ADDENDUM 4--HEALTH CLAIM STATUS

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The transaction selected for the health claim status is ASC X12N 276/277 - Health Care Claim Status Request and Response (004010X093).

A. Implementation Guide and Source

The source of the implementation guide for the health claim status transaction set is: Washington Publishing Company, 806 W. Diamond Ave., Suite 400, Gaithersburg, MD, 20878, Telephone 301- 590-9337, FAX: 301-869-9460. The website address is http://www.wpc-edi.com/hipaa/

B. Data Elements

Adjudication or Payment Date

Amount Qualifier Code

Bill Type Identifier

Check or EFT Trace Number

Check/EFT Issue Date

Claim Payment Amount

Claim Service Period

Creation Date

Date Time Period Format Qualifier

Date/Time Qualifier

Entity Identifier Code

Entity Type Qualifier

Extra Narrative Data

Health Care Claim Status Category Code

Health Care Claim Status Code

Hierarchical Child Code

Hierarchical ID Number

Hierarchical Level Code

Hierarchical Parent ID Number

Hierarchical Structure Code

Identification Code Qualifier

Information Receiver Additional Address

Information Receiver Address

Information Receiver City

Information Receiver First Name

Information Receiver Identification Number

Information Receiver Last or Organization Name

Information Receiver Middle Name

Information Receiver Name Prefix

Information Receiver Name Suffix

Information Receiver Specific Location

Information Receiver State

Information Receiver ZIP Code

Line Charge Amount

Line Item Control Number

Line Item Service Date

Location Qualifier

Original Service Unit Count

Originator Application Transaction Identifier

Patient Control Number

Patient First Name

Patient Last Name

Patient Middle Name

Patient Name Prefix

Patient Name Suffix

Payer City Name

Payer Claim Control Number

Payer First Address Line

Payer Identifier

Payer Name

Payer Second Address Line

Payer State Code

Payer ZIP Code

Payment Method Code

Procedure Modifier

Product/Service ID Qualifier

Provider First Name

Provider Identifier

Provider Last or Organization Name

Provider Middle Name

Provider Name Prefix

Provider Name Suffix

Reference Identification Qualifier

Revenue Code

Service Identification Code

Service Line Date

Service Unit Count

Status Information Effective Date

Subscriber Birth Date

Subscriber City

Subscriber First Address Line

Subscriber First Name

Subscriber Gender Code

Subscriber Identifier

Subscriber Last Name

Subscriber Middle Name

Subscriber Name Prefix

Subscriber Name Suffix

Subscriber Postal ZIP Code

Subscriber Second Address Line

Subscriber State

Total Claim Charge Amount

Trace Type Code

Transaction Segment Count

Transaction Set Control Number

Transaction Set Identifier Code

Transaction Set Purpose Code

Transaction Type Code