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_Ref_ |
Id |
_________Element Name__________ |
Req |
Type |
Min/Max |
|
|
| |
CLM01 |
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 |
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CLM02 |
782 |
Monetary Amount |
O |
R |
1/18 |
|
|
| |
|
|
Description: Monetary amount |
| |
CLM05 |
C023 |
Health Care Service Location Information |
O |
Comp |
|
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|
| |
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|
Description: To provide information that identifies the place of service or the type of bill related to the location at which a health care service was rendered |
| |
|
1331 |
Facility Code Value |
M |
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 |
| |
|
1325 |
Claim Frequency Type Code |
O |
ID |
1/1 |
|
|
| |
|
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Description: Code specifying the frequency of the claim; this is the third position of the Uniform Billing Claim Form Bill Type |
| |
|
|
|
Code |
Name_______________________________ |
| |
|
|
|
1 |
ORIGINAL (Admit thru Discharge Claim) |
| |
|
|
|
6 |
CORRECTED (Adjustment of Prior Claim) |
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|
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7 |
REPLACEMENT (Replacement of Prior Claim) |
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|
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8 |
VOID (Void/Cancel of Prior Claim) |
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CLM06 |
1073 |
Yes/No Condition or Response Code |
O |
ID |
1/1 |
|
|
| |
|
|
Description: Code indicating a Yes or No condition or response |
| |
|
|
|
Code |
Name_______________________________ |
| |
|
|
|
N |
No |
| |
|
|
|
Y |
Yes |
| |
CLM07 |
1359 |
Provider Accept Assignment Code |
O |
ID |
1/1 |
|
|
| |
|
|
Description: Code indicating whether the provider accepts assignment |
| |
|
|
|
Code |
Name_______________________________ |
| |
|
|
|
A |
Assigned |
| |
|
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B |
Assignment Accepted on Clinical Lab Services Only |
| |
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C |
Not Assigned |
| |
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P |
Patient Refuses to Assign Benefits |
| |
CLM08 |
1073 |
Yes/No Condition or Response Code |
O |
ID |
1/1 |
|
|
| |
|
|
Description: Code indicating a Yes or No condition or response |
| |
|
|
|
Code |
Name_______________________________ |
| |
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N |
No |
| |
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Y |
Yes |
| |
CLM09 |
1363 |
Release of Information Code |
O |
ID |
1/1 |
|
|
| |
|
|
Description: Code indicating whether the provider has on file a signed statement by the patient authorizing the release of medical data to other organizations |
| |
|
|
|
Code |
Name_______________________________ |
| |
|
|
|
A |
Appropriate Release of Information on File at Health Care Service Provider or at Utilization Review Organization |
| |
|
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I |
Informed Consent to Release Medical Information for Conditions or Diagnoses Regulated by Federal Statutes |
| |
|
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M |
The Provider has Limited or Restricted Ability to Release Data Related to a Claim |
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N |
No, Provider is Not Allowed to Release Data |
| |
|
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O |
On file at Payor or at Plan Sponsor |
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Y |
Yes, Provider has a Signed Statement Permitting Release of Medical Billing Data Related to a Claim |
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CLM10 |
1351 |
Patient Signature Source Code |
O |
ID |
1/1 |
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| |
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Description: Code indicating how the patient or subscriber authorization signatures were obtained and how they are being retained by the provider |
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Code |
Name_______________________________ |
| |
|
|
|
B |
Signed signature authorization form or forms for both HCFA-1500 Claim Form block 12 and block 13 are on file |
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C |
Signed HCFA-1500 Claim Form on file |
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M |
Signed signature authorization form for HCFA-1500 Claim Form block 13 on file |
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P |
Signature generated by provider because the patient was not physically present for services |
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S |
Signed signature authorization form for HCFA-1500 Claim Form block 12 on file |
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CLM11 |
C024 |
Related Causes Information |
O |
Comp |
|
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|
| |
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Description: To identify one or more related causes and associated state or country information |
| |
|
1362 |
Related-Causes Code |
M |
ID |
2/3 |
|
|
| |
|
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Description: Code identifying an accompanying cause of an illness, injury or an accident |
| |
|
|
|
Code |
Name_______________________________ |
| |
|
|
|
AA |
Auto Accident |
| |
|
|
|
AB |
Abuse |
| |
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|
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AP |
Another Party Responsible |
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EM |
Employment |
| |
|
|
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OA |
Other Accident |
| |
|
1362 |
Related-Causes Code |
O |
ID |
2/3 |
|
|
| |
|
|
Description: Code identifying an accompanying cause of an illness, injury or an accident |
| |
|
|
|
Code |
Name_______________________________ |
| |
|
|
|
AA |
Auto Accident |
| |
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AB |
Abuse |
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AP |
Another Party Responsible |
| |
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EM |
Employment |
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OA |
Other Accident |
| |
|
1362 |
Related-Causes Code |
O |
ID |
2/3 |
|
|
| |
|
|
Description: Code identifying an accompanying cause of an illness, injury or an accident |
| |
|
|
|
Code |
Name_______________________________ |
| |
|
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|
AA |
Auto Accident |
| |
|
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AB |
Abuse |
| |
|
|
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AP |
Another Party Responsible |
| |
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|
EM |
Employment |
| |
|
|
|
OA |
Other Accident |
| |
|
156 |
State or Province Code |
O |
ID |
2/2 |
|
|
| |
|
|
Description: Code (Standard State/Province) as defined by appropriate government agency |
| |
|
26 |
Country Code |
O |
ID |
2/3 |
|
|
| |
|
|
Description: Code identifying the country |
| |
CLM12 |
1366 |
Special Program Code |
O |
ID |
2/3 |
|
|
| |
|
|
Description: Code indicating the Special Program under which the services rendered to the patient were performed |
| |
|
|
|
Code |
Name_______________________________ |
| |
|
|
|
01 |
Early & Periodic Screening, Diagnosis, and Treatment (EPSDT) or Child Health Assessment Program (CHAP) |
| |
|
|
|
02 |
Physically Handicapped Children's Program |
| |
|
|
|
03 |
Special Federal Funding |
| |
|
|
|
05 |
Disability |
| |
|
|
|
07 |
Induced Abortion - Danger to Life |
| |
|
|
|
08 |
Induced Abortion - Rape or Incest |
| |
|
|
|
09 |
Second Opinion or Surgery |
| |
CLM16 |
1360 |
Provider Agreement Code |
O |
ID |
1/1 |
|
|
| |
|
|
Description: Code indicating the type of agreement under which the provider is submitting this claim |
| |
|
|
|
Code |
Name_______________________________ |
| |
|
|
|
P |
Participation Agreement |
| |
|
|
|
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Description: Any agreement between the provider of service and the plan administrator |
| |
CLM20 |
1514 |
Delay Reason Code |
O |
ID |
1/2 |
|
|
| |
|
|
Description: Code indicating the reason why a request was delayed |
| |
|
|
|
Code |
Name_______________________________ |
| |
|
|
|
1 |
Proof of Eligibility Unknown or Unavailable |
| |
|
|
|
2 |
Litigation |
| |
|
|
|
3 |
Authorization Delays |
| |
|
|
|
4 |
Delay in Certifying Provider |
| |
|
|
|
5 |
Delay in Supplying Billing Forms |
| |
|
|
|
6 |
Delay in Delivery of Custom-made Appliances |
| |
|
|
|
7 |
Third Party Processing Delay |
| |
|
|
|
8 |
Delay in Eligibility Determination |
| |
|
|
|
9 |
Original Claim Rejected or Denied Due to a Reason Unrelated to the Billing Limitation Rules |
| |
|
|
|
10 |
Administration Delay in the Prior Approval Process |
| |
|
|
|
11 |
Other |
