| | | | | | | | | | | |
| | _Ref_ | Id | _________Element Name__________ | Req | Type | Min/Max | | |
| | CLP01 | 1028 | Claim Submitter's Identifier | M | AN | 1/38 | | |
| | | | Description: Identifier used to track a claim from creation by the health care provider through payment |
| | CLP02 | 1029 | Claim Status Code | M | ID | 1/2 | | |
| | | | Description: Code identifying the status of an entire claim as assigned by the payor, claim review organization or repricing organization |
| | | | | Code | Name_______________________________ |
| | | | | 1 | Processed as Primary |
| | | | | 2 | Processed as Secondary |
| | | | | 3 | Processed as Tertiary |
| | | | | 4 | Denied |
| | | | | 5 | Pended |
| | | | | 10 | Received, but not in process |
| | | | | 13 | Suspended |
| | | | | 15 | Suspended - investigation with field |
| | | | | 16 | Suspended - return with material |
| | | | | 17 | Suspended - review pending |
| | | | | 19 | Processed as Primary, Forwarded to Additional Payer(s) |
| | | | | 20 | Processed as Secondary, Forwarded to Additional Payer(s) |
| | | | | 21 | Processed as Tertiary, Forwarded to Additional Payer(s) |
| | | | | 22 | Reversal of Previous Payment |
| | | | | 23 | Not Our Claim, Forwarded to Additional Payer(s) |
| | | | | 25 | Predetermination Pricing Only - No Payment |
| | | | | 27 | Reviewed |
| | CLP03 | 782 | Monetary Amount | M | R | 1/18 | | |
| | | | Description: Monetary amount |
| | CLP04 | 782 | Monetary Amount | M | R | 1/18 | | |
| | | | Description: Monetary amount |
| | CLP05 | 782 | Monetary Amount | O | R | 1/18 | | |
| | | | Description: Monetary amount |
| | CLP06 | 1032 | Claim Filing Indicator Code | O | ID | 1/2 | | |
| | | | Description: Code identifying type of claim |
| | | | | Code | Name_______________________________ |
| | | | | 12 | Preferred Provider Organization (PPO) |
| | | | | 13 | Point of Service (POS) |
| | | | | 14 | Exclusive Provider Organization (EPO) |
| | | | | 15 | Indemnity Insurance |
| | | | | 16 | Health Maintenance Organization (HMO) Medicare Risk |
| | | | | AM | Automobile Medical |
| | | | | CH | Champus |
| | | | | DS | Disability |
| | | | | HM | Health Maintenance Organization |
| | | | | LM | Liability Medical |
| | | | | MA | Medicare Part A |
| | | | | MB | Medicare Part B |
| | | | | MC | Medicaid |
| | | | | OF | Other Federal Program |
| | | | | TV | Title V |
| | | | | VA | Veteran Administration Plan |
| | | | | WC | Workers' Compensation Health Claim |
| | CLP07 | 127 | Reference Identification | O | AN | 1/30 | | |
| | | | Description: Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier |
| | CLP08 | 1331 | Facility Code Value | O | AN | 1/2 | | |
| | | | Description: Code identifying the type of facility where services were performed; the first and second positions of the Uniform Bill Type code or the Place of Service code from the Electronic Media Claims National Standard Format |
| | CLP09 | 1325 | Claim Frequency Type Code | O | ID | 1/1 | | |
| | | | Description: Code specifying the frequency of the claim; this is the third position of the Uniform Billing Claim Form Bill Type |
| | CLP11 | 1354 | Diagnosis Related Group (DRG) Code | O | ID | 1/4 | | |
| | | | Description: Code indicating a patient's diagnosis group based on a patient's illness, diseases, and medical problems |
| | CLP12 | 380 | Quantity | O | R | 1/15 | | |
| | | | Description: Numeric value of quantity |
| | CLP13 | 954 | Percent | O | R | 1/10 | | |
| | | | Description: Percentage expressed as a decimal |
