2320.dmg Segment On 837p
4010A1 to 5010 Training
1 2
Loop ID
Reference
Name
Codes
Notes / Comments
SD 2
Loop ID
Reference
Name
Codes
3
4010A1
4
8 9 10
1000A
PER03
1000A
PER05
1000A
PER07
Communication Number ED, EM, FX. Qualifier TE Communication Number ED, EM, EX, Qualifier FX, TE Communication Number ED, EM, EX, Qualifier FX, TE
2010AA NM108
Identification Code Qualifier
2010AA NM109
Billing Provider Identifier
2010AB NM108
Identification Code Qualifier
2010AB NM109
Pay-to Provider Identifier
11 12 13
5010
START 837 P
5 6 7
24, 34, XX
837P - 1000A - PER - SUBMITTER EDI CONTACT INFORMATION Communication Number EM, FX. TE 1000A PER03 R Qualifier Communication Number EM, EX, FX, 1000A PER05 S Qualifier TE Communication Number EM, EX, FX, 1000A PER07 S Qualifier TE 837P - 2010AA - NM1 - BILLING PROVIDER NAME R
2010AA NM108
Identification Code Qualifier
Billing Provider Identifier 837P - 2010AB - NM1 - PAY-TO ADDRESS NAME 24, 34, XX
XX
Value Deleted Value Deleted Value Deleted Value Deleted Usage change to Situational Usage change to Situational
4010 - 70/ 5010 - 77 4010 -71/ 5010 - 77 4010 - 71/ 5010 - 78 4010 - 83/ 5010 - 89 4010 - 83/ 5010 - 90
R
2010AA NM109
R
2010AB NM108
Identification Code Qualifier
Value Deleted 4010 - 97/ Usage changed 5010 to N/U 102
R
2010AB NM109
Identification Code
Name Change 4010 - 97/ Usage changed 5010 to N/U 102
14
15 16
4010 Notes / Page # / FOR REVIEW 5010 Comments Page #
837P - 2300 - HI - HEALTH CARE DIAGNOSIS CODE
2300
HI
HEALTH CARE DIAGNOSIS CODE
S
17 18
NM101
Entity Identifier Code
77, FA, LI, TL
19 20 2320
SBR01
21
2320
24 25
SBR02
Payer Responsibility Sequence Number Code
Individual Relationship Code
P, S, T
R
2310C
HEALTH CARE DIAGNOSIS CODE
NM101
Entity Identifier Code
837P - 2320 - SBR - OTHER SUBSCRIBER INFORMATION Payer Responsibility 2320 SBR01 Sequence Number R Code
77
A, B, C, D, E, F, G, H, P, S, T, U
01, 04, 05, 07, 10, 15, 17, 18, 19, Individual Relationship 20, 21, 22, 2320 SBR02 R Code 23, 24, 29, 01, 18, 19, 32, 33, 36, 20, 21, 39, 39, 40, 41, 43, 53, G8 40, 53, G8 837P - 2320 - AMT - COORDINATION OF BENEFITS (COB) TOTAL NON-COVERED AMOUNT COORDINATION OF BENEFITS (COB) 2320 AMT TOTAL NONCOVERED AMOUNT 837P - 2320 - AMT - REMAINING PATIENT LIABILITY 2320
26 27
HI
Usage changed to Required
4010 252 / 5010 - 226
Loop ID Change Value Deleted
4010 2310D 289 5010 2310C 270
Value Added
4010 302/ 5010-296
Value Deleted
4010 302/ 5010-296
837P - 2310C - NM1 - SERVICE FACILITY LOCATION NAME
2310D
22 23
2300
AMT
REMAINING PATIENT LIABILITY
837P 2320 - AMT - COORDINATION OF BENEFITS (COB) PATIENT RESPONSIBILITY AMOUNT
New Segment 5010-306
New Segment 5010 -307
2320
AMT
28 29
COORDINATION OF BENEFITS (COB) PATIENT RESPONSIBILITY AMOUNT
S
DMG
30 31
OTHER SUBSCRIBER DEMOGRAPHIC INFORMATION
S
Segment Deleted
4010 326
Value Deleted
4010 329 / 5010 - 308
New Segment
5010 322
Usage changed to Situational ERRATA Jun 10
5010 323
837P - 2320 - OI - OTHER INSURANCE COVERAGE 2320
OI06
Release of Information Code
A, I, M, N, O, Y
32 33
R
2320
OI06
Release of Information Code
I, Y
837P - 2330B - N3 - OTHER PAYER ADDRESS OTHER PAYER S 2330B N3 ADDRESS 837P - 2330B - N4 - OTHER PAYER CITY, STATE, ZIP CODE
2330B
2330B
S
36 37
2330B
N4
OTHER PAYER CITY, STATE, ZIP CODE
837P - 2420A - PRV - RENDERING PROVIDER SPECIALTY INFORMATION 2420A
PRV02
Reference Identification Qualifier
ZZ
38 39
R
2420A
PRV02
Reference Identification Qualifier
PXC
4010 Value Changed 490 / 5010 - 433
837P 2420C - NM1 - SERVICE FACILITY LOCATION NAME 2420C
40
4010 318
837P - 2320 - DMG - OTHER SUBSCRIBER DEMOGRAPHIC INFORMATION 2320
34 35
Segment Deleted
NM101
Entity Identifier Code
77, FA, LI, TL
R
2420C
NM101
Entity Identifier Code
77
Value Deleted
4010 499 / 5010 - 442
2420C
NM103
Laboratory or Facility Name
S
41 42
NM103
837P - 2430 - SVD - LINE ADJUDICATION INFORMATION 2430
SVD03-1
Product or Service ID Qualifier
HC, IV, ZZ
43 44
R
2430
SVD03-1
Product or Service ID Qualifier
ER, HC, IV, WK
837P - 2430 - AMT - REMAINING PATIENT LIABILITY REMAINING PATIENT 2430 AMT LIABILITY
45 46
END 837 P
47 48
START 835
Value Change
4010 555 / 5010 - 481
New Segment
5010 491
Value Deleted
4010 - 53 / 5010 78
835 - __ - TRN - REASSOCIATION TRACE NUMBER ___
TRN03
Payer Identifier
=BPR10
49 50
R
___
TRN03
Payer Identifier
835 - 1000A - PER - PAYER TECHNICAL CONTACT INFORMATION PAYER TECHNICAL 1000A PER CONTACT INFORMATION 835 - 2100 - DTM - CLAIM RECEIVED DATE CLAIM RECEIVED 2100 DTM DATE
51 52 53 54 55 56
New Segment 5010 - 97
New Segment
5010 177
END 835 START 837 I
837I - 1000A - PER - SUBMITTER EDI CONTACT INFORMATION 1000A
PER03
Communication Number ED, EM, FX. Qualifier TE
R
1000A
PER03
Communication Number EM, FX. TE Qualifier
Value Deleted
1000A
PER05
Communication Number ED, EM, EX, Qualifier FX, TE
S
1000A
PER05
Communication Number EM, EX, FX, Qualifier TE
Value Deleted
1000A
PER07
Communication Number ED, EM, EX, Qualifier FX, TE
S
1000A
PER07
Communication Number EM, EX, FX, Qualifier TE
Value Deleted
57
58
59
2420C
Usage changed 4010 to Required 499 / 5010 Increase from - 442 35 -60
Laboratory or Facility Name
4010 - 65 / 5010 74 4010 - 65 / 5010 74 4010 - 66 / 5010 75
837I - 2010AA - NM - BILLING PROVIDER NAME
60 2010AA NM108
Identification Code Qualifier
2010AA NM109
Billing Provider Identifier
61
24, 34, XX
62 63
R
2010AA NM108
Identification Code Qualifier
R
2010AA NM109
Billing Provider Identifier
Value Deleted Usage change to Situational Usage change to Situational
4010 - 77 / 5010 86 4010 - 78 / 5010 86
837I - 2010AB - NM - PAY-TO ADDRESS NAME 2010AB NM108
Identification Code Qualifier
2010AB NM109
Pay-to Provider Identifier
24, 34, XX
R
2010AB NM108
Identification Code Qualifier
Value Deleted 4010 - 92 Usage changed / 5010 to N/U 95
R
2010AB NM109
Identification Code
Name Change 4010 - 93 Usage changed / 5010 to N/U 95
64
65 66
837I - 2010BC - NM1 - PAYER NAME 2010BC NM1
PAYER NAME
67 68
R
2010BB NM1
PAYER NAME
Loop Change
4010 123 / 5010 - 122
837I - 2010BB - N3 - PAYER ADDRESS
2010BC N3
PAYER ADDRESS
69 70
S
2010BB N3
PAYER ADDRESS
4010 Loop Change 126 / 5010 - 124
837I - N4 - PAYER CITY, STATE, ZIP CODE
2010BC N4
71
XX
PAYER CITY/STATE/ZIP CODE
S
2010BB N4
PAYER CITY, STATE, ZIP CODE
Usage Changed to Required Usage changed to Situational ERRATA Jun 10 Loop Change Name Change
4010 127 / 5010 125
837I - 2300 CL1 - INSTITUTIONAL CLAIM CODE
72 2300
CL1
INSTITUTIONAL CLAIM CODE
S
2300
CL1
INSTITUTIONAL CLAIM CODE
4010 Usage change 166 / 5010 to Required - 153
4010 166 / 5010 - 153
4010 167 / 5010 - 153
73
2300
CL101
Admission Type Code
S
2300
CL101
Admission Type Code
Code Source Change, Change to required ERRATA Jun 10
2300
CL103
Patient Status Code
S
2300
CL103
Patient Status Code
Usage change to Required
HI
PRINCIPAL ADMITTING, E-CODE AND PATIENT REASON FOR VISIT DIAGNOSIS INFORMATION
74
75 76
837I - 2300 - HI - PRINCIPAL DIAGNOSIS
2300 77 78
S
HI
Name Change 4010 Usage change 234 / 5010 - 184 to Required
PRINCIPAL DIAGNOSIS
837I - 2310E - NM1 - SERVICE FACILITY LOCATION NAME 2310E
NM101
Entity Identifier Code
FA
79 80
R
2310E
NM101
Entity Identifier Code
77
Value Change
4010 346 / 5010 - 342
Value Added
4010 354 / 5010 - 355
837I - 2320 - SBR - OTHER SUBSCRIBER INFORMATION 2320
81
2300
SBR01
Payer Responsibility Sequence Number Code
P, S, T
R
2320
SBR01
Payer Responsibility Sequence Number Code
A, B, C, D, E, F, G, H, P, S, T, U
2320
SBR02
Individual Relationship Code
2320
AMT01
Amount Qualifier Code
82 83
84 85
C4
R
2320
AMT01
Amount Qualifier Code
D
837I - 2320 - AMT - REMAINING PATIENT LIABILITY REMAINING PATIENT 2320 AMT LIABILITY 837I - 2320 - AMT - COORDINATION OF BENEFITS (COB) TOTAL NON-COVERED AMOUNT COORDINATION OF BENEFITS (COB) 2320 AMT TOTAL NONCOVERED AMOUNT 837I - DMG - OTHER SUBSCRIBER DEMOGRAPHIC INFORMATION
86 87
88 89 2320
DMG
90 91
OTHER SUBSCRIBER DEMOGRAPHIC INFORMATION
S
Value Deleted
4010 355 / 5010 - 355
Value Change
4010 365 / 5010 - 364
New Segment
5010 365
New Segment
5010 366
Segment Deleted
4010 382
Value Deleted
4010 385 / 5010 - 368
837I - 2320 - OI - OTHER INSURANCE COVERAGE 2320
OI06
Release of Information Code
92 93
A, I, M, N, O, Y
R
2320
OI06
Release of Information Code
I, Y
837I - 2400 - SV2 - INSTITUTIONAL SERVICE LINE 2400
94 95
01, 04, 05, 07, 10, 15, 17, 18, 19, 01, 18, 19, Individual Relationship 20, 21, 22, 2320 SBR02 20, 21, 39, R Code 23, 24, 29, 40, 53, G8 32, 33, 36, 39, 40, 41, 43, 53, G8 837I - 2320 - AMT - COORDINATION OF BENEFITS (COB) PAYER PAID AMOUNT
SV206
Service Line Rate
S
2400
SV206
Unit Rate
837I - 2400 - REF - LINE ITEM CONTROL NUMBER
Name Change, 4010 Usage change 439 / 5010 - 428 to Not Used
LINE ITEM CONTROL NUMBER 837I - 2400 - NTE - THIRD PARTY ORGANIZATION NOTES THIRD PARTY 2400 NTE ORGANIZATION NOTES 837I - 2430 - SVD - LINE ADJUDICATION INFORMATION 2400
96 97
98 99 2430
SVD03-1
Product or Service ID Qualifier
HC, IV, ZZ
100 101
Segment Added
5010 441
Value Change
4010 480 / 5010 - 477
New Segment
5010 487
BHT05
Time
___
BHT05
Change from 4010 - 51 Not used to / Required Element Name 5010 - 38 Change
Transaction Set Creation Time
276 - 2000D - DMG - SUBSCRIBER DEMOGRAPHIC INFORMATION 2000D
DMG03
Subscriber Gender Code
F, M, U
108 109
114 115
ER, HC, HP, IV, WK
5010 435
276 - ___ - BHT - BEGINNING OF HIERARCHICAL TRANSACTION
106 107
112 113
Product or Service ID Qualifier
New Segment
END 837 I START 276
___
111
SVD03-1
837I - 2430 - AMT - REMAINING PATIENT LIABILITY REMAINING PATIENT 2430 AMT LIABILITY
102 103 104 105
110
R
2430
REF
R
2000D
DMG03
Subscriber Gender Code
F, M
Usage 4010 - 73 changed from R / 5010 - S, Code - 55 Removed
276 - 2200D - REF - MEDICAL RECORD IDENTIFICATION 2200D
REF REF01 REF02 REF03 REF04 END 276
MEDICAL RECORD IDENTIFICATION Reference Identification Qualifier Medical Record Number Description REFERENCE IDENTIFIER
S EA
R R
Segment Deleted
4010 - 83
116 117 118
START 277
277 - 2200D - REF - MEDICAL RECORD IDENTIFICATION 2200D
REF REF01
119
REF02
120 121
REF03 REF04
122 123
MEDICAL RECORD IDENTIFICATION Reference Identification EA Qualifier Medical Record Number Description REFERENCE IDENTIFIER
S
Segment Deleted
4010 174
Value Added
4010 177 / 5010 - 155
New format allowed
4010 177 / 5010 156
R R
277 - 2200D - DTP - CLAIM SERVICE DATE 2200D
DTP02
Date Time Period Format Qualifier
2200D
DTP03
Claim Service Period
RD8
R
2200D
DTP02
Date Time Period Format Qualifier
CCYYMMDDCCYYMMDD
R
2200D
DTP03
Claim Service Period
D8, RD8
124
125 126
END 277
CCYYMMDD , CCYYMMDDCCYYMMDD
1 2
Loop ID
Reference
Name
Codes
Notes / Comments
SD 2
Loop ID
Reference
Name
Codes
3
4010A1
4
8 9 10
1000A
PER03
1000A
PER05
1000A
PER07
Communication Number ED, EM, FX. Qualifier TE Communication Number ED, EM, EX, Qualifier FX, TE Communication Number ED, EM, EX, Qualifier FX, TE
2010AA NM108
Identification Code Qualifier
2010AA NM109
Billing Provider Identifier
2010AB NM108
Identification Code Qualifier
2010AB NM109
Pay-to Provider Identifier
11 12 13
5010
START 837 P
5 6 7
24, 34, XX
837P - 1000A - PER - SUBMITTER EDI CONTACT INFORMATION Communication Number EM, FX. TE 1000A PER03 R Qualifier Communication Number EM, EX, FX, 1000A PER05 S Qualifier TE Communication Number EM, EX, FX, 1000A PER07 S Qualifier TE 837P - 2010AA - NM1 - BILLING PROVIDER NAME R
2010AA NM108
Identification Code Qualifier
Billing Provider Identifier 837P - 2010AB - NM1 - PAY-TO ADDRESS NAME 24, 34, XX
XX
Value Deleted Value Deleted Value Deleted Value Deleted Usage change to Situational Usage change to Situational
4010 - 70/ 5010 - 77 4010 -71/ 5010 - 77 4010 - 71/ 5010 - 78 4010 - 83/ 5010 - 89 4010 - 83/ 5010 - 90
R
2010AA NM109
R
2010AB NM108
Identification Code Qualifier
Value Deleted 4010 - 97/ Usage changed 5010 to N/U 102
R
2010AB NM109
Identification Code
Name Change 4010 - 97/ Usage changed 5010 to N/U 102
14
15 16
4010 Notes / Page # / FOR REVIEW 5010 Comments Page #
837P - 2300 - HI - HEALTH CARE DIAGNOSIS CODE
2300
HI
HEALTH CARE DIAGNOSIS CODE
S
17 18
NM101
Entity Identifier Code
77, FA, LI, TL
19 20 2320
SBR01
21
2320
24 25
SBR02
Payer Responsibility Sequence Number Code
Individual Relationship Code
P, S, T
R
2310C
HEALTH CARE DIAGNOSIS CODE
NM101
Entity Identifier Code
837P - 2320 - SBR - OTHER SUBSCRIBER INFORMATION Payer Responsibility 2320 SBR01 Sequence Number R Code
77
A, B, C, D, E, F, G, H, P, S, T, U
01, 04, 05, 07, 10, 15, 17, 18, 19, Individual Relationship 20, 21, 22, 2320 SBR02 R Code 23, 24, 29, 01, 18, 19, 32, 33, 36, 20, 21, 39, 39, 40, 41, 43, 53, G8 40, 53, G8 837P - 2320 - AMT - COORDINATION OF BENEFITS (COB) TOTAL NON-COVERED AMOUNT COORDINATION OF BENEFITS (COB) 2320 AMT TOTAL NONCOVERED AMOUNT 837P - 2320 - AMT - REMAINING PATIENT LIABILITY 2320
26 27
HI
Usage changed to Required
4010 252 / 5010 - 226
Loop ID Change Value Deleted
4010 2310D 289 5010 2310C 270
Value Added
4010 302/ 5010-296
Value Deleted
4010 302/ 5010-296
837P - 2310C - NM1 - SERVICE FACILITY LOCATION NAME
2310D
22 23
2300
AMT
REMAINING PATIENT LIABILITY
837P 2320 - AMT - COORDINATION OF BENEFITS (COB) PATIENT RESPONSIBILITY AMOUNT
New Segment 5010-306
New Segment 5010 -307
2320
AMT
28 29
COORDINATION OF BENEFITS (COB) PATIENT RESPONSIBILITY AMOUNT
S
DMG
30 31
OTHER SUBSCRIBER DEMOGRAPHIC INFORMATION
S
Segment Deleted
4010 326
Value Deleted
4010 329 / 5010 - 308
New Segment
5010 322
Usage changed to Situational ERRATA Jun 10
5010 323
837P - 2320 - OI - OTHER INSURANCE COVERAGE 2320
OI06
Release of Information Code
A, I, M, N, O, Y
32 33
R
2320
OI06
Release of Information Code
I, Y
837P - 2330B - N3 - OTHER PAYER ADDRESS OTHER PAYER S 2330B N3 ADDRESS 837P - 2330B - N4 - OTHER PAYER CITY, STATE, ZIP CODE
2330B
2330B
S
36 37
2330B
N4
OTHER PAYER CITY, STATE, ZIP CODE
837P - 2420A - PRV - RENDERING PROVIDER SPECIALTY INFORMATION 2420A
PRV02
Reference Identification Qualifier
ZZ
38 39
R
2420A
PRV02
Reference Identification Qualifier
PXC
4010 Value Changed 490 / 5010 - 433
837P 2420C - NM1 - SERVICE FACILITY LOCATION NAME 2420C
40
4010 318
837P - 2320 - DMG - OTHER SUBSCRIBER DEMOGRAPHIC INFORMATION 2320
34 35
Segment Deleted
NM101
Entity Identifier Code
77, FA, LI, TL
R
2420C
NM101
Entity Identifier Code
77
Value Deleted
4010 499 / 5010 - 442
2420C
NM103
Laboratory or Facility Name
S
41 42
NM103
837P - 2430 - SVD - LINE ADJUDICATION INFORMATION 2430
SVD03-1
Product or Service ID Qualifier
HC, IV, ZZ
43 44
R
2430
SVD03-1
Product or Service ID Qualifier
ER, HC, IV, WK
837P - 2430 - AMT - REMAINING PATIENT LIABILITY REMAINING PATIENT 2430 AMT LIABILITY
45 46
END 837 P
47 48
START 835
Value Change
4010 555 / 5010 - 481
New Segment
5010 491
Value Deleted
4010 - 53 / 5010 78
835 - __ - TRN - REASSOCIATION TRACE NUMBER ___
TRN03
Payer Identifier
=BPR10
49 50
R
___
TRN03
Payer Identifier
835 - 1000A - PER - PAYER TECHNICAL CONTACT INFORMATION PAYER TECHNICAL 1000A PER CONTACT INFORMATION 835 - 2100 - DTM - CLAIM RECEIVED DATE CLAIM RECEIVED 2100 DTM DATE
51 52 53 54 55 56
New Segment 5010 - 97
New Segment
5010 177
END 835 START 837 I
837I - 1000A - PER - SUBMITTER EDI CONTACT INFORMATION 1000A
PER03
Communication Number ED, EM, FX. Qualifier TE
R
1000A
PER03
Communication Number EM, FX. TE Qualifier
Value Deleted
1000A
PER05
Communication Number ED, EM, EX, Qualifier FX, TE
S
1000A
PER05
Communication Number EM, EX, FX, Qualifier TE
Value Deleted
1000A
PER07
Communication Number ED, EM, EX, Qualifier FX, TE
S
1000A
PER07
Communication Number EM, EX, FX, Qualifier TE
Value Deleted
57
58
59
2420C
Usage changed 4010 to Required 499 / 5010 Increase from - 442 35 -60
Laboratory or Facility Name
4010 - 65 / 5010 74 4010 - 65 / 5010 74 4010 - 66 / 5010 75
837I - 2010AA - NM - BILLING PROVIDER NAME
60 2010AA NM108
Identification Code Qualifier
2010AA NM109
Billing Provider Identifier
61
24, 34, XX
62 63
R
2010AA NM108
Identification Code Qualifier
R
2010AA NM109
Billing Provider Identifier
Value Deleted Usage change to Situational Usage change to Situational
4010 - 77 / 5010 86 4010 - 78 / 5010 86
837I - 2010AB - NM - PAY-TO ADDRESS NAME 2010AB NM108
Identification Code Qualifier
2010AB NM109
Pay-to Provider Identifier
24, 34, XX
R
2010AB NM108
Identification Code Qualifier
Value Deleted 4010 - 92 Usage changed / 5010 to N/U 95
R
2010AB NM109
Identification Code
Name Change 4010 - 93 Usage changed / 5010 to N/U 95
64
65 66
837I - 2010BC - NM1 - PAYER NAME 2010BC NM1
PAYER NAME
67 68
R
2010BB NM1
PAYER NAME
Loop Change
4010 123 / 5010 - 122
837I - 2010BB - N3 - PAYER ADDRESS
2010BC N3
PAYER ADDRESS
69 70
S
2010BB N3
PAYER ADDRESS
4010 Loop Change 126 / 5010 - 124
837I - N4 - PAYER CITY, STATE, ZIP CODE
2010BC N4
71
XX
PAYER CITY/STATE/ZIP CODE
S
2010BB N4
PAYER CITY, STATE, ZIP CODE
Usage Changed to Required Usage changed to Situational ERRATA Jun 10 Loop Change Name Change
4010 127 / 5010 125
837I - 2300 CL1 - INSTITUTIONAL CLAIM CODE
72 2300
CL1
INSTITUTIONAL CLAIM CODE
S
2300
CL1
INSTITUTIONAL CLAIM CODE
4010 Usage change 166 / 5010 to Required - 153
4010 166 / 5010 - 153
4010 167 / 5010 - 153
73
2300
CL101
Admission Type Code
S
2300
CL101
Admission Type Code
Code Source Change, Change to required ERRATA Jun 10
2300
CL103
Patient Status Code
S
2300
CL103
Patient Status Code
Usage change to Required
HI
PRINCIPAL ADMITTING, E-CODE AND PATIENT REASON FOR VISIT DIAGNOSIS INFORMATION
74
75 76
837I - 2300 - HI - PRINCIPAL DIAGNOSIS
2300 77 78
S
HI
Name Change 4010 Usage change 234 / 5010 - 184 to Required
PRINCIPAL DIAGNOSIS
837I - 2310E - NM1 - SERVICE FACILITY LOCATION NAME 2310E
NM101
Entity Identifier Code
FA
79 80
R
2310E
NM101
Entity Identifier Code
77
Value Change
4010 346 / 5010 - 342
Value Added
4010 354 / 5010 - 355
837I - 2320 - SBR - OTHER SUBSCRIBER INFORMATION 2320
81
2300
SBR01
Payer Responsibility Sequence Number Code
P, S, T
R
2320
SBR01
Payer Responsibility Sequence Number Code
A, B, C, D, E, F, G, H, P, S, T, U
2320
SBR02
Individual Relationship Code
2320
AMT01
Amount Qualifier Code
82 83
84 85
C4
R
2320
AMT01
Amount Qualifier Code
D
837I - 2320 - AMT - REMAINING PATIENT LIABILITY REMAINING PATIENT 2320 AMT LIABILITY 837I - 2320 - AMT - COORDINATION OF BENEFITS (COB) TOTAL NON-COVERED AMOUNT COORDINATION OF BENEFITS (COB) 2320 AMT TOTAL NONCOVERED AMOUNT 837I - DMG - OTHER SUBSCRIBER DEMOGRAPHIC INFORMATION
86 87
88 89 2320
DMG
90 91
OTHER SUBSCRIBER DEMOGRAPHIC INFORMATION
S
Value Deleted
4010 355 / 5010 - 355
Value Change
4010 365 / 5010 - 364
New Segment
5010 365
New Segment
5010 366
Segment Deleted
4010 382
Value Deleted
4010 385 / 5010 - 368
837I - 2320 - OI - OTHER INSURANCE COVERAGE 2320
OI06
Release of Information Code
92 93
A, I, M, N, O, Y
R
2320
OI06
Release of Information Code
I, Y
837I - 2400 - SV2 - INSTITUTIONAL SERVICE LINE 2400
94 95
01, 04, 05, 07, 10, 15, 17, 18, 19, 01, 18, 19, Individual Relationship 20, 21, 22, 2320 SBR02 20, 21, 39, R Code 23, 24, 29, 40, 53, G8 32, 33, 36, 39, 40, 41, 43, 53, G8 837I - 2320 - AMT - COORDINATION OF BENEFITS (COB) PAYER PAID AMOUNT
SV206
Service Line Rate
S
2400
SV206
Unit Rate
837I - 2400 - REF - LINE ITEM CONTROL NUMBER
Name Change, 4010 Usage change 439 / 5010 - 428 to Not Used
LINE ITEM CONTROL NUMBER 837I - 2400 - NTE - THIRD PARTY ORGANIZATION NOTES THIRD PARTY 2400 NTE ORGANIZATION NOTES 837I - 2430 - SVD - LINE ADJUDICATION INFORMATION 2400
96 97
98 99 2430
SVD03-1
Product or Service ID Qualifier
HC, IV, ZZ
100 101
Segment Added
5010 441
Value Change
4010 480 / 5010 - 477
New Segment
5010 487
BHT05
Time
___
BHT05
Change from 4010 - 51 Not used to / Required Element Name 5010 - 38 Change
Transaction Set Creation Time
276 - 2000D - DMG - SUBSCRIBER DEMOGRAPHIC INFORMATION 2000D
DMG03
Subscriber Gender Code
F, M, U
108 109
114 115
ER, HC, HP, IV, WK
5010 435
276 - ___ - BHT - BEGINNING OF HIERARCHICAL TRANSACTION
106 107
112 113
Product or Service ID Qualifier
New Segment
END 837 I START 276
___
111
SVD03-1
837I - 2430 - AMT - REMAINING PATIENT LIABILITY REMAINING PATIENT 2430 AMT LIABILITY
102 103 104 105
110
R
2430
REF
R
2000D
DMG03
Subscriber Gender Code
F, M
Usage 4010 - 73 changed from R / 5010 - S, Code - 55 Removed
276 - 2200D - REF - MEDICAL RECORD IDENTIFICATION 2200D
REF REF01 REF02 REF03 REF04 END 276
MEDICAL RECORD IDENTIFICATION Reference Identification Qualifier Medical Record Number Description REFERENCE IDENTIFIER
S EA
R R
Segment Deleted
4010 - 83
116 117 118
START 277
277 - 2200D - REF - MEDICAL RECORD IDENTIFICATION 2200D
REF REF01
119
REF02
120 121
REF03 REF04
122 123
MEDICAL RECORD IDENTIFICATION Reference Identification EA Qualifier Medical Record Number Description REFERENCE IDENTIFIER
S
Segment Deleted
4010 174
Value Added
4010 177 / 5010 - 155
New format allowed
4010 177 / 5010 156
R R
277 - 2200D - DTP - CLAIM SERVICE DATE 2200D
DTP02
Date Time Period Format Qualifier
2200D
DTP03
Claim Service Period
RD8
R
2200D
DTP02
Date Time Period Format Qualifier
CCYYMMDDCCYYMMDD
R
2200D
DTP03
Claim Service Period
D8, RD8
124
125 126
END 277
CCYYMMDD , CCYYMMDDCCYYMMDD
2320.dmg Segment On 837p Number
2320.dmg Segment On 837p Claim
ASC X12 On-Line Store. Business Scenario 1 - 837 Institutional Claim. D&d eldritch blast dmg walkthrough. ASC X12 Version: 005010 Transaction Set: 837 TR3 ID: 005010X223.
Dec 10, 2018 Click 'Load DMG' to import your DMG file into the program. Insert a blank DVD and click Burn against the DVD option to write the DMG to the disk. In three simple steps, your bootable DVD is ready. You won't find that many tools that are so easy to operate. Now open a Finder window and drag your DMG file into Disk Utility. Drop it in the blank area below the drive names on the left panel. Step 3: You can now insert your USB drive and wait for it to appear in the drives list. Next, click on your mounted DMG file on the left panel and click on ‘Burn' in the top toolbar. TransMac - Make DMG File Bootable USB on Windows. This is a fairly robust application for creating bootable USB on Windows from a DMG file. However, there's a preparatory step to be executed before you can create the bootable USB drive. The typical disk partition used is MBR, but you will need to do a partition with GPT for this to work. Windows write dmg to disl. Apr 02, 2019 A DMG File stands for Disk Image file and it is a file format which is used to create mountable disks on the Macintosh operating system. The DMG File format contains data in the form of blocks which are often secured using encryption methods.