NRPM: Standards for Electronic Transactions. ADDENDUM 1--HEALTH CLAIMS OR EQUIVALENT ENCOUNTER INFORMATION

05/07/1998

Note: These Addenda will not appear in the Code of Federal Regulations.

[Please label any written comments or e-mailed comments about this section with the subject: Addendum 1]

A. Retail Drug Claim or Equivalent Encounter

The transactions selected for retail drug claims are accredited by the American National Standards Institute (ANSI). The transactions are: NCPDP Telecommunications Standard Format version 3.2 and the equivalent NCPDP Batch Standard Version 1.0.

1. Implementation Guide and Source

The source of the implementation guide for the NCPDP Telecommunication Standard Format Version 3.2 and the equivalent NCPDP Batch Standard Version 1.0 is the National Council for Prescription Drug Programs, 4201 North 24th Street, Suite 365, Phoenix, AZ, 85016, Telephone 602-957-9105, FAX 602-955-0749. The web site address is http://www.ncpdp.org

2. Data Elements

Accumulated Deductible Amount

Additional Message Information

Adjustment/reject Code - 1

Adjustment/reject Code - 2

Adjustment/reject Code - 3

Alternate Product Code

Alternate Product Type

Amount Attributed to Sales Tax

Amount Billed

Amount of Co-pay/co-insurance

Amount Rejected

Amt. Applied to Periodic Deduct

Amt. Attrib. To Prod. Selection

Amt. Exceed. Periodic Benefit Max

Authorization Number

Basis of Cost Determination

Basis of Days Supply Determination

Basis of Reimb. Determination

Batch Number

Bin Number

Cardholder First Name

Cardholder Id Number

Cardholder Last Name

Carrier Address

Carrier Correction Notice Fields

Carrier Identification Number

Carrier Location City

Carrier Location State

Carrier Name

Carrier Telephone Number

Carrier Zip Code

Claim Count

Claim/reference Id Number

Clinic Id Number

Co-pay Amount

Comments-1

Comments-2

Compound Code

Contract Fee Paid

Customer Location

Date Filled

Date of Birth

Date of Injury

Date Prescription Written

Days Supply

Destination Name

Destination Processor Number

Diagnosis Code

Diskette Record Id

Dispense as Written (Daw)

Dispensing Fee Submitted

Dollar Count

Dollars Adjusted

Dollars Billed

Dollars Rejected

Drug Name

Drug Type

Dur Conflict Code

Dur Intervention Code

Dur Outcome Code

Dur Response Data

Eligibility Clarification Code

Employer City Address

Employer Contact Name

Employer Name

Employer Phone Number

Employer State Address

Employer Street Address

Employer Zip Code

Fee or Markup

Gross Amount Due

Group Number

Home Plan

Host Plan

Incentive Amount Submitted

Incentive Fee Paid

Ingredient Cost Billed

Ingredient Cost Paid

Ingredient Cost

Level of Service

Master Sequence Number

Message

Metric Decimal Quantity

Metric Quantity

Ndc Number

New/refill Code

Number of Refills Authorized

Other Coverage Code

Other Payor Amount

Patient City Address

Patient First Name

Patient Last Name

Patient Paid Amount

Patient Pay Amount

Patient Phone Number

Patient Social Security

Patient State Address

Patient Street Address

Patient Zip Code

Payment Processor Id

Person Code

Pharmacy Address

Pharmacy Count

Pharmacy Location City

Pharmacy Location State

Pharmacy Name

Pharmacy Number

Pharmacy Telephone Number

Pharmacy Zip Code

Plan Identification

Postage Amount Claimed

Postage Amount Paid

Prescriber Id

Prescriber Last Name

Prescription Denial Clarification

Prescription Number

Prescription Origin Code

Primary Prescriber

Prior Authorization/medical Certification Code And Number

Processor Address

Processor Control Number

Processor Location City

Processor Location State

Processor Name

Processor Number

Processor Telephone Number

Processor Zip Code

Record Identifier

Reject Code

Reject Count

Relationship Code

Remaining Benefit Amount

Remaining Deductible Amount

Response Data

Response Status

Resubmission Cycle Count

Run Date

Sales Tax Paid

Sales Tax

Sex Code

System Id

Terminal Id

Third Party Type

Total Amount Paid

Transaction Code

Unit Dose Indicator

Usual And Customary Charge

Version Release Number

B. Professional Health Claim or Equivalent Encounter

The transaction selected for the professional (non- institutional) health claim or equivalent encounter information is ASC X12N 837 - Health Care Claim: Professional (004010X098)

1. Implementation Guide and Source

The source of the implementation guide for the professional health care claim or equivalent encounter is: Washington Publishing Company, 806 W. Diamond Ave., Suite 400, Gaithersburg, MD, 20878, Telephone 301-590-9337, FAX: 301-869-9460. The web site address is http://www.wpc-edi.com/hipaa/

2. Data Elements

Accident Date

Acute Manifestation Date

Additional Submitter or Receiver Name

Adjudication or Payment Date

Adjusted Repriced Claim Reference Number

Adjusted Repriced Line Item Reference Number

Adjustment Amount

Adjustment Quantity

Adjustment Reason Code

Agency Qualifier Code

Allowed Amount

Ambulatory Patient Group Number

Amino Acid Name

Amount Qualifier Code

Anesthesia or Oxygen Minute Count

Approved Ambulatory Patient Group Amount

Approved Ambulatory Patient Group Code

Approved Service Unit Count

Arterial Blood Gas Quantity

Arterial Blood Gas Test Date

Assigned Number

Assumed or Relinquished Care Date

Attachment Control Number

Attachment Description Text

Attachment Report Type Code

Attachment Transmission Code

Auto Accident State or Province Code

Benefits Assignment Certification Indicator

Billing Provider Additional Name

Billing Provider City Name

Billing Provider Contact Name

Billing Provider Credit Card Identifier

Billing Provider First Address Line

Billing Provider First Name

Billing Provider Identifier

Billing Provider Last or Organizational Name

Billing Provider Middle Name

Billing Provider Name Suffix

Billing Provider Postal Zone or ZIP Code

Billing Provider Second Address Line

Billing Provider State or Province Code

Bundled or Unbundled Line Number

Certification Form Number

Certification Period Projected Visit Count

Certified Registered Nurse Anesthetist Supervision Indicator

Claim Adjustment Group Code

Claim Encounter Identifier

Claim Filing Indicator Code

Claim Frequency Code

Claim Note Text

Claim Payment Remark Code

Claim Submission Reason Code

Clinical Laboratory Improvement Amendment Number

Code Category

Code List Qualifier Code

Coinsurance Amount

Communication Number Qualifier

Communication Number

Complication Indicator

Condition Codes

Condition Indicator

Contact Function Code

Contact Inquiry Reference

Continuous Passive Motion Date

Contract Amount

Contract Code

Contract Percentage

Contract Type Code

Contract Version Identifier

Country Code

Coverage Certification Period Count

Creation Date

Credit or Debit Card Holder Additional Name

Credit or Debit Card Holder First Name

Credit or Debit Card Holder Last or Organizational Name

Credit or Debit Card Holder Middle Name

Credit or Debit Card Holder Name Suffix

Credit or Debit Card Maximum Amount

Credit or Debit Card Number

Credit/Debit Flag Code

Currency Code

Current Illness or Injury Date

CHAMPUS Non-availability Indicator

Daily Amino Acid Gram Use Count

Daily Amino Acid Prescription Milliliter Use Count

Daily Dextrose Prescription Milliliter Use Count

Daily Prescribed Nutrient Calorie Count

Daily Prescribed Product Calorie Count

Date of Surgical Procedure

Date Time Period Format Qualifier

Date/Time Qualifier

Deductible Amount

Diagnosis Associated Amount

Diagnosis Code Pointer

Diagnosis Code

Disability Type Code

Disability-From Date

Disability-To Date

Discipline Type Code

Drug Formulary Number

Drug Unit Price

Emergency Indicator

Emergency Medical Technician (EMT) or Paramedic First Name

Emergency Medical Technician or Paramedic Middle Name

Emergency Medical Technician or Paramedic City Name

Emergency Medical Technician or Paramedic First Address Line

Emergency Medical Technician or Paramedic Last Name

Emergency Medical Technician or Paramedic Name Additional Text

Emergency Medical Technician or Paramedic Primary Identifier

Emergency Medical Technician or Paramedic Second Address Line

Emergency Medical Technician or Paramedic Secondary Identifier

Emergency Medical Technician or Paramedic State Code

Emergency Medical Technician or Paramedic ZIP Code

Employment Status Code

End Stage Renal Disease Payment Amount

Enteral or Parenteral Indicator

Entity Identifier Code

Entity Type Qualifier

Exception Code

Exchange Rate

Explanation of Benefits Indicator

EPSDT Indicator

Facility Type Code

Family Planning Indicator

Feeding Count

File Creation Time

First Visit Date

Fixed Format Information

Functional Status Code

Group or Policy Number

Hierarchical Child Code

Hierarchical ID Number

Hierarchical Level Code

Hierarchical Parent ID Number

Hierarchical Structure Code

Homebound Indicator

Hospice Employed Provider Indicator

HCPCS Payable Amount

Identification Code Qualifier

Immunization Status Code

Immunization Type Code

Independent Lab Charge Amount

Individual Relationship Code

Information Release Code

Information Release Date

Ingredient Cost Claimed Amount

Initial Treatment Date

Insurance Type Code

Insured Employer Additional Name

Insured Employer City Name

Insured Employer Contact Name

Insured Employer First Address Line

Insured Employer First Name

Insured Employer Identifier

Insured Employer Middle Name

Insured Employer Name Suffix

Insured Employer Name

Insured Employer Second Address Line

Insured Employer State Code

Insured Employer ZIP Code

Insured Group Name

Insured Group Number

Investigational Device Exemption Identifier

Laboratory or Facility City Name

Laboratory or Facility Contact Name

Laboratory or Facility First Address Line

Laboratory or Facility Name Additional Text

Laboratory or Facility Name

Laboratory or Facility Postal ZIP or Zonal Code

Laboratory or Facility Primary Identifier

Laboratory or Facility Second Address Line

Laboratory or Facility Secondary Identifier

Laboratory or Facility State or Province Code

Last Certification Date

Last Menstrual Period Date

Last Seen Date

Last Worked Date

Last X-Ray Date

Legal Representative Additional Name

Legal Representative City Name

Legal Representative First Address Line

Legal Representative First Name

Legal Representative Last or Organization Name

Legal Representative Middle Name

Legal Representative Second Address Line

Legal Representative State Code

Legal Representative Suffix Name

Legal Representative ZIP Code

Line Item Control Number

Line Note Text

Mammography Certification Number

Measurement Qualifier

Measurement Reference Identification Code

Medical Justification Text

Medical Record Number

Medicare Assignment Code

Medicare Coverage Indicator

Multiple Procedure Indicator

National Drug Code

National Drug Unit Count

Nature of Condition Code

Non-Payable Professional Component Billed Amount

Non-Visit Code

Note Reference Code

Nutrient Administration Method Code

Nutrient Administration Technique Code

Onset Date

Ordering Provider City Name

Ordering Provider Contact Name

Ordering Provider First Address Line

Ordering Provider First Name

Ordering Provider Identifier

Ordering Provider Last Name

Ordering Provider Middle Name

Ordering Provider Name Additional Text

Ordering Provider Name Suffix

Ordering Provider Second Address Line

Ordering Provider Secondary Identifier

Ordering Provider State Code

Ordering Provider ZIP Code

Original Line Item Reference Number

Originator Application Transaction Identifier

Other Employer Additional Name

Other Employer City Name

Other Employer First Address Line

Other Employer First Name

Other Employer Last or Organization Name

Other Employer Middle Name

Other Employer Second Address Line

Other Employer State Code

Other Employer ZIP Code

Other Insured Additional Identifier

Other Insured Additional Name

Other Insured Birth Date

Other Insured City Name

Other Insured First Address Line

Other Insured First Name

Other Insured Gender Code

Other Insured Identifier

Other Insured Last Name

Other Insured Middle Name

Other Insured Name Suffix

Other Insured Plan Name or Program Name

Other Insured Second Address Line

Other Insured State Code

Other Insured ZIP Code

Other Payer Additional Name Text

Other Payer City Name

Other Payer Covered Amount

Other Payer Discount Amount

Other Payer Federal Mandate Amount

Other Payer First Address Line

Other Payer Interest Amount

Other Payer Last or Organization Name

Other Payer Patient Paid Amount

Other Payer Patient Responsibility Amount

Other Payer Per Day Limit Amount

Other Payer Pre-Tax Claim Total Amount

Other Payer Primary Identifier

Other Payer Second Address Line

Other Payer Secondary Identifier

Other Payer State Code

Other Payer Tax Amount

Other Payer ZIP Code

Oxygen Saturation Quantity

Oxygen Saturation Test Date

Paid Service Unit Count

Paramedic Contact Name

Patient Account Number

Patient Additional Name

Patient Age

Patient Amount Paid

Patient Birth Date

Patient City Name

Patient Death Date

Patient Facility Additional Name Text

Patient Facility City Name

Patient Facility First Address Line

Patient Facility Name

Patient Facility Second Address Line

Patient Facility State Code

Patient Facility Zip Code

Patient First Address Line

Patient First Name

Patient Gender Code

Patient Height

Patient Last Name

Patient Marital Status Code

Patient Middle Name

Patient Name Suffix

Patient Primary Identifier

Patient Second Address Line

Patient Secondary Identifier

Patient Signature Source Code

Patient State Code

Patient ZIP Code

Pay-to Provider Additional Name

Pay-to Provider City Name

Pay-to Provider Contact Name

Pay-to Provider First Address Line

Pay-to Provider First Name

Pay-to Provider Identifier

Pay-to Provider Last or Organizational Name

Pay-to Provider Middle Name

Pay-to Provider Name Suffix

Pay-to Provider Second Address Line

Pay-to Provider State Code

Pay-to Provider ZIP Code

Payer Additional Identifier

Payer Additional Name

Payer City Name

Payer First Address Line

Payer Identifier

Payer Name

Payer Paid Amount

Payer Responsibility Sequence Number Code

Payer Second Address Line

Payer State Code

Payer ZIP Code

Period Count

Place of Service Code

Policy Compliance Code

Postage Claimed Amount

Prescription Amino Acid Concentration Percent

Prescription Date

Prescription Dextrose Concentration Percent

Prescription Lipid Concentration Percent

Prescription Lipid Milliliter Use Count

Prescription Number

Prescription Period Count

Pricing Methodology

Prior Authorization Number

Procedure Modifier

Product Name

Product/Service ID Qualifier

Product/Service Procedure Code

Prognosis Code

Property Casualty Claim Number

Provider or Supplier Signature Indicator

Provider Code

Provider Identifier

Provider Organization Code

Provider Signature Date

Provider Specialty Certification Code

Provider Specialty Code

Purchase Price Amount

Purchase Service Charge Amount

Purchase Service Provider Identifier

Purchase Service State Code

Purchased Service Provider City Name

Purchased Service Provider Contact Name

Purchased Service Provider First Address Line

Purchased Service Provider First Name

Purchased Service Provider Last or Organization Name

Purchased Service Provider Middle Name

Purchased Service Provider Name Additional Text

Purchased Service Provider Second Address Line

Purchased Service Provider Secondary Identifier

Purchased Service Provider State Code

Purchased Service Provider ZIP Code

Quantity Qualifier

Record Format Code

Reference Identification Qualifier

Referral Number

Referring Provider City Name

Referring Provider Contact Name

Referring Provider First Address Line

Referring Provider First Name

Referring Provider Identification Number

Referring Provider Last Name

Referring Provider Middle Name

Referring Provider Name Additional Text

Referring Provider Name Suffix

Referring Provider Second Address Line

Referring Provider Secondary Identifier

Referring Provider State Code

Referring Provider ZIP Code

Reimbursement Rate

Reject Reason Code

Related Hospitalization Admission Date

Related Hospitalization Discharge Date

Related Nursing Home Admission Date

Related-Causes Code

Rendering Provider City Name

Rendering Provider Contact Name

Rendering Provider First Address Line

Rendering Provider First Name

Rendering Provider Identifier

Rendering Provider Last Name

Rendering Provider Middle Name

Rendering Provider Name Additional Text

Rendering Provider Name Suffix

Rendering Provider Second Address Line

Rendering Provider Secondary Identifier

Rendering Provider State Code

Rendering Provider ZIP Code

Rental Equipment Billing Frequency Code

Rental Price Amount

Repriced Claim Reference Number

Repriced Line Item Reference Number

Repricing Organization Identifier

Repricing Per Diem or Flat Rate Amount

Resource Utilization Group Number

Resubmission Number

Retirement or Insurance Card Date

Review By Code Indicator

Sales Tax Amount

Sample Selection Modules

Saving Amount

School City Name

School Contact Name

School First Address Line

School Name Additional Text

School Name

School Primary Identifier

School Second Address Line

School State Code

School ZIP Code

Second Admission Date

Second Discharge Date

Service Date

Service From Date

Service Line Paid Amount

Service Type Code

Service Unit Count

Ship/Delivery or Calendar Pattern Code

Ship/Delivery Pattern Time Code

Shipped Date

Similar Illness or Symptom Date

Special Program Indicator

Statement Covers Period End Date

Statement Covers Period Start Date

Student Status Code

Submittal Date

Submitted Charge Amount

Submitter or Receiver Address Line

Submitter or Receiver City Name

Submitter or Receiver Contact Name

Submitter or Receiver First Name

Submitter or Receiver Identifier

Submitter or Receiver Last or Organization Name

Submitter or Receiver Middle Name

Submitter or Receiver State Code

Submitter or Receiver ZIP Code

Submitter Additional Name

Subscriber or Dependent Death Date

Subscriber Additional Identifier

Subscriber Birth Date

Subscriber Contact Name

Subscriber First Name

Subscriber Gender Code

Subscriber Identifier

Subscriber Last Name

Subscriber Marital Status Code

Subscriber Middle Name

Subscriber Name Suffix

Subscriber Postal ZIP Code

Subscriber Second Address Line

Subscriber State

Supervising Provider City Name

Supervising Provider Contact Name

Supervising Provider First Address Line

Supervising Provider First Name

Supervising Provider Identification Number

Supervising Provider Last Name

Supervising Provider Middle Name

Supervising Provider Name Additional Text

Supervising Provider Name Suffix

Supervising Provider Second Address Line

Supervising Provider Secondary Identifier

Supervising Provider State Code

Supervising Provider ZIP Code

Supporting Document Question Identifier

Supporting Document Response Code

Surgical Procedure Code

Terms Discount Percentage

Test Performed Date

Test Results

Time Period Qualifier

Total Claim Charge Amount

Total Purchased Service Amount

Total Visits Rendered Count

Transaction Segment Count

Transaction Set Control Number

Transaction Set Identifier Code

Transaction Set Purpose Code

Treatment or Therapy Date

Treatment Length

Unit or Basis for Measurement Code

Value Added Network Trace Number

Version Identification Code

Version Identifier

Weekly Prescription Lipid Use Count

Work Return Date

X-Ray Availability Indicator Code

C. Institutional Claim or Equivalent Encounter

The transaction selected for the institutional health care claim or equivalent encounter information is ASC X12N 837 - Health Care Claim: Institutional (004010X096).

1. Implementation Guide and Source

The source of the implementation guide for the institutional health care claim or equivalent encounter is: Washington Publishing Company, 806 W. Diamond Ave., Suite 400, Gaithersburg, MD, 20878, Telephone 301-590-9337, FAX: 301-869-9460. The web site address is http://www.wpc-edi.com/hipaa/

2. Data Elements

Activities Permitted

Adjusted Repriced Claim Reference Number

Adjustment Amount

Adjustment Quantity

Adjustment Reason Code

Admission Date and Hour

Admission Source Code

Admission Type Code

Allowed Amount

Amount Qualifier Code

Approved Amount

Approved Diagnosis Related Group Code

Approved HCPCS Code

Approved Revenue Code

Approved Service Unit Count

Assigned Number

Attachment Control Number

Attachment Description Text

Attachment Report Type Code

Attachment Transmission Code

Attending Physician First Name

Attending Physician Last Name

Attending Physician Middle Name

Attending Physician Primary Identifier

Auto Accident State or Province Code

Benefits Assignment Certification Indicator

Billing Note Text

Billing Provider City Name

Billing Provider Contact Name

Billing Provider First Address Line

Billing Provider Identifier

Billing Provider Last or Organizational Name

Billing Provider Postal Zone or ZIP Code

Billing Provider Second Address Line

Billing Provider State or Province Code

Certification Condition Indicator

Certification Type Code

Claim Adjustment Group Code

Claim Days Count

Claim Disproportionate Share Amount

Claim DRG Amount

Claim DRG Outlier Amount

Claim Encounter Identifier

Claim ESRD Payment Amount

Claim Filing Indicator Code

Claim Frequency Code

Claim HCPCS payable amount

Claim Indirect Teaching Amount

Claim MSP Pass-through amount

Claim Note Text

Claim Original Reference Number

Claim Payment Remark Code

Claim PPS capital amount

Claim PPS capital outlier amount

Claim Total Denied Charge Amount

Code Associated Amount

Code Associated Date

Code Associated Quantity

Code Category

Code List Qualifier Code

Contact Function Code

Contract Amount

Contract Code

Contract Percentage

Contract Type Code

Contract Version Identifier

Cost Report Day Count

Country Code

Covered Days or Visits Count

Creation Date

Credit or Debit Card Authorization Number

Credit or Debit Card Holder First Name

Credit or Debit Card Holder Last or Organizational Name

Credit or Debit Card Holder Middle Name

Credit or Debit Card Maximum Amount

Credit or Debit Card Number

Currency Code

Date Time Period Format Qualifier

Date/Time Qualifier

Diagnosis Date

Discharge Hour

Discipline Type Code

Document Control Identifier

Employer Identification Number

Employment Status Code

Entity Identifier Code

Entity Type Qualifier

Estimated Amount Due

Estimated Claim Due Amount

Exception Code

Explanation of Benefits Indicator

Facility Code Qualifier

Facility Type Code

File Creation Time

Frequency Number

Functional Limitation Code

Group or Policy Number

Hierarchical Child Code

Hierarchical ID Number

Hierarchical Level Code

Hierarchical Parent ID Number

Hierarchical Structure Code

Home Health Certification Period

HCPCS Modifier Code

HCPCS/CPT-4 Code

Identification Code Qualifier

Implant Date

Implant Status Code

Implant Type Code

Individual Relationship Code

Industry Code

Information Release Code

Insurance Type Code

Insured Employer First Address Line

Insured Employer First Name

Insured Employer Identifier

Insured Group Name

Insured Group Number

Investigational Device Exemption Identifier

Last Admission Date

Last Visit Date

Leads Left In Patient Indicator

Legal Representative City Name

Legal Representative Contact Name

Legal Representative First Address Line

Legal Representative First Name

Legal Representative Last or Organization Name

Legal Representative Middle Name

Legal Representative Second Address Line

Legal Representative State Code

Legal Representative ZIP Code

Lifetime Psychiatric Days Count

Lifetime Reserve Days Count

Line Charge Amount

Line Item Denied Charge or Non-Covered Charge Amount

Manufacturer Identifier

Medicare Coverage Indicator

Medicare Paid at 100% Amount

Medicare Paid at 80% Amount

Mental Status Code

Model Number

Non-Covered Charge Amount

Non-Insured Employer City Name

Non-Insured Employer First Address Line

Non-Insured Employer First Name

Non-Insured Employer Identifier

Non-Insured Employer Last or Organization Name

Non-Insured Employer Middle Name

Non-Insured Employer Second Address Line

Non-Insured Employer State Code

Non-Insured Employer ZIP Code

Note Reference Code

Old Capital Amount

Operating Physician First Name

Operating Physician Last Name

Operating Physician Middle Name

Operating Physician Primary Identifier

Ordering Provider Identifier

Ordering Provider Last Name

Originator Application Transaction Identifier

Other Employer City Name

Other Employer First Address Line

Other Employer First Name

Other Employer Last or Organization Name

Other Employer Second Address Line

Other Employer Secondary Identifier

Other Employer State Code

Other Employer ZIP Code

Other Insured Additional Identifier

Other Insured Birth Date

Other Insured City Name

Other Insured First Address Line

Other Insured First Name

Other Insured Gender Code

Other Insured Identifier

Other Insured Last Name

Other Insured Middle Name

Other Insured Plan Name or Program Name

Other Insured Second Address Line

Other Insured State Code

Other Insured ZIP Code

Other Payer City Name

Other Payer First Address Line

Other Payer Last or Organization Name

Other Payer Patient Paid Amount

Other Payer Primary Identifier

Other Payer Second Address Line

Other Payer Secondary Identifier

Other Payer State Code

Other Payer ZIP Code

Other Physician First Name

Other Physician Identifier

Other Physician Last Name

Other Physician Middle Name

Paid From Part A Medicare Trust Fund Amount

Paid From Part B Medicare Trust Fund Amount

Patient Account Number

Patient Amount Paid

Patient Birth Date

Patient City Name

Patient Discharge Facility Type Code

Patient First Address Line

Patient First Name

Patient Gender Code

Patient Last Name

Patient Liability Amount

Patient Marital Status Code

Patient Middle Name

Patient Name Suffix

Patient Primary Identifier

Patient Second Address Line

Patient Secondary Identifier

Patient State Code

Patient Status Code

Patient ZIP Code

Payer Additional Identifier

Payer City Name

Payer First Address Line

Payer Identifier

Payer Name

Payer Paid Amount

Payer Responsibility Sequence Number Code

Payer Second Address Line

Payer State Code

Payer ZIP Code

Period Count

Physician Contact Date

Physician Order Date

Policy Compliance Code

Pricing Methodology

Prior Authorization Number

Procedure Modifier

Product/Service ID Qualifier

Product/Service Procedure Code

Professional Component Amount

Prognosis Code

PPS-Capital DSH DRG Amount

PPS-Capital Exception Amount

PPS-Capital FSP DRG Amount

PPS-Capital HSP DRG Amount

PPS-Capital IME amount

PPS-Operating Federal Specific DRG Amount

PPS-Operating Hospital Specific DRG Amount

Quantity Qualifier

Reference Identification Qualifier

Reimbursement Rate

Reject Reason Code

Related-Causes Code

Repriced Claim Reference Number

Repricing Organization Identifier

Repricing Per Diem or Flat Rate Amount

Returned to Manufacturer Indicator

Saving Amount

School City Name

School First Address Line

School Name

School Primary Identifier

School Second Address Line

School State Code

School ZIP Code

Serial Number

Service Date

Service From Date

Service Line Paid Amount

Service Line Rate

Service Line Revenue Code

Service Unit Count

Statement From or To Date

Submission or Resubmission Number

Submitted Charge Amount

Submitter or Receiver Contact Name

Submitter or Receiver Identifier

Submitter or Receiver Last or Organization Name

Subscriber Additional Identifier

Subscriber Birth Date

Subscriber First Address Line

Subscriber First Name

Subscriber Gender Code

Subscriber Last Name

Subscriber Marital Status Code

Subscriber Middle Name

Subscriber Second Address Line

Subscriber State

Surgery Date

Surgical Procedure Code

Terms Discount Percentage

Time Period Qualifier

Total Claim Charge Amount

Total Medicare Paid Amount

Total Visits Projected This Certification Count

Transaction Segment Count

Transaction Set Control Number

Transaction Set Identifier Code

Transaction Set Purpose Code

Unit or Basis for Measurement Code

Value Added Network Trace Number

Version Identification Code

Visits Prior to Recertification Date Count

Warranty Expiration Date

1861J1 Facility Indicator

D. Dental Claim or Equivalent Encounter

The transaction selected for the dental health care claim or equivalent encounter is: ASC X12N 837 - Health Care Claim: Dental (004010X097).

1. Implementation Guide and Source

The source of the implementation guide for the dental health care claim or equivalent encounter is: Washington Publishing Company, 806 W. Diamond Ave., Suite 400, Gaithersburg, MD, 20878, Telephone 301-590-9337, FAX: 301-869-9460. The web site address is http://www.wpc-edi.com/hipaa/

2. Data Elements

Accident Date

Adjudication or Payment Date

Adjustment Amount

Adjustment Quantity

Adjustment Reason Code

Admission Date or Start of Care Date

Amount Qualifier Code

Anesthesia Unit Count

Appliance Placement Date

Assigned Number

Assistant Surgeon City Name

Assistant Surgeon First Address Line

Assistant Surgeon First Name

Assistant Surgeon Last Name

Assistant Surgeon Middle Name

Assistant Surgeon Primary Identification Number

Assistant Surgeon Second Address Line

Assistant Surgeon State Code

Assistant Surgeon Suffix Name

Assistant Surgeon ZIP Code

Attachment Control Number

Attachment Report Type Code

Attachment Transmission Code

Auto Accident State or Province Code

Benefits Assignment Certification Indicator

Billing Provider City Name

Billing Provider Credit Card Identifier

Billing Provider First Address Line

Billing Provider First Name

Billing Provider Identifier

Billing Provider Last or Organizational Name

Billing Provider Middle Name

Billing Provider Name Suffix

Billing Provider Postal Zone or ZIP Code

Billing Provider Second Address Line

Billing Provider State or Province Code

Claim Adjustment Group Code

Claim Encounter Identifier

Claim Filing Indicator Code

Claim Submission Reason Code

Clinical Laboratory Improvement Amendment Number

Code List Qualifier Code

Contact Function Code

Coordination of Benefits Code

Country Code

Creation Date

Credit or Debit Card Authorization Number

Credit or Debit Card Holder First Name

Credit or Debit Card Holder Last or Organizational Name

Credit or Debit Card Holder Middle Name

Credit or Debit Card Holder Name Suffix

Credit or Debit Card Maximum Amount

Credit or Debit Card Number

Credit/Debit Flag Code

Currency Code

Date Time Period Format Qualifier

Date/Time Qualifier

Destination Payer Code

Diagnosis Code

Diagnosis Date

Diagnosis Type Code

Discharge Date / End Of Care Date

Entity Identifier Code

Entity Type Qualifier

Facility Code Qualifier

Facility Type Code

File Creation Time

Group or Policy Number

Hierarchical Child Code

Hierarchical ID Number

Hierarchical Level Code

Hierarchical Parent ID Number

Hierarchical Structure Code

Identification Code Qualifier

Individual Relationship Code

Information Release Code

Information Release Date

Initial Placement Date

Insured Employer First Address Line

Insured Employer First Name

Insured Employer Identifier

Insured Employer Middle Name

Insured Employer Name Suffix

Insured Group Name

Insured Group Number

Laboratory or Facility City Name

Laboratory or Facility First Address Line

Laboratory or Facility Name

Laboratory or Facility Postal ZIP or Zonal Code

Laboratory or Facility Primary Identifier

Laboratory or Facility Second Address Line

Laboratory or Facility State or Province Code

Legal Representative or Responsible Party Identifier

Legal Representative City Name

Legal Representative First Address Line

Legal Representative First Name

Legal Representative Last or Organization Name

Legal Representative Middle Name

Legal Representative Second Address Line

Legal Representative State Code

Legal Representative Suffix Name

Legal Representative ZIP Code

Line Charge Amount

Medicare Assignment Code

Oral Cavity Designation Code

Originator Application Transaction Identifier

Orthodontic Treatment Months Count

Orthodontic Treatment Months Remaining Count

Other Insured Birth Date

Other Insured City Name

Other Insured First Address Line

Other Insured First Name

Other Insured Gender Code

Other Insured Identifier

Other Insured Last Name

Other Insured Middle Name

Other Insured Name Suffix

Other Insured Second Address Line

Other Insured State Code

Other Insured ZIP Code

Other Payer Covered Amount

Other Payer Discount Amount

Other Payer Last or Organization Name

Other Payer Patient Paid Amount

Other Payer Patient Responsibility Amount

Other Payer Primary Identifier

Patient Account Number

Patient Amount Paid

Patient Birth Date

Patient City Name

Patient First Address Line

Patient First Name

Patient Gender Code

Patient Last Name

Patient Marital Status Code

Patient Middle Name

Patient Name Suffix

Patient Primary Identifier

Patient Second Address Line

Patient Signature Source Code

Patient State Code

Patient ZIP Code

Pay-to Provider City Name

Pay-to Provider First Address Line

Pay-to Provider First Name

Pay-to Provider Identifier

Pay-to Provider Last or Organizational Name

Pay-to Provider Middle Name

Pay-to Provider Name Suffix

Pay-to Provider Second Address Line

Pay-to Provider State Code

Pay-to Provider ZIP Code

Payer Additional Identifier

Payer City Name

Payer First Address Line

Payer Identifier

Payer Name

Payer Paid Amount

Payer Responsibility Sequence Number Code

Payer Second Address Line

Payer State Code

Payer ZIP Code

Periodontal Charting Measurement

Policy Name

Predetermination of Benefits Identifier

Predetermination of Benefits Indicator

Prior Authorization Number

Prior Placement Date

Procedure Count

Procedure Modifier

Product/Service ID Qualifier

Product/Service Procedure Code

Prothesis, Crown or Inlay Code

Provider or Supplier Signature Indicator

Provider Signature Date

Quantity Qualifier

Reference Identification Qualifier

Referring Provider City Name

Referring Provider First Address Line

Referring Provider First Name

Referring Provider Identification Number

Referring Provider Last Name

Referring Provider Middle Name

Referring Provider Name Suffix

Referring Provider Second Address Line

Referring Provider State Code

Referring Provider ZIP Code

Related-Causes Code

Rendering Provider City Name

Rendering Provider First Address Line

Rendering Provider First Name

Rendering Provider Identifier

Rendering Provider Last Name

Rendering Provider Middle Name

Rendering Provider Name Suffix

Rendering Provider Second Address Line

Rendering Provider State Code

Rendering Provider ZIP Code

Replacement Date

Retirement or Insurance Card Date

School City Name

School First Address Line

School Name

School Primary Identifier

School Second Address Line

School State Code

School ZIP Code

Service Date

Service Line Paid Amount

Student Status Code

Submitter or Receiver Address Line

Submitter or Receiver City Name

Submitter or Receiver Contact Name

Submitter or Receiver First Name

Submitter or Receiver Identifier

Submitter or Receiver Last or Organization Name

Submitter or Receiver Middle Name

Submitter or Receiver State Code

Submitter or Receiver ZIP Code

Subscriber Birth Date

Subscriber First Address Line

Subscriber First Name

Subscriber Gender Code

Subscriber Identifier

Subscriber Last Name

Subscriber Marital Status Code

Subscriber Middle Name

Subscriber Name Suffix

Subscriber Postal ZIP Code

Subscriber Second Address Line

Subscriber State

Title XIX Identification Number

Tooth Code

Tooth Number

Tooth Status Code

Tooth Surface

Total Claim Charge Amount

Transaction Segment Count

Transaction Set Control Number

Transaction Set Identifier Code

Transaction Set Purpose Code

Unit or Basis for Measurement Code