Note: These Addenda will not appear in the Code of Federal
Regulations.
ADDENDUM 1--HEALTH CLAIMS OR EQUIVALENT ENCOUNTER INFORMATION
[Please label any written comments or e-mailed comments about this
section with the subject: Addendum 1]
A. Retail Drug Claim or Equivalent Encounter
The transactions selected for retail drug claims are accredited by the
American National Standards Institute (ANSI). The transactions are: NCPDP
Telecommunications Standard Format version 3.2 and the equivalent NCPDP
Batch Standard Version 1.0.
1. Implementation Guide and Source
The source of the implementation guide for the NCPDP Telecommunication
Standard Format Version 3.2 and the equivalent NCPDP Batch Standard
Version 1.0 is the National Council for Prescription Drug Programs, 4201
North 24th Street, Suite 365, Phoenix, AZ, 85016, Telephone 602-957-9105,
FAX 602-955-0749. The web site address is http://www.ncpdp.org
2. Data Elements
- Accumulated Deductible Amount
- Additional Message Information
- Adjustment/reject Code - 1
- Adjustment/reject Code - 2
- Adjustment/reject Code - 3
- Alternate Product Code
- Alternate Product Type
- Amount Attributed to Sales Tax
- Amount Billed
- Amount of Co-pay/co-insurance
- Amount Rejected
- Amt. Applied to Periodic Deduct
- Amt. Attrib. To Prod. Selection
- Amt. Exceed. Periodic Benefit Max
- Authorization Number
- Basis of Cost Determination
- Basis of Days Supply Determination
- Basis of Reimb. Determination
- Batch Number
- Bin Number
- Cardholder First Name
- Cardholder Id Number
- Cardholder Last Name
- Carrier Address
- Carrier Correction Notice Fields
- Carrier Identification Number
- Carrier Location City
- Carrier Location State
- Carrier Name
- Carrier Telephone Number
- Carrier Zip Code
- Claim Count
- Claim/reference Id Number
- Clinic Id Number
- Co-pay Amount
- Comments-1
- Comments-2
- Compound Code
- Contract Fee Paid
- Customer Location
- Date Filled
- Date of Birth
- Date of Injury
- Date Prescription Written
- Days Supply
- Destination Name
- Destination Processor Number
- Diagnosis Code
- Diskette Record Id
- Dispense as Written (Daw)
- Dispensing Fee Submitted
- Dollar Count
- Dollars Adjusted
- Dollars Billed
- Dollars Rejected
- Drug Name
- Drug Type
- Dur Conflict Code
- Dur Intervention Code
- Dur Outcome Code
- Dur Response Data
- Eligibility Clarification Code
- Employer City Address
- Employer Contact Name
- Employer Name
- Employer Phone Number
- Employer State Address
- Employer Street Address
- Employer Zip Code
- Fee or Markup
- Gross Amount Due
- Group Number
- Home Plan
- Host Plan
- Incentive Amount Submitted
- Incentive Fee Paid
- Ingredient Cost Billed
- Ingredient Cost Paid
- Ingredient Cost
- Level of Service
- Master Sequence Number
- Message
- Metric Decimal Quantity
- Metric Quantity
- Ndc Number
- New/refill Code
- Number of Refills Authorized
- Other Coverage Code
- Other Payor Amount
- Patient City Address
- Patient First Name
- Patient Last Name
- Patient Paid Amount
- Patient Pay Amount
- Patient Phone Number
- Patient Social Security
- Patient State Address
- Patient Street Address
- Patient Zip Code
- Payment Processor Id
- Person Code
- Pharmacy Address
- Pharmacy Count
- Pharmacy Location City
- Pharmacy Location State
- Pharmacy Name
- Pharmacy Number
- Pharmacy Telephone Number
- Pharmacy Zip Code
- Plan Identification
- Postage Amount Claimed
- Postage Amount Paid
- Prescriber Id
- Prescriber Last Name
- Prescription Denial Clarification
- Prescription Number
- Prescription Origin Code
- Primary Prescriber
- Prior Authorization/medical Certification Code And Number
- Processor Address
- Processor Control Number
- Processor Location City
- Processor Location State
- Processor Name
- Processor Number
- Processor Telephone Number
- Processor Zip Code
- Record Identifier
- Reject Code
- Reject Count
- Relationship Code
- Remaining Benefit Amount
- Remaining Deductible Amount
- Response Data
- Response Status
- Resubmission Cycle Count
- Run Date
- Sales Tax Paid
- Sales Tax
- Sex Code
- System Id
- Terminal Id
- Third Party Type
- Total Amount Paid
- Transaction Code
- Unit Dose Indicator
- Usual And Customary Charge
- Version Release Number
B. Professional Health Claim or Equivalent Encounter
The transaction selected for the professional (non- institutional)
health claim or equivalent encounter information is ASC X12N 837 - Health
Care Claim: Professional (004010X098)
1. Implementation Guide and Source
The source of the implementation guide for the professional health care
claim or equivalent encounter is: Washington Publishing Company, 806 W.
Diamond Ave., Suite 400, Gaithersburg, MD, 20878, Telephone 301-590-9337,
FAX: 301-869-9460. The web site address is
http://www.wpc-edi.com/hipaa/
2. Data Elements
- Accident Date
- Acute Manifestation Date
- Additional Submitter or Receiver Name
- Adjudication or Payment Date
- Adjusted Repriced Claim Reference Number
- Adjusted Repriced Line Item Reference Number
- Adjustment Amount
- Adjustment Quantity
- Adjustment Reason Code
- Agency Qualifier Code
- Allowed Amount
- Ambulatory Patient Group Number
- Amino Acid Name
- Amount Qualifier Code
- Anesthesia or Oxygen Minute Count
- Approved Ambulatory Patient Group Amount
- Approved Ambulatory Patient Group Code
- Approved Service Unit Count
- Arterial Blood Gas Quantity
- Arterial Blood Gas Test Date
- Assigned Number
- Assumed or Relinquished Care Date
- Attachment Control Number
- Attachment Description Text
- Attachment Report Type Code
- Attachment Transmission Code
- Auto Accident State or Province Code
- Benefits Assignment Certification Indicator
- Billing Provider Additional Name
- Billing Provider City Name
- Billing Provider Contact Name
- Billing Provider Credit Card Identifier
- Billing Provider First Address Line
- Billing Provider First Name
- Billing Provider Identifier
- Billing Provider Last or Organizational Name
- Billing Provider Middle Name
- Billing Provider Name Suffix
- Billing Provider Postal Zone or ZIP Code
- Billing Provider Second Address Line
- Billing Provider State or Province Code
- Bundled or Unbundled Line Number
- Certification Form Number
- Certification Period Projected Visit Count
- Certified Registered Nurse Anesthetist Supervision Indicator
- Claim Adjustment Group Code
- Claim Encounter Identifier
- Claim Filing Indicator Code
- Claim Frequency Code
- Claim Note Text
- Claim Payment Remark Code
- Claim Submission Reason Code
- Clinical Laboratory Improvement Amendment Number
- Code Category
- Code List Qualifier Code
- Coinsurance Amount
- Communication Number Qualifier
- Communication Number
- Complication Indicator
- Condition Codes
- Condition Indicator
- Contact Function Code
- Contact Inquiry Reference
- Continuous Passive Motion Date
- Contract Amount
- Contract Code
- Contract Percentage
- Contract Type Code
- Contract Version Identifier
- Country Code
- Coverage Certification Period Count
- Creation Date
- Credit or Debit Card Holder Additional Name
- Credit or Debit Card Holder First Name
- Credit or Debit Card Holder Last or Organizational Name
- Credit or Debit Card Holder Middle Name
- Credit or Debit Card Holder Name Suffix
- Credit or Debit Card Maximum Amount
- Credit or Debit Card Number
- Credit/Debit Flag Code
- Currency Code
- Current Illness or Injury Date
- CHAMPUS Non-availability Indicator
- Daily Amino Acid Gram Use Count
- Daily Amino Acid Prescription Milliliter Use Count
- Daily Dextrose Prescription Milliliter Use Count
- Daily Prescribed Nutrient Calorie Count
- Daily Prescribed Product Calorie Count
- Date of Surgical Procedure
- Date Time Period Format Qualifier
- Date/Time Qualifier
- Deductible Amount
- Diagnosis Associated Amount
- Diagnosis Code Pointer
- Diagnosis Code
- Disability Type Code
- Disability-From Date
- Disability-To Date
- Discipline Type Code
- Drug Formulary Number
- Drug Unit Price
- Emergency Indicator
- Emergency Medical Technician (EMT) or Paramedic First Name
- Emergency Medical Technician or Paramedic Middle Name
- Emergency Medical Technician or Paramedic City Name
- Emergency Medical Technician or Paramedic First Address Line
- Emergency Medical Technician or Paramedic Last Name
- Emergency Medical Technician or Paramedic Name Additional Text
- Emergency Medical Technician or Paramedic Primary Identifier
- Emergency Medical Technician or Paramedic Second Address Line
- Emergency Medical Technician or Paramedic Secondary Identifier
- Emergency Medical Technician or Paramedic State Code
- Emergency Medical Technician or Paramedic ZIP Code
- Employment Status Code
- End Stage Renal Disease Payment Amount
- Enteral or Parenteral Indicator
- Entity Identifier Code
- Entity Type Qualifier
- Exception Code
- Exchange Rate
- Explanation of Benefits Indicator
- EPSDT Indicator
- Facility Type Code
- Family Planning Indicator
- Feeding Count
- File Creation Time
- First Visit Date
- Fixed Format Information
- Functional Status Code
- Group or Policy Number
- Hierarchical Child Code
- Hierarchical ID Number
- Hierarchical Level Code
- Hierarchical Parent ID Number
- Hierarchical Structure Code
- Homebound Indicator
- Hospice Employed Provider Indicator
- HCPCS Payable Amount
- Identification Code Qualifier
- Immunization Status Code
- Immunization Type Code
- Independent Lab Charge Amount
- Individual Relationship Code
- Information Release Code
- Information Release Date
- Ingredient Cost Claimed Amount
- Initial Treatment Date
- Insurance Type Code
- Insured Employer Additional Name
- Insured Employer City Name
- Insured Employer Contact Name
- Insured Employer First Address Line
- Insured Employer First Name
- Insured Employer Identifier
- Insured Employer Middle Name
- Insured Employer Name Suffix
- Insured Employer Name
- Insured Employer Second Address Line
- Insured Employer State Code
- Insured Employer ZIP Code
- Insured Group Name
- Insured Group Number
- Investigational Device Exemption Identifier
- Laboratory or Facility City Name
- Laboratory or Facility Contact Name
- Laboratory or Facility First Address Line
- Laboratory or Facility Name Additional Text
- Laboratory or Facility Name
- Laboratory or Facility Postal ZIP or Zonal Code
- Laboratory or Facility Primary Identifier
- Laboratory or Facility Second Address Line
- Laboratory or Facility Secondary Identifier
- Laboratory or Facility State or Province Code
- Last Certification Date
- Last Menstrual Period Date
- Last Seen Date
- Last Worked Date
- Last X-Ray Date
- Legal Representative Additional Name
- Legal Representative City Name
- Legal Representative First Address Line
- Legal Representative First Name
- Legal Representative Last or Organization Name
- Legal Representative Middle Name
- Legal Representative Second Address Line
- Legal Representative State Code
- Legal Representative Suffix Name
- Legal Representative ZIP Code
- Line Item Control Number
- Line Note Text
- Mammography Certification Number
- Measurement Qualifier
- Measurement Reference Identification Code
- Medical Justification Text
- Medical Record Number
- Medicare Assignment Code
- Medicare Coverage Indicator
- Multiple Procedure Indicator
- National Drug Code
- National Drug Unit Count
- Nature of Condition Code
- Non-Payable Professional Component Billed Amount
- Non-Visit Code
- Note Reference Code
- Nutrient Administration Method Code
- Nutrient Administration Technique Code
- Onset Date
- Ordering Provider City Name
- Ordering Provider Contact Name
- Ordering Provider First Address Line
- Ordering Provider First Name
- Ordering Provider Identifier
- Ordering Provider Last Name
- Ordering Provider Middle Name
- Ordering Provider Name Additional Text
- Ordering Provider Name Suffix
- Ordering Provider Second Address Line
- Ordering Provider Secondary Identifier
- Ordering Provider State Code
- Ordering Provider ZIP Code
- Original Line Item Reference Number
- Originator Application Transaction Identifier
- Other Employer Additional Name
- Other Employer City Name
- Other Employer First Address Line
- Other Employer First Name
- Other Employer Last or Organization Name
- Other Employer Middle Name
- Other Employer Second Address Line
- Other Employer State Code
- Other Employer ZIP Code
- Other Insured Additional Identifier
- Other Insured Additional Name
- Other Insured Birth Date
- Other Insured City Name
- Other Insured First Address Line
- Other Insured First Name
- Other Insured Gender Code
- Other Insured Identifier
- Other Insured Last Name
- Other Insured Middle Name
- Other Insured Name Suffix
- Other Insured Plan Name or Program Name
- Other Insured Second Address Line
- Other Insured State Code
- Other Insured ZIP Code
- Other Payer Additional Name Text
- Other Payer City Name
- Other Payer Covered Amount
- Other Payer Discount Amount
- Other Payer Federal Mandate Amount
- Other Payer First Address Line
- Other Payer Interest Amount
- Other Payer Last or Organization Name
- Other Payer Patient Paid Amount
- Other Payer Patient Responsibility Amount
- Other Payer Per Day Limit Amount
- Other Payer Pre-Tax Claim Total Amount
- Other Payer Primary Identifier
- Other Payer Second Address Line
- Other Payer Secondary Identifier
- Other Payer State Code
- Other Payer Tax Amount
- Other Payer ZIP Code
- Oxygen Saturation Quantity
- Oxygen Saturation Test Date
- Paid Service Unit Count
- Paramedic Contact Name
- Patient Account Number
- Patient Additional Name
- Patient Age
- Patient Amount Paid
- Patient Birth Date
- Patient City Name
- Patient Death Date
- Patient Facility Additional Name Text
- Patient Facility City Name
- Patient Facility First Address Line
- Patient Facility Name
- Patient Facility Second Address Line
- Patient Facility State Code
- Patient Facility Zip Code
- Patient First Address Line
- Patient First Name
- Patient Gender Code
- Patient Height
- Patient Last Name
- Patient Marital Status Code
- Patient Middle Name
- Patient Name Suffix
- Patient Primary Identifier
- Patient Second Address Line
- Patient Secondary Identifier
- Patient Signature Source Code
- Patient State Code
- Patient ZIP Code
- Pay-to Provider Additional Name
- Pay-to Provider City Name
- Pay-to Provider Contact Name
- Pay-to Provider First Address Line
- Pay-to Provider First Name
- Pay-to Provider Identifier
- Pay-to Provider Last or Organizational Name
- Pay-to Provider Middle Name
- Pay-to Provider Name Suffix
- Pay-to Provider Second Address Line
- Pay-to Provider State Code
- Pay-to Provider ZIP Code
- Payer Additional Identifier
- Payer Additional Name
- Payer City Name
- Payer First Address Line
- Payer Identifier
- Payer Name
- Payer Paid Amount
- Payer Responsibility Sequence Number Code
- Payer Second Address Line
- Payer State Code
- Payer ZIP Code
- Period Count
- Place of Service Code
- Policy Compliance Code
- Postage Claimed Amount
- Prescription Amino Acid Concentration Percent
- Prescription Date
- Prescription Dextrose Concentration Percent
- Prescription Lipid Concentration Percent
- Prescription Lipid Milliliter Use Count
- Prescription Number
- Prescription Period Count
- Pricing Methodology
- Prior Authorization Number
- Procedure Modifier
- Product Name
- Product/Service ID Qualifier
- Product/Service Procedure Code
- Prognosis Code
- Property Casualty Claim Number
- Provider or Supplier Signature Indicator
- Provider Code
- Provider Identifier
- Provider Organization Code
- Provider Signature Date
- Provider Specialty Certification Code
- Provider Specialty Code
- Purchase Price Amount
- Purchase Service Charge Amount
- Purchase Service Provider Identifier
- Purchase Service State Code
- Purchased Service Provider City Name
- Purchased Service Provider Contact Name
- Purchased Service Provider First Address Line
- Purchased Service Provider First Name
- Purchased Service Provider Last or Organization Name
- Purchased Service Provider Middle Name
- Purchased Service Provider Name Additional Text
- Purchased Service Provider Second Address Line
- Purchased Service Provider Secondary Identifier
- Purchased Service Provider State Code
- Purchased Service Provider ZIP Code
- Quantity Qualifier
- Record Format Code
- Reference Identification Qualifier
- Referral Number
- Referring Provider City Name
- Referring Provider Contact Name
- Referring Provider First Address Line
- Referring Provider First Name
- Referring Provider Identification Number
- Referring Provider Last Name
- Referring Provider Middle Name
- Referring Provider Name Additional Text
- Referring Provider Name Suffix
- Referring Provider Second Address Line
- Referring Provider Secondary Identifier
- Referring Provider State Code
- Referring Provider ZIP Code
- Reimbursement Rate
- Reject Reason Code
- Related Hospitalization Admission Date
- Related Hospitalization Discharge Date
- Related Nursing Home Admission Date
- Related-Causes Code
- Rendering Provider City Name
- Rendering Provider Contact Name
- Rendering Provider First Address Line
- Rendering Provider First Name
- Rendering Provider Identifier
- Rendering Provider Last Name
- Rendering Provider Middle Name
- Rendering Provider Name Additional Text
- Rendering Provider Name Suffix
- Rendering Provider Second Address Line
- Rendering Provider Secondary Identifier
- Rendering Provider State Code
- Rendering Provider ZIP Code
- Rental Equipment Billing Frequency Code
- Rental Price Amount
- Repriced Claim Reference Number
- Repriced Line Item Reference Number
- Repricing Organization Identifier
- Repricing Per Diem or Flat Rate Amount
- Resource Utilization Group Number
- Resubmission Number
- Retirement or Insurance Card Date
- Review By Code Indicator
- Sales Tax Amount
- Sample Selection Modules
- Saving Amount
- School City Name
- School Contact Name
- School First Address Line
- School Name Additional Text
- School Name
- School Primary Identifier
- School Second Address Line
- School State Code
- School ZIP Code
- Second Admission Date
- Second Discharge Date
- Service Date
- Service From Date
- Service Line Paid Amount
- Service Type Code
- Service Unit Count
- Ship/Delivery or Calendar Pattern Code
- Ship/Delivery Pattern Time Code
- Shipped Date
- Similar Illness or Symptom Date
- Special Program Indicator
- Statement Covers Period End Date
- Statement Covers Period Start Date
- Student Status Code
- Submittal Date
- Submitted Charge Amount
- Submitter or Receiver Address Line
- Submitter or Receiver City Name
- Submitter or Receiver Contact Name
- Submitter or Receiver First Name
- Submitter or Receiver Identifier
- Submitter or Receiver Last or Organization Name
- Submitter or Receiver Middle Name
- Submitter or Receiver State Code
- Submitter or Receiver ZIP Code
- Submitter Additional Name
- Subscriber or Dependent Death Date
- Subscriber Additional Identifier
- Subscriber Birth Date
- Subscriber Contact Name
- Subscriber First Name
- Subscriber Gender Code
- Subscriber Identifier
- Subscriber Last Name
- Subscriber Marital Status Code
- Subscriber Middle Name
- Subscriber Name Suffix
- Subscriber Postal ZIP Code
- Subscriber Second Address Line
- Subscriber State
- Supervising Provider City Name
- Supervising Provider Contact Name
- Supervising Provider First Address Line
- Supervising Provider First Name
- Supervising Provider Identification Number
- Supervising Provider Last Name
- Supervising Provider Middle Name
- Supervising Provider Name Additional Text
- Supervising Provider Name Suffix
- Supervising Provider Second Address Line
- Supervising Provider Secondary Identifier
- Supervising Provider State Code
- Supervising Provider ZIP Code
- Supporting Document Question Identifier
- Supporting Document Response Code
- Surgical Procedure Code
- Terms Discount Percentage
- Test Performed Date
- Test Results
- Time Period Qualifier
- Total Claim Charge Amount
- Total Purchased Service Amount
- Total Visits Rendered Count
- Transaction Segment Count
- Transaction Set Control Number
- Transaction Set Identifier Code
- Transaction Set Purpose Code
- Treatment or Therapy Date
- Treatment Length
- Unit or Basis for Measurement Code
- Value Added Network Trace Number
- Version Identification Code
- Version Identifier
- Weekly Prescription Lipid Use Count
- Work Return Date
- X-Ray Availability Indicator Code
C. Institutional Claim or Equivalent Encounter
The transaction selected for the institutional health care claim or
equivalent encounter information is ASC X12N 837 - Health Care Claim:
Institutional (004010X096).
1. Implementation Guide and Source
The source of the implementation guide for the institutional health care
claim or equivalent encounter is: Washington Publishing Company, 806 W.
Diamond Ave., Suite 400, Gaithersburg, MD, 20878, Telephone 301-590-9337,
FAX: 301-869-9460. The web site address is
http://www.wpc-edi.com/hipaa/
2. Data Elements
- Activities Permitted
- Adjusted Repriced Claim Reference Number
- Adjustment Amount
- Adjustment Quantity
- Adjustment Reason Code
- Admission Date and Hour
- Admission Source Code
- Admission Type Code
- Allowed Amount
- Amount Qualifier Code
- Approved Amount
- Approved Diagnosis Related Group Code
- Approved HCPCS Code
- Approved Revenue Code
- Approved Service Unit Count
- Assigned Number
- Attachment Control Number
- Attachment Description Text
- Attachment Report Type Code
- Attachment Transmission Code
- Attending Physician First Name
- Attending Physician Last Name
- Attending Physician Middle Name
- Attending Physician Primary Identifier
- Auto Accident State or Province Code
- Benefits Assignment Certification Indicator
- Billing Note Text
- Billing Provider City Name
- Billing Provider Contact Name
- Billing Provider First Address Line
- Billing Provider Identifier
- Billing Provider Last or Organizational Name
- Billing Provider Postal Zone or ZIP Code
- Billing Provider Second Address Line
- Billing Provider State or Province Code
- Certification Condition Indicator
- Certification Type Code
- Claim Adjustment Group Code
- Claim Days Count
- Claim Disproportionate Share Amount
- Claim DRG Amount
- Claim DRG Outlier Amount
- Claim Encounter Identifier
- Claim ESRD Payment Amount
- Claim Filing Indicator Code
- Claim Frequency Code
- Claim HCPCS payable amount
- Claim Indirect Teaching Amount
- Claim MSP Pass-through amount
- Claim Note Text
- Claim Original Reference Number
- Claim Payment Remark Code
- Claim PPS capital amount
- Claim PPS capital outlier amount
- Claim Total Denied Charge Amount
- Code Associated Amount
- Code Associated Date
- Code Associated Quantity
- Code Category
- Code List Qualifier Code
- Contact Function Code
- Contract Amount
- Contract Code
- Contract Percentage
- Contract Type Code
- Contract Version Identifier
- Cost Report Day Count
- Country Code
- Covered Days or Visits Count
- Creation Date
- Credit or Debit Card Authorization Number
- Credit or Debit Card Holder First Name
- Credit or Debit Card Holder Last or Organizational Name
- Credit or Debit Card Holder Middle Name
- Credit or Debit Card Maximum Amount
- Credit or Debit Card Number
- Currency Code
- Date Time Period Format Qualifier
- Date/Time Qualifier
- Diagnosis Date
- Discharge Hour
- Discipline Type Code
- Document Control Identifier
- Employer Identification Number
- Employment Status Code
- Entity Identifier Code
- Entity Type Qualifier
- Estimated Amount Due
- Estimated Claim Due Amount
- Exception Code
- Explanation of Benefits Indicator
- Facility Code Qualifier
- Facility Type Code
- File Creation Time
- Frequency Number
- Functional Limitation Code
- Group or Policy Number
- Hierarchical Child Code
- Hierarchical ID Number
- Hierarchical Level Code
- Hierarchical Parent ID Number
- Hierarchical Structure Code
- Home Health Certification Period
- HCPCS Modifier Code
- HCPCS/CPT-4 Code
- Identification Code Qualifier
- Implant Date
- Implant Status Code
- Implant Type Code
- Individual Relationship Code
- Industry Code
- Information Release Code
- Insurance Type Code
- Insured Employer First Address Line
- Insured Employer First Name
- Insured Employer Identifier
- Insured Group Name
- Insured Group Number
- Investigational Device Exemption Identifier
- Last Admission Date
- Last Visit Date
- Leads Left In Patient Indicator
- Legal Representative City Name
- Legal Representative Contact Name
- Legal Representative First Address Line
- Legal Representative First Name
- Legal Representative Last or Organization Name
- Legal Representative Middle Name
- Legal Representative Second Address Line
- Legal Representative State Code
- Legal Representative ZIP Code
- Lifetime Psychiatric Days Count
- Lifetime Reserve Days Count
- Line Charge Amount
- Line Item Denied Charge or Non-Covered Charge Amount
- Manufacturer Identifier
- Medicare Coverage Indicator
- Medicare Paid at 100% Amount
- Medicare Paid at 80% Amount
- Mental Status Code
- Model Number
- Non-Covered Charge Amount
- Non-Insured Employer City Name
- Non-Insured Employer First Address Line
- Non-Insured Employer First Name
- Non-Insured Employer Identifier
- Non-Insured Employer Last or Organization Name
- Non-Insured Employer Middle Name
- Non-Insured Employer Second Address Line
- Non-Insured Employer State Code
- Non-Insured Employer ZIP Code
- Note Reference Code
- Old Capital Amount
- Operating Physician First Name
- Operating Physician Last Name
- Operating Physician Middle Name
- Operating Physician Primary Identifier
- Ordering Provider Identifier
- Ordering Provider Last Name
- Originator Application Transaction Identifier
- Other Employer City Name
- Other Employer First Address Line
- Other Employer First Name
- Other Employer Last or Organization Name
- Other Employer Second Address Line
- Other Employer Secondary Identifier
- Other Employer State Code
- Other Employer ZIP Code
- Other Insured Additional Identifier
- Other Insured Birth Date
- Other Insured City Name
- Other Insured First Address Line
- Other Insured First Name
- Other Insured Gender Code
- Other Insured Identifier
- Other Insured Last Name
- Other Insured Middle Name
- Other Insured Plan Name or Program Name
- Other Insured Second Address Line
- Other Insured State Code
- Other Insured ZIP Code
- Other Payer City Name
- Other Payer First Address Line
- Other Payer Last or Organization Name
- Other Payer Patient Paid Amount
- Other Payer Primary Identifier
- Other Payer Second Address Line
- Other Payer Secondary Identifier
- Other Payer State Code
- Other Payer ZIP Code
- Other Physician First Name
- Other Physician Identifier
- Other Physician Last Name
- Other Physician Middle Name
- Paid From Part A Medicare Trust Fund Amount
- Paid From Part B Medicare Trust Fund Amount
- Patient Account Number
- Patient Amount Paid
- Patient Birth Date
- Patient City Name
- Patient Discharge Facility Type Code
- Patient First Address Line
- Patient First Name
- Patient Gender Code
- Patient Last Name
- Patient Liability Amount
- Patient Marital Status Code
- Patient Middle Name
- Patient Name Suffix
- Patient Primary Identifier
- Patient Second Address Line
- Patient Secondary Identifier
- Patient State Code
- Patient Status Code
- Patient ZIP Code
- Payer Additional Identifier
- Payer City Name
- Payer First Address Line
- Payer Identifier
- Payer Name
- Payer Paid Amount
- Payer Responsibility Sequence Number Code
- Payer Second Address Line
- Payer State Code
- Payer ZIP Code
- Period Count
- Physician Contact Date
- Physician Order Date
- Policy Compliance Code
- Pricing Methodology
- Prior Authorization Number
- Procedure Modifier
- Product/Service ID Qualifier
- Product/Service Procedure Code
- Professional Component Amount
- Prognosis Code
- PPS-Capital DSH DRG Amount
- PPS-Capital Exception Amount
- PPS-Capital FSP DRG Amount
- PPS-Capital HSP DRG Amount
- PPS-Capital IME amount
- PPS-Operating Federal Specific DRG Amount
- PPS-Operating Hospital Specific DRG Amount
- Quantity Qualifier
- Reference Identification Qualifier
- Reimbursement Rate
- Reject Reason Code
- Related-Causes Code
- Repriced Claim Reference Number
- Repricing Organization Identifier
- Repricing Per Diem or Flat Rate Amount
- Returned to Manufacturer Indicator
- Saving Amount
- School City Name
- School First Address Line
- School Name
- School Primary Identifier
- School Second Address Line
- School State Code
- School ZIP Code
- Serial Number
- Service Date
- Service From Date
- Service Line Paid Amount
- Service Line Rate
- Service Line Revenue Code
- Service Unit Count
- Statement From or To Date
- Submission or Resubmission Number
- Submitted Charge Amount
- Submitter or Receiver Contact Name
- Submitter or Receiver Identifier
- Submitter or Receiver Last or Organization Name
- Subscriber Additional Identifier
- Subscriber Birth Date
- Subscriber First Address Line
- Subscriber First Name
- Subscriber Gender Code
- Subscriber Last Name
- Subscriber Marital Status Code
- Subscriber Middle Name
- Subscriber Second Address Line
- Subscriber State
- Surgery Date
- Surgical Procedure Code
- Terms Discount Percentage
- Time Period Qualifier
- Total Claim Charge Amount
- Total Medicare Paid Amount
- Total Visits Projected This Certification Count
- Transaction Segment Count
- Transaction Set Control Number
- Transaction Set Identifier Code
- Transaction Set Purpose Code
- Unit or Basis for Measurement Code
- Value Added Network Trace Number
- Version Identification Code
- Visits Prior to Recertification Date Count
- Warranty Expiration Date
- 1861J1 Facility Indicator
D. Dental Claim or Equivalent Encounter
The transaction selected for the dental health care claim or equivalent
encounter is: ASC X12N 837 - Health Care Claim: Dental (004010X097).
1. Implementation Guide and Source
The source of the implementation guide for the dental health care claim
or equivalent encounter is: Washington Publishing Company, 806 W. Diamond
Ave., Suite 400, Gaithersburg, MD, 20878, Telephone 301-590-9337, FAX:
301-869-9460. The web site address is
http://www.wpc-edi.com/hipaa/
2. Data Elements
- Accident Date
- Adjudication or Payment Date
- Adjustment Amount
- Adjustment Quantity
- Adjustment Reason Code
- Admission Date or Start of Care Date
- Amount Qualifier Code
- Anesthesia Unit Count
- Appliance Placement Date
- Assigned Number
- Assistant Surgeon City Name
- Assistant Surgeon First Address Line
- Assistant Surgeon First Name
- Assistant Surgeon Last Name
- Assistant Surgeon Middle Name
- Assistant Surgeon Primary Identification Number
- Assistant Surgeon Second Address Line
- Assistant Surgeon State Code
- Assistant Surgeon Suffix Name
- Assistant Surgeon ZIP Code
- Attachment Control Number
- Attachment Report Type Code
- Attachment Transmission Code
- Auto Accident State or Province Code
- Benefits Assignment Certification Indicator
- Billing Provider City Name
- Billing Provider Credit Card Identifier
- Billing Provider First Address Line
- Billing Provider First Name
- Billing Provider Identifier
- Billing Provider Last or Organizational Name
- Billing Provider Middle Name
- Billing Provider Name Suffix
- Billing Provider Postal Zone or ZIP Code
- Billing Provider Second Address Line
- Billing Provider State or Province Code
- Claim Adjustment Group Code
- Claim Encounter Identifier
- Claim Filing Indicator Code
- Claim Submission Reason Code
- Clinical Laboratory Improvement Amendment Number
- Code List Qualifier Code
- Contact Function Code
- Coordination of Benefits Code
- Country Code
- Creation Date
- Credit or Debit Card Authorization Number
- Credit or Debit Card Holder First Name
- Credit or Debit Card Holder Last or Organizational Name
- Credit or Debit Card Holder Middle Name
- Credit or Debit Card Holder Name Suffix
- Credit or Debit Card Maximum Amount
- Credit or Debit Card Number
- Credit/Debit Flag Code
- Currency Code
- Date Time Period Format Qualifier
- Date/Time Qualifier
- Destination Payer Code
- Diagnosis Code
- Diagnosis Date
- Diagnosis Type Code
- Discharge Date / End Of Care Date
- Entity Identifier Code
- Entity Type Qualifier
- Facility Code Qualifier
- Facility Type Code
- File Creation Time
- Group or Policy Number
- Hierarchical Child Code
- Hierarchical ID Number
- Hierarchical Level Code
- Hierarchical Parent ID Number
- Hierarchical Structure Code
- Identification Code Qualifier
- Individual Relationship Code
- Information Release Code
- Information Release Date
- Initial Placement Date
- Insured Employer First Address Line
- Insured Employer First Name
- Insured Employer Identifier
- Insured Employer Middle Name
- Insured Employer Name Suffix
- Insured Group Name
- Insured Group Number
- Laboratory or Facility City Name
- Laboratory or Facility First Address Line
- Laboratory or Facility Name
- Laboratory or Facility Postal ZIP or Zonal Code
- Laboratory or Facility Primary Identifier
- Laboratory or Facility Second Address Line
- Laboratory or Facility State or Province Code
- Legal Representative or Responsible Party Identifier
- Legal Representative City Name
- Legal Representative First Address Line
- Legal Representative First Name
- Legal Representative Last or Organization Name
- Legal Representative Middle Name
- Legal Representative Second Address Line
- Legal Representative State Code
- Legal Representative Suffix Name
- Legal Representative ZIP Code
- Line Charge Amount
- Medicare Assignment Code
- Oral Cavity Designation Code
- Originator Application Transaction Identifier
- Orthodontic Treatment Months Count
- Orthodontic Treatment Months Remaining Count
- Other Insured Birth Date
- Other Insured City Name
- Other Insured First Address Line
- Other Insured First Name
- Other Insured Gender Code
- Other Insured Identifier
- Other Insured Last Name
- Other Insured Middle Name
- Other Insured Name Suffix
- Other Insured Second Address Line
- Other Insured State Code
- Other Insured ZIP Code
- Other Payer Covered Amount
- Other Payer Discount Amount
- Other Payer Last or Organization Name
- Other Payer Patient Paid Amount
- Other Payer Patient Responsibility Amount
- Other Payer Primary Identifier
- Patient Account Number
- Patient Amount Paid
- Patient Birth Date
- Patient City Name
- Patient First Address Line
- Patient First Name
- Patient Gender Code
- Patient Last Name
- Patient Marital Status Code
- Patient Middle Name
- Patient Name Suffix
- Patient Primary Identifier
- Patient Second Address Line
- Patient Signature Source Code
- Patient State Code
- Patient ZIP Code
- Pay-to Provider City Name
- Pay-to Provider First Address Line
- Pay-to Provider First Name
- Pay-to Provider Identifier
- Pay-to Provider Last or Organizational Name
- Pay-to Provider Middle Name
- Pay-to Provider Name Suffix
- Pay-to Provider Second Address Line
- Pay-to Provider State Code
- Pay-to Provider ZIP Code
- Payer Additional Identifier
- Payer City Name
- Payer First Address Line
- Payer Identifier
- Payer Name
- Payer Paid Amount
- Payer Responsibility Sequence Number Code
- Payer Second Address Line
- Payer State Code
- Payer ZIP Code
- Periodontal Charting Measurement
- Policy Name
- Predetermination of Benefits Identifier
- Predetermination of Benefits Indicator
- Prior Authorization Number
- Prior Placement Date
- Procedure Count
- Procedure Modifier
- Product/Service ID Qualifier
- Product/Service Procedure Code
- Prothesis, Crown or Inlay Code
- Provider or Supplier Signature Indicator
- Provider Signature Date
- Quantity Qualifier
- Reference Identification Qualifier
- Referring Provider City Name
- Referring Provider First Address Line
- Referring Provider First Name
- Referring Provider Identification Number
- Referring Provider Last Name
- Referring Provider Middle Name
- Referring Provider Name Suffix
- Referring Provider Second Address Line
- Referring Provider State Code
- Referring Provider ZIP Code
- Related-Causes Code
- Rendering Provider City Name
- Rendering Provider First Address Line
- Rendering Provider First Name
- Rendering Provider Identifier
- Rendering Provider Last Name
- Rendering Provider Middle Name
- Rendering Provider Name Suffix
- Rendering Provider Second Address Line
- Rendering Provider State Code
- Rendering Provider ZIP Code
- Replacement Date
- Retirement or Insurance Card Date
- School City Name
- School First Address Line
- School Name
- School Primary Identifier
- School Second Address Line
- School State Code
- School ZIP Code
- Service Date
- Service Line Paid Amount
- Student Status Code
- Submitter or Receiver Address Line
- Submitter or Receiver City Name
- Submitter or Receiver Contact Name
- Submitter or Receiver First Name
- Submitter or Receiver Identifier
- Submitter or Receiver Last or Organization Name
- Submitter or Receiver Middle Name
- Submitter or Receiver State Code
- Submitter or Receiver ZIP Code
- Subscriber Birth Date
- Subscriber First Address Line
- Subscriber First Name
- Subscriber Gender Code
- Subscriber Identifier
- Subscriber Last Name
- Subscriber Marital Status Code
- Subscriber Middle Name
- Subscriber Name Suffix
- Subscriber Postal ZIP Code
- Subscriber Second Address Line
- Subscriber State
- Title XIX Identification Number
- Tooth Code
- Tooth Number
- Tooth Status Code
- Tooth Surface
- Total Claim Charge Amount
- Transaction Segment Count
- Transaction Set Control Number
- Transaction Set Identifier Code
- Transaction Set Purpose Code
- Unit or Basis for Measurement Code