False False False 0 0 -1 Official X12 5010 Message Definitions False Health Care Claim Status Request group Health Care Information Status Notification group Health Care Services Review Information group Health Care Services Review Information group Payment Order/Remittance Advice group Benefit Enrollment and Maintenance group Health Care Claim Payment/Advice group Health Care Claim group Health Care Claim group Health Care Eligibility Benefit Inquiry group Health Care Eligibility Benefit Response group Health Care Claim group Functional Acknowledgment group Implementation Acknowledgment group "Implementation Acknowledgment" group TM Time False HH mm SS .SSSS +/-ZZZZ DT Date False YYYY MM DD DTM DateTime False YYYY MM DD HH mm SS .SSSS +/-ZZZZ String Value -1 True False String Date Value -1 True False String Identifier Value -1 True False String Numeric Value -1 True False String Numeric Value -1 True False String Decimal Value -1 True False String Time Value -1 True False String Currency Code Value 3 True False Composite ID Percent Qualifier Value 2 True False Composite ID Hierarchical Structure Code Value 4 True False Composite ID Exponent Value 15 True False Composite R Ownership Code Value 1 True False Composite ID Claim Submitter's Identifier Value 38 True False Composite AN Claim Status Code Value 2 True False Composite ID Packaging Code Value 5 True False Composite AN Claim Filing Indicator Code Value 2 True False Composite ID Claim Adjustment Group Code Value 2 True False Composite ID Claim Adjustment Reason Code Value 5 True False Composite ID Name Last or Organization Name Value 60 True False Composite AN Name First Value 35 True False Composite AN Name Middle Value 25 True False Composite AN Name Prefix Value 10 True False Composite AN Name Suffix Value 10 True False Composite AN Business Function Code Value 3 True False Composite ID Entity Type Qualifier Value 1 True False Composite ID Citizenship Status Code Value 2 True False Composite ID Marital Status Code Value 1 True False Composite ID Gender Code Value 1 True False Composite ID Individual Relationship Code Value 2 True False Composite ID Payment Method Type Code Value 2 True False Composite ID Yes/No Condition or Response Code Value 1 True False Composite ID Type of Real Estate Asset Code Value 2 True False Composite ID Year Value 4 True False Composite N0 Race or Ethnicity Code Value 1 True False Composite ID Adjustment Reason Code Characteristic Value 2 True False Composite ID Primary or Contingent Code Value 1 True False Composite ID Code Category Value 2 True False Composite ID Medical Code Value Value 15 True False Composite AN Payer Responsibility Sequence Number Code Value 1 True False Composite ID Coordination of Benefits Code Value 1 True False Composite ID Disability Type Code Value 1 True False Composite ID Occupation Code Value 6 True False Composite ID Work Intensity Code Value 1 True False Composite ID Postal Code Value 15 True False Composite ID Product Option Code Value 2 True False Composite ID Confidentiality Code Value 1 True False Composite ID Contract Type Code Value 2 True False Composite ID Sample Selection Modulus Value 6 True False Composite R Employment Class Code Value 3 True False Composite ID Rate Value 9 True False Composite R Type of Account Code Value 2 True False Composite ID Type of Personal or Business Asset Code Value 2 True False Composite ID Information Status Code Value 1 True False Composite ID Flexible Spending Account Selection Code Value 1 True False Composite ID Maintenance Reason Code Value 3 True False Composite ID Plan Coverage Description Value 50 True False Composite AN Insurance Line Code Value 3 True False Composite ID Coverage Level Code Value 3 True False Composite ID Underwriting Decision Code Value 1 True False Composite ID Drug House Code Value 3 True False Composite ID Health-Related Code Value 1 True False Composite ID Current Health Condition Code Value 1 True False Composite ID Salary Grade Value 5 True False Composite AN Identification Card Type Code Value 1 True False Composite ID Benefit Status Code Value 1 True False Composite ID Medicare Plan Code Value 1 True False Composite ID Consolidated Omnibus Budget Reconciliation Act (COBRA) Qualifying Value 2 True False Composite ID Student Status Code Value 1 True False Composite ID Provider Code Value 3 True False Composite ID Provider Specialty Code Value 3 True False Composite AN Provider Organization Code Value 3 True False Composite ID Contribution Code Value 2 True False Composite ID Number of Received Transaction Sets Value 6 True False Composite N0 Date Time Period Format Qualifier Value 3 True False Composite ID Date Time Period Value 35 True False Composite AN Immunization Status Code Value 2 True False Composite ID Reference Identification Value 50 True False Composite AN Code List Qualifier Code Value 3 True False Composite ID Industry Code Value 30 True False Composite AN Reference Identification Qualifier Value 3 True False Composite ID Participant Status Code Value 2 True False Composite ID Special Processing Type Value 6 True False Composite AN Service, Promotion, Allowance, or Charge Code Value 4 True False Composite ID Agency Service, Promotion, Allowance, or Charge Code Value 10 True False Composite AN Use of Language Indicator Value 2 True False Composite ID Admission Source Code Value 1 True False Composite ID Admission Type Code Value 1 True False Composite ID Ambulance Transport Code Value 1 True False Composite ID Ambulance Transport Reason Code Value 1 True False Composite ID Approval Code Value 1 True False Composite ID Basis of Cost Determination Code Value 2 True False Composite ID Basis of Days Supply Determination Code Value 1 True False Composite ID Condition Indicator Value 3 True False Composite ID Certification Type Code Value 1 True False Composite ID Claim Frequency Type Code Value 1 True False Composite ID Copay Status Code Value 1 True False Composite ID Diagnosis Code Pointer Value 2 True False Composite N0 Dispense as Written Code Value 1 True False Composite ID Dosage Form Code Value 2 True False Composite ID Facility Code Value Value 2 True False Composite AN Facility Code Qualifier Value 2 True False Composite ID Record Format Code Value 2 True False Composite ID Health Care Professional Shortage Area Code Value 1 True False Composite ID Insulin Dependent Code Value 1 True False Composite ID Insurance Type Code Value 3 True False Composite ID Level of Care Code Value 1 True False Composite ID Level of Service Code Value 3 True False Composite ID Procedure Modifier Value 2 True False Composite AN Multiple Procedure Code Value 2 True False Composite ID National or Local Assigned Review Value Value 2 True False Composite AN Nature of Condition Code Value 1 True False Composite ID Non-Institutional Claim Type Code Value 2 True False Composite ID Non-Visit Code Value 1 True False Composite ID Nursing Home Residential Status Code Value 1 True False Composite ID Nutrient Administration Method Code Value 1 True False Composite ID Nutrient Administration Technique Code Value 1 True False Composite ID Oxygen Equipment Type Code Value 1 True False Composite ID Oxygen Test Condition Code Value 1 True False Composite ID Oxygen Test Findings Code Value 1 True False Composite ID Patient Signature Source Code Value 1 True False Composite ID Patient Status Code Value 2 True False Composite ID Diagnosis Related Group (DRG) Code Value 4 True False Composite ID Prescription Denial Override Code Value 2 True False Composite ID Prescription Origin Code Value 1 True False Composite ID Prior Authorization Type Code Value 1 True False Composite ID Prosthesis, Crown or Inlay Code Value 1 True False Composite ID Provider Accept Assignment Code Value 1 True False Composite ID Provider Agreement Code Value 1 True False Composite ID Oral Cavity Designation Code Value 3 True False Composite ID Related-Causes Code Value 3 True False Composite ID Release of Information Code Value 1 True False Composite ID Review Code Value 2 True False Composite ID Service Type Code Value 2 True False Composite ID Special Program Code Value 3 True False Composite ID Subluxation Level Code Value 3 True False Composite ID Tooth Status Code Value 2 True False Composite ID Tooth Surface Code Value 2 True False Composite ID Unit Dose Code Value 1 True False Composite ID Unit Rate Value 10 True False Composite R Measurement Method or Device Value 4 True False Composite ID Oxygen Delivery System Code Value 1 True False Composite ID Claim Submission Reason Code Value 2 True False Composite ID Patient Location Code Value 1 True False Composite ID Eligibility or Benefit Information Code Value 2 True False Composite ID Implant Type Code Value 1 True False Composite ID Implant Status Code Value 1 True False Composite ID Construction Type Value 2 True False Composite ID Transaction Set Identifier Code Value 3 True False Composite ID Number Value 9 True False Composite N0 Pricing Methodology Value 2 True False Composite ID Language Proficiency Indicator Value 1 True False Composite ID Authority Value 20 True False Composite AN Delay Reason Code Value 2 True False Composite ID Request Category Code Value 2 True False Composite ID Policy Compliance Code Value 2 True False Composite ID Exception Code Value 2 True False Composite ID Component Data Element Position in Composite Value 2 True False Composite N0 State or Province Code Value 2 True False Composite ID Government Service Affiliation Code Value 1 True False Composite ID Military Service Rank Code Value 2 True False Composite ID Address Information Value 55 True False Composite AN Repeating Data Element Position Value 4 True False Composite N0 Eligibility Reason Code Value 1 True False Composite ID Implementation Convention Reference Value 35 True False Composite AN Country Subdivision Code Value 3 True False Composite ID Volume Value 8 True False Composite R Volume Unit Qualifier Value 1 True False Composite ID Weight Unit Code Value 1 True False Composite ID City Name Value 30 True False Composite AN Number of Accepted Transaction Sets Value 6 True False Composite N0 Unit Price Value 17 True False Composite R Commodity Code Value 30 True False Composite AN Commodity Code Qualifier Value 1 True False Composite ID Product/Service ID Value 48 True False Composite AN Product/Service ID Qualifier Value 2 True False Composite ID Price Identifier Code Value 3 True False Composite ID Allowance or Charge Indicator Value 1 True False Composite ID Country Code Value 3 True False Composite ID Group Control Number Value 9 True False Composite N0 Exchange Rate Value 10 True False Composite R Multiple Price Quantity Value 2 True False Composite N0 Transaction Handling Code Value 2 True False Composite ID Action Code Value 2 True False Composite ID Location Qualifier Value 2 True False Composite ID Location Identifier Value 30 True False Composite AN Transaction Set Control Number Value 9 True False Composite AN Allowance or Charge Method of Handling Code Value 2 True False Composite ID Percent, Decimal Format Value 6 True False Composite R Time Value 8 True False Composite TM Terms Discount Percent Value 6 True False Composite R Item Description Type Value 1 True False Composite ID Assigned Identification Value 20 True False Composite AN Description Value 80 True False Composite AN Transaction Set Purpose Code Value 2 True False Composite ID Unit or Basis for Measurement Code Value 2 True False Composite ID Quantity Invoiced Value 15 True False Composite R Note Reference Code Value 3 True False Composite ID Communication Number Value 256 True False Composite AN Communication Number Qualifier Value 2 True False Composite ID Contact Function Code Value 2 True False Composite ID Date Value 8 True False Composite DT Date/Time Qualifier Value 3 True False Composite ID Allowance/Charge Percent Qualifier Value 1 True False Composite ID Quantity Value 15 True False Composite R Adjustment Reason Code Value 2 True False Composite ID Check Number Value 16 True False Composite AN Contact Inquiry Reference Value 20 True False Composite AN Loop Identifier Code Value 4 True False Composite AN Fixed Format Information Value 80 True False Composite AN Credit/Debit Flag Code Value 1 True False Composite ID Functional Identifier Code Value 2 True False Composite ID Version / Release / Industry Identifier Code Value 12 True False Composite AN Trace Type Code Value 2 True False Composite ID Payment Action Code Value 2 True False Composite ID Condition Value Value 10 True False Composite AN (DFI) ID Number Qualifier Value 2 True False Composite ID (DFI) Identification Number Value 12 True False Composite AN Account Number Value 35 True False Composite AN Originating Company Identifier Value 10 True False Composite AN Originating Company Supplemental Code Value 9 True False Composite AN Amount Qualifier Code Value 3 True False Composite ID Vehicle Identification Number Value 30 True False Composite AN Assigned Number Value 6 True False Composite N0 Agency Qualifier Code Value 2 True False Composite ID Account Number Qualifier Value 3 True False Composite ID Employment Status Code Value 2 True False Composite ID Payment Method Code Value 3 True False Composite ID Frequency Code Value 1 True False Composite ID Count Value 9 True False Composite N0 Free-form Information Value 30 True False Composite AN Amount Value 15 True False Composite N2 Time Period Qualifier Value 2 True False Composite ID Number of Periods Value 3 True False Composite N0 Implementation Transaction Set Syntax Error Code Value 3 True False Composite ID Implementation Segment Syntax Error Code Value 3 True False Composite ID Implementation Data Element Syntax Error Code Value 3 True False Composite ID Time Code Value 2 True False Composite ID Hierarchical ID Number Value 12 True False Composite AN Basis of Unit Price Code Value 2 True False Composite ID Transaction Type Code Value 2 True False Composite ID Price Multiplier Qualifier Value 3 True False Composite ID Multiplier Value 10 True False Composite R Height Value 8 True False Composite R Basis of Verification Code Value 2 True False Composite ID Identification Code Qualifier Value 2 True False Composite ID Relationship Code Value 1 True False Composite ID Currency Market/Exchange Code Value 3 True False Composite ID Identification Code Value 80 True False Composite AN Quantity Qualifier Value 2 True False Composite ID Ship/Delivery or Calendar Pattern Code Value 2 True False Composite ID Ship/Delivery Pattern Time Code Value 1 True False Composite ID Class of Trade Code Value 2 True False Composite ID Occupancy Code Value 2 True False Composite ID Paperwork/Report Action Code Value 2 True False Composite ID Entity Relationship Code Value 2 True False Composite ID Functional Group Acknowledge Code Value 1 True False Composite ID Functional Group Syntax Error Code Value 3 True False Composite ID Transaction Set Acknowledgment Code Value 1 True False Composite ID Transaction Set Syntax Error Code Value 3 True False Composite ID Segment Position in Transaction Set Value 10 True False Composite N0 Segment Syntax Error Code Value 3 True False Composite ID Segment ID Code Value 3 True False Composite ID Element Position in Segment Value 2 True False Composite N0 Data Element Syntax Error Code Value 3 True False Composite ID Copy of Bad Data Element Value 99 True False Composite AN Data Element Reference Number Value 4 True False Composite N0 Hierarchical Parent ID Number Value 12 True False Composite AN Hierarchical Level Code Value 2 True False Composite ID Hierarchical Child Code Value 1 True False Composite ID Measurement Reference ID Code Value 2 True False Composite ID Measurement Qualifier Value 3 True False Composite ID Measurement Value Value 20 True False Composite R Range Minimum Value 20 True False Composite R Range Maximum Value 20 True False Composite R Product/Process Characteristic Code Value 3 True False Composite ID Product Description Code Value 12 True False Composite AN Surface/Layer/Position Code Value 2 True False Composite ID Packaging Description Code Value 7 True False Composite AN Report Type Code Value 2 True False Composite ID Report Transmission Code Value 2 True False Composite ID Report Copies Needed Value 2 True False Composite N0 Option Number Value 20 True False Composite AN Monetary Amount Value 18 True False Composite R Security Level Code Value 2 True False Composite ID Version Identifier Value 30 True False Composite AN Weight Value 10 True False Composite R Payment Format Code Value 10 True False Composite ID Language Code Value 3 True False Composite ID Length Value 8 True False Composite R Safety Characteristic/Hazard Code Value 3 True False Composite ID Source Subqualifier Value 15 True False Composite AN Maintenance Type Code Value 3 True False Composite ID Follow-up Action Code Value 1 True False Composite ID Late Reason Code Value 2 True False Composite ID Reject Reason Code Value 2 True False Composite ID Discipline Type Code Value 2 True False Composite ID Prognosis Code Value 1 True False Composite ID Name Value 60 True False Composite AN Free-form Message Text Value 264 True False Composite AN Printer Carriage Control Code Value 2 True False Composite ID Measurement Significance Code Value 2 True False Composite ID Measurement Attribute Code Value 2 True False Composite ID Percentage as Decimal Value 10 True False Composite R Number of Included Segments Value 10 True False Composite N0 Number of Transaction Sets Included Value 6 True False Composite N0 Entity Identifier Code Value 3 True False Composite ID Context Reference Value 35 True False Composite AN Context Name Value 35 True False Composite AN Composite Medical Procedure Identifier Product/Service ID Qualifier -1 True False Composite 235 Product/Service ID -1 True False Composite 234 Procedure Modifier -1 False False Composite 1339 Procedure Modifier -1 False False Composite 1339 Procedure Modifier -1 False False Composite 1339 Procedure Modifier -1 False False Composite 1339 Description -1 False False Composite 352 Product/Service ID -1 False False Composite 234 Reference Identifier Reference Identification Qualifier -1 True False Composite 128 Reference Identification -1 True False Composite 127 Reference Identification Qualifier -1 True False Composite 128 Reference Identification -1 True False Composite 127 Reference Identification Qualifier -1 True False Composite 128 Reference Identification -1 True False Composite 127 Composite Race or Ethnicity Information Race or Ethnicity Code -1 False False Composite 1109 Code List Qualifier Code -1 True False Composite 1270 Industry Code -1 True False Composite 1271 Composite Medical Procedure Identifier Product or Service ID Qualifier -1 True False Composite 235 Procedure Code -1 True False Composite 234 Procedure Modifier -1 False False Composite 1339 Procedure Modifier -1 False False Composite 1339 Procedure Modifier -1 False False Composite 1339 Procedure Modifier -1 False False Composite 1339 Not Used -1 False False Composite 352 Not Used -1 False False Composite 234 Composite Medical Procedure Identifier Product or Service ID Qualifier -1 True False Composite 235 Procedure Code -1 True False Composite 234 Procedure Modifier -1 False False Composite 1339 Procedure Modifier -1 False False Composite 1339 Procedure Modifier -1 False False Composite 1339 Procedure Modifier -1 False False Composite 1339 Not Used -1 False False Composite 352 Not Used -1 False False Composite 234 Actions Indicated Paperwork/Report Action Code -1 True False Composite 704 Paperwork/Report Action Code -1 False False Composite 704 Paperwork/Report Action Code -1 False False Composite 704 Paperwork/Report Action Code -1 False False Composite 704 Paperwork/Report Action Code -1 False False Composite 704 Health Care Claim Status Industry Code -1 True False Composite 1271 Industry Code -1 True False Composite 1271 Entity Identifier Code -1 False False Composite 98 Code List Qualifier Code -1 False False Composite 1270 Health Care Claim Status Health Care Claim Status Category Code -1 True False Composite 1271 Status Code -1 True False Composite 1271 Entity Identifier Code -1 False False Composite 98 Not Used -1 False False Composite 1270 Health Care Claim Status Health Care Claim Status Category Code -1 True False Composite 1271 Status Code -1 True False Composite 1271 Entity Identifier Code -1 False False Composite 98 Not Used -1 False False Composite 1270 Health Care Claim Status Health Care Claim Status Category Code -1 True False Composite 1271 Status Code -1 True False Composite 1271 Entity Identifier Code -1 False False Composite 98 Code List Qualifier Code -1 False False Composite 1270 Composite Medical Procedure Identifier Product or Service ID Qualifier -1 True False Composite 235 Procedure Code -1 True False Composite 234 Procedure Modifier -1 False False Composite 1339 Procedure Modifier -1 False False Composite 1339 Procedure Modifier -1 False False Composite 1339 Procedure Modifier -1 False False Composite 1339 Not Used -1 False False Composite 352 Not Used -1 False False Composite 234 Health Care Claim Status Health Care Claim Status Category Code -1 True False Composite 1271 Status Code -1 True False Composite 1271 Entity Identifier Code -1 False False Composite 98 Code List Qualifier Code -1 False False Composite 1270 Health Care Claim Status Health Care Claim Status Category Code -1 True False Composite 1271 Status Code -1 True False Composite 1271 Entity Identifier Code -1 False False Composite 98 Code List Qualifier Code -1 False False Composite 1270 Composite Medical Procedure Identifier Product or Service ID Qualifier -1 True False Composite 235 Procedure Code -1 True False Composite 234 Procedure Modifier -1 False False Composite 1339 Procedure Modifier -1 False False Composite 1339 Procedure Modifier -1 False False Composite 1339 Procedure Modifier -1 False False Composite 1339 Not Used -1 False False Composite 352 Not Used -1 False False Composite 234 Health Care Claim Status Health Care Claim Status Category Code -1 True False Composite 1271 Status Code -1 True False Composite 1271 Entity Identifier Code -1 False False Composite 98 Code List Qualifier Code -1 False False Composite 1270 Composite Diagnosis Code Pointer Diagnosis Code Pointer -1 True False Composite 1328 Diagnosis Code Pointer -1 False False Composite 1328 Diagnosis Code Pointer -1 False False Composite 1328 Diagnosis Code Pointer -1 False False Composite 1328 Tooth Surface Tooth Surface Code -1 True False Composite 1369 Tooth Surface Code -1 False False Composite 1369 Tooth Surface Code -1 False False Composite 1369 Tooth Surface Code -1 False False Composite 1369 Tooth Surface Code -1 False False Composite 1369 Oral Cavity Designation Oral Cavity Designation Code -1 True False Composite 1361 Oral Cavity Designation Code -1 False False Composite 1361 Oral Cavity Designation Code -1 False False Composite 1361 Oral Cavity Designation Code -1 False False Composite 1361 Oral Cavity Designation Code -1 False False Composite 1361 Health Care Code Information Code List Qualifier Code -1 True False Composite 1270 Industry Code -1 True False Composite 1271 Date Time Period Format Qualifier -1 True False Composite 1250 Date Time Period -1 True False Composite 1251 Monetary Amount -1 False False Composite 782 Quantity -1 False False Composite 380 Version Identifier -1 False False Composite 799 Industry Code -1 True False Composite 1271 Yes/No Condition or Response Code -1 True False Composite 1073 Health Care Service Location Information Facility Code Value -1 True False Composite 1331 Facility Code Qualifier -1 False False Composite 1332 Claim Frequency Type Code -1 False False Composite 1325 Related Causes Information Related-Causes Code -1 True False Composite 1362 Related-Causes Code -1 False False Composite 1362 Related-Causes Code -1 False False Composite 1362 State or Province Code -1 False False Composite 156 Country Code -1 False False Composite 26 Provider Specialty Information Provider Specialty Code -1 True False Composite 1222 Agency Qualifier Code -1 False False Composite 559 Yes/No Condition or Response Code -1 False False Composite 1073 Medicare Status Code Medicare Plan Code -1 True False Composite 1218 Eligibility Reason Code -1 False False Composite 1701 Eligibility Reason Code -1 False False Composite 1701 Eligibility Reason Code -1 False False Composite 1701 Health Care Service Location Information Facility Type Code -1 True False Composite 1331 Facility Code Qualifier -1 True False Composite 1332 Not Used -1 False False Composite 1325 Related Causes Information Related Causes Code -1 True False Composite 1362 Related Causes Code -1 False False Composite 1362 Related Causes Code -1 False False Composite 1362 State or Province Code -1 False False Composite 156 Country Code -1 False False Composite 26 Health Care Code Information Diagnosis Type Code -1 True False Composite 1270 Diagnosis Code -1 True False Composite 1271 Date Time Period Format Qualifier -1 False False Composite 1250 Diagnosis Date -1 False False Composite 1251 Not Used -1 False False Composite 782 Not Used -1 False False Composite 380 Not Used -1 False False Composite 799 Not Used -1 False False Composite 1271 Not Used -1 False False Composite 1073 Reference Identifier Reference Identification Qualifier -1 True False Composite 128 Other UMO Denial Reason -1 True False Composite 127 Reference Identification Qualifier -1 False False Composite 128 Other UMO Denial Reason -1 False False Composite 127 Reference Identification Qualifier -1 False False Composite 128 Reference Identification -1 False False Composite 127 Health Care Service Location Information Facility Type Code -1 True False Composite 1331 Facility Code Qualifier -1 True False Composite 1332 Not Used -1 False False Composite 1325 Composite Medical Procedure Identifier Product or Service ID Qualifier -1 True False Composite 235 Procedure Code -1 True False Composite 234 Procedure Modifier -1 False False Composite 1339 Procedure Modifier -1 False False Composite 1339 Procedure Modifier -1 False False Composite 1339 Procedure Modifier -1 False False Composite 1339 Procedure Code Description -1 False False Composite 352 Procedure Code -1 False False Composite 234 Composite Diagnosis Code Pointer Diagnosis Code Pointer -1 True False Composite 1328 Diagnosis Code Pointer -1 False False Composite 1328 Diagnosis Code Pointer -1 False False Composite 1328 Diagnosis Code Pointer -1 False False Composite 1328 Composite Medical Procedure Identifier Product or Service ID Qualifier -1 True False Composite 235 Procedure Code -1 True False Composite 234 Procedure Modifier -1 False False Composite 1339 Procedure Modifier -1 False False Composite 1339 Procedure Modifier -1 False False Composite 1339 Procedure Modifier -1 False False Composite 1339 Procedure Code Description -1 False False Composite 352 Procedure Code -1 False False Composite 234 Composite Medical Procedure Identifier Product or Service ID Qualifier -1 True False Composite 235 Procedure Code -1 True False Composite 234 Procedure Modifier -1 False False Composite 1339 Procedure Modifier -1 False False Composite 1339 Procedure Modifier -1 False False Composite 1339 Procedure Modifier -1 False False Composite 1339 Procedure Code Description -1 False False Composite 352 Procedure Code -1 False False Composite 234 Oral Cavity Designation Oral Cavity Designation Code -1 True False Composite 1361 Oral Cavity Designation Code -1 False False Composite 1361 Oral Cavity Designation Code -1 False False Composite 1361 Oral Cavity Designation Code -1 False False Composite 1361 Oral Cavity Designation Code -1 False False Composite 1361 Tooth Surface Tooth Surface Code -1 True False Composite 1369 Tooth Surface Code -1 False False Composite 1369 Tooth Surface Code -1 False False Composite 1369 Tooth Surface Code -1 False False Composite 1369 Tooth Surface Code -1 False False Composite 1369 Health Care Service Location Information Facility Type Code -1 True False Composite 1331 Facility Code Qualifier -1 True False Composite 1332 Not Used -1 False False Composite 1325 Health Care Code Information Diagnosis Type Code -1 True False Composite 1270 Diagnosis Code -1 True False Composite 1271 Date Time Period Format Qualifier -1 False False Composite 1250 Diagnosis Date -1 False False Composite 1251 Not Used -1 False False Composite 782 Not Used -1 False False Composite 380 Not Used -1 False False Composite 799 Not Used -1 False False Composite 1271 Not Used -1 False False Composite 1073 Health Care Service Location Information Facility Type Code -1 True False Composite 1331 Facility Code Qualifier -1 True False Composite 1332 Not Used -1 False False Composite 1325 Health Care Code Information Code List Qualifier Code -1 True False Composite 1270 LOINC Code -1 True False Composite 1271 Not Used -1 False False Composite 1250 Not Used -1 False False Composite 1251 Not Used -1 False False Composite 782 Not Used -1 False False Composite 380 Not Used -1 False False Composite 799 Not Used -1 False False Composite 1271 Not Used -1 False False Composite 1073 Composite Medical Procedure Identifier Product or Service ID Qualifier -1 True False Composite 235 Procedure Code -1 True False Composite 234 Procedure Modifier -1 False False Composite 1339 Procedure Modifier -1 False False Composite 1339 Procedure Modifier -1 False False Composite 1339 Procedure Modifier -1 False False Composite 1339 Procedure Code Description -1 False False Composite 352 Procedure Code -1 False False Composite 234 Composite Medical Procedure Identifier Product or Service ID Qualifier -1 True False Composite 235 Procedure Code -1 True False Composite 234 Procedure Modifier -1 False False Composite 1339 Procedure Modifier -1 False False Composite 1339 Procedure Modifier -1 False False Composite 1339 Procedure Modifier -1 False False Composite 1339 Procedure Code Description -1 False False Composite 352 Procedure Code -1 False False Composite 234 Composite Medical Procedure Identifier Product or Service ID Qualifier -1 True False Composite 235 Procedure Code -1 True False Composite 234 Procedure Modifier -1 False False Composite 1339 Procedure Modifier -1 False False Composite 1339 Procedure Modifier -1 False False Composite 1339 Procedure Modifier -1 False False Composite 1339 Procedure Code Description -1 False False Composite 352 Procedure Code -1 False False Composite 234 Oral Cavity Designation Oral Cavity Designation Code -1 True False Composite 1361 Oral Cavity Designation Code -1 False False Composite 1361 Oral Cavity Designation Code -1 False False Composite 1361 Oral Cavity Designation Code -1 False False Composite 1361 Oral Cavity Designation Code -1 False False Composite 1361 Tooth Surface Tooth Surface Code -1 True False Composite 1369 Tooth Surface Code -1 False False Composite 1369 Tooth Surface Code -1 False False Composite 1369 Tooth Surface Code -1 False False Composite 1369 Tooth Surface Code -1 False False Composite 1369 Composite Unit of Measure Unit or Basis for Measurement Code -1 True False Composite 355 Exponent -1 False False Composite 1018 Multiplier -1 False False Composite 649 Unit or Basis for Measurement Code -1 False False Composite 355 Exponent -1 False False Composite 1018 Multiplier -1 False False Composite 649 Unit or Basis for Measurement Code -1 False False Composite 355 Exponent -1 False False Composite 1018 Multiplier -1 False False Composite 649 Unit or Basis for Measurement Code -1 False False Composite 355 Exponent -1 False False Composite 1018 Multiplier -1 False False Composite 649 Unit or Basis for Measurement Code -1 False False Composite 355 Exponent -1 False False Composite 1018 Multiplier -1 False False Composite 649 Composite Unit of Measure Unit or Basis for Measurement Code -1 True False Composite 355 Not Used -1 False False Composite 1018 Not Used -1 False False Composite 649 Not Used -1 False False Composite 355 Not Used -1 False False Composite 1018 Not Used -1 False False Composite 649 Not Used -1 False False Composite 355 Not Used -1 False False Composite 1018 Not Used -1 False False Composite 649 Not Used -1 False False Composite 355 Not Used -1 False False Composite 1018 Not Used -1 False False Composite 649 Not Used -1 False False Composite 355 Not Used -1 False False Composite 1018 Not Used -1 False False Composite 649 Medicare Status Code Medicare Plan Code -1 True False Composite 1218 Medicare Eligibility Reason Code -1 False False Composite 1701 Not Used -1 False False Composite 1701 Not Used -1 False False Composite 1701 Composite Race or Ethnicity Information Race or Ethnicity Code -1 False False Composite 1109 Code List Qualifier Code -1 False False Composite 1270 Race or Ethnicity Code -1 False False Composite 1271 Composite Race or Ethnicity Information Race or Ethnicity Code -1 False False Composite 1109 Code List Qualifier Code -1 False False Composite 1270 Race or Ethnicity Code -1 False False Composite 1271 Adjustment Identifier Adjustment Reason Code -1 True False Composite 426 Reference Identification -1 False False Composite 127 Composite Medical Procedure Identifier Product or Service ID Qualifier -1 True False Composite 235 Procedure Code -1 True False Composite 234 Procedure Modifier -1 False False Composite 1339 Procedure Modifier -1 False False Composite 1339 Procedure Modifier -1 False False Composite 1339 Procedure Modifier -1 False False Composite 1339 Procedure Code Description -1 False False Composite 352 Not Used -1 False False Composite 234 Adjustment Identifier Adjustment Reason Code -1 True False Composite 426 Provider Adjustment Identifier -1 False False Composite 127 Health Care Service Location Information Facility Type Code -1 True False Composite 1331 Facility Code Qualifier -1 True False Composite 1332 Claim Frequency Code -1 True False Composite 1325 Health Care Code Information Code List Qualifier Code -1 True False Composite 1270 Principal Diagnosis Code -1 True False Composite 1271 Not Used -1 False False Composite 1250 Not Used -1 False False Composite 1251 Not Used -1 False False Composite 782 Not Used -1 False False Composite 380 Not Used -1 False False Composite 799 Not Used -1 False False Composite 1271 Present on Admission Indicator -1 False False Composite 1073 Health Care Code Information Code List Qualifier Code -1 True False Composite 1270 Admitting Diagnosis Code -1 True False Composite 1271 Not Used -1 False False Composite 1250 Not Used -1 False False Composite 1251 Not Used -1 False False Composite 782 Not Used -1 False False Composite 380 Not Used -1 False False Composite 799 Not Used -1 False False Composite 1271 Not Used -1 False False Composite 1073 Health Care Code Information Code List Qualifier Code -1 True False Composite 1270 Patient Reason For Visit -1 True False Composite 1271 Not Used -1 False False Composite 1250 Not Used -1 False False Composite 1251 Not Used -1 False False Composite 782 Not Used -1 False False Composite 380 Not Used -1 False False Composite 799 Not Used -1 False False Composite 1271 Not Used -1 False False Composite 1073 Health Care Code Information Code List Qualifier Code -1 True False Composite 1270 External Cause of Injury Code -1 True False Composite 1271 Not Used -1 False False Composite 1250 Not Used -1 False False Composite 1251 Not Used -1 False False Composite 782 Not Used -1 False False Composite 380 Not Used -1 False False Composite 799 Not Used -1 False False Composite 1271 Present on Admission Indicator -1 False False Composite 1073 Health Care Code Information Code List Qualifier Code -1 True False Composite 1270 Diagnosis Related Group (DRG) Code -1 True False Composite 1271 Not Used -1 False False Composite 1250 Not Used -1 False False Composite 1251 Not Used -1 False False Composite 782 Not Used -1 False False Composite 380 Not Used -1 False False Composite 799 Not Used -1 False False Composite 1271 Not Used -1 False False Composite 1073 Health Care Code Information Code List Qualifier Code -1 True False Composite 1270 Other Diagnosis -1 True False Composite 1271 Not Used -1 False False Composite 1250 Not Used -1 False False Composite 1251 Not Used -1 False False Composite 782 Not Used -1 False False Composite 380 Not Used -1 False False Composite 799 Not Used -1 False False Composite 1271 Present on Admission Indicator -1 False False Composite 1073 Health Care Code Information Code List Qualifier Code -1 True False Composite 1270 Principal Procedure Code -1 True False Composite 1271 Date Time Period Format Qualifier -1 True False Composite 1250 Principal Procedure Date -1 True False Composite 1251 Not Used -1 False False Composite 782 Not Used -1 False False Composite 380 Not Used -1 False False Composite 799 Not Used -1 False False Composite 1271 Not Used -1 False False Composite 1073 Health Care Code Information Code List Qualifier Code -1 True False Composite 1270 Procedure Code -1 True False Composite 1271 Date Time Period Format Qualifier -1 True False Composite 1250 Procedure Date -1 True False Composite 1251 Not Used -1 False False Composite 782 Not Used -1 False False Composite 380 Not Used -1 False False Composite 799 Not Used -1 False False Composite 1271 Not Used -1 False False Composite 1073 Health Care Code Information Code List Qualifier Code -1 True False Composite 1270 Occurrence Span Code -1 True False Composite 1271 Date Time Period Format Qualifier -1 True False Composite 1250 Occurrence Span Code Date -1 True False Composite 1251 Not Used -1 False False Composite 782 Not Used -1 False False Composite 380 Not Used -1 False False Composite 799 Not Used -1 False False Composite 1271 Not Used -1 False False Composite 1073 Health Care Code Information Code List Qualifier Code -1 True False Composite 1270 Occurrence Code -1 True False Composite 1271 Date Time Period Format Qualifier -1 True False Composite 1250 Occurrence Code Date -1 True False Composite 1251 Not Used -1 False False Composite 782 Not Used -1 False False Composite 380 Not Used -1 False False Composite 799 Not Used -1 False False Composite 1271 Not Used -1 False False Composite 1073 Health Care Code Information Code List Qualifier Code -1 True False Composite 1270 Value Code -1 True False Composite 1271 Not Used -1 False False Composite 1250 Not Used -1 False False Composite 1251 Value Code Amount -1 True False Composite 782 Not Used -1 False False Composite 380 Not Used -1 False False Composite 799 Not Used -1 False False Composite 1271 Not Used -1 False False Composite 1073 Health Care Code Information Code List Qualifier Code -1 True False Composite 1270 Condition Code -1 True False Composite 1271 Not Used -1 False False Composite 1250 Not Used -1 False False Composite 1251 Not Used -1 False False Composite 782 Not Used -1 False False Composite 380 Not Used -1 False False Composite 799 Not Used -1 False False Composite 1271 Not Used -1 False False Composite 1073 Health Care Code Information Code List Qualifier Code -1 True False Composite 1270 Treatment Code -1 True False Composite 1271 Not Used -1 False False Composite 1250 Not Used -1 False False Composite 1251 Not Used -1 False False Composite 782 Not Used -1 False False Composite 380 Not Used -1 False False Composite 799 Not Used -1 False False Composite 1271 Not Used -1 False False Composite 1073 Composite Medical Procedure Identifier Product or Service ID Qualifier -1 True False Composite 235 Procedure Code -1 True False Composite 234 Procedure Modifier -1 False False Composite 1339 Procedure Modifier -1 False False Composite 1339 Procedure Modifier -1 False False Composite 1339 Procedure Modifier -1 False False Composite 1339 Description -1 False False Composite 352 Not Used -1 False False Composite 234 Composite Unit of Measure Code Qualifier -1 True False Composite 355 Not Used -1 False False Composite 1018 Not Used -1 False False Composite 649 Not Used -1 False False Composite 355 Not Used -1 False False Composite 1018 Not Used -1 False False Composite 649 Not Used -1 False False Composite 355 Not Used -1 False False Composite 1018 Not Used -1 False False Composite 649 Not Used -1 False False Composite 355 Not Used -1 False False Composite 1018 Not Used -1 False False Composite 649 Not Used -1 False False Composite 355 Not Used -1 False False Composite 1018 Not Used -1 False False Composite 649 Reference Identifier Reference Identification Qualifier -1 True False Composite 128 Other Payer Primary Identifier -1 True False Composite 127 Not Used -1 False False Composite 128 Not Used -1 False False Composite 127 Not Used -1 False False Composite 128 Not Used -1 False False Composite 127 Reference Identifier Reference Identification Qualifier -1 True False Composite 128 Other Payer Primary Identifier -1 True False Composite 127 Not Used -1 False False Composite 128 Not Used -1 False False Composite 127 Not Used -1 False False Composite 128 Not Used -1 False False Composite 127 Reference Identifier Reference Identification Qualifier -1 True False Composite 128 Other Payer Primary Identifier -1 True False Composite 127 Not Used -1 False False Composite 128 Not Used -1 False False Composite 127 Not Used -1 False False Composite 128 Not Used -1 False False Composite 127 Reference Identifier Reference Identification Qualifier -1 True False Composite 128 Other Payer Primary Identifier -1 True False Composite 127 Not Used -1 False False Composite 128 Not Used -1 False False Composite 127 Not Used -1 False False Composite 128 Not Used -1 False False Composite 127 Composite Medical Procedure Identifier Product or Service ID Qualifier -1 True False Composite 235 Procedure Code -1 True False Composite 234 Procedure Modifier -1 False False Composite 1339 Procedure Modifier -1 False False Composite 1339 Procedure Modifier -1 False False Composite 1339 Procedure Modifier -1 False False Composite 1339 Procedure Code Description -1 False False Composite 352 Not Used -1 False False Composite 234 Health Care Service Location Information Place of Service Code -1 True False Composite 1331 Facility Code Qualifier -1 True False Composite 1332 Claim Frequency Code -1 True False Composite 1325 Related Causes Information Related Causes Code -1 True False Composite 1362 Related Causes Code -1 False False Composite 1362 Not Used -1 False False Composite 1362 Auto Accident State or Province Code -1 False False Composite 156 Country Code -1 False False Composite 26 Health Care Code Information Code List Qualifier Code -1 True False Composite 1270 Diagnosis Code -1 True False Composite 1271 Not Used -1 False False Composite 1250 Not Used -1 False False Composite 1251 Not Used -1 False False Composite 782 Not Used -1 False False Composite 380 Not Used -1 False False Composite 799 Not Used -1 False False Composite 1271 Not Used -1 False False Composite 1073 Composite Medical Procedure Identifier Product or Service ID Qualifier -1 True False Composite 235 Procedure Code -1 True False Composite 234 Procedure Modifier -1 False False Composite 1339 Procedure Modifier -1 False False Composite 1339 Procedure Modifier -1 False False Composite 1339 Procedure Modifier -1 False False Composite 1339 Procedure Code Description -1 False False Composite 352 Not Used -1 False False Composite 234 Oral Cavity Designation Oral Cavity Designation Code -1 True False Composite 1361 Oral Cavity Designation Code -1 False False Composite 1361 Oral Cavity Designation Code -1 False False Composite 1361 Oral Cavity Designation Code -1 False False Composite 1361 Oral Cavity Designation Code -1 False False Composite 1361 Composite Diagnosis Code Pointer Diagnosis Code Pointer -1 True False Composite 1328 Diagnosis Code Pointer -1 False False Composite 1328 Diagnosis Code Pointer -1 False False Composite 1328 Diagnosis Code Pointer -1 False False Composite 1328 Tooth Surface Tooth Surface Code -1 True False Composite 1369 Tooth Surface Code -1 False False Composite 1369 Tooth Surface Code -1 False False Composite 1369 Tooth Surface Code -1 False False Composite 1369 Tooth Surface Code -1 False False Composite 1369 Reference Identifier Reference Identification Qualifier -1 True False Composite 128 Other Payer Primary Identifier -1 True False Composite 127 Not Used -1 False False Composite 128 Not Used -1 False False Composite 127 Not Used -1 False False Composite 128 Not Used -1 False False Composite 127 Reference Identifier Reference Identification Qualifier -1 True False Composite 128 Other Payer Primary Identifier -1 True False Composite 127 Not Used -1 False False Composite 128 Not Used -1 False False Composite 127 Not Used -1 False False Composite 128 Not Used -1 False False Composite 127 Reference Identifier Reference Identification Qualifier -1 True False Composite 128 Other Payer Primary Identifier -1 True False Composite 127 Not Used -1 False False Composite 128 Not Used -1 False False Composite 127 Not Used -1 False False Composite 128 Not Used -1 False False Composite 127 Reference Identifier Reference Identification Qualifier -1 True False Composite 128 Other Payer Primary Identifier -1 True False Composite 127 Not Used -1 False False Composite 128 Not Used -1 False False Composite 127 Not Used -1 False False Composite 128 Not Used -1 False False Composite 127 Reference Identifier Reference Identification Qualifier -1 True False Composite 128 Other Payer Primary Identifier -1 True False Composite 127 Not Used -1 False False Composite 128 Not Used -1 False False Composite 127 Not Used -1 False False Composite 128 Not Used -1 False False Composite 127 Reference Identifier Reference Identification Qualifier -1 True False Composite 128 Other Payer Primary Identifier -1 True False Composite 127 Not Used -1 False False Composite 128 Not Used -1 False False Composite 127 Not Used -1 False False Composite 128 Not Used -1 False False Composite 127 Reference Identifier Reference Identification Qualifier -1 True False Composite 128 Other Payer Primary Identifier -1 True False Composite 127 Not Used -1 False False Composite 128 Not Used -1 False False Composite 127 Not Used -1 False False Composite 128 Not Used -1 False False Composite 127 Composite Medical Procedure Identifier Product or Service ID Qualifier -1 True False Composite 235 Procedure Code -1 True False Composite 234 Procedure Modifier -1 False False Composite 1339 Procedure Modifier -1 False False Composite 1339 Procedure Modifier -1 False False Composite 1339 Procedure Modifier -1 False False Composite 1339 Procedure Code Description -1 False False Composite 352 Not Used -1 False False Composite 234 Health Care Code Information Diagnosis Type Code -1 True False Composite 1270 Diagnosis Code -1 True False Composite 1271 Not Used -1 False False Composite 1250 Not Used -1 False False Composite 1251 Not Used -1 False False Composite 782 Not Used -1 False False Composite 380 Not Used -1 False False Composite 799 Not Used -1 False False Composite 1271 Not Used -1 False False Composite 1073 Composite Medical Procedure Identifier Product or Service ID Qualifier -1 True False Composite 235 Procedure Code -1 True False Composite 234 Procedure Modifier -1 False False Composite 1339 Procedure Modifier -1 False False Composite 1339 Procedure Modifier -1 False False Composite 1339 Procedure Modifier -1 False False Composite 1339 Not Used -1 False False Composite 352 Not Used -1 False False Composite 234 Composite Diagnosis Code Pointer Diagnosis Code Pointer -1 True False Composite 1328 Diagnosis Code Pointer -1 False False Composite 1328 Diagnosis Code Pointer -1 False False Composite 1328 Diagnosis Code Pointer -1 False False Composite 1328 Health Care Code Information Diagnosis Type Code -1 True False Composite 1270 Diagnosis Code -1 True False Composite 1271 Not Used -1 False False Composite 1250 Not Used -1 False False Composite 1251 Not Used -1 False False Composite 782 Not Used -1 False False Composite 380 Not Used -1 False False Composite 799 Not Used -1 False False Composite 1271 Not Used -1 False False Composite 1073 Composite Medical Procedure Identifier Product or Service ID Qualifier -1 True False Composite 235 Procedure Code -1 True False Composite 234 Procedure Modifier -1 False False Composite 1339 Procedure Modifier -1 False False Composite 1339 Procedure Modifier -1 False False Composite 1339 Procedure Modifier -1 False False Composite 1339 Not Used -1 False False Composite 352 Not Used -1 False False Composite 234 Composite Diagnosis Code Pointer Diagnosis Code Pointer -1 True False Composite 1328 Diagnosis Code Pointer -1 False False Composite 1328 Diagnosis Code Pointer -1 False False Composite 1328 Diagnosis Code Pointer -1 False False Composite 1328 Health Care Code Information Diagnosis Type Code -1 True False Composite 1270 Diagnosis Code -1 True False Composite 1271 Not Used -1 False False Composite 1250 Not Used -1 False False Composite 1251 Not Used -1 False False Composite 782 Not Used -1 False False Composite 380 Not Used -1 False False Composite 799 Not Used -1 False False Composite 1271 Not Used -1 False False Composite 1073 Composite Medical Procedure Identifier Product or Service ID Qualifier -1 True False Composite 235 Procedure Code -1 True False Composite 234 Procedure Modifier -1 False False Composite 1339 Procedure Modifier -1 False False Composite 1339 Procedure Modifier -1 False False Composite 1339 Procedure Modifier -1 False False Composite 1339 Not Used -1 False False Composite 352 Product or Service ID -1 False False Composite 234 Composite Diagnosis Code Pointer Diagnosis Code Pointer -1 True False Composite 1328 Diagnosis Code Pointer -1 False False Composite 1328 Diagnosis Code Pointer -1 False False Composite 1328 Diagnosis Code Pointer -1 False False Composite 1328 Health Care Code Information Diagnosis Type Code -1 True False Composite 1270 Diagnosis Code -1 True False Composite 1271 Not Used -1 False False Composite 1250 Not Used -1 False False Composite 1251 Not Used -1 False False Composite 782 Not Used -1 False False Composite 380 Not Used -1 False False Composite 799 Not Used -1 False False Composite 1271 Not Used -1 False False Composite 1073 Composite Medical Procedure Identifier Product or Service ID Qualifier -1 True False Composite 235 Procedure Code -1 True False Composite 234 Procedure Modifier -1 False False Composite 1339 Procedure Modifier -1 False False Composite 1339 Procedure Modifier -1 False False Composite 1339 Procedure Modifier -1 False False Composite 1339 Not Used -1 False False Composite 352 Product or Service ID -1 False False Composite 234 Composite Diagnosis Code Pointer Diagnosis Code Pointer -1 True False Composite 1328 Diagnosis Code Pointer -1 False False Composite 1328 Diagnosis Code Pointer -1 False False Composite 1328 Diagnosis Code Pointer -1 False False Composite 1328 Health Care Service Location Information Place of Service Code -1 True False Composite 1331 Facility Code Qualifier -1 True False Composite 1332 Claim Frequency Code -1 True False Composite 1325 Related Causes Information Related Causes Code -1 True False Composite 1362 Related Causes Code -1 False False Composite 1362 Not Used -1 False False Composite 1362 Auto Accident State or Province Code -1 False False Composite 156 Country Code -1 False False Composite 26 Health Care Code Information Diagnosis Type Code -1 True False Composite 1270 Diagnosis Code -1 True False Composite 1271 Not Used -1 False False Composite 1250 Not Used -1 False False Composite 1251 Not Used -1 False False Composite 782 Not Used -1 False False Composite 380 Not Used -1 False False Composite 799 Not Used -1 False False Composite 1271 Not Used -1 False False Composite 1073 Health Care Code Information Code List Qualifier Code -1 True False Composite 1270 Industry Code -1 True False Composite 1271 Not Used -1 False False Composite 1250 Not Used -1 False False Composite 1251 Not Used -1 False False Composite 782 Not Used -1 False False Composite 380 Not Used -1 False False Composite 799 Not Used -1 False False Composite 1271 Not Used -1 False False Composite 1073 Health Care Code Information Code List Qualifier Code -1 True False Composite 1270 Condition Code -1 True False Composite 1271 Not Used -1 False False Composite 1250 Not Used -1 False False Composite 1251 Not Used -1 False False Composite 782 Not Used -1 False False Composite 380 Not Used -1 False False Composite 799 Not Used -1 False False Composite 1271 Not Used -1 False False Composite 1073 Composite Medical Procedure Identifier Product or Service ID Qualifier -1 True False Composite 235 Procedure Code -1 True False Composite 234 Procedure Modifier -1 False False Composite 1339 Procedure Modifier -1 False False Composite 1339 Procedure Modifier -1 False False Composite 1339 Procedure Modifier -1 False False Composite 1339 Description -1 False False Composite 352 Not Used -1 False False Composite 234 Composite Diagnosis Code Pointer Diagnosis Code Pointer -1 True False Composite 1328 Diagnosis Code Pointer -1 False False Composite 1328 Diagnosis Code Pointer -1 False False Composite 1328 Diagnosis Code Pointer -1 False False Composite 1328 Composite Medical Procedure Identifier Procedure Identifier -1 True False Composite 235 Procedure Code -1 True False Composite 234 Not Used -1 False False Composite 1339 Not Used -1 False False Composite 1339 Not Used -1 False False Composite 1339 Not Used -1 False False Composite 1339 Not Used -1 False False Composite 352 Not Used -1 False False Composite 234 Reference Identifier Reference Identification Qualifier -1 True False Composite 128 Other Payer Primary Identifier -1 True False Composite 127 Not Used -1 False False Composite 128 Not Used -1 False False Composite 127 Not Used -1 False False Composite 128 Not Used -1 False False Composite 127 Reference Identifier Reference Identification Qualifier -1 True False Composite 128 Other Payer Primary Identifier -1 True False Composite 127 Not Used -1 False False Composite 128 Not Used -1 False False Composite 127 Not Used -1 False False Composite 128 Not Used -1 False False Composite 127 Composite Unit of Measure Code Qualifier -1 True False Composite 355 Not Used -1 False False Composite 1018 Not Used -1 False False Composite 649 Not Used -1 False False Composite 355 Not Used -1 False False Composite 1018 Not Used -1 False False Composite 649 Not Used -1 False False Composite 355 Not Used -1 False False Composite 1018 Not Used -1 False False Composite 649 Not Used -1 False False Composite 355 Not Used -1 False False Composite 1018 Not Used -1 False False Composite 649 Not Used -1 False False Composite 355 Not Used -1 False False Composite 1018 Not Used -1 False False Composite 649 Reference Identifier Reference Identification Qualifier -1 True False Composite 128 Other Payer Primary Identifier -1 True False Composite 127 Not Used -1 False False Composite 128 Not Used -1 False False Composite 127 Not Used -1 False False Composite 128 Not Used -1 False False Composite 127 Reference Identifier Reference Identification Qualifier -1 True False Composite 128 Other Payer Primary Identifier -1 True False Composite 127 Not Used -1 False False Composite 128 Not Used -1 False False Composite 127 Not Used -1 False False Composite 128 Not Used -1 False False Composite 127 Reference Identifier Reference Identification Qualifier -1 True False Composite 128 Other Payer Primary Identifier -1 True False Composite 127 Not Used -1 False False Composite 128 Not Used -1 False False Composite 127 Not Used -1 False False Composite 128 Not Used -1 False False Composite 127 Reference Identifier Reference Identification Qualifier -1 True False Composite 128 Other Payer Primary Identifier -1 True False Composite 127 Not Used -1 False False Composite 128 Not Used -1 False False Composite 127 Not Used -1 False False Composite 128 Not Used -1 False False Composite 127 Reference Identifier Reference Identification Qualifier -1 True False Composite 128 Other Payer Primary Identifier -1 True False Composite 127 Not Used -1 False False Composite 128 Not Used -1 False False Composite 127 Not Used -1 False False Composite 128 Not Used -1 False False Composite 127 Reference Identifier Reference Identification Qualifier -1 True False Composite 128 Other Payer Primary Identifier -1 True False Composite 127 Not Used -1 False False Composite 128 Not Used -1 False False Composite 127 Not Used -1 False False Composite 128 Not Used -1 False False Composite 127 Composite Medical Procedure Identifier Product or Service ID Qualifier -1 True False Composite 235 Procedure Code -1 True False Composite 234 Procedure Modifier -1 False False Composite 1339 Procedure Modifier -1 False False Composite 1339 Procedure Modifier -1 False False Composite 1339 Procedure Modifier -1 False False Composite 1339 Procedure Code Description -1 False False Composite 352 Not Used -1 False False Composite 234 Position in Segment Element Position in Segment -1 True False Composite 722 Component Data Element Position in Composite -1 False False Composite 1528 Repeating Data Element Position -1 False False Composite 1686 Position in Segment Accident Date -1 True False Composite 722 Accident Date -1 False False Composite 1528 Accident Date -1 False False Composite 1686 Context Identification Context Name -1 True False Composite 9999 Context Reference -1 False False Composite 9998 Reference in Segment Data Element Reference Number -1 True False Composite 725 Data Element Reference Number -1 False False Composite 725 Context Identification Context Name -1 True False Composite 9999 Not Used -1 False False Composite 9998 Position in Segment Element Position in Segment -1 True False Composite 722 Component Data Element Position in Composite -1 False False Composite 1528 Repeating Data Element Position -1 False False Composite 1686 Reference in Segment Data Element Reference Number -1 True False Composite 725 Not Used -1 False False Composite 725 Context Identification Context Name -1 True False Composite 9999 Context Reference -1 True False Composite 9998 Position in Segment Element Position in Segment -1 True False Composite 722 Component Data Element Position in Composite -1 False False Composite 1528 Repeating Data Element Position -1 False False Composite 1686 Context Identification Context Name -1 True False Composite 9999 Not Used -1 False False Composite 9998 Position in Segment Element Position in Segment -1 True False Composite 722 Component Data Element Position in Composite -1 False False Composite 1528 Repeating Data Element Position -1 False False Composite 1686 Reference in Segment Data Element Reference Number -1 True False Composite 725 Not Used -1 False False Composite 725 AMT Monetary Amount Information True Amount Qualifier Code 0 True -1 522 Monetary Amount 0 True -1 782 Credit/Debit Flag Code 0 False -1 478 BHT Beginning of Hierarchical Transaction True Hierarchical Structure Code 0 True -1 1005 Transaction Set Purpose Code 0 True -1 353 Reference Identification 0 False -1 127 Date 0 False -1 373 Time 0 False -1 337 Transaction Type Code 0 False -1 640 DMG Demographic Information True Date Time Period Format Qualifier 0 False -1 1250 Date Time Period 0 False -1 1251 Gender Code 0 False -1 1068 Marital Status Code 0 False -1 1067 Composite Race or Ethnicity Information 0 False -1 C056 Citizenship Status Code 0 False -1 1066 Country Code 0 False -1 26 Basis of Verification Code 0 False -1 659 Quantity 0 False -1 380 Code List Qualifier Code 0 False -1 1270 Industry Code 0 False -1 1271 DTP Date or Time or Period True Date/Time Qualifier 0 True -1 374 Date Time Period Format Qualifier 0 True -1 1250 Date Time Period 0 True -1 1251 HL Hierarchical Level True Hierarchical ID Number 0 True -1 628 Hierarchical Parent ID Number 0 False -1 734 Hierarchical Level Code 0 True -1 735 Hierarchical Child Code 0 False -1 736 N2 Additional Name Information True Name 0 True -1 93 Name 0 False -1 93 N3 Party Location True Address Information 0 True -1 166 Address Information 0 False -1 166 N4 Geographic Location True City Name 0 False -1 19 State or Province Code 0 False -1 156 Postal Code 0 False -1 116 Country Code 0 False -1 26 Location Qualifier 0 False -1 309 Location Identifier 0 False -1 310 Country Subdivision Code 0 False -1 1715 NM1 Individual or Organizational Name True Entity Identifier Code 0 True -1 98 Entity Type Qualifier 0 True -1 1065 Name Last or Organization Name 0 False -1 1035 Name First 0 False -1 1036 Name Middle 0 False -1 1037 Name Prefix 0 False -1 1038 Name Suffix 0 False -1 1039 Identification Code Qualifier 0 False -1 66 Identification Code 0 False -1 67 Entity Relationship Code 0 False -1 706 Entity Identifier Code 0 False -1 98 Name Last or Organization Name 0 False -1 1035 PAT Patient Information True Individual Relationship Code 0 False -1 1069 Patient Location Code 0 False -1 1384 Employment Status Code 0 False -1 584 Student Status Code 0 False -1 1220 Date Time Period Format Qualifier 0 False -1 1250 Date Time Period 0 False -1 1251 Unit or Basis for Measurement Code 0 False -1 355 Weight 0 False -1 81 Yes/No Condition or Response Code 0 False -1 1073 PER Administrative Communications Contact True Contact Function Code 0 True -1 366 Name 0 False -1 93 Communication Number Qualifier 0 False -1 365 Communication Number 0 False -1 364 Communication Number Qualifier 0 False -1 365 Communication Number 0 False -1 364 Communication Number Qualifier 0 False -1 365 Communication Number 0 False -1 364 Contact Inquiry Reference 0 False -1 443 REF Reference Information True Reference Identification Qualifier 0 True -1 128 Reference Identification 0 False -1 127 Description 0 False -1 352 Reference Identifier 0 False -1 C040 SBR Subscriber Information True Payer Responsibility Sequence Number Code 0 True -1 1138 Individual Relationship Code 0 False -1 1069 Reference Identification 0 False -1 127 Name 0 False -1 93 Insurance Type Code 0 False -1 1336 Coordination of Benefits Code 0 False -1 1143 Yes/No Condition or Response Code 0 False -1 1073 Employment Status Code 0 False -1 584 Claim Filing Indicator Code 0 False -1 1032 SE Transaction Set Trailer True Number of Included Segments 0 True -1 96 Transaction Set Control Number 0 True -1 329 ST Transaction Set Header True Transaction Set Identifier Code 0 True -1 143 Transaction Set Control Number 0 True -1 329 Implementation Convention Reference 0 False -1 1705 SVC Service Information True Composite Medical Procedure Identifier 0 True -1 C003 Monetary Amount 0 True -1 782 Monetary Amount 0 False -1 782 Product/Service ID 0 False -1 234 Quantity 0 False -1 380 Composite Medical Procedure Identifier 0 False -1 C003 Quantity 0 False -1 380 TRN Trace True Trace Type Code 0 True -1 481 Reference Identification 0 True -1 127 Originating Company Identifier 0 False -1 509 Reference Identification 0 False -1 127 ST Transaction Set Header S0100 A1 True Transaction Set Identifier Code 0 True -1 143 Transaction Set Control Number 0 True -1 329 Version, Release, or Industry Identifier 0 False -1 1705 276 0 0 BHT Beginning of Hierarchical Transaction S0200 A1 True Hierarchical Structure Code 0 True -1 1005 Transaction Set Purpose Code 0 True -1 353 Reference Identification 0 False -1 127 Transaction Set Creation Date 0 False -1 373 Transaction Set Creation Time 0 False -1 337 Transaction Type Code 0 False -1 640 0010 0 0 13 1 0 HL Information Source Level S0100 A2 True Hierarchical ID Number 0 True -1 628 Hierarchical Parent ID Number 0 False -1 734 Hierarchical Level Code 0 True -1 735 Hierarchical Child Code 0 False -1 736 20 2 0 NM1 Payer Name S0500 A2 True Entity Identifier Code 0 True -1 98 Entity Type Qualifier 0 True -1 1065 Payer Name 0 False -1 1035 Name First 0 False -1 1036 Name Middle 0 False -1 1037 Name Prefix 0 False -1 1038 Name Suffix 0 False -1 1039 Identification Code Qualifier 0 False -1 66 Payer Identifier 0 False -1 67 Entity Relationship Code 0 False -1 706 Entity Identifier Code 0 False -1 98 Name Last or Organization Name 0 False -1 1035 PR 0 0 2 1 0 HL Information Receiver Level S0100 A3 True Hierarchical ID Number 0 True -1 628 Hierarchical Parent ID Number 0 False -1 734 Hierarchical Level Code 0 True -1 735 Hierarchical Child Code 0 False -1 736 21 2 0 NM1 Information Receiver Name S0500 A3 True Entity Identifier Code 0 True -1 98 Entity Type Qualifier 0 True -1 1065 Information Receiver Last or Organization Name 0 False -1 1035 Information Receiver First Name 0 False -1 1036 Information Receiver Middle Name 0 False -1 1037 Name Prefix 0 False -1 1038 Name Suffix 0 False -1 1039 Identification Code Qualifier 0 False -1 66 Information Receiver Identification Number 0 False -1 67 Entity Relationship Code 0 False -1 706 Entity Identifier Code 0 False -1 98 Name Last or Organization Name 0 False -1 1035 41 0 0 1|2 1 0 HL Service Provider Level S0100 A4 True Hierarchical ID Number 0 True -1 628 Hierarchical Parent ID Number 0 False -1 734 Hierarchical Level Code 0 True -1 735 Hierarchical Child Code 0 False -1 736 19 2 0 NM1 Provider Name S0500 A4 True Entity Identifier Code 0 True -1 98 Entity Type Qualifier 0 True -1 1065 Provider Last or Organization Name 0 False -1 1035 Provider First Name 0 False -1 1036 Provider Middle Name 0 False -1 1037 Name Prefix 0 False -1 1038 Provider Name Suffix 0 False -1 1039 Identification Code Qualifier 0 False -1 66 Provider Identifier 0 False -1 67 Entity Relationship Code 0 False -1 706 Entity Identifier Code 0 False -1 98 Name Last or Organization Name 0 False -1 1035 1P 0 0 1|2 1 0 HL Subscriber Level S0100 A5 True Hierarchical ID Number 0 True -1 628 Hierarchical Parent ID Number 0 False -1 734 Hierarchical Level Code 0 True -1 735 Hierarchical Child Code 0 False -1 736 22 2 0 DMG Subscriber Demographic Information S0400 A5 True Date Time Period Format Qualifier 0 False -1 1250 Subscriber Birth Date 0 False -1 1251 Subscriber Gender Code 0 False -1 1068 Marital Status Code 0 False -1 1067 Composite Race or Ethnicity Information 0 False -1 C056 Citizenship Status Code 0 False -1 1066 Country Code 0 False -1 26 Basis of Verification Code 0 False -1 659 Quantity 0 False -1 380 Code List Qualifier Code 0 False -1 1270 Industry Code 0 False -1 1271 NM1 Subscriber Name S0500 A5 True Entity Identifier Code 0 True -1 98 Entity Type Qualifier 0 True -1 1065 Subscriber Last Name 0 False -1 1035 Subscriber First Name 0 False -1 1036 Subscriber Middle Name or Initial 0 False -1 1037 Name Prefix 0 False -1 1038 Subscriber Name Suffix 0 False -1 1039 Identification Code Qualifier 0 False -1 66 Subscriber Identifier 0 False -1 67 Entity Relationship Code 0 False -1 706 Entity Identifier Code 0 False -1 98 Name Last or Organization Name 0 False -1 1035 IL 0 0 1|2 1 0 TRN Claim Status Tracking Number S0900 A5 True Trace Type Code 0 True -1 481 Current Transaction Trace Number 0 True -1 127 Originating Company Identifier 0 False -1 509 Reference Identification 0 False -1 127 1 0 0 REF Payer Claim Control Number S1000 A5 True Reference Identification Qualifier 0 True -1 128 Payer Claim Control Number 0 False -1 127 Description 0 False -1 352 Reference Identifier 0 False -1 C040 1K 0 0 REF Institutional Bill Type Identification S1010 A5 True Reference Identification Qualifier 0 True -1 128 Bill Type Identifier 0 False -1 127 Description 0 False -1 352 Reference Identifier 0 False -1 C040 BLT 0 0 REF Application or Location System Identifier S1030 A5 True Reference Identification Qualifier 0 True -1 128 Application or Location System Identifier 0 False -1 127 Description 0 False -1 352 Reference Identifier 0 False -1 C040 LU 0 0 REF Group Number S1035 A5 True Reference Identification Qualifier 0 True -1 128 Group Number 0 False -1 127 Description 0 False -1 352 Reference Identifier 0 False -1 C040 6P 0 0 REF Patient Control Number S1040 A5 True Reference Identification Qualifier 0 True -1 128 Patient Control Number 0 False -1 127 Description 0 False -1 352 Reference Identifier 0 False -1 C040 EJ 0 0 REF Pharmacy Prescription Number S1045 A5 True Reference Identification Qualifier 0 True -1 128 Pharmacy Prescription Number 0 False -1 127 Description 0 False -1 352 Reference Identifier 0 False -1 C040 XZ 0 0 REF Claim Identification Number For Clearinghouses and Other Transmission Intermediaries S1050 A5 True Reference Identification Qualifier 0 True -1 128 Clearinghouse Trace Number 0 False -1 127 Description 0 False -1 352 Reference Identifier 0 False -1 C040 D9 0 0 AMT Claim Submitted Charges S1100 A5 True Amount Qualifier Code 0 True -1 522 Total Claim Charge Amount 0 True -1 782 Credit/Debit Flag Code 0 False -1 478 T3 0 0 DTP Claim Service Date S1200 A5 True Date Time Qualifier 0 True -1 374 Date Time Period Format Qualifier 0 True -1 1250 Claim Service Period 0 True -1 1251 472 0 0 D8|RD8 1 0 SVC Service Line Information S1300 A5 True Composite Medical Procedure Identifier 0 True -1 C003_276-A1_SVC_5_1300 Line Item Charge Amount 0 True -1 782 Monetary Amount 0 False -1 782 Revenue Code 0 False -1 234 Quantity 0 False -1 380 Composite Medical Procedure Identifier 0 False -1 C003 Units of Service Count 0 False -1 380 REF Service Line Item Identification S1400 A5 True Reference Identification Qualifier 0 True -1 128 Line Item Control Number 0 False -1 127 Description 0 False -1 352 Reference Identifier 0 False -1 C040 FJ 0 0 DTP Service Line Date S1500 A5 True Date Time Qualifier 0 True -1 374 Date Time Period Format Qualifier 0 True -1 1250 Service Line Date 0 True -1 1251 472 0 0 D8|RD8 1 0 HL Dependent Level S0100 A6 True Hierarchical ID Number 0 True -1 628 Hierarchical Parent ID Number 0 False -1 734 Hierarchical Level Code 0 True -1 735 Hierarchical Child Code 0 False -1 736 23 2 0 DMG Dependent Demographic Information S0400 A6 True Date Time Period Format Qualifier 0 False -1 1250 Patient Birth Date 0 False -1 1251 Patient Gender Code 0 False -1 1068 Marital Status Code 0 False -1 1067 Composite Race or Ethnicity Information 0 False -1 C056 Citizenship Status Code 0 False -1 1066 Country Code 0 False -1 26 Basis of Verification Code 0 False -1 659 Quantity 0 False -1 380 Code List Qualifier Code 0 False -1 1270 Industry Code 0 False -1 1271 NM1 Dependent Name S0500 A6 True Entity Identifier Code 0 True -1 98 Entity Type Qualifier 0 True -1 1065 Patient Last Name 0 False -1 1035 Patient First Name 0 False -1 1036 Patient Middle Name or Initial 0 False -1 1037 Name Prefix 0 False -1 1038 Patient Name Suffix 0 False -1 1039 Identification Code Qualifier 0 False -1 66 Identification Code 0 False -1 67 Entity Relationship Code 0 False -1 706 Entity Identifier Code 0 False -1 98 Name Last or Organization Name 0 False -1 1035 QC 0 0 1 1 0 TRN 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Qualifier 0 True -1 128 Requester Supplemental Identifier 0 False -1 127 Description 0 False -1 352 Reference Identifier 0 False -1 C040 1G|1J|EI|G5|N5|N7|SY|ZH 0 0 N3 Requester Address S2000 A3 True Requester Address Line 0 True -1 166 Requester Address Line 0 False -1 166 N4 Requester City, State, ZIP Code S2100 A3 True Requester City Name 0 False -1 19 Requester State or Province Code 0 False -1 156 Requester Postal Zone or ZIP Code 0 False -1 116 Country Code 0 False -1 26 Location Qualifier 0 False -1 309 Location Identifier 0 False -1 310 Country Subdivision Code 0 False -1 1715 PER Requester Contact Information S2200 A3 True Contact Function Code 0 True -1 366 Requester Contact Name 0 False -1 93 Communication Number Qualifier 0 False -1 365 Requester Contact Communication Number 0 False -1 364 Communication Number Qualifier 0 False -1 365 Requester Contact Communication Number 0 False -1 364 Communication Number Qualifier 0 False -1 365 Requester Contact Communication Number 0 False -1 364 Contact Inquiry Reference 0 False -1 443 IC 0 0 PRV Requester Provider Information S2400 A3 True Provider Code 0 True -1 1221 Reference Identification Qualifier 0 False -1 128 Provider Taxonomy Code 0 False -1 127 State or Province Code 0 False -1 156 Provider Specialty Information 0 False -1 C035 Provider Organization Code 0 False -1 1223 AD|AS|AT|CO|CV|OP|OR|OT|PC|PE|RF 0 0 HL Subscriber Level S0100 A4 True Hierarchical ID Number 0 True -1 628 Hierarchical Parent ID Number 0 False -1 734 Hierarchical Level Code 0 True -1 735 Hierarchical Child Code 0 False -1 736 22 2 0 NM1 Subscriber Name S1700 A4 True Entity Identifier Code 0 True -1 98 Entity Type Qualifier 0 True -1 1065 Subscriber Last Name 0 False -1 1035 Subscriber First Name 0 False -1 1036 Subscriber Middle Name or Initial 0 False -1 1037 Subscriber Name Prefix 0 False -1 1038 Subscriber Name Suffix 0 False -1 1039 Identification Code Qualifier 0 False -1 66 Subscriber Primary Identifier 0 False -1 67 Entity Relationship Code 0 False -1 706 Entity Identifier Code 0 False -1 98 Name Last or Organization Name 0 False -1 1035 IL 0 0 1 1 0 REF Subscriber Supplemental Identification S1800 A4 True Reference Identification Qualifier 0 True -1 128 Subscriber Supplemental Identifier 0 False -1 127 Description 0 False -1 352 Reference Identifier 0 False -1 C040 1L|3L|6P|DP|EJ|F6|HJ|IG|N6|NQ|SY 0 0 N3 Subscriber Address S2000 A4 True Subscriber Address Line 0 True -1 166 Subscriber Address Line 0 False -1 166 N4 Subscriber City, State, ZIP Code S2100 A4 True Subscriber City Name 0 False -1 19 Subscriber State Code 0 False -1 156 Subscriber Postal Zone or ZIP Code 0 False -1 116 Country Code 0 False -1 26 Location Qualifier 0 False -1 309 Location Identifier 0 False -1 310 Country Subdivision Code 0 False -1 1715 DMG Subscriber Demographic Information S2500 A4 True Date Time Period Format Qualifier 0 False -1 1250 Subscriber Birth Date 0 False -1 1251 Subscriber Gender Code 0 False -1 1068 Marital Status Code 0 False -1 1067 Composite Race or Ethnicity Information 0 False -1 C056 Citizenship Status Code 0 False -1 1066 Country Code 0 False -1 26 Basis of Verification Code 0 False -1 659 Quantity 0 False -1 380 Code List Qualifier Code 0 False -1 1270 Industry Code 0 False -1 1271 INS Subscriber Relationship S2600 A4 True Insured Indicator 0 True -1 1073 Individual Relationship Code 0 True -1 1069 Maintenance Type Code 0 False -1 875 Maintenance Reason Code 0 False -1 1203 Benefit Status Code 0 False -1 1216 Medicare Status Code 0 False -1 C052 Consolidated Omnibus Budget Reconciliation Act (COBRA) Qualifying 0 False -1 1219 Employment Status Code 0 False -1 584 Student Status Code 0 False -1 1220 Yes/No Condition or Response Code 0 False -1 1073 Date Time Period Format Qualifier 0 False -1 1250 Date Time Period 0 False -1 1251 Confidentiality Code 0 False -1 1165 City Name 0 False -1 19 State or Province Code 0 False -1 156 Country Code 0 False -1 26 Number 0 False -1 1470 Y 0 0 18 1 0 HL Dependent Level S0100 A5 True Hierarchical ID Number 0 True -1 628 Hierarchical Parent ID Number 0 False -1 734 Hierarchical Level Code 0 True -1 735 Hierarchical Child Code 0 False -1 736 23 2 0 NM1 Dependent Name S1700 A5 True Entity Identifier Code 0 True -1 98 Entity Type Qualifier 0 True -1 1065 Dependent Last Name 0 False -1 1035 Dependent First Name 0 False -1 1036 Dependent Middle Name 0 False -1 1037 Name Prefix 0 False -1 1038 Dependent Name Suffix 0 False -1 1039 Identification Code Qualifier 0 False -1 66 Identification Code 0 False -1 67 Entity Relationship Code 0 False -1 706 Entity Identifier Code 0 False -1 98 Name Last or Organization Name 0 False -1 1035 QC 0 0 1 1 0 REF Dependent Supplemental Identification S1800 A5 True Reference Identification Qualifier 0 True -1 128 Dependent Supplemental Identifier 0 False -1 127 Description 0 False -1 352 Reference Identifier 0 False -1 C040 EJ|SY 0 0 N3 Dependent Address S2000 A5 True Dependent Address Line 0 True -1 166 Dependent Address Line 0 False -1 166 N4 Dependent City, State, ZIP Code S2100 A5 True Dependent City Name 0 False -1 19 Dependent State Code 0 False -1 156 Dependent Postal Zone or ZIP Code 0 False -1 116 Country Code 0 False -1 26 Location Qualifier 0 False -1 309 Location Identifier 0 False -1 310 Country Subdivision Code 0 False -1 1715 DMG Dependent Demographic Information S2500 A5 True Date Time Period Format Qualifier 0 False -1 1250 Dependent Birth Date 0 False -1 1251 Dependent Gender Code 0 False -1 1068 Marital Status Code 0 False -1 1067 Composite Race or Ethnicity Information 0 False -1 C056 Citizenship Status Code 0 False -1 1066 Country Code 0 False -1 26 Basis of Verification Code 0 False -1 659 Quantity 0 False -1 380 Code List Qualifier Code 0 False -1 1270 Industry Code 0 False -1 1271 INS Dependent Relationship S2600 A5 True Insured Indicator 0 True -1 1073 Individual Relationship Code 0 True -1 1069 Maintenance Type Code 0 False -1 875 Maintenance Reason Code 0 False -1 1203 Benefit Status Code 0 False -1 1216 Medicare Status Code 0 False -1 C052 Consolidated Omnibus Budget Reconciliation Act (COBRA) Qualifying 0 False -1 1219 Employment Status Code 0 False -1 584 Student Status Code 0 False -1 1220 Yes/No Condition or Response Code 0 False -1 1073 Date Time Period Format Qualifier 0 False -1 1250 Date Time Period 0 False -1 1251 Confidentiality Code 0 False -1 1165 City Name 0 False -1 19 State or Province Code 0 False -1 156 Country Code 0 False -1 26 Birth Sequence Number 0 False -1 1470 N 0 0 01|19|G8 1 0 HL Patient Event Level S0100 A6 True Hierarchical ID Number 0 True -1 628 Hierarchical Parent ID Number 0 False -1 734 Hierarchical Level Code 0 True -1 735 Hierarchical Child Code 0 False -1 736 EV 2 0 TRN Patient Event Tracking Number S0200 A6 True Trace Type Code 0 True -1 481 Patient Event Trace Number 0 True -1 127 Trace Assigning Entity Identifier 0 False -1 509 Trace Assigning Entity Additional Identifier 0 False -1 127 1 0 0 UM Health Care Services Review Information S0400 A6 True Request Category Code 0 True -1 1525 Certification Type Code 0 False -1 1322 Service Type Code 0 False -1 1365 Health Care Service Location Information 0 False -1 C023_278-A1_UM_6_0400 Related Causes Information 0 False -1 C024_278-A1_UM_6_0400 Level of Service Code 0 False -1 1338 Current Health Condition Code 0 False -1 1213 Prognosis Code 0 False -1 923 Release of Information Code 0 False -1 1363 Delay Reason Code 0 False -1 1514 AR|HS|IN|SC 0 0 REF Previous Review Authorization Number S0600 A6 True Reference Identification Qualifier 0 True -1 128 Previous Review Authorization Number 0 False -1 127 Description 0 False -1 352 Reference Identifier 0 False -1 C040 BB 0 0 REF Previous Review Administrative Reference Number S0610 A6 True Reference Identification Qualifier 0 True -1 128 Previous Administrative Reference Number 0 False -1 127 Description 0 False -1 352 Reference Identifier 0 False -1 C040 NT 0 0 DTP Accident Date S0700 A6 True Date Time Qualifier 0 True -1 374 Date Time Period Format Qualifier 0 True -1 1250 Accident Date 0 True -1 1251 439 0 0 D8 1 0 DTP Last Menstrual Period Date S0720 A6 True Date Time Qualifier 0 True -1 374 Date Time Period Format Qualifier 0 True -1 1250 Last Menstrual Period Date 0 True -1 1251 484 0 0 D8 1 0 DTP Estimated Date of Birth S0740 A6 True Date Time Qualifier 0 True -1 374 Date Time Period Format Qualifier 0 True -1 1250 Estimated Birth Date 0 True -1 1251 ABC 0 0 D8 1 0 DTP Onset of Current Symptoms or Illness Date S0760 A6 True Date Time Qualifier 0 True -1 374 Date Time Period Format Qualifier 0 True -1 1250 Onset Date 0 True -1 1251 431 0 0 D8 1 0 DTP Event Date S0765 A6 True Date Time Qualifier 0 True -1 374 Date Time Period Format Qualifier 0 True -1 1250 Proposed or Actual Event Date 0 True -1 1251 AAH 0 0 D8|RD8 1 0 DTP Admission Date S0770 A6 True Date Time Qualifier 0 True -1 374 Date Time Period Format Qualifier 0 True -1 1250 Proposed or Actual Admission Date 0 True -1 1251 435 0 0 D8|RD8 1 0 DTP Discharge Date S0775 A6 True Date Time Qualifier 0 True -1 374 Date Time Period Format Qualifier 0 True -1 1250 Proposed or Actual Discharge Date 0 True -1 1251 096 0 0 D8 1 0 HI Patient Diagnosis S0800 A6 True Health Care Code Information 0 True -1 C022_278-A1_HI_6_0800 Health Care Code Information 0 False -1 C022 Health Care Code Information 0 False -1 C022 Health Care Code Information 0 False -1 C022 Health Care Code Information 0 False -1 C022 Health Care Code Information 0 False -1 C022 Health Care Code Information 0 False -1 C022 Health Care Code Information 0 False -1 C022 Health Care Code Information 0 False -1 C022 Health Care Code Information 0 False -1 C022 Health Care Code Information 0 False -1 C022 Health Care Code Information 0 False -1 C022 HSD Health Care Services Delivery S0900 A6 True Quantity Qualifier 0 False -1 673 Service Unit Count 0 False -1 380 Unit or Basis for Measurement Code 0 False -1 355 Sample Selection Modulus 0 False -1 1167 Time Period Qualifier 0 False -1 615 Period Count 0 False -1 616 Delivery Frequency Code 0 False -1 678 Delivery Pattern Time Code 0 False -1 679 CRC Ambulance Certification Information S1000 A6 True Code Category 0 True -1 1136 Certification Condition Indicator 0 True -1 1073 Condition Code 0 True -1 1321 Condition Code 0 False -1 1321 Condition Code 0 False -1 1321 Condition Code 0 False -1 1321 Condition Code 0 False -1 1321 07 0 0 N|Y 1 0 01|02|03|04|05|06|07|08|09|41|43|5A|60|9D 2 0 CRC Chiropractic Certification Information S1005 A6 True Code Category 0 True -1 1136 Certification Condition Indicator 0 True -1 1073 Condition Code 0 True -1 1321 Condition Code 0 False -1 1321 Condition Code 0 False -1 1321 Condition Code 0 False -1 1321 Condition Code 0 False -1 1321 08 0 0 N|Y 1 0 11|12|14|24|25|27|30 2 0 CRC Durable Medical Equipment Information S1010 A6 True Code Category 0 True -1 1136 Certification Condition Indicator 0 True -1 1073 Condition Code 0 True -1 1321 Condition Code 0 False -1 1321 Condition Code 0 False -1 1321 Condition Code 0 False -1 1321 Condition Code 0 False -1 1321 09 0 0 N|Y 1 0 01|02|03|04|05|06|07|08|09|10|11|12|13|14|15|16|17|18|19|20|21|22|23|24|25|26|27|29|30|31|32|33|35|37|38|40|41|42|43|44|45|46|58|59|60|9D|9H|9J|9K|IH|LB|SL 2 0 CRC Oxygen Therapy Certification Information S1015 A6 True Code Category 0 True -1 1136 Certification Condition Indicator 0 True -1 1073 Condition Code 0 True -1 1321 Condition Code 0 False -1 1321 Condition Code 0 False -1 1321 Condition Code 0 False -1 1321 Condition Code 0 False -1 1321 11 0 0 N|Y 1 0 06|16|17|25|33|37|39|5A|9J|9K|DY 2 0 CRC Functional Limitations Information S1020 A6 True Code Category 0 True -1 1136 Certification Condition Indicator 0 True -1 1073 Condition Code 0 True -1 1321 Condition Code 0 False -1 1321 Condition Code 0 False -1 1321 Condition Code 0 False -1 1321 Condition Code 0 False -1 1321 75 0 0 N|Y 1 0 02|03|04|05|06|11|12|14|15|16|17|18|19|20|21|22|23|24|25|26|27|28|30|31|32|35|37|39|40|41|42|43|44|45|46|5A|68|69|9E|9F|9H|AA|AL|BL|BPD|BTD|CA|CB|CNJ|CO|DY|EL|EP|HL|LB|LE|OL|PA|PW|SL|TNJ|WA|WR 2 0 CRC Activities Permitted Information S1025 A6 True Code Category 0 True -1 1136 Certification Condition Indicator 0 True -1 1073 Condition Code 0 True -1 1321 Condition Code 0 False -1 1321 Condition Code 0 False -1 1321 Condition Code 0 False -1 1321 Condition Code 0 False -1 1321 76 0 0 N|Y 1 0 10|13|19|21|22|27|31|40|BR|CA|CB|CR|EL|EP|IH|NR|PA|PW|TR|UT|WA|WR 2 0 CRC Mental Status Information S1030 A6 True Code Category 0 True -1 1136 Certification Condition Indicator 0 True -1 1073 Condition Code 0 True -1 1321 Condition Code 0 False -1 1321 Condition Code 0 False -1 1321 Condition Code 0 False -1 1321 Condition Code 0 False -1 1321 77 0 0 N|Y 1 0 01|05|07|13|20|22|23|26|33|34|5A|68|69|9E|9F|9J|9K|AG|BPD|BTD|CB|CM|DI|DP|FO|HO|LE|MC|OT|UN 2 0 CL1 Institutional Claim Code S1100 A6 True Admission Type Code 0 False -1 1315 Admission Source Code 0 False -1 1314 Patient Status Code 0 False -1 1352 Nursing Home Residential Status Code 0 False -1 1345 CR1 Ambulance Transport Information S1200 A6 True Unit or Basis for Measurement Code 0 False -1 355 Patient Weight 0 False -1 81 Ambulance Transport Code 0 False -1 1316 Ambulance Transport Reason Code 0 False -1 1317 Unit or Basis for Measurement Code 0 False -1 355 Transport Distance 0 False -1 380 Address Information 0 False -1 166 Address Information 0 False -1 166 Round Trip Purpose Description 0 False -1 352 Stretcher Purpose Description 0 False -1 352 CR2 Spinal Manipulation Service Information S1300 A6 True Treatment Series Number 0 False -1 609 Treatment Count 0 False -1 380 Subluxation Level Code 0 False -1 1367 Subluxation Level Code 0 False -1 1367 Unit or Basis for Measurement Code 0 False -1 355 Quantity 0 False -1 380 Quantity 0 False -1 380 Patient Condition Code 0 False -1 1342 Complication Indicator 0 False -1 1073 Patient Condition Description 0 False -1 352 Patient Condition Description 0 False -1 352 X-ray Availability Indicator 0 False -1 1073 CR5 Home Oxygen Therapy Information S1400 A6 True Certification Type Code 0 False -1 1322 Quantity 0 False -1 380 Oxygen Equipment Type Code 0 False -1 1348 Oxygen Equipment Type Code 0 False -1 1348 Equipment Reason Description 0 False -1 352 Oxygen Flow Rate 0 False -1 380 Daily Oxygen Use Count 0 False -1 380 Oxygen Use Period Hour Count 0 False -1 380 Respiratory Therapist Order Text 0 False -1 352 Arterial Blood Gas Quantity 0 False -1 380 Oxygen Saturation Quantity 0 False -1 380 Oxygen Test Condition Code 0 False -1 1349 Oxygen Test Findings Code 0 False -1 1350 Oxygen Test Findings Code 0 False -1 1350 Oxygen Test Findings Code 0 False -1 1350 Portable Oxygen System Flow Rate 0 False -1 380 Oxygen Delivery System Code 0 False -1 1382 Oxygen Equipment Type Code 0 False -1 1348 CR6 Home Health Care Information S1500 A6 True Prognosis Code 0 True -1 923 Home Health Start Date 0 True -1 373 Date Time Period Format Qualifier 0 False -1 1250 Home Health Certification Period 0 False -1 1251 Date 0 False -1 373 Yes/No Condition or Response Code 0 False -1 1073 Medicare Coverage Indicator 0 True -1 1073 Certification Type Code 0 True -1 1322 Surgery Date 0 False -1 373 Product or Service ID Qualifier 0 False -1 235 Surgical Procedure Code 0 False -1 1137 Physician Order Date 0 False -1 373 Last Visit Date 0 False -1 373 Physician Contact Date 0 False -1 373 Date Time Period Format Qualifier 0 False -1 1250 Last Admission Period 0 False -1 1251 Patient Location Code 0 False -1 1384 Date 0 False -1 373 Date 0 False -1 373 Date 0 False -1 373 Date 0 False -1 373 1|2|3|4|5|6|7|8 0 0 W 6 0 1|2|3|4|6|I|R|S 7 0 PWK Additional Patient Information S1550 A6 True Attachment Report Type Code 0 True -1 755 Report Transmission Code 0 False -1 756 Report Copies Needed 0 False -1 757 Entity Identifier Code 0 False -1 98 Identification Code Qualifier 0 False -1 66 Attachment Control Number 0 False -1 67 Attachment Description 0 False -1 352 Actions Indicated 0 False -1 C002 Request Category Code 0 False -1 1525 03|04|05|06|07|08|09|10|11|13|15|21|48|55|59|77|A3|A4|AM|AS|AT|B2|B3|BR|BS|BT|CB|CK|D2|DA|DB|DG|DJ|DS|FM|HC|HR|I5|IR|LA|M1|NN|OB|OC|OD|OE|OX|P4|P5|P6|P7|PE|PN|PO|PQ|PY|PZ|QC|QR|RB|RR|RT|RX|SG|V5|XP 0 0 MSG Message Text S1600 A6 True Free Form Message Text 0 True -1 933 Printer Carriage Control Code 0 False -1 934 Number 0 False -1 1470 NM1 Patient Event Provider Name S1700 A6 True Entity Identifier Code 0 True -1 98 Entity Type Qualifier 0 True -1 1065 Patient Event Provider Last or Organization Name 0 False -1 1035 Patient Event Provider First Name 0 False -1 1036 Patient Event Provider Middle Name 0 False -1 1037 Patient Event Provider Name Prefix 0 False -1 1038 Patient Event Provider Name Suffix 0 False -1 1039 Identification Code Qualifier 0 False -1 66 Patient Event Provider Identifier 0 False -1 67 Entity Relationship Code 0 False -1 706 Entity Identifier Code 0 False -1 98 Name Last or Organization Name 0 False -1 1035 71|72|73|77|AAJ|DD|DK|DN|FA|G3|P3|QB|QV|SJ 0 0 1|2 1 0 REF Patient Event Provider Supplemental Information S1800 A6 True Reference Identification Qualifier 0 True -1 128 Patient Event Provider Supplemental Identifier 0 False -1 127 License Number State Code 0 False -1 352 Reference Identifier 0 False -1 C040 0B|1G|1J|EI|N5|N7|SY|ZH 0 0 N3 Patient Event Provider Address S2000 A6 True Patient Event Provider Address Line 0 True -1 166 Patient Event Provider Address Line 0 False -1 166 N4 Patient Event City, State, ZIP Code S2100 A6 True Patient Event Provider City Name 0 False -1 19 Patient Event Provider State Code 0 False -1 156 Patient Event Provider Postal Zone or ZIP Code 0 False -1 116 Country Code 0 False -1 26 Location Qualifier 0 False -1 309 Location Identifier 0 False -1 310 Country Subdivision Code 0 False -1 1715 PER Patient Event Provider Contact Information S2200 A6 True Contact Function Code 0 True -1 366 Patient Event Provider Contact Name 0 False -1 93 Communication Number Qualifier 0 False -1 365 Patient Event Provider Contact Communications Number 0 False -1 364 Communication Number Qualifier 0 False -1 365 Patient Event Provider Contact Communications Number 0 False -1 364 Communication Number Qualifier 0 False -1 365 Patient Event Provider Contact Communications Number 0 False -1 364 Contact Inquiry Reference 0 False -1 443 IC 0 0 PRV Patient Event Provider Information S2400 A6 True Provider Code 0 True -1 1221 Reference Identification Qualifier 0 False -1 128 Provider Taxonomy Code 0 False -1 127 State or Province Code 0 False -1 156 Provider Specialty Information 0 False -1 C035 Provider Organization Code 0 False -1 1223 AD|AS|AT|OP|OR|OT|PC|PE|RF 0 0 NM1 Patient Event Transport Information S2800 A6 True Entity Identifier Code 0 True -1 98 Entity Type Qualifier 0 True -1 1065 Patient Event Transport Location Name 0 False -1 1035 Name First 0 False -1 1036 Name Middle 0 False -1 1037 Name Prefix 0 False -1 1038 Name Suffix 0 False -1 1039 Identification Code Qualifier 0 False -1 66 Identification Code 0 False -1 67 Entity Relationship Code 0 False -1 706 Entity Identifier Code 0 False -1 98 Name Last or Organization Name 0 False -1 1035 45|FS|ND|PW|R3 0 0 2 1 0 N3 Patient Event Transport Location Address S3100 A6 True Patient Event Transport Location Address Line 0 True -1 166 Patient Event Transport Location Address Line 0 False -1 166 N4 Patient Event Transport Location City/State/ZIP Code S3200 A6 True Patient Event Transport Location City Name 0 False -1 19 Patient Event Transport Location State or Province Code 0 False -1 156 Patient Event Transport Location Postal Zone or ZIP Code 0 False -1 116 Country Code 0 False -1 26 Location Qualifier 0 False -1 309 Location Identifier 0 False -1 310 Country Subdivision Code 0 False -1 1715 NM1 Patient Event Other UMO Name S3900 A6 True Entity Identifier Code 0 True -1 98 Entity Type Qualifier 0 True -1 1065 Other UMO Name 0 False -1 1035 Name First 0 False -1 1036 Name Middle 0 False -1 1037 Name Prefix 0 False -1 1038 Name Suffix 0 False -1 1039 Identification Code Qualifier 0 False -1 66 Identification Code 0 False -1 67 Entity Relationship Code 0 False -1 706 Entity Identifier Code 0 False -1 98 Name Last or Organization Name 0 False -1 1035 00|CA|GG 0 0 2 1 0 REF Other UMO Denial Reason S4000 A6 True Reference Identification Qualifier 0 True -1 128 Other UMO Denial Reason 0 False -1 127 Description 0 False -1 352 Reference Identifier 0 False -1 C040_278-A1_REF_6_4000 ZZ 0 0 DTP Other UMO Denial Date S4900 A6 True Date Time Qualifier 0 True -1 374 Date Time Period Format Qualifier 0 True -1 1250 Other UMO Denial Date 0 True -1 1251 598 0 0 D8 1 0 HL Service Level S0100 A7 True Hierarchical ID Number 0 True -1 628 Hierarchical Parent ID Number 0 False -1 734 Hierarchical Level Code 0 True -1 735 Hierarchical Child Code 0 False -1 736 SS 2 0 TRN Service Trace Number S0200 A7 True Trace Type Code 0 True -1 481 Service Trace Number 0 True -1 127 Trace Assigning Entity Identifier 0 False -1 509 Trace Assigning Entity Additional Identifier 0 False -1 127 1 0 0 UM Health Care Services Review Information S0400 A7 True Request Category Code 0 True -1 1525 Certification Type Code 0 False -1 1322 Service Type Code 0 False -1 1365 Health Care Service Location Information 0 False -1 C023_278-A1_UM_7_0400 Related Causes Information 0 False -1 C024 Level of Service Code 0 False -1 1338 Current Health Condition Code 0 False -1 1213 Prognosis Code 0 False -1 923 Release of Information Code 0 False -1 1363 Delay Reason Code 0 False -1 1514 HS|SC 0 0 REF Previous Review Authorization Number S0600 A7 True Reference Identification Qualifier 0 True -1 128 Previous Review Authorization Number 0 False -1 127 Description 0 False -1 352 Reference Identifier 0 False -1 C040 BB 0 0 REF Previous Review Administrative Reference Number S0610 A7 True Reference Identification Qualifier 0 True -1 128 Previous Administrative Reference Number 0 False -1 127 Description 0 False -1 352 Reference Identifier 0 False -1 C040 NT 0 0 DTP Service Date S0700 A7 True Date Time Qualifier 0 True -1 374 Date Time Period Format Qualifier 0 True -1 1250 Proposed or Actual Service Date 0 True -1 1251 472 0 0 D8|RD8 1 0 SV1 Professional Service S0810 A7 True Composite Medical Procedure Identifier 0 True -1 C003_278-A1_SV1_7_0810 Service Line Amount 0 False -1 782 Unit or Basis for Measurement Code 0 False -1 355 Service Unit Count 0 False -1 380 Facility Code Value 0 False -1 1331 Service Type Code 0 False -1 1365 Composite Diagnosis Code Pointer 0 False -1 C004_278-A1_SV1_7_0810 Monetary Amount 0 False -1 782 Yes/No Condition or Response Code 0 False -1 1073 Multiple Procedure Code 0 False -1 1340 EPSDT Indicator 0 False -1 1073 Yes/No Condition or Response Code 0 False -1 1073 Review Code 0 False -1 1364 National or Local Assigned Review Value 0 False -1 1341 Copay Status Code 0 False -1 1327 Health Care Professional Shortage Area Code 0 False -1 1334 Reference Identification 0 False -1 127 Postal Code 0 False -1 116 Monetary Amount 0 False -1 782 Nursing Home Level of Care 0 False -1 1337 Provider Agreement Code 0 False -1 1360 SV2 Institutional Service Line S0820 A7 True Service Line Revenue Code 0 False -1 234 Composite Medical Procedure Identifier 0 False -1 C003_278-A1_SV2_7_0820 Service Line Amount 0 False -1 782 Unit or Basis for Measurement Code 0 False -1 355 Service Unit Count 0 False -1 380 Service Line Rate 0 False -1 1371 Monetary Amount 0 False -1 782 Yes/No Condition or Response Code 0 False -1 1073 Nursing Home Residential Status Code 0 False -1 1345 Nursing Home Level of Care 0 False -1 1337 SV3 Dental Service S0830 A7 True Composite Medical Procedure Identifier 0 True -1 C003_278-A1_SV3_7_0830 Service Line Amount 0 False -1 782 Facility Code Value 0 False -1 1331 Oral Cavity Designation 0 False -1 C006_278-A1_SV3_7_0830 Prosthesis, Crown, or Inlay Code 0 False -1 1358 Service Unit Count 0 False -1 380 Description 0 False -1 352 Copay Status Code 0 False -1 1327 Provider Agreement Code 0 False -1 1360 Yes/No Condition or Response Code 0 False -1 1073 Composite Diagnosis Code Pointer 0 False -1 C004 TOO Tooth Information S0840 A7 True Code List Qualifier Code 0 False -1 1270 Tooth Code 0 False -1 1271 Tooth Surface 0 False -1 C005_278-A1_TOO_7_0840 HSD Health Care Services Delivery S0900 A7 True Quantity Qualifier 0 False -1 673 Service Unit Count 0 False -1 380 Unit or Basis for Measurement Code 0 False -1 355 Sample Selection Modulus 0 False -1 1167 Time Period Qualifier 0 False -1 615 Period Count 0 False -1 616 Delivery Frequency Code 0 False -1 678 Delivery Pattern Time Code 0 False -1 679 PWK Additional Service Information S1550 A7 True Attachment Report Type Code 0 True -1 755 Report Transmission Code 0 False -1 756 Report Copies Needed 0 False -1 757 Entity Identifier Code 0 False -1 98 Identification Code Qualifier 0 False -1 66 Attachment Control Number 0 False -1 67 Attachment Description 0 False -1 352 Actions Indicated 0 False -1 C002 Request Category Code 0 False -1 1525 03|04|05|06|07|08|09|10|11|13|15|21|48|55|59|77|A3|A4|AM|AS|AT|B2|B3|BR|BS|BT|CB|CK|D2|DA|DB|DG|DJ|DS|FM|HC|HR|I5|IR|LA|M1|NN|OB|OC|OD|OE|OX|P4|P5|P6|P7|PE|PN|PO|PQ|PY|PZ|QC|QR|RB|RR|RT|RX|SG|V5|XP 0 0 MSG Message Text S1600 A7 True Free Form Message Text 0 True -1 933 Printer Carriage Control Code 0 False -1 934 Number 0 False -1 1470 NM1 Service Provider Name S1700 A7 True Entity Identifier Code 0 True -1 98 Entity Type Qualifier 0 True -1 1065 Service Provider Last or Organization Name 0 False -1 1035 Service Provider First Name 0 False -1 1036 Service Provider Middle Name 0 False -1 1037 Service Provider Name Prefix 0 False -1 1038 Service Provider Name Suffix 0 False -1 1039 Identification Code Qualifier 0 False -1 66 Service Provider Identifier 0 False -1 67 Entity Relationship Code 0 False -1 706 Entity Identifier Code 0 False -1 98 Name Last or Organization Name 0 False -1 1035 1T|72|73|77|DD|DK|DQ|FA|G3|P3|QB|QV|SJ 0 0 1|2 1 0 REF Service Provider Supplemental Identification S1800 A7 True Reference Identification Qualifier 0 True -1 128 Service Provider Supplemental Identifier 0 False -1 127 License Number State Code 0 False -1 352 Reference Identifier 0 False -1 C040 0B|1G|1J|EI|N5|N7|SY|ZH 0 0 N3 Service Provider Address S2000 A7 True Service Provider Address Line 0 True -1 166 Service Provider Address Line 0 False -1 166 N4 Service Provider City, State, ZIP Code S2100 A7 True Service Provider City Name 0 False -1 19 Service Provider State or Province Code 0 False -1 156 Service Provider Postal Zone or ZIP Code 0 False -1 116 Country Code 0 False -1 26 Location Qualifier 0 False -1 309 Location Identifier 0 False -1 310 Country Subdivision Code 0 False -1 1715 PER Service Provider Contact Information S2200 A7 True Contact Function Code 0 True -1 366 Service Provider Contact Name 0 False -1 93 Communication Number Qualifier 0 False -1 365 Service Provider Contact Communication Number 0 False -1 364 Communication Number Qualifier 0 False -1 365 Service Provider Contact Communication Number 0 False -1 364 Communication Number Qualifier 0 False -1 365 Service Provider Contact Communication Number 0 False -1 364 Contact Inquiry Reference 0 False -1 443 IC 0 0 PRV Service Provider Information S2400 A7 True Provider Code 0 True -1 1221 Reference Identification Qualifier 0 False -1 128 Provider Taxonomy Code 0 False -1 127 State or Province Code 0 False -1 156 Provider Specialty Information 0 False -1 C035 Provider Organization Code 0 False -1 1223 AS|OP|OR|OT|PC|PE 0 0 SE Transaction Set Trailer S2800 A7 True Transaction Segment Count 0 True -1 96 Transaction Set Control Number 0 True -1 329 ST Transaction Set Header S0100 A1 True Transaction Set Identifier Code 0 True -1 143 Transaction Set Control Number 0 True -1 329 Implementation Guide Version Name 0 False -1 1705 278 0 0 BHT Beginning of Hierarchical Transaction S0200 A1 True Hierarchical Structure Code 0 True -1 1005 Transaction Set Purpose Code 0 True -1 353 Submitter Transaction Identifier 0 False -1 127 Transaction Set Creation Date 0 False -1 373 Transaction Set Creation Time 0 False -1 337 Transaction Type Code 0 False -1 640 0007 0 0 11 1 0 HL Utilization Management Organization (UMO) Level S0100 A2 True Hierarchical ID Number 0 True -1 628 Hierarchical Parent ID Number 0 False -1 734 Hierarchical Level Code 0 True -1 735 Hierarchical Child Code 0 False -1 736 20 2 0 AAA Request Validation S0300 A2 True Valid Request Indicator 0 True -1 1073 Agency Qualifier Code 0 False -1 559 Reject Reason Code 0 False -1 901 Follow-up Action Code 0 False -1 889 N|Y 0 0 NM1 Utilization Management Organization (UMO) Name S1700 A2 True Entity Identifier Code 0 True -1 98 Entity Type Qualifier 0 True -1 1065 Utilization Management Organization (UMO) Last or Organization Name 0 False -1 1035 Utilization Management Organization (UMO) First Name 0 False -1 1036 Utilization Management Organization (UMO) Middle Name 0 False -1 1037 Name Prefix 0 False -1 1038 Utilization Management Organization (UMO) Name Suffix 0 False -1 1039 Identification Code Qualifier 0 False -1 66 Utilization Management Organization (UMO) Identifier 0 False -1 67 Entity Relationship Code 0 False -1 706 Entity Identifier Code 0 False -1 98 Name Last or Organization Name 0 False -1 1035 2B|36|PR|X3 0 0 1|2 1 0 PER Utilization Management Organization (UMO) Contact Information S2200 A2 True Contact Function Code 0 True -1 366 Utilization Management Organization (UMO) Contact Name 0 False -1 93 Communication Number Qualifier 0 False -1 365 Utilization Management Organization (UMO) Contact Communication Number 0 False -1 364 Communication Number Qualifier 0 False -1 365 Utilization Management Organization (UMO) Contact Communication Number 0 False -1 364 Communication Number Qualifier 0 False -1 365 Utilization Management Organization (UMO) Contact Communication Number 0 False -1 364 Contact Inquiry Reference 0 False -1 443 IC 0 0 AAA Utilization Management Organization (UMO) Request Validation S2300 A2 True Valid Request Indicator 0 True -1 1073 Agency Qualifier Code 0 False -1 559 Reject Reason Code 0 False -1 901 Follow-up Action Code 0 False -1 889 N 0 0 HL Requester Level S0100 A3 True Hierarchical ID Number 0 True -1 628 Hierarchical Parent ID Number 0 False -1 734 Hierarchical Level Code 0 True -1 735 Hierarchical Child Code 0 False -1 736 21 2 0 NM1 Requester Name S1700 A3 True Entity Identifier Code 0 True -1 98 Entity Type Qualifier 0 True -1 1065 Requester Last or Organization Name 0 False -1 1035 Requester First Name 0 False -1 1036 Requester Middle Name 0 False -1 1037 Name Prefix 0 False -1 1038 Requester Name Suffix 0 False -1 1039 Identification Code Qualifier 0 False -1 66 Requester Identifier 0 False -1 67 Entity Relationship Code 0 False -1 706 Entity Identifier Code 0 False -1 98 Name Last or Organization Name 0 False -1 1035 1P|FA 0 0 1|2 1 0 REF Requester Supplemental Identification S1800 A3 True Reference Identification Qualifier 0 True -1 128 Requester Supplemental Identifier 0 False -1 127 Description 0 False -1 352 Reference Identifier 0 False -1 C040 1G|1J|EI|G5|N5|N7|SY|ZH 0 0 AAA Requester Request Validation S2300 A3 True Valid Request Indicator 0 True -1 1073 Agency Qualifier Code 0 False -1 559 Reject Reason Code 0 False -1 901 Follow-up Action Code 0 False -1 889 N 0 0 PRV Requester Provider Information S2400 A3 True Provider Code 0 True -1 1221 Reference Identification Qualifier 0 False -1 128 Provider Taxonomy Code 0 False -1 127 State or Province Code 0 False -1 156 Provider Specialty Information 0 False -1 C035 Provider Organization Code 0 False -1 1223 AD|AS|AT|CO|CV|OP|OR|OT|PC|PE|RF 0 0 HL Subscriber Level S0100 A4 True Hierarchical ID Number 0 True -1 628 Hierarchical Parent ID Number 0 False -1 734 Hierarchical Level Code 0 True -1 735 Hierarchical Child Code 0 False -1 736 22 2 0 NM1 Subscriber Name S1700 A4 True Entity Identifier Code 0 True -1 98 Entity Type Qualifier 0 True -1 1065 Subscriber Last Name 0 False -1 1035 Subscriber First Name 0 False -1 1036 Subscriber Middle Name or Initial 0 False -1 1037 Subscriber Name Prefix 0 False -1 1038 Subscriber Name Suffix 0 False -1 1039 Identification Code Qualifier 0 False -1 66 Subscriber Primary Identifier 0 False -1 67 Entity Relationship Code 0 False -1 706 Entity Identifier Code 0 False -1 98 Name Last or Organization Name 0 False -1 1035 IL 0 0 1 1 0 REF Subscriber Supplemental Identification S1800 A4 True Reference Identification Qualifier 0 True -1 128 Subscriber Supplemental Identifier 0 False -1 127 Description 0 False -1 352 Reference Identifier 0 False -1 C040 1L|3L|6P|DP|EJ|F6|HJ|IG|N6|NQ|SY 0 0 N3 Subscriber Mailing Address S2000 A4 True Subscriber Address Line 0 True -1 166 Subscriber Address Line 0 False -1 166 N4 Subscriber City, State, ZIP Code S2100 A4 True Subscriber City Name 0 False -1 19 Subscriber State Code 0 False -1 156 Subscriber Postal Zone or ZIP Code 0 False -1 116 Country Code 0 False -1 26 Location Qualifier 0 False -1 309 Location Identifier 0 False -1 310 Country Subdivision Code 0 False -1 1715 AAA Subscriber Request Validation S2300 A4 True Valid Request Indicator 0 True -1 1073 Agency Qualifier Code 0 False -1 559 Reject Reason Code 0 False -1 901 Follow-up Action Code 0 False -1 889 N 0 0 DMG Subscriber Demographic Information S2500 A4 True Date Time Period Format Qualifier 0 False -1 1250 Subscriber Birth Date 0 False -1 1251 Subscriber Gender Code 0 False -1 1068 Marital Status Code 0 False -1 1067 Composite Race or Ethnicity Information 0 False -1 C056 Citizenship Status Code 0 False -1 1066 Country Code 0 False -1 26 Basis of Verification Code 0 False -1 659 Quantity 0 False -1 380 Code List Qualifier Code 0 False -1 1270 Industry Code 0 False -1 1271 INS Subscriber Relationship S2600 A4 True Insured Indicator 0 True -1 1073 Individual Relationship Code 0 True -1 1069 Maintenance Type Code 0 False -1 875 Maintenance Reason Code 0 False -1 1203 Benefit Status Code 0 False -1 1216 Medicare Status Code 0 False -1 C052 Consolidated Omnibus Budget Reconciliation Act (COBRA) Qualifying 0 False -1 1219 Employment Status Code 0 False -1 584 Student Status Code 0 False -1 1220 Yes/No Condition or Response Code 0 False -1 1073 Date Time Period Format Qualifier 0 False -1 1250 Date Time Period 0 False -1 1251 Confidentiality Code 0 False -1 1165 City Name 0 False -1 19 State or Province Code 0 False -1 156 Country Code 0 False -1 26 Number 0 False -1 1470 Y 0 0 18 1 0 HL Dependent Level S0100 A5 True Hierarchical ID Number 0 True -1 628 Hierarchical Parent ID Number 0 False -1 734 Hierarchical Level Code 0 True -1 735 Hierarchical Child Code 0 False -1 736 23 2 0 NM1 Dependent Name S1700 A5 True Entity Identifier Code 0 True -1 98 Entity Type Qualifier 0 True -1 1065 Dependent Last Name 0 False -1 1035 Dependent First Name 0 False -1 1036 Dependent Middle Name 0 False -1 1037 Name Prefix 0 False -1 1038 Dependent Name Suffix 0 False -1 1039 Identification Code Qualifier 0 False -1 66 Dependent Primary Identifier 0 False -1 67 Entity Relationship Code 0 False -1 706 Entity Identifier Code 0 False -1 98 Name Last or Organization Name 0 False -1 1035 QC 0 0 1 1 0 REF Dependent Supplemental Identification S1800 A5 True Reference Identification Qualifier 0 True -1 128 Dependent Supplemental Identifier 0 False -1 127 Description 0 False -1 352 Reference Identifier 0 False -1 C040 EJ|SY 0 0 N3 Dependent Address S2000 A5 True Dependent Address Line 0 True -1 166 Dependent Address Line 0 False -1 166 N4 Dependent City, State, ZIP Code S2100 A5 True Dependent City Name 0 False -1 19 Dependent State Code 0 False -1 156 Dependent Postal Zone or ZIP Code 0 False -1 116 Country Code 0 False -1 26 Location Qualifier 0 False -1 309 Location Identifier 0 False -1 310 Country Subdivision Code 0 False -1 1715 AAA Dependent Request Validation S2300 A5 True Valid Request Indicator 0 True -1 1073 Agency Qualifier Code 0 False -1 559 Reject Reason Code 0 False -1 901 Follow-up Action Code 0 False -1 889 N 0 0 DMG Dependent Demographic Information S2500 A5 True Date Time Period Format Qualifier 0 False -1 1250 Dependent Birth Date 0 False -1 1251 Dependent Gender Code 0 False -1 1068 Marital Status Code 0 False -1 1067 Composite Race or Ethnicity Information 0 False -1 C056 Citizenship Status Code 0 False -1 1066 Country Code 0 False -1 26 Basis of Verification Code 0 False -1 659 Quantity 0 False -1 380 Code List Qualifier Code 0 False -1 1270 Industry Code 0 False -1 1271 INS Dependent Relationship S2600 A5 True Insured Indicator 0 True -1 1073 Individual Relationship Code 0 True -1 1069 Maintenance Type Code 0 False -1 875 Maintenance Reason Code 0 False -1 1203 Benefit Status Code 0 False -1 1216 Medicare Status Code 0 False -1 C052 Consolidated Omnibus Budget Reconciliation Act (COBRA) Qualifying 0 False -1 1219 Employment Status Code 0 False -1 584 Student Status Code 0 False -1 1220 Yes/No Condition or Response Code 0 False -1 1073 Date Time Period Format Qualifier 0 False -1 1250 Date Time Period 0 False -1 1251 Confidentiality Code 0 False -1 1165 City Name 0 False -1 19 State or Province Code 0 False -1 156 Country Code 0 False -1 26 Birth Sequence Number 0 False -1 1470 N 0 0 01|19|G8 1 0 HL Patient Event Level S0100 A6 True Hierarchical ID Number 0 True -1 628 Hierarchical Parent ID Number 0 False -1 734 Hierarchical Level Code 0 True -1 735 Hierarchical Child Code 0 False -1 736 EV 2 0 TRN Patient Event Tracking Number S0200 A6 True Trace Type Code 0 True -1 481 Patient Event Trace Number 0 True -1 127 Trace Assigning Entity Identifier 0 False -1 509 Trace Assigning Entity Additional Identifier 0 False -1 127 1|2 0 0 AAA Patient Event Request Validation S0300 A6 True Valid Request Indicator 0 True -1 1073 Agency Qualifier Code 0 False -1 559 Reject Reason Code 0 False -1 901 Follow-up Action Code 0 False -1 889 N 0 0 UM Health Care Services Review Information S0400 A6 True Request Category Code 0 True -1 1525 Certification Type Code 0 False -1 1322 Service Type Code 0 False -1 1365 Health Care Service Location Information 0 False -1 C023_278-A3_UM_6_0400 Related Causes Information 0 False -1 C024 Level of Service Code 0 False -1 1338 Current Health Condition Code 0 False -1 1213 Prognosis Code 0 False -1 923 Release of Information Code 0 False -1 1363 Delay Reason Code 0 False -1 1514 AR|HS|IN|SC 0 0 HCR Health Care Services Review S0500 A6 True Action Code 0 True -1 306 Review Identification Number 0 False -1 127 Review Decision Reason Code 0 False -1 1271 Second Surgical Opinion Indicator 0 False -1 1073 A1|A2|A3|A4|A6|C|CT|NA 0 0 REF Administrative Reference Number S0600 A6 True Reference Identification Qualifier 0 True -1 128 Administrative Reference Number 0 False -1 127 Description 0 False -1 352 Reference Identifier 0 False -1 C040 NT 0 0 REF Previous Review Authorization Number S0610 A6 True Reference Identification Qualifier 0 True -1 128 Previous Review Authorization Number 0 False -1 127 Description 0 False -1 352 Reference Identifier 0 False -1 C040 BB 0 0 DTP Accident Date S0700 A6 True Date Time Qualifier 0 True -1 374 Date Time Period Format Qualifier 0 True -1 1250 Accident Date 0 True -1 1251 439 0 0 D8 1 0 DTP Last Menstrual Period Date S0705 A6 True Date Time Qualifier 0 True -1 374 Date Time Period Format Qualifier 0 True -1 1250 Last Menstrual Period Date 0 True -1 1251 484 0 0 D8 1 0 DTP Estimated Date of Birth S0710 A6 True Date Time Qualifier 0 True -1 374 Date Time Period Format Qualifier 0 True -1 1250 Estimated Birth Date 0 True -1 1251 ABC 0 0 D8 1 0 DTP Onset of Current Symptoms or Illness Date S0715 A6 True Date Time Qualifier 0 True -1 374 Date Time Period Format Qualifier 0 True -1 1250 Onset Date 0 True -1 1251 431 0 0 D8 1 0 DTP Event Date S0720 A6 True Date Time Qualifier 0 True -1 374 Date Time Period Format Qualifier 0 True -1 1250 Proposed or Actual Event Date 0 True -1 1251 AAH 0 0 D8|RD8 1 0 DTP Admission Date S0725 A6 True Date Time Qualifier 0 True -1 374 Date Time Period Format Qualifier 0 True -1 1250 Proposed or Actual Admission Date 0 True -1 1251 435 0 0 D8|RD8 1 0 DTP Discharge Date S0730 A6 True Date Time Qualifier 0 True -1 374 Date Time Period Format Qualifier 0 True -1 1250 Proposed or Actual Discharge Date 0 True -1 1251 096 0 0 D8 1 0 DTP Certification Issue Date S0735 A6 True Date Time Qualifier 0 True -1 374 Date Time Period Format Qualifier 0 True -1 1250 Certification Issue Date 0 True -1 1251 102 0 0 D8 1 0 DTP Certification Expiration Date S0740 A6 True Date Time Qualifier 0 True -1 374 Date Time Period Format Qualifier 0 True -1 1250 Certification Expiration Date 0 True -1 1251 036 0 0 D8 1 0 DTP Certification Effective Date S0745 A6 True Date Time Qualifier 0 True -1 374 Date Time Period Format Qualifier 0 True -1 1250 Certification Effective Date 0 True -1 1251 007 0 0 D8|RD8 1 0 HI Patient Diagnosis S0800 A6 True Health Care Code Information 0 True -1 C022_278-A3_HI_6_0800 Health Care Code Information 0 False -1 C022 Health Care Code Information 0 False -1 C022 Health Care Code Information 0 False -1 C022 Health Care Code Information 0 False -1 C022 Health Care Code Information 0 False -1 C022 Health Care Code Information 0 False -1 C022 Health Care Code Information 0 False -1 C022 Health Care Code Information 0 False -1 C022 Health Care Code Information 0 False -1 C022 Health Care Code Information 0 False -1 C022 Health Care Code Information 0 False -1 C022 HSD Health Care Services Delivery S0900 A6 True Quantity Qualifier 0 False -1 673 Service Unit Count 0 False -1 380 Unit or Basis for Measurement Code 0 False -1 355 Sample Selection Modulus 0 False -1 1167 Time Period Qualifier 0 False -1 615 Period Count 0 False -1 616 Delivery Frequency Code 0 False -1 678 Delivery Pattern Time Code 0 False -1 679 CL1 Institutional Claim Code S1100 A6 True Admission Type Code 0 False -1 1315 Admission Source Code 0 False -1 1314 Patient Status Code 0 False -1 1352 Nursing Home Residential Status Code 0 False -1 1345 CR1 Ambulance Transport Information S1200 A6 True Unit or Basis for Measurement Code 0 False -1 355 Weight 0 False -1 81 Ambulance Transport Code 0 False -1 1316 Ambulance Transport Reason Code 0 False -1 1317 Unit or Basis for Measurement Code 0 False -1 355 Transport Distance 0 False -1 380 Address Information 0 False -1 166 Address Information 0 False -1 166 Description 0 False -1 352 Description 0 False -1 352 CR2 Spinal Manipulation Service Information S1300 A6 True Treatment Series Number 0 False -1 609 Treatment Count 0 False -1 380 Subluxation Level Code 0 False -1 1367 Subluxation Level Code 0 False -1 1367 Unit or Basis for Measurement Code 0 False -1 355 Quantity 0 False -1 380 Quantity 0 False -1 380 Nature of Condition Code 0 False -1 1342 Yes/No Condition or Response Code 0 False -1 1073 Description 0 False -1 352 Description 0 False -1 352 Yes/No Condition or Response Code 0 False -1 1073 CR5 Home Oxygen Therapy Information S1400 A6 True Certification Type Code 0 False -1 1322 Quantity 0 False -1 380 Oxygen Equipment Type Code 0 False -1 1348 Oxygen Equipment Type Code 0 False -1 1348 Description 0 False -1 352 Oxygen Flow Rate 0 False -1 380 Daily Oxygen Use Count 0 False -1 380 Oxygen Use Period Hour Count 0 False -1 380 Respiratory Therapist Order Text 0 False -1 352 Quantity 0 False -1 380 Quantity 0 False -1 380 Oxygen Test Condition Code 0 False -1 1349 Oxygen Test Findings Code 0 False -1 1350 Oxygen Test Findings Code 0 False -1 1350 Oxygen Test Findings Code 0 False -1 1350 Portable Oxygen System Flow Rate 0 False -1 380 Oxygen Delivery System Code 0 False -1 1382 Oxygen Equipment Type Code 0 False -1 1348 CR6 Home Health Care Information S1500 A6 True Prognosis Code 0 True -1 923 Home Health Start Date 0 True -1 373 Date Time Period Format Qualifier 0 False -1 1250 Home Health Certification Period 0 False -1 1251 Date 0 False -1 373 Yes/No Condition or Response Code 0 False -1 1073 Medicare Coverage Indicator 0 True -1 1073 Certification Type Code 0 True -1 1322 Date 0 False -1 373 Product/Service ID Qualifier 0 False -1 235 Medical Code Value 0 False -1 1137 Date 0 False -1 373 Date 0 False -1 373 Date 0 False -1 373 Date Time Period Format Qualifier 0 False -1 1250 Date Time Period 0 False -1 1251 Patient Location Code 0 False -1 1384 Date 0 False -1 373 Date 0 False -1 373 Date 0 False -1 373 Date 0 False -1 373 1|2|3|4|5|6|7|8 0 0 W 6 0 1|2|3|4|5|6|I|R|S 7 0 PWK Additional Patient Information S1550 A6 True Attachment Report Type Code 0 True -1 755 Report Transmission Code 0 False -1 756 Report Copies Needed 0 False -1 757 Entity Identifier Code 0 False -1 98 Identification Code Qualifier 0 False -1 66 Attachment Control Number 0 False -1 67 Attachment Description 0 False -1 352 Actions Indicated 0 False -1 C002 Request Category Code 0 False -1 1525 03|04|05|06|07|08|09|10|11|13|15|21|48|55|59|77|A3|A4|AM|AS|AT|B2|B3|BR|BS|BT|CB|CK|D2|DA|DB|DG|DJ|DS|FM|HC|HR|I5|IR|LA|M1|NN|OB|OC|OD|OE|OX|P4|P5|P6|P7|PE|PN|PO|PQ|PY|PZ|QC|QR|RB|RR|RT|RX|SG|V5|XP 0 0 MSG Message Text S1600 A6 True Free Form Message Text 0 True -1 933 Printer Carriage Control Code 0 False -1 934 Number 0 False -1 1470 NM1 Patient Event Provider Name S1700 A6 True Entity Identifier Code 0 True -1 98 Entity Type Qualifier 0 True -1 1065 Patient Event Provider Last or Organization Name 0 False -1 1035 Patient Event Provider First Name 0 False -1 1036 Patient Event Provider Middle Name 0 False -1 1037 Patient Event Provider Name Prefix 0 False -1 1038 Patient Event Provider Name Suffix 0 False -1 1039 Identification Code Qualifier 0 False -1 66 Patient Event Provider Identifier 0 False -1 67 Entity Relationship Code 0 False -1 706 Entity Identifier Code 0 False -1 98 Name Last or Organization Name 0 False -1 1035 71|72|73|77|AAJ|DD|DK|DN|FA|G3|P3|QB|QV|SJ 0 0 1|2 1 0 REF Patient Event Provider Supplemental Identification S1800 A6 True Reference Identification Qualifier 0 True -1 128 Patient Event Provider Supplemental Identifier 0 False -1 127 License Number State Code 0 False -1 352 Reference Identifier 0 False -1 C040 0B|1G|1J|EI|N5|N7|SY|ZH 0 0 N3 Patient Event Provider Address S2000 A6 True Patient Event Provider Address Line 0 True -1 166 Patient Event Provider Address Line 0 False -1 166 N4 Patient Event Provider City, State, ZIP Code S2100 A6 True Patient Event Provider City Name 0 False -1 19 Patient Event Provider State Code 0 False -1 156 Patient Event Provider Postal Zone or ZIP Code 0 False -1 116 Country Code 0 False -1 26 Location Qualifier 0 False -1 309 Location Identifier 0 False -1 310 Country Subdivision Code 0 False -1 1715 PER Provider Contact Information S2200 A6 True Contact Function Code 0 True -1 366 Patient Event Provider Contact Name 0 False -1 93 Communication Number Qualifier 0 False -1 365 Patient Event Provider Contact Communications Number 0 False -1 364 Communication Number Qualifier 0 False -1 365 Patient Event Provider Contact Communications Number 0 False -1 364 Communication Number Qualifier 0 False -1 365 Patient Event Provider Contact Communications Number 0 False -1 364 Contact Inquiry Reference 0 False -1 443 IC 0 0 AAA Patient Event Provider Request Validation S2300 A6 True Valid Request Indicator 0 True -1 1073 Agency Qualifier Code 0 False -1 559 Reject Reason Code 0 False -1 901 Follow-up Action Code 0 False -1 889 N 0 0 PRV Patient Event Provider Information S2400 A6 True Provider Code 0 True -1 1221 Reference Identification Qualifier 0 False -1 128 Provider Taxonomy Code 0 False -1 127 State or Province Code 0 False -1 156 Provider Specialty Information 0 False -1 C035 Provider Organization Code 0 False -1 1223 AD|AS|AT|OP|OR|OT|PC|PE|RF 0 0 NM1 Additional Patient Information Contact Name S2800 A6 True Entity Identifier Code 0 True -1 98 Entity Type Qualifier 0 True -1 1065 Response Contact Last or Organization Name 0 False -1 1035 Response Contact First Name 0 False -1 1036 Response Contact Middle Name 0 False -1 1037 Name Prefix 0 False -1 1038 Response Contact Name Suffix 0 False -1 1039 Identification Code Qualifier 0 False -1 66 Response Contact Identifier 0 False -1 67 Entity Relationship Code 0 False -1 706 Entity Identifier Code 0 False -1 98 Name Last or Organization Name 0 False -1 1035 L5 0 0 1|2 1 0 N3 Additional Patient Information Contact Address S2850 A6 True Response Contact Address Line 0 True -1 166 Response Contact Address Line 0 False -1 166 N4 Additional Patient Information Contact City, State, ZIP Code S2900 A6 True Additional Patient Information Contact City Name 0 False -1 19 Additional Patient Information Contact State Code 0 False -1 156 Additional Patient Information Contact Postal Zone or ZIP Code 0 False -1 116 Country Code 0 False -1 26 Location Qualifier 0 False -1 309 Location Identifier 0 False -1 310 Country Subdivision Code 0 False -1 1715 PER Additional Patient Information Contact Information S2950 A6 True Contact Function Code 0 True -1 366 Response Contact Name 0 False -1 93 Communication Number Qualifier 0 False -1 365 Response Contact Communication Number 0 False -1 364 Communication Number Qualifier 0 False -1 365 Response Contact Communication Number 0 False -1 364 Communication Number Qualifier 0 False -1 365 Response Contact Communication Number 0 False -1 364 Contact Inquiry Reference 0 False -1 443 IC 0 0 NM1 Patient Event Transport Information S3100 A6 True Entity Identifier Code 0 True -1 98 Entity Type Qualifier 0 True -1 1065 Patient Event Transport Location Name 0 False -1 1035 Name First 0 False -1 1036 Name Middle 0 False -1 1037 Name Prefix 0 False -1 1038 Name Suffix 0 False -1 1039 Identification Code Qualifier 0 False -1 66 Identification Code 0 False -1 67 Entity Relationship Code 0 False -1 706 Entity Identifier Code 0 False -1 98 Name Last or Organization Name 0 False -1 1035 45|FS|ND|PW|R3 0 0 2 1 0 N3 Patient Event Transport Location Address S3200 A6 True Patient Event Transport Location Address Line 0 True -1 166 Patient Event Transport Location Address Line 0 False -1 166 N4 Patient Event Transport Location City/State/ZIP Code S3250 A6 True Patient Event Transport Location City Name 0 False -1 19 Patient Event Transport Location State or Province Code 0 False -1 156 Patient Event Transport Location Postal Zone or ZIP Code 0 False -1 116 Country Code 0 False -1 26 Location Qualifier 0 False -1 309 Location Identifier 0 False -1 310 Country Subdivision Code 0 False -1 1715 AAA Patient Event Transport Location Request Validation S3450 A6 True Valid Request Indicator 0 True -1 1073 Agency Qualifier Code 0 False -1 559 Reject Reason Code 0 False -1 901 Follow-up Action Code 0 False -1 889 N 0 0 HL Service Level S0100 A7 True Hierarchical ID Number 0 True -1 628 Hierarchical Parent ID Number 0 False -1 734 Hierarchical Level Code 0 True -1 735 Hierarchical Child Code 0 False -1 736 SS 2 0 TRN Service Trace Number S0200 A7 True Trace Type Code 0 True -1 481 Service Trace Number 0 True -1 127 Trace Assigning Entity Identifier 0 False -1 509 Trace Assigning Entity Additional Identifier 0 False -1 127 1|2 0 0 AAA Service Request Validation S0300 A7 True Valid Request Indicator 0 True -1 1073 Agency Qualifier Code 0 False -1 559 Reject Reason Code 0 False -1 901 Follow-up Action Code 0 False -1 889 N 0 0 UM Health Care Services Review Information S0400 A7 True Request Category Code 0 True -1 1525 Certification Type Code 0 False -1 1322 Service Type Code 0 False -1 1365 Health Care Service Location Information 0 False -1 C023_278-A3_UM_7_0400 Related Causes Information 0 False -1 C024 Level of Service Code 0 False -1 1338 Current Health Condition Code 0 False -1 1213 Prognosis Code 0 False -1 923 Release of Information Code 0 False -1 1363 Delay Reason Code 0 False -1 1514 HS|SC 0 0 HCR Health Care Services Review S0500 A7 True Action Code 0 True -1 306 Review Identification Number 0 False -1 127 Review Decision Reason Code 0 False -1 1271 Second Surgical Opinion Indicator 0 False -1 1073 A1|A3|A4|A6|C|CT|NA 0 0 REF Administrative Reference Number S0600 A7 True Reference Identification Qualifier 0 True -1 128 Administrative Reference Number 0 False -1 127 Description 0 False -1 352 Reference Identifier 0 False -1 C040 NT 0 0 REF Previous Review Authorization Number S0610 A7 True Reference Identification Qualifier 0 True -1 128 Previous Review Authorization Number 0 False -1 127 Description 0 False -1 352 Reference Identifier 0 False -1 C040 BB 0 0 DTP Service Date S0700 A7 True Date Time Qualifier 0 True -1 374 Date Time Period Format Qualifier 0 True -1 1250 Proposed or Actual Service Date 0 True -1 1251 472 0 0 D8|RD8 1 0 DTP Certification Issue Date S0780 A7 True Date Time Qualifier 0 True -1 374 Date Time Period Format Qualifier 0 True -1 1250 Certification Issue Date 0 True -1 1251 102 0 0 D8 1 0 DTP Certification Expiration Date S0790 A7 True Date Time Qualifier 0 True -1 374 Date Time Period Format Qualifier 0 True -1 1250 Certification Expiration Date 0 True -1 1251 036 0 0 D8 1 0 DTP Certification Effective Date S07A0 A7 True Date Time Qualifier 0 True -1 374 Date Time Period Format Qualifier 0 True -1 1250 Certification Effective Date 0 True -1 1251 007 0 0 D8|RD8 1 0 HI Request For Additional Information S0800 A7 True Health Care Code Information 0 True -1 C022_278-A3_HI_7_0800 Health Care Code Information 0 False -1 C022 Health Care Code Information 0 False -1 C022 Health Care Code Information 0 False -1 C022 Health Care Code Information 0 False -1 C022 Health Care Code Information 0 False -1 C022 Health Care Code Information 0 False -1 C022 Health Care Code Information 0 False -1 C022 Health Care Code Information 0 False -1 C022 Health Care Code Information 0 False -1 C022 Health Care Code Information 0 False -1 C022 Health Care Code Information 0 False -1 C022 SV1 Professional Service S0810 A7 True Composite Medical Procedure Identifier 0 True -1 C003_278-A3_SV1_7_0810 Service Line Amount 0 False -1 782 Unit or Basis for Measurement Code 0 False -1 355 Service Unit Count 0 False -1 380 Facility Code Value 0 False -1 1331 Service Type Code 0 False -1 1365 Composite Diagnosis Code Pointer 0 False -1 C004 Monetary Amount 0 False -1 782 Yes/No Condition or Response Code 0 False -1 1073 Multiple Procedure Code 0 False -1 1340 EPSDT Indicator 0 False -1 1073 Yes/No Condition or Response Code 0 False -1 1073 Review Code 0 False -1 1364 National or Local Assigned Review Value 0 False -1 1341 Copay Status Code 0 False -1 1327 Health Care Professional Shortage Area Code 0 False -1 1334 Reference Identification 0 False -1 127 Postal Code 0 False -1 116 Monetary Amount 0 False -1 782 Nursing Home Level of Care 0 False -1 1337 Provider Agreement Code 0 False -1 1360 SV2 Institutional Service Line S0820 A7 True Service Line Revenue Code 0 False -1 234 Composite Medical Procedure Identifier 0 False -1 C003_278-A3_SV2_7_0820 Service Line Amount 0 False -1 782 Unit or Basis for Measurement Code 0 False -1 355 Service Unit Count 0 False -1 380 Service Line Rate 0 False -1 1371 Monetary Amount 0 False -1 782 Yes/No Condition or Response Code 0 False -1 1073 Nursing Home Residential Status Code 0 False -1 1345 Nursing Home Level of Care 0 False -1 1337 SV3 Dental Service S0830 A7 True Composite Medical Procedure Identifier 0 True -1 C003_278-A3_SV3_7_0830 Service Line Amount 0 False -1 782 Facility Code Value 0 False -1 1331 Oral Cavity Designation 0 False -1 C006_278-A3_SV3_7_0830 Prosthesis, Crown, or Inlay Code 0 False -1 1358 Service Unit Count 0 False -1 380 Description 0 False -1 352 Copay Status Code 0 False -1 1327 Provider Agreement Code 0 False -1 1360 Yes/No Condition or Response Code 0 False -1 1073 Composite Diagnosis Code Pointer 0 False -1 C004 TOO Tooth Information S0840 A7 True Code List Qualifier Code 0 False -1 1270 Tooth Code 0 False -1 1271 Tooth Surface 0 False -1 C005_278-A3_TOO_7_0840 HSD Health Care Services Delivery S0900 A7 True Quantity Qualifier 0 False -1 673 Service Unit Count 0 False -1 380 Unit or Basis for Measurement Code 0 False -1 355 Sample Selection Modulus 0 False -1 1167 Time Period Qualifier 0 False -1 615 Period Count 0 False -1 616 Delivery Frequency Code 0 False -1 678 Delivery Pattern Time Code 0 False -1 679 PWK Additional Service Information S1550 A7 True Attachment Report Type Code 0 True -1 755 Report Transmission Code 0 False -1 756 Report Copies Needed 0 False -1 757 Entity Identifier Code 0 False -1 98 Identification Code Qualifier 0 False -1 66 Attachment Control Number 0 False -1 67 Attachment Description 0 False -1 352 Actions Indicated 0 False -1 C002 Request Category Code 0 False -1 1525 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03|04|05|06|07|08|09|10|11|13|15|21|A3|A4|AM|AS|B2|B3|B4|BR|BS|BT|CB|CK|CT|D2|DA|DB|DG|DJ|DS|EB|HC|HR|I5|IR|LA|M1|MT|NN|OB|OC|OD|OE|OX|OZ|P4|P5|PE|PN|PO|PQ|PY|PZ|RB|RR|RT|RX|SG|V5|XP 0 0 CN1 Contract Information S1600 AC True Contract Type Code 0 True -1 1166 Contract Amount 0 False -1 782 Contract Percentage 0 False -1 332 Contract Code 0 False -1 127 Terms Discount Percentage 0 False -1 338 Contract Version Identifier 0 False -1 799 01|02|03|04|05|06|09 0 0 AMT Patient Estimated Amount Due S1770 AC True Amount Qualifier Code 0 True -1 522 Patient Responsibility Amount 0 True -1 782 Credit/Debit Flag Code 0 False -1 478 F3 0 0 REF Service Authorization Exception Code S1795 AC True Reference Identification Qualifier 0 True -1 128 Service Authorization Exception Code 0 False -1 127 Description 0 False -1 352 Reference Identifier 0 False -1 C040 4N 0 0 REF Referral Number S1796 AC True Reference Identification Qualifier 0 True -1 128 Referral Number 0 False -1 127 Description 0 False -1 352 Reference Identifier 0 False -1 C040 9F 0 0 REF Prior Authorization S1797 AC True Reference Identification Qualifier 0 True -1 128 Prior Authorization Number 0 False -1 127 Description 0 False -1 352 Reference Identifier 0 False -1 C040 G1 0 0 REF Payer Claim Control Number S1798 AC True Reference Identification Qualifier 0 True -1 128 Payer Claim Control Number 0 False -1 127 Description 0 False -1 352 Reference Identifier 0 False -1 C040 F8 0 0 REF Repriced Claim Number S1799 AC True Reference Identification Qualifier 0 True -1 128 Repriced Claim Reference Number 0 False -1 127 Description 0 False -1 352 Reference Identifier 0 False -1 C040 9A 0 0 REF Adjusted Repriced Claim Number S1800 AC True Reference Identification Qualifier 0 True -1 128 Adjusted Repriced Claim Reference Number 0 False -1 127 Description 0 False -1 352 Reference Identifier 0 False -1 C040 9C 0 0 REF Investigational Device Exemption Number S1810 AC True Reference Identification Qualifier 0 True -1 128 Investigational Device Exemption Identifier 0 False -1 127 Description 0 False -1 352 Reference Identifier 0 False -1 C040 LX 0 0 REF Claim Identifier For Transmission Intermediaries S1820 AC True Reference Identification Qualifier 0 True -1 128 Value Added Network Trace Number 0 False -1 127 Description 0 False -1 352 Reference Identifier 0 False -1 C040 D9 0 0 REF Auto Accident State S1830 AC True Reference Identification Qualifier 0 True -1 128 Auto Accident State or Province Code 0 False -1 127 Description 0 False -1 352 Reference Identifier 0 False -1 C040 LU 0 0 REF Medical Record Number S18A0 AC True Reference Identification Qualifier 0 True -1 128 Medical Record Number 0 False -1 127 Description 0 False -1 352 Reference Identifier 0 False -1 C040 EA 0 0 REF Demonstration Project Identifier S18B0 AC True Reference Identification Qualifier 0 True -1 128 Demonstration Project Identifier 0 False -1 127 Description 0 False -1 352 Reference Identifier 0 False -1 C040 P4 0 0 REF Peer Review Organization (PRO) Approval Number S18B1 AC True Reference Identification Qualifier 0 True -1 128 Peer Review Authorization Number 0 False -1 127 Description 0 False -1 352 Reference Identifier 0 False -1 C040 G4 0 0 K3 File Information S18C0 AC True Fixed Format Information 0 True -1 449 Record Format Code 0 False -1 1333 Composite Unit of Measure 0 False -1 C001 NTE Claim Note S1900 AC True Note Reference Code 0 False -1 363 Claim Note Text 0 True -1 352 NTE Billing Note S1910 AC True Note Reference Code 0 False -1 363 Billing Note Text 0 True -1 352 CRC EPSDT Referral S2225 AC True Code Qualifier 0 True -1 1136 Certification Condition Code Applies Indicator 0 True -1 1073 Condition Indicator 0 True -1 1321 Condition Indicator 0 False -1 1321 Condition Indicator 0 False -1 1321 Condition Indicator 0 False -1 1321 Condition Indicator 0 False -1 1321 ZZ 0 0 N|Y 1 0 AV|NU|S2|ST 2 0 HI Principal Diagnosis S2310 AC True Health Care Code Information 0 True -1 C022_837-Q3_HI_C_2310 Health Care Code Information 0 False -1 C022 Health Care Code Information 0 False -1 C022 Health Care Code Information 0 False -1 C022 Health Care Code Information 0 False -1 C022 Health Care Code Information 0 False -1 C022 Health Care Code Information 0 False -1 C022 Health Care Code Information 0 False -1 C022 Health Care Code Information 0 False -1 C022 Health Care Code Information 0 False -1 C022 Health Care Code Information 0 False -1 C022 Health Care Code Information 0 False -1 C022 HI Admitting Diagnosis S2314 AC True Health Care Code Information 0 True -1 C022_837-Q3_HI_C_2314 Health Care Code Information 0 False -1 C022 Health Care Code Information 0 False -1 C022 Health Care Code Information 0 False -1 C022 Health Care Code Information 0 False -1 C022 Health Care Code Information 0 False -1 C022 Health Care Code Information 0 False -1 C022 Health Care Code Information 0 False -1 C022 Health Care Code Information 0 False -1 C022 Health Care Code Information 0 False -1 C022 Health Care Code Information 0 False -1 C022 Health Care Code Information 0 False -1 C022 HI Patient's Reason For Visit S2315 AC True Health Care Code Information 0 True -1 C022_837-Q3_HI_C_2315 Health Care Code Information 0 False -1 C022 Health Care Code Information 0 False -1 C022 Health Care Code Information 0 False -1 C022 Health Care Code Information 0 False -1 C022 Health Care Code Information 0 False -1 C022 Health Care Code Information 0 False -1 C022 Health Care Code Information 0 False -1 C022 Health Care Code Information 0 False -1 C022 Health Care Code Information 0 False -1 C022 Health Care Code Information 0 False -1 C022 Health Care Code Information 0 False -1 C022 HI External Cause of Injury S2317 AC True Health Care Code Information 0 True -1 C022_837-Q3_HI_C_2317 Health Care Code Information 0 False -1 C022 Health Care Code Information 0 False -1 C022 Health Care Code Information 0 False -1 C022 Health Care Code Information 0 False -1 C022 Health Care Code Information 0 False -1 C022 Health Care Code Information 0 False -1 C022 Health Care Code Information 0 False -1 C022 Health Care Code Information 0 False -1 C022 Health Care Code Information 0 False -1 C022 Health Care Code Information 0 False -1 C022 Health Care Code Information 0 False -1 C022 HI Diagnosis Related Group (DRG) Information S2320 AC True Health Care Code Information 0 True -1 C022_837-Q3_HI_C_2320 Health Care Code Information 0 False -1 C022 Health Care Code Information 0 False -1 C022 Health Care Code Information 0 False -1 C022 Health Care Code Information 0 False -1 C022 Health Care Code Information 0 False -1 C022 Health Care Code Information 0 False -1 C022 Health Care Code Information 0 False -1 C022 Health Care Code Information 0 False -1 C022 Health Care Code Information 0 False -1 C022 Health Care Code Information 0 False -1 C022 Health Care Code Information 0 False -1 C022 HI Other Diagnosis Information S2330 AC True Health Care Code Information 0 True -1 C022_837-Q3_HI_C_2330 Health Care Code Information 0 False -1 C022 Health Care Code Information 0 False -1 C022 Health Care Code Information 0 False -1 C022 Health Care Code Information 0 False -1 C022 Health Care Code Information 0 False -1 C022 Health Care Code Information 0 False -1 C022 Health Care Code Information 0 False -1 C022 Health Care Code Information 0 False -1 C022 Health Care Code Information 0 False -1 C022 Health Care Code Information 0 False -1 C022 Health Care Code Information 0 False -1 C022 HI Principal Procedure Information S2340 AC True Health Care Code Information 0 True -1 C022_837-Q3_HI_C_2340 Health Care Code Information 0 False -1 C022 Health Care Code Information 0 False -1 C022 Health Care Code Information 0 False -1 C022 Health Care Code Information 0 False -1 C022 Health Care Code Information 0 False -1 C022 Health Care Code Information 0 False -1 C022 Health Care Code Information 0 False -1 C022 Health Care Code Information 0 False -1 C022 Health Care Code Information 0 False -1 C022 Health Care Code Information 0 False -1 C022 Health Care Code Information 0 False -1 C022 HI Other Procedure Information S2350 AC True Health Care Code Information 0 True -1 C022_837-Q3_HI_C_2350 Health Care Code Information 0 False -1 C022 Health Care Code Information 0 False -1 C022 Health Care Code Information 0 False -1 C022 Health Care Code Information 0 False -1 C022 Health Care Code Information 0 False -1 C022 Health Care Code Information 0 False -1 C022 Health Care Code Information 0 False -1 C022 Health Care Code Information 0 False -1 C022 Health Care Code Information 0 False -1 C022 Health Care Code Information 0 False -1 C022 Health Care Code Information 0 False -1 C022 HI Occurrence Span Information S2360 AC True Health Care Code Information 0 True -1 C022_837-Q3_HI_C_2360 Health Care Code Information 0 False -1 C022 Health Care Code Information 0 False -1 C022 Health Care Code Information 0 False -1 C022 Health Care Code Information 0 False -1 C022 Health Care Code Information 0 False -1 C022 Health Care Code Information 0 False -1 C022 Health Care Code Information 0 False -1 C022 Health Care Code Information 0 False -1 C022 Health Care Code Information 0 False -1 C022 Health Care Code Information 0 False -1 C022 Health Care Code Information 0 False -1 C022 HI Occurrence Information S2370 AC True Health Care Code Information 0 True -1 C022_837-Q3_HI_C_2370 Health Care Code Information 0 False -1 C022 Health Care Code Information 0 False -1 C022 Health Care Code Information 0 False -1 C022 Health Care Code Information 0 False -1 C022 Health Care Code Information 0 False -1 C022 Health Care Code Information 0 False -1 C022 Health Care Code Information 0 False -1 C022 Health Care Code Information 0 False -1 C022 Health Care Code Information 0 False -1 C022 Health Care Code Information 0 False -1 C022 Health Care Code Information 0 False -1 C022 HI Value Information S2380 AC True Health Care Code Information 0 True -1 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Information 0 False -1 C022 Health Care Code Information 0 False -1 C022 Health Care Code Information 0 False -1 C022 HI Treatment Code Information S23A0 AC True Health Care Code Information 0 True -1 C022_837-Q3_HI_C_23A0 Health Care Code Information 0 False -1 C022 Health Care Code Information 0 False -1 C022 Health Care Code Information 0 False -1 C022 Health Care Code Information 0 False -1 C022 Health Care Code Information 0 False -1 C022 Health Care Code Information 0 False -1 C022 Health Care Code Information 0 False -1 C022 Health Care Code Information 0 False -1 C022 Health Care Code Information 0 False -1 C022 Health Care Code Information 0 False -1 C022 Health Care Code Information 0 False -1 C022 HCP Claim Pricing/Repricing Information S2410 AC True Pricing Methodology 0 False -1 1473 Repriced Allowed Amount 0 False -1 782 Repriced Saving Amount 0 False -1 782 Repricing Organization Identifier 0 False -1 127 Repricing Per Diem or Flat Rate Amount 0 False -1 118 Repriced Approved DRG Code 0 False -1 127 Repriced Approved Amount 0 False -1 782 Repriced Approved Revenue Code 0 False -1 234 Product/Service ID Qualifier 0 False -1 235 Product/Service ID 0 False -1 234 Unit or Basis for Measurement Code 0 False -1 355 Repriced Approved Service Unit Count 0 False -1 380 Reject Reason Code 0 False -1 901 Policy Compliance Code 0 False -1 1526 Exception Code 0 False -1 1527 NM1 Attending Provider Name S2500 AC True Entity Identifier Code 0 True -1 98 Entity Type Qualifier 0 True -1 1065 Attending Provider Last Name 0 False -1 1035 Attending Provider First Name 0 False -1 1036 Attending Provider Middle Name or Initial 0 False -1 1037 Name Prefix 0 False -1 1038 Attending Provider Name Suffix 0 False -1 1039 Identification Code Qualifier 0 False -1 66 Attending Provider Primary Identifier 0 False -1 67 Entity Relationship Code 0 False -1 706 Entity Identifier Code 0 False -1 98 Name Last or Organization Name 0 False -1 1035 71 0 0 1 1 0 PRV Attending Provider Specialty Information S2550 AC True Provider Code 0 True -1 1221 Reference Identification Qualifier 0 False -1 128 Provider Taxonomy Code 0 False -1 127 State or Province Code 0 False -1 156 Provider Specialty Information 0 False -1 C035 Provider Organization Code 0 False -1 1223 AT 0 0 REF Attending Provider Secondary Identification S2710 AC True Reference Identification Qualifier 0 True -1 128 Attending Provider Secondary Identifier 0 False -1 127 Description 0 False -1 352 Reference Identifier 0 False -1 C040 0B|1G|G2|LU 0 0 NM1 Operating Physician Name S2500 AD True Entity Identifier Code 0 True -1 98 Entity Type Qualifier 0 True -1 1065 Operating Physician Last Name 0 False -1 1035 Operating Physician First Name 0 False -1 1036 Operating Physician Middle Name or Initial 0 False -1 1037 Name Prefix 0 False -1 1038 Operating Physician Name Suffix 0 False -1 1039 Identification Code Qualifier 0 False -1 66 Operating Physician Primary Identifier 0 False -1 67 Entity Relationship Code 0 False -1 706 Entity Identifier Code 0 False -1 98 Name Last or Organization Name 0 False -1 1035 72 0 0 1 1 0 REF Operating Physician Secondary Identification S2710 AD True Reference Identification Qualifier 0 True -1 128 Operating Physician Secondary Identifier 0 False -1 127 Description 0 False -1 352 Reference Identifier 0 False -1 C040 0B|1G|G2|LU 0 0 NM1 Other Operating Physician Name S2500 AE True Entity Identifier Code 0 True -1 98 Entity Type Qualifier 0 True -1 1065 Other Operating Physician Last Name 0 False -1 1035 Other Operating Physician First Name 0 False -1 1036 Other Operating Physician Middle Name or Initial 0 False -1 1037 Name Prefix 0 False -1 1038 Other Operating Physician Name Suffix 0 False -1 1039 Identification Code Qualifier 0 False -1 66 Other Operating Physician Identifier 0 False -1 67 Entity Relationship Code 0 False -1 706 Entity Identifier Code 0 False -1 98 Name Last or Organization Name 0 False -1 1035 ZZ 0 0 1 1 0 REF Other Operating Physician Secondary Identification S2710 AE True Reference Identification Qualifier 0 True -1 128 Other Provider Secondary Identifier 0 False -1 127 Description 0 False -1 352 Reference Identifier 0 False -1 C040 0B|1G|G2|LU 0 0 NM1 Rendering Provider Name S2500 AF True Entity Identifier Code 0 True -1 98 Entity Type Qualifier 0 True -1 1065 Rendering Provider Last Name 0 False -1 1035 Rendering Provider First Name 0 False -1 1036 Rendering Provider Middle Name or Initial 0 False -1 1037 Name Prefix 0 False -1 1038 Rendering Provider Name Suffix 0 False -1 1039 Identification Code Qualifier 0 False -1 66 Rendering Provider Identifier 0 False -1 67 Entity Relationship Code 0 False -1 706 Entity Identifier Code 0 False -1 98 Name Last or Organization Name 0 False -1 1035 82 0 0 1 1 0 REF Rendering Provider Secondary Identification S2710 AF True Reference Identification Qualifier 0 True -1 128 Rendering Provider Secondary Identifier 0 False -1 127 Description 0 False -1 352 Reference Identifier 0 False -1 C040 0B|1G|G2|LU 0 0 NM1 Service Facility Location Name S2500 AG True Entity Identifier Code 0 True -1 98 Entity Type Qualifier 0 True -1 1065 Laboratory or Facility Name 0 False -1 1035 Name First 0 False -1 1036 Name Middle 0 False -1 1037 Name Prefix 0 False -1 1038 Name Suffix 0 False -1 1039 Identification Code Qualifier 0 False -1 66 Laboratory or Facility Primary Identifier 0 False -1 67 Entity Relationship Code 0 False -1 706 Entity Identifier Code 0 False -1 98 Name Last or Organization Name 0 False -1 1035 77 0 0 2 1 0 N3 Service Facility Location Address S2650 AG True Laboratory or Facility Address Line 0 True -1 166 Laboratory or Facility Address Line 0 False -1 166 N4 Service Facility Location City, State, ZIP Code S2700 AG True Laboratory or Facility City Name 0 False -1 19 Laboratory or Facility State or Province Code 0 False -1 156 Laboratory or Facility Postal Zone or ZIP Code 0 False -1 116 Country Code 0 False -1 26 Location Qualifier 0 False -1 309 Location Identifier 0 False -1 310 Country Subdivision Code 0 False -1 1715 REF Service Facility Location Secondary Identification S2710 AG True Reference Identification Qualifier 0 True -1 128 Laboratory or Facility Secondary Identifier 0 False -1 127 Description 0 False -1 352 Reference Identifier 0 False -1 C040 0B|G2|LU 0 0 NM1 Referring Provider Name S2800 AG True Entity Identifier Code 0 True -1 98 Entity Type Qualifier 0 True -1 1065 Referring Provider Last Name 0 False -1 1035 Referring Provider First Name 0 False -1 1036 Referring Provider Middle Name or Initial 0 False -1 1037 Name Prefix 0 False -1 1038 Referring Provider Name Suffix 0 False -1 1039 Identification Code Qualifier 0 False -1 66 Referring Provider Identifier 0 False -1 67 Entity Relationship Code 0 False -1 706 Entity Identifier Code 0 False -1 98 Name Last or Organization Name 0 False -1 1035 DN 0 0 1 1 0 REF Referring Provider Secondary Identification S2850 AG True Reference Identification Qualifier 0 True -1 128 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Identifier 0 False -1 C040 EI 0 0 HL Subscriber Hierarchical Level S0010 A4 True Hierarchical ID Number 0 True -1 628 Hierarchical Parent ID Number 0 False -1 734 Hierarchical Level Code 0 True -1 735 Hierarchical Child Code 0 False -1 736 22 2 0 SBR Subscriber Information S0050 A4 True Payer Responsibility Sequence Number Code 0 True -1 1138 Individual Relationship Code 0 False -1 1069 Subscriber Group or Policy Number 0 False -1 127 Subscriber Group Name 0 False -1 93 Insurance Type Code 0 False -1 1336 Coordination of Benefits Code 0 False -1 1143 Yes/No Condition or Response Code 0 False -1 1073 Employment Status Code 0 False -1 584 Claim Filing Indicator Code 0 False -1 1032 A|B|C|D|E|F|G|H|P|S|T|U 0 0 PAT Patient Information S0070 A4 True Individual Relationship Code 0 False -1 1069 Patient Location Code 0 False -1 1384 Employment Status Code 0 False -1 584 Student Status Code 0 False -1 1220 Date Time Period Format Qualifier 0 False -1 1250 Patient Death Date 0 False -1 1251 Unit or Basis for Measurement Code 0 False -1 355 Patient Weight 0 False -1 81 Pregnancy Indicator 0 False -1 1073 NM1 Subscriber Name S0150 A4 True Entity Identifier Code 0 True -1 98 Entity Type Qualifier 0 True -1 1065 Subscriber Last Name 0 False -1 1035 Subscriber First Name 0 False -1 1036 Subscriber Middle Name or Initial 0 False -1 1037 Name Prefix 0 False -1 1038 Subscriber Name Suffix 0 False -1 1039 Identification Code Qualifier 0 False -1 66 Subscriber Primary Identifier 0 False -1 67 Entity Relationship Code 0 False -1 706 Entity Identifier Code 0 False -1 98 Name Last or Organization Name 0 False -1 1035 IL 0 0 1|2 1 0 N3 Subscriber Address S0250 A4 True Subscriber Address Line 0 True -1 166 Subscriber Address Line 0 False -1 166 N4 Subscriber City, State, ZIP Code S0300 A4 True Subscriber City Name 0 False -1 19 Subscriber State Code 0 False -1 156 Subscriber Postal Zone or ZIP Code 0 False -1 116 Country Code 0 False -1 26 Location Qualifier 0 False -1 309 Location Identifier 0 False -1 310 Country Subdivision Code 0 False -1 1715 DMG Subscriber Demographic Information S0320 A4 True Date Time Period Format Qualifier 0 False -1 1250 Subscriber Birth Date 0 False -1 1251 Subscriber Gender Code 0 False -1 1068 Marital Status Code 0 False -1 1067 Composite Race or Ethnicity Information 0 False -1 C056 Citizenship Status Code 0 False -1 1066 Country Code 0 False -1 26 Basis of Verification Code 0 False -1 659 Quantity 0 False -1 380 Code List Qualifier Code 0 False -1 1270 Industry Code 0 False -1 1271 REF Subscriber Secondary Identification S0350 A4 True Reference Identification Qualifier 0 True -1 128 Subscriber Supplemental Identifier 0 False -1 127 Description 0 False -1 352 Reference Identifier 0 False -1 C040 SY 0 0 REF Property and Casualty Claim Number S0360 A4 True Reference Identification Qualifier 0 True -1 128 Property Casualty Claim Number 0 False -1 127 Description 0 False -1 352 Reference Identifier 0 False -1 C040 Y4 0 0 PER Property 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0 True -1 1250 Acute Manifestation Date 0 True -1 1251 453 0 0 D8 1 0 DTP Date - Accident S13D0 AC True Date Time Qualifier 0 True -1 374 Date Time Period Format Qualifier 0 True -1 1250 Accident Date 0 True -1 1251 439 0 0 D8 1 0 DTP Date - Last Menstrual Period S13E0 AC True Date Time Qualifier 0 True -1 374 Date Time Period Format Qualifier 0 True -1 1250 Last Menstrual Period Date 0 True -1 1251 484 0 0 D8 1 0 DTP Date - Last X-ray Date S13F0 AC True Date Time Qualifier 0 True -1 374 Date Time Period Format Qualifier 0 True -1 1250 Last X-Ray Date 0 True -1 1251 455 0 0 D8 1 0 DTP Date - Hearing and Vision Prescription Date S13J0 AC True Date Time Qualifier 0 True -1 374 Date Time Period Format Qualifier 0 True -1 1250 Prescription Date 0 True -1 1251 471 0 0 D8 1 0 DTP Date - Disability Dates S13L0 AC True Date Time Qualifier 0 True -1 374 Date Time Period Format Qualifier 0 True -1 1250 Disability From Date 0 True -1 1251 314|360|361 0 0 D8|RD8 1 0 DTP Date - Last Worked S13N0 AC True Date Time Qualifier 0 True -1 374 Date Time Period Format Qualifier 0 True -1 1250 Last Worked Date 0 True -1 1251 297 0 0 D8 1 0 DTP Date - Authorized Return to Work S13O0 AC True Date Time Qualifier 0 True -1 374 Date Time Period Format Qualifier 0 True -1 1250 Work Return Date 0 True -1 1251 296 0 0 D8 1 0 DTP Date - Admission S13P0 AC True Date Time Qualifier 0 True -1 374 Date Time Period Format Qualifier 0 True -1 1250 Related Hospitalization Admission Date 0 True -1 1251 435 0 0 D8 1 0 DTP Date - Discharge S13Q0 AC True Date Time Qualifier 0 True -1 374 Date Time Period Format Qualifier 0 True -1 1250 Related Hospitalization Discharge Date 0 True -1 1251 096 0 0 D8 1 0 DTP Date - Assumed and Relinquished Care Dates S13U0 AC True Date Time Qualifier 0 True -1 374 Date Time Period Format Qualifier 0 True -1 1250 Assumed or Relinquished Care Date 0 True -1 1251 090|091 0 0 D8 1 0 DTP Date - Property and Casualty Date of First Contact S13W0 AC True Date Time Qualifier 0 True -1 374 Date Time Period Format Qualifier 0 True -1 1250 Date Time Period 0 True -1 1251 444 0 0 D8 1 0 DTP Date - Repricer Received Date S13Y0 AC True Date Time Qualifier 0 True -1 374 Date Time Period Format Qualifier 0 True -1 1250 Repricer Received Date 0 True -1 1251 050 0 0 D8 1 0 PWK Claim Supplemental Information S1550 AC True Attachment Report Type Code 0 True -1 755 Attachment Transmission Code 0 False -1 756 Report Copies Needed 0 False -1 757 Entity Identifier Code 0 False -1 98 Identification Code Qualifier 0 False -1 66 Attachment Control Number 0 False -1 67 Description 0 False -1 352 Actions Indicated 0 False -1 C002 Request Category Code 0 False -1 1525 03|04|05|06|07|08|09|10|11|13|15|21|A3|A4|AM|AS|B2|B3|B4|BR|BS|BT|CB|CK|CT|D2|DA|DB|DG|DJ|DS|EB|HC|HR|I5|IR|LA|M1|MT|NN|OB|OC|OD|OE|OX|OZ|P4|P5|PE|PN|PO|PQ|PY|PZ|RB|RR|RT|RX|SG|V5|XP 0 0 CN1 Contract Information S1600 AC True Contract Type Code 0 True -1 1166 Contract Amount 0 False -1 782 Contract Percentage 0 False -1 332 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S17H0 AC True Reference Identification Qualifier 0 True -1 128 Referral Number 0 False -1 127 Description 0 False -1 352 Reference Identifier 0 False -1 C040 9F 0 0 REF Prior Authorization S1800 AC True Reference Identification Qualifier 0 True -1 128 Prior Authorization Number 0 False -1 127 Description 0 False -1 352 Reference Identifier 0 False -1 C040 G1 0 0 REF Payer Claim Control Number S1810 AC True Reference Identification Qualifier 0 True -1 128 Payer Claim Control Number 0 False -1 127 Description 0 False -1 352 Reference Identifier 0 False -1 C040 F8 0 0 REF Clinical Laboratory Improvement Amendment (CLIA) Number S1820 AC True Reference Identification Qualifier 0 True -1 128 Clinical Laboratory Improvement Amendment Number 0 False -1 127 Description 0 False -1 352 Reference Identifier 0 False -1 C040 X4 0 0 REF Repriced Claim Number S1830 AC True Reference Identification Qualifier 0 True -1 128 Repriced Claim Reference Number 0 False -1 127 Description 0 False -1 352 Reference Identifier 0 False -1 C040 9A 0 0 REF Adjusted Repriced Claim Number S1840 AC True Reference Identification Qualifier 0 True -1 128 Adjusted Repriced Claim Reference Number 0 False -1 127 Description 0 False -1 352 Reference Identifier 0 False -1 C040 9C 0 0 REF Investigational Device Exemption Number S1850 AC True Reference Identification Qualifier 0 True -1 128 Investigational Device Exemption Identifier 0 False -1 127 Description 0 False -1 352 Reference Identifier 0 False -1 C040 LX 0 0 REF Claim Identifier For Transmission Intermediaries S1860 AC True Reference Identification Qualifier 0 True -1 128 Value Added Network Trace Number 0 False -1 127 Description 0 False -1 352 Reference Identifier 0 False -1 C040 D9 0 0 REF Medical Record Number S1890 AC True Reference Identification Qualifier 0 True -1 128 Medical Record Number 0 False -1 127 Description 0 False -1 352 Reference Identifier 0 False -1 C040 EA 0 0 REF Demonstration Project Identifier S18A0 AC True Reference Identification Qualifier 0 True -1 128 Demonstration Project Identifier 0 False -1 127 Description 0 False -1 352 Reference Identifier 0 False -1 C040 P4 0 0 REF Care Plan Oversight S18A1 AC True Reference Identification Qualifier 0 True -1 128 Care Plan Oversight Number 0 False -1 127 Description 0 False -1 352 Reference Identifier 0 False -1 C040 1J 0 0 K3 File Information S18B0 AC True Fixed Format Information 0 True -1 449 Record Format Code 0 False -1 1333 Composite Unit of Measure 0 False -1 C001 NTE Claim Note S1900 AC True Note Reference Code 0 False -1 363 Claim Note Text 0 True -1 352 CR1 Ambulance Transport Information S1950 AC True Unit or Basis for Measurement Code 0 False -1 355 Patient Weight 0 False -1 81 Ambulance Transport Code 0 False -1 1316 Ambulance Transport Reason Code 0 False -1 1317 Unit or Basis for Measurement Code 0 False -1 355 Transport Distance 0 False -1 380 Address Information 0 False -1 166 Address Information 0 False -1 166 Round Trip Purpose Description 0 False -1 352 Stretcher Purpose Description 0 False -1 352 CR2 Spinal Manipulation Service Information S2000 AC True Count 0 False -1 609 Quantity 0 False -1 380 Subluxation Level Code 0 False -1 1367 Subluxation Level Code 0 False -1 1367 Unit or Basis for Measurement Code 0 False -1 355 Quantity 0 False -1 380 Quantity 0 False -1 380 Patient Condition Code 0 False -1 1342 Yes/No Condition or Response Code 0 False -1 1073 Patient Condition Description 0 False -1 352 Patient Condition Description 0 False -1 352 Yes/No Condition or Response Code 0 False -1 1073 CRC Ambulance Certification S2200 AC True Code Category 0 True -1 1136 Certification Condition Indicator 0 True -1 1073 Condition Code 0 True -1 1321 Condition Code 0 False -1 1321 Condition Code 0 False -1 1321 Condition Code 0 False -1 1321 Condition Code 0 False -1 1321 07 0 0 N|Y 1 0 01|04|05|06|07|08|09|12 2 0 CRC Patient Condition Information: Vision S2210 AC True Code Category 0 True -1 1136 Certification Condition Indicator 0 True -1 1073 Condition Code 0 True -1 1321 Condition Code 0 False -1 1321 Condition Code 0 False -1 1321 Condition Code 0 False -1 1321 Condition Code 0 False -1 1321 E1|E2|E3 0 0 N|Y 1 0 L1|L2|L3|L4|L5 2 0 CRC Homebound Indicator S2220 AC True Code Category 0 True -1 1136 Certification Condition Indicator 0 True -1 1073 Homebound Indicator 0 True -1 1321 Condition Indicator 0 False -1 1321 Condition Indicator 0 False -1 1321 Condition Indicator 0 False -1 1321 Condition Indicator 0 False -1 1321 75 0 0 Y 1 0 IH 2 0 CRC EPSDT Referral S2230 AC True Code Qualifier 0 True -1 1136 Certification Condition Code Applies Indicator 0 True -1 1073 Condition Indicator 0 True -1 1321 Condition Indicator 0 False -1 1321 Condition Indicator 0 False -1 1321 Condition Indicator 0 False -1 1321 Condition Indicator 0 False -1 1321 ZZ 0 0 N|Y 1 0 AV|NU|S2|ST 2 0 HI Health Care Diagnosis Code S2310 AC True Health Care Code Information 0 True -1 C022_837-Q1_HI_C_2310 Health Care Code 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Care Code Information 0 False -1 C022 Health Care Code Information 0 False -1 C022 HI Condition Information S2320 AC True Health Care Code Information 0 True -1 C022_837-Q1_HI_C_2320 Health Care Code Information 0 False -1 C022 Health Care Code Information 0 False -1 C022 Health Care Code Information 0 False -1 C022 Health Care Code Information 0 False -1 C022 Health Care Code Information 0 False -1 C022 Health Care Code Information 0 False -1 C022 Health Care Code Information 0 False -1 C022 Health Care Code Information 0 False -1 C022 Health Care Code Information 0 False -1 C022 Health Care Code Information 0 False -1 C022 Health Care Code Information 0 False -1 C022 HCP Claim Pricing/Repricing Information S2410 AC True Pricing Methodology 0 False -1 1473 Repriced Allowed Amount 0 False -1 782 Repriced Saving Amount 0 False -1 782 Repricing Organization Identifier 0 False -1 127 Repricing Per Diem or Flat Rate Amount 0 False -1 118 Repriced Approved Ambulatory Patient Group Code 0 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Reference Identification Qualifier 0 True -1 128 Referring Provider Secondary Identifier 0 False -1 127 Description 0 False -1 352 Reference Identifier 0 False -1 C040 0B|1G|G2 0 0 NM1 Rendering Provider Name S2500 AD True Entity Identifier Code 0 True -1 98 Entity Type Qualifier 0 True -1 1065 Rendering Provider Last or Organization Name 0 False -1 1035 Rendering Provider First Name 0 False -1 1036 Rendering Provider Middle Name or Initial 0 False -1 1037 Name Prefix 0 False -1 1038 Rendering Provider Name Suffix 0 False -1 1039 Identification Code Qualifier 0 False -1 66 Rendering Provider Identifier 0 False -1 67 Entity Relationship Code 0 False -1 706 Entity Identifier Code 0 False -1 98 Name Last or Organization Name 0 False -1 1035 82 0 0 1|2 1 0 PRV Rendering Provider Specialty Information S2550 AD True Provider Code 0 True -1 1221 Reference Identification Qualifier 0 False -1 128 Provider Taxonomy Code 0 False -1 127 State or Province Code 0 False -1 156 Provider Specialty Information 0 False -1 C035 Provider Organization Code 0 False -1 1223 PE 0 0 REF Rendering Provider Secondary Identification S2710 AD True Reference Identification Qualifier 0 True -1 128 Rendering Provider Secondary Identifier 0 False -1 127 Description 0 False -1 352 Reference Identifier 0 False -1 C040 0B|1G|G2|LU 0 0 NM1 Service Facility Location Name S2500 AF True Entity Identifier Code 0 True -1 98 Entity Type Qualifier 0 True -1 1065 Laboratory or Facility Name 0 False -1 1035 Name First 0 False -1 1036 Name Middle 0 False -1 1037 Name Prefix 0 False -1 1038 Name Suffix 0 False -1 1039 Identification Code Qualifier 0 False -1 66 Laboratory or Facility Primary Identifier 0 False -1 67 Entity Relationship Code 0 False -1 706 Entity Identifier Code 0 False -1 98 Name Last or Organization Name 0 False -1 1035 77 0 0 2 1 0 N3 Service Facility Location Address S2650 AF True Laboratory or Facility Address Line 0 True -1 166 Laboratory or Facility Address Line 0 False -1 166 N4 Service 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Provider Identifier 0 False -1 67 Entity Relationship Code 0 False -1 706 Entity Identifier Code 0 False -1 98 Name Last or Organization Name 0 False -1 1035 DQ 0 0 1 1 0 REF Supervising Provider Secondary Identification S5250 AS True Reference Identification Qualifier 0 True -1 128 Supervising Provider Secondary Identifier 0 False -1 127 Description 0 False -1 352 Reference Identifier 0 False -1 C040_837-Q1_REF_S_5250 0B|1G|G2|LU 0 0 NM1 Ordering Provider Name S5000 AT True Entity Identifier Code 0 True -1 98 Entity Type Qualifier 0 True -1 1065 Ordering Provider Last Name 0 False -1 1035 Ordering Provider First Name 0 False -1 1036 Ordering Provider Middle Name or Initial 0 False -1 1037 Name Prefix 0 False -1 1038 Ordering Provider Name Suffix 0 False -1 1039 Identification Code Qualifier 0 False -1 66 Ordering Provider Identifier 0 False -1 67 Entity Relationship Code 0 False -1 706 Entity Identifier Code 0 False -1 98 Name Last or Organization Name 0 False -1 1035 DK 0 0 1 1 0 N3 Ordering Provider Address S5140 AT True Ordering Provider Address Line 0 True -1 166 Ordering Provider Address Line 0 False -1 166 N4 Ordering Provider City, State, ZIP Code S5200 AT True Ordering Provider City Name 0 False -1 19 Ordering Provider State or Province Code 0 False -1 156 Ordering Provider Postal Zone or ZIP Code 0 False -1 116 Country Code 0 False -1 26 Location Qualifier 0 False -1 309 Location Identifier 0 False -1 310 Country Subdivision Code 0 False -1 1715 REF Ordering Provider Secondary Identification S5250 AT True Reference Identification Qualifier 0 True -1 128 Ordering Provider Secondary Identifier 0 False -1 127 Description 0 False -1 352 Reference Identifier 0 False -1 C040_837-Q1_REF_T_5250 0B|1G|G2 0 0 PER Ordering Provider Contact Information S5300 AT True Contact Function Code 0 True -1 366 Ordering Provider Contact Name 0 False -1 93 Communication Number Qualifier 0 False -1 365 Communication Number 0 False -1 364 Communication Number Qualifier 0 False -1 365 Communication Number 0 False -1 364 Communication Number Qualifier 0 False -1 365 Communication Number 0 False -1 364 Contact Inquiry Reference 0 False -1 443 IC 0 0 NM1 Referring Provider Name S5000 AU True Entity Identifier Code 0 True -1 98 Entity Type Qualifier 0 True -1 1065 Referring Provider Last Name 0 False -1 1035 Referring Provider First Name 0 False -1 1036 Referring Provider Middle Name or Initial 0 False -1 1037 Name Prefix 0 False -1 1038 Referring Provider Name Suffix 0 False -1 1039 Identification Code Qualifier 0 False -1 66 Referring Provider Identifier 0 False -1 67 Entity Relationship Code 0 False -1 706 Entity Identifier Code 0 False -1 98 Name Last or Organization Name 0 False -1 1035 DN|P3 0 0 1 1 0 REF Referring Provider Secondary Identification S5250 AU True Reference Identification Qualifier 0 True -1 128 Referring Provider Secondary Identifier 0 False -1 127 Description 0 False -1 352 Reference Identifier 0 False -1 C040_837-Q1_REF_U_5250 0B|1G|G2 0 0 NM1 Ambulance Pick-up Location S5310 AV True Entity Identifier Code 0 True -1 98 Entity Type Qualifier 0 True -1 1065 Name Last or Organization Name 0 False -1 1035 Name First 0 False -1 1036 Name Middle 0 False -1 1037 Name Prefix 0 False -1 1038 Name Suffix 0 False -1 1039 Identification Code Qualifier 0 False -1 66 Identification Code 0 False -1 67 Entity Relationship Code 0 False -1 706 Entity Identifier Code 0 False -1 98 Name Last or Organization Name 0 False -1 1035 PW 0 0 2 1 0 N3 Ambulance Pick-up Location Address S5340 AV True Ambulance Pick-up Address Line 0 True -1 166 Ambulance Pick-up Address Line 0 False -1 166 N4 Ambulance Pick-up Location City, State, ZIP Code S5350 AV True Ambulance Pick-up City Name 0 False -1 19 Ambulance Pick-up State or Province Code 0 False -1 156 Ambulance Pick-up Postal Zone or ZIP Code 0 False -1 116 Country Code 0 False -1 26 Location Qualifier 0 False -1 309 Location Identifier 0 False -1 310 Country Subdivision Code 0 False -1 1715 NM1 Ambulance Drop-off Location S5380 AV True Entity Identifier Code 0 True -1 98 Entity Type Qualifier 0 True -1 1065 Ambulance Drop-off Location 0 False -1 1035 Name First 0 False -1 1036 Name Middle 0 False -1 1037 Name Prefix 0 False -1 1038 Name Suffix 0 False -1 1039 Identification Code Qualifier 0 False -1 66 Identification Code 0 False -1 67 Entity Relationship Code 0 False -1 706 Entity Identifier Code 0 False -1 98 Name Last or Organization Name 0 False -1 1035 45 0 0 2 1 0 N3 Ambulance Drop-off Location Address S5410 AV True Ambulance Drop-off Address Line 0 True -1 166 Ambulance Drop-off Address Line 0 False -1 166 N4 Ambulance Drop-off Location City, State, ZIP Code S5420 AV True Ambulance Drop-off City Name 0 False -1 19 Ambulance Drop-off State or Province Code 0 False -1 156 Ambulance Drop-off Postal Zone or ZIP Code 0 False -1 116 Country Code 0 False -1 26 Location Qualifier 0 False -1 309 Location Identifier 0 False -1 310 Country Subdivision Code 0 False -1 1715 SVD Line Adjudication Information S5400 AW True Other Payer Primary Identifier 0 True -1 67 Service Line Paid Amount 0 True -1 782 Composite Medical Procedure Identifier 0 False -1 C003_837-Q1_SVD_W_5400 Product/Service ID 0 False -1 234 Paid Service Unit Count 0 False -1 380 Bundled or Unbundled Line Number 0 False -1 554 CAS Line Adjustment S5450 AW True Claim Adjustment Group Code 0 True -1 1033 Adjustment Reason Code 0 True -1 1034 Adjustment Amount 0 True -1 782 Adjustment Quantity 0 False -1 380 Adjustment Reason Code 0 False -1 1034 Adjustment Amount 0 False -1 782 Adjustment Quantity 0 False -1 380 Adjustment Reason Code 0 False -1 1034 Adjustment Amount 0 False -1 782 Adjustment Quantity 0 False -1 380 Adjustment Reason Code 0 False -1 1034 Adjustment Amount 0 False -1 782 Adjustment Quantity 0 False -1 380 Adjustment Reason Code 0 False -1 1034 Adjustment Amount 0 False -1 782 Adjustment Quantity 0 False -1 380 Adjustment Reason Code 0 False -1 1034 Adjustment Amount 0 False -1 782 Adjustment Quantity 0 False -1 380 CO|CR|OA|PI|PR 0 0 DTP Line Check or Remittance Date S5500 AW True Date Time Qualifier 0 True -1 374 Date Time Period Format Qualifier 0 True -1 1250 Adjudication or Payment Date 0 True -1 1251 573 0 0 D8 1 0 AMT Remaining Patient Liability S5505 AW True Amount Qualifier Code 0 True -1 522 Remaining Patient Liability 0 True -1 782 Credit/Debit Flag Code 0 False -1 478 EAF 0 0 LQ Form Identification Code S5510 AY True Code List Qualifier Code 0 False -1 1270 Form Identifier 0 False -1 1271 FRM Supporting Documentation S5520 AY True Question Number/Letter 0 True -1 350 Question Response 0 False -1 1073 Question Response 0 False -1 127 Question Response 0 False -1 373 Question Response 0 False -1 332 SE Transaction Set Trailer S5550 AZ True Transaction Segment Count 0 True -1 96 Transaction Set Control Number 0 True -1 329 AK1 Functional Group Response Header True Functional Identifier Code 0 True -1 479 Group Control Number 0 True -1 28 Version / Release / Industry Identifier Code 0 False -1 480 AK2 Transaction Set Response Header True Transaction Set Identifier Code 0 True -1 143 Transaction Set Control Number 0 True -1 329 Implementation Convention Reference 0 False -1 1705 AK3 Data Segment Note True Segment ID Code 0 True -1 721 Segment Position in Transaction Set 0 True -1 719 Loop Identifier Code 0 False -1 447 Segment Syntax Error Code 0 False -1 720 AK4 Data Element Note True Position in Segment 0 True -1 C030 Data Element Reference Number 0 False -1 725 Data Element Syntax Error Code 0 True -1 723 Copy of Bad Data Element 0 False -1 724 AK5 Transaction Set Response Trailer True Transaction Set Acknowledgment Code 0 True -1 717 Transaction Set Syntax Error Code 0 False -1 718 Transaction Set Syntax Error Code 0 False -1 718 Transaction Set Syntax Error Code 0 False -1 718 Transaction Set Syntax Error Code 0 False -1 718 Transaction Set Syntax Error Code 0 False -1 718 AK9 Functional Group Response Trailer True Functional Group Acknowledge Code 0 True -1 715 Number of Transaction Sets Included 0 True -1 97 Number of Received Transaction Sets 0 True -1 123 Number of Accepted Transaction Sets 0 True -1 2 Functional Group Syntax Error Code 0 False -1 716 Functional Group Syntax Error Code 0 False -1 716 Functional Group Syntax Error Code 0 False -1 716 Functional Group Syntax Error Code 0 False -1 716 Functional Group Syntax Error Code 0 False -1 716 ST Transaction Set Header S0100 A1 True Accident Date 0 True -1 143 Accident Date 0 True -1 329 Accident Date 0 False -1 1705 997 0 0 AK1 Functional Group Response Header S0200 A1 True Accident Date 0 True -1 479 Accident Date 0 True -1 28 Accident Date 0 False -1 480 AK2 Transaction Set Response Header S0300 A1 True Accident Date 0 True -1 143 Accident Date 0 True -1 329 Accident Date 0 False -1 1705 AK3 AK2/AK3 Error Identification S0400 A1 True Accident Date 0 True -1 721 Accident Date 0 True -1 719 Accident Date 0 False -1 447 Accident Date 0 False -1 720 AK4 Data Element Note S0500 A1 True Position in Segment 0 True -1 C030_997-A1_AK4_1_0500 Accident Date 0 False -1 725 Accident Date 0 True -1 723 Accident Date 0 False -1 724 1|2|3|4|5|6|7|8|9|10|12|13 2 0 AK5 Transaction Set Response Trailer S0600 A1 True Accident Date 0 True -1 717 Accident Date 0 False -1 718 Accident Date 0 False -1 718 Accident Date 0 False -1 718 Accident Date 0 False -1 718 Accident Date 0 False -1 718 A|E|M|R|W|X 0 0 AK9 Functional Group Response Trailer S0700 A1 True Accident Date 0 True -1 715 Accident Date 0 True -1 97 Accident Date 0 True -1 123 Accident Date 0 True -1 2 Accident Date 0 False -1 716 Accident Date 0 False -1 716 Accident Date 0 False -1 716 Accident Date 0 False -1 716 Accident Date 0 False -1 716 A|E|M|P|R|W|X 0 0 SE Transaction Set Trailer S0800 A1 True Accident Date 0 True -1 96 Accident Date 0 True -1 329 CTX Context True Context Identification 0 True -1 C998 Segment ID Code 0 False -1 721 Segment Position in Transaction Set 0 False -1 719 Loop Identifier Code 0 False -1 447 Position in Segment 0 False -1 C030 Reference in Segment 0 False -1 C999 IK3 Implementation Data Segment Note True Segment ID Code 0 True -1 721 Segment Position in Transaction Set 0 True -1 719 Loop Identifier Code 0 False -1 447 Implementation Segment Syntax Error Code 0 False -1 620 IK4 Implementation Data Element Note True Position in Segment 0 True -1 C030 Data Element Reference Number 0 False -1 725 Implementation Data Element Syntax Error Code 0 True -1 621 Copy of Bad Data Element 0 False -1 724 IK5 Implementation Transaction Set Response Trailer True Transaction Set Acknowledgment Code 0 True -1 717 Implementation Transaction Set Syntax Error Code 0 False -1 618 Implementation Transaction Set Syntax Error Code 0 False -1 618 Implementation Transaction Set Syntax Error Code 0 False -1 618 Implementation Transaction Set Syntax Error Code 0 False -1 618 Implementation Transaction Set Syntax Error Code 0 False -1 618 ST Transaction Set Header S0100 A1 True Transaction Set Identifier Code 0 True -1 143 Transaction Set Control Number 0 True -1 329 Implementation Convention Reference 0 False -1 1705 999 0 0 AK1 Functional Group Response Header S0200 A1 True Functional Identifier Code 0 True -1 479 Group Control Number 0 True -1 28 Version, Release, or Industry Identifier Code 0 False -1 480 AK2 Transaction Set Response Header S0300 A1 True Transaction Set Identifier Code 0 True -1 143 Transaction Set Control Number 0 True -1 329 Implementation Convention Reference 0 False -1 1705 IK3 Error Identification S0400 A1 True Segment ID Code 0 True -1 721 Segment Position in Transaction Set 0 True -1 719 Loop Identifier Code 0 False -1 447 Implementation Segment Syntax Error Code 0 False -1 620 CTX Segment Context S0500 A1 True Context Identification 0 True -1 C998_999-A1_CTX_1_0500 Segment ID Code 0 False -1 721 Segment Position in Transaction Set 0 False -1 719 Loop Identifier Code 0 False -1 447 Position in Segment 0 False -1 C030_999-A1_CTX_1_0500 Reference in Segment 0 False -1 C999_999-A1_CTX_1_0500 CTX Business Unit Identifier S0510 A1 True Context Identification 0 True -1 C998_999-A1_CTX_1_0510 Segment ID Code 0 False -1 721 Segment Position in Transaction Set 0 False -1 719 Loop Identifier Code 0 False -1 447 Position in Segment 0 False -1 C030 Reference in Segment 0 False -1 C999 IK4 Implementation Data Element Note S0600 A1 True Position in Segment 0 True -1 C030_999-A1_IK4_1_0600 Data Element Reference Number 0 False -1 725 Implementation Data Element Syntax Error Code 0 True -1 621 Copy of Bad Data Element 0 False -1 724 1|2|3|4|5|6|7|8|9|10|12|13|I10|I11|I12|I13|I6|I9 2 0 CTX Element Context S0700 A1 True Context Identification 0 True -1 C998_999-A1_CTX_1_0700 Segment ID Code 0 False -1 721 Segment Position in Transaction Set 0 False -1 719 Loop Identifier Code 0 False -1 447 Position in Segment 0 False -1 C030_999-A1_CTX_1_0700 Reference in Segment 0 False -1 C999_999-A1_CTX_1_0700 IK5 Transaction Set Response Trailer S0800 A1 True Transaction Set Acknowledgment Code 0 True -1 717 Implementation Transaction Set Syntax Error Code 0 False -1 618 Implementation Transaction Set Syntax Error Code 0 False -1 618 Implementation Transaction Set Syntax Error Code 0 False -1 618 Implementation Transaction Set Syntax Error Code 0 False -1 618 Implementation Transaction Set Syntax Error Code 0 False -1 618 A|E|M|R|W|X 0 0 AK9 Functional Group Response Trailer S0900 A1 True Functional Group Acknowledge Code 0 True -1 715 Number of Transaction Sets Included 0 True -1 97 Number of Received Transaction Sets 0 True -1 123 Number of Accepted Transaction Sets 0 True -1 2 Functional Group Syntax Error Code 0 False -1 716 Functional Group Syntax Error Code 0 False -1 716 Functional Group Syntax Error Code 0 False -1 716 Functional Group Syntax Error Code 0 False -1 716 Functional Group Syntax Error Code 0 False -1 716 A|E|M|P|R|W|X 0 0 SE Transaction Set Trailer S1000 A1 True Number of Included Segments 0 True -1 96 Transaction Set Control Number 0 True -1 329 ST Transaction Set Header S0100 A1 True Transaction Set Identifier Code 0 True -1 143 Transaction Set Control Number 0 True -1 329 Implementation Convention Reference 0 False -1 1705 999 0 0 AK1 Functional Group Response Header S0200 A1 True Functional Identifier Code 0 True -1 479 Group Control Number 0 True -1 28 Version, Release, or Industry Identifier Code 0 False -1 480 AK2 Transaction Set Response Header S0300 A1 True Transaction Set Identifier Code 0 True -1 143 Transaction Set Control Number 0 True -1 329 Implementation Convention Reference 0 False -1 1705 IK3 Error Identification S0400 A1 True Segment ID Code 0 True -1 721 Segment Position in Transaction Set 0 True -1 719 Loop Identifier Code 0 False -1 447 Implementation Segment Syntax Error Code 0 False -1 620 CTX Segment Context S0500 A1 True Context Identification 0 True -1 C998 Segment ID Code 0 False -1 721 Segment Position in Transaction Set 0 False -1 719 Loop Identifier Code 0 False -1 447 Position in Segment 0 False -1 C030 Reference in Segment 0 False -1 C999 CTX Business Unit Identifier S0510 A1 True Context Identification 0 True -1 C998 Segment ID Code 0 False -1 721 Segment Position in Transaction Set 0 False -1 719 Loop Identifier Code 0 False -1 447 Position in Segment 0 False -1 C030 Reference in Segment 0 False -1 C999 IK4 Implementation Data Element Note S0600 A1 True Position in Segment 0 True -1 C030 Data Element Reference Number 0 False -1 725 Implementation Data Element Syntax Error Code 0 True -1 621 Copy of Bad Data Element 0 False -1 724 1|2|3|4|5|6|7|8|9|10|12|13|I10|I11|I12|I13|I6|I9 2 0 CTX Element Context S0700 A1 True Context Identification 0 True -1 C998 Segment ID Code 0 False -1 721 Segment Position in Transaction Set 0 False -1 719 Loop Identifier Code 0 False -1 447 Position in Segment 0 False -1 C030 Reference in Segment 0 False -1 C999 IK5 Transaction Set Response Trailer S0800 A1 True Transaction Set Acknowledgment Code 0 True -1 717 Implementation Transaction Set Syntax Error Code 0 False -1 618 Implementation Transaction Set Syntax Error Code 0 False -1 618 Implementation Transaction Set Syntax Error Code 0 False -1 618 Implementation Transaction Set Syntax Error Code 0 False -1 618 Implementation Transaction Set Syntax Error Code 0 False -1 618 A|E|M|R|W|X 0 0 AK9 Functional Group Response Trailer S0900 A1 True Functional Group Acknowledge Code 0 True -1 715 Number of Transaction Sets Included 0 True -1 97 Number of Received Transaction Sets 0 True -1 123 Number of Accepted Transaction Sets 0 True -1 2 Functional Group Syntax Error Code 0 False -1 716 Functional Group Syntax Error Code 0 False -1 716 Functional Group Syntax Error Code 0 False -1 716 Functional Group Syntax Error Code 0 False -1 716 Functional Group Syntax Error Code 0 False -1 716 A|E|M|P|R|W|X 0 0 SE Transaction Set Trailer S1000 A1 True Number of Included Segments 0 True -1 96 Transaction Set Control Number 0 True -1 329 True False Message False False False 0 group ST False False False 0 segment 17 BHT False False False 0 segment 18 1000A True True False 0 group 2000A False True False 0 group HL False False False 0 segment 19 2100A True False False 1 group NM1 False False False 0 segment 20 2200A True True False 0 group 2210A True True False 0 group 2000B False True False 0 group HL False False False 0 segment 21 2100B True False False 1 group NM1 False False False 0 segment 22 2200B True True False 0 group 2210B True True False 0 group 2000C False True False 0 group HL False False False 0 segment 23 2100C True True False 2 group NM1 False False False 0 segment 24 2200C True True False 0 group 2210C True True False 0 group 2000D False True False 0 group HL False False False 0 segment 25 DMG True False False 0 segment 26 2100D True False False 1 group NM1 False False False 0 segment 27 2200D True True False 0 group TRN True False False 0 segment 28 REF True False False 0 segment 29 REF True False False 0 segment 30 REF True False False 0 segment 31 REF True False False 0 segment 32 REF True False False 0 segment 33 REF True False False 0 segment 34 REF True False False 0 segment 35 AMT True False False 0 segment 36 DTP True False False 0 segment 37 2210D True True False 0 group SVC True False False 0 segment 38 REF True False False 0 segment 39 DTP False False False 0 segment 40 2000E True True False 0 group HL True False False 0 segment 41 DMG False False False 0 segment 42 2100E True False False 1 group NM1 False False False 0 segment 43 2200E True True False 0 group TRN False False False 0 segment 44 REF True False False 0 segment 45 REF True False False 0 segment 46 REF True False False 0 segment 47 REF True False False 0 segment 48 REF True False False 0 segment 49 REF True False False 0 segment 50 REF True False False 0 segment 51 AMT True False False 0 segment 52 DTP True False False 0 segment 53 2210E True True False 0 group SVC True False False 0 segment 54 REF True False False 0 segment 55 DTP False False False 0 segment 56 SE False False False 0 segment 57 ST 276 0 0 group -1 0 True False Message False False False 0 group ST False False False 0 segment 61 BHT False False False 0 segment 62 1000 True True False 0 group 2000A False True False 0 group HL False False False 0 segment 63 2100A True False False 1 group NM1 False False False 0 segment 64 PER True False False 0 segment 65 2200A True True False 0 group 2210A True True False 0 group 2220A True True False 0 group 2225A True True False 0 group 2000B False True False 0 group HL False False False 0 segment 66 2100B True False False 1 group NM1 False False False 0 segment 67 2200B True False False 1 group TRN True False False 0 segment 68 STC False False False 0 segment 69 2210B True True False 0 group 2220B True True False 0 group 2225B True True False 0 group 2000C True True False 0 group HL True False False 0 segment 70 2100C True True False 2 group NM1 False False False 0 segment 71 2200C True False False 1 group TRN True False False 0 segment 72 STC False False False 0 segment 73 2210C True True False 0 group 2220C True True False 0 group 2225C True True False 0 group 2000D True True False 0 group HL True False False 0 segment 74 2100D True False False 1 group NM1 False False False 0 segment 75 2200D True True False 0 group TRN True False False 0 segment 76 STC False False False 0 segment 77 REF True False False 0 segment 78 REF True False False 0 segment 79 REF True False False 0 segment 80 REF True False False 0 segment 81 REF True False False 0 segment 82 REF True False False 0 segment 83 DTP True False False 0 segment 84 2210D True True False 0 group 2220D True True False 0 group SVC True False False 0 segment 85 STC False False False 0 segment 86 REF True False False 0 segment 87 DTP False False False 0 segment 88 2225D True True False 0 group 2000E True True False 0 group HL True False False 0 segment 89 2100E True False False 1 group NM1 False False False 0 segment 90 2200E True True False 0 group TRN False False False 0 segment 91 STC False False False 0 segment 92 REF True False False 0 segment 93 REF True False False 0 segment 94 REF True False False 0 segment 95 REF True False False 0 segment 96 REF True False False 0 segment 97 REF True False False 0 segment 98 DTP True False False 0 segment 99 2210E True True False 0 group 2220E True True False 0 group SVC True False False 0 segment 100 STC False False False 0 segment 101 REF True False False 0 segment 102 DTP False False False 0 segment 103 2225E True True False 0 group SE False False False 0 segment 104 ST 277 0 0 group -1 0 True False Message False False False 0 group ST False False False 0 segment 126 BHT False False False 0 segment 127 2000A False False False 1 group HL False False False 0 segment 128 2010A True False False 1 group NM1 False False False 0 segment 129 2000B False False False 1 group HL False False False 0 segment 130 2010B True False False 1 group NM1 False False False 0 segment 131 REF True False False 0 segment 132 N3 True False False 0 segment 133 N4 True False False 0 segment 134 PER True False False 0 segment 135 PRV True False False 0 segment 136 2000C False False False 1 group HL False False False 0 segment 137 2010C True False False 1 group NM1 False False False 0 segment 138 REF True False False 0 segment 139 N3 True False False 0 segment 140 N4 True False False 0 segment 141 DMG True False False 0 segment 142 INS True False False 0 segment 143 2000D True False False 1 group HL True False False 0 segment 144 2010D True False False 1 group NM1 False False False 0 segment 145 REF True False False 0 segment 146 N3 True False False 0 segment 147 N4 True False False 0 segment 148 DMG True False False 0 segment 149 INS True False False 0 segment 150 2000E False False False 1 group HL False False False 0 segment 151 TRN True False False 0 segment 152 UM False False False 0 segment 153 REF True False False 0 segment 154 REF True False False 0 segment 155 DTP True False False 0 segment 156 DTP True False False 0 segment 157 DTP True False False 0 segment 158 DTP True False False 0 segment 159 DTP True False False 0 segment 160 DTP True False False 0 segment 161 DTP True False False 0 segment 162 HI True False False 0 segment 163 HSD True False False 0 segment 164 CRC True False False 0 segment 165 CRC True False False 0 segment 166 CRC True False False 0 segment 167 CRC True False False 0 segment 168 CRC True False False 0 segment 169 CRC True False False 0 segment 170 CRC True False False 0 segment 171 CL1 True False False 0 segment 172 CR1 True False False 0 segment 173 CR2 True False False 0 segment 174 CR5 True False False 0 segment 175 CR6 True False False 0 segment 176 PWK True False False 0 segment 177 MSG True False False 0 segment 178 2010EA True True False 14 group NM1 True False False 0 segment 179 REF True False False 0 segment 180 N3 True False False 0 segment 181 N4 True False False 0 segment 182 PER True False False 0 segment 183 PRV True False False 0 segment 184 2010EB True True False 5 group NM1 True False False 0 segment 185 N3 False False False 0 segment 186 N4 False False False 0 segment 187 2010EC True True False 3 group NM1 True False False 0 segment 188 REF False False False 0 segment 189 DTP False False False 0 segment 190 2000F True True False 0 group HL True False False 0 segment 191 TRN True False False 0 segment 192 UM True False False 0 segment 193 REF True False False 0 segment 194 REF True False False 0 segment 195 DTP True False False 0 segment 196 SV1 True False False 0 segment 197 SV2 True False False 0 segment 198 SV3 True False False 0 segment 199 TOO True False False 0 segment 200 HSD True False False 0 segment 201 PWK True False False 0 segment 202 MSG True False False 0 segment 203 2010F True True False 10 group NM1 True False False 0 segment 204 REF True False False 0 segment 205 N3 True False False 0 segment 206 N4 True False False 0 segment 207 PER True False False 0 segment 208 PRV True False False 0 segment 209 SE False False False 0 segment 210 ST 278 0 0 group -1 0 True False Message False False False 0 group ST False False False 0 segment 211 BHT False False False 0 segment 212 2000A False False False 1 group HL False False False 0 segment 213 AAA True False False 0 segment 214 2010A True False False 1 group NM1 False False False 0 segment 215 PER True False False 0 segment 216 AAA True False False 0 segment 217 2000B True False False 1 group HL True False False 0 segment 218 2010B True True False 2 group NM1 False False False 0 segment 219 REF True False False 0 segment 220 AAA True False False 0 segment 221 PRV True False False 0 segment 222 2000C True False False 1 group HL True False False 0 segment 223 2010C True False False 1 group NM1 False False False 0 segment 224 REF True False False 0 segment 225 N3 True False False 0 segment 226 N4 True False False 0 segment 227 AAA True False False 0 segment 228 DMG True False False 0 segment 229 INS True False False 0 segment 230 2010CB True False False 1 group 2000D True False False 1 group HL True False False 0 segment 231 2010D True False False 1 group NM1 False False False 0 segment 232 REF True False False 0 segment 233 N3 True False False 0 segment 234 N4 True False False 0 segment 235 AAA True False False 0 segment 236 DMG True False False 0 segment 237 INS True False False 0 segment 238 2010DB True False False 1 group 2000E True True False 0 group HL True False False 0 segment 239 TRN True False False 0 segment 240 AAA True False False 0 segment 241 UM False False False 0 segment 242 HCR True False False 0 segment 243 REF True False False 0 segment 244 REF True False False 0 segment 245 DTP True False False 0 segment 246 DTP True False False 0 segment 247 DTP True False False 0 segment 248 DTP True False False 0 segment 249 DTP True False False 0 segment 250 DTP True False False 0 segment 251 DTP True False False 0 segment 252 DTP True False False 0 segment 253 DTP True False False 0 segment 254 DTP True False False 0 segment 255 HI True False False 0 segment 256 HSD True False False 0 segment 257 CL1 True False False 0 segment 258 CR1 True False False 0 segment 259 CR2 True False False 0 segment 260 CR5 True False False 0 segment 261 CR6 True False False 0 segment 262 PWK True False False 0 segment 263 MSG True False False 0 segment 264 2010EA True True False 14 group NM1 True False False 0 segment 265 REF True False False 0 segment 266 N3 True False False 0 segment 267 N4 True False False 0 segment 268 PER True False False 0 segment 269 AAA True False False 0 segment 270 PRV True False False 0 segment 271 2010EB True False False 1 group NM1 True False False 0 segment 272 N3 True False False 0 segment 273 N4 True False False 0 segment 274 PER True False False 0 segment 275 2010EC True True False 5 group NM1 True False False 0 segment 276 N3 False False False 0 segment 277 N4 False False False 0 segment 278 AAA True False False 0 segment 279 2000F True True False 0 group HL True False False 0 segment 280 TRN True False False 0 segment 281 AAA True False False 0 segment 282 UM True False False 0 segment 283 HCR True False False 0 segment 284 REF True False False 0 segment 285 REF True False False 0 segment 286 DTP True False False 0 segment 287 DTP True False False 0 segment 288 DTP True False False 0 segment 289 DTP True False False 0 segment 290 HI True False False 0 segment 291 SV1 True False False 0 segment 292 SV2 True False False 0 segment 293 SV3 True False False 0 segment 294 TOO True False False 0 segment 295 HSD True False False 0 segment 296 PWK True False False 0 segment 297 MSG True False False 0 segment 298 2010FA True True False 12 group NM1 True False False 0 segment 299 REF True False False 0 segment 300 N3 True False False 0 segment 301 N4 True False False 0 segment 302 PER True False False 0 segment 303 AAA True False False 0 segment 304 PRV True False False 0 segment 305 2010FB True False False 1 group NM1 True False False 0 segment 306 N3 True False False 0 segment 307 N4 True False False 0 segment 308 PER True False False 0 segment 309 SE False False False 0 segment 310 ST 278 0 0 group -1 0 True False Message False False False 0 group ST False False False 0 segment 322 BPR False False False 0 segment 323 TRN False False False 0 segment 324 CUR True False False 0 segment 325 REF True False False 0 segment 326 DTM True False False 0 segment 327 DTM True False False 0 segment 328 DTM True False False 0 segment 329 DTM True False False 0 segment 330 1000A True False False 1 group N1 False False False 0 segment 331 N2 True False False 0 segment 332 N3 True False False 0 segment 333 N4 True False False 0 segment 334 RDM True False False 0 segment 335 1000B True False False 1 group N1 False False False 0 segment 336 N2 True False False 0 segment 337 N3 True False False 0 segment 338 N4 True False False 0 segment 339 PER True False False 0 segment 340 1000C True True False 14 group N1 True False False 0 segment 341 N2 True False False 0 segment 342 N3 True False False 0 segment 343 N4 True False False 0 segment 344 PER True False False 0 segment 345 2000A True False False 1 group ENT True False False 0 segment 346 2200A True True False 0 group ADX True False False 0 segment 347 2300A True True False 0 group RMR False False False 0 segment 348 REF True False False 0 segment 349 DTM True False False 0 segment 350 2310A True False False 1 group IT1 True False False 0 segment 351 2312A True True False 4 group SAC True False False 0 segment 352 2315A True True False 3 group SLN True False False 0 segment 353 2320A True True False 0 group ADX True False False 0 segment 354 2000B True True False 0 group ENT True False False 0 segment 355 2100B True True False 0 group NM1 True False False 0 segment 356 2200B True True False 0 group ADX True False False 0 segment 357 2300B True True False 0 group RMR False False False 0 segment 358 REF True False False 0 segment 359 DTM True False False 0 segment 360 2320B True True False 0 group ADX True False False 0 segment 361 SE False False False 0 segment 362 ST 820 0 0 group -1 0 True False Message False False False 0 group ST False False False 0 segment 389 BGN False False False 0 segment 390 REF True False False 0 segment 391 DTP True False False 0 segment 392 QTY True False False 0 segment 393 1000A False False False 1 group N1 False False False 0 segment 394 1100A True True False 10 group 1000B False False False 1 group N1 False False False 0 segment 395 1100B True True False 10 group 1000C True True False 2 group N1 True False False 0 segment 396 1100C True False False 1 group ACT True False False 0 segment 397 2000 True True False 0 group INS False False False 0 segment 398 REF False False False 0 segment 399 REF True False False 0 segment 400 REF True False False 0 segment 401 DTP True False False 0 segment 402 2100A True False False 1 group NM1 False False False 0 segment 403 PER True False False 0 segment 404 N3 True False False 0 segment 405 N4 False False False 0 segment 406 DMG True False False 0 segment 407 EC True False False 0 segment 408 ICM True False False 0 segment 409 AMT True False False 0 segment 410 HLH True False False 0 segment 411 LUI True False False 0 segment 412 2100B True False False 1 group NM1 True False False 0 segment 413 DMG True False False 0 segment 414 2100C True False False 1 group NM1 True False False 0 segment 415 N3 False False False 0 segment 416 N4 False False False 0 segment 417 2100D True True False 3 group NM1 True False False 0 segment 418 PER True False False 0 segment 419 N3 True False False 0 segment 420 N4 False False False 0 segment 421 2100E True True False 3 group NM1 True False False 0 segment 422 PER True False False 0 segment 423 N3 True False False 0 segment 424 N4 False False False 0 segment 425 2100F True False False 1 group NM1 True False False 0 segment 426 PER True False False 0 segment 427 N3 True False False 0 segment 428 N4 False False False 0 segment 429 2100G True True False 13 group NM1 True False False 0 segment 430 PER True False False 0 segment 431 N3 True False False 0 segment 432 N4 False False False 0 segment 433 2100H True False False 1 group NM1 True False False 0 segment 434 N3 True False False 0 segment 435 N4 False False False 0 segment 436 2200 True True False 0 group DSB True False False 0 segment 437 DTP True False False 0 segment 438 2300 True True False 99 group HD True False False 0 segment 439 DTP False False False 0 segment 440 AMT True False False 0 segment 441 REF True False False 0 segment 442 REF True False False 0 segment 443 IDC True False False 0 segment 444 2310 True True False 30 group LX True False False 0 segment 445 NM1 False False False 0 segment 446 N3 True False False 0 segment 447 N4 False False False 0 segment 448 PER True False False 0 segment 449 PLA True False False 0 segment 450 2320 True True False 5 group COB True False False 0 segment 451 REF True False False 0 segment 452 DTP True False False 0 segment 453 2330 True True False 3 group NM1 True False False 0 segment 454 N3 True False False 0 segment 455 N4 False False False 0 segment 456 PER True False False 0 segment 457 2400 True True False 10 group 2410 True True False 20 group 2500 True True False 5 group 2600 True True False 0 group 2610 True True False 0 group 2620 True True False 0 group 2630 True True False 0 group LS True False False 0 segment 458 2710 True True False 0 group LX True False False 0 segment 459 2750 True False False 1 group N1 True False False 0 segment 460 REF True False False 0 segment 461 DTP True False False 0 segment 462 LE True False False 0 segment 463 SE False False False 0 segment 464 ST 834 0 0 group -1 0 True False Message False False False 0 group ST False False False 0 segment 473 BPR False False False 0 segment 474 TRN False False False 0 segment 475 CUR True False False 0 segment 476 REF True False False 0 segment 477 REF True False False 0 segment 478 DTM True False False 0 segment 479 1000A True False False 1 group N1 False False False 0 segment 480 N3 False False False 0 segment 481 N4 False False False 0 segment 482 REF True False False 0 segment 483 PER True False False 0 segment 484 PER False False False 0 segment 485 PER True False False 0 segment 486 1000B True False False 1 group N1 False False False 0 segment 487 N3 True False False 0 segment 488 N4 False False False 0 segment 489 REF True False False 0 segment 490 RDM True False False 0 segment 491 2000 True True False 0 group LX True False False 0 segment 492 TS3 True False False 0 segment 493 TS2 True False False 0 segment 494 2100 False True False 0 group CLP False False False 0 segment 495 CAS True False False 0 segment 496 NM1 False False False 0 segment 497 NM1 True False False 0 segment 498 NM1 True False False 0 segment 499 NM1 True False False 0 segment 500 NM1 True False False 0 segment 501 NM1 True False False 0 segment 502 NM1 True False False 0 segment 503 MIA True False False 0 segment 504 MOA True False False 0 segment 505 REF True False False 0 segment 506 REF True False False 0 segment 507 DTM True False False 0 segment 508 DTM True False False 0 segment 509 DTM True False False 0 segment 510 PER True False False 0 segment 511 AMT True False False 0 segment 512 QTY True False False 0 segment 513 2110 True True False 999 group SVC True False False 0 segment 514 DTM True False False 0 segment 515 CAS True False False 0 segment 516 REF True False False 0 segment 517 REF True False False 0 segment 518 REF True False False 0 segment 519 REF True False False 0 segment 520 AMT True False False 0 segment 521 QTY True False False 0 segment 522 LQ True False False 0 segment 523 PLB True False False 0 segment 524 SE False False False 0 segment 525 ST 835 0 0 group -1 0 True False Message False False False 0 group ST False False False 0 segment 534 BHT False False False 0 segment 535 1000A True False False 1 group NM1 False False False 0 segment 536 PER False False False 0 segment 537 1000B True False False 1 group NM1 False False False 0 segment 538 2000A False True False 0 group HL False False False 0 segment 539 PRV True False False 0 segment 540 CUR True False False 0 segment 541 2010AA True False False 1 group NM1 False False False 0 segment 542 N3 False False False 0 segment 543 N4 False False False 0 segment 544 REF False False False 0 segment 545 PER True False False 0 segment 546 2010AB True False False 1 group NM1 True False False 0 segment 547 N3 False False False 0 segment 548 N4 False False False 0 segment 549 2010AC True False False 1 group NM1 True False False 0 segment 550 N3 False False False 0 segment 551 N4 False False False 0 segment 552 REF True False False 0 segment 553 REF False False False 0 segment 554 2000B False True False 0 group HL False False False 0 segment 555 SBR False False False 0 segment 556 2010BA True False False 1 group NM1 False False False 0 segment 557 N3 True False False 0 segment 558 N4 False False False 0 segment 559 DMG True False False 0 segment 560 REF True False False 0 segment 561 REF True False False 0 segment 562 2010BB True False False 1 group NM1 False False False 0 segment 563 N3 True False False 0 segment 564 N4 False False False 0 segment 565 REF True False False 0 segment 566 REF True False False 0 segment 567 2010BC True False False 1 group 2000C True True False 0 group HL True False False 0 segment 568 PAT False False False 0 segment 569 2010CA True False False 1 group NM1 False False False 0 segment 570 N3 False False False 0 segment 571 N4 False False False 0 segment 572 DMG False False False 0 segment 573 REF True False False 0 segment 574 2300 True True False 100 group CLM False False False 0 segment 575 DTP True False False 0 segment 576 DTP False False False 0 segment 577 DTP True False False 0 segment 578 DTP True False False 0 segment 579 CL1 False False False 0 segment 580 PWK True False False 0 segment 581 CN1 True False False 0 segment 582 AMT True False False 0 segment 583 REF True False False 0 segment 584 REF True False False 0 segment 585 REF True False False 0 segment 586 REF True False False 0 segment 587 REF True False False 0 segment 588 REF True False False 0 segment 589 REF True False False 0 segment 590 REF True False False 0 segment 591 REF True False False 0 segment 592 REF True False False 0 segment 593 REF True False False 0 segment 594 REF True False False 0 segment 595 K3 True False False 0 segment 596 NTE True False False 0 segment 597 NTE True False False 0 segment 598 CRC True False False 0 segment 599 HI False False False 0 segment 600 HI True False False 0 segment 601 HI True False False 0 segment 602 HI True False False 0 segment 603 HI True False False 0 segment 604 HI True False False 0 segment 605 HI True False False 0 segment 606 HI True False False 0 segment 607 HI True False False 0 segment 608 HI True False False 0 segment 609 HI True False False 0 segment 610 HI True False False 0 segment 611 HI True False False 0 segment 612 HCP True False False 0 segment 613 2305 True True False 6 group 2310A True False False 1 group NM1 True False False 0 segment 614 PRV True False False 0 segment 615 REF True False False 0 segment 616 2310B True False False 1 group NM1 True False False 0 segment 617 REF True False False 0 segment 618 2310C True False False 1 group NM1 True False False 0 segment 619 REF True False False 0 segment 620 2310D True False False 1 group NM1 True False False 0 segment 621 REF True False False 0 segment 622 2310E True False False 1 group NM1 True False False 0 segment 623 N3 False False False 0 segment 624 N4 False False False 0 segment 625 REF True False False 0 segment 626 2310F True False False 1 group NM1 True False False 0 segment 627 REF True False False 0 segment 628 2320 True True False 10 group SBR True False False 0 segment 629 CAS True False False 0 segment 630 AMT True False False 0 segment 631 AMT True False False 0 segment 632 AMT True False False 0 segment 633 OI False False False 0 segment 634 MIA True False False 0 segment 635 MOA True False False 0 segment 636 2330A True False False 1 group NM1 False False False 0 segment 637 N3 True False False 0 segment 638 N4 False False False 0 segment 639 REF True False False 0 segment 640 2330B True False False 1 group NM1 False False False 0 segment 641 N3 True False False 0 segment 642 N4 False False False 0 segment 643 DTP True False False 0 segment 644 REF True False False 0 segment 645 REF True False False 0 segment 646 REF True False False 0 segment 647 REF True False False 0 segment 648 REF True False False 0 segment 649 2330C True False False 1 group NM1 True False False 0 segment 650 REF False False False 0 segment 651 2330D True False False 1 group NM1 True False False 0 segment 652 REF False False False 0 segment 653 2330E True False False 1 group NM1 True False False 0 segment 654 REF False False False 0 segment 655 2330F True False False 1 group NM1 True False False 0 segment 656 REF False False False 0 segment 657 2330G True False False 1 group NM1 True False False 0 segment 658 REF False False False 0 segment 659 2330H True False False 1 group NM1 True False False 0 segment 660 REF False False False 0 segment 661 2330I True False False 1 group NM1 True False False 0 segment 662 REF False False False 0 segment 663 2400 True True False 999 group LX False False False 0 segment 664 SV2 False False False 0 segment 665 PWK True False False 0 segment 666 DTP True False False 0 segment 667 REF True False False 0 segment 668 REF True False False 0 segment 669 REF True False False 0 segment 670 AMT True False False 0 segment 671 AMT True False False 0 segment 672 NTE True False False 0 segment 673 HCP True False False 0 segment 674 2410 True False False 1 group LIN True False False 0 segment 675 CTP False False False 0 segment 676 REF True False False 0 segment 677 2420A - NO True False False 1 group 2420A True False False 1 group NM1 True False False 0 segment 678 REF True False False 0 segment 679 2420B True False False 1 group NM1 True False False 0 segment 680 REF True False False 0 segment 681 2420C True False False 1 group NM1 True False False 0 segment 682 REF True False False 0 segment 683 2420D True False False 1 group NM1 True False False 0 segment 684 REF True False False 0 segment 685 2430 True True False 15 group SVD True False False 0 segment 686 CAS True False False 0 segment 687 DTP False False False 0 segment 688 AMT True False False 0 segment 689 SE False False False 0 segment 690 ST 837 0 0 group -1 0 True False Message False False False 0 group ST False False False 0 segment 693 BHT False False False 0 segment 694 1000A True False False 1 group NM1 False False False 0 segment 695 PER False False False 0 segment 696 1000B True False False 1 group NM1 False False False 0 segment 697 2000A False True False 0 group HL False False False 0 segment 698 PRV True False False 0 segment 699 CUR True False False 0 segment 700 2010AA True False False 1 group NM1 False False False 0 segment 701 N3 False False False 0 segment 702 N4 False False False 0 segment 703 REF False False False 0 segment 704 REF True False False 0 segment 705 PER True False False 0 segment 706 2010AB True False False 1 group NM1 True False False 0 segment 707 N3 False False False 0 segment 708 N4 False False False 0 segment 709 2010AC True False False 1 group NM1 True False False 0 segment 710 N3 False False False 0 segment 711 N4 False False False 0 segment 712 REF True False False 0 segment 713 REF False False False 0 segment 714 2000B False True False 0 group HL False False False 0 segment 715 SBR False False False 0 segment 716 2010BA True False False 1 group NM1 False False False 0 segment 717 N3 True False False 0 segment 718 N4 False False False 0 segment 719 DMG True False False 0 segment 720 REF True False False 0 segment 721 REF True False False 0 segment 722 2010BB True False False 1 group NM1 False False False 0 segment 723 N3 True False False 0 segment 724 N4 False False False 0 segment 725 REF True False False 0 segment 726 REF True False False 0 segment 727 2010BC True False False 1 group 2000C True True False 0 group HL True False False 0 segment 728 PAT False False False 0 segment 729 2010CA True False False 1 group NM1 False False False 0 segment 730 N3 False False False 0 segment 731 N4 False False False 0 segment 732 DMG False False False 0 segment 733 REF True False False 0 segment 734 2300 True True False 100 group CLM False False False 0 segment 735 DTP True False False 0 segment 736 DTP True False False 0 segment 737 DTP True False False 0 segment 738 DTP True False False 0 segment 739 DN1 True False False 0 segment 740 DN2 True False False 0 segment 741 PWK True False False 0 segment 742 CN1 True False False 0 segment 743 AMT True False False 0 segment 744 REF True False False 0 segment 745 REF True False False 0 segment 746 REF True False False 0 segment 747 REF True False False 0 segment 748 REF True False False 0 segment 749 REF True False False 0 segment 750 REF True False False 0 segment 751 REF True False False 0 segment 752 K3 True False False 0 segment 753 NTE True False False 0 segment 754 HI True False False 0 segment 755 HCP True False False 0 segment 756 2310A True True False 2 group NM1 True False False 0 segment 757 PRV True False False 0 segment 758 REF True False False 0 segment 759 2310B True False False 1 group NM1 True False False 0 segment 760 PRV False False False 0 segment 761 REF True False False 0 segment 762 2310C True False False 1 group NM1 True False False 0 segment 763 N3 False False False 0 segment 764 N4 False False False 0 segment 765 REF True False False 0 segment 766 2310D True False False 1 group NM1 True False False 0 segment 767 PRV False False False 0 segment 768 REF True False False 0 segment 769 2310E True False False 1 group NM1 True False False 0 segment 770 REF True False False 0 segment 771 2320 True True False 10 group SBR True False False 0 segment 772 CAS True False False 0 segment 773 AMT True False False 0 segment 774 AMT True False False 0 segment 775 AMT True False False 0 segment 776 OI False False False 0 segment 777 MOA True False False 0 segment 778 2330A True False False 1 group NM1 False False False 0 segment 779 N3 True False False 0 segment 780 N4 False False False 0 segment 781 REF True False False 0 segment 782 2330B True False False 1 group NM1 False False False 0 segment 783 N3 True False False 0 segment 784 N4 False False False 0 segment 785 DTP True False False 0 segment 786 REF True False False 0 segment 787 REF True False False 0 segment 788 REF True False False 0 segment 789 REF True False False 0 segment 790 REF True False False 0 segment 791 REF True False False 0 segment 792 2330C - NO True False False 1 group 2330C True True False 2 group NM1 True False False 0 segment 793 REF False False False 0 segment 794 2330D True False False 1 group NM1 True False False 0 segment 795 REF False False False 0 segment 796 2330E True False False 1 group NM1 True False False 0 segment 797 REF False False False 0 segment 798 2330F True False False 1 group NM1 True False False 0 segment 799 REF False False False 0 segment 800 2330G True False False 1 group NM1 True False False 0 segment 801 REF False False False 0 segment 802 2330H True False False 1 group NM1 True False False 0 segment 803 REF False False False 0 segment 804 2400 True True False 50 group LX False False False 0 segment 805 SV3 False False False 0 segment 806 TOO True False False 0 segment 807 DTP True False False 0 segment 808 DTP True False False 0 segment 809 DTP True False False 0 segment 810 DTP True False False 0 segment 811 DTP True False False 0 segment 812 DTP True False False 0 segment 813 CN1 True False False 0 segment 814 REF True False False 0 segment 815 REF True False False 0 segment 816 REF True False False 0 segment 817 REF True False False 0 segment 818 REF True False False 0 segment 819 REF True False False 0 segment 820 AMT True False False 0 segment 821 K3 True False False 0 segment 822 HCP True False False 0 segment 823 2420A True False False 1 group NM1 True False False 0 segment 824 PRV False False False 0 segment 825 REF True False False 0 segment 826 2420B - NO True False False 1 group 2420B True False False 1 group NM1 True False False 0 segment 827 PRV True False False 0 segment 828 REF True False False 0 segment 829 2420C True False False 1 group NM1 True False False 0 segment 830 REF True False False 0 segment 831 2420D True False False 1 group NM1 True False False 0 segment 832 N3 False False False 0 segment 833 N4 False False False 0 segment 834 REF True False False 0 segment 835 2430 True True False 15 group SVD True False False 0 segment 836 CAS True False False 0 segment 837 DTP False False False 0 segment 838 AMT True False False 0 segment 839 SE False False False 0 segment 840 ST 837 0 0 group -1 0 True False Message False False False 0 group ST False False False 0 segment 846 BHT False False False 0 segment 847 2000A False True False 0 group HL False False False 0 segment 848 2100A False False False 1 group NM1 False False False 0 segment 849 2110A True True False 99 group 2000B False True False 0 group HL False False False 0 segment 850 2100B False False False 1 group NM1 False False False 0 segment 851 REF True False False 0 segment 852 N3 True False False 0 segment 853 N4 True False False 0 segment 854 PRV True False False 0 segment 855 2110B True True False 99 group 2000C False True False 0 group HL False False False 0 segment 856 TRN True False False 0 segment 857 2100C False False False 1 group NM1 False False False 0 segment 858 REF True False False 0 segment 859 N3 True False False 0 segment 860 N4 True False False 0 segment 861 PRV True False False 0 segment 862 DMG True False False 0 segment 863 INS True False False 0 segment 864 HI True False False 0 segment 865 DTP True False False 0 segment 866 2110C True True False 99 group EQ True False False 0 segment 867 AMT True False False 0 segment 868 AMT True False False 0 segment 869 III True False False 0 segment 870 REF True False False 0 segment 871 DTP True False False 0 segment 872 2000D True True False 0 group HL True False False 0 segment 873 TRN True False False 0 segment 874 2100D False False False 1 group NM1 False False False 0 segment 875 REF True False False 0 segment 876 N3 True False False 0 segment 877 N4 True False False 0 segment 878 PRV True False False 0 segment 879 DMG True False False 0 segment 880 INS True False False 0 segment 881 HI True False False 0 segment 882 DTP True False False 0 segment 883 2110D True True False 99 group EQ False False False 0 segment 884 III True False False 0 segment 885 REF True False False 0 segment 886 DTP True False False 0 segment 887 SE False False False 0 segment 888 ST 270 0 0 group -1 0 True False Message False False False 0 group ST False False False 0 segment 896 BHT False False False 0 segment 897 2000A False True False 0 group HL False False False 0 segment 898 AAA True False False 0 segment 899 2100A True False False 1 group NM1 False False False 0 segment 900 PER True False False 0 segment 901 AAA True False False 0 segment 902 2110A True True False 0 group 2115A True True False 0 group 2117A True True False 0 group 2120A True False False 1 group 2000B True True False 0 group HL True False False 0 segment 903 2100B True False False 1 group NM1 False False False 0 segment 904 REF True False False 0 segment 905 AAA True False False 0 segment 906 PRV True False False 0 segment 907 2110B True True False 0 group 2115B True True False 0 group 2117B True True False 0 group 2120B True False False 1 group 2000C True True False 0 group HL True False False 0 segment 908 TRN True False False 0 segment 909 2100C True False False 1 group NM1 False False False 0 segment 910 REF True False False 0 segment 911 N3 True False False 0 segment 912 N4 True False False 0 segment 913 AAA True False False 0 segment 914 PRV True False False 0 segment 915 DMG True False False 0 segment 916 INS True False False 0 segment 917 HI True False False 0 segment 918 DTP True False False 0 segment 919 MPI True False False 0 segment 920 2110C True True False 0 group EB True False False 0 segment 921 HSD True False False 0 segment 922 REF True False False 0 segment 923 DTP True False False 0 segment 924 AAA True False False 0 segment 925 MSG True False False 0 segment 926 2115C True True False 10 group III True False False 0 segment 927 2117C True True False 0 group LS True False False 0 segment 928 2120C True True False 23 group NM1 True False False 0 segment 929 N3 True False False 0 segment 930 N4 True False False 0 segment 931 PER True False False 0 segment 932 PRV True False False 0 segment 933 LE True False False 0 segment 934 2000D True True False 0 group HL True False False 0 segment 935 TRN True False False 0 segment 936 2100D True False False 1 group NM1 False False False 0 segment 937 REF True False False 0 segment 938 N3 True False False 0 segment 939 N4 True False False 0 segment 940 AAA True False False 0 segment 941 PRV True False False 0 segment 942 DMG True False False 0 segment 943 INS True False False 0 segment 944 HI True False False 0 segment 945 DTP True False False 0 segment 946 MPI True False False 0 segment 947 2110D True True False 0 group EB True False False 0 segment 948 HSD True False False 0 segment 949 REF True False False 0 segment 950 DTP True False False 0 segment 951 AAA True False False 0 segment 952 MSG True False False 0 segment 953 2115D True True False 10 group III True False False 0 segment 954 2117D True True False 0 group LS True False False 0 segment 955 2120D True True False 23 group NM1 True False False 0 segment 956 N3 True False False 0 segment 957 N4 True False False 0 segment 958 PER True False False 0 segment 959 PRV True False False 0 segment 960 LE True False False 0 segment 961 SE False False False 0 segment 962 ST 271 0 0 group -1 0 True False Message False False False 0 group ST False False False 0 segment 972 BHT False False False 0 segment 973 1000A True False False 1 group NM1 False False False 0 segment 974 PER False False False 0 segment 975 1000B True False False 1 group NM1 False False False 0 segment 976 2000A False True False 0 group HL False False False 0 segment 977 PRV True False False 0 segment 978 CUR True False False 0 segment 979 2010AA True False False 1 group NM1 False False False 0 segment 980 N3 False False False 0 segment 981 N4 False False False 0 segment 982 REF False False False 0 segment 983 REF True False False 0 segment 984 PER True False False 0 segment 985 2010AB True False False 1 group NM1 True False False 0 segment 986 N3 False False False 0 segment 987 N4 False False False 0 segment 988 2010AC True False False 1 group NM1 True False False 0 segment 989 N3 False False False 0 segment 990 N4 False False False 0 segment 991 REF True False False 0 segment 992 REF False False False 0 segment 993 2000B False True False 0 group HL False False False 0 segment 994 SBR False False False 0 segment 995 PAT True False False 0 segment 996 2010BA True False False 1 group NM1 False False False 0 segment 997 N3 True False False 0 segment 998 N4 False False False 0 segment 999 DMG True False False 0 segment 1000 REF True False False 0 segment 1001 REF True False False 0 segment 1002 PER True False False 0 segment 1003 2010BB True False False 1 group NM1 False False False 0 segment 1004 N3 True False False 0 segment 1005 N4 False False False 0 segment 1006 REF True False False 0 segment 1007 REF True False False 0 segment 1008 2010BC True False False 1 group 2010BD True False False 1 group 2010BC True False False 1 group 2010BD True False False 1 group 2000C True True False 0 group HL True False False 0 segment 1009 PAT False False False 0 segment 1010 2010CA True False False 1 group NM1 False False False 0 segment 1011 N3 False False False 0 segment 1012 N4 False False False 0 segment 1013 DMG False False False 0 segment 1014 REF True False False 0 segment 1015 PER True False False 0 segment 1016 2010CB True False False 1 group 2010CC True True False 2 group 2300 True True False 100 group CLM False False False 0 segment 1017 DTP True False False 0 segment 1018 DTP True False False 0 segment 1019 DTP True False False 0 segment 1020 DTP True False False 0 segment 1021 DTP True False False 0 segment 1022 DTP True False False 0 segment 1023 DTP True False False 0 segment 1024 DTP True False False 0 segment 1025 DTP True False False 0 segment 1026 DTP True False False 0 segment 1027 DTP True False False 0 segment 1028 DTP True False False 0 segment 1029 DTP True False False 0 segment 1030 DTP True False False 0 segment 1031 DTP True False False 0 segment 1032 DTP True False False 0 segment 1033 PWK True False False 0 segment 1034 CN1 True False False 0 segment 1035 AMT True False False 0 segment 1036 REF True False False 0 segment 1037 REF True False False 0 segment 1038 REF True False False 0 segment 1039 REF True False False 0 segment 1040 REF True False False 0 segment 1041 REF True False False 0 segment 1042 REF True False False 0 segment 1043 REF True False False 0 segment 1044 REF True False False 0 segment 1045 REF True False False 0 segment 1046 REF True False False 0 segment 1047 REF True False False 0 segment 1048 REF True False False 0 segment 1049 REF True False False 0 segment 1050 K3 True False False 0 segment 1051 NTE True False False 0 segment 1052 CR1 True False False 0 segment 1053 CR2 True False False 0 segment 1054 CRC True False False 0 segment 1055 CRC True False False 0 segment 1056 CRC True False False 0 segment 1057 CRC True False False 0 segment 1058 HI False False False 0 segment 1059 HI True False False 0 segment 1060 HI True False False 0 segment 1061 HCP True False False 0 segment 1062 2305 True True False 6 group 2310A True True False 2 group NM1 True False False 0 segment 1063 REF True False False 0 segment 1064 2310B True False False 1 group NM1 True False False 0 segment 1065 PRV True False False 0 segment 1066 REF True False False 0 segment 1067 2310C - NO True False False 1 group 2310C True False False 1 group NM1 True False False 0 segment 1068 N3 False False False 0 segment 1069 N4 False False False 0 segment 1070 REF True False False 0 segment 1071 PER True False False 0 segment 1072 2310D True False False 1 group NM1 True False False 0 segment 1073 REF True False False 0 segment 1074 2310E True False False 1 group NM1 True False False 0 segment 1075 N3 False False False 0 segment 1076 N4 False False False 0 segment 1077 2310F True False False 1 group NM1 True False False 0 segment 1078 N3 False False False 0 segment 1079 N4 False False False 0 segment 1080 2310G True False False 1 group 2320 True True False 10 group SBR True False False 0 segment 1081 CAS True False False 0 segment 1082 AMT True False False 0 segment 1083 AMT True False False 0 segment 1084 AMT True False False 0 segment 1085 OI False False False 0 segment 1086 MOA True False False 0 segment 1087 2330A True False False 1 group NM1 False False False 0 segment 1088 N3 True False False 0 segment 1089 N4 False False False 0 segment 1090 REF True False False 0 segment 1091 2330B True False False 1 group NM1 False False False 0 segment 1092 N3 True False False 0 segment 1093 N4 False False False 0 segment 1094 DTP True False False 0 segment 1095 REF True False False 0 segment 1096 REF True False False 0 segment 1097 REF True False False 0 segment 1098 REF True False False 0 segment 1099 REF True False False 0 segment 1100 2330C - NO True False False 1 group 2330C True True False 2 group NM1 True False False 0 segment 1101 REF False False False 0 segment 1102 2330D True False False 1 group NM1 True False False 0 segment 1103 REF False False False 0 segment 1104 2330F - NO True False False 1 group 2330E True False False 1 group NM1 True False False 0 segment 1105 REF False False False 0 segment 1106 2330F True False False 1 group NM1 True False False 0 segment 1107 REF False False False 0 segment 1108 2330G True False False 1 group NM1 True False False 0 segment 1109 REF False False False 0 segment 1110 2400 True True False 50 group LX False False False 0 segment 1111 SV1 False False False 0 segment 1112 SV5 True False False 0 segment 1113 PWK True False False 0 segment 1114 PWK True False False 0 segment 1115 CR1 True False False 0 segment 1116 CR3 True False False 0 segment 1117 CRC True False False 0 segment 1118 CRC True False False 0 segment 1119 CRC True False False 0 segment 1120 DTP False False False 0 segment 1121 DTP True False False 0 segment 1122 DTP True False False 0 segment 1123 DTP True False False 0 segment 1124 DTP True False False 0 segment 1125 DTP True False False 0 segment 1126 DTP True False False 0 segment 1127 DTP True False False 0 segment 1128 DTP True False False 0 segment 1129 DTP True False False 0 segment 1130 QTY True False False 0 segment 1131 QTY True False False 0 segment 1132 MEA True False False 0 segment 1133 CN1 True False False 0 segment 1134 REF True False False 0 segment 1135 REF True False False 0 segment 1136 REF True False False 0 segment 1137 REF True False False 0 segment 1138 REF True False False 0 segment 1139 REF True False False 0 segment 1140 REF True False False 0 segment 1141 REF True False False 0 segment 1142 REF True False False 0 segment 1143 AMT True False False 0 segment 1144 AMT True False False 0 segment 1145 K3 True False False 0 segment 1146 NTE True False False 0 segment 1147 NTE True False False 0 segment 1148 PS1 True False False 0 segment 1149 HCP True False False 0 segment 1150 2410 True False False 1 group LIN True False False 0 segment 1151 CTP False False False 0 segment 1152 REF True False False 0 segment 1153 2420A True False False 1 group NM1 True False False 0 segment 1154 PRV True False False 0 segment 1155 REF True False False 0 segment 1156 2420B True False False 1 group NM1 True False False 0 segment 1157 REF True False False 0 segment 1158 2420C True False False 1 group NM1 True False False 0 segment 1159 N3 False False False 0 segment 1160 N4 False False False 0 segment 1161 REF True False False 0 segment 1162 2420D True False False 1 group NM1 True False False 0 segment 1163 REF True False False 0 segment 1164 2420E True False False 1 group NM1 True False False 0 segment 1165 N3 True False False 0 segment 1166 N4 False False False 0 segment 1167 REF True False False 0 segment 1168 PER True False False 0 segment 1169 2420F True True False 2 group NM1 True False False 0 segment 1170 REF True False False 0 segment 1171 2420G - NO True False False 1 group 2420G True False False 1 group NM1 True False False 0 segment 1172 N3 False False False 0 segment 1173 N4 False False False 0 segment 1174 2420H True False False 1 group NM1 True False False 0 segment 1175 N3 False False False 0 segment 1176 N4 False False False 0 segment 1177 2430 True True False 15 group SVD True False False 0 segment 1178 CAS True False False 0 segment 1179 DTP False False False 0 segment 1180 AMT True False False 0 segment 1181 2440 True True False 0 group LQ True False False 0 segment 1182 FRM False False False 0 segment 1183 SE False False False 0 segment 1184 ST 837 0 0 group -1 0 True False Message False False False 0 group ST False False False 0 segment 1191 AK1 False False False 0 segment 1192 2000 True True False 0 group AK2 True False False 0 segment 1193 2100 True True False 0 group AK3 True False False 0 segment 1194 AK4 True False False 0 segment 1195 AK5 False False False 0 segment 1196 AK9 False False False 0 segment 1197 SE False False False 0 segment 1198 ST 997 0 0 group -1 0 True False Message False False False 0 group ST False False False 0 segment 1203 AK1 False False False 0 segment 1204 2000 - AK2 True True False 0 group AK2 True False False 0 segment 1205 2100 - AK2 True True False 0 group IK3 True False False 0 segment 1206 CTX True False False 0 segment 1207 CTX True False False 0 segment 1208 2110 - AK2 True True False 0 group IK4 True False False 0 segment 1209 CTX True False False 0 segment 1210 IK5 False False False 0 segment 1211 AK9 False False False 0 segment 1212 SE False False False 0 segment 1213 ST 999 0 0 group -1 0 True False Message False False False 0 group ST False False False 0 segment 1214 AK1 False False False 0 segment 1215 2000 - AK2 True True False 0 group AK2 True False False 0 segment 1216 2100 - AK2 True True False 0 group IK3 True False False 0 segment 1217 CTX True False False 0 segment 1218 CTX True False False 0 segment 1219 2110 - AK2 True True False 0 group IK4 True False False 0 segment 1220 CTX True False False 0 segment 1221 IK5 False False False 0 segment 1222 AK9 False False False 0 segment 1223 SE False False False 0 segment 1224 ST 999 0 0 group -1 0 0 48 92 69 -1 HL7 False False 32 255 X12 True 46 TABLE - Short Tags False True 1 False 2 False True False 2 126 0 0 118 -1 -1 42 0 0 32 -1 -1 58 0 0 118 -1 -1 True True