Vendor Specifications 278 Healthcare Services Request for ... Companion Guides... · Segment End B...

Vendor Specifications

278 Healthcare Services

Request for Review and Response

ASC X12N Version 5010

for

State of Idaho MMIS

Date of Publication: 03/30/2020

Document Number: TL418

Version: 7.0

Idaho MMIS 278 Healthcare Services Request for Review and Response-5010

Last Updated: 03/30/2020 Page ii

Revision History

Version Date Author Action/Summary of Changes

1.0 07/01/2011 Molina Initial Document

1.1 04/22/2014 M McFadden Added ICD-10 references and updates

for CCF10735B1-Edifecs

2.0 8/15/2014 TQD DHW validated 8/15/14

2.1 5/19/2015 Doug Greer Semi-annual review performed – made

corrections

3.0 6/8/2015 TQD DHW validated 6/5/15

3.1 12/10/2015 Doug Greer Semi-annual review performed – made

corrections

4.0 1/25/2016 TQD DHW validated changes 1/22/16

4.0 5/25/2016 Cathy Butler Semi-annual review – no changes made

4.0 12/15/2016 Jimmy Phillips Semi-annual review – no changes made

4.1 6/2/2017 Douglas Greer Semi-annual review – Minor corrections

in tables 2-1 and 2-2

5.0 7/25/2017 TQD DHW validate changes 7/25/17

5.0 11/7/2017 Cathy Butler Semi-annual review – no changes made

5.1 6/19/2018 Douglas Greer Semi-annual review – correction to table

in figure 2.2

6.0 09/10/2018 TQD Finalized per 30-day Notification

agreement

6.1 10/05/2018 M Zampierin Removed all Molina references and

replaced with DXC Technology

6.1 11/27/2018 Jimmy Phillips Semi-annual review – no changes made

6.2 01/11/2019 M Zampierin Updated Copyright statement to DXC

6.2 11/27/2019 Cathy Lavacchia Semi-annual review – no changes made

6.3 03/09/2020 Jimmy Phillips Changed for Rebranding CR 58031

7.0 03/30/2020 TQD Finalized per DHW validated changes.

© 2018-2019 DXC Technology Company. All rights reserved. -

http://www.dxc.technology/legal


Last Updated: 03/30/2020 Page ii

Table of Contents

1. Companion Guide Purpose ...................................................................................... 1

1.1. Required Information ....................................................................................... 1

1.2. Trading Partner ID .......................................................................................... 1

1.3. Delimiters ...................................................................................................... 2

1.4. Additional Information ..................................................................................... 2

2. 278 Request for Review ......................................................................................... 3

2.1. 278 Response ............................................................................................... 34

Appendix A. ........................................................................................................... 62

Table of Figures

Figure 2-1: Request for Review .................................................................................... 3

Figure 2-2: 278 Response .......................................................................................... 34


Last Updated: 03/30/2020 Page 1 of 62

1. Companion Guide Purpose This companion guide documents the transaction type listed below and further defines

situational and required data elements that are used for processing healthcare service

requests for reviews and responses for programs administered by the Idaho Medicaid. This

document is not the complete EDI transaction format specifications.

Please refer to the 5010 Implementation Guide for information not supplied in this

document, such as code lists, definitions, and edits.

Health Care Services Request for Review and Response ASC X12N 278

(005010X217) May 2006


(005010X217E1) April 2008


(005010X217E2) January 2009

For any questions, or to begin testing, please contact the DXC Technology EDI Helpdesk at

1 (866) 686-4272 option 2 and ask for Technical Support, or e-mail us at

[email protected].

1.1. Required Information Data elements, segments, and loops not included in this guide are not used for processing

authorization requests by Idaho Medicaid, but must still be sent if the information is

required for compliance with the ASC X12N version 5010 format.

1.2. Trading Partner ID A trading partner is defined as any entity with which DXC Technology exchanges electronic

data. The term electronic data is not limited to HIPAA X12 transactions. Idaho Medicaid’s

Health PAS system supports the following categories of trading partner:

Provider

Billing Agency

Clearinghouse

Health Plan

DXC Technology will assign trading partner IDs to support the exchange of X12 EDI

transactions for providers, billing agencies and clearinghouses, and other health plans.

All trading partners must be authorized to submit production EDI transactions. Any trading

partner may submit test EDI transactions. The Usage Indicator, element 15 of the

Interchange Control Header (ISA) of an X12 file, indicates if a file is test or production.

Authorization is granted on a per transaction basis. For example, a trading partner may be

certified to submit 837P professional claims but not certified to submit 837I institutional

claim files.

Trading partners must submit three test files of a particular transaction type, with a

minimum of fifteen transactions within each file, and have no failures or rejections in order

to become certified for production. Users will be notified via e-mail and the Trading Partner

Status page of Health PAS-Online when testing for a particular transaction has been

completed.

mailto:[email protected]



Detailed instructions for retrieving and interpreting HIPAA validation acknowledgments may

be found in Appendix A of this document.

To obtain a trading partner ID please visit our website at http://www.idmedicaid.com or

contact us at 1 (866) 686-4272.

1.3. Delimiters Idaho Medicaid does not require the use of specific values for the delimiters used in

electronic transactions. The suggested values are included in the specifications below.

1.4. Additional Information Please refer to the 5010 Implementation Guide for information not supplied in this

document, such as code lists, definitions, and edits.

http://www.idmedicaid.com/



2. 278 Request for Review

Figure 2-1: Request for Review

Loop Segment

ID

Segment Name/ Data

Element Name

Format Length DE Ref

#

Req

Des.

Value

Interchange Control Record

HEADER ISA Interchange Control

Header

3 R ISA

Element Separator AN 1 *

ISA01 Authorization Information

Qualifier

ID 2 I01 R 00 – No Authorization Information

Present


ISA02 Authorization Information AN 10 I02 R Space fill


ISA03 Security Information

Qualifier

ID 2 I03 R 00 – No Security Information

Present


ISA04 Security Information AN 10 I04 R Space fill


ISA05 Interchange ID Qualifier ID 2 I05 R ZZ – Mutually Defined


ISA06 Interchange Sender ID AN 15 I06 R DXCMS assigned trading partner ID


ISA07 Interchange ID Qualifier ID 2 I05 R ZZ – Mutually Defined


ISA08 Interchange Receiver ID AN 15 I07 R ID_MMIS_4_DXCMS or

ID_MMIS_4MOLINA


ISA09 Interchange Date DT 6 I08 R YYMMDD


ISA10 Interchange Time TM 4 I09 R HHMM




Loop Segment

ID

Segment Name/ Data

Element Name


#

Req

Des.

Value

ISA11 Repetition Separator 1 I65 R ^


ISA12 Interchange Version

Number

ID 5 I11 R 00501


ISA13 Interchange Control

Number

N0 9 I12 R Must be identical to the

interchange trailer IEA02 - defined

by sender


ISA14 Acknowledgment

Requested

ID 1 I13 R 0 – No Acknowledgment Requested

1- Interchange Acknowledgement

requested


ISA15 Interchange Usage

Indicator

ID 1 I14 R P – Production Data

T – Test Data


ISA16 Component Element

Separator

1 I15 R :

Segment End B 1 ~

Functional Group Header

GS Functional Group Header 2 R GS


GS01 Functional Identifier Code ID 2 479 R HI


GS02 Application Sender's Code AN 2/15 142 R DXCMS Assigned Trading Partner

ID


GS03 Application Receiver's

Code

AN 2/15 124 R ID_MMIS_4_DXCMS or

ID_MMIS_4MOLINA


GS04 Date DT 8 373 R CCYYMMDD


GS05 Time TM 4/8 337 R HHMM




Loop Segment

ID

Segment Name/ Data

Element Name


#

Req

Des.

Value

GS06 Group Control Number N0 1/9 28 R Assigned by Sender


GS07 Responsible Agency Code ID 1/2 455 R X – Accredited Standards

Committee X12


GS08 Version / Release Code AN 1/12 480 R 005010X217

Segment End B 1 ~

Transaction Set Header

ST Transaction Set Header 2 R ST


ST01 Transaction Set Identifier

Code

ID 3 143 R 278 – Health Care Services Review

Information


ST02 Transaction Set Control

Number

AN 4/9 329 R Sequential number assigned by

sender ST and SE must be equal


ST03 Implementation

Convention Reference

AN 1/35 1705 R 005010X217

Segment End B 1 ~

Beginning of Hierarchical Transaction

BHT Beginning Hierarchical

Transaction Segment

ID 3 R BHT


BHT01 Hierarchical Structure

Code

ID 4 1005 R 0007 – Information Source,

Information Receiver, Subscriber,

Dependent, Provider of Service,

Services


BHT02 Transaction Set Purpose

Code

ID 2 353 R 01 = Cancellation

13 – Request


BHT03 Reference identification AN 1/50 127 R Submitter Transaction Identifier.




Loop Segment

ID

Segment Name/ Data

Element Name


#

Req

Des.

Value

BHT04 Date DT 8 373 R CCYYMMDD

- Transaction Set Creation Date


BHT05 Time TM 4/8 337 R HHMM

- Transaction Set Creation Time

Segment End B 1 ~

UMO (Loop 2000A)

2000A HL Hierarchical Level

Segment

ID 2 R HL


HL01 Hierarchical ID Number AN 1/12 628 R 1



HL03 Hierarchical Level Code ID 1/2 735 R 20 – Information Source


HL04 Hierarchical Child Code ID 1 736 R 1 – Additional Subordinate HL Data

Segment in This Hierarchical

Structure.

Segment End B 1 ~

2010A NM1 Individual or

Organizational Name

ID 3 R NM1


NM101 Entity Identifier Code ID 2/3 98 R X3 - UMO


NM102 Entity Type Qualifier ID 1 1065 R 2 – Non-Person Entity


NM103 Name Last or

Organization Name

AN 1/60 1035 R IDAHO MEDICAID


NM104 Name First AN 1/25 1036 S


NM105 Name Middle AN 1/25 1037





Loop Segment

ID

Segment Name/ Data

Element Name


#

Req

Des.

Value

NM107 Name Suffix AN 1/10 1039 S


NM108 Identification Code

Qualifier

ID 1/2 66 R PI – Payor Identification


NM109 Identification Code AN 2/80 67 R ID_MMIS_4MOLINA

Segment End B 1 ~

Requester (Loop 2000B)

2000B HL Hierarchical Level

Segment

ID 2 R HL




HL02 Hierarchical Parent ID

Number

AN 1/12 734 R 1


HL03 Hierarchical Level Code ID 1/2 735 R 21 – Information Receiver


HL04 Hierarchical Child Code ID 1 736 R 1 – Additional Subordinate HL Data

Segment in This Hierarchical

Structure.

Segment End B 1 ~

2010B NM1 Individual or

Organizational Name

ID 3 R NM1


NM101 Entity Identifier Code ID 2/3 98 R 1P – Provider, FA – Facility


NM102 Entity Type Qualifier ID 1 1065 R 1 – Person 2 – Non Person Entity


NM103 Name Last or

Organization Name

AN 1/60 1035 R


NM104 Name First AN 1/35 1036 S Required if NM102=1 (Person)




Loop Segment

ID

Segment Name/ Data

Element Name


#

Req

Des.

Value

NM105 Name Middle AN 1/25 1037 S






Qualifier

ID 1/2 66 R 24=Employer’s Identification

Number (for Atypical Providers

Only)

XX= National Provider Identifier

34 = SSN (Atypical providers

without EIN)


NM109 Identification Code AN 2/80 67 R Provider NPI, Idaho EIN, or SSN

Segment End B 1 ~

2010B REF Reference Identification ID 3 S REF


REF01 Reference Identification

Qualifier

ID 2/3 128 R N5


REF02 Reference Identification AN 1/50 127 R Medicaid assigned provider ID for

the Requesting Provider – for

Atypical providers only

Segment End B 1 ~

Subscriber (Loop 2000C)

2000C HL Hierarchical Level

Segment

ID 2 R HL





Number

AN 1/12 734 R 2


HL03 Hierarchical Level Code ID 1/2 735 R 22=Subscriber




Loop Segment

ID

Segment Name/ Data

Element Name


#

Req

Des.

Value

HL04 Hierarchical Child Code ID 1 736 R 1

Segment End B 1 ~

2010C NM1 Individual or

Organizational Name

ID 3 R NM1


NM101 Entity Identifier Code ID 2/3 98 R IL = Insured or Provider


NM102 Entity Type Qualifier ID 1 1065 R 1 = Person


NM103 Name Last or

Organization Name

AN 1/60 1035 S






NM106 Name Prefix AN 1/10 1038 S





Qualifier

ID 1/2 66 R MI = Member Identification

Number


NM109 Identification Code AN 7/10 67 R Enter the Idaho Medicaid member’s

7 or 10 digit identification number

as it appears on their ID card

Segment End B 1 ~

2010C DMG Demographic Information ID 3 S DMG


DMG01 Date Time Period Format

Qualifier

ID 2/3 1250 R D8


DMG02 Date Time Period AN 1/35 1251 R Patient Date of Birth



Loop Segment

ID

Segment Name/ Data

Element Name


#

Req

Des.

Value


DMG03 Gender Code ID 1 1068 S Patient Gender

Segment End B 1 ~

Service Provider (Loop 2000E)

2000E HL Hierarchical Level

Segment

ID 2 R HL





Number

AN 1/12 734 R 3


HL03 Hierarchical Level Code ID 1/2 735 R EV=Event


HL04 Hierarchical Child Code ID 1/1 736 R 0 = No Subordinate HL Segment

1= Additional Subordinate HL Data

Segment

Segment End B 1 ~

2000E TRN Patient Event Tracking

Number Segment

ID 3 S TRN


TRN01 Trace Type Code ID 1/2 481 R 1


TRN02 Reference Identification AN 1/50 127 R


TRN03 Originating Company

Identifier

AN 10 509 R


TRN04 Reference Identification AN 1/50 127 S

Segment End B 1 ~

2000E UM Health Care Services

Review Information

ID 2 R UM


UM01 Request Category Code ID 1/2 1525 R AR=Admission Review



Loop Segment

ID

Segment Name/ Data

Element Name


#

Req

Des.

Value

HS=Health Services Review


UM02 Certification Type Code ID 1/1 1322 R I = Initial

3 = Cancel

4 = Extension


UM03 Service Type Code ID 1/2 1365 R For Prior Authorizations see UM03

Service Type PA Crosswalk in this

guide


UM04 Health Care Service

Location Information

ID C023 S

UM04-1 Facility Code Value AN 1/2 1331 R

Component Element

Separator

1 :

UM04-2 Facility Code Qualifier ID 1/2 1332 R


UM05 Related Causes

Information

ID C024 S Required when the patient’s

condition is accident or

employment related

UM05-1 Related-Causes Code ID 2/3 1362 R Always use this data element if the

related cause is an auto accident

Component Element

Separator

1 :

UM05-2 Related-Causes Code ID 2/3 1362 S

Component Element

Separator

1 :

UM05-3 Related-Causes Code ID 2/3 1362 S

Component Element

Separator

1 :

UM05-4 State or Province Code ID 2/2 156 S Required on review requests if

UM05-1=AA, if the accident

occurred out of the service

provider's state



Loop Segment

ID

Segment Name/ Data

Element Name


#

Req

Des.

Value

Component Element

Separator

1 :

UM05-5 Country Code ID 2/3 26 S Required if automobile accident

occurred out of the U.S.


UM06 Level of Service Code ID 1/3 1338 S Recommended if the service

requested would not be authorized

unless the patient's condition is

Emergency or Urgent


UM07 Current Health Condition

Code

ID 1 1213 S


UM08 Prognosis Code ID 1 923 S


UM09 Release of Information

Code

ID 1 1363 S


UM10 Delay Reason Code ID 1/2 1514 S Required if the request is not

submitted within the normal

timeframe of the UMO

Segment End B 1 ~

2000E REF Reference Identification ID 3 S REF



Qualifier

ID 2/3 128 R BB=Authorization Number


REF02 Reference Identification AN 1/50 127 R Required if UM02 segment under

2000E Health Care Services review

Information equals a 3, indicating

action on previous authorization

Segment End B 1 ~

2000E DTP Date or Time or Period ID 3 S DTP




Loop Segment

ID

Segment Name/ Data

Element Name


#

Req

Des.

Value

DTP01 Date/Time Qualifier ID 3 374 R 439 = Accident


DTP02 Date Time Period Format

Qualifier

ID 2/3 1250 R D8 = date expressed in format

CCYYMMDD


DTP03 Date Time Period AN 1/35 1251 R format = CCYYMMDD

Segment End B 1 ~



DTP01 Date/Time Qualifier ID 3 374 R 484 = Last Menstrual Period



Qualifier


CCYYMMDD



Segment End B 1 ~



DTP01 Date/Time Qualifier ID 3 374 R ABC = Estimated Date of Birth



Qualifier


CCYYMMDD



Segment End B 1 ~



DTP01 Date/Time Qualifier ID 3 374 R 431 = Onset of Current Symptoms

or Illness



Qualifier


CCYYMMDD




Loop Segment

ID

Segment Name/ Data

Element Name


#

Req

Des.

Value


Segment End B 1 ~



DTP01 Date/Time Qualifier ID 3 374 R AAH = Event



Qualifier


CCYYMMDD

RD8 = date expressed in format

CCYYMMDD-CCYYMMDD


DTP03 Date Time Period AN 1/35 1251 R format = CCYYMMDD if DTP02 =

D8

format = CCYYMMDD-CCYYMMDD

if DTP02 = RD8

Segment End B 1 ~



DTP01 Date/Time Qualifier ID 3 374 R 435 =Admission



Qualifier


CCYYMMDD


CCYYMMDD-CCYYMMDD


DTP03 Date Time Period AN 1/35 1251 R format = CCYYMMDD if DTP02 =

D8

format = CCYYMMDD-CCYYMMDD

if DTP02 = RD8

Segment End B 1 ~



DTP01 Date/Time Qualifier ID 3 374 R 096 = Discharge




Loop Segment

ID

Segment Name/ Data

Element Name


#

Req

Des.

Value


Qualifier


CCYYMMDD



Segment End B 1 ~

2000E HI Health Care Information

Codes

ID 2 S HI


HI01 Health Care Code

Information – Alias

Diagnosis 1

ID 4 C022 S

HI01-1 Code List Qualifier Code ID 1/3 1270 R BK (ICD-9) – Principal Diagnosis

ABK (ICD-10) – Principal Diagnosis

BF (ICD-9) - Diagnosis

ABF (ICD-10) - Diagnosis

BJ (ICD-9) – Admitting Diagnosis

ABJ (ICD-10) – Admitting

Diagnosis

Component Element

Separator

1 :

HI01-2 Industry Code AN 1/30 1271 R Diagnosis Code

Component Element

Separator

1 :

HI01-3 Date Time Period Format

Qualifier

ID 2/3 1250 S D8 = date expressed in format

CCYYMMDD

Component Element

Separator

1 :

HI01-4 Date Time Period AN 1/35 1251 S Diagnosis Date. Format date

CCYYMMDD




Loop Segment

ID

Segment Name/ Data

Element Name


#

Req

Des.

Value



Diagnosis 2

ID 4 C022 S

HI02-1 Code List Qualifier Code ID 1/3 1270 R BF (ICD-9) - Diagnosis


BJ (ICD-9) – Admitting Diagnosis


Diagnosis

Component Element

Separator

1 :


Component Element

Separator

1 :


Qualifier


CCYYMMDD

Component Element

Separator

1 :


CCYYMMDD




Diagnosis 3

ID 4 C022 S



Component Element

Separator

1 :


Component Element

Separator

1 :


Qualifier


CCYYMMDD



Loop Segment

ID

Segment Name/ Data

Element Name


#

Req

Des.

Value

Component Element

Separator

1 :


CCYYMMDD


Note: Can be up to 10 HI0x-1 thru

HI0x-4 BF/ABF (Other Diagnosis

Code) elements separated by *

Segment End B 1 ~

2000E HSD Health Care Delivery

Services

ID 3 S HSD


HSD01 Quantity Qualifier ID 2 673 S


HSD02 Quantity R 1/15 380 S


HSD03 Unit or Basis for

Measurement Code

ID 2 355 S


HSD04 Sample Selection Modulus R 1/6 1167 S


HSD05 Time Period Qualifier ID 1/2 615 S


HSD06 Number of Periods N0 1/3 616 S


HSD07 Ship/Delivery or Calendar

Pattern Code

ID 1/2 678 S


HSD08 Ship/Delivery Pattern

Time Code

ID 1 679 S

Segment End B 1 ~

2000E CRC Conditions Indicator ID 3 S CRC


CRC01 Code Category ID 2 1136 R 07 = Ambulance Certification



Loop Segment

ID

Segment Name/ Data

Element Name


#

Req

Des.

Value


CRC02 Yes/No Condition or

Response Code

ID 1 1073 R


CRC03 Condition Indicator ID 2/3 1321 R


CRC04 Condition Indicator ID 2/3 1321 S







Segment End B 1 ~



CRC01 Code Category ID 2 1136 R 08 = Chiropractic Certification



Response Code

ID 1 1073 R











Segment End B 1 ~





Loop Segment

ID

Segment Name/ Data

Element Name


#

Req

Des.

Value

CRC01 Code Category ID 2 1136 R 09 = Durable Medical Equipment

Certification



Response Code

ID 1 1073 R











Segment End B 1 ~



CRC01 Code Category ID 2 1136 R 11 = Oxygen Therapy Certification



Response Code

ID 1 1073 R











Segment End B 1 ~



Loop Segment

ID

Segment Name/ Data

Element Name


#

Req

Des.

Value



CRC01 Code Category ID 2 1136 R 75 = Functional Limitations



Response Code

ID 1 1073 R











Segment End B 1 ~



CRC01 Code Category ID 2 1136 R 76 = Activities Permitted



Response Code

ID 1 1073 R













Loop Segment

ID

Segment Name/ Data

Element Name


#

Req

Des.

Value

Segment End B 1 ~



CRC01 Code Category ID 2 1136 R 77 = Mental Status



Response Code

ID 1 1073 R











Segment End B 1 ~

2000E CL1 Claim Codes ID 3 S CL1 Required when UM01 = AR


CL101 Admission Type Code ID 1 1315 S


CL102 Admission Source Code R 1 1314 S


CL103 Patient Status Code ID ½ 1352 S


CL104 Nursing Home Residential

Status Code

ID 1 1345 S

Segment End B 1 ~

2000E CR1 Ambulance Certification ID 3 S CR1

Note: Loop 2010EB is

required when 2000E/CR1

is used



Loop Segment

ID

Segment Name/ Data

Element Name


#

Req

Des.

Value


CR101 Unit or Basis for

Measurement Code

ID 2 355 S


CR102 Weight R 1/10 81 S


CR103 Ambulance Transport

Code

ID 1 1316 R



Reason Code

ID 1 1317 R



Measurement Code

ID 2 355 S


CR106 Quantity R 1/15 380 S




CR109 Description AN 1/80 352 S Required if needed when CR103 =

X. Otherwise Not Used.


CR110 Description AN 1/80 352 S

Segment End B 1 ~

2000E CR2 Chiropractic Certification ID 3 S CR2


CR201 Count N0 1/9 609 S




CR203 Subluxation Level Code ID 2/3 1367 S





Loop Segment

ID

Segment Name/ Data

Element Name


#

Req

Des.

Value





CR208 Nature of Condition Code ID 1 1342 R


CR209 Yes/No Condition or

Response Code

ID 1 1073 R





Note: CR211 should not

be used when element

CR210 is not used



Response Code

ID 1 1073 R

Segment End B 1 ~

2000E CR6 Home Health Care

Certification

ID 3 S CR6


CR601 Prognosis Code ID 1 923 R


CR602 Date DT 8 373 R format CCYYMMDD


CR603 Date Time Period Format

Qualifier

ID 2/3 1250 S RD8


CR604 Date Time Period AN 1/35 1251 S format CCYYMMDD-CCYYMMDD






Loop Segment

ID

Segment Name/ Data

Element Name


#

Req

Des.

Value


Response Code

ID 1 1073 R W


CR608 Certification Type Code ID 1 1322 R


CR609 Date DT 8 373 S


CR610 Product/Service ID

Qualifier

ID 2 235 S


CR611 Medical Code Value AN 1/15 1137 S









Qualifier

ID 2/3 1250 S RD8 Required if the patient had a

recent inpatient stay



Required if the patient had a recent

inpatient stay


CR617 Patient Location Code ID 1 1384 S Required if the patient had a recent

inpatient stay

Segment End B 1 ~

2010EA NM1 Individual or

Organizational Name

ID 3 R NM1


NM101 Entity Identifier Code ID 2/3 98 R


NM102 Entity Type Qualifier ID 1 1065 R 1=Person, 2=Non-Person Entity



Loop Segment

ID

Segment Name/ Data

Element Name


#

Req

Des.

Value


NM103 Name Last or

Organization Name

AN 1/60 1035 S


NM104 Name First AN 1/35 1036 S Required if NM102=1 & NM103 is

present


NM105 Name Middle AN 1/25 1037 S Only used if NM102=1







Qualifier

ID 1/2 66 S 24=Employer’s Identification

Number (for atypical providers

only)



NM109 Identification Code AN 2/80 67 S Enter NPI or if provider is atypical

enter Employer Identification

Number

Segment End B 1 ~

2010EA REF Reference Information ID 3 S REF



Qualifier

ID 2/3 128 R N5 = Provider Plan Network

Identifier


REF02 Reference Identification AN 1/50 127 R Used for atypical providers only, to

enter their assigned Provider ID

Segment End B 1 ~

2010EB NM1 Individual or

Organizational Name

ID 3 R NM1





Loop Segment

ID

Segment Name/ Data

Element Name


#

Req

Des.

Value


NM102 Entity Type Qualifier ID 1 1065 R 2 = Non-Person Entity


NM103 Name Last or

Organization Name

AN 1/60 1035 S

Segment End B 1 ~

2010EC NM1 Individual or

Organizational Name

ID 3 R NM1




NM102 Entity Type Qualifier ID 1 1065 R 2 = Non-Person Entity


NM103 Name Last or

Organization Name

AN 1/60 1035 S

Segment End B 1 ~

2010EC REF Reference Information ID 3 S REF



Qualifier

ID 2/3 128 R ZZ – Mutually Defined


REF02 Reference Identification AN 1/50 127 R



REF04 Reference Identifier O C040 S

REF04-1 Reference Identification

Qualifier

ID 2/3 128 R ZZ – Mutually Defined

Element Separator AN 1 :

REF04-2 Reference Identification AN 1/50 127 R



Qualifier

ID 2/3 128 S ZZ – Mutually Defined




Loop Segment

ID

Segment Name/ Data

Element Name


#

Req

Des.

Value

REF04-4 Reference Identification AN 1/50 127 S



Qualifier

ID 2/3 128 S ZZ – Mutually Defined


REF04-6 Reference Identification AN 1/50 127 S

Segment End B 1 ~

2000EC DTP Date or Time or Period ID 3 R DTP


DTP01 Date/Time Qualifier ID 3 374 R 598 = Rejected



Qualifier

ID 2/3 1250 R D8



Segment End B 1 ~

Service (Loop 2000F)

2000F HL Hierarchical Level

Segment

ID 2 R HL





Number

AN 1/12 734 R 4


HL03 Hierarchical Level Code ID 1/2 735 R SS


HL04 Hierarchical Child Code ID 1/1 736 R 0

Segment End B 1 ~

2000F DTP Date or Time or Period ID 3 S DTP required if SV2 is used


DTP01 Date/Time Qualifier ID 3 374 R 472 – Service




Loop Segment

ID

Segment Name/ Data

Element Name


#

Req

Des.

Value

DTP02 Date Time Period Qualifier ID 2/3 1250 R D8 – Date Format CCYYMMDD

RD8 – Date Format CCYYMMDD-

CCYYMMDD


DTP03 Date Time Period AN 1/35 1251 R CCYYMMDD if DTP02 = D8

CCYYMMDD-CCYYMMDD if DTP02 =

RD8

Segment End B 1 ~

2000F SV1 Professional Service ID 3 S SV1


SV101 Composite Medical

Procedure Identifier

C003 R

SV101-1 Product/Service ID

Qualifier

ID 2 235 R HC = HCPCS Code


SV101-2 Product/Service ID AN 1/48 234 R


SV101-3 Procedure Modifier AN 2 1339 S








SV101-7 Description AN 1/80 352 S


SV101-8 Product/Service ID AN 1/48 234 S


SV102 Monetary Amount R 1/18 782 S


SV103 Unit or Basis for

Measurement Code

ID 2 355 S UN = Unit




Loop Segment

ID

Segment Name/ Data

Element Name


#

Req

Des.

Value

SV104 Quantity R 1/15 380 S




SV107 Composite Diagnosis

Code Pointer

C004 S

SV107-1 Diagnosis Code Pointer N0 1/2 1328 R


SV107-2 Diagnosis Code Pointer N0 1/2 1328 S









SV111 Yes/No Condition or

Response Code

ID 1 1073 S N = No

Y = Yes










SV120 Level of Care Code ID 1 1337 S

Segment End B 1 ~

2000F SV2 Institutional Service ID 3 S SV2


SV201 Product/Service ID AN 1/48 234 S



Loop Segment

ID

Segment Name/ Data

Element Name


#

Req

Des.

Value




C003 S


Qualifier




















Measurement Code

ID 2 355 S DA =Days

UN = Unit




SV206 Unit Rate R 1/10 1371 S




SV209 Nursing Home Residential

Status Code

ID 1 1345 S



Loop Segment

ID

Segment Name/ Data

Element Name


#

Req

Des.

Value



Segment End B 1 ~

2000F SV3 Dental Service ID 3 S SV3




C003 R


Qualifier

ID 2 235 R AD = American Dental Association

Codes



















SV304 Oral Cavity Designation C006 S


SV304-1 Oral Cavity Designation

Code

ID 1/3 1361 R




Loop Segment

ID

Segment Name/ Data

Element Name


#

Req

Des.

Value


Code

ID 1/3 1361 S



Code

ID 1/3 1361 S



Code

ID 1/3 1361 S



Code

ID 1/3 1361 S


SV305 Prosthesis, Crown or Inlay

Code

ID 1 1358 S I = Initial Placement

R = Replacement


SV306 Quantity R 1/15 380 R


SV307 Description AN 1/80 352 S

Segment End B 1 ~

2000F TOO Tooth Identification ID 3 S TOO


TOO01 Code List Qualifier Code ID 1/3 1270 R JP = Universal National Tooth

Designation System


TOO02 Industry Code AN 1/30 1271 R


TOO03 Tooth Surface C005 S

TOO03-1 Tooth Surface Code ID 1/2 1369 R


TOO03-2 Tooth Surface Code ID ½ 1369 S


TOO03-3 Tooth Surface Code ID 1/2 1369 S




Loop Segment

ID

Segment Name/ Data

Element Name


#

Req

Des.

Value




Segment End B 1 ~

Transaction Set Trailer

TRAILER SE Transaction Set Trailer ID 2 R SE


SE01 Number of Included

Segments

N0 1/10 96 R


SE02 Transaction Set Control

Number

AN 4/9 329 R SE02 must be identical to ST02

Segment End B 1 ~

Functional Group Trailer

GE Functional Group Trailer ID 2 R GE


GE01 Number of Transaction

Sets Included

N0 1/6 97 R


GE02 Group Control Number N0 1/9 28 R GE02 must be identical to GS06

Segment End B 1 ~

Interchange Control Trailer

IEA Interchange Control

Trailer

ID 3 R IEA


IEA01 Number of Included

Functional Groups

N0 1/5 I16 R


IEA02 Interchange Control

Number

N0 9 I12 R Must be identical to the value in

ISA13

Segment End B 1 ~



2.1. 278 Response

Figure 2-2: 278 Response

Loop Segment

ID

Segment Name/ Data

Element Name Format Length

DE

Ref

#

Req

Des. Value

Interchange Control Record

HEADER ISA Interchange Control

Header

3 R ISA


ISA01 Authorization Information

Qualifier

ID 2 I01 R 00


ISA02 Authorization Information AN 10 I02 R


ISA03 Security Information

Qualifier

ID 2 I03 R 00


ISA04 Security Information AN 10 I04 R


ISA05 Interchange ID Qualifier ID 2 I05 R ZZ=Mutually Defined


ISA06 Interchange Sender ID AN 15 I06 R ID_MMIS_4_DXCMS


ISA07 Interchange ID Qualifier ID 2 I05 R ZZ=Mutually Defined


ISA08 Interchange Receiver ID AN 15 I07 R DXCMS assigned trading partner

ID


ISA09 Interchange Date DT 6 I08 R YYMMDD


ISA10 Interchange Time TM 4 I09 R HHMM


ISA11 Repetition Separator 1 I65 R ^




Loop Segment

ID

Segment Name/ Data


DE

Ref

#

Req

Des. Value

ISA12 Interchange Version

Number

ID 5 I11 R 00501


ISA13 Interchange Control

Number

N0 9 I12 R


ISA14 Acknowledgment

Requested

ID 1 I13 R 0=No Acknowledgment

Requested


ISA15 Interchange Usage

Indicator

ID 1 I14 R P


ISA16 Component Element

Separator

1 I15 R :

Segment End B 1 ~

Functional Group Header

GS Functional Group Header 2 R GS


GS01 Functional Identifier Code ID 2 479 R HI


GS02 Application Sender's Code AN 2/15 142 R ID_MMIS_4_DXCMS


GS03 Application Receiver's

Code

AN 2/15 124 R DXCMS Assigned trading Partner

ID


GS04 Date DT 8 373 R CCYYMMDD


GS05 Time TM 4/8 337 R HHMM


GS06 Group Control Number N0 1/9 28 R Assigned by Sender


GS07 Responsible Agency Code ID 1/2 455 R X



Loop Segment

ID

Segment Name/ Data


DE

Ref

#

Req

Des. Value


GS08 Version / Release Code AN 1/12 480 R 005010X217

Segment End B 1 ~

Transaction Set Header

ST Transaction Set Header 2 R ST


ST01 Transaction Set Identifier

Code

ID 3 143 R 278


ST02 Transaction Set Control

Number

AN 4/9 329 R Sequential number assigned by

sender


ST03 Implementation

Convention Reference

AN 1/35 1705 R 005010X217

Segment End B 1 ~

Beginning of Hierarchical Transaction

BHT Beginning Hierarchical

Transaction Segment

ID 3 R BHT


BHT01 Hierarchical Structure

Code

ID 4 1005 R 0078


BHT02 Transaction Set Purpose

Code

ID 2 353 R 11


BHT03 Reference identification AN 1/30 127 R Submitter Transaction

Identifier. Value from the

original 278 request.


BHT04 Date DT 8 373 R CCYYMMDD

Transaction Set Creation Date


BHT05 Time TM 4/8 337 R HHMM



Loop Segment

ID

Segment Name/ Data


DE

Ref

#

Req

Des. Value

Transaction Set Creation Time


BHT06 Transaction Type Code ID 2/2 640 S 18 = No further updates to

follow

19 = Further updates to follow

Segment End B 1 ~

UMO (Loop 2000A)

2000A HL Hierarchical Level

Segment

ID 2 R HL





HL03 Hierarchical Level Code ID 1/2 735 R 20 = Information Source



Segment End B 1 ~

2010A NM1 Individual or

Organizational Name

ID 3 R NM1


NM101 Entity Identifier Code ID 2/3 98 R X3 = UMO


NM102 Entity Type Qualifier ID 1/1 1065 R 2


NM103 Name Last or

Organization Name

AN 1/35 1035 R IDAHO MEDICAID




NM105 Name Middle AN 1/25






Loop Segment

ID

Segment Name/ Data


DE

Ref

#

Req

Des. Value



Qualifier

ID 1/2 66 R PI – Payor Identification


NM109 Identification Code AN 2/80 67 R ID_MMIS_4MOLINA

Segment End B 1 ~

Requester (Loop 2000B)

2000B HL Hierarchical Level

Segment

ID 2 R HL





Number

AN 1/12 734 R 1


HL03 Hierarchical Level Code ID 1/2 735 R 21=Information Receiver



Segment End B 1 ~

2010B NM1 Individual or

Organizational Name

ID 3 R NM1 - segment populated from

Request


NM101 Entity Identifier Code ID 2/3 98 R 1P=Provider, FA=Facility




NM103 Name Last or

Organization Name

AN 1/60 1035 S






Loop Segment

ID

Segment Name/ Data


DE

Ref

#

Req

Des. Value

NM105 Name Middle AN 1/25 1037 S Use if NM104 is present and the

middle name/initial of the

person is known.






Qualifier

ID 1/2 66 R 24=Employer’s Identification

Number

XX = NPI


NM109 Identification Code AN 2/80 67 R NPI or if provider is atypical,

use EIN

Segment End B 1 ~

2010B REF Reference Identification ID 3 S REF - segment populated from

Request



Qualifier

ID 2/3 128 R N5


REF02 Reference Identification AN 1/50 127 R Medicaid assigned provider ID

for the Requesting Provider –

for Atypical providers only

Segment End B 1 ~

2010CA AAA Subscriber Request

Validation

ID 3 S AAA


AAA01 Yes/No Condition or

Response Code

ID 1 1073 R N = No



AAA03 Reject Reason Code ID 2 901 R




Loop Segment

ID

Segment Name/ Data


DE

Ref

#

Req

Des. Value

AAA04 Follow-up Action Code ID 1 889 R

Segment End B 1 ~

Subscriber (Loop 2000C)

2000C HL Hierarchical Level

Segment

ID 2 R HL





Number

AN 1/12 734 R 2


HL03 Hierarchical Level Code ID 1/2 735 R 22 = Subscriber



Segment End B 1 ~

2010C NM1 Individual or

Organizational Name

ID 3 R NM1 - populated from Request




NM102 Entity Type Qualifier ID 1 1065 R


NM103 Name Last or

Organization Name

AN 1/50 1035 S











Loop Segment

ID

Segment Name/ Data


DE

Ref

#

Req

Des. Value



Qualifier

ID 1/2 66 R


NM109 Identification Code AN 2/80 67 R

Segment End B 1 ~

2010C AAA Subscriber Request

Validation

ID 3 S AAA



Response Code

ID 1 1073 R N = No






Segment End B 1 ~

2010C DMG Demographic Information ID 3 S DMG


DMG01 Date Time Period Format

Qualifier

ID 2/3 1250 R D8


DMG02 Date Time Period AN 1/35 1251 R


DMG03 Gender Code ID 1 1068 S

Segment End B 1 ~

2000E HL Hierarchical Level

Segment

ID 2 R HL - populated from Request





Number

AN 1/12 734 R 4



Loop Segment

ID

Segment Name/ Data


DE

Ref

#

Req

Des. Value


HL03 Hierarchical Level Code ID 1/2 735 R EV = Event



Segment End B 1 ~

2000E TRN Patient Event Tracking

Number Segment

ID 3 S TRN


TRN01 Trace Type Code ID 1/2 481 R 1


TRN02 Reference Identification AN 1/50 127 R


TRN03 Originating Company

Identifier

AN 10 509 R


TRN04 Reference Identification AN 1/50 127 S

Segment End B 1 ~

2000E AAA Subscriber Request

Validation

ID 3 S AAA



Response Code

ID 1 1073 R N = No






Segment End B 1 ~

2000E UM Health Care Services

Review Information

ID 2 R UM


UM01 Request Category Code ID 1/2 1525 R AR = Admission Review

HS = Health Services Review



Loop Segment

ID

Segment Name/ Data


DE

Ref

#

Req

Des. Value


UM02 Certification Type Code ID 1/1 1322 R I = Initial

3 = Cancel

4 = Extension


UM03 Service Type Code ID 1/2 1365 R For Prior Authorizations, see

UM03 Service Type PA

Crosswalk in this guide


UM04 Health Care Service

Location Information

ID C023 S

UM04-1 Facility Code Value AN 1/2 1331 R

Component Element

Separator

1 :

UM04-2 Facility Code Qualifier ID 1/2 1332 R



UM06 Level of Service Code ID 1/3 1338 S

Segment End B 1 ~

2000E HCR Health Care Services

Review

ID 3 S HCR


HCR01 Action Code ID 1/2 306 R


HCR02 Reference Identification AN 1/50 127 S


HCR03 Industry Code AN 1/30 1271 S


HCR04 Yes/No Condition or

Response Code

ID 1 1073 S

Element Separator AN 1 ~

2000E REF Reference Identification ID 3 S REF




Loop Segment

ID

Segment Name/ Data


DE

Ref

#

Req

Des. Value


Qualifier

ID 2/3 128 R BB = Authorization Number


REF02 Reference Identification AN 1/50 127 R




DTP01 Date/Time Qualifier ID 3 374 R 439 = Accident



Qualifier


CCYYMMDD



Segment End B 1 ~



DTP01 Date/Time Qualifier ID 3 374 R 484 = Last Menstrual Period



Qualifier


CCYYMMDD



Segment End B 1 ~



DTP01 Date/Time Qualifier ID 3 374 R ABC = Estimated Date of Birth



Qualifier


CCYYMMDD



Segment End B 1 ~



Loop Segment

ID

Segment Name/ Data


DE

Ref

#

Req

Des. Value



DTP01 Date/Time Qualifier ID 3 374 R 431 = Onset of Current

Symptoms or Illness



Qualifier


CCYYMMDD



Segment End B 1 ~



DTP01 Date/Time Qualifier ID 3 374 R AAH = Event



Qualifier


CCYYMMDD


CCYYMMDD-CCYYMMDD


DTP03 Date Time Period AN 1/35 1251 R format = CCYYMMDD if DTP02

= D8

format = CCYYMMDD-

CCYYMMDD if DTP02 = RD8

Segment End B 1 ~



DTP01 Date/Time Qualifier ID 3 374 R 435 =Admission



Qualifier


CCYYMMDD


CCYYMMDD-CCYYMMDD




Loop Segment

ID

Segment Name/ Data


DE

Ref

#

Req

Des. Value

DTP03 Date Time Period AN 1/35 1251 R format = CCYYMMDD if DTP02

= D8

format = CCYYMMDD-

CCYYMMDD if DTP02 = RD8

Segment End B 1 ~



DTP01 Date/Time Qualifier ID 3 374 R 096 = Discharge



Qualifier


CCYYMMDD



Segment End B 1 ~

2000E HI Health Care Information

Codes

ID 2 S HI




Diagnosis 1

ID 4 C022 S

HI01-1 Code List Qualifier Code ID 1/3 1270 R BK (ICD-9) – Principal Diagnosis

ABK (ICD-10) – Principal

Diagnosis

BF (ICD-9) - Diagnosis


BJ (ICD-9) –Admitting Diagnosis


Diagnosis

Component Element

Separator

1 :




Loop Segment

ID

Segment Name/ Data


DE

Ref

#

Req

Des. Value

Component Element

Separator

1 :


Qualifier


CCYYMMDD

Component Element

Separator

1 :


CCYYMMDD




Diagnosis 2

ID 4 C022 S



BJ (ICD-9) –Admitting Diagnosis


Diagnosis

Component Element

Separator

1 :


Component Element

Separator

1 :


Qualifier


CCYYMMDD

Component Element

Separator

1 :


CCYYMMDD




Diagnosis 3

ID 4 C022 S



Loop Segment

ID

Segment Name/ Data


DE

Ref

#

Req

Des. Value



Component Element

Separator

1 :


Component Element

Separator

1 :


Qualifier


CCYYMMDD

Component Element

Separator

1 :


CCYYMMDD

Note: Can be up to 10 HI0x-1

thru HI0x-4 BF/ABF (Other

Diagnosis Code) elements

separated by *

Segment End B 1 ~

2000E HSD Health Care Delivery

Services

ID 3 S HSD


HSD01 Quantity Qualifier ID 2 673 S


HSD02 Quantity R 1/15 380 S


HSD03 Unit or Basis for

Measurement Code

ID 2 355 S


HSD04 Sample Selection Modulus R 1/6 1167 S


HSD05 Time Period Qualifier ID 1/2 615 S


HSD06 Number of Periods N0 1/3 616 S



Loop Segment

ID

Segment Name/ Data


DE

Ref

#

Req

Des. Value


HSD07 Ship/Delivery or Calendar

Pattern Code

ID 1/2 678 S


HSD08 Ship/Delivery Pattern

Time Code

ID 1 679 S

Segment End B 1 ~

2000E CL1 Claim Codes ID 3 S CL1


CL101 Admission Type Code ID 1 1315 S


CL102 Admission Source Code R 1 1314 S


CL103 Patient Status Code ID ½ 1352 S


CL104 Nursing Home Residential

Status Code

ID 1 1345 S

Segment End B 1 ~

2000E CR1 Ambulance Certification ID 3 S CR1





Code

ID 1 1316 R



Reason Code

ID 1 1317 R



Measurement Code

ID 2 355 S



Segment End B 1 ~



Loop Segment

ID

Segment Name/ Data


DE

Ref

#

Req

Des. Value

2000E CR2 Chiropractic Certification ID 3 S CR2


CR201 Count N0 1/9 609 S








2000E CR6 Home Health Care

Certification

ID 3 S CR6


CR601 Prognosis Code ID 1 923 R


CR602 Date DT 8 373 R format CCYYMMDD



Qualifier

ID 2/3 1250 S RD8







Response Code

ID 1 1073 R W


CR608 Certification Type Code ID 1 1322 R


2010EA NM1 Individual or

Organizational Name

ID 3 R NM1




Loop Segment

ID

Segment Name/ Data


DE

Ref

#

Req

Des. Value





NM103 Name Last or

Organization Name

AN 1/60 1035 S


NM104 Name First AN 1/35 1036 S Required if NM102=1 & NM103

is present


NM105 Name Middle AN 1/25 1037 S Only used if NM102=1







Qualifier



only)



NM109 Identification Code AN 2/80 67 S Enter NPI or if provider is

atypical enter Employer

Identification Number

Segment End B 1 ~

2010EA REF Reference Information ID 3 S REF



Qualifier

ID 2/3 128 R N5 = Provider Plan Network

Identifier


REF02 Reference Identification AN 1/50 127 R Used for atypical providers only,

to enter their assigned Provider

ID



Loop Segment

ID

Segment Name/ Data


DE

Ref

#

Req

Des. Value

Segment End B 1 ~

2010EA AAA Request Validation ID 3 S AAA



Response Code

ID 1 1073 R N = No






Segment End B 1 ~

2010EB NM1 Individual or

Organizational Name

ID 3 R NM1




NM102 Entity Type Qualifier ID 1 1065 R 1=Person

2=Non-Person Entity


NM103 Name Last or

Organization Name

AN 1/60 1035 S


NM104 Name First AN 1/35 1036 S Required if NM102=1 & NM103

is present


NM105 Name Middle AN 1/25 1037 S Only used if NM104 is valued

and middle name/initial is

known







Loop Segment

ID

Segment Name/ Data


DE

Ref

#

Req

Des. Value


Qualifier



only)



NM109 Identification Code AN 2/80 67 S Enter NPI or if provider is

atypical enter Employer

Identification Number

Segment End B 1 ~

2010EC NM1 Individual or

Organizational Name

ID 3 R NM1




NM102 Entity Type Qualifier ID 1 1065 R 2=Non-Person Entity


NM103 Name Last or

Organization Name

AN 1/60 1035 S

Segment End B 1 ~

2010EC AAA Request Validation ID 3 S AAA



Response Code

ID 1 1073 R N = No






Segment End B 1 ~

Service (Loop 2000F)

2000F HL Hierarchical Level

Segment

ID 2 R HL - populated from Request




Loop Segment

ID

Segment Name/ Data


DE

Ref

#

Req

Des. Value




Number

AN 1/12 734 R 5


HL03 Hierarchical Level Code ID 1/2 735 R SS=Services



Segment End B 1 ~

2000F AAA Service Request

Validation

ID 3 S AAA



Response Code

ID 1/1 1073 R N = No






Segment End B 1 ~

2000F HCR Health Care Services

Review

ID 3 S HCR


HCR01 Action Code ID 1/2 306 R


HCR02 Reference Identification AN 1/50 127 S


HCR03 Industry Code AN 1/30 1271 S


HCR04 Yes/No Condition or

Response Code

ID 1 1073 S


2000F DTP Date or Time or Period ID 3 S DTP - populated from Request



Loop Segment

ID

Segment Name/ Data


DE

Ref

#

Req

Des. Value


DTP01 Date/Time Qualifier ID 3 374 R 472 - Service



Qualifier

ID 2/3 1250 R D8 - CCYYMMDD

RD8 - CCYYMMDD-CCYYMMDD



CCYYMMDD-CCYYMMDD if

DTP02 = RD8

Segment End B 1 ~

2000F DTP Date or Time or Period ID 3 S DTP


DTP01 Date/Time Qualifier ID 3 374 R 102 - Issue



Qualifier



DTP03 Date Time Period AN 1/35 1251 R

Segment End B 1 ~



DTP01 Date/Time Qualifier ID 3 374 R 036 - Expiration



Qualifier



DTP03 Date Time Period AN 1/35 1251 R

Segment End B 1 ~



DTP01 Date/Time Qualifier ID 3 374 R 007 - Effective




Loop Segment

ID

Segment Name/ Data


DE

Ref

#

Req

Des. Value


Qualifier


RD8 – CCYYMMDD-CCYYMMDD



CCYYMMDD-CCYYMMDD if

DTP02 = RD8

Segment End B 1 ~

2000F SV1 Professional Service ID 3 S SV1




C003 R


Qualifier




















Measurement Code

ID 2 355 S UN = Unit




Loop Segment

ID

Segment Name/ Data


DE

Ref

#

Req

Des. Value









SV111 Yes/No Condition or

Response Code

ID 1 1073 S N = No

Y = Yes











Segment End B 1 ~

2000F SV2 Institutional Service ID 3 S SV2


SV201 Product/Service ID AN 1/48 234 S




C003 S


Qualifier







Loop Segment

ID

Segment Name/ Data


DE

Ref

#

Req

Des. Value
















Measurement Code

ID 2 355 S DA =Days

UN = Unit




SV206 Unit Rate R 1/10 1371 S






Segment End B 1 ~

2000F SV3 Dental Service ID 3 S SV3




C003 R


Qualifier

ID 2 235 R AD = American Dental

Association Codes



Loop Segment

ID

Segment Name/ Data


DE

Ref

#

Req

Des. Value



















SV304 Oral Cavity Designation C006 S



Code

ID 1/3 1361 R



Code

ID 1/3 1361 S



Code

ID 1/3 1361 S



Code

ID 1/3 1361 S




Loop Segment

ID

Segment Name/ Data


DE

Ref

#

Req

Des. Value


Code

ID 1/3 1361 S


SV305 Prosthesis, Crown or Inlay

Code

ID 1 1358 S I = Initial Placement

R = Replacement


SV306 Quantity R 1/15 380 R


SV307 Description AN 1/80 352 S


2000F TOO Tooth Identification ID 3 S TOO


TOO01 Code List Qualifier Code ID 1/3 1270 R JP = Universal National Tooth

Designation System


TOO02 Industry Code AN 1/30 1271 R


TOO03 Tooth Surface C005 S

TOO03-1 Tooth Surface Code ID 1/2 1369 R


TOO03-2 Tooth Surface Code ID ½ 1369 S







Segment End B 1 ~

Transaction Set Trailer

TRAILER SE Transaction Set Trailer ID 2 R SE

SE01 Number of Included

Segments

N0 1/10 96 R



Loop Segment

ID

Segment Name/ Data


DE

Ref

#

Req

Des. Value


SE02 Transaction Set Control

Number

AN 4/9 329 R must equal ST02 on transaction

header

Segment End B 1 ~

Functional Group Trailer

GE Functional Group Trailer ID 2 R GE

GE01 Number of Transaction

Sets Included

N0 1/6 97 R


GE02 Group Control Number N0 1/9 28 R

Segment End B 1 ~

Interchange Control Trailer

IEA Interchange Control

Trailer

ID 3 R IEA

IEA01 Number of Included

Functional Groups

N0 1/5 I16 R


IEA02 Interchange Control

Number

N0 9 I12 R

Segment End B 1 ~



Appendix A.

Please see Appendix_A_Vendor_Specs-5010.docx.

Date post:	20-Jul-2020
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Vendor Specifications 278 Healthcare Services Request for ... Companion Guides... · Segment End B...

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