FL |
Field description |
Loops |
Segments |
Qualifiers |
Electronic description |
---|---|---|---|---|---|
01 |
Provider name |
2010AA |
NM1 |
85 |
Billing provider name |
01 |
Provider address |
2010AA |
N3, N4 |
N/A |
Billing provider address |
02 |
Pay-to name |
2010AB |
NM1 |
87 |
Pay-to name |
02 |
Pay-to address |
2010AB |
N3, N4 |
N/A |
Pay-to address |
03a |
Patient’s control number |
2300 |
CLM |
N/A |
Patient’s control number |
03c |
Medical record number |
2300 |
REF |
EA |
Medical Reference number |
04 |
Type of bill |
2300 |
CLM5-1, CLM05-3 |
N/A |
Type of Bill |
05 |
Fed. Tax No. |
2010AA |
REF |
EI |
Billing provider tax ID |
06 |
Statement covers period (from; through) |
2300 |
DTP |
434 |
Statement dates |
08a |
Patient’s name |
2010BA |
NM1 |
IL |
Subscriber name |
09a-09e |
Patient’s address |
2010BA |
N3, N4 |
N/A |
Subscriber address |
10 |
Birth date |
2010BA |
DMG |
D8 |
Subscriber demographic info |
11 |
Sex |
2010BA |
DMG |
N/A |
Subscriber demographic info |
12 |
Admission date |
2300 |
DTP |
435 |
Admission date/HR |
13 |
Admission hour |
2300 |
DTP |
DT |
Admission date/HR |
14 |
Admission type |
2300 |
CL1 |
N/A |
Institutional claim code |
15 |
Admission source |
2300 |
CL1 |
N/A |
Institutional claim code |
17 |
STAT |
2300 |
CL1 |
N/A |
Institutional claim code |
18-28 |
Condition codes |
2300 |
HI |
BG |
Condition info |
31-36 |
Occurrence code/Date |
2300 |
HI |
BH |
Occurrence info |
39-41 |
Value code code/Amount |
2300 |
HI |
BE |
Value info A value code of one of the following values must be reported if 2000B SBR01="S" 12, 13, 14, 15, 16, 41, 42, 43, or 47 |
42 |
Revenue Code |
2400 |
SV2 |
N/A |
Revenue code |
44 |
HCPCS/RATE/HIPPS CODE |
2400 |
SV2 |
HC |
HCPCS/Rate/HIPPS code |
45 |
Service date |
2400 |
DTP |
472 |
Date of service |
46 |
Service units |
2400 |
SV2 |
UN -UNITS DA - DAYS |
Service units |
47 |
Total charges |
2400 |
SV2 |
N/A |
Total charges |
48 |
Non-covered charges |
2400 |
SV2 |
N/A |
Non-covered charges |
50 |
Payer name |
2000B |
SBR |
N/A |
Payer name |
51 |
Health plan ID |
2000B |
SBR |
N/A |
Health plan ID |
52 |
Release of info |
2300 |
CLM |
N/A |
Release of info |
53 |
Assignment of benefits |
2300 |
CLM |
N/A |
Assignment of benefits |
55 |
Estimated amount due |
2300 |
AMT |
F3 |
Patient estimated amount due |
56 |
National Provider Identifier (NPI) |
2010AA |
NM1 |
XX |
NPI |
57 |
Other Prv. ID |
2310C |
NM1 |
73 |
N/A |
58 |
Insured’s name |
2010BA |
NM1 |
IL |
Insured’s name |
59 |
Patient relationship |
2000B |
SBR |
18 |
N/A |
60 |
Insured’s unique ID |
2010BA |
REF |
N/A |
Insured’s unique ID |
63 |
Treatment authorization codes |
2300 |
REF |
G1 |
Treatment authorization codes |
64 |
Document control number |
2300 |
REF |
F8 |
Document control number |
65 |
Employer name |
2320 |
SBR |
N/A |
N/A |
67 |
Dx. |
2300 |
HI |
ABK |
Principal diagnosis code |
67a-q |
Other dx |
2300 |
HI |
ABF |
Other diagnosis code |
69 |
Admit dx. |
2300 |
HI |
ABJ |
Admitting diagnosis code |
70 |
Patient reason dx |
2300 |
HI |
ZZ |
Patient reason for visit |
71 |
Prospective payment system (PPS) code |
2400 |
SV2 |
N/A |
PPS code |
74 |
Principle procedure code |
2300 |
HI |
BBR |
Principle procedure code |
74 |
Principle procedure date |
2300 |
HI |
D8 |
Principle procedure date |
74b |
Other procedure code |
2300 |
HI |
BBQ |
Other procedure code |
74b |
Other procedure date |
2300 |
HI |
D8 |
Other procedure date |
74d |
Other procedure code |
2300 |
HI |
BBQ |
Other procedure code |
74d |
Other procedure date |
2300 |
HI |
D8 |
Other procedure date |
76 |
Attending (NPI, qualifier, last name, first name) |
2310A |
NM1 |
71 |
Attending name/NPI |
77 |
Operating (NPI, qualifier, last name, first name) |
2420A |
NM1 |
72 |
Operating name/NPI |
78 |
Other (NPI, qualifier, last name, first name) |
2420B |
NM1 |
ZZ |
Other provider name/NPI |
79 |
Other (NPI, qualifier, last name, First name) |
2420B |
NM1 |
ZZ |
Other Provider Name/NPI |
80 |
Remarks |
2300 |
NTE |
N/A |
Remarks |
81 |
Health care taxonomy code |
2000A |
PRV |
PXC |
Taxonomy code |
81a |
Condition code |
2300 |
HI |
BG |
Condition code |
81b-c |
Occurrence code |
2300 |
HI |
BH/BI |
Occurrence code |