Transcription
INSTITUTIONAL escription837-I 4010A1ISA01ISA02ID2-2AN 10-10RR00, 03ISA03ISA04Security Information QualifierSecurity InformationID2-2AN 10-10RR00, 01ISA05ISA06Interchange ID QualifierInterchange Sender IDID2-2AN 15-15RRISA07ISA08ISA09ISA10ID2-2AN 15-15DT6-6TM 4-4RRRRISA12Interchange ID QualifierInterchange Receiver IDInterchange DateInterchange TimeInterchange ControlStandards IDInterchange Control VersionNumberISA13Interchange Control 06GS07GS081R1ISA03ISA04Security Information QualifierSecurity InformationID2-2AN 10-10RR00, 0101, 14, 20, 27, 28,29, 30, 33, ZZISA05ISA06Interchange ID QualifierInterchange Sender IDID2-2AN 15-15RR01, 14, 20, 27, 28,29, 30, 33, ZZISA07ISA08ISA09ISA10ID2-2AN 15-15DT6-6TM 4-4RRRR5-5RISA12N09-9RISA13Interchange Control NumberAcknowledgement Requested IDUsage IndicatorIDComponent RRRR100, 2-2AN 10-10RTimeGroup Control NumberResponsible Agency CodeVersion Identifier GE CONTROLHEADERAuthorization InformationQualifierAuthorization InformationInterchange ID QualifierInterchange Receiver IDInterchange DateInterchange TimeInterchange ControlStandards IDInterchange Control VersionNumberFUNCTIONAL GROUPHEADERFunctional Identifier CodeApplication Sender CodeApplication Receiver CodeDateMin.Max.837-I 5010INTERCHANGE CONTROLHEADERAuthorization InformationQualifierAuthorization InformationISAIDYYMMDDHHMM0, 1P, TISA14ISA15ISA161CCYYMMDDHHMM, ent Requested IDUsage IndicatorIDComponent FUNCTIONAL GROUPHEADERFunctional Identifier CodeApplication Sender CodeApplication Receiver CodeDateTimeGroup Control NumberResponsible Agency CodeVersion Identifier CodePage 1 of 93IDANANDTTMN0IDAN4-81-91-21-12RRRR01, 14, 20, 27, 28,29, 30, 33, ZZ01, 14, 20, 27, 28,29, 30, 33, ZZYYMMDDHHMM005010, 1P, T1CCYYMMDDHHMM, HHMMSS,HHMMSSD,HHMMSSDDX005010X223Code Change
INSTITUTIONAL escription837-I 4010A1STST01ST02TRANSACTION SETHEADERTransaction Set IdentifierCodeTransaction Set on Set CreationTimeClaim or Encounter ID 1ST837ST01ST02TRANSMISSION TYPEIDENTIFICATIONReference IdentificationQualifierReference IdentificationDescriptionReference IdentifierSUBMITTER NAMEEntity Identifier CodeEntity Type QualifierSubmitter Last orOrganization NameSubmitter First NameSubmitter Middle NameName PrefixName SuffixIdentification Code QualifierSubmitter IdentifierEntity Relationship CodeEntity Identifier M, HHMMSS,HHMMSSD,HHMMSSDDCH, N/URRN/UN/UTMIDMin.Max.UsageReg.LoopLoopRepeat 1Values837-I 5010ST03BEGINNING OFHIERARCHICALTRANSACTIONHierarchical Structure CodeTransaction Set PurposeCodeOriginator ApplicationTransaction IDTransaction Set CreationDateID10019BHTBHT0100, 18BHT02BHT03BHT04BHT05BHT06TRANSACTION SETHEADERTransaction Set IdentifierCodeTransaction Set ControlNumberImplementation ConventionReferenceBEGINNING OFHIERARCHICALTRANSACTIONHierarchical Structure CodeTransaction Set PurposeCodeOriginator ApplicationTransaction IDTransaction Set CreationDateTransaction Set CreationTimeClaim or Encounter 837New Element1001900, 18Increase from 30 - 50TMID4-82-2CCYYMMDDHHMM, HHMMSS,HHMMSSD,HHMMSSDD31, CH, RPCode AddedRRSegment Deleted871000A1411, 9NM110NM111NM112SUBMITTER NAMEEntity Identifier CodeEntity Type QualifierSubmitter Last orOrganization NameSubmitter First NameSubmitter Middle NameName PrefixName SuffixIdentification Code QualifierSubmitter IdentifierEntity Relationship CodeEntity Identifier CodeName Last or OrganizationNamePage 2 of 11, 2Increase from 35 - 60Increase from 25 - 3546New Element
INSTITUTIONAL MITTER EDI CONTACTINFORMATIONContact Function mentIdentifierDescriptionPERPER01SUBMITTER EDI CONTACTINFORMATIONContact Function Code837-I ubmitter Contact NameCommunication NumberQualifierCommunication NumberCommunication NumberQualifierCommunication NumberCommunication NumberQualifierCommunication NumberContact Inquiry M104NM105NM106NM107NM108NM109NM110NM111RECEIVER NAMEEntity Identifier CodeEntity Type QualifierReceiver NameName FirstName MiddleName PrefixName SuffixIdentification Code QualifierReceiver Primary IdentifierEntity Relationship CodeEntity Identifier 01PRV02PRV03PRV04BILLING/PAY-TOPROVIDER SPECIALTYINFORMATIONProvider CodeReference IdentificationQualifierProvider Taxonomy CodeState or Province CodeMin.Max.UsageReg.LoopLoopRepeatValues837-I 50101000AICPER02ED, EM, FX. TEED, EM, EX, FX,TESSED, EM, EX, M110NM111NM112BILLING/PAY-TOPROVIDER HIERARCHICALLEVELHierarchical ID NumberANHierarchical Parent IDNumberANHierarchical Level CodeIDHierarchical Child CodeIDIDSubmitter Contact NameCommunication NumberQualifierCommunication NumberCommunication NumberQualifierCommunication NumberCommunication NumberQualifierCommunication NumberContact Inquiry ReferenceRECEIVER NAMEEntity Identifier CodeEntity Type QualifierReceiver NameName FirstName MiddleName PrefixName SuffixIdentification Code QualifierReceiver Primary IdentifierEntity Relationship CodeEntity Identifier CodeName Last or OrganizationNameID22-2RR1000AAN1-60SID2-2AN 1-256RREM, FX. TEID2-2AN 1-256SSEM, EX, FX, TEID2-2AN 1-256AN 1-20SSN/UEM, EX, FX, sage change toSituationalCode deletedIncrease from 80 - 256Code deletedIncrease from 80 - 256Code deletedIncrease from 80 - 2561000B1402Increase from 35 - 60Increase from 25 - 3546New ElementName Change11-12RR1-121-21-1N/URR2000A 1HLHL01201HL02HL03HL04BILLING PROVIDERHIERARCHICAL LEVELHierarchical ID NumberHierarchical Parent IDNumberHierarchical Level CodeHierarchical Child CodeAN11-12RRANIDID1-121-21-1N/URR2000A 1201Name ChangeID11-3SRIDANID2-31-302-2RRN/U2000ABI, PTZZPRVPRV01PRV02PRV03PRV04BILLING PROVIDERSPECIALTY INFORMATIONProvider CodeIDReference IdentificationQualifierIDProvider Taxonomy CodeANState or Province CodeIDPage 3 of 9311-3SR2-31-502-2RRN/U2000ABICode DeletedCode ChangePXCIncrease from 30 - 50
INSTITUTIONAL ER SPECIALTYINFORMATIONPRV06Provider Organization mentIdentifierDescription837-I UR19CUR20CUR21FOREIGN CURRENCYINFORMATIONEntity Identifier CodeCurrency CodeExchange RateEntity Identifier CodeCurrency CodeCurrency Market/ExchangeCodeDate/Time QualifierDateTimeDate/Time QualifierDateTimeDate/Time QualifierDateTimeDate/Time QualifierDateTimeDate/Time QualifierDateTimeN/UPRV05ID3-3N/UPRV06Provider Organization 351-25RN/UNM105NM106Name MiddleName PrefixANAN1-251-10NM107Name SuffixAN1-10NM108NM109NM110NM111Identification Code QualifierBilling Provider IdentifierEntity Relationship CodeEntity Identifier R17CUR18CUR19CUR20CUR21FOREIGN CURRENCYINFORMATIONEntity Identifier CodeCurrency CodeExchange RateEntity Identifier CodeCurrency CodeCurrency Market/ExchangeCodeDate/Time QualifierDateTimeDate/Time QualifierDateTimeDate/Time QualifierDateTimeDate/Time QualifierDateTimeDate/Time -31-1RRRNM103NM104Billing Provider NameEntity Identifier CodeEntity Type QualifierBilling Provider Lastor Organizational NameBilling Provider First NameANAN1-601-35RN/UN/UN/UNM105NM106Billing Provider Middle NameName PrefixANAN1-251-10N/UN/UN/UNM107Billing Provider Name SuffixAN1-10N/URSN/UN/ULoop837-I 5010PROVIDER SPECIALTYINFORMATIONBilling Provider NameEntity Identifier CodeEntity Type QualifierBilling Provider Lastor Organizational NameName FirstNM1NM101NM102ID2010AA185224, 34, tion Code QualifierBilling Provider IdentifierEntity Relationship CodeEntity Identifier CodeName Last or OrganizationNamePage 4 of 932000A852010AA1852Increase from 35 - 60IDANIDID1-22-802-22-3SSN/UN/UAN1-60N/UIncrease from 25 - 35XXCode DeletedUsage change toSituationalNew Element
INSTITUTIONAL CLAIM4010A1ElementIdentifierDescriptionN3BILLING PROVIDERADDRESSN301Billing Provider Address LineN302Billing Provider Address mentIdentifierDescriptionN3BILLING PROVIDERADDRESS837-I REF04BILLING PROVIDERCITY/STATE/ZIP CODEBilling Provider City NameBilling Provider State orProvince CodeBilling Provider Postal Zone orZIP CodeCountry CodeLocation QualifierLocation IdentifierReference IdentificationQualifierBilling Provider AdditionalIdentifierDescriptionREFERENCE IDENTIFIERREF02REF03REF04CREDIT/DEBIT CARDBILLING INFORMATIONReference IdentificationQualifierBilling Provider AdditionalIdentifierDescriptionREFERENCE IDENTIFIERPERPER01BILLING PROVIDERCONTACT INFORMATIONContact Function g Provider Address LineAN1-55SN302Billing Provider Address N/UN403N404N405N406N407BILLING PROVIDERCITY/STATE/ZIP CODEBilling Provider City NameBilling Provider State orProvince CodeBilling Provider Postal Zone orZIP CodeCountry CodeLocation QualifierLocation IdentifierCountry Subdivision CodeREFBILLING PROVIDER Values837-I 50101BILLING PROVIDER TAXIDENTIFICATIONID2010AA2010AAN4N4012010AA0B, 1A, 1B, 1C,1D, 1G, 1H, 1J,B3, BQ, EI, FH,G2, G5, LU, RN/UN/UID22-2SR1-60R2-21-80RREM, FX, TE2-2SEM, EX, FX, 1-21-301-3SSN/UN/US1R2010AA2010AAUsage change toSituationalUsage change toSituationalNew Element# Repeats change to 12010AACode DeletedREF01REF02REF03REF04Reference IdentificationQualifierBilling Provider AdditionalIdentifierDescriptionREFERENCE IDENTIFIERID2-3RANAN1-501-80RN/UN/UEIIncrease from 30 - 50Segment DeletedBilling Provider Contact Name ANCommunication NumberQualifierIDCommunication NumberANCommunication NumberQualifierID2010AA06, 8U, EM, IJ, LU,RB, ST, TT2010AAICPERPER01PER02PER03PER04PER05BILLING PROVIDERCONTACT INFORMATIONContact Function CodeID22-2Billing Provider Contact Name AN 1-60Communication NumberQualifierID2-2Communication NumberAN 1-256Communication NumberQualifierID2-2Page 5 of 93SR2010AAICUsage change toSituationalSRREM, FX, TESEM, EX, FX, TEIncrease from 80 - 256
INSTITUTIONAL escription837-I 4010A1PER06PER07PER08PER09Communication NumberCommunication NumberQualifierCommunication NumberContact Inquiry RRNM103PAY-TO PROVIDER NAMEEntity Identifier CodeEntity Type QualifierPay-to Provider Last orOrganization NameAN1-35N/UNM104Name FirstAN1-25NM105NM106Name MiddleName PrefixANANNM107Name SuffixNM108NM109NM110NM111Identification Code QualifierPay-to Provider IdentifierEntity Relationship CodeEntity Identifier Values837-I 5010PER06EM, EX, FX, TEPER07PER08PER09Communication NumberCommunication NumberQualifierCommunication NumberContact Inquiry ReferenceAN 1-256SID2-2AN 1-256AN 1-20SSN/UIDID12-31-1SRRNM103PAY-TO ADDRESS NAMEEntity Identifier CodeEntity Type QualifierPay-to Provider Last orOrganization NameAN1-60N/UN/UNM104Pay-to Provider First NameAN1-35N/U1-251-10N/UN/UNM105NM106Pay-to Provider Middle Name ANName PrefixAN1-251-10N/UN/UAN1-10N/UNM107Pay-to Provider Name UNM112Identification Code QualifierPay-to Provider IdentifierEntity Relationship CodeEntity Identifier CodeName Last or OrganizationNameAN1-60N/UN3PAY-TO PROVIDERADDRESS1R2010AB1872NM1NM101NM102Increase from 80 - 256EM, EX, FX, TEIncrease from 80 - 2562010ABName Change1872Increase from 35 - 60Increase from 25 - 35Name ChangeName ChangeName ChangeN3PAY-TO PROVIDERADDRESS1R24, 34, XX2010ABCode DeletedNew Element2010ABN301Pay-to Provider Address Line AN1-55RN301Pay-to Provider Address Line AN1-55RN302Pay-to Provider Address Line AN1-55SN302Pay-to Provider Address Line AN1-55SAN12-30RRAN12-30RRID2-2RN402ID2-2SUsage change toSituationalUsagechange toID3-15RN403ID3-15SSituationalPay-to Provider Country Code IDLocation QualifierIDLocation o Provider Country Code IDLocation QualifierIDLocation IdentifierANCountry Subdivision 406REFPAY-TO PROVIDERCITY/STATE/ZIP CODEPay-to Provider City NamePay-to Provider State CodePay-to Provider Postal Zoneor ZIP CodePAY-TO 1PAY-TO PROVIDERCITY/STATE/ZIP CODEPay-to Provider City NamePay-to Provider State CodePay-to Provider Postal Zoneor ZIP Code2010ABNew ElementSegment Deleted0B, 1A, 1B, 1C,1D, 1G, 1H, 1J,B3, BQ, EI, FH,G2, G5, LU, SY,X5Page 6 of 93
INSTITUTIONAL escription837-I 4010A1REF01REF02REF03REF04Reference IdentificationQualifierBilling Provider AdditionalIdentifierDescriptionREFERENCE Reg.LoopLoopRepeat2010AC1Values837-I 5010NM1NM101NM102NM103NM104NM105NM106NM107PAY TO PLAN NAMEEntity Identifier CodeEntity Type QualifierPay to Plan OrganizationalNameName FirstName MiddleName PrefixName SuffixNM112Identification Code QualifierIdentification CodeEntity Relationship CodeEntity Identifier CodeName Last or OrganizationNameN3N301N302PAY-TO PLAN ADDRESSPay-to Plan Address LinePay-to Plan Address N407PAY-TO PLANCITY/STATE/ZIP CODEPay-to Plan City NamePay-to Plan State CodePay-to Plan Postal Zone orZIP CodePay-to Plan Country CodeLocation QualifierLocation IdentifierCountry Subdivision erence IdentificationQualifierReference IdentificationDescriptionREFERENCE IDENTIFIERREFPAY-TO PLAN TAXIDENTIFICATIONREFPage 7 of ew SegmentPE2PI, XVNew SegmentNew SegmentNew SegmentIDANAN2010AC2U, FY, NFNew Segment2010AC
INSTITUTIONAL escriptionREF01REF02REF03REF04Reference IdentificationQualifierReference IdentificationDescriptionREFERENCE IDENTIFIER837-I 05SBR06SBR07SBR08SUBSCRIBERHIERARCHICAL LEVELHierarchical ID NumberHierarchical Parent IDNumberHierarchical Level CodeHierarchical Child CodeANRRANIDID1-121-21-1RRR1RID1-1RP, S, 4SBR05Coordination of Benefits Code IDYes/No Condition orResponse CodeIDEmployment Status CodeID1-1N/USBR061-12-2N/UN/USBR07SBR08Individual Relationship CodeInsured Group or PolicyNumberInsured Group NameInsurance Type CodeSBR09Claim Filing Indicator BSCRIBER NAMEEntity Identifier CodeEntity Type QualifierSubscriber Last NameSubscriber First NameSubscriber Middle NameName PrefixSubscriber Name RSSN/USMin.Max.UsageReg.LoopLoopRepeatValues837-I 501011-12SUBSCRIBERINFORMATIONPayer ResponsibilitySequence Number CodeID2000B 1HLHL01220, 12000BSBR09, 10, 11, 12, 13,14, 15, 16, AM,BL, CH, CI, DS,HM, LI, LM, MA,MB, MC, OF, TV,VA, WC, ZZ2010BAHL02HL03HL041IL1, on of Benefits Code IDYes/No Condition orResponse CodeIDEmployment Status CodeID1-1N/U1-12-2N/UN/USUBSCRIBERHIERARCHICAL LEVELHierarchical ID NumberHierarchical Parent IDNumberHierarchical Level CodeHierarchical Child CodeSUBSCRIBERINFORMATIONPayer ResponsibilitySequence Number CodeIndividual Relationship CodeInsured Group or PolicyNumberInsured Group NameInsurance Type CodeEI2000B 1220, 12000BA, B, C, D, E, F, Code AddedG, H, P, S, T, U18Increase from 30 - 50SBR09Claim Filing Indicator BSCRIBER NAMEEntity Identifier CodeEntity Type QualifierSubscriber Last NameSubscriber First NameSubscriber Middle NameName PrefixSubscriber Name RSSN/US11, 12, 13, 14, 15, Code Change16, 17, AM, BL,CH, CI, DS, FI,HM, LM, MA, MB,MC, OF, TV, VA,WC, ZZ2010BA1IL1, 2Increase from 35 - 60Increase from 25 - 35Code ChangeUsage change to RequiredNM108Identification Code QualifierID1-2SNM109NM110Subscriber Primary IdentifierEntity Relationship CodeANID2-802-2SN/UMI, ZZNM108Identification Code QualifierID1-2RNM109NM110Subscriber Primary IdentifierEntity Relationship CodeANID2-802-2RN/UII, MIUsage change to RequiredPage 8 of 93
INSTITUTIONAL CLAIM4010A1ElementIdentifierDescriptionNM111Entity Identifier mentIdentifierN3N301N302SUBSCRIBER ADDRESSSubscriber Address LineSubscriber Address LineN4N401SUBSCRIBERCITY/STATE/ZIP CODESubscriber City NameN402N403N404N405N406Subscriber State CodeSubscriber Postal Zone orZIP CodeSubscriber Country CodeLocation QualifierLocation DEMOGRAPHICINFORMATIONDate Time Period FormatQualifierSubscriber Birth DateSubscriber Gender CodeMarital Status CodeRace or Ethnicity CodeCitizenship Status CodeDMG07DMG08DMG09Country CodeBasis of Verification M112Entity Identifier CodeName Last or OrganizationNameAN1-60N/UN3N301N302SUBSCRIBER ADDRESSSubscriber Address LineSubscriber Address TE/ZIP CODESubscriber City 0RN/UN/U1S2-3RLoopLoopRepeatValues837-I 5010N/UANANSUBSCRIBER SECONDARYIDENTIFICATIONReference IdentificationQualifierIDSubscriber SupplementalIdentifierANDescriptionANREFERENCE IDENTIFIERCASUALTY CLAIMNUMBERReference IdentificationQualifier2-3UsageReg.ID837-I G04DMG05DMG06SUBSCRIBERDEMOGRAPHICINFORMATIONDate Time Period FormatQualifierSubscriber Birth DateSubscriber Gender CodeMarital Status CodeRace or Ethnicity CodeCitizenship Status 07DMG08DMG09DMG10DMG11Country CodeBasis of Verification CodeQuantityCode List Qualifier CodeIndustry R1-501-80RN/UN/U1S2-3RDMGD8CCYYMMDDF, M, U2010BAREF1W, 23, IG, SYREF01REF02REF03REF042010BAREFY4Subscriber State CodeSubscriber Postal Zone orZIP CodeSubscriber Country CodeLocation QualifierLocation IdentifierCountry Subdivision CodeNew ElementREF01SUBSCRIBER SECONDARYIDENTIFICATIONReference IdentificationQualifierIDSubscriber SupplementalIdentifierANDescriptionANREFERENCE IDENTIFIERCASUALTY CLAIMNUMBERReference IdentificationQualifierPage 9 of 93IDUsage change toSituationalUsage change toSituationalNew Element2010BAD8CCYYMMDDF, M, UNew ElementNew Element2010BACode DeletedSYIncrease rom 30 - 502010BAY4
INSTITUTIONAL EF04Property Casualty ClaimNumberDescriptionREFERENCE erty Casualty ClaimNumberDescriptionREFERENCE IDENTIFIER837-I 4010A1NM107CREDIT/DEBIT CARDACCOUNT HOLDER NAMEEntity Identifier CodeEntity Type QualifierCredit or Debt Card HolderLast or Organization NameCredit or Debt Card HolderFirst NameCredit or Debt Card HolderMiddle NameName PrefixCredit or Debt Card HolderName SuffixNM108NM109NM110NM111Identification Code QualifierPayer IdentifierEntity Relationship CodeEntity Identifier 7PAYER NAMEEntity Identifier CodeEntity Type QualifierPayer NameName FirstName MiddleName PrefixName RN/UN/UN/UN/UNM108NM109NM110NM111Identification Code QualifierPayer IdentifierEntity Relationship CodeEntity Identifier CodeIDANIDID1-22-802-22-3RRN/UN/UN3PAYER ADDRESSUsageReg.LoopLoopRepeatValues837-I 5010Increase rom 30 - 50ANAN1-501-80RN/UN/U2010BB1AO1, 2MISegment DeletedREF02REF03REF04REF01Min.Max.Segment DeletedCREDIT/DEBT CARDINFORMATIONReference IdentificationQualifierCredit or Debt CardAuthorization NumberDescriptionREFERENCE IDENTIFIERREFID1S2010BBAB, BB2010BC1PR2PI, R NAMEEntity Identifier CodeEntity Type QualifierPayer NameName FirstName MiddleName PrefixName SuffixNM108NM109NM110NM111NM112Identification Code QualifierPayer IdentifierEntity Relationship CodeEntity Identifier CodeName Last or OrganizationNameN3PAYER ADDRESSPage 10 of 010BBLoop Change1PR2Increase from 35 - 60Increase from 25 - 35PI, XVNew Element2010BBLoop Change
INSTITUTIONAL er Address LinePayer Address LineN4N401PAYER CITY/STATE/ZIPCODEPayer City criptionIDN301N302Payer Address LinePayer Address LineANAN1-551-55RSN4N401PAYER CITY/STATE/ZIPCODEPayer City UN/US3S2-31-501-80RRN/UN/U837-I ayer State CodePayer Postal Zone or ZIPCodePayer Country CodeLocation QualifierLocation IdentifierPAYER SECONDARYIDENTIFICATIONReference IdentificationQualifierPayer Additional IdentifierDescriptionREFERENCE -301-80RRN/UN/U2010BC2010BCREF2U, FY, NF, 101NM102NM103NM104NM105NM106NM107RESPONSIBLE PARTYNAMEEntity Identifier CodeEntity Type QualifierPayer NameName FirstName MiddleName PrefixName SuffixNM108NM109NM110NM111Identification Code QualifierIdentification CodeEntity Relationship CodeEntity Identifier CodeN3RESPONSIBLE PARTYADDRESSLoopLoopRepeatValues837-I 5010ANAN3Min.Max.UsageReg.ElementIdentifierPayer State CodePayer Postal Zone or ZIPCodePayer Country CodeLocation QualifierLocation IdentifierCountry Subdivision CodePAYER SECONDARYIDENTIFICATIONReference IdentificationQualifierPayer Additional IdentifierDescriptionREFERENCE IDENTIFIERBILLING PROVIDERSECONDARYIDENTIFICATIONReference IdentificationQualifierPayer Additional IdentifierDescriptionREFERENCE IDENTIFIERLoop Change2010BBUsage change toSituationalUsage change toSituationalNew ElementLoop Change2010BBCode ChangeIDANAN2U, EI, FY, NFIncrease from 30 - 50Segment AddedIDANAN1S2-31-501-80RRN/UN/U2010BBG2, LUSegment QDSegment Deleted2010BCPage 11 of 93
INSTITUTIONAL escription837-I 4010A1N302Responsible Party AddressLineResponsible Party AddressLineN4RESPONSIBLE PARTYCITY/STATE/ZIP CODEN301AN1-55RAN1-55S1RResponsible Party City Name AN2-30RN402Responsible Party State Code D1-121-21-1RRR1RN404N405N406Responsible Party ZIP CodeResponsible Party CountryCodeLocation QualifierLocation IdentifierHL02HL03HL04PATIENT HIERARCHICALLEVELHierarchical ID NumberHierarchical Parent IDNumberHierarchical Level CodeHierarchical Child CodePATPATIENT lues837-I 5010Segment DeletedN401N403ID2010BC2000C 1HL02HL03HL04PATIENT HIERARCHICALLEVELHierarchical ID NumberHierarchical Parent IDNumberHierarchical Level CodeHierarchical Child CodePATPATIENT RRR1R2000C 12302000CCode ividual Relationship CodePatient Location CodeEmployment Status CodeStudent Status CodeDate Time Period FormatQualifierPatientUnit orDeathBasis DateforIDAN2-31-35N/UN/UPAT07PAT08PAT09Measurement CodePatient WeightPregnancy 3PATIENT NAMEEntity Identifier CodeEntity Type QualifierPatient Last NameIDIDAN12-31-11-35RRRRPAT01PAT02PAT03PAT0401, 04, 05, 07, 10,15, 17, 19, 20, 21,22, 23, 24, 29, 32,33, 36, 39, 40, 41,43, 53, 06Individual Relationship CodePatient Location CodeEmployment Status CodeStudent Status CodeDate Time Period FormatQualifierPatientUnit orDeathBasis DateforIDAN2-31-35N/UN/UPAT07PAT08PAT09Measurement CodePatient WeightPregnancy 3PATIENT NAMEEntity Identifier CodeEntity Type QualifierPatient Last NameIDIDAN12-31-11-60RRRRPAT01PAT02PAT03PAT04Page 12 of 9301, 19, 20, 21, 39,40, 53, G82010CA1QC1Increase from 35 - 60
INSTITUTIONAL escription837-I 4010A1NM104NM105NM106NM107Patient First NamePatient Middle NameName PrefixPatient Name oopLoopRepeatValues837-I 5010RSN/USNM104NM105NM106NM107Patient First NamePatient Middle NameName PrefixPatient Name SuffixANANANAN1-351-251-101-10Increase from 25 - 35Usage change toSituationalSSN/USCode DeletedUsage change to Not UsedNM108Identification Code QualifierID1-2SNM109NM110NM111Patient Primary IdentifierEntity Relationship CodeEntity Identifier CodeANIDID2-802-22-3SN/UN/UMI, ZZNM108Identification Code UN/UN/UNM112Patient Primary IdentifierEntity Relationship CodeEntity Identifier CodeName Last or OrganizationNameAN1-60N/UN3N301N302PATIENT ADDRESSPatient Address LinePatient Address Line11-551-55RRS2010CAANANN4N401PATIENT CITY/STATE/ZIPCODEPatient City RRN/UN/UN/UN/UN/UN/UN/UN/UUsage change to Not UsedN3N301N302PATIENT ADDRESSPatient Address LinePatient Address LineN4N401PATIENT CITY/STATE/ZIPCODEPatient City 05DMG06DMG07DMG08DMG09Patient State CodePatient Postal Zone or ZIPCodePatient Country CodeLocation QualifierLocation IdentifierPATIENT DEMOGRAPHICINFORMATIONDate Time Period FormatQualifierPatient Birth DatePatient Gender CodeMarital Status CodeRace or Ethnicity CodeCitizenship Status CodeCountry CodeBasis of Verification 1-21-15RRRN/UN/UN/UN/UN/UN/U2010CADMGD8CCYYMMDDF, M, 0DMG11Patient State CodePatient Postal Zone or ZIPCodePatient Country CodeLocation QualifierLocation IdentifierCountry Subdivision CodePATIENT DEMOGRAPHICINFORMATIONDate Time Period FormatQualifierPatient Birth DatePatient Gender CodeMarital Status CodeRace or Ethnicity CodeCitizenship Status CodeCountry CodeBasis of Verification CodeQuantityCode List Qualifier CodeIndustry CodeNew ElementIDANIDIDIDIDIDIDRIDANUsage change toSituationalUsage change toSituationalNew Element2010CAD8CCYYMMDDF, M, UNew ElementNew ElementSegment DeletedREFPATIENT SECONDARYIDENTIFICATION NUMBER5S2010CAPage 13 of 93
INSTITUTIONAL nce IdentificationQualifierREF02REF03REF04Patient Secondary IdentifierDescriptionREFERENCE uesElementIdentifierDescription837-I 4010A1REFPROPERTY ANDCASUALTY CLAIMNUMBERReference IdentificationQualifierProperty Casualty ClaimNumberDescriptionREFERENCE IDENTIFIERID2-3RANAN1
SUBMITTER EDI CONTACT INFORMATION 2 R 1000A PER SUBMITTER EDI CONTACT INFORMATION 2 R 1000A PER01 Contact Function Code ID 2-2 R IC PER01 Contact Function Code ID 2-2 R IC PER02 Submitter Contact Name AN 1-60 R PER02 Submitter Contact Name AN 1-60 S Usage change to Situational PER03 Communication Number Qualifier ID 2-2 R ED, EM, FX. TE PER03
