Transcription
PROFESSIONAL escription837-P 4010A1ISA01ISA02ID2-2AN 10-10RR00, 03ISA03ISA04Security Information QualifierSecurity InformationID2-2AN 10-10RR00, 01ISA05ISA06Interchange ID QualifierInterchange Sender IDID2-2AN 15-15RRISA07ISA08ISA09ISA10ID2-2AN 15-15DT6-6TM 4-4RRRRID1-1ISA12Interchange ID QualifierInterchange Receiver IDInterchange DateInterchange TimeInterchange ControlStandards IDInterchange Control VersionNumberIDISA13Interchange Control 7-P 5010INTERCHANGE CONTROLHEADERAuthorization InformationQualifierAuthorization InformationISAIDISA01ISA02INTERCHANGE CONTROLHEADERAuthorization InformationQualifierAuthorization InformationID2-2AN 10-10RR00, 03ISA03ISA04Security Information QualifierSecurity InformationID2-2AN 10-10RR00, 01ISA05ISA06Interchange ID QualifierInterchange Sender IDID2-2AN 15-15RRYYMMDDHHMMISA07ISA08ISA09ISA10ID2-2AN 15-15DT6-6TM 4-4RRRRRUISA115-5R00401ISA12Interchange ID QualifierInterchange Receiver IDInterchange DateInterchange TimeInterchange ControlStandards IDInterchange Control VersionNumberN09-9RISA13Interchange Control NumberAcknowledgement Requested IDUsage IndicatorIDComponent 91-21-12RRRRRRRRRFUNCTIONAL GROUPHEADERFunctional Identifier CodeApplication Sender CodeApplication Receiver CodeDateTimeGroup Control NumberResponsible Agency CodeVersion Identifier Code1IDANANDTTMN0IDANR1ISA01, 14, 20, 27, 28,29, 30, 33, ZZ01, 14, 20, 27, 28,29, 30, 33, ZZ0, 1P, TISA14ISA15ISA16 GS05GS06GS07GS081R1-1RID5-5RN09-9RAcknowledgement Requested IDUsage IndicatorIDComponent 91-21-12RRRRRRRRRFUNCTIONAL GROUPHEADERFunctional Identifier CodeApplication Sender CodeApplication Receiver CodeDateTimeGroup Control NumberResponsible Agency CodeVersion Identifier CodePage 1 of 93IDANANDTTMN0IDAN01, 14, 20, 27, 28,29, 30, 33, ZZ01, 14, 20, 27, 28,29, 30, 33, ZZYYMMDDHHMM005010, 1P, T1CCYYMMDDHHMMX005010X222Code Change
PROFESSIONAL escription837-P 4010A1STST01ST02BHTTRANSACTION SETHEADERTransaction Set IdentifierCodeTransaction Set ControlNumberBHT04BHT05BHT06Transaction Set CreationTimeClaim or Encounter IDBHT02BHT03RID3-3RAN4-9RBEGINNING OFHIERARCHICALTRANSACTIONHierarchical Structure CodeTransaction Set PurposeCodeOriginator ApplicationTransaction IDTransaction Set CreationDateBHT011 1ST03BHTBEGINNING HT01ID2-2R00, 18BHT02AN1-30RDT8-8RCCYYMMDD4-82-2RRHHMM, HHMMSS,HHMMSSD,HHMMSSDDCH, RP1RID2-3RANAN1-301-80RN/UN/UREF01TRANSMISSION TYPEIDENTIFICATIONReference IdentificationQualifierREF02REF03REF04Transmission Type CodeDescriptionREFERENCE 05NM106NM107SUBMITTER NAMEEntity Identifier CodeEntity Type QualifierSubmitter Last orOrganization NameSubmitter First NameSubmitter Middle NameName PrefixName NM109NM110NM111Identification Code QualifierSubmitter IdentifierEntity Relationship CodeEntity Identifier eg.LoopLoopRepeat 1Values837-P 5010TRANSACTION SETHEADERTransaction Set IdentifierCodeTransaction Set ControlNumberImplementation ConventionReference1TMIDID1BHT04Hierarchical Structure CodeTransaction Set PurposeCodeOriginator ApplicationTransaction IDTransaction Set CreationDateBHT05BHT06Transaction Set CreationTimeClaim or Encounter IDBHT031RID3-3RAN4-9RAN1-35R1RID4-4R0019ID2-2R00, 18AN1-50RDT8-8RCCYYMMDDRRHHMM, HHMMSS,HHMMSSD,HHMMSSDD31, CH, RP837New ElementTMID4-82-211Segment Deleted87004010X098A1,004010X098DA11000A1411, R NAMEEntity Identifier CodeEntity Type QualifierSubmitter Last orOrganization NameSubmitter First NameSubmitter Middle NameName PrefixName NM109NM110NM111Identification Code QualifierSubmitter IdentifierEntity Relationship CodeEntity Identifier CodeIDANIDID1-22-802-22-3RRN/UN/UNM1NM101NM102Page 2 of 931000A1411, 2Increase from 35 - 60Increase from 25 - 3546
PROFESSIONAL escriptionNM112Name Last or OrganizationName837-P 4010A1PER07PER08PER09SUBMITTER EDI CONTACTINFORMATIONContact Function CodeSubmitter Contact NameCommunication NumberQualifierCommunication NumberCommunication NumberQualifierCommunication NumberCommunication NumberQualifierCommunication NumberContact Inquiry SSN/URECEIVER NAMEEntity Identifier CodeEntity Type QualifierReceiver NameName FirstName MiddleName PrefixName RN/UN/UN/UN/UIdentification Code QualifierReceiver Primary IdentifierEntity Relationship CodeEntity Identifier CodeIDANIDID1-22-802-22-3RRN/UN/U1000AICED, EM, FX. TEED, EM, EX, FX,TEED, EM, EX, FX,TE1000B140246PER07PER08PER09SUBMITTER EDI CONTACTINFORMATIONContact Function CodeSubmitter Contact NameCommunication NumberQualifierCommunication NumberCommunication NumberQualifierCommunication NumberCommunication NumberQualifierCommunication NumberContact Inquiry EIVER NAMEEntity Identifier CodeEntity Type QualifierReceiver NameName FirstName MiddleName PrefixName SuffixNM108NM109NM110NM111Identification Code QualifierReceiver Primary IdentifierEntity Relationship CodeEntity Identifier CodeName Last or ROVIDER HIERARCHICALLEVELHierarchical ID NumberANHierarchical Parent IDNumberANHierarchical Level CodeIDHierarchical Child CodeIDBILLING/PAY-TOPROVIDER SPECIALTYINFORMATIONProvider CodeReference peatValues837-P 2-2AN 1-256RREM, FX. TEID2-2AN 1-256SSEM, EX, FX, TEID2-2AN 1-256AN 1-20SSN/UEM, EX, FX, 0AICCode 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 ChangeID11-3SRID2-3R2000ABI, PTPRVPRV01ZZPRV02BILLING PROVIDERSPECIALTY INFORMATIONProvider CodeReference IdentificationQualifierPage 3 of 93ID11-3SRID2-3R2000ABIPXC
PROFESSIONAL escription837-P 4010A1ANIDPRV05Provider Taxonomy CodeState or Province CodePROVIDER SPECIALTYINFORMATIONPRV06Provider Organization UR17CUR18CUR19CUR20CUR21FOREIGN CURRENCYINFORMATIONEntity Identifier CodeCurrency CodeExchange RateEntity Identifier CodeCurrency CodeCurrency Market/ExchangeCodeDate/Time QualifierDateTimeDate/Time QualifierDateTimeDate/Time QualifierDateTimeDate/Time QualifierDateTimeDate/Time QualifierDateTime1-302-2ANIDPRV05PRV06Provider Organization ling Provider Middle NameName PrefixANAN1-251-10NM107Billing Provider Name SuffixANNM108Identification Code QualifierNM109NM110Billing Provider IdentifierEntity Relationship CodeUsageReg.LoopLoopRepeatValues837-P 5010PRV03PRV0412-31-1Min.Max.Provider Taxonomy CodeState or Province CodePROVIDER SPECIALTYINFORMATIONRN/UBilling Provider NameSuffixEntity Identifier CodeEntity Type QualifierBilling Provider Lastor Organizational NameBilling Provider First UR15CUR16CUR17CUR18CUR19CUR20CUR21FOREIGN CURRENCYINFORMATIONEntity Identifier CodeCurrency CodeExchange RateEntity Identifier CodeCurrency CodeCurrency Market/ExchangeCodeDate/Time QualifierDateTimeDate/Time QualifierDateTimeDate/Time QualifierDateTimeDate/Time QualifierDateTimeDate/Time QualifierDateTime1-502-2RN/UIncrease 30 - 50N/U2000A85Name ChangeIDID12-31-1NM103NM104Billing Provider NameEntity Identifier CodeEntity Type QualifierBilling Provider Lastor Organizational NameBilling Provider First NameANAN1-601-35RSSN/UNM105NM106Billing Provider Middle NameName PrefixANAN1-251-10SN/U1-10SNM107Billing Provider Name SuffixAN1-10SID1-2RNM108Identification Code QualifierID1-2SANID2-802-2RN/UNM109NM110Billing Provider IdentifierEntity Relationship CodeANID2-802-2SN/U2010AA1851, 224, 34, XXNM1NM101NM102Page 4 of 932010AA1851, 2Increase from 35 - 60Increase from 25 - 35XXUsage changed toSituationalCode DeletedUsage changed toSituationalUsage changed toSituational
PROFESSIONAL CLAIM4010A1ElementIdentifierDescriptionNM111Entity Identifier mentIdentifierDescription837-P 4010A1N3BILLING PROVIDERADDRESSN301Billing Provider Address LineN302Billing Provider Address F04BILLING PROVIDERCITY/STATE/ZIP CODEBilling Provider City NameBilling Provider State orProvince CodeBilling Provider Postal Zone orZIP CodeCountry CodeLocation QualifierLocation IdentifierIDMin.Max.UsageReg.NM112Entity Identifier CodeName Last or OrganizationNameN3BILLING ing Provider Address LineAN1-55RAN1-55SN302Billing Provider Address NG PROVIDERCITY/STATE/ZIP CODEBilling Provider City NameBilling Provider State orProvince CodeBilling Provider Postal Zone orZIP CodeCountry CodeLocation QualifierLocation IdentifierCountry Subdivision CodeIDIDIDANID3-152-31-21-301-3SSN/UN/USREFBILLING PROVIDER atValuesNew ElementANS2010AAIDR8Loop837-P 5010N/U1BILLING PROVIDERSECONDARYIDENTIFICATIONReference IdentificationQualifierBilling Provider AdditionalIdentifierDescriptionREFERENCE IDENTIFIER2-3ID2010AAN4N4012010AA0B, 1A, 1B, 1C,1D, 1G, 1H, 1J,B3, BQ, EI, FH,G2, G5, LU, SY,U3, X52010AA2010AAUsage changed toSituationalUsage changed toSituationalNew ElementName ChangeUsage changed to Required1R2010AACode DeletedREF02REF03REF04Reference IdentificationQualifierBilling Provider AdditionalIdentifierDescriptionREFERENCE IDENTIFIERREF04-1Reference Identifier QualifierID2-3N/UREF04-2Other Payer Primary Idenitifer ANReference IdentificationQualifierIDReference IdentificationANReference IdentificationQualifierIDReference EF01ID2-3RANAN1-501-80RN/UN/UEI, SYIncrease from 30 - 50New ElementNew ElementREF04-3REF04-4REF04-5REF04-6REFCREDIT/DEBIT CARDBILLING INFORMATION8S2010AAREFBILLING PROVIDERUPIN/LICENSEINFORMATIONPage 5 of 93New ElementNew ElementNew ElementNew ElementName Change2S2010AA
PROFESSIONAL escription837-P 4010A1REF01REF02REF03REF04Reference IdentificationQualifierBilling Provider Credit CardIdentifierDescriptionREFERENCE Reg.LoopLoopRepeatValues837-P 501006, 8U, EM, IJ, LU,RB, ST, TTREF02REF03REF04Reference IdentificationQualifierBilling Provider AdditionalIdentifierDescriptionREFERENCE IDENTIFIERREF04-1Reference Identifier QualifierID2-3N/UREF04-2Other Payer Primary Idenitifer ANReference IdentificationQualifierIDReference IdentificationANReference IdentificationQualifierIDReference D22-2SRAN1-60SID2-2AN 1-256RREM, FX, TEID2-2AN 1-256SSEM, EX, FX, TEID2-2AN 1-256AN 1-20SSN/UEM, EX, FX, TEREF01Code DeletedID2-3RANAN1-501-80RN/UN/U0B, 1GIncrease from 30 - 50New ElementNew ElementREF04-3REF04-4REF04-5REF04-6PERPER01BILLING PROVIDERCONTACT INFORMATIONContact Function CodeID22-2SRAN1-60RIDAN2-21-80RREM, FX, TEIDAN2-21-80SSEM, EX, FX, TEIDANAN2-21-801-20SSN/UEM, EX, FX, TEIDID12-31-1SRRPER07PER08PER09Billing Provider Contact NameCommunication NumberQualifierCommunication NumberCommunication NumberQualifierCommunication NumberCommunication NumberQualifierCommunication NumberContact Inquiry ReferenceNM1NM101NM102PAY-TO PROVIDER NAMEEntity Identifier CodeEntity Type QualifierNM103Pay-to Provider Last orOrganization NameAN1-35NM104Pay-to Provider First NameANPay-to Provider Middle Name ANPER02PER03PER04PER05PER062010AAICPERPER01BILLING PROVIDERCONTACT INFORMATIONContact Function CodeNew ElementPER07PER08PER09Billing Provider Contact NameCommunication NumberQualifierCommunication NumberCommunication NumberQualifierCommunication NumberCommunication NumberQualifierCommunication NumberContact Inquiry ReferenceNM1NM101NM102PAY-TO ADDRESS NAMEEntity Identifier CodeEntity Type QualifierRNM103Pay-to Provider Last orOrganization NameAN1-60N/U1-25SNM104Pay-to Provider First NameAN1-35N/U1-25SNM105Pay-to Provider Middle Name AN1-25N/UPER02PER03PER04PER05PER06New ElementNew ElementNew Element2010AAICUsage changed toSituationalIncrease from 80 - 256Increase from 80 - 256Increase from 80 - 256Name ChangeNM1052010AB1871, 2IDID12-31-1SRRNM106Name PrefixAN1-10N/UNM106Name PrefixAN1-10N/UNM107Pay-to Provider Name SuffixAN1-10SNM107Pay-to Provider Name SuffixAN1-10N/UPage 6 of 932010AB1871, 2Increase from 35 - 60Usage changed to NotUsedIncrease from 25 - 35Usage changed to NotUsedUsage changed to NotUsedUsage changed to NotUsedUsage changed to NotUsed
PROFESSIONAL escription837-P 4010A1NM108Identification Code QualifierID1-2RNM109Pay-to Provider IdentifierAN2-80NM110Entity Relationship CodeIDNM111Entity Identifier CodeIDN3PAY-TO PROVIDERADDRESSIDMin.Max.UsageReg.Identification Code QualifierID1-2N/URNM109Pay-to Provider IdentifierAN2-80N/U2-2N/UNM110Entity Relationship CodeID2-2N/U2-3N/UNM111ID2-3N/UNM112Entity Identifier CodeName Last or OrganizationNameAN1-60N/UN3PAY-TO PROVIDERADDRESS1RR24, 34, XX2010ABN301Pay-to Provider Address Line AN1-55RN301Pay-to Provider Address Line AN1-55RN302Pay-to Provider Address Line AN1-55SN302Pay-to Provider Address Line 03ID3-15SPay-to Provider Country Code IDLocation QualifierIDLocation o Provider Country Code IDLocation QualifierIDLocation IdentifierANCountry Subdivision 406REFREF01REF02REF03REF04PAY-TO PROVIDERCITY/STATE/ZIP CODEPay-to Provider City NamePay-to Provider State CodePay-to Provider Postal Zoneor ZIP CodeValues2010ABN4N401PAY-TO PROVIDERCITY/STATE/ZIP CODEPay-to Provider City NamePay-to Provider State CodePay-to Provider Postal Zoneor ZIP CodeCode DeletedUsage changed to NotUsedUsage changed to NotUsedUsage changed to NotUsedUsage changed to NotUsedNew Element2010AB2010ABUsage changed toSituationalUsage changed toSituationalNew ElementSegment DeletedPAY-TO PROVIDERSECONDARYIDENTIFICATIONReference IdentificationQualifierPay-to Provider IdentifierDescriptionREFERENCE IDENTIFIERLoopRepeat837-P 5010NM1081Loop5IDANAN2-31-301-80SRRN/UN/U2010AB0B, 1A, 1B, 1C,1D, 1G, 1H, 1J,B3, BQ, EI, FH,G2, G5, LU, SY,U3, X5NM1NM101NM102NM103NM104PAY TO PLAN NAMEEntity Identifier CodeEntity Type QualifierPay to Plan OrganizationalNameName FirstPage 7 of 93IDID12-31-1SRRANAN1-601-35RN/U2010AC1New SegmentPE2
PROFESSIONAL lementIdentifierDescriptionNM105NM106NM107Name MiddleName PrefixName n Code QualifierIdentification CodeEntity Relationship CodeEntity Identifier CodeName Last or OrganizationNameAN1-60N/UN3N301N302PAY-TO PLAN ADDRESSPay-to Plan Address LinePay-to Plan Address DIDANID3-152-31-21-301-3SSN/UN/US837-P 4010A1IDLoopLoopRepeatValues837-P 5010N4N401N402N403N404N405N406N407PAY-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 CodeNew SegmentREF01REF02REF03REF04REF04-1Reference Identifier QualifierID2-3N/UREF04-2Other Payer Primary Idenitifer ANReference IdentificationQualifierIDReference IdentificationANReference IdentificationQualifierIDReference 2PAY-TO PLAN TAXIDENTIFICATIONReference IdentificationQualifierReference IdentificationPage 8 of 93New SegmentNew SegmentPAY-TO PLANSECONDARYIDENTIFICATIONReference IdentificationQualifierReference IdentificationDescriptionREFERENCE IDENTIFIERREFPI, XV1SIDANAN2-31-501-80RRN/UN/U2010AC2U, FY, NFNew SegmentIDAN2010ACEI
PROFESSIONAL ionREFERENCE IDENTIFIERAN1-80N/UN/UREF04-1Reference Identifier QualifierID2-3N/UREF04-2Other Payer Primary Idenitifer ANReference IdentificationQualifierIDReference IdentificationANReference IdentificationQualifierIDReference L02HL03HL04SBRSBR01SUBSCRIBERINFORMATIONPayer ResponsibilitySequence Number CodeAN11-12RR2000B 1HLHL01ANIDID1-121-21-1RRR1RID1-1RP, S, TSBR0118SBR02220, 12000BHL02HL03HL04SBRID2-2SSBR03SBR04Individual Relationship CodeInsured Group or PolicyNumberInsured Group NameANAN1-301-60SSSBR05Insurance Type CodeID1-3SCoordination of Benefits Code IDYes/No Condition orResponse CodeIDEmployment Status BR07SBR08SBR09Claim Filing Indicator CodePATPATIENT INFORMATIONPAT01PAT02PAT03Individual Relationship CodePatient Location CodeEmployment Status at2000B 1Values837-P 5010REF04-3REF04-4SUBSCRIBERHIERARCHICAL LEVELHierarchical ID NumberHierarchical Parent IDNumberHierarchical Level CodeHierarchical Child CodeUsageReg.Description837-P 4010A1HLHL01Min.Max.ElementIdentifier12, 13, 14, 15, 16,41, 42, 43, 4709, 10, 11, 12, 13,14, 15, 16, AM,BL, CH, CI, DS,HM, LI, LM, MB,MC, OF, TV, VA,WC, ZZ2000BSUBSCRIBERHIERARCHICAL LEVELHierarchical ID NumberHierarchical Parent IDNumberHierarchical Level CodeHierarchical Child CodeSUBSCRIBERINFORMATIONPayer ResponsibilitySequence Number CodeID2-2SSBR03SBR04Individual Relationship CodeInsured Group or PolicyNumberInsured Group NameANAN1-501-60SSSBR05Insurance Type CodeID1-3SCoordination of Benefits Code IDYes/No Condition orResponse CodeIDEmployment Status CodeID1-1N/U1-12-2N/UN/USBR09Claim Filing Indicator CodePATPATIENT INFORMATIONPAT01PAT02PAT03Individual Relationship CodePatient Location CodeEmployment Status CodePage 9 of 93220, 12000BA, B, C, D, E, F, Code DeletedG, H, P, S, T, U18Increase from 30 - 50IDIDIDID1-2S1S2-21-12-2N/UN/UN/U12, 13, 14, 15, 16,41, 42, 43, 4711, 12, 13, 14, 15, Code Change16, 17, AM, BL,CH, CI, DS, FI,HM, LM, MA, MB,MC, OF, TV, VA,WC, ZZ2000B
PROFESSIONAL escription837-P M103NM104NM105NM106NM107Student Status CodeDate Time Period FormatQualifier1-1N/UID2-3SD8PAT05Insured Individual Death Date ANUnit or Basis forMeasurement CodeIDPatient Weight 9(6)V99RPregnancy -P 5010IDSUBSCRIBER NAMEEntity Identifier CodeEntity Type QualifierSubscriber Last NameSubscriber First NameSubscriber Middle NameName PrefixSubscriber Name SuffixIDPAT04Y2010BA1IL1, 2NM1NM101NM102NM103NM104NM105NM106NM107Student Status CodeDate Time Period FormatQualifierID1-1N/UID2-3SD8Insured Individual Death Date ANUnit or Basis forMeasurement CodeIDPatient Weight 9(6)V99RPregnancy 1-351-251-101-10RRRRSSN/USSUBSCRIBER NAMEEntity Identifier CodeEntity Type QualifierSubscriber Last NameSubscriber First NameSubscriber Middle NameName PrefixSubscriber Name SuffixIDIDANANANANANY2010BA1IL1, 2Increase from 35 - 60Increase from 25 - 35Code ChangeUsage changed to ReqiredNM108Identification Code QualifierID1-2SNM109NM110NM111Subscriber Primary IdentifierEntity Relationship CodeEntity Identifier CodeANIDID2-802-22-3SN/UN/UMI, ZZNM108Identification Code QualifierID1-2RII, riber Primary IdentifierEntity Relationship CodeEntity Identifier CodeName Last or OrganizationNameAN1-60N/UN3N301N302SUBSCRIBER ADDRESSSubscriber Address LineSubscriber Address TE/ZIP CODESubscriber City -3SSN/UN/US1S2-31-35RRUsage changed to RequiredN3N301N302SUBSCRIBER ADDRESSSubscriber Address LineSubscriber Address LineN4N401SUBSCRIBERCITY/STATE/ZIP CODESubscriber City NameN402N403N404N405N406DMGDMG01DMG02Subscriber State CodeSubscriber Postal Zone orZIP CodeSubscriber Country CodeLocation QualifierLocation IdentifierSUBSCRIBERDEMOGRAPHICINFORMATIONDate Time Period FormatQualifierSubscriber Birth riber State CodeSubscriber Postal Zone orZIP CodeSubscriber Country CodeLocation QualifierLocation IdentifierCountry Subdivision CodeSUBSCRIBERDEMOGRAPHICINFORMATIONDate Time Period FormatQualifierSubscriber Birth DatePage 10 of 93New ElementIDANUsage changed toSituationalUsage changed toSituationalNew Element2010BAD8CCYYMMDD
PROFESSIONAL MG05DMG06DMG07DMG08DMG09Subscriber Gender CodeMarital Status CodeRace or Ethnicity CodeCitizenship Status CodeCountry CodeBasis of Verification G06DMG07DMG08DMG09DMG10DMG11Subscriber Gender CodeMarital Status CodeRace or Ethnicity CodeCitizenship Status CodeCountry CodeBasis of Verification CodeQuantityCode List Qualifier CodeIndustry Code837-P ER SECONDARYIDENTIFICATIONReference IdentificationQualifierIDSubscriber SupplementalIdentifierANDescriptionANREFERENCE /UMin.Max.UsageReg.LoopLoopRepeatValues837-P 5010F, M, URN/UN/UN/UN/UN/UN/U4ID2010BAREF1W, 23, IG, SYREF01REF02REF03REF04IDIDIDIDIDIDRIDANSUBSCRIBER SECONDARYIDENTIFICATIONReference IdentificationQualifierIDSubscriber SupplementalIdentifierANDescriptionANREFERENCE /UN/UN/UN/UN/U1S2-3R1-501-80RN/UN/UF, M, UNew ElementNew Element2010BACode RemovedSYIncrease from 30 - 50New ElementREF04-1Reference Identifier QualifierID2-3N/UREF04-2Other Payer Primary Idenitifer ANReference IdentificationQualifierIDReference IdentificationANReference IdentificationQualifierIDReference SID2-3RANAN1-501-80RN/UN/UNew F03REF04PROPERTY ANDCASUALTY CLAIMNUMBERReference IdentificationQualifierProperty Casualty ClaimNumberDescriptionREFERENCE F03REF04PROPERTY ANDCASUALTY CLAIMNUMBERReference IdentificationQualifierProperty Casualty ClaimNumberDescriptionREFERENCE IDENTIFIERREF04-1Reference Identifier QualifierID2-3N/UREF04-2Other Payer Primary Idenitifer ANReference IdentificationQualifierIDReference IdentificationANReference IdentificationQualifierIDReference EFY4New ElementREF01New ElementNew ElementNew Element2010BAY4Increase from 30 - 50New ElementNew ElementREF04-3REF04-4REF04-5REF04-6Page 11 of 93New ElementNew ElementNew ElementNew Element
PROFESSIONAL escriptionPERPER01PROPERTY ANDCASUALTY SUBSCRIBERCONTACT INFORMATIONContact Function Code837-P M108NM109NM110NM111Identification Code QualifierPayer IdentifierEntity Relationship CodeEntity Identifier CodeIDANIDID1-22-802-22-3RRN/UN/UN3N301N302PAYER ADDRESSPayer Address LinePayer Address LineN4N401PAYER CITY/STATE/ZIPCODEPayer City NameN402N403N404N405N406Payer State CodePayer Postal Zone or ZIPCodePayer Country CodeLocation QualifierLocation IdentifierLoopLoopRepeatValues2010BB1PR2PI, XVNew SegmentID12-2SR2010BAAN1-60SID2-2AN 1-256RRTEID2-2AN 1-256SSEXID2-2AN 1-256AN NM103NM104NM105NM106NM107PAYER NAMEEntity Identifier CodeEntity Type QualifierPayer NameName FirstName MiddleName PrefixName /UN/UNM112Identification Code QualifierPayer IdentifierEntity Relationship CodeEntity Identifier CodeName Last or OrganizationNameAN1-60N/UN3N301N302PAYER ADDRESSPayer Address LinePayer Address Line11-551-55SRS2010BBANANN4N401PAYER CITY/STATE/ZIPCODEPayer City g Provider Contact NameCommunication NumberQualifierCommunication NumberCommunication NumberQualifierCommunication NumberCommunication NumberQualifierCommunication NumberContact Inquiry ReferencePER03PER04PAYER NAMEEntity Identifier CodeEntity Type QualifierPayer NameName FirstName MiddleName PrefixName SuffixMin.Max.837-P r State CodePayer Postal Zone or ZIPCodePayer Country CodeLocation QualifierLocation IdentifierCountry Subdivision CodePage 12 of 932010BB1PR2Increase from 35 - 60Increase from 25 - 35PI, XVNew ElementUsage changed to RequiredUsage changed toSituationalUsage changed toSituationalNew Element
PROFESSIONAL escription837-P 4010A1REFREF01REF02REF03REF04PAYER SECONDARYIDENTIFICATIONReference IdentificationQualifierPayer Additional IdentifierDescriptionREFERENCE geReg.LoopLoopRepeatValues837-P 50102010BBREF01REF02REF03REF04PAYER SECONDARYIDENTIFICATIONReference IdentificationQualifierPayer Additional IdentifierDescriptionREFERENCE IDENTIFIERREF04-1Reference Identifier QualifierID2-3N/UREF04-2Other Payer Primary Idenitifer AN1-50N/U2-31-50N/UN/UREF2U, FY, NF, TJ3SIDANAN2-31-501-80RRN/UN/U2010BBCode Change2U, EI, FY, NFIncrease from 30 - 50New ElementNew ElementREF04-5Reference IdentificationQualifierReference IdentificationReference IdentificationQualifierREF04-6Reference sponsible Party First NameResponsible Party MiddleNameName PrefixResponsible Party SuffixNameN/UN/UNew ElementNew ElementNew ElementNew SegmentREF04-1Reference Identifier QualifierID2-3N/UREF04-2Other Payer Primary Idenitifer ANReference IdentificationQualifierIDReference IdentificationANReference IdentificationQualifierIDReference -3REF04-4RESPONSIBLE PARTYNAMEEntity Identifier CodeEntity Type QualifierResponsible Party Last orOrganization NameIDANBILLING PROVIDERSECONDARYIDENTIFICATIONReference IdentificationQualifierPayer Additional IdentifierDescriptionREFERENCE IDENTIFIERREFNM1NM101NM102New ElementIDAN2SIDANAN2-31-501-80RRN/UN/U2010BBG2, LUSegment UAN1-10S2010BC1QD1, 2Page 13 of 93
PROFESSIONAL 37-P 4010A1NM108NM109NM110NM111Identification Code QualifierIdentification CodeEntity Relationship CodeEntity Identifier CodeN302RESPONSIBLE PARTYADDRESSResponsible Party AddressLineResponsible Party AddressLineN4RESPONSIBLE PARTYCITY/STATE/ZIP nsible Party State CodeResponsible Party PostalZone or ZIP CodeResponsible Party CountryCodeLocation QualifierLocation IT/DEBIT CARDHOLDER NAMEEntity Identifier CodeEntity Type N/UAN1-10SNM107NM108Identification Code QualifierID1-2RNM109NM110NM111Credit or Debit Card NumberEntity Relationship CodeEntity Identifier CodeANIDID2-802-22-3RN/UN/UREFCREDIT/DEBIT Values837-P 50102010BC2010BCSegment DeletedCredit or Debit Card HolderLast or Organizational NameCredi
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 PER03 Communication Number Qualifier ID 2-2 R ED, EM, FX. TE PER03 Communication Number
