 HCP02 

706 Repriced Approved Amount. Start: 01/24/2010 A6, A7 or A8 HCP04 


Repriced Approved Ambulatory Patient Group Amount. Start: 


A6, A7 or A8 HCP07 

708 Repriced Approved Revenue Code. Start: 01/24/2010 A6, A7 or A8 HCP08 

709 Repriced Approved Service Unit Count. Start: 01/24/2010 A6, A7 or A8 HCP12 


Line Adjudication Information. Note: At least one other status code is required to 

identify the data element in error. Start: 01/24/2010 

A6, A7 or A8 SVD 

711 Stretcher purpose Start: 01/24/2010 A6, A7 or A8 CR110 

Page 61 of 63


712 Obstetric Additional Units Start: 01/24/2010 A6, A7 or A8 QTY02 

713 Patient Condition Description Start: 01/24/2010 A6, A7 or A8 CR210 and CR211 

714 Care Plan Oversight Number Start: 01/24/2010 A6, A7 or A8 REF 

715 Acute Manifestation Date Start: 01/24/2010 A6, A7 or A8 DTP 

716 Repriced Approved DRG Code Start: 01/24/2010 A6, A7 or A8 HCP06 

717 This claim has been split for processing. Start: 01/24/2010 A5 

718 

Claim/service not submitted within the required timeframe (timely filing). 


719 NUBC Occurrence Code(s) Start: 01/24/2010 A6, A7 or A8 

A3 

HI-OCCURRENCE INFORMATION 

461 DEACTIVATED 

720 NUBC Occurrence Code Date(s) Start: 01/24/2010 A6, A7 or A8 

721 NUBC Occurrence Span Code(s) Start: 01/24/2010 A6, A7 or A8 

722 NUBC Occurrence Span Code Date(s) Start: 01/24/2010 A6, A7 or A8 

723 Drug days supply Start: 01/24/2010 A6, A7 or A8 

724 Drug dosage Start: 01/24/2010 A6, A7 or A8 

725 NUBC Value Code(s) Start: 01/24/2010 A6, A7 or A8 

726 NUBC Value Code Amount(s) Start: 01/24/2010 A6, A7 or A8 

727 Accident date Start: 01/24/2010 A6, A7 or A8 

728 Accident state Start: 01/24/2010 A6, A7 or A8 

729 Accident description Start: 01/24/2010 NA 

730 Accident cause Start: 01/24/2010 A6, A7 or A8 

HI-OCCURRENCE INFORMATION 


HI-OCCURRENCE SPAN 

INFORMATION 


HI-OCCURRENCE SPAN 

INFORMATION 


NCPDP 


NCPDP 


HI-VALUE INFORMATION 


HI-VALUE INFORMATION 


DTP 


REF 


CLM11 


731 Measurement value/test result Start: 01/24/2010 A6, A7 or A8 MEA03 

732 

Information submitted inconsistent with billing guidelines. Note: At least one other 

status code is required to identify the inconsistent information. 


A3,A6, A7 or A8 

dependant upon second status 

733 Prefix for entity's contract/member number. Start: 01/24/2010 A6 or A7 NM108 subscriber loop 

734 Verifying premium payment NA adjudication related 

735 This service/claim is included in the allowance for another service or claim NA adjudication related 

736 A related or qualifying service/claim has not been received/adjudicated NA adjudication related 

737 Current Dental Terminology (CDT) code A6 or A7 SV301 

738 

Institutional-SV2 or SVD 

Home Infusion EDI Coalition (HIEC) Product/Service Code 

A6 or A7 professional-SV1 or SVD 

HK 

Page 62 of 63


739 

740 

741 

742 

Jurisdiction Specific Procedure and Supply Code 

drop off location 

entity must be a person 

payer responsibility sequence number code 

A6 or A7 


A3 


Institutional-SV2 or SVD 

professional-SV1 or SVD 

NM1-AMBULANCE DROP OFF 

LOCATION 

Loop 2010BA NM102 to qualify 

subscribers as people 

pertains to elements SBR01 and 

SBR02 

Page 63 of 63

AUC Acknowledgements TAG Meeting Materials 07-29-10

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