Loop ID's 1000A SUBMITTER NAME NM1

Segments

Seg's usage

Ele's Usage R R R R R R NM101 NM102 NM103 NM104 NM108 NM109

Elements in a S

Submitter Name

PER

Submitter EDI Contact Information

R S R R

PER01 PER02 PER03 PER04 NM101 NM102 NM103 NM108 NM109

1000B RECEIVER NAME NM1 Receiver Name R R R R R R Detail, Billing/Pay-to Provider Hierarchical Level 2000A BILLING/PAY-TO PROVIDER HL HL Billing Provider Hierarchical Level R R R R PRV Billing Provider Speciality Information S R R R CUR Foreign Currency Information S R R 2010AA BILLING PROVIDER NAME NM1 Billing Provider Name R R R R S S S S S N3 N4 Billing Provider Address Billing Provider City/State/ZipCode R R R S R S S S NM101 NM102 NM103 NM104 NM105 NM107 NM108 NM109 N301 N302 N401 N402 N403 N404 HL01 HL03 HL04 PVR01 PVR02 PVR03 CUR01 CUR02

S REF Billing Provider TAX Identification R R R

N407 REF01 REF02 REF01 REF02

REF PER

Billing Provider UPIN/ License Information S Billing Provider Contact Information S

R R S R R S S S S

REF01 REF02 PER01 PER02 PER03 PER04 PER05 PER06 PER07 PER08 NM101 NM102 N301 N302 N401 N402 N403 N404 N407 NM101 NM102 NM103 NM108 NM109 N301 N302 N401 N402 N403 N404 N407 REF01 REF02 REF01 REF02

2010AB PAY-TO ADDRESS NAME NM1 Pay-to Address Name S R R N3 N4 Pay-to Address-ADDRESS Pay-To Address city,State,ZIP Code R R R S S S S 2010AC PAY-TO PLAN NAME NM1 Pay-to Plan Name S R R R R R N3 Pay-to Provider Address R R S N4 Pay-to Provider City/State/ZipCode R R S S S S REF Pay-to Provider Secondary Identification S R R REF Pay-To Plan Tax Idetification Number R R R Detail, Subscriber Hierarchical Level 2000B SUBSCRIBER HL R S

HL

Subscriber Hierarchical Level

R R R R

HL01 HL02 HL03 HL04

SBR

Subscriber Information

R S S S S S

SBR01 SBR02 SBR03 SBR04 SBR05 SBR09

PAT

Patiet Information

S S S S S

PAT05 PAT06 PAT07 PAT08 PAT09 NM01 NM02 NM03 NM04 NM05 NM07 NM08 NM09

2010BA SUBSCRIBER NAME NM1 Subscriber Name R R R R S S S S R

N3

Subscriber Address

R S

N301 N302 N401 N402 N403 N404 N407 DMG01 DMG02 DMG03 REF01 REF02 REF01 REF02 PER01 PER02

N4

Subscriber City/State/Zipcode

R R R S S

DMG

Subscriber Demographic Information

R R R

REF

Subscriber Secondary Identification

R R

REF PER

Property and casualty Claim Number

R R R S

Property and casualty Subcriber Contact Information S

R R S S 2010BB PAYER NAME NM1 Payer Name R R R R R

PER03 PER04 PER05 PER06 NM101 NM102 NM103 NM108

NM109

N3

Payer Address

R S

N301 N302 N401 N402 N403 N407 REF01 REF02 REF01 REF02

N4

Payer City/State/Zipcode

R S S S

REF

Payer Secondary Identification

R R

REF

Billing Provider Secondary Identification

R R

Detail, Patient Hierarchical Level 2000C PATIENT HL HL Patient Hierarchical Level S R R R R PAT Patient Information R R S S S S S 2010CA PATIENT NAME NM1 Patient Name R R R R R S S N3 Patient Address R R S NM101 NM102 NM103 NM104 NM105 NM107 N301 N302 HL01 HL02 HL03 HL04 PAT01 PAT05 PAT06 PAT07 PAT08 PAT09

N4

Patient City/State/ZipCode

R S S S S

N401 N402 N403 N404 N407 DMG01 DMG02 DMG03 REF01 REF02 REF01 REF02 PER01 PER02 PER03 PER04 PER05 PER06

DMG

Patient Demographic Information

R R R

REF REF PER

Property and Casualty Calim Number Property and Casualty Patient Identifier

S S

R R R R R S R R S S

Property and Casualty Patient Contact Information S

2300 CLAIM INFORMATION CLM Claim Information R R R R R R R R CLM01 CLM02 CLM05 CLM05-1 CLM05-2 CLM05-3 CLM06 CLM07

R R

CLM08 CLM09

S S R

CLM10 CLM11 CLM11-1

S S S S

CLM11-2 CLM11-4 CLM11-5 CLM12

S DTP Date - Onset of Current Illness/Symptom S R R

CLM20 DTP01 DPT02

R DTP Date-Initial Treatment Date S R R R DTP DATE-Last Seen Date S R R R DTP Date - Acute Manifestation R R R DTP Date - Accident S R R R DTP Date - Last Menstrual Period S R R R DTP Date - Last X-ray S R R R DTP Date - Hearing and Vision Prescription Date S S S DTP Date - Disability Dates S R R R R R R DTP Date - Last Worked S R R R DTP Date - Authorized Return to Work S R R R DTP Date - Admission S R R R DTP Date - Discharge S R R R DTP Date - Assumed and Relinquished Care Dates S R R R

DPT03 DPT01 DPT02 DTP03 DPT01 DPT02 DTP03 DTP01 DTP02 DTP03 DTP01 DTP02 DTP03 DTP01 DTP02 DTP03 DTP01 DTP02 DTP03 DTP01 DTP02 DTP03 DTP01 DTP02 DTP03 DTP01 DTP02 DTP03 DTP01 DTP02 DTP03 DTP01 DTP02 DTP03 DTP01 DTP02 DTP03 DTP01 DTP02 DTP03

DTP

Date-Property and Casualty Date of First Contact S

R R R

DTP01 DTP02 DTP03 DTP01 DTP02 DTP03 PWK01 PWK02 PWK05 PWK06 CN101 CN102 CN103 CN104 CN105 CN106 AMT01 AMT02 REF01 REF02

DTP

Date-Repricer Received Date

R R R

PWK

Claim Supplemental Information

R R S S

CN1

Contract Information

R S S S S S

AMT

Patient Amount Paid

R R

REF

Service Authorization Exception Code

R R

REF

Mandatory Medicare (Section 4081) Crossover Indicator S

R R

REF01 REF02 REF01 REF02 REF01 REF02 REF01 REF02 REF01 REF02 REF01 REF02 REF01 REF02 REF01 REF02

REF

Mammography Certification Number

R R

REF

Referral Number

R R

REF

Prior Authorization

R R

REF

Payer Claim Control Number

R R

REF

(CLIA) Number

R R

REF

Repriced Claim Number

R R

REF

Adjusted Repriced Claim Number

R R

REF

Investigational Device Exemption Number S

REF01 REF02

REF

Claim Identification Number for Transmission Intermediaries S

REF01 REF02

REF

Medical Record Number

REF01 REF02

REF

Demonstration Project Identifier

REF01 REF02

REF

Care Plan Oversight

REF01 REF02

K3 NTE

File Information Claim Note

S S

R R

K301 NTE01

R CR1 Ambulance Transport Information S S S R R R S S CR2 Spinal Manipulation Service Information S S S

NTE02 CR101 CR102 CR104 CR105 CR106 CR109 CR110 CR208 CR211

CRC

Ambulance Certification

R R R S S S S

CRC01 CRC02 CRC03 CRC04 CRC05 CRC06 CRC07 CRC01 CRC02 CRC03

CRC

Patient Condition Information: Vision

R R S

S S S S CRC Homebound Indicator S R R R CRC EPSDT Referral S R R R S S HI Health Care Diagnosis Code R R S S S S

CRC04 CRC05 CRC04 CRC05 CRC01 CRC02 CRC03 CRC01 CRC02 CRC03 CRC04 CRC05 HI01 HI02 HI03 HI04 HI05

S HI Anesthesia Related Procedure S S

HI06

HI07

S S S S S

HI08 HI09 HI10 HI11 HI12

HI

Anesthesia Related Procedure

R S

HI01 HI02

HI

Condition Information

HI01

S S S S S S S S S S S

HI02 HI03 HI04 HI05 HI06 HI07 HI08 HI09 HI10 HI11 HI12

HCP

Claim Pricing/Repricing Information

R R S S S S S S

HCP01 HCP02 HCP03 HCP04 HCP05 HCP06 HCP07 HCP13

HCP14

HCP15

2310A REFERRING PROVIDER NAME NM1 Referring Provider Name S R R R S NM101 NM102 NM103 NM104

S S S S REF Referring Provider Secondary Identification S R

NM105 Nm107 NM108 NM109 REF01 REF02

2310B RENDERING PROVIDER NAME NM1 Rendering Provider Name S R R R S S S S S PRV Rendering Provider Specialty Information S R R R REF Rendering Provider Secondary Identification R R 2310C SERVICE FACILITY LOCATION NM1 Service Facility Location Name S R R R S S N3 N4 Service Facility Location Address Service Facility Location City/State/ZIP R R R S R S S S S REF Service Facility Location Secondary Identification S R NM101 NM102 NM103 NM108 NM109 N301 N302 N401 N402 N403 N404 N407 REF01 REF02 PER Service Facility Contact Information S R S R R S PER01 PER02 PER03 PER04 PER05 NM101 NM102 NM103 NM104 NM105 NM107 NM108 NM109 PRV01 PRV02 PRV03 REF01 REF02

S 2310D SUPERVISING PROVIDER NAME NM1 Supervising Provider Name S R R R S S S S R REF Supervising Provider Secondary Identification S R R 2310E AMBULANCE PICK-UP LOCATION NM1 N3 N4 Ambulance Pick-Up Location Ambulance Pick-Up Location Address S R R R S Ambulance Pick-Up Location City,State,ZIP R Code R S S S 2310F AMBULANCE DROP-OFF LOCATION NM1 Ambulance Drop-off Location S R R R N3 Ambulance Drop-off Location Address R R S N4 Ambulance Drop-off Location City,State ZIP R Code R S S S S 2320 OTHER SUBSCRIBER INFORMATION SBR Other Subscriber Information S R R S S S

PER06

NM01 NM02 NM03 NM04 NM05 NM07 NM08 NM09 REF01 REF02

NM01 NM02 N301 N302 N401 N402 N404 N407

NM101 NM102 NM103 N301 N302 N401 N402 N403 N404 N407

SBR01 SBR02 SBR03 SBR04 SBR05

SBR09

CAS

Claim Level Adjustments

CAS01

R R S S S S S S S S S S S S S S S S AMT Coordination of Benefits (COB) Payer Paid Amount S R R

CAS02 CAS03 CAS04 CAS05 CAS06 CAS07 CAS08 CAS09 CAS10 CAS11 CAS12 CAS13 CAS14 CAS15 CAS16 CAS17 CAS18 CAS19 AMT01 AMT02

AMT

Coordination of Benefits (COB) Total non-Covered Amount S

R R

AMT01 AMT02 AMT01 AMT02 OI03 OI04 OI06 MOA01 MOA02 MOA03 MOA04 MOA05 MOA06 MOA07 MOA08 MOA09

AMT

Remaining Patient Liabilty

R R

OI

Other Insurance Coverage Information

R S R

MOA

Medicare Outpatient Adjudication Information S

S S S S S S S S S

2330A OTHER SUBSCRIBER NAME NM1 Other Subscriber Name R R R R S S S R R NM101 NM102 NM103 NM104 NM105 NM107 NM108 NM109

N3 N4

Other Subscriber Address Other Subscriber City/State/ZIP Code

S S

R S R S S S S

N301 N302 N401 N402 N403 N404 N407

REF 2330B OTHER PAYER NAME NM1

Other Subscriber Secondary Identification

R R

REF01 REF02 NM101 NM102 NM103 NM108 NM109 N301 N302 N401 N402 N403 N404 N407 DTP01 DTP02 DTP03 REF01 REF02 REF01 REF02

Other Payer Name

R R R R R

N3

Other Payer Address

R S

N4

Other Payer City/State/ZIP Code

R S S S S

DTP

Claim Adjudication Date

R R R

REF

Other Payer Secondary Identifier

R R

REF

Other Payer Prior Authorization Number

REF REF REF

Other Payer Referral Number Other Payer Claim Adjustment Indicator Other Payer Claim Control Number

S S S

R R R R R

REF01 REF02 REF01 REF02 REF01 REF02

2330C OTHER PAYER REFERRING PROVIDER NM1 Other Payer Referring Provider S R R REF Other Payer Referring Provider IdentificationR R R 2330D OTHER PAYER RENDERING PROVIDER NM101 Nm102 REF01 REF02

NM1

Other Payer Rendering Provider

R R

NM01 NM02 REF01 REF02

REF

Other Payer Rendering Provider Secondary R Identification

R R

2330E OTHER PAYER SERVICE FACILITY LOCATION NM1 Other Payer Service Facility Location S R R REF Other Payer Service Facility Location Identification R R R 2330F OTHER PAYER SUPERVISING PROVIDER NM1 Other Payer Supervising Provider S R R REF Other Payer Supervising Provider Identification R R R 2330G OTHER PAYER BILLING PROVIDER NM1 REF Other Payer Billing Provider Other Payer Billing Provider Secondary Identification S R R NM101 NM102 REF01 REF02 2400 SERVICE LINE LX SV1 Service Line Professional Service R R R LX01 SV101 NM101 NM102 REF01 REF02 NM01 NM02 REF01 REF02

R R R S R

SV102 SV103 SV104 SV105 SV107

S S S S SV5 Durable Medical Equipment Service S R R R

SV109 SV111 SV112 SV115 SV501 SV502 SV503

R R R PWK Line Supplemental Information S R R S S PWK CR1 Durable Medicl Equipment Certificate of Medical Necessity Indicator S Ambulance Transport Information S R R S S R R R S S CR3 Durable Medical Equipment Certification S R R R CRC Ambulance Certification S R R R S S S S CRC Hospice Employee Indicator S R R R CRC Condition Indicator/Durable Medical Equipment S R R R S DTP Date - Service Date R R R R DTP Date-Prescription Date S R R R DTP Date - Certification Revision/ Recertification S Date R R R DTP Date - Begin Therapy Date S R R R DTP Date - Last Certification Date S R R R DTP Date - Last Seen Date S R R R DTP Date - Test Date S R

SV504 SV505 SV506 PWK01 PWK02 PWK05 PWK06 PWK01 PWK02 CR101 CR102 CR104 CR105 CR106 CR109 CR110 CR301 CR302 CR303 CRC01 CRC02 CRC03 CRC04 CRC05 CRC06 CRC07 CRC01 CRC02 CRC03 CRC01 CRC02 CRC03 CRC04 DTP01 DTP02 DTP03 DTP01 DTP02 DTP03 DTP01 DTP02 DTP03 DTP01 DTP02 DTP03 DTP01 DTP02 DTP03 DTP01 DTP02 DTP03 DTP01

R R DTP Date - Shipped Date S R R R DTP Date - Last X-ray Date S R R R DTP Date - Initial Treatment Date S R R R QTY QTY MEA Ambulance Patient Count Obstetric Anesthesia Additional Units Test Result S S S R R R R R R R CN1 Contract Information S R

DTP02 DTP03 DTP01 DTP02 DTP03 DTP01 DTP02 DTP03 DTP01 DTP02 DTP03 QTY01 QTY02 QTY01 QTY02 MEA01 MEA02 MEA03 CN101

S S S S S REF REF REF Repriced Line Item Reference Number S R R Adjusted Repriced Line Item Reference Number S Prior Authorization S R R R R S R R REF REF REF REF REF REF Line Item Control Number Mammography Certification Number S S R R R R Clinical Laboratory Improvement Amendment S (CLIA) Identification Referring Clinical Laboratory Improvement Amendment S (CLIA) facility identification Immunization Batch Number Referral Number S S R R R R R R R R

CN102 CN103 CN104 CN105 CN106 REF01 REF02 REF01 REF02 REF01 REF02 REF04 REF04-1 REF04-2 REF01 REF02 REF01 REF02 REF01 REF02 REF01 REF02 REF01 REF02 REF01 REF02

S R R AMT AMT K3 NTE Sales Tax Amount Postage Claimed Amount File Information Line Note S S S S R R R R R R

REF04 REF04-1 REF01-2 AMT01 AMT02 AMT01 AMT02 K301 NTE01

R NTE PS1 HCP Third Party Organization Note Purchased Service Information Line Pricing/Repricing Information S S S R R R R R R S S S S S S S S S S S S

NTE02 NTEO1 NTEO2 PS101 PS102 HCP01 HCP02 HCP03 HCP04 HCP05 HCP06 HCP07 HCP09 HCP10 HCP11 HCP12 HCP13 HCP14 HCP15

2410 DRUG IDENTIFICATION LIN CPT Drug Identification Drug Quantity S R R R R R R LIN02 LIN03 CPT04 CPT05 CPT05-1

REF

Prescription or Compound Drug Association S Number

R R

REF01 REF02 NM01

2420A RENDERING PROVIDER NAME NM1 Rendering Provider Name S R

R R S S S S S

NM02 NM03 NM104 NM105 NM107 NM108 NM109

PRV

Rendering Provider Specialty Information

R R R

PRV01 PRV02 PRV03 REF01 REF02 REF04

REF

Rendering Provider Secondary IdentificationS

R R S

2420B PURCHASED SERVICE PROVIDER NAME NM1 Purchased Service Provider Name S R R S S REF Purchased Service Provider Secondary Identification S R R R 2420C SERVICE FACILITY LOCATION NM1 Service Facility Location S R R R S S N3 Service Facility Location Address R R S N4 Service Facility Location City/State/ZIP R R S S S S REF Service Facility Location Secondary Identification R R R S NM01 NM02 NM03 NM108 NM109 N301 N302 N401 N402 N403 N404 N407 REF01 REF02 REF04 NM101 NM102 NM108 NM109 REF01 REF02 REF04

2420D SUPERVISING PROVIDER NAME NM1 Supervising Provider Name S R R NM01 NM02

R S S S S S

NM03 NM104 NM105 NM107 NM108 NM109

REF

Supervising Provider Secondary Identification S

R R S

REF01 REF02 REF04

2420E ORDERING PROVIDER NAME NM1 Ordering Provider Name S R R R S S S S S N3 Ordering Provider Address S R S N4 Ordering Provider City/State/ZIP Code S R S S S S REF Ordering Provider Secondary Identification S R R S R R PER Ordering Provider Contact Information S R S R R S S S S 2420F REFERRING PROVIDER NAME NM1 Referring Provider Name S R R R S S S S S NM101 NM102 NM103 NM104 NM105 NM107 NM108 NM109 NM101 NM102 NM103 NM104 NM105 NM107 NM108 NM109 N301 N302 N401 N402 N403 N404 N407 REF01 REF02 REF04 REF04-1 REF04-2 PER01 PER02 PER03 PER04 PER05 PER06 PER07 PER08

REF

Referring Provider Secondary Identification S

R R S R R

REF01 REF02 REF04 REF04-1 REF04-2 NM101 NM102 N301 N302 N401 N402 N403 N404 N407 NM101 NM102 NM103 N301 N302 N401 N402 N403 N404 N407

2420G AMBULANCE PICK-UP LOCATION NM1 N3 N4 Ambulance Pick-Up Location Ambulance Pick-Up Location Address S R R R S Ambulance Pick-up Location City,State,ZIP R Code R S S S S 2420H AMBULANCE DROP-OFF LOCATION NM1 Ambulance Drop-off Location S R S N3 N4 Ambulance Drop-off Location Address R R S Ambulance Drop-off Location City,State,ZIPR Code R S S S S 2430 LINE ADJUDICATION INFORMATION SVD Line Adjudication Information S R R R SVD01 SVD02 SVD03

R S CAS Line Adjustment S R

SVD05 SVD06 CAS01

R R S S S S S S S S S S S S S S S S

CAS02 CAS03 CAS04 CAS05 CAS06 CAS07 CAS08 CAS09 CAS10 CAS11 CAS12 CAS13 CAS14 CAS15 CAS16 CAS17 CAS18 CAS19

DTP

Line Adjudication Date

R R R

DTP01 DTP02 DTP03 AMT01 AMT02

AMT

Remaining Patient Liability

R R

2440 FORM IDENTIFICATION CODE LQ Form Identification Code S R R FRM Supporting Documentation R R S S S S LQ01 LQ02 FRM01 FRM02 FRM03 FRM04 FRM05

SE

Transaction Set Trailer

R R

SE01 SE02

Elements in a Segment

Data Type- Min/Max

Disucssion

Task

Entity Identifier Code Entity Type Qualifier Name Last or Organization Name NameFirst Identification Code Qualifier Identification Code

ID-

Contact Function Code Name(Submitter Contact Name) Communication Number Qualifier Communication Number Entity Identifier Code Entity Type Qualifier Name Last or Organization Name Identification Code Qualifier Identification Code

Hierarchical ID Number Hierarchical Level Code Hierarchical Child Code Provider Code Reference Identification Qualifier Reference Identification Entity Identifier Code Currency Code

Entity Identifier Code Entity Type Qualifier Name Last or Organization Name Name First Name Middle Name Suffix Identification Code Qualifier Identification Code Address Information Address Information City Name State or Province Code Postal Code Country Code

Country Subdivision Code Reference Identification Qualifier Reference Identification Reference Identification Qualifier Reference Identification Reference Identification Qualifier Reference Identification Contact Function Code Name Communication Number Qualifier Communication Number Communication Number Qualifier Communication Number Communication Number Qualifier Communication Number Entity Identifier Entity Type Quailifierr Addres Information Addres Information City Name State or Province Code Postal Code Country Code Country Subdivision Code Entity Identifier Code EntityType Qualifier Name Last Or Organization Name Identification Code Qualifier Identification Code Addres Information Addres Information City Name State or Province Code Postal Code Country Code Country Subdivision Code Reference Identification Qualifier Reference Identification Reference Identification Qualifier Reference Identification

Hierarchical ID Number Hierarchical Parent ID Number Hierarchical Level Code Hierarchical Child Code

Payer Responsibility Seq No: Code Individual Relationship Code Reference Identification Name Insurance Type Code Identification Code

Date Time Period Format Qualifier Date Time Period Unit or Dasis for Measurement Code Weight Yes/No Condition or Response Code Entity Identifier Code Entity Type Qualifier Name Last or Organization Name Name First Name Middle Name Suffix Identification Code Qualifier Identification Code

Address Information Address Information City Name State or Province Code Postal Code Country Code Country Subdivisiion Code Date Time Period Format Qualifier Date Time Period Gender Code Reference Identification Qualifier Reference Identification Reference Identification Qualifier Reference Identification Contact Function Code Name

Communication Number Qualifier Communication Number Communication Number Qualifier Communication Number Entity Identifier Code Entity Type Qualifier Name Last or Organization Name Identification Code Qualifier

Identification Code

Address Information Address Information City Name State or Province Code Postal Code Cuntry Subdivision Code Reference Identification Qualifier Reference Identification Reference Identification Qualifier Reference Identification

Hierarchical ID Number Hierarchical Parent ID Number Hierarchical Level Code Hierarchical Child Code Individual Relationship Code Date Time Period Format Qualifier Date Time Period Unit or Basis for Measurement Code Weight Yes/No Condition or Response Code Entity Identifier Code Entity Type Qualifier Name Last or Organization Name Name First Name Middle Name Suffix Address Information Address Information

City Name State or Province Code Postal Code Cuntry Code Country Subdivision Code Date Time Period Format Qualifier Date Time Period Gender Code Reference Identification Qualifier Reference Identifiction Reference Identification Qualifier Reference Identifiction Contact Function Code Name Communication Number Qualifier Communication Number Communication Number Qualifier Communication Number

Claim Submitters Identifier Monetary Amount HEALTH CARE SERVICE LOCATION INFORMATION Facility code value Facility code Qualifier Claim frequency Type Code Yes/No Condition or Response Code Provider Accept Assignment Code

Yes/No Condition or Response Code Release of Information Code

Patient Signature Source Code RELATED CAUSES INFORMATION Related-Causes Code

Related-Causes Code Satae or Province Code Country Code Special Program Code

Delay Reason Code Date/Time Qualifier Date Time Period Format Qualifier

DATE TIME PERIOD Date/Time Qualifier Date Time Period Format Qualifier Date Time Period Date/Time Qualifier Date Time Period Format Qualifier Date Time Period Date/Time Qualifier Date Time Period Format Qualifier Date Time Period Date/Time Qualifier Date Time Period Format Qualifier Date Time Period Date/Time Qualifier Date Time Period Format Qualifier Date Time Period Date/Time Qualifier Date Time Period Format Qualifier Date Time Period Date/Time Qualifier Date Time Period Format Qualifier Date Time Period Date/Time Qualifier Date Time Period Format Qualifier Date Time Period Date/Time Qualifier Date Time Period Format Qualifier Date Time Period Date/Time Qualifier Date Time Period Format Qualifier Date Time Period Date/Time Qualifier Date Time Period Format Qualifier Date Time Period Date/Time Qualifier Date Time Period Format Qualifier Date Time Period Date/Time Qualifier Date Time Period Format Qualifier Date Time Period

Date/Time Qualifier Date Time Period Format Qualifier Date Time Period Date/Time Qualifier Date Time Period Format Qualifier Date Time Period Reort Type Code Report Transmission Code Identification Code Qualifier Identification Code Contract Type Code Monetary Amount Percent Decimal Format Reference Identification Terms Discount Percent Verson Identifier Amount Qualifier Code Monetary Amount Reference Identification Qualifier Reference Identification

Reference Identification Qualifier Reference Identification Reference Identification Qualifier Reference Identification Reference Identification Qualifier Reference Identification Reference Identification Qualifier Reference Identification Reference Identification Qualifier Reference Identification Reference Identification Qualifier Reference Identification Reference Identification Qualifier Reference Identification Reference Identification Qualifier Reference Identification

Reference Identification Qualifier Reference Identification Reference Identification Qualifier Reference Identification Reference Identification Qualifier Reference Identification Reference Identification Qualifier Reference Identification Reference Identification Qualifier Reference Identification Fixed Format Information Note Reference Code

Claim Note Text Unit or Basis for Measurement Code Weight Ambulance Transport Reason Code Unit or Basis for Measurement Code Quantity Description Description Nature of Condition Code Description

Code Category Yes/No Condition or Response Code Condition Indicator Condition Indicator Condition Indicator Condition Indicator Condition Indicator Code Category Yes/No Condition or Response Code Condition Indicator

Condition Indicator Condition Indicator Condition Indicator Condition Indicator Code Category Y/N Condition Or Response Code Condition Indicator Code Category Y/N Condition Or Response Code Condition Indicator Condition Indicator Condition Indicator HEALTH CARE CODE INFORMATION HEALTH CARE CODE INFORMATION Code List Qualifier Code Health Cate Code Information Health Care Code Information

Health Care Code Information

Health Care Code Information

Health Care Code Information Health Care Code Information Health Care Code Information Health Care Code Information Health Care Code Information

Health Care Code Information Health Care Code Information

Health Care Code Information

Health Care Code Information Health Care Code Information Health Care Code Information Health Care Code Information Health Care Code Information Health Care Code Information Health Care Code Information Health Care Code Information Health Care Code Information Health Care Code Information Health Care Code Information

Pricing Methodology Monetary Amount Monetary Amount Reference Identification Rate Reference Identification Monetary Amount Reject Reason Code

Policy Compliance Code

Exception Code

Entity Identifier Code Entity Type Qualifier Name Last or Organization Name Name First

Name Middle Name Suffix Identification Code Qualifier Identification Code Reference Identification Qualifier REference Identification

Entity Identifier Code Entity Type Qualifier Name Last or Organization Name Name First Name Middle Name Suffix Identification Code Qualifier Identification Code Provider Code Reference Identification Qualifier Reference Identification Reference Identification Qualifier Reference Identification

Entity Identifier Code Entity Type Qualifier Name Last or Organization Name Identification Code Qualifier Identification Code Address Information Address Information City Name State or Province Code Postal Code Cuntry Code Country Subdivision Code Reference Identification Qualifier Reference Identification Contact Function Code Name Communication Number Qualifier Communication Number Communication Number Qualifier

Communication Number

Entity Identifier Code Entity Type Qualifier Name Last or Organization Name Name First Name Middle Name Suffix Identification Code Qualifier Identification Code Reference Identification Qualifier Reference Identification

Entity Identifier Code Entity Type Qualifier Address Information Address Information City Name State or Province Code Cuntry Code Country Subdivision Code

Entity Identifier Code Entity Type Qualifier Name Last or Organization Name Address Information Address Information City Name State or Province Code Postal Code Cuntry Code Country Subdivision Code

Payer Responsibility Sequence Number Code Individual Relationship Code Reference Identification Name Insurance Type Code

Claim Filling Indicator Code

Claim Adjustment Group Code

Claim Adjustment Reason Code Monetary Amount Quantity Claim Adjustment Reason Code Monetary Amount Quantity Claim Adjustment Reason Code Monetary Amount Quantity Claim Adjustment Reason Code Monetary Amount Quantity Claim Adjustment Reason Code Monetary Amount Quantity Claim Adjustment Reason Code Monetary Amount Quantity Amount Qualifier Code Monetary Amount

Amount Qualifier Code 0 Amount Qualifier Code Monetary Amount Yes/No Condition or Response Code Patient Signature Source Code Release of Information Code Percentage as Decimal Monetary Amount Reference Identification Reference Identification Reference Identification Reference Identification Reference Identification Reference Identification Reference Identification

Entity Identifier Code Entity Type Qualifier Name Last or Organization Name Name First Name Middle Name Suffix Identification Code Qualifier Identification Code

Address Information Address Information City Name State or Province Code Postal Code Cuntry Code Country Subdivision Code

Reference Identification Qualifier Reference Identification Entity Identifier Code Entity Type Qualifier Name Last or Organization Name Identification Code Qualifier Identification Code Address Information Address Information City Name State or Province Code Postal Code Cuntry Code Country Subdivision Code Date/Time Qualifier DateTime Period format Qualifier Date Time Period Reference Identification Qualifier Reference Identification Reference Identification Qualifier reference Identification Reference Identification Qualifier reference Identification Reference Identification Qualifier reference Identification Reference Identification Qualifier reference Identification Entity Identifier Code Entity Type Code Reference Identification Qualifier Reference Identification

Entity Identifier Code Entity type Qualifier Reference Identification Qualifier REference Identification

Entity Identifier Code Entity Type Qualifier Reference Identification Qualifier REference Identification

Entity Identifier Code EntityType Qualifier Reference Identification Qualifier REference Identification

Entity Identifier Code EntityType Qualifier Reference Identification Qualifier REference Identification

Assigned Number COMPOSITE MEDICAL PROCEDURE IDENTIFIER

Monetary Amount Unit or Basis for Measurement Code Quantity Faculty Code Value COMPOSITE DIAGNOSIS CODE POINTER

Yes/No Condition or Response Code Yes/No Condition or Response Code Yes/No Condition or Response Code Copay Status Code COMPOSITE MEDICAL PROCEDURE IDENTIFIER Unit or Basis for Measurement Code Quantity

Monetary Amount Monetary Amount Frequency Code Report Type Code Report Transmission Code Identification Code Qualifier Identification Code Report Type Code Report Transmission Code Unit or Basis for Measurement Code Weight Ambulance Transport Reason Code Unit or Basis for Measurement Code Quantity Description Description Certification Type Code Unit or Basis for Measurement Code Quantity Code Category Yes/No Condition or Response Code Condition Indicator Condition Indicator Condition Indicator Condition Indicator Condition Indicator Code Category Yes/No Condition or Response Code Condition Indicator Code Category Yes/No Condition or Response Code Condition Indicator Condition Indicator Date/Time Qualifier Date Time Period Format Qualifier Date Time Period Date/Time Qualifier Date Time Period Format Qualifier Date Time Period Date/Time Qualifier Date Time Period Format Qualifier Date Time Period Date/Time Qualifier Date Time Period Format Qualifier Date Time Period Date/Time Qualifier Date Time Period Format Qualifier Date Time Period Date/Time Qualifier Date Time Period Format Qualifier Date Time Period Date/Time Qualifier

Date Time Period Format Qualifier Date Time Period Date/Time Qualifier Date Time Period Format Qualifier Date Time Period Date/Time Qualifier Date Time Period Format Qualifier Date Time Period Date/Time Qualifier Date Time Period Format Qualifier Date Time Period Quantity Qualifier Quantity Quantity Qualifier Quantity Measurement Reference ID Code Measurement Qualifier Measurement Values Contract Type Code

Monetary Amount Percent,Decimal Format Reference Identification Terms Discount Percent Version Identifier Reference Identification Qualifier Reference Identification Reference Identification Qualifier Reference Identification Reference Identification Qualifier Reference Identification Reference Identifier Reference Identification Qualifier Reference Identification Reference Identification Qualifier Reference Identification Reference Identification Qualifier Reference Identification Reference Identification Qualifier Reference Identification Reference Identification Qualifier Reference Identification Reference Identification Qualifier Reference Identification Reference Identification Qualifier Reference Identification

Reference Identifier Reference Identification Qualifier Reference Identification Amount Qualifier Code Monetory Amount Amount Qualifier Code Monetory Amount Fixed Format Information Note Reference Code

Description Note Reference Code Description Reference Identification Monetory Amount Pricing Methodology Monetory Amount Monetory Amount Reference Identification Rate Reference Identification Monetory Amount Product/Service ID Qualifier Product/Service ID Unit or Basis for Measurement Code Quantity Reject Reason Code Policy Compliance Code Exception Code

Product/Service ID Qualifier Product/Service ID Quantity Composite Unit of Measure Unit or Basis for Measurement Code

Reference Identification Qualifier Reference identification Entity Identifier Code

Entity Type Qualifier Name Last Or Organization Name Name First Name Middle Name Suffix Identification Code Qualifier Identification Code

Provider Code Reference Identification Qualifier Reference identification Reference Identification Qualifier Reference Identification Reference Identification

Entity Identifier Code Entity Type Qualifier Identification Code Qualifier Identification Code Reference Identification Qualifier Reference Identification Reference Identifier

Entity Identifier Code Entity Type Qualifier Namne Last or Organization Name Identification Code Qualifier Identification Code Address Information Address Information City Name State or Province Code Postal Code Cuntry Code Country Subdivision Code Reference Identification Qualifier Reference Identification Reference Idenftifier

Entity Identifier Code Entity Type Qualifier

Name Last Or Organization Name Name First Name Middle Name Suffix Identification Code Qualifier Identification Code

Reference Identification Qualifier Reference Identification Reference Idenftifier

Entity Idetifier Code Entity Type Qualifier Name Last or OrganiZation Name Name First Name Middle Name Suffix Identification Code Qualifier Identification Code Address Information Address Information City Name State or Province Code Postal Code Country Code Country Subdivision Code Reference Identification Qualifier Reference identification Reference identifier Reference Identification Qualifier Reference identification Contact Function Code Name Communication Number Qualifier Communication Number Communication Number Qualifier Communication Number Communication Number Qualifier Communication Number Entity Idetifier Code Entity Type Qualifier Name Last or OrganiZation Name Name First Name Middle Name Suffix Identification Code Qualifier Identification Code

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Identification Code Monetary Amount COMPOSITE MEDICAL PROCEDURE IDENTIFIER

Quantity Assigned Number Claim Adjustment Group Code

Claim Adjustment Reason Code Monetary Amount Quantity Claim Adjustment Reason Code Monetary Amount Quantity Claim Adjustment Reason Code Monetary Amount Quantity Claim Adjustment Reason Code Monetary Amount Quantity Claim Adjustment Reason Code Monetary Amount Quantity Claim Adjustment Reason Code Monetary Amount Quantity

Date/Time Qualifier Date Time Period Format Qualifier Date Time Period Amount Qualifier Code Monetary Amount

Code List Qualifier Code Industry Code Assigned Identification Yes/No Condition or Response Code Reference Identification Date Percent Decimal Format

Number Of Included Segments Transaction Set Control Number