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A (Interchange Control Header)
Page HIPAA Medicaid
Field HIPAA Guide Name # Usage Note MMIS Instruction
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NA (No Loop Name)
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ISA (Interchange Control Header)
ISA01 Authorization Information Qualifier C.4 R Y Use value 00
ISA02 Authorization Information C.4 R N
ISA03 Security Information Qualifier C.4 R Y Use value 00
ISA04 Security Information C.4 R N
ISA05 Interchange ID Qualifier C.4 R Y Use ZZ for VT MEDICAID.
ISA06 Interchange Sender ID C.4 R Y Use the VT MEDICAID assigned trading partner ID.
ISA07 Interchange ID Qualifier C.5 R Y Use ZZ for VT MEDICAID..
ISA08 Interchange Receiver ID C.5 R Y Use 822287119, the VT MEDICAID EIN
ISA09 Interchange Date C.5 R N
ISA10 Interchange Time C.5 R N
ISA11 Repetition Separator C.5 R N
ISA12 Interchange Control Version C.5 R N Number
ISA13 Interchange Control Number C.5 R N
ISA14 Acknowledgment Requested C.6 R N
ISA15 Interchange Usage Indicator C.6 R N
ISA16 Component Element Separator C.6 R N
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NA (No Loop Name)
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GS (Functional Group Header)
GS01 Functional Identifier Code C.7 R N
GS02 Application Sender's Code C.7 R Y
GS03 Application Receiver's Code C.7 R Y
Use the Trading Partner ID assigned by VT
MEDICAID.
Use 822287119 - the VT MEDICAID EIN
GS04 Date C.7 R N
GS05 Time C.8 R N
GS06 Group Control Number C.8 R N
GS07 Responsible Agency Code C.8 R N
GS08 Version / Release / Industry C.8 R Y Use 00501X224A2 Identifier Code
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NA (No Loop Name)
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ST (Transaction Set Header)
ST01 Transaction Set Identifier Code 65 R N
ST02 Transaction Set Control Number 65 R N
ST03 Implementation Convention 65 R N Use 00501X224A2 Reference
BHT (Beginning of Hierarchical Transaction)
BHT01 Hierarchical Structure Code 66 R N
BHT02 Transaction Set Purpose Code 66 R N
BHT03 Reference Identification 67 R N
BHT04 Date 67 R N
BHT05 Time 67 R N
BHT06 Transaction Type Code 67 R Y VT MEDICAID will only process charge transactions (CH).
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1000A (Submitter Name)
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NM1 (Submitter Name)
NM101 Entity Identifier Code 69 R N
NM102 Entity Type Qualifier 70 R N
NM103 Name Last or Organization 70 R N Name
NM104 Name First 70 S N
NM105 Name Middle 70 S N
NM108 Identification Code Qualifier 70 R N
NM109 Identification Code 70 R Y Enter the 3 byte Submitter Identifier as assigned by VT MEDICAID.
PER (Submitter EDI Contact Information)
PER01 Contact Function Code 72 R Y VT MEDICAID will only capture the information in the first PER segment.
PER02 Name 72 S N
PER03 Communication Number Qualifier 72 R Y VT MEDICAID will utilize TE, EM or FX
PER04 Communication Number 72 R N
PER05 Communication Number Qualifier 72 S Y VT MEDICAID will utilize TE, EX, EM or FX
PER06 Communication Number 73 S N
PER07 Communication Number Qualifier 73 S Y VT MEDICAID will utilize TE, EX, EM or FX
PER08 Communication Number 73 S N
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1000B (Receiver Name)
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NM1 (Receiver Name)
NM101 Entity Identifier Code 74 R N
NM102 Entity Type Qualifier 74 R N
NM103 Name Last or Organization 75 R Y Use "VT MEDICAID" Name
NM108 Identification Code Qualifier 75 R N
NM109 Receiver Primary Identifier 75 R Y Use 822287119 - the VT MEDICAID EIN
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2000A (Billing Provider Hierarchical Level)
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HL (Billing Provider Hierarchical Level)
HL01 Hierarchical ID Number 76 R N
HL03 Hierarchical Level Code 76 R N
HL04 Hierarchical Child Code 77 R N
PRV (Billing Provider Specialty Information)
PRV01 Provider Code 78 R N
PRV02 Reference Identification Qualifier 78 R N
PRV03 Reference Identification 78 R Y The Taxonomy code is required for VT Medicaid
CUR (Foreign Currency Information)
CUR01 Entity Identifier Code 80 R X
CUR02 Currency Code 80 R X
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2010AA (Billing Provider Name)
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NM1 (Billing Provider Name)
NM101 Entity Identifier Code 83 R N
NM102 Entity Type Qualifier 83 R N
NM103 Name Last or Organization 83 R N Name
NM104 Name First 83 S N
NM105 Name Middle 84 S N
NM107 Name Suffix 84 S N
NM108 Identification Code Qualifier 84 S Y Use XX if sending the NPI in NM109
NM109 Identification Code 85 S Y Enter the 10-digit NPI if XX was entered in NM108
N3 (Billing Provider Address)
N301 Address Information 86 R N
N302 Address Information 86 S N
N4 (Billing Provider City, State, ZIP Code)
N401 City Name 87 R N
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N402 State or Province Code 88 S N
N403 Postal Code 88 S N
N404 Country Code 88 S N
N407 Country Subdivision Code 88 S N
REF (Billing Provider Tax Identification)
REF01 Reference Identification Qualifier 89 R N
REF02 Reference Identification 89 R N
REF (Billing Provider UPIN/License Information)
REF01 Reference Identification Qualifier 91 R N
REF02 Reference Identification 92 R N
PER (Billing Provider Contact Information)
PER01 Contact Function Code 94 R N
PER02 Name 94 S N
PER03 Communication Number Qualifier 94 R N
PER04 Communication Number 94 R N
PER05 Communication Number Qualifier 94 S N
PER06 Communication Number 95 S N
PER07 Communication Number Qualifier 95 S N
PER08 Communication Number 95 S N
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2010AB (Pay-to Address Name)
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NM1 (Pay-to Address Name)
NM101 Entity Identifier Code 96 R X
NM102 Entity Type Qualifier 97 R X
N3 (Pay-to Address - Address)
N301 Address Information 98 R X
N302 Address Information 98 S X
N4 (Pay-to Provider City, State, Zip)
N401 City Name 99 R X
N402 State or Province Code 100 S X N
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N403 Postal Code 100 S X
N404 Country Code 100 S X
N407 Country Subdivision Code 100 S X
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2010AC (Pay-to Plan Name)
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NM1 (Pay-to Plan Name)
NM101 Entity Identifier Code 101 R X
NM102 Entity Type Qualifier 102 R X
NM103 Name Last or Organization 102 R X Name
NM108 Identification Code Qualifier 102 R X
NM109 Identification Code 102 R X
N3 (Pay-to Plan Address)
N301 Address Information 103 R X
N302 Address Information 103 S X
N4 (Pay-to Plan City, State, ZIP Code)
N401 City Name 104 R X
N402 State or Province Code 104 S X
N403 Postal Code 105 S X
N404 Country Code 105 S X
N407 Country Subdivision Code 105 S X
REF (Pay-to Plan Secondary Identification)
REF01 Reference Identification Qualifier 106 R X
REF02 Reference Identification 106 R X
REF (Pay-to Plan Tax Identification)
REF01 Reference Identification Qualifier 108 R X
REF02 Reference Identification 108 R X
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2000B (Subscriber Hierarchical Level)
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HL (Subscriber Hierarchical Level)
HL01 Hierarchical ID Number 109 R Y The subscriber always equals the patient for VT Medicaid claims. Report Patient/Recipient information in this loop. HL02 Hierarchical Parent ID Number 110 R N
HL03 Hierarchical Level Code 110 R N
HL04 Hierarchical Child Code 110 R Y HL04 should always equal 0. The subscriber is the patient for VT MEDICAID claims.
SBR (Subscriber Information)
SBR01 Payer Responsibility Sequence 111 R N Number Code
SBR02 Individual Relationship Code 112 S N
SBR03 Reference Identification 112 S N
SBR04 Name 112 S N
SBR05 Insurance Type Code 112 S N
SBR09 Claim Filing Indicator Code 113 S Y Use MC for VT MEDICAID claims.
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2010BA (Subscriber Name)
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NM1 (Subscriber Name)
NM101 Entity Identifier Code 114 R N
NM102 Entity Type Qualifier 115 R Y VT MEDICAID Subscriber is always a Person. Use 1.
NM103 Name Last or Organization 115 R N Name
NM104 Name First 115 S N
NM105 Name Middle 115 S N
NM107 Name Suffix 115 S N
NM108 Identification Code Qualifier 115 R Y Enter qualifier MI for VT MEDICAID claims
NM109 Identification Code 116 R Y Enter the patient's VT Medicaid Unique Identification Number. This ID is 1-8 numeric character(s). Do not zero or space fill. Do not use special characters.
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N3 (Subscriber Address)
N301 Address Information 117 R N
N302 Address Information 117 S N
N4 (Subscriber City, State, ZIP Code)
N401 City Name 118 R N
N402 State or Province Code 118 S N
N403 Postal Code 119 S N
N404 Country Code 119 S N
N407 Country Subdivision Code 119 S N
DMG (Subscriber Demographic Information)
DMG01 Date Time Period Format Qualifier 120 R N
DMG02 Date Time Period 120 R N
DMG03 Gender Code 121 R N
REF (Subscriber Secondary Identification)
REF01 Reference Identification Qualifier 122 R N
REF02 Reference Identification 122 R N
REF (Property and Casualty Claim Number)
REF01 Reference Identification Qualifier 123 R N
REF02 Reference Identification 123 R N
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2010BB (Payer Name)
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NM1 (Payer Name)
NM101 Entity Identifier Code 124 R N
NM102 Entity Type Qualifier 125 R N
NM103 Name Last or Organization 125 R Y Enter "VT MEDICAID" Name
NM108 Identification Code Qualifier 125 R Y
NM109 Identification Code 125 R Y
Enter 'PI' to qualify the next code as a payer
identifer.
Use 822287119 - the VT MEDICAID EIN
N3 (Payer Address)
N301 Address Information 126 R N
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N302 Address Information 126 S N
N4 (Payer City, State, ZIP Code)
N401 City Name 127 R N
N402 State or Province Code 127 S N
N403 Postal Code 128 S N
N404 Country Code 128 S N
N407 Country Subdivision Code 128 S N
REF (Payer Secondary Identification)
REF01 Reference Identification Qualifier 129 R N
REF02 Reference Identification 130 R N
REF (Billing Provider Secondary Identification)
REF01 Reference Identification Qualifier 131 R Y Enter G2 for VT MEDICAID Provider ID when the billing provider is atypical
REF02 Reference Identification 132 R Y If Billing Provider reported is atypical use the 7-digit VT MEDICAID provider number
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2000C (Patient Hierarchical Level)
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HL (Patient Hierarchical Level)
HL01 Hierarchical ID Number 133 R X
HL02 Hierarchical Parent ID Number 134 R X
HL03 Hierarchical Level Code 134 R X
HL04 Hierarchical Child Code 134 R X
PAT (Patient Information)
PAT01 Individual Relationship Code 135 R X
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2010CA (Patient Name)
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NM1 (Patient Name)
NM101 Entity Type Qualifier 137 R X
NM102 Entity Type Qualifier 137 R X
NM103 Name Last or Organization 138 R X Name
NM104 Name First 138 S X
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NM105 Name Middle 138 S X
NM107 Name Suffix 138 S X
N3 (Patient Address)
N301 Address Information 139 R X
N302 Address Information 139 S X
N4 (Patient City, State, ZIP Code)
N401 City Name 140 R X
N402 State or Province Code 140 S X
N403 Postal Code 141 S X
N404 Country Code 141 S X
N407 Country Subdivision Code 141 S X
DMG (Patient Demographic Information)
DMG01 Date Time Period Format Qualifier 142 R X
DMG02 Date Time Period 142 R X
DMG03 Gender Code 143 R X
REF (Property and Casualty Claim Number)
REF01 Reference Identification Qualifier 144 R X
REF02 Reference Identification 144 R X
REF (Property and Casualty Patient Identifier)
REF01 Reference Identification Qualifier A2-17 R X
REF02 Reference Identification A2-17 R X
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2300 (Claim Information)
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CLM (Claim Information)
CLM01 Claim Submitter's Identifier 146 R Y VT MEDICAID will capture up to the first 20 characters and return them on the 835. Fields longer than 20 will be truncated. CLM02 Monetary Amount 147 R N
CLM05 HEALTH CARE SERVICE 147 R N LOCATION INFORMATION
CLM05 CLM05-1 Facility Code Value 147 R N
CLM05 CLM05-2 Facility Code Qualifier 147 N
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CLM05 CLM05-3 Claim Frequency Type Code 147 N
CLM06 Yes/No Condition or Response 147 R N Code
CLM07 Provider Accept Assignment Code 148 R N
CLM08 Yes/No Condition or Response 148 R N Code
CLM09 Release of Information Code 148 R N
CLM11 RELATED CAUSES 149 S N INFORMATION
CLM11 CLM11-1 Related-Causes Code 149 R N
CLM11 CLM11-2 Related-Causes Code 149 S N
CLM11 CLM11-4 State or Province Code 149 S N
CLM11 CLM11-5 Country Code 150 S N
CLM12 Special Program Code 150 S Y Enter 01 if service is EPSDT related.
CLM19 Claim Submission Reason Code 150 S N
CLM20 Delay Reason Code 151 S N
DTP (Date - Accident)
DTP01 Date/Time Qualifier 152 R N
DTP02 Date Time Period Format Qualifier 152 R N
DTP03 Date Time Period 152 R N
DTP (Date - Appliance Placement)
DTP01 Date/Time Qualifier 153 R N
DTP02 Date Time Period Format Qualifier 153 R N
DTP03 Date Time Period 153 R N
DTP (Date – Service Date)
DTP01 Date/Time Qualifier 154 R N
DTP02 Date Time Period Format Qualifier 154 R N
DTP03 Date Time Period 154 R N
DTP (Date – Repricer Received Date)
DTP01 Date/Time Qualifier 155 R N
DTP02 Date Time Period Format Qualifier 155 R N
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DTP03 Date Time Period 155 R N
DN1 (Orthodontic Total Months of Treatment)
DN101 Quantity 156 S N
DN102 Quantity 156 S N
DN104 Description 157 S N
DN2 (Tooth Status)
DN201 Reference Identification 158 R N
DN202 Tooth Status Code 158 R N
DN206 Code List Qualifier Code A1-12 R N
PWK (Claim Supplemental Information)
PWK01 Report Type Code 160 R N
PWK02 Report Transmission Code 160 R N
PWK05 Identification Code Qualifier 161 S N
PWK06 Identification Code 161 S N
CN1 (Contract Information)
CN101 Contract Type Code 162 R N
CN102 Monetary Amount 162 S N
CN103 Percent, Decimal Format 163 S N
CN104 Reference Identification 163 S N
CN105 Terms Discount Percent 163 S N
CN106 Version Identifier 163 S N
AMT (Patient Amount Paid)
AMT01 Amount Qualifier Code 164 R N
AMT02 Monetary Amount 164 R N
REF (Predetermination Identification)
REF01 Reference Identification Qualifier 165 R N
REF02 Reference Identification 165 R N
REF (Service Authorization Exception Code)
REF01 Reference Identification Qualifier 166 R N
REF02 Reference Identification 166 R N
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REF (Payer Claim Control Number)
REF01 Reference Identification Qualifier 168 R N
REF02 Reference Identification 168 R Y Report the 15 digit Internal Control Number (ICN) assigned to the original claim by VT MEDICAID. Required when Claim Frequency Code = 7 or 8.
REF (Referral Number)
REF01 Reference Identification Qualifier 169 R N
REF02 Reference Identification 169 R N
REF (Prior Authorization)
REF01 Reference Identification Qualifier 172 R N
REF02 Reference Identification 172 R N
REF (Repriced Claim Number)
REF01 Reference Identification Qualifier 173 R N
REF02 Reference Identification 173 R N
REF (Adjusted Repriced Claim Number)
REF01 Reference Identification Qualifier 174 R N
REF02 Reference Identification 174 R N
REF (Claim Identifier for Transmission Intermediaries)
REF01 Reference Identification Qualifier 175 R N
REF02 Reference Identification 176 R N
K3 (File Information)
NTE01 Fixed Format Information 178 R N
NTE (Claim Note)
NTE01 Note Reference Code 179 R N
NTE02 Description 179 R N
HI (Health Care Diagnosis Code)
HI01 HEALTH CARE CODE 180 R N INFORMATION
HI01 HI01-1 Code List Qualifier Code 181 R N
HI01 HI01-2 Industry Code 181 R N
HI02 HEALTH CARE CODE 181 S N INFORMATION
HI02 HI02-1 Code List Qualifier Code 182 R N
HI02 HI02-2 Industry Code 182 R N
HI03 HEALTH CARE CODE 183 S N INFORMATION
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HI03 HI03-1 Code List Qualifier Code 183 R N
HI03 HI03-2 Industry Code 183 R N
HI04 HEALTH CARE CODE 183 S N INFORMATION
HI04 HI04-1 Code List Qualifier Code 184 R N
HI04 HI04-2 Industry Code 184 R N
HCP (Claim Pricing/Repricing Information)
HCP01 Pricing Methodology 186 R N
HCP02 Monetary Amount 186 R N
HCP03 Monetary Amount 186 S N
HCP04 Reference Identification 187 S N
HCP05 Rate 187 S N
HCP06 Reference Identification 187 S N
HCP13 Reject Reason Code 188 S N
HCP14 Policy Compliance Code 188 S N
HCP15 Exception Code 189 S N
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2310A (Referring Provider Name)
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NM1 (Referring Provider Name)
NM101 Entity Identifier Code 191 R N
NM102 Entity Type Qualifier 191 R N
NM103 Name Last or Organization Name 191 R N
NM104 Name First 191 S N
NM105 Name Middle 191 S N
NM107 Name Suffix 191 S N
NM108 Identification Code Qualifier 192 S Y Use XX if sending the NPI in NM109
NM109 Identification Code 192 S Y Enter the 10-digit NPI if XX was entered in NM108
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PRV (Referring Provider Specialty Information)
PRV01 Provider Code 193 R N
PRV02 Reference Identification Qualifier 193 R N
PRV03 Reference Identification 193 R N
REF (Referring Provider Secondary Identification)
REF01 Reference Identification Qualifier 194 R Y Enter G2 for VT MEDICAID Provider ID when the billing provider is atypical
REF02 Reference Identification 195 R Y If Referring Provider information is reported on the claim, use the 7 digit VT MEDICAID provider number.
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2310B (Rendering Provider Name)
---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
NM1 (Rendering Provider Name)
NM101 Entity Identifier Code 197 R N
NM102 Entity Type Qualifier 197 R N
NM103 Name Last or Organization Name 197 R N
NM104 Name First 197 S N
NM105 Name Middle 197 S N
NM107 Name Suffix 197 S N
NM108 Identification Code Qualifier 198 S N
NM109 Identification Code 198 S N
PRV (Rendering Provider Specialty Information)
PRV01 Provider Code 199 R N
PRV02 Reference Identification Qualifier 199 R N
PRV03 Reference Identification 199 R N
REF (Rendering Provider Secondary Identification)
REF01 Reference Identification Qualifier 200 R N
REF02 Reference Identification 201 R N
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2310C (Service Facility Location Name)
---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
NM1 (Service Facility Location Name)
NM101 Entity Identifier Code 203 R N
NM102 Entity Type Qualifier 203 R N
NM103 Name Last or Organization Name 203 R N
NM108 Identification Code Qualifier 203 S N
NM109 Identification Code 204 S N
N3 (Service Facility Location Address)
N301 Address Information 205 R N
N302 Address Information 205 S N
N4 (Service Facility Location City, State, ZIP Code)
N401 City Name 206 R N
N402 State or Province Code 207 S N
N403 Postal Code 207 S N
N404 Country Code 207 S N
N407 Country Subdivision Code 207 S N
REF (Service Facility Location Secondary Identification)
REF01 Reference Identification Qualifier 208 R N
REF02 Reference Identification 209 R N
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2310D (Assistant Surgeon Name)
---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
NM1 (Assistant Surgeon Name)
NM101 Entity Identifier Code 210 R N
NM102 Entity Type Qualifier 211 R N
NM103 Name Last or Organization Name 211 R N
NM104 Name First 211 S N
NM105 Name Middle 211 S N
NM107 Name Suffix 211 S N
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NM108 Identification Code Qualifier 212 S N
NM109 Identification Code 212 S N
PRV (Assistant Surgeon Specialty Information)
PRV01 Provider Code 213 R N
PRV02 Reference Identification Qualifier 213 R N
PRV03 Reference Identification 213 R N
REF (Assistant Surgeon Secondary Identification)
REF01 Reference Identification Qualifier 214 R N
REF02 Reference Identification 215 R N
---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
2310E (Supervising Provider Name)
---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
NM1 (Supervising Provider Name)
NM101 Entity Identifier Code 216 R N
NM102 Entity Type Qualifier 217 R N
NM103 Name Last or Organization Name 217 R N
NM104 Name First 217 S N
NM105 Name Middle 217 S N
NM107 Name Suffix 217 S N
NM108 Identification Code Qualifier 218 S N
NM109 Identification Code 218 S N
REF (Supervising Provider Secondary Identification)
REF01 Reference Identification Qualifier 219 R N
REF02 Reference Identification 220 R N
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2320 (Other Subscriber Information)
---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
SBR (Other Subscriber Information)
SBR01 Payer Responsibility Sequence 222 R N Number Code
SBR02 Individual Relationship Code 222 R N
SBR03 Reference Identification 223 S N
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SBR04 Name 223 S N
SBR05 Insurance Type Code 223 S N
SBR09 Claim Filing Indicator Code 224 S N
CAS (Claim Level Adjustments)
CAS01 Claim Adjustment Group Code 227 R N
CAS02 Claim Adjustment Reason Code 227 R N
CAS03 Monetary Amount 227 R N
CAS04 Quantity 227 S N
CAS05 Claim Adjustment Reason Code 227 S N
CAS06 Monetary Amount 227 S N
CAS07 Quantity 228 S N
CAS08 Claim Adjustment Reason Code 228 S N
CAS09 Monetary Amount 228 S N
CAS10 Quantity 228 S N
CAS11 Claim Adjustment Reason Code 228 S N
CAS12 Monetary Amount 229 S N
CAS13 Quantity 229 S N
CAS14 Claim Adjustment Reason Code 229 S N
CAS15 Monetary Amount 229 S N
CAS16 Quantity 229 S N
CAS17 Claim Adjustment Reason Code 230 S N
CAS18 Monetary Amount 230 S N
CAS19 Quantity 230 S N
AMT (Coordination of Benefits (COB) Payer Paid Amount)
AMT01 Amount Qualifier Code 231 R N
AMT02 Monetary Amount 231 R N
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AMT (Remaining Patient Liability)
AMT01 Amount Qualifier Code 232 R N
AMT02 Monetary Amount 232 R N
AMT (Coordination of Benefits (COB) Total Non-covered Amount)
AMT01 Amount Qualifier Code 233 R N
AMT02 Monetary Amount 233 R N
OI (Other Insurance Coverage Information)
OI03 Yes/No condition or Response 234 R N Code
OI06 Release of Information Code 235 R N
MOA (Outpatient Adjudication Information)
MOA01 Percentage as Decimal 236 S N
MOA02 Monetary Amount 237 S N
MOA03 Reference Identification 237 S N
MOA04 Reference Identification 237 S N
MOA05 Reference Identification 237 S N
MOA06 Reference Identification 237 S N
MOA07 Reference Identification 237 S N
MOA09 Monetary Amount 238 S N
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2330A (Other Subscriber Name)
---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
NM1 (Other Subscriber Name)
NM101 Entity Identifier Code 240 R N
NM102 Entity Type Qualifier 240 R N
NM103 Name Last or Organization Name 240 R N
NM104 Name First 240 S N
NM105 Name Middle 240 S N
NM107 Name Suffix 240 S N
NM108 Identification Code Qualifier 241 R N
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NM109 Identification Code 241 R N
N3 (Other Subscriber Address)
N301 Address Information 242 R N
N302 Address Information 242 S N
N4 (Other Subscriber City, State, Zip Code)
N401 City Name 243 R N
N402 State or Province Code 244 S N
N403 Postal Code 244 S N
N404 Country Code 244 S N
N407 Country Subdivision Code 244 S N
REF (Other Subscriber Secondary Identification)
REF01 Reference Identification Qualifier 245 R N
REF02 Reference Identification 245 R N
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2330B (Other Payer Name)
---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
NM1 (Other Payer Name)
NM101 Entity Identifier Code 246 R N
NM102 Entity Type Qualifier 246 R N
NM103 Name Last or Organization Name 247 R N
NM108 Identification Code Qualifier 247 R N Use qualifier PI
NM109 Identification Code 247 R N If reporting Other Insurance Carriers, use the VT Medicaid Carrier Code in this field
N3 (Other Payer Address)
N301 Address Information 248 R N
N302 Address Information 248 S N
N4 (Other Payer City, State, ZIP Code)
N401 City Name 249 R N
N402 State or Province Code 249 S N
N403 Postal Code 250 S N
N404 Country Code 250 S N
N407 Country Subdivision Code 250 S N
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DTP (ClaimCheck or Remittance Date)
DTP01 Date/Time Qualifier 251 R N
DTP02 Date Time Period Format Qualifier 251 R N
DTP03 Date Time Period 251 R N
REF (Other Payer Secondary Identifier)
REF01 Reference Identification Qualifier 252 R N
REF02 Reference Identification 253 R N
REF (Other Payer Prior Authorization Number)
REF01 Reference Identification Qualifier 254 R N
REF02 Reference Identification 254 R N
REF (Other Payer Referral Number)
REF01 Reference Identification Qualifier 255 R N
REF02 Reference Identification 255 R N
REF (Other Payer Claim Adjustment Indicator)
REF01 Reference Identification Qualifier 256 R N
REF02 Reference Identification 256 R N
REF (Other Payer Predetermination Identification)
REF01 Reference Identification Qualifier 257 R N
REF02 Reference Identification 257 R N
REF (Other Payer Claim Control Number)
REF01 Reference Identification Qualifier 258 R N
REF02 Reference Identification 258 R N
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2330C (Other Payer Referring Provider)
---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
NM1 (Other Payer Referring Provider)
NM101 Entity Identifier Code 260 R N
NM102 Entity Type Qualifier 260 R N
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REF (Other Payer Referring Provider Secondary Identification)
REF01 Reference Identification Qualifier 261 R N
REF02 Reference Identification 262 R N
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2330D (Other Payer Rendering Provider)
---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
NM1 (Other Payer Rendering Provider)
NM101 Entity Identifier Code 264 R N
NM102 Entity Type Qualifier 264 R N
REF (Other Payer Rendering Provider Secondary Identification)
REF01 Reference Identification Qualifier 265 R N
REF02 Reference Identification 266 R N
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2330E (Other Payer Supervising Provider)
---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
NM1 (Other Payer Supervising Provider)
NM101 Entity Identifier Code 268 R N
NM102 Entity Type Qualifier 268 R N
REF (Other Payer Supervising Provider Secondary Identification)
REF01 Reference Identification Qualifier 269 R N
REF02 Reference Identification 270 R N
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2330F (Other Payer Billing Provider)
---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
NM1 (Other Payer Billing Provider)
NM101 Entity Identifier Code 272 R N
NM102 Entity Type Qualifier 272 R N
REF (Other Payer Billing Provider Secondary Identification)
REF01 Reference Identification Qualifier 273 R N
REF02 Reference Identification 273 R N
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2330G (Other Payer Service Facility Location)
---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
NM1 (Other Payer Service Facility Location)
NM101 Entity Identifier Code 275 R N
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NM102 Entity Type Qualifier 275 R N
REF (Other Payer Service Facility Location Secondary Identification)
REF01 Reference Identification Qualifier 276 R N
REF02 Reference Identification 276 R N
---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
2330H (Other Payer Assistant Surgeon)
---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
NM1 (Other Payer Assistant Surgeon)
NM101 Entity Identifier Code 278 R N
NM102 Entity Type Qualifier 278 R N
REF (Other Payer Assistant Surgeon Secondary Identification)
REF01 Reference Identification Qualifier 279 R N
REF02 Reference Identification 280 R N
---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
2400 (Service Line Number)
---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
LX (Service Line Number)
LX01 Assigned Number 281 R Y Always start with 01 and increment by 1 with each subsequent service line.
SV3 (Dental Service)
SV301 COMPOSITE MEDICAL 282 R N PROCEDURE IDENTIFIER
SV301 SV301-1 Product/Service ID Qualifier 282 R N
SV301 SV301-2 Product/Service ID 282 R N
SV301 SV301-3 Procedure Modifier 283 S N
SV301 SV301-4 Procedure Modifier 283 S N
SV301 SV301-5 Procedure Modifier 283 S N
SV301 SV301-6 Procedure Modifier 283 S N
SV301 SV301-7 Description 284 S N
SV302 Monetary Amount 284 R N
SV303 Facility Code Value 284 S N
SV304 ORAL CAVITY DESIGNATION 284 S N
SV304 SV304-1 Oral Cavity Designation Code 285 R N
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SV304 SV304-2 Oral Cavity Designation Code 285 S N
SV304 SV304-3 Oral Cavity Designation Code 285 S N
SV304 SV304-4 Oral Cavity Designation Code 285 S N
SV304 SV304-5 Oral Cavity Designation Code 285 S N
SV305 Prosthesis, Crown or Inlay Code 285 S N
SV306 Quantity 286 S N
SV311 COMPOSITE DIAGNOSIS 286 R N CODE POINTER
SV311 SV311-1 Diagnosis Code Pointer 286 R N
SV311 SV311-2 Diagnosis Code Pointer 286 S N
SV311 SV311-3 Diagnosis Code Pointer 286 S N
SV311 SV311-4 Diagnosis Code Pointer 286 S N
TOO (Tooth Information)
TOO01 Code List Qualifier Code 288 R N
TOO02 Industry Code 288 R N
TOO03 TOOTH SURFACE 289 S N
TOO03 TOO03-1 Tooth Surface Code 289 R N
TOO03 TOO03-2 Tooth Surface Code 289 S N
TOO03 TOO03-3 Tooth Surface Code 289 S N
TOO03 TOO03-4 Tooth Surface Code 289 S N
TOO03 TOO03-5 Tooth Surface Code 289 S N
DTP (Date – Service Date)
DTP01 Date/Time Qualifier 290 R N
DTP02 Date Time Period Format Qualifier 290 R N
DTP03 Date Time Period 290 R N
DTP (Date - Prior Placement)
DTP01 Date/Time Qualifier 291 R N
DTP02 Date Time Period Format Qualifier 291 R N
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DTP03 Date Time Period 291 R N
DTP (Date - Appliance Placement)
DTP01 Date/Time Qualifier 292 R N
DTP02 Date Time Period Format Qualifier 292 R N
DTP03 Date Time Period 292 R N
DTP (Date - Replacement)
DTP01 Date/Time Qualifier 293 R N
DTP02 Date Time Period Format Qualifier 293 R N
DTP03 Date Time Period 293 R N
DTP (Date – Treatment Start)
DTP01 Date/Time Qualifier 294 R N
DTP02 Date Time Period Format Qualifier 294 R N
DTP03 Date Time Period 294 R N
DTP (Date – Treatment Completion)
DTP01 Date/Time Qualifier 295 R N
DTP02 Date Time Period Format Qualifier 295 R N
DTP03 Date Time Period 295 R N
CN1 (Contract Information)
CN101 Contract Type Code 296 R N
CN102 Monetary Amount 296 S N
CN103 Percent, Decimal Format 297 S N
CN104 Reference Identification 297 S N
CN105 Terms Discount Percent 297 S N
CN106 Version Identifier 297 S N
REF (Service Predetermination Identification)
REF01 Reference Identification Qualifier 298 R N
REF02 Reference Identification 298 R N
REF04 REFERENCE IDENTIFIER 299 R N
REF04 REF04-1 Reference Identification Qualifier 299 S N
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REF04 REF04-2 Reference Identification 299 S N
REF (Prior Authorization)
REF01 Reference Identification Qualifier 300 R N
REF02 Reference Identification 300 R N
REF04 REFERENCE IDENTIFIER 301 S N
REF04 REF04-1 Reference Identification Qualifier 301 R N
REF04 REF04-2 Reference Identification 301 R N
REF (Line Item Control Number)
REF01 Reference Identification Qualifier 302 R N
REF02 Reference Identification 303 R N
REF (Repriced Claim Number)
REF01 Reference Identification Qualifier 304 R N
REF02 Reference Identification 304 R N
REF (Adjusted Repriced Claim Number)
REF01 Reference Identification Qualifier 305 R N
REF02 Reference Identification 305 R N
REF (Referral Number)
REF01 Reference Identification Qualifier 306 R N
REF02 Reference Identification 306 R N
REF04 REFERENCE IDENTIFIER 307 S N
REF04 REF04-1 Reference Identification Qualifier 307 R N
REF04 REF04-2 Reference Identification 307 R N
AMT (Sales Tax Amount)
AMT01 Amount Qualifier Code 308 R N
AMT02 Monetary Amount 308 R N
K3 (File Information)
K301 Fixed Format Information 310 R N
HCP (Line Pricing/Repricing Information)
HCP01 Pricing Methodology 312 R N
HCP02 Monetary Amount 312 R N
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HCP03 Monetary Amount 312 S N
HCP04 Reference Identification 313 S N
HCP05 Rate 313 S N
HCP09 Product/Service ID Qualifier 313 S N
HCP10 Product/Service ID 313 S N
HCP11 Unit or Basis for Measurement 314 S N Code
HCP12 Quantity 314 S N
HCP13 Reject Reason Code 314 S N
HCP14 Policy Compliance Code 315 S N
HCP15 Exception Code 315 S N
---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
2420A (Rendering Provider Name)
---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
NM1 (Rendering Provider Name)
NM101 Entity Identifier Code 317 R N
NM102 Entity Type Qualifier 317 R N
NM103 Name Last or Organization Name 317 R N
NM104 Name First 317 S N
NM105 Name Middle 317 S N
NM107 Name Suffix 317 S N
NM108 Identification Code Qualifier 318 S N
NM109 Rendering Provider Primary 318 S N Identifier
PRV (Rendering Provider Specialty Information)
PRV01 Provider Code 319 R N
PRV02 Reference Identification Qualifier 319 R N
PRV03 Reference Identification 319 R N .
REF (Rendering Provider Secondary Identification)
REF01 Reference Identification Qualifier 320 R N
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REF02 Reference Identification 321 R N
REF04 REFERENCE IDENTIFIER 321 S N
REF04 REF04-1 Reference Identification Qualifier 321 R N
REF04 REF04-2 Reference Identification 321 R N
---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
2420B (Assistant Surgeon Name)
---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
NM1 (Assistant Surgeon Name)
NM101 Entity Identifier Code 322 R N
NM102 Entity Type Qualifier 323 R N
NM103 Name Last or Organization Name 323 R N
NM104 Name First 323 S N
NM105 Name Middle 323 S N
NM107 Name Suffix 323 S N
NM108 Identification Code Qualifier 324 S N
NM109 Identification Code 324 S N
PRV (Assistant Surgeon Specialty Information)
PRV01 Provider Code 325 R N
PRV02 Reference Identification Qualifier 325 R N
PRV03 Reference Identification 325 R N .
REF (Assistant Surgeon Secondary Identification)
REF01 Reference Identification Qualifier 326 R N
REF02 Reference Identification 327 R N
REF04 REFERENCE IDENTIFIER 327 S N
REF04 REF04-1 Reference Identification Qualifier 327 R N
REF04 REF04-2 Reference Identification 327 R N
---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
2420C (Supervising Provider Name)
---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
NM1 (Supervising Provider Name)
NM101 Entity Identifier Code 329 R N
NM102 Entity Type Qualifier 329 R N
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NM103 Name Last or Organization Name 329 R N
NM104 Name First 329 S N
NM105 Name Middle 329 S N
NM107 Name Suffix 329 S N
NM108 Identification Code Qualifier 310 S N
NM109 Assistant Surgeon Identifier 310 S N
REF (Supervising Provider Secondary Identification)
REF01 Reference Identification Qualifier 331 R N
REF02 Reference Identification 332 R N
REF04 REFERENCE IDENTIFIER 332 S N
REF04 REF04-1 Reference Identification Qualifier 332 R N
REF04 REF04-2 Reference Identification 332 R N
---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
2420D (Service Facility Location Name)
---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
NM1 (Service Facility Location Name)
NM101 Entity Identifier Code 334 R N
NM102 Entity Type Qualifier 334 R N
NM103 Name Last or Organization 334 R N Name
NM108 Identification Code Qualifier 334 S N
NM109 Identification Code 334 S N
N3 (Service Facility Location Address)
N301 Address Information 336 R N
N302 Address Information 336 S N
N4 (Service Facility Location City, State, ZIP)
N401 City Name 337 R N
N402 State or Province Code 338 S N
N403 Postal Code 338 S N
N404 Country Code 338 S N
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N407 Country Subdivision Code 338 S N
REF (Service Facility Location Secondary Identification)
REF01 Reference Identification Qualifier 339 R N
REF02 Reference Identification 340 R N
REF04 REFERENCE IDENTIFIER 340 S N
REF04 REF04-1 Reference Identification Qualifier 340 R N
REF04 REF04-2 Reference Identification 340 R N
---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
2430 (Line Adjudication Information)
---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
SVD (Line Adjudication Information)
SVD01 Identification Code 341 R Y Use the VT MEDICAID Carrier Code
SVD02 Monetary Amount 342 R N
SVD03 COMPOSITE MEDICAL 342 R N PROCEDURE IDENTIFIER
SVD03 SVD03-1 Product/Service ID Qualifier 342 R N
SVD03 SVD03-2 Product/Service ID 342 R N
SVD03 SVD03-3 Procedure Modifier 342 S N
SVD03 SVD03-4 Procedure Modifier 343 S N
SVD03 SVD03-5 Procedure Modifier 343 S N
SVD03 SVD03-6 Procedure Modifier 343 S N
SVD03 SVD03-7 Description 344 S N
SVD05 Quantity 344 R N
SVD06 Assigned Number 344 S N
CAS (Line Adjustment)
CAS01 Claim Adjustment Group Code 346 R N
CAS02 Claim Adjustment Reason Code 347 R N
CAS04 Quantity 347 S N
CAS05 Claim Adjustment Reason Code 347 S N
CAS07 Quantity 347 S N
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CAS08 Claim Adjustment Reason Code 348 S N
CAS10 Quantity 348 S N
CAS11 Claim Adjustment Reason Code 348 S N
CAS13 Quantity 349 S N
CAS14 Claim Adjustment Reason Code 349 S N
CAS16 Quantity 349 S N
CAS17 Claim Adjustment Reason Code 349 S N
CAS19 Quantity 350 S N
DTP (Line Check or Remittance Date)
DTP01 Date/Time Qualifier 351 R N
DTP02 Date Time Period Format Qualifier 351 R N
DTP03 Date Time Period 351 R N
AMT (Remaining Patient Liability)
AMT01 Amount Qualifier Code 352 R N
AMT02 Monetary Amount 352 R N
---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
NA (No Loop Name)
---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
SE (Transaction Set Trailer)
SE01 Number of Included Segments 353 R N
SE02 Transaction Set Control Number 353 R N
--------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
NA (No Loop Name)
---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
GE (Functional Group Trailer)
GE01 Number of Transaction Sets C.9 R N Included
GE02 Group Control Number C.9 R N
---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
NA (No Loop Name)
---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
IEA (Interchange Control Trailer)
IEA01 Number of Included Functional C.10 R N Groups
IEA02 Interchange Control Number C.10 R N
