5010 Health Care Claim: Institutional [W1]


Loop Qualifiers
xx - Loop Iteration Prefix
xxyy - Outer Loop Iteration and Inner Loop Iteration
yy / yyy - Loop Value Qualifier
xxyy / xxyyy - Loop Iteration and Value Qualifier
Segment Modifiers:
X - Distinguishing Identifier Suffix
nn - Segment Iteration (only after first iterartion)
nn - Element Repeat Iteration (only after first iterartion)

ISA - GROUP HEADERS
ISAISAInterchange Control Header
02ISA_ISA02_NO_AUTH_NFOStringNo Authorization Information Present
02ISA_ISA02_ADDL_DATA_IDStringAdditional Data Identification
04ISA_ISA04_NO_SEC_NFOStringNo Security Information Present
04ISA_ISA04_PSSWDStringPassword
06ISA_ISA06_DUN_BRDSTStringDun and Brandstreet
06ISA_ISA06_DUN_BRDST_SFXStringDuns Plus Suffix
06ISA_ISA06_HINStringHealth Industry Number
06ISA_ISA06_CARR_IDStringCarrier Identification Number as assigned by Health Care Financing Administration
06ISA_ISA06_HCFA_FIINStringFiscal Intermediary Identification Number as assigned by Health Care Financing Administration
06ISA_ISA06_HCFA_IDStringMedicare Provider and Supplier Identification Number as assigned by Health Care Financing Administration
06ISA_ISA06_TAX_IDStringUS Federal Tax Identification Number
06ISA_ISA06_NAIC_CDStringNational Association of Insurance Commissioners Company Code
06ISA_ISA06_MUTLY_DEFStringMutually Defined
08ISA_ISA08_DUN_BRDSTStringDun and Brandstreet
08ISA_ISA08_DUN_BRDST_SFXStringDuns Plus Suffix
08ISA_ISA08_HINStringHealth Industry Number
08ISA_ISA08_CARR_IDStringCarrier Identification Number as assigned by Health Care Financing Administration
08ISA_ISA08_HCFA_FIINStringFiscal Intermediary Identification Number as assigned by Health Care Financing Administration
08ISA_ISA08_HCFA_IDStringMedicare Provider and Supplier Identification Number as assigned by Health Care Financing Administration
08ISA_ISA08_TAX_IDStringUS Federal Tax Identification Number
08ISA_ISA08_NAIC_CDStringNational Association of Insurance Commissioners Company Code
08ISA_ISA08_MUTLY_DEFStringMutually Defined
09ISA_ISA09_INTCHG_DTDate (YYMMDD)Interchange Date
10ISA_ISA10_INTCHG_TMTime (HHMM)Interchange Time
11ISA_ISA11_REPTN_SEPStringRepetition Separator
12ISA_ISA12_ICN_VERS_NRStringInterchang Control Version Number
13ISA_ISA13_ICNIntegerInterchange Control Number
14ISA_ISA14_ACK_REQStringAcknowledgment Requested
15ISA_ISA15_ICN_USG_INDStringInterchange Usage Indicator
16ISA_ISA16_COMP_ELE_SEPStringComponent Element Separator
GSHDR - GROUP HEADER
GSHDRGSFunctional Group Header
02GSHDR_GS02_APP_SNDR_CDStringApplication Senders Code
03GSHDR_GS03_APP_RCV_CDStringApplication Receivers Code
04GSHDR_GS04_D8Date (YYYYMMDD)Date
05GSHDR_GS05_TMTime (HHMM)Time
05GSHDR_GS05_TM8Time (HHMMSSCC)Time
06GSHDR_GS06_GCNIntegerGroup Control Number
STHDR - TRANSACTION SET HEADER
STHDRSTTransaction Set Header
02STHDR_ST02_TCNStringTransaction Set Control Number
03STHDR_ST03_VERS_REL_IND_IDStringVersion, Release, or Industry Identifier
STHDRBHTBeginning of Hierarchical Transaction
01STHDR_BHT01_HIER_STRUC_CDStringHierarchical Structure Code
02STHDR_BHT02_TS_PURP_CDStringTransaction Set Purpose Code
03STHDR_BHT03_ORIG_APP_TRANS_IDStringOriginator Application Transaction Identifier
04STHDR_BHT04_TS_CRTN_D8Date (YYYYMMDD)Transaction Set Creation Date
05STHDR_BHT05_TS_CRTN_TMTime (HHMM)Transaction Set Creation Time
05STHDR_BHT05_TS_CRTN_TM8Time (HHMMSSCC)Transaction Set Creation Time
06STHDR_BHT06_CLM_IDStringClaim Identifier
L1000A - SUBMITTER NAME
L1000ANM1Submitter Name
03L1000A_NM103_PERSN_LNMStringPerson Last Name
03L1000A_NM103_NONPSNENT_NMStringNon-Person Entity Name
04L1000A_NM104_SBM_FNMStringSubmitter First Name
05L1000A_NM105_SBM_MNMStringSubmitter Middle Name or Initial
09L1000A_NM109_ETN_NRStringElectronic Transmitter Identification Number (ETIN)
L1000APERSubmitter EDI Contact Information
02L1000A_nnPER02_SBM_CON_NMStringSubmitter Contact Name
04L1000A_nnPER04_EMAILStringElectronic Mail
04L1000A_nnPER04_FAXStringFacsimile
04L1000A_nnPER04_PHN_NRStringTelephone
06L1000A_nnPER06_EMAILStringElectronic Mail
06L1000A_nnPER06_PHN_EXTStringTelephone Extension
06L1000A_nnPER06_FAXStringFacsimile
06L1000A_nnPER06_PHN_NRStringTelephone
08L1000A_nnPER08_EMAILStringElectronic Mail
08L1000A_nnPER08_PHN_EXTStringTelephone Extension
08L1000A_nnPER08_FAXStringFacsimile
08L1000A_nnPER08_PHN_NRStringTelephone
L1000B - RECEIVER NAME
L1000BNM1Receiver Name
03L1000B_NM103_NONPSNENT_NMStringNon-Person Entity Name
09L1000B_NM109_ETN_NRStringElectronic Transmitter Identification Number (ETIN)
L2000A - BILLING PROVIDER HIERARCHICAL LEVEL
L2000AHLBilling Provider Hierarchical Level
01L2000A_HL01_HIER_ID_NRStringHierarchical ID Number
L2000APRVBilling Provider Specialty Information
03L2000A_PRV03_PVD_TAXNMY_CDStringHealth Care Provider Taxonomy Code
L2000ACURForeign Currency Information
02L2000A_CUR02_CURRNCY_CDStringCurrency Code
L2010AA - BILLING PROVIDER NAME
L2010AANM1Billing Provider Name
03L2010AA_NM103_NONPSNENT_NMStringNon-Person Entity Name
09L2010AA_NM109_NPIStringCenters for Medicare and Medicaid Services National Provider Identifier
L2010AAN3Billing Provider Address
01L2010AA_N301_BILL_PROV_ADDRStringBilling Provider Address Line
02L2010AA_N302_BILL_PROV_ADDRStringBilling Provider Address Line
L2010AAN4Billing Provider City, State, ZIP Code
01L2010AA_N401_BILL_PVR_CITYStringBilling Provider City Name
02L2010AA_N402_BILL_PVR_STATStringBilling Provider State or Province Code
03L2010AA_N403_BILL_PVR_ZIPStringBilling Provider Postal Zone or ZIP Code
04L2010AA_N404_CNTRY_CDStringCountry Code
07L2010AA_N407_CNTRY_SUBDV_CDStringCountry Subdivision Code
L2010AAREFBilling Provider Tax Identification
02L2010AA_REF_EMPLR_ID_NRStringEmployer's Identification Number
L2010AAPERBilling Provider Contact Information
02L2010AA_nnPER02_BL_PVR_CONT_NMStringBilling Provider Contact Name
04L2010AA_nnPER04_EMAILStringElectronic Mail
04L2010AA_nnPER04_FAXStringFacsimile
04L2010AA_nnPER04_PHN_NRStringTelephone
06L2010AA_nnPER06_EMAILStringElectronic Mail
06L2010AA_nnPER06_PHN_EXTStringTelephone Extension
06L2010AA_nnPER06_FAXStringFacsimile
06L2010AA_nnPER06_PHN_NRStringTelephone
08L2010AA_nnPER08_EMAILStringElectronic Mail
08L2010AA_nnPER08_PHN_EXTStringTelephone Extension
08L2010AA_nnPER08_FAXStringFacsimile
08L2010AA_nnPER08_PHN_NRStringTelephone
L2010AB - PAY-TO ADDRESS NAME
L2010ABNM1Pay-to Address Name
L2010ABN3Pay-to Address - ADDRESS
01L2010AB_N301_PAY2_ADDRStringPay-To Address Line
02L2010AB_N302_PAY2_ADDRStringPay-To Address Line
L2010ABN4Pay-To Address City, State, ZIP Code
01L2010AB_N401_PAY2_CITYStringPay-to Address City Name
02L2010AB_N402_PAY2_STATStringPay-to Address State Code
03L2010AB_N403_PAY2_ZIPStringPay-to Address Postal Zone or ZIP Code
04L2010AB_N404_CNTRY_CDStringCountry Code
07L2010AB_N407_CNTRY_SUBDV_CDStringCountry Subdivision Code
L2010AC - PAY-TO PLAN NAME
L2010ACNM1Pay-To Plan Name
03L2010AC_NM103_NONPSNENT_NMStringNon-Person Entity Name
09L2010AC_NM109_PAYR_IDStringPayor Identification
09L2010AC_NM109_HCFA_PLAN_IDStringCenters for Medicare and Medicaid Services PlanID
L2010ACN3Pay-to Plan Address
01L2010AC_N301_PAY2_PLN_ADDRStringPay-To Plan Address Line
02L2010AC_N302_PAY2_PLN_ADDRStringPay-To Plan Address Line
L2010ACN4Pay-To Plan City, State, ZIP Code
01L2010AC_N401_PAY2_PLN_CITYStringPay-To Plan City Name
02L2010AC_N402_PAY2_PLN_STATStringPay-To Plan State or Province Code
03L2010AC_N403_PAY2_PLN_ZIPStringPay-To Plan Postal Zone or ZIP Code
04L2010AC_N404_CNTRY_CDStringCountry Code
07L2010AC_N407_CNTRY_SUBDV_CDStringCountry Subdivision Code
L2010ACREFPay-to Plan Secondary Identification
02L2010AC_REF_PYR_IDStringPayer Identification Number
02L2010AC_REF_CLM_OFC_NRStringClaim Office Number
02L2010AC_REF_NAICStringNational Association of Insurance Commissioners (NAIC) Code
L2010ACREFPay-To Plan Tax Identification Number
02L2010AC_REF_EMPLR_ID_NRStringEmployer's Identification Number
L2000B - SUBSCRIBER HIERARCHICAL LEVEL
L2000BHLSubscriber Hierarchical Level
01L2000B_HL01_HIER_ID_NRStringHierarchical ID Number
02L2000B_HL02_HIER_PARNT_ID_NRStringHierarchical Parent ID Number
04L2000B_HL04_HL_CHLD_CDStringHierarchical Child Code
L2000BSBRSubscriber Information
01L2000B_SBR01_PYR_RESP_SEQ_NRStringPayer Responsibility Sequence Number Code
02L2000B_SBR02_IND_RELAT_CDStringIndividual Relationship Code
03L2000B_SBR03_SBR_POLCY_NRStringSubscriber Group or Policy Number
04L2000B_SBR04_SBR_GRP_NMStringSubscriber Group Name
09L2000B_SBR09_CLM_FIL_IND_CDStringClaim Filing Indicator Code
L2010BA - SUBSCRIBER NAME
L2010BANM1Subscriber Name
03L2010BA_NM103_PERSN_LNMStringPerson Last Name
03L2010BA_NM103_NONPSNENT_NMStringNon-Person Entity Name
04L2010BA_NM104_SBR_FNMStringSubscriber First Name
05L2010BA_NM105_SBR_MNMStringSubscriber Middle Name or Initial
07L2010BA_NM107_SBR_SFXStringSubscriber Name Suffix
09L2010BA_NM109_UNQ_HLTH_IDStringStandard Unique Health Identifier for each Individual in the United States
09L2010BA_NM109_MEM_ID_NRStringMember Identification Number
L2010BAN3Subscriber Address
01L2010BA_N301_SBR_ADDRStringSubscriber Address Line
02L2010BA_N302_SBR_ADDRStringSubscriber Address Line
L2010BAN4Subscriber City, State, ZIP Code
01L2010BA_N401_SBR_CITYStringSubscriber City Name
02L2010BA_N402_SBR_STATStringSubscriber State Code
03L2010BA_N403_SBR_ZIPStringSubscriber Postal Zone or ZIP Code
04L2010BA_N404_CNTRY_CDStringCountry Code
07L2010BA_N407_CNTRY_SUBDV_CDStringCountry Subdivision Code
L2010BADMGSubscriber Demographic Information
02L2010BA_DMG02_D8DateTimeSubscriber Birth Date
03L2010BA_DMG03_SUB_GENDR_CDStringSubscriber Gender Code
L2010BAREFSubscriber Secondary Identification
02L2010BA_REF_SSNStringSocial Security Number
L2010BAREFProperty and Casualty Claim Number
02L2010BA_REF_AGNCY_CLM_NRStringAgency Claim Number
L2010BB - PAYER NAME
L2010BBNM1Payer Name
03L2010BB_NM103_NONPSNENT_NMStringNon-Person Entity Name
09L2010BB_NM109_PAYR_IDStringPayor Identification
09L2010BB_NM109_HCFA_PLAN_IDStringCenters for Medicare and Medicaid Services PlanID
L2010BBN3Payer Address
01L2010BB_N301_PYR_ADDR_LNStringPayer Address Line
02L2010BB_N302_PYR_ADDR_LNStringPayer Address Line
L2010BBN4Payer City, State, ZIP Code
01L2010BB_N401_PYR_CITY_NMStringPayer City Name
02L2010BB_N402_PYR_STATStringPayer State Code
03L2010BB_N403_PYR_ZIPStringPayer Postal Zone or ZIP Code
04L2010BB_N404_CNTRY_CDStringCountry Code
07L2010BB_N407_CNTRY_SUBDV_CDStringCountry Subdivision Code
L2010BBREFPayer Secondary Identification
02L2010BB_nnREF_PYR_IDStringPayer Identification Number
02L2010BB_nnREF_EMPLR_ID_NRStringEmployer's Identification Number
02L2010BB_nnREF_CLM_OFC_NRStringClaim Office Number
02L2010BB_nnREF_NAICStringNational Association of Insurance Commissioners (NAIC) Code
L2010BBREFBilling Provider Secondary Identification
02L2010BB_REF_PVR_COMM_NRStringProvider Commercial Number
02L2010BB_REF_LOC_NRStringLocation Number
L2000C - PATIENT HIERARCHICAL LEVEL
L2000CHLPatient Hierarchical Level
01L2000C_HL01_HIER_ID_NRStringHierarchical ID Number
02L2000C_HL02_HIER_PARNT_ID_NRStringHierarchical Parent ID Number
L2000CPATPatient Information
01L2000C_PAT01_IND_RELAT_CDStringIndividual Relationship Code
L2010CA - PATIENT NAME
L2010CANM1Patient Name
03L2010CA_NM103_PERSN_LNMStringPerson Last Name
04L2010CA_NM104_PT_FNMStringPatient First Name
05L2010CA_NM105_PT_MNMStringPatient Middle Name or Initial
07L2010CA_NM107_PT_SFXStringPatient Name Suffix
L2010CAN3Patient Address
01L2010CA_N301_PT_ADDRStringPatient Address Line
02L2010CA_N302_PT_ADDRStringPatient Address Line
L2010CAN4Patient City, State, ZIP Code
01L2010CA_N401_PT_CITYStringPatient City Name
02L2010CA_N402_PT_STATStringPatient State Code
03L2010CA_N403_PT_ZIPStringPatient Postal Zone or ZIP Code
04L2010CA_N404_CNTRY_CDStringCountry Code
07L2010CA_N407_CNTRY_SUBDV_CDStringCountry Subdivision Code
L2010CADMGPatient Demographic Information
02L2010CA_DMG02_D8DateTimePatient Birth Date
03L2010CA_DMG03_PAT_GNDR_CDStringPatient Gender Code
L2010CAREFProperty and Casualty Claim Number
02L2010CA_REF_AGNCY_CLM_NRStringAgency Claim Number
L2300 - CLAIM INFORMATION
L2300CLMClaim Information
01L2300_CLM01_PT_CTL_NRStringPatient Control Number
02L2300_CLM02_TOT_CLM_CHG_AMTNumberTotal Claim Charge Amount
0501L2300_CLM0501_FAC_TYP_CDStringFacility Type Code
0503L2300_CLM0503_CLM_FREQ_CDStringClaim Frequency Code
07L2300_CLM07_PLAN_PART_CDStringAssignment or Plan Participation Code
08L2300_CLM08_BEN_ASGT_CRT_INDStringBenefits Assignment Certification Indicator
09L2300_CLM09_RELS_NFO_CDStringRelease of Information Code
20L2300_CLM20_DELAY_RSN_CDStringDelay Reason Code
L2300DTPDischarge Hour
03L2300_DTP_DISCHG_D8Date (YYYYMMDD)Discharge (TM)
L2300DTPStatement Dates
03L2300_DTP_STMNT_RD8_1Start Date (YYYYMMDD)Statement (RD8)
03L2300_DTP_STMNT_RD8_2End Date (YYYYMMDD)Statement (RD8)
L2300DTPAdmission Date/Hour
03L2300_DTP_ADMSN_D8Date (YYYYMMDD)Admission Date
L2300DTPDate - Repricer Received Date
03L2300_DTP_RCVD_D8Date (YYYYMMDD)Received Date
L2300CL1Institutional Claim Code
01L2300_CL101_ADMSN_TYP_CDStringAdmission Type Code
02L2300_CL102_ADMSN_SRC_CDStringAdmission Source Code
03L2300_CL103_PT_STATS_CDStringPatient Status Code
L2300PWKClaim Supplemental Information
01L2300_nnPWK01_ATT_REP_TYP_CDStringAttachment Report Type Code
02L2300_nnPWK02_ATT_TRANS_CDStringAttachment Transmission Code
06L2300_nnPWK06_ATTACH_CTL_NRStringAttachment Control Number
L2300CN1Contract Information
01L2300_CN101_CNTRCT_TYP_CDStringContract Type Code
02L2300_CN102_CONTRCT_AMTNumberContract Amount
03L2300_CN103_CONTRCT_PERCNumberContract Percentage
04L2300_CN104_CONTRCT_CDStringContract Code
05L2300_CN105_TERMS_DISCT_PERCNumberTerms Discount Percentage
06L2300_CN106_CONTRCT_VERS_IDStringContract Version Identifier
L2300AMTPatient Estimated Amount Due
02L2300_AMT02_PAT_RESP_ESTNumberPatient Responsibility - Estimated
L2300REFService Authorization Exception Code
02L2300_REF_SP_PMT_REF_NRStringSpecial Payment Reference Number
L2300REFReferral Number
02L2300_REF_REFRL_NRStringReferral Number
L2300REFPrior Authorization
02L2300_REF_PRIOR_AUTHStringPrior Authorization Number
L2300REFPayer Claim Control Number
02L2300_REF_ORIG_REF_NRStringOriginal Reference Number
L2300REFRepriced Claim Number
02L2300_REF_REP_CLM_IDStringRepriced Claim Reference Number
L2300REFAdjusted Repriced Claim Number
02L2300_REF_ADJ_REP_CLM_IDStringAdjusted Repriced Claim Reference Number
L2300REFInvestigational Device Exemption Number
02L2300_nnREF_QUAL_PRD_LSTStringQualified Products List
L2300REFClaim Identifier For Transmission Intermediaries
02L2300_REF_CLM_NRStringClaim Number
L2300REFAuto Accident State
02L2300_REF_LOC_NRStringLocation Number
L2300REFMedical Record Number
02L2300_REF_MED_REC_IDStringMedical Record Identification Number
L2300REFDemonstration Project Identifier
02L2300_REF_PROJCT_CDStringProject Code
L2300REFPeer Review Organization (PRO) Approval Number
02L2300_REF_PPO_APPR_NRStringPeer Review Organization (PRO) Approval Number
L2300K3File Information
01L2300_nnK301_FIXD_FMT_NFOStringFixed Format Information
L2300NTEClaim Note
02L2300_nnNTE02_ALLRGSStringAllergies
02L2300_nnNTE02_GOALS_DISCHG_PLNStringGoals, Rehabilitation Potential, or Discharge Plans
02L2300_nnNTE02_DIAG_DESCStringDiagnosis Description
02L2300_nnNTE02_DME_SUPPStringDurable Medical Equipment (DME) and Supplies
02L2300_nnNTE02_MEDCTNStringMedications
02L2300_nnNTE02_NUTRTL_REQStringNutritional Requirements
02L2300_nnNTE02_ORD_DISC_TMTSStringOrders for Disciplines and Treatments
02L2300_nnNTE02_RSN_HOMBNDStringFunctional Limitations, Reason Homebound, or Both
02L2300_nnNTE02_RSN_PAT_LV_HMStringReasons Patient Leaves Home
02L2300_nnNTE02_TIME_RSN_PTStringTimes and Reasons Patient Not at Home
02L2300_nnNTE02_UNSL_HM_SOC_ENVStringUnusual Home, Social Environment, or Both
02L2300_nnNTE02_SAFTY_MSRSStringSafety Measures
02L2300_nnNTE02_SUPP_PLAN_TMNTStringSupplementary Plan of Treatment
02L2300_nnNTE02_UPDTD_NFOStringUpdated Information
L2300NTEBilling Note
02L2300_NTE02_ADDL_NFOStringAdditional Information
L2300CRCEPSDT ReferralSegment Suffix: A
02L2300_CRCA02_CERT_COND_CD_INDStringCertification Condition Code Applies Indicator
03L2300_CRCA03_CONDTN_INDStringCondition Indicator
04L2300_CRCA04_CONDTN_INDStringCondition Indicator
05L2300_CRCA05_CONDTN_INDStringCondition Indicator
L2300HIPrincipal Diagnosis
0102L2300_HI0102_ICD10_PRIN_DIAGStringInternational Classification of Diseases Clinical Modification (ICD-10-CM) Principal Diagnosis
0102L2300_HI0102_ICD9_PRIN_DIAGStringInternational Classification of Diseases Clinical Modification (ICD-9-CM) Principal Diagnosis
0109L2300_HI0109_PRSNT_ADMN_INDStringPresent on Admission Indicator
L2300HIAdmitting Diagnosis
0102L2300_HI0102_ICD10_ADMTG_DIAGStringInternational Classification of Diseases Clinical Modification (ICD-10-CM) Admitting Diagnosis
0102L2300_HI0102_ICD9_ADMTG_DIAGStringInternational Classification of Diseases Clinical Modification (ICD-9-CM) Admitting Diagnosis
L2300HIPatient?s Reason For VisitSegment Suffix: B
0102L2300_HIB0102_ICD10_RSN_VISITStringInternational Classification of Diseases Clinical Modification (ICD-10-CM) Patient's Reason for Visit
0102L2300_HIB0102_ICD9_RSN_VISITStringInternational Classification of Diseases Clinical Modification (ICD-9-CM) Patient's Reason for Visit
0202L2300_HIB0202_ICD10_RSN_VISITStringInternational Classification of Diseases Clinical Modification (ICD-10-CM) Patient's Reason for Visit
0202L2300_HIB0202_ICD9_RSN_VISITStringInternational Classification of Diseases Clinical Modification (ICD-9-CM) Patient's Reason for Visit
0302L2300_HIB0302_ICD10_RSN_VISITStringInternational Classification of Diseases Clinical Modification (ICD-10-CM) Patient's Reason for Visit
0302L2300_HIB0302_ICD9_RSN_VISITStringInternational Classification of Diseases Clinical Modification (ICD-9-CM) Patient's Reason for Visit
L2300HIExternal Cause of InjurySegment Suffix: C
0102L2300_HIC0102_ICD10_EXT_INJRYStringInternational Classification of Diseases Clinical Modification (ICD-10-CM) External Cause of Injury
0102L2300_HIC0102_ICD9_ECODEStringInternational Classification of Diseases Clinical Modification (ICD-9-CM) External Cause of Injury Code (E-codes)
0109L2300_HIC0109_PRSNT_ADMN_INDStringPresent on Admission Indicator
0202L2300_HIC0202_ICD10_EXT_INJRYStringInternational Classification of Diseases Clinical Modification (ICD-10-CM) External Cause of Injury
0202L2300_HIC0202_ICD9_ECODEStringInternational Classification of Diseases Clinical Modification (ICD-9-CM) External Cause of Injury Code (E-codes)
0209L2300_HIC0209_PRSNT_ADMN_INDStringPresent on Admission Indicator
0302L2300_HIC0302_ICD10_EXT_INJRYStringInternational Classification of Diseases Clinical Modification (ICD-10-CM) External Cause of Injury
0302L2300_HIC0302_ICD9_ECODEStringInternational Classification of Diseases Clinical Modification (ICD-9-CM) External Cause of Injury Code (E-codes)
0309L2300_HIC0309_PRSNT_ADMN_INDStringPresent on Admission Indicator
0402L2300_HIC0402_ICD10_EXT_INJRYStringInternational Classification of Diseases Clinical Modification (ICD-10-CM) External Cause of Injury
0402L2300_HIC0402_ICD9_ECODEStringInternational Classification of Diseases Clinical Modification (ICD-9-CM) External Cause of Injury Code (E-codes)
0409L2300_HIC0409_PRSNT_ADMN_INDStringPresent on Admission Indicator
0502L2300_HIC0502_ICD10_EXT_INJRYStringInternational Classification of Diseases Clinical Modification (ICD-10-CM) External Cause of Injury
0502L2300_HIC0502_ICD9_ECODEStringInternational Classification of Diseases Clinical Modification (ICD-9-CM) External Cause of Injury Code (E-codes)
0509L2300_HIC0509_PRSNT_ADMN_INDStringPresent on Admission Indicator
0602L2300_HIC0602_ICD10_EXT_INJRYStringInternational Classification of Diseases Clinical Modification (ICD-10-CM) External Cause of Injury
0602L2300_HIC0602_ICD9_ECODEStringInternational Classification of Diseases Clinical Modification (ICD-9-CM) External Cause of Injury Code (E-codes)
0609L2300_HIC0609_PRSNT_ADMN_INDStringPresent on Admission Indicator
0702L2300_HIC0702_ICD10_EXT_INJRYStringInternational Classification of Diseases Clinical Modification (ICD-10-CM) External Cause of Injury
0702L2300_HIC0702_ICD9_ECODEStringInternational Classification of Diseases Clinical Modification (ICD-9-CM) External Cause of Injury Code (E-codes)
0709L2300_HIC0709_PRSNT_ADMN_INDStringPresent on Admission Indicator
0802L2300_HIC0802_ICD10_EXT_INJRYStringInternational Classification of Diseases Clinical Modification (ICD-10-CM) External Cause of Injury
0802L2300_HIC0802_ICD9_ECODEStringInternational Classification of Diseases Clinical Modification (ICD-9-CM) External Cause of Injury Code (E-codes)
0809L2300_HIC0809_PRSNT_ADMN_INDStringPresent on Admission Indicator
0902L2300_HIC0902_ICD10_EXT_INJRYStringInternational Classification of Diseases Clinical Modification (ICD-10-CM) External Cause of Injury
0902L2300_HIC0902_ICD9_ECODEStringInternational Classification of Diseases Clinical Modification (ICD-9-CM) External Cause of Injury Code (E-codes)
0909L2300_HIC0909_PRSNT_ADMN_INDStringPresent on Admission Indicator
1002L2300_HIC1002_ICD10_EXT_INJRYStringInternational Classification of Diseases Clinical Modification (ICD-10-CM) External Cause of Injury
1002L2300_HIC1002_ICD9_ECODEStringInternational Classification of Diseases Clinical Modification (ICD-9-CM) External Cause of Injury Code (E-codes)
1009L2300_HIC1009_PRSNT_ADMN_INDStringPresent on Admission Indicator
1102L2300_HIC1102_ICD10_EXT_INJRYStringInternational Classification of Diseases Clinical Modification (ICD-10-CM) External Cause of Injury
1102L2300_HIC1102_ICD9_ECODEStringInternational Classification of Diseases Clinical Modification (ICD-9-CM) External Cause of Injury Code (E-codes)
1109L2300_HIC1109_PRSNT_ADMN_INDStringPresent on Admission Indicator
1202L2300_HIC1202_ICD10_EXT_INJRYStringInternational Classification of Diseases Clinical Modification (ICD-10-CM) External Cause of Injury
1202L2300_HIC1202_ICD9_ECODEStringInternational Classification of Diseases Clinical Modification (ICD-9-CM) External Cause of Injury Code (E-codes)
1209L2300_HIC1209_PRSNT_ADMN_INDStringPresent on Admission Indicator
L2300HIDiagnosis Related Group (DRG) InformationSegment Suffix: D
0102L2300_HID0102_DRG_CDStringDiagnosis Related Group (DRG)
L2300HIOther Diagnosis InformationSegment Suffix: E
0102L2300_nnHIE0102_ICD10_DIAGStringInternational Classification of Diseases Clinical Modification (ICD-10-CM) Diagnosis
0102L2300_nnHIE0102_ICD9_DIAGStringInternational Classification of Diseases Clinical Modification (ICD-9-CM) Diagnosis
0109L2300_nnHIE0109_PRSNT_ADMN_INDStringPresent on Admission Indicator
0202L2300_nnHIE0202_ICD10_DIAGStringInternational Classification of Diseases Clinical Modification (ICD-10-CM) Diagnosis
0202L2300_nnHIE0202_ICD9_DIAGStringInternational Classification of Diseases Clinical Modification (ICD-9-CM) Diagnosis
0209L2300_nnHIE0209_PRSNT_ADMN_INDStringPresent on Admission Indicator
0302L2300_nnHIE0302_ICD10_DIAGStringInternational Classification of Diseases Clinical Modification (ICD-10-CM) Diagnosis
0302L2300_nnHIE0302_ICD9_DIAGStringInternational Classification of Diseases Clinical Modification (ICD-9-CM) Diagnosis
0309L2300_nnHIE0309_PRSNT_ADMN_INDStringPresent on Admission Indicator
0402L2300_nnHIE0402_ICD10_DIAGStringInternational Classification of Diseases Clinical Modification (ICD-10-CM) Diagnosis
0402L2300_nnHIE0402_ICD9_DIAGStringInternational Classification of Diseases Clinical Modification (ICD-9-CM) Diagnosis
0409L2300_nnHIE0409_PRSNT_ADMN_INDStringPresent on Admission Indicator
0502L2300_nnHIE0502_ICD10_DIAGStringInternational Classification of Diseases Clinical Modification (ICD-10-CM) Diagnosis
0502L2300_nnHIE0502_ICD9_DIAGStringInternational Classification of Diseases Clinical Modification (ICD-9-CM) Diagnosis
0509L2300_nnHIE0509_PRSNT_ADMN_INDStringPresent on Admission Indicator
0602L2300_nnHIE0602_ICD10_DIAGStringInternational Classification of Diseases Clinical Modification (ICD-10-CM) Diagnosis
0602L2300_nnHIE0602_ICD9_DIAGStringInternational Classification of Diseases Clinical Modification (ICD-9-CM) Diagnosis
0609L2300_nnHIE0609_PRSNT_ADMN_INDStringPresent on Admission Indicator
0702L2300_nnHIE0702_ICD10_DIAGStringInternational Classification of Diseases Clinical Modification (ICD-10-CM) Diagnosis
0702L2300_nnHIE0702_ICD9_DIAGStringInternational Classification of Diseases Clinical Modification (ICD-9-CM) Diagnosis
0709L2300_nnHIE0709_PRSNT_ADMN_INDStringPresent on Admission Indicator
0802L2300_nnHIE0802_ICD10_DIAGStringInternational Classification of Diseases Clinical Modification (ICD-10-CM) Diagnosis
0802L2300_nnHIE0802_ICD9_DIAGStringInternational Classification of Diseases Clinical Modification (ICD-9-CM) Diagnosis
0809L2300_nnHIE0809_PRSNT_ADMN_INDStringPresent on Admission Indicator
0902L2300_nnHIE0902_ICD10_DIAGStringInternational Classification of Diseases Clinical Modification (ICD-10-CM) Diagnosis
0902L2300_nnHIE0902_ICD9_DIAGStringInternational Classification of Diseases Clinical Modification (ICD-9-CM) Diagnosis
0909L2300_nnHIE0909_PRSNT_ADMN_INDStringPresent on Admission Indicator
1002L2300_nnHIE1002_ICD10_DIAGStringInternational Classification of Diseases Clinical Modification (ICD-10-CM) Diagnosis
1002L2300_nnHIE1002_ICD9_DIAGStringInternational Classification of Diseases Clinical Modification (ICD-9-CM) Diagnosis
1009L2300_nnHIE1009_PRSNT_ADMN_INDStringPresent on Admission Indicator
1102L2300_nnHIE1102_ICD10_DIAGStringInternational Classification of Diseases Clinical Modification (ICD-10-CM) Diagnosis
1102L2300_nnHIE1102_ICD9_DIAGStringInternational Classification of Diseases Clinical Modification (ICD-9-CM) Diagnosis
1109L2300_nnHIE1109_PRSNT_ADMN_INDStringPresent on Admission Indicator
1202L2300_nnHIE1202_ICD10_DIAGStringInternational Classification of Diseases Clinical Modification (ICD-10-CM) Diagnosis
1202L2300_nnHIE1202_ICD9_DIAGStringInternational Classification of Diseases Clinical Modification (ICD-9-CM) Diagnosis
1209L2300_nnHIE1209_PRSNT_ADMN_INDStringPresent on Admission Indicator
L2300HIPrincipal Procedure InformationSegment Suffix: F
0102L2300_HIF0102_ICD10_PRIN_PROCStringInternational Classification of Diseases Clinical Modification (ICD-10-PCS) Principal Procedure
0102L2300_HIF0102_ICD9_PRN_PROC_CDStringInternational Classification of Diseases Clinical Modification (ICD-9-CM) Principal Procedure Codes
0102L2300_HIF0102_ABC_CDStringAdvanced Billing Concepts (ABC) Codes
0104L2300_HIF0104_PRIN_PROCDateTimePrincipal Procedure Date
L2300HIOther Procedure InformationSegment Suffix: G
0102L2300_nnHIG0102_ICD10_OPROC_CDStringInternational Classification of Diseases Clinical Modification (ICD-10-PCS) Other Procedure Codes
0102L2300_nnHIG0102_ICD9_OPROC_CDStringInternational Classification of Diseases Clinical Modification (ICD-9-CM) Other Procedure Codes
0104L2300_nnHIG0104_PROCDateTimeProcedure Date
0202L2300_nnHIG0202_ICD10_OPROC_CDStringInternational Classification of Diseases Clinical Modification (ICD-10-PCS) Other Procedure Codes
0202L2300_nnHIG0202_ICD9_OPROC_CDStringInternational Classification of Diseases Clinical Modification (ICD-9-CM) Other Procedure Codes
0204L2300_nnHIG0204_PROCDateTimeProcedure Date
0302L2300_nnHIG0302_ICD10_OPROC_CDStringInternational Classification of Diseases Clinical Modification (ICD-10-PCS) Other Procedure Codes
0302L2300_nnHIG0302_ICD9_OPROC_CDStringInternational Classification of Diseases Clinical Modification (ICD-9-CM) Other Procedure Codes
0304L2300_nnHIG0304_PROCDateTimeProcedure Date
0402L2300_nnHIG0402_ICD10_OPROC_CDStringInternational Classification of Diseases Clinical Modification (ICD-10-PCS) Other Procedure Codes
0402L2300_nnHIG0402_ICD9_OPROC_CDStringInternational Classification of Diseases Clinical Modification (ICD-9-CM) Other Procedure Codes
0404L2300_nnHIG0404_PROCDateTimeProcedure Date
0502L2300_nnHIG0502_ICD10_OPROC_CDStringInternational Classification of Diseases Clinical Modification (ICD-10-PCS) Other Procedure Codes
0502L2300_nnHIG0502_ICD9_OPROC_CDStringInternational Classification of Diseases Clinical Modification (ICD-9-CM) Other Procedure Codes
0504L2300_nnHIG0504_PROCDateTimeProcedure Date
0602L2300_nnHIG0602_ICD10_OPROC_CDStringInternational Classification of Diseases Clinical Modification (ICD-10-PCS) Other Procedure Codes
0602L2300_nnHIG0602_ICD9_OPROC_CDStringInternational Classification of Diseases Clinical Modification (ICD-9-CM) Other Procedure Codes
0604L2300_nnHIG0604_PROCDateTimeProcedure Date
0702L2300_nnHIG0702_ICD10_OPROC_CDStringInternational Classification of Diseases Clinical Modification (ICD-10-PCS) Other Procedure Codes
0702L2300_nnHIG0702_ICD9_OPROC_CDStringInternational Classification of Diseases Clinical Modification (ICD-9-CM) Other Procedure Codes
0704L2300_nnHIG0704_PROCDateTimeProcedure Date
0802L2300_nnHIG0802_ICD10_OPROC_CDStringInternational Classification of Diseases Clinical Modification (ICD-10-PCS) Other Procedure Codes
0802L2300_nnHIG0802_ICD9_OPROC_CDStringInternational Classification of Diseases Clinical Modification (ICD-9-CM) Other Procedure Codes
0804L2300_nnHIG0804_PROCDateTimeProcedure Date
0902L2300_nnHIG0902_ICD10_OPROC_CDStringInternational Classification of Diseases Clinical Modification (ICD-10-PCS) Other Procedure Codes
0902L2300_nnHIG0902_ICD9_OPROC_CDStringInternational Classification of Diseases Clinical Modification (ICD-9-CM) Other Procedure Codes
0904L2300_nnHIG0904_PROCDateTimeProcedure Date
1002L2300_nnHIG1002_ICD10_OPROC_CDStringInternational Classification of Diseases Clinical Modification (ICD-10-PCS) Other Procedure Codes
1002L2300_nnHIG1002_ICD9_OPROC_CDStringInternational Classification of Diseases Clinical Modification (ICD-9-CM) Other Procedure Codes
1004L2300_nnHIG1004_PROCDateTimeProcedure Date
1102L2300_nnHIG1102_ICD10_OPROC_CDStringInternational Classification of Diseases Clinical Modification (ICD-10-PCS) Other Procedure Codes
1102L2300_nnHIG1102_ICD9_OPROC_CDStringInternational Classification of Diseases Clinical Modification (ICD-9-CM) Other Procedure Codes
1104L2300_nnHIG1104_PROCDateTimeProcedure Date
1202L2300_nnHIG1202_ICD10_OPROC_CDStringInternational Classification of Diseases Clinical Modification (ICD-10-PCS) Other Procedure Codes
1202L2300_nnHIG1202_ICD9_OPROC_CDStringInternational Classification of Diseases Clinical Modification (ICD-9-CM) Other Procedure Codes
1204L2300_nnHIG1204_PROCDateTimeProcedure Date
L2300HIOccurrence Span InformationSegment Suffix: H
0102L2300_nnHIH0102_OCC_SPAN_CDStringOccurrence Span
0104L2300_nnHIH0104_RD8_1DateTimeOccurrence Span Code Date
0104L2300_nnHIH0104_RD8_2DateTimeOccurrence Span Code Date
0202L2300_nnHIH0202_OCC_SPAN_CDStringOccurrence Span
0204L2300_nnHIH0204_RD8_1DateTimeOccurrence Span Code Date
0204L2300_nnHIH0204_RD8_2DateTimeOccurrence Span Code Date
0302L2300_nnHIH0302_OCC_SPAN_CDStringOccurrence Span
0304L2300_nnHIH0304_RD8_1DateTimeOccurrence Span Code Date
0304L2300_nnHIH0304_RD8_2DateTimeOccurrence Span Code Date
0402L2300_nnHIH0402_OCC_SPAN_CDStringOccurrence Span
0404L2300_nnHIH0404_RD8_1DateTimeOccurrence Span Code Date
0404L2300_nnHIH0404_RD8_2DateTimeOccurrence Span Code Date
0502L2300_nnHIH0502_OCC_SPAN_CDStringOccurrence Span
0504L2300_nnHIH0504_RD8_1DateTimeOccurrence Span Code Date
0504L2300_nnHIH0504_RD8_2DateTimeOccurrence Span Code Date
0602L2300_nnHIH0602_OCC_SPAN_CDStringOccurrence Span
0604L2300_nnHIH0604_RD8_1DateTimeOccurrence Span Code Date
0604L2300_nnHIH0604_RD8_2DateTimeOccurrence Span Code Date
0702L2300_nnHIH0702_OCC_SPAN_CDStringOccurrence Span
0704L2300_nnHIH0704_RD8_1DateTimeOccurrence Span Code Date
0704L2300_nnHIH0704_RD8_2DateTimeOccurrence Span Code Date
0802L2300_nnHIH0802_OCC_SPAN_CDStringOccurrence Span
0804L2300_nnHIH0804_RD8_1DateTimeOccurrence Span Code Date
0804L2300_nnHIH0804_RD8_2DateTimeOccurrence Span Code Date
0902L2300_nnHIH0902_OCC_SPAN_CDStringOccurrence Span
0904L2300_nnHIH0904_RD8_1DateTimeOccurrence Span Code Date
0904L2300_nnHIH0904_RD8_2DateTimeOccurrence Span Code Date
1002L2300_nnHIH1002_OCC_SPAN_CDStringOccurrence Span
1004L2300_nnHIH1004_RD8_1DateTimeOccurrence Span Code Date
1004L2300_nnHIH1004_RD8_2DateTimeOccurrence Span Code Date
1102L2300_nnHIH1102_OCC_SPAN_CDStringOccurrence Span
1104L2300_nnHIH1104_RD8_1DateTimeOccurrence Span Code Date
1104L2300_nnHIH1104_RD8_2DateTimeOccurrence Span Code Date
1202L2300_nnHIH1202_OCC_SPAN_CDStringOccurrence Span
1204L2300_nnHIH1204_RD8_1DateTimeOccurrence Span Code Date
1204L2300_nnHIH1204_RD8_2DateTimeOccurrence Span Code Date
L2300HIOccurrence InformationSegment Suffix: I
0102L2300_nnHII0102_OCC_CDStringOccurrence
0104L2300_nnHII0104_OCC_CDDateTimeOccurrence Code Date
0202L2300_nnHII0202_OCC_CDStringOccurrence
0204L2300_nnHII0204_OCC_CDDateTimeOccurrence Code Date
0302L2300_nnHII0302_OCC_CDStringOccurrence
0304L2300_nnHII0304_OCC_CDDateTimeOccurrence Code Date
0402L2300_nnHII0402_OCC_CDStringOccurrence
0404L2300_nnHII0404_OCC_CDDateTimeOccurrence Code Date
0502L2300_nnHII0502_OCC_CDStringOccurrence
0504L2300_nnHII0504_OCC_CDDateTimeOccurrence Code Date
0602L2300_nnHII0602_OCC_CDStringOccurrence
0604L2300_nnHII0604_OCC_CDDateTimeOccurrence Code Date
0702L2300_nnHII0702_OCC_CDStringOccurrence
0704L2300_nnHII0704_OCC_CDDateTimeOccurrence Code Date
0802L2300_nnHII0802_OCC_CDStringOccurrence
0804L2300_nnHII0804_OCC_CDDateTimeOccurrence Code Date
0902L2300_nnHII0902_OCC_CDStringOccurrence
0904L2300_nnHII0904_OCC_CDDateTimeOccurrence Code Date
1002L2300_nnHII1002_OCC_CDStringOccurrence
1004L2300_nnHII1004_OCC_CDDateTimeOccurrence Code Date
1102L2300_nnHII1102_OCC_CDStringOccurrence
1104L2300_nnHII1104_OCC_CDDateTimeOccurrence Code Date
1202L2300_nnHII1202_OCC_CDStringOccurrence
1204L2300_nnHII1204_OCC_CDDateTimeOccurrence Code Date
L2300HIValue InformationSegment Suffix: J
0102L2300_nnHIJ0102_VAL_CDStringValue
0105L2300_nnHIJ0105_VAL_CD_AMTNumberValue Code Amount
0202L2300_nnHIJ0202_VAL_CDStringValue
0205L2300_nnHIJ0205_VAL_CD_AMTStringValue Code Amount
0302L2300_nnHIJ0302_VAL_CDStringValue
0305L2300_nnHIJ0305_VAL_CD_AMTNumberValue Code Amount
0402L2300_nnHIJ0402_VAL_CDStringValue
0405L2300_nnHIJ0405_VAL_CD_AMTNumberValue Code Amount
0502L2300_nnHIJ0502_VAL_CDStringValue
0505L2300_nnHIJ0505_VAL_CD_AMTNumberValue Code Amount
0602L2300_nnHIJ0602_VAL_CDStringValue
0605L2300_nnHIJ0605_VAL_CD_AMTNumberValue Code Amount
0702L2300_nnHIJ0702_VAL_CDStringValue
0705L2300_nnHIJ0705_VAL_CD_AMTNumberValue Code Amount
0802L2300_nnHIJ0802_VAL_CDStringValue
0805L2300_nnHIJ0805_VAL_CD_AMTNumberValue Code Amount
0902L2300_nnHIJ0902_VAL_CDStringValue
0905L2300_nnHIJ0905_VAL_CD_AMTNumberValue Code Amount
1002L2300_nnHIJ1002_VAL_CDStringValue
1005L2300_nnHIJ1005_VAL_CD_AMTNumberValue Code Amount
1102L2300_nnHIJ1102_VAL_CDStringValue
1105L2300_nnHIJ1105_VAL_CD_AMTNumberValue Code Amount
1202L2300_nnHIJ1202_VAL_CDStringValue
1205L2300_nnHIJ1205_VAL_CD_AMTNumberValue Code Amount
L2300HICondition InformationSegment Suffix: A
0102L2300_nnHIA0102_CONDTN_CDStringCondition
0202L2300_nnHIA0202_CONDTN_CDStringCondition
0302L2300_nnHIA0302_CONDTN_CDStringCondition
0402L2300_nnHIA0402_CONDTN_CDStringCondition
0502L2300_nnHIA0502_CONDTN_CDStringCondition
0602L2300_nnHIA0602_CONDTN_CDStringCondition
0702L2300_nnHIA0702_CONDTN_CDStringCondition
0802L2300_nnHIA0802_CONDTN_CDStringCondition
0902L2300_nnHIA0902_CONDTN_CDStringCondition
1002L2300_nnHIA1002_CONDTN_CDStringCondition
1102L2300_nnHIA1102_CONDTN_CDStringCondition
1202L2300_nnHIA1202_CONDTN_CDStringCondition
L2300HITreatment Code InformationSegment Suffix: L
0102L2300_nnHIL0102_TMT_CDStringTreatment Codes
0202L2300_nnHIL0202_TMT_CDStringTreatment Codes
0302L2300_nnHIL0302_TMT_CDStringTreatment Codes
0402L2300_nnHIL0402_TMT_CDStringTreatment Codes
0502L2300_nnHIL0502_TMT_CDStringTreatment Codes
0602L2300_nnHIL0602_TMT_CDStringTreatment Codes
0702L2300_nnHIL0702_TMT_CDStringTreatment Codes
0802L2300_nnHIL0802_TMT_CDStringTreatment Codes
0902L2300_nnHIL0902_TMT_CDStringTreatment Codes
1002L2300_nnHIL1002_TMT_CDStringTreatment Codes
1102L2300_nnHIL1102_TMT_CDStringTreatment Codes
1202L2300_nnHIL1202_TMT_CDStringTreatment Codes
L2300HCPClaim Pricing/Repricing Information
01L2300_HCP01_PRIC_METHDStringPricing Methodology
02L2300_HCP02_REPRCD_ALLWD_AMTNumberRepriced Allowed Amount
03L2300_HCP03_REPRCD_SAVNG_AMTNumberRepriced Saving Amount
04L2300_HCP04_REPRCNG_ORG_IDStringRepricing Organization Identifier
05L2300_HCP05_REPRCD_PERDIEM_AMTNumberRepricing Per Diem or Flat Rate Amount
06L2300_HCP06_REP_APP_DRG_CDStringRepriced Approved DRG Code
07L2300_HCP07_REPR_APPR_AMTNumberRepriced Approved Amount
08L2300_HCP08_REPR_APPR_REV_CDStringRepriced Approved Revenue Code
12L2300_HCP12_DAYSNumberDays
12L2300_HCP12_UNNumberUnit
13L2300_HCP13_REJ_RSN_CDStringReject Reason Code
14L2300_HCP14_POLCY_COMP_CDStringPolicy Compliance Code
15L2300_HCP15_EXCPTN_CDStringException Code
L2310A - ATTENDING PROVIDER NAME
L2310ANM1Attending Provider Name
03L2310A_NM103_PERSN_LNMStringPerson Last Name
04L2310A_NM104_ATT_PVR_FNMStringAttending Provider First Name
05L2310A_NM105_ATT_PVR_MNMStringAttending Provider Middle Name or Initial
07L2310A_NM107_ATT_PVR_SFXStringAttending Provider Name Suffix
09L2310A_NM109_NPIStringCenters for Medicare and Medicaid Services National Provider Identifier
L2310APRVAttending Provider Specialty Information
03L2310A_PRV03_PVD_TAXNMY_CDStringHealth Care Provider Taxonomy Code
L2310AREFAttending Provider Secondary Identification
02L2310A_REF_STAT_LIC_NRStringState License Number
02L2310A_REF_UPINStringProvider UPIN Number
02L2310A_REF_PVR_COMM_NRStringProvider Commercial Number
02L2310A_REF_LOC_NRStringLocation Number
L2310B - OPERATING PHYSICIAN NAME
L2310BNM1Operating Physician Name
03L2310B_NM103_PERSN_LNMStringPerson Last Name
04L2310B_NM104_OPER_PHYS_FNMStringOperating Physician First Name
05L2310B_NM105_OPER_PHYS_MNMStringOperating Physician Middle Name or Initial
07L2310B_NM107_OPER_PHYS_SFXStringOperating Physician Name Suffix
09L2310B_NM109_NPIStringCenters for Medicare and Medicaid Services National Provider Identifier
L2310BREFOperating Physician Secondary Identification
02L2310B_REF_STAT_LIC_NRStringState License Number
02L2310B_REF_UPINStringProvider UPIN Number
02L2310B_REF_PVR_COMM_NRStringProvider Commercial Number
02L2310B_REF_LOC_NRStringLocation Number
L2310C - OTHER OPERATING PHYSICIAN NAME
L2310CNM1Other Operating Physician Name
03L2310C_NM103_PERSN_LNMStringPerson Last Name
04L2310C_NM104_OOPER_PHYS_FNMStringOther Operating Physician First Name
05L2310C_NM105_OOPER_PHYS_MNMStringOther Operating Physician Middle Name or Initial
07L2310C_NM107_OOPER_PHYS_SFXStringOther Operating Physician Name Suffix
09L2310C_NM109_NPIStringCenters for Medicare and Medicaid Services National Provider Identifier
L2310CREFOther Operating Physician Secondary Identification
02L2310C_REF_STAT_LIC_NRStringState License Number
02L2310C_REF_UPINStringProvider UPIN Number
02L2310C_REF_PVR_COMM_NRStringProvider Commercial Number
02L2310C_REF_LOC_NRStringLocation Number
L2310D - RENDERING PROVIDER NAME
L2310DNM1Rendering Provider Name
03L2310D_NM103_PERSN_LNMStringPerson Last Name
04L2310D_NM104_REND_PVR_FNMStringRendering Provider First Name
05L2310D_NM105_REND_PVR_MNMStringRendering Provider Middle Name or Initial
07L2310D_NM107_REND_PROV_SFXStringRendering Provider Name Suffix
09L2310D_NM109_NPIStringCenters for Medicare and Medicaid Services National Provider Identifier
L2310DREFRendering Provider Secondary Identification
02L2310D_REF_STAT_LIC_NRStringState License Number
02L2310D_REF_UPINStringProvider UPIN Number
02L2310D_REF_PVR_COMM_NRStringProvider Commercial Number
02L2310D_REF_LOC_NRStringLocation Number
L2310E - SERVICE FACILITY LOCATION NAME
L2310ENM1Service Facility Location Name
03L2310E_NM103_NONPSNENT_NMStringNon-Person Entity Name
09L2310E_NM109_NPIStringCenters for Medicare and Medicaid Services National Provider Identifier
L2310EN3Service Facility Location Address
01L2310E_N301_LAB_FAC_ADDRStringLaboratory or Facility Address Line
02L2310E_N302_LAB_FAC_ADDRStringLaboratory or Facility Address Line
L2310EN4Service Facility Location City, State, ZIP Code
01L2310E_N401_LAB_FAC_CITYStringLaboratory or Facility City Name
02L2310E_N402_LAB_FAC_STATStringLaboratory or Facility State or Province Code
03L2310E_N403_LAB_ZIPStringLaboratory or Facility Postal Zone or ZIP Code
04L2310E_N404_CNTRY_CDStringCountry Code
07L2310E_N407_CNTRY_SUBDV_CDStringCountry Subdivision Code
L2310EREFService Facility Location Secondary Identification
02L2310E_REF_STAT_LIC_NRStringState License Number
02L2310E_REF_PVR_COMM_NRStringProvider Commercial Number
02L2310E_REF_LOC_NRStringLocation Number
L2310F - REFERRING PROVIDER NAME
L2310FNM1Referring Provider Name
03L2310F_NM103_PERSN_LNMStringPerson Last Name
04L2310F_NM104_REF_PVR_FNMStringReferring Provider First Name
05L2310F_NM105_REF_PVR_MNMStringReferring Provider Middle Name or Initial
07L2310F_NM107_REF_PVR_SFXStringReferring Provider Name Suffix
09L2310F_NM109_NPIStringCenters for Medicare and Medicaid Services National Provider Identifier
L2310FREFReferring Provider Secondary Identification
02L2310F_REF_STAT_LIC_NRStringState License Number
02L2310F_REF_UPINStringProvider UPIN Number
02L2310F_REF_PVR_COMM_NRStringProvider Commercial Number
L2320 - OTHER SUBSCRIBER INFORMATION (Single Iteration)
L2320SBROther Subscriber Information
01L2320_xx_SBR01_PYR_RESP_SEQ_NRStringPayer Responsibility Sequence Number Code
02L2320_xx_SBR02_IND_RELAT_CDStringIndividual Relationship Code
03L2320_xx_SBR03_INS_GRP_PLCY_NRStringInsured Group or Policy Number
04L2320_xx_SBR04_OINS_GRP_NMStringOther Insured Group Name
09L2320_xx_SBR09_CLM_FIL_IND_CDStringClaim Filing Indicator Code
L2320CASClaim Level Adjustments
01L2320_xx_nnCAS01_CLMADJ_GRP_CDStringClaim Adjustment Group Code
02L2320_xx_nnCAS02_ADJ_RSN_CDStringAdjustment Reason Code
03L2320_xx_nnCAS03_ADJ_AMTNumberAdjustment Amount
04L2320_xx_nnCAS04_ADJ_QTYNumberAdjustment Quantity
05L2320_xx_nnCAS05_ADJ_RSN_CDStringAdjustment Reason Code
06L2320_xx_nnCAS06_ADJ_AMTNumberAdjustment Amount
07L2320_xx_nnCAS07_ADJ_QTYNumberAdjustment Quantity
08L2320_xx_nnCAS08_ADJ_RSN_CDStringAdjustment Reason Code
09L2320_xx_nnCAS09_ADJ_AMTNumberAdjustment Amount
10L2320_xx_nnCAS10_ADJ_QTYNumberAdjustment Quantity
11L2320_xx_nnCAS11_ADJ_RSN_CDStringAdjustment Reason Code
12L2320_xx_nnCAS12_ADJ_AMTNumberAdjustment Amount
13L2320_xx_nnCAS13_ADJ_QTYNumberAdjustment Quantity
14L2320_xx_nnCAS14_ADJ_RSN_CDStringAdjustment Reason Code
15L2320_xx_nnCAS15_ADJ_AMTNumberAdjustment Amount
16L2320_xx_nnCAS16_ADJ_QTYNumberAdjustment Quantity
17L2320_xx_nnCAS17_ADJ_RSN_CDStringAdjustment Reason Code
18L2320_xx_nnCAS18_ADJ_AMTNumberAdjustment Amount
19L2320_xx_nnCAS19_ADJ_QTYNumberAdjustment Quantity
L2320AMTCoordination of Benefits (COB) Payer Paid Amount
02L2320_xx_AMT02_PAYR_AMT_PDNumberPayor Amount Paid
L2320AMTRemaining Patient Liability
02L2320_xx_AMT02_AMT_OWEDNumberAmount Owed
L2320AMTCoordination of Benefits (COB) Total Non-Covered Amount
02L2320_xx_AMT02_NONCVD_CHG_ACTLNumberNoncovered Charges - Actual
L2320OIOther Insurance Coverage Information
03L2320_xx_OI03_BEN_ASGT_CRT_INDStringBenefits Assignment Certification Indicator
06L2320_xx_OI06_RELS_NFO_CDStringRelease of Information Code
L2320MIAInpatient Adjudication Information
01L2320_xx_MIA01_COV_DAYS_VST_CTNumberCovered Days or Visits Count
03L2320_xx_MIA03_LFTM_PSYCH_DAYSNumberLifetime Psychiatric Days Count
04L2320_xx_MIA04_CLM_DRG_AMTNumberClaim DRG Amount
05L2320_xx_MIA05_CLM_PMT_RMK_CDStringClaim Payment Remark Code
06L2320_xx_MIA06_CLM_DIS_SHR_AMTNumberClaim Disproportionate Share Amount
07L2320_xx_MIA07_CLM_MSP_PSS_AMTNumberClaim MSP Pass-through Amount
08L2320_xx_MIA08_CLM_PPS_CAP_AMTNumberClaim PPS Capital Amount
09L2320_xx_MIA09_PPS_FSP_DRG_AMTNumberPPS-Capital FSP DRG Amount
10L2320_xx_MIA10_PPS_HSP_DRG_AMTNumberPPS-Capital HSP DRG Amount
11L2320_xx_MIA11_PPS_DSH_DRG_AMTNumberPPS-Capital DSH DRG Amount
12L2320_xx_MIA12_OLD_CAP_AMTNumberOld Capital Amount
13L2320_xx_MIA13_PPS_CAP_IME_AMTNumberPPS-Capital IME amount
14L2320_xx_MIA14_PPS_OPRS_DRGAMTNumberPPS-Operating Hospital Specific DRG Amount
15L2320_xx_MIA15_COST_RPT_DAY_CTNumberCost Report Day Count
16L2320_xx_MIA16_PPS_FED_DRG_AMTNumberPPS-Operating Federal Specific DRG Amount
17L2320_xx_MIA17_CLM_CAP_OUT_AMTNumberClaim PPS Capital Outlier Amount
18L2320_xx_MIA18_CLM_IND_TCH_AMTNumberClaim Indirect Teaching Amount
19L2320_xx_MIA19_NONPAY_PROF_BLLNumberNon-Payable Professional Component Billed
20L2320_xx_MIA20_CLM_PMT_RMK_CDStringClaim Payment Remark Code
21L2320_xx_MIA21_CLM_PMT_RMK_CDStringClaim Payment Remark Code
22L2320_xx_MIA22_CLM_PMT_RMK_CDStringClaim Payment Remark Code
23L2320_xx_MIA23_CLM_PMT_RMK_CDStringClaim Payment Remark Code
24L2320_xx_MIA24_PPS_EXCPTN_AMTNumberPPS-Capital Exception Amount
L2320MOAOutpatient Adjudication Information
01L2320_xx_MOA01_REIMBRSMT_RTNumberReimbursement Rate
02L2320_xx_MOA02_HCPCS_PAYBL_AMTNumberHCPCS Payable Amount
03L2320_xx_MOA03_CLM_PMT_RMK_CDStringClaim Payment Remark Code
04L2320_xx_MOA04_CLM_PMT_RMK_CDStringClaim Payment Remark Code
05L2320_xx_MOA05_CLM_PMT_RMK_CDStringClaim Payment Remark Code
06L2320_xx_MOA06_CLM_PMT_RMK_CDStringClaim Payment Remark Code
07L2320_xx_MOA07_CLM_PMT_RMK_CDStringClaim Payment Remark Code
08L2320_xx_MOA08_ESRD_PMT_AMTNumberEnd Stage Renal Disease Payment Amount
09L2320_xx_MOA09_NONPAY_PROF_BLLStringNon-Payable Professional Component Billed
L2330A - OTHER SUBSCRIBER NAME (Inherited Loop Iteration)
L2330ANM1Other Subscriber Name
03L2330A_xx_NM103_PERSN_LNMStringPerson Last Name
03L2330A_xx_NM103_NONPSNENT_NMStringNon-Person Entity Name
04L2330A_xx_NM104_OINS_FNMStringOther Insured First Name
05L2330A_xx_NM105_OINS_MNMStringOther Insured Middle Name
07L2330A_xx_NM107_OINS_SFXStringOther Insured Name Suffix
09L2330A_xx_NM109_UNQ_IND_IDStringStandard Unique Health Identifier for each Individual in the United States
09L2330A_xx_NM109_MEM_ID_NRStringMember Identification Number
L2330AN3Other Subscriber Address
01L2330A_xx_N301_OINS_ADDRStringOther Insured Address Line
02L2330A_xx_N302_OINS_ADDRStringOther Insured Address Line
L2330AN4Other Subscriber City, State, ZIP Code
01L2330A_xx_N401_OINS_CITYStringOther Insured City Name
02L2330A_xx_N402_OINS_STATStringOther Insured State Code
03L2330A_xx_N403_OINS_ZIPStringOther Insured Postal Zone or ZIP Code
04L2330A_xx_N404_CNTRY_CDStringCountry Code
07L2330A_xx_N407_CNTRY_SUBDV_CDStringCountry Subdivision Code
L2330AREFOther Subscriber Secondary Identification
02L2330A_xx_nnREF_SSNStringSocial Security Number
L2330B - OTHER PAYER NAME (Inherited Loop Iteration)
L2330BNM1Other Payer Name
03L2330B_xx_NM103_NONPSNENT_NMStringNon-Person Entity Name
09L2330B_xx_NM109_PAYR_IDStringPayor Identification
09L2330B_xx_NM109_HCFA_PLAN_IDStringCenters for Medicare and Medicaid Services PlanID
L2330BN3Other Payer Address
01L2330B_xx_N301_OPYR_ADDRStringOther Payer Address Line
02L2330B_xx_N302_OPYR_ADDRStringOther Payer Address Line
L2330BN4Other Payer City, State, ZIP Code
01L2330B_xx_N401_OPYR_CITY_NMStringOther Payer City Name
02L2330B_xx_N402_OPYR_STATStringOther Payer State Code
03L2330B_xx_N403_OPYR_POSTL_ZIPStringOther Payer Postal Zone or ZIP Code
04L2330B_xx_N404_CNTRY_CDStringCountry Code
07L2330B_xx_N407_CNTRY_SUBDV_CDStringCountry Subdivision Code
L2330BDTPClaim Check or Remittance Date
03L2330B_xx_DTP_CLM_PD_D8Date (YYYYMMDD)Date Claim Paid Date
L2330BREFOther Payer Secondary Identifier
02L2330B_xx_nnREF_PYR_IDStringPayer Identification Number
02L2330B_xx_nnREF_EMPLR_ID_NRStringEmployer's Identification Number
02L2330B_xx_nnREF_CLM_OFC_NRStringClaim Office Number
02L2330B_xx_nnREF_NAICStringNational Association of Insurance Commissioners (NAIC) Code
L2330BREFOther Payer Prior Authorization Number
02L2330B_xx_REF_PRIOR_AUTHStringPrior Authorization Number
L2330BREFOther Payer Referral Number
02L2330B_xx_REF_REFRL_NRStringReferral Number
L2330BREFOther Payer Claim Adjustment Indicator
02L2330B_xx_REF_SIGNL_CDStringSignal Code
L2330BREFOther Payer Claim Control Number
02L2330B_xx_REF_ORIG_REF_NRStringOriginal Reference Number
L2330C - OTHER PAYER ATTENDING PROVIDER (Inherited Loop Iteration)
L2330CNM1Other Payer Attending Provider
L2330CREFOther Payer Attending Provider Secondary Identification
02L2330C_xx_REF_STAT_LIC_NRStringState License Number
02L2330C_xx_REF_UPINStringProvider UPIN Number
02L2330C_xx_REF_PVR_COMM_NRStringProvider Commercial Number
02L2330C_xx_REF_LOC_NRStringLocation Number
L2330D - OTHER PAYER OPERATING PHYSICIAN (Inherited Loop Iteration)
L2330DNM1Other Payer Operating Physician
L2330DREFOther Payer Operating Physician Secondary Identification
02L2330D_xx_REF_STAT_LIC_NRStringState License Number
02L2330D_xx_REF_UPINStringProvider UPIN Number
02L2330D_xx_REF_PVR_COMM_NRStringProvider Commercial Number
02L2330D_xx_REF_LOC_NRStringLocation Number
L2330E - OTHER PAYER OTHER OPERATING PHYSICIAN (Inherited Loop Iteration)
L2330ENM1Other Payer Other Operating Physician
L2330EREFOther Payer Other Operating Physician Secondary Identification
02L2330E_xx_REF_STAT_LIC_NRStringState License Number
02L2330E_xx_REF_UPINStringProvider UPIN Number
02L2330E_xx_REF_PVR_COMM_NRStringProvider Commercial Number
02L2330E_xx_REF_LOC_NRStringLocation Number
L2330F - OTHER PAYER SERVICE FACILITY LOCATION (Inherited Loop Iteration)
L2330FNM1Other Payer Service Facility Location
L2330FREFOther Payer Service Facility Location Secondary Identification
02L2330F_xx_REF_STAT_LIC_NRStringState License Number
02L2330F_xx_REF_PVR_COMM_NRStringProvider Commercial Number
02L2330F_xx_REF_LOC_NRStringLocation Number
L2330G - OTHER PAYER RENDERING PROVIDER NAME (Inherited Loop Iteration)
L2330GNM1Other Payer Rendering Provider Name
L2330GREFOther Payer Rendering Provider Secondary Identification
02L2330G_xx_REF_STAT_LIC_NRStringState License Number
02L2330G_xx_REF_UPINStringProvider UPIN Number
02L2330G_xx_REF_PVR_COMM_NRStringProvider Commercial Number
02L2330G_xx_REF_LOC_NRStringLocation Number
L2330H - OTHER PAYER REFERRING PROVIDER (Inherited Loop Iteration)
L2330HNM1Other Payer Referring Provider
L2330HREFOther Payer Referring Provider Secondary Identification
02L2330H_xx_REF_STAT_LIC_NRStringState License Number
02L2330H_xx_REF_UPINStringProvider UPIN Number
02L2330H_xx_REF_PVR_COMM_NRStringProvider Commercial Number
L2330I - OTHER PAYER BILLING PROVIDER (Inherited Loop Iteration)
L2330INM1Other Payer Billing Provider
L2330IREFOther Payer Billing Provider Secondary Identification
02L2330I_xx_REF_PVR_COMM_NRStringProvider Commercial Number
02L2330I_xx_REF_LOC_NRStringLocation Number
L2400 - SERVICE LINE NUMBER
L2400LXService Line Number
01L2400_LX01_ASSGD_NRIntegerAssigned Number
L2400SV2Institutional Service Line
01L2400_SV201_SVC_LIN_REV_CDStringService Line Revenue Code
0202L2400_SV20202_JS_PRC_SPY_CDStringJurisdiction Specific Procedure and Supply Codes
0202L2400_SV20202_HCPCS_CDStringHealth Care Financing Administration Common Procedural Coding System (HCPCS) Codes
0202L2400_SV20202_HIPPA_SNF_RT_CDStringHealth Insurance Prospective Payment System (HIPPS) Skilled Nursing Facility Rate Code
0202L2400_SV20202_HIC_PRD_SVCCDStringHome Infusion EDI Coalition (HIEC) Product/Service Code
0202L2400_SV20202_ABC_CDStringAdvanced Billing Concepts (ABC) Codes
0203L2400_SV20203_PROC_MODStringProcedure Modifier
0204L2400_SV20204_PROC_MODStringProcedure Modifier
0205L2400_SV20205_PROC_MODStringProcedure Modifier
0206L2400_SV20206_PROC_MODStringProcedure Modifier
0207L2400_SV20207_DESCRStringDescription
03L2400_SV203_LIN_ITM_CHG_AMTNumberLine Item Charge Amount
05L2400_SV205_DAYSNumberDays
05L2400_SV205_UNNumberUnit
07L2400_SV207_LIN_ITM_DENY_CHGNumberLine Item Denied Charge or Non-Covered Charge
L2400PWKLine Supplemental Information
01L2400_nnPWK01_ATT_REP_TYP_CDStringAttachment Report Type Code
02L2400_nnPWK02_ATT_TRANS_CDStringAttachment Transmission Code
06L2400_nnPWK06_ATTACH_CTL_NRStringAttachment Control Number
L2400DTPDate - Service Date
03L2400_DTP_SVC_D8Date (YYYYMMDD)Service Date
03L2400_DTP_SVC_RD8_1Start Date (YYYYMMDD)Service Date
03L2400_DTP_SVC_RD8_2End Date (YYYYMMDD)Service Date
L2400REFLine Item Control Number
02L2400_REF_PRV_CTL_NRStringProvider Control Number
L2400REFRepriced Line Item Reference Number
02L2400_REF_REP_LIN_ITMStringRepriced Line Item Reference Number
L2400REFAdjusted Repriced Line Item Reference Number
02L2400_REF_ADJ_REP_LIN_ITMStringAdjusted Repriced Line Item Reference Number
L2400AMTService Tax Amount
02L2400_AMT02_GDS_SVCS_TAXNumberGoods and Services Tax
L2400AMTFacility Tax Amount
02L2400_AMT02_MISC_TAXNumberMiscellaneous Taxes
L2400NTEThird Party Organization Notes
02L2400_NTE02_TPO_NOTEStringThird Party Organization Notes
L2400HCPLine Pricing/Repricing Information
01L2400_HCP01_PRIC_METHDStringPricing Methodology
02L2400_HCP02_MONTRY_AMTNumberMonetary Amount
03L2400_HCP03_MONTRY_AMTNumberMonetary Amount
04L2400_HCP04_REF_IDStringReference Identification
05L2400_HCP05_RATENumberRate
06L2400_HCP06_REF_IDStringReference Identification
07L2400_HCP07_MONTRY_AMTNumberMonetary Amount
08L2400_HCP08_PROD_SVC_IDStringProduct or Service ID
10L2400_HCP10_JS_PRC_SPY_CDStringJurisdiction Specific Procedure and Supply Codes
10L2400_HCP10_HCPCS_CDStringHealth Care Financing Administration Common Procedural Coding System (HCPCS) Codes
10L2400_HCP10_HIPPA_SNF_RT_CDStringHealth Insurance Prospective Payment System (HIPPS) Skilled Nursing Facility Rate Code
10L2400_HCP10_HIC_PRD_SVCCDStringHome Infusion EDI Coalition (HIEC) Product/Service Code
10L2400_HCP10_ABC_CDStringAdvanced Billing Concepts (ABC) Codes
12L2400_HCP12_DAYSNumberDays
12L2400_HCP12_UNNumberUnit
13L2400_HCP13_REJ_RSN_CDStringReject Reason Code
14L2400_HCP14_POLCY_COMP_CDStringPolicy Compliance Code
15L2400_HCP15_EXCPTN_CDStringException Code
L2410 - DRUG IDENTIFICATION
L2410LINDrug Identification
03L2410_LIN03_NDC542StringNational Drug Code in 5-4-2 Format
L2410CTPDrug Quantity
04L2410_CTP04_NATL_DRG_UNIT_CTNumberNational Drug Unit Count
0501L2410_CTP0501_CD_QUALStringCode Qualifier
L2410REFPrescription or Compound Drug Association Number
02L2410_REF_LNK_SEQ_NRStringLink Sequence Number
02L2410_REF_PHRM_RX_NRStringPharmacy Prescription Number
L2420A - OPERATING PHYSICIAN NAME
L2420ANM1Operating Physician Name
03L2420A_NM103_PERSN_LNMStringPerson Last Name
04L2420A_NM104_OPER_PHYS_FNMStringOperating Physician First Name
05L2420A_NM105_OPER_PHYS_MNMStringOperating Physician Middle Name or Initial
07L2420A_NM107_OPER_PHYS_SFXStringOperating Physician Name Suffix
09L2420A_NM109_NPIStringCenters for Medicare and Medicaid Services National Provider Identifier
L2420AREFOperating Physician Secondary Identification
02L2420A_nnREF_STAT_LIC_NRStringState License Number
02L2420A_nnREF_UPINStringProvider UPIN Number
02L2420A_nnREF_PVR_COMM_NRStringProvider Commercial Number
02L2420A_nnREF_LOC_NRStringLocation Number
0402L2420A_nnREF0402_OPYR_PRI_IDStringPayer Identification Number
L2420B - OTHER OPERATING PHYSICIAN NAME
L2420BNM1Other Operating Physician Name
03L2420B_NM103_PERSN_LNMStringPerson Last Name
04L2420B_NM104_OOPER_PHYS_FNMStringOther Operating Physician First Name
05L2420B_NM105_OOPER_PHYS_MNMStringOther Operating Physician Middle Name or Initial
07L2420B_NM107_OOPER_PHYS_SFXStringOther Operating Physician Name Suffix
09L2420B_NM109_NPIStringCenters for Medicare and Medicaid Services National Provider Identifier
L2420BREFOther Operating Physician Secondary Identification
02L2420B_nnREF_STAT_LIC_NRStringState License Number
02L2420B_nnREF_UPINStringProvider UPIN Number
02L2420B_nnREF_PVR_COMM_NRStringProvider Commercial Number
02L2420B_nnREF_LOC_NRStringLocation Number
0402L2420B_nnREF0402_OPYR_PRI_IDStringPayer Identification Number
L2420C - RENDERING PROVIDER NAME
L2420CNM1Rendering Provider Name
03L2420C_NM103_PERSN_LNMStringPerson Last Name
04L2420C_NM104_REND_PVR_FNMStringRendering Provider First Name
05L2420C_NM105_REND_PVR_MNMStringRendering Provider Middle Name or Initial
07L2420C_NM107_REND_PROV_SFXStringRendering Provider Name Suffix
09L2420C_NM109_NPIStringCenters for Medicare and Medicaid Services National Provider Identifier
L2420CREFRendering Provider Secondary Identification
02L2420C_nnREF_STAT_LIC_NRStringState License Number
02L2420C_nnREF_UPINStringProvider UPIN Number
02L2420C_nnREF_PVR_COMM_NRStringProvider Commercial Number
02L2420C_nnREF_LOC_NRStringLocation Number
0402L2420C_nnREF0402_OPYR_PRI_IDStringPayer Identification Number
L2420D - REFERRING PROVIDER NAME
L2420DNM1Referring Provider Name
03L2420D_NM103_PERSN_LNMStringPerson Last Name
04L2420D_NM104_REF_PVR_FNMStringReferring Provider First Name
05L2420D_NM105_REF_PVR_MNMStringReferring Provider Middle Name or Initial
07L2420D_NM107_REF_PVR_SFXStringReferring Provider Name Suffix
09L2420D_NM109_NPIStringCenters for Medicare and Medicaid Services National Provider Identifier
L2420DREFReferring Provider Secondary Identification
02L2420D_nnREF_STAT_LIC_NRStringState License Number
02L2420D_nnREF_UPINStringProvider UPIN Number
02L2420D_nnREF_PVR_COMM_NRStringProvider Commercial Number
0402L2420D_nnREF0402_OPYR_PRI_IDStringPayer Identification Number
L2430 - LINE ADJUDICATION INFORMATION (Single Iteration)
L2430SVDLine Adjudication Information
01L2430_xx_SVD01_OPYR_PRI_IDStringOther Payer Primary Identifier
02L2430_xx_SVD02_SVC_LIN_PD_AMTNumberService Line Paid Amount
0302L2430_xx_SVD0302_JS_PRC_SPY_CDStringJurisdiction Specific Procedure and Supply Codes
0302L2430_xx_SVD0302_HCPCS_CDStringHealth Care Financing Administration Common Procedural Coding System (HCPCS) Codes
0302L2430_xx_SVD0302_HPPSStringHealth Insurance Prospective Payment System
0302L2430_xx_SVD0302_HIC_PRD_SVCCDStringHome Infusion EDI Coalition (HIEC) Product/Service
0302L2430_xx_SVD0302_ABC_CDStringAdvanced Billing Concepts (ABC) Codes
0303L2430_xx_SVD0303_PROC_MODStringProcedure Modifier
0304L2430_xx_SVD0304_PROC_MODStringProcedure Modifier
0305L2430_xx_SVD0305_PROC_MODStringProcedure Modifier
0306L2430_xx_SVD0306_PROC_MODStringProcedure Modifier
0307L2430_xx_SVD0307_PROC_CD_DESCStringProcedure Code Description
05L2430_xx_SVD05_PD_SVC_UN_CTNumberPaid Service Unit Count
06L2430_xx_SVD06_BUNDL_LIN_NRIntegerBundled Line Number
L2430CASLine Adjustment
01L2430_xx_nnCAS01_CLMADJ_GRP_CDStringClaim Adjustment Group Code
02L2430_xx_nnCAS02_ADJ_RSN_CDStringAdjustment Reason Code
03L2430_xx_nnCAS03_ADJ_AMTNumberAdjustment Amount
04L2430_xx_nnCAS04_ADJ_QTYNumberAdjustment Quantity
05L2430_xx_nnCAS05_ADJ_RSN_CDStringAdjustment Reason Code
06L2430_xx_nnCAS06_ADJ_AMTNumberAdjustment Amount
07L2430_xx_nnCAS07_ADJ_QTYNumberAdjustment Quantity
08L2430_xx_nnCAS08_ADJ_RSN_CDStringAdjustment Reason Code
09L2430_xx_nnCAS09_ADJ_AMTNumberAdjustment Amount
10L2430_xx_nnCAS10_ADJ_QTYNumberAdjustment Quantity
11L2430_xx_nnCAS11_ADJ_RSN_CDStringAdjustment Reason Code
12L2430_xx_nnCAS12_ADJ_AMTNumberAdjustment Amount
13L2430_xx_nnCAS13_ADJ_QTYNumberAdjustment Quantity
14L2430_xx_nnCAS14_ADJ_RSN_CDStringAdjustment Reason Code
15L2430_xx_nnCAS15_ADJ_AMTNumberAdjustment Amount
16L2430_xx_nnCAS16_ADJ_QTYNumberAdjustment Quantity
17L2430_xx_nnCAS17_ADJ_RSN_CDStringAdjustment Reason Code
18L2430_xx_nnCAS18_ADJ_AMTNumberAdjustment Amount
19L2430_xx_nnCAS19_ADJ_QTYNumberAdjustment Quantity
L2430DTPLine Check or Remittance Date
03L2430_xx_DTP_CLM_PD_D8Date (YYYYMMDD)Date Claim Paid Date
L2430AMTRemaining Patient Liability
02L2430_xx_AMT02_AMT_OWEDNumberAmount Owed
STHDRSETransaction Set Trailer
01STHDR_SE01_TS_SEG_CTIntegerTransaction Segment Count
02STHDR_SE02_TCNStringTransaction Set Control Number
GSHDRGEFunctional Group Trailer
01GSHDR_GE01_NR_TS_INCLUDEDIntegerNumber of Transaction Sets Included
02GSHDR_GE02_GCNIntegerGroup Control Number
ISAIEAInterchange Control Trailer
01ISA_IEA01_NR_INC_FUNC_GRPIntegerNumber of Included Functional Groups
02ISA_IEA02_ICNIntegerInterchange Control Number