837I (Institutional Claim) CSV Data Dictionary

Claim

Loop: 2300, Segment: CLM CSV Example Interactive Example Open API Schema
NameDescriptionTypeEDI Reference

id

Unique payment identifier assigned by the converter

String

transactionType

Transaction set identifier code

String

ST01

fileName

Converted X12 EDI file name

String

transactionControlNumber

Transaction set control number

String

ST02

transactionSetPurposeCode

Transaction set purpose code

String

BHT02

originatorApplicationTransactionId

Originator application transaction id

String

BHT03

transactionCreationDateTime

Transaction creation date time

Date and Time

BHT04
BHT05

claimOrEncounterIdentifierType

Claim or encounter identifier type

String

BHT06

patientControlNumber

Patient control number

String

CLM01

chargeAmount

Charge amount

Number

CLM02

facility

Place of service code for professional/dental claims or UB facility code for institutional claims

View codes and descriptions

Code

CLM05-1

frequencyTypeCode

Frequency type code

View codes and descriptions

String

CLM05-3

assignmentParticipationCode

Assignment participation code

String

CLM07

assignmentCertificationIndicator

Assignment certification indicator

String

CLM08

releaseOfInformationCode

Release of information code

String

CLM09

delayReasonCode

Delay reason code

String

CLM20

billingProvider

Billing provider

Provider

NM1*85

subscriber

The insured (subscriber)

Subscriber

NM1*44

patient

Patient if different from the the insured (subscriber)

Patient

NM1*QC

statementDateFrom

Statement date from

Date

DTP03*434

statementDateTo

Statement date to

Date

DTP03*434

dischargeTime

Discharge time

Time

DTP03*096

admissionDateAndHour

Admission date and hour

Date and Time

DTP03*435

admissionTypeCode

Admission type code

String

CL101

admissionSourceCode

Admission source code

String

CL102

patientStatusCode

Patient status code

String

Required

CL103

patientResponsibilityAmount

Patient responsibility amount

Number

AMT02*F3

serviceAuthorizationExceptionCode

Service authorization exception code

String

REF02*4N

referralNumber

Referral number

String

REF02*9F

priorAuthorizationNumber

Prior authorization number

String

REF02*G1

payerClaimControlNumber

Payer claim control number

String

REF02*F8

clearinghouseTraceNumber

Clearinghouse trace number

String

REF02*D9

repricedReferenceNumber

Repriced reference number

String

REF02*9A

adjustedRepricedReferenceNumber

Adjusted repriced reference number

String

REF02*9C

accidentState

Accident state

String

REF02*LU

medicalRecordNumber

Medical record number

String

REF02*EA

demonstrationProjectIdentifier

Demonstration project identifier

String

REF02*P4

note

Free-form comments or instructions. All note segments are concatenated together into this field

String

NTE02

billingNote

Billing note

String

NTE02*ADD

principalDiag

Principal diagnosis

InstDiagnosis

HI*ABK

admittingDiag

Admitting diagnosis

View codes and descriptions

Code

HI*ABJ

reasonForVisitDiags

Reason for visit diags

View codes and descriptions

List of Code

HI*APR

externalCauseOfInjuryDiags

External cause of injury diags

View codes and descriptions

List of Code

HI*ABN

drg

Drg

Code

otherDiags

Other diags

List of InstDiagnosis

HI*ABF

principalProcedure

Principal procedure

View codes and descriptions

CodeAndDate

HI*BBR
HI*CAH

otherProcedures

Other procedures

View codes and descriptions

List of CodeAndDate

HI*BBQ

occurrences

Occurrences

View codes and descriptions

List of CodeAndDate

HI*BH

occurrenceSpans

Occurrence spans

View codes and descriptions

List of CodeAndDate

HI*BI

conditions

Conditions

View codes and descriptions

List of Code

HI*BG

valueInfos

Value infos

View codes and descriptions

List of CodeAndAmount

HI*BE

attachments

Attachments

List of Attachment

PWK

attendingProvider

Attending provider

Party

NM1*71

operatingPhysician

Operating physician

Provider

NM1*72

otherOperatingPhysician

Other operating physician

Party

NM1*ZZ

referringProvider

Referring provider

Party

NM1*DN

renderingProvider

Rendering provider

Provider

NM1*82

serviceFacility

Service facility

Party

NM1*77

otherSubscribers

Other subscribers and their payer's information

List of OtherSubscriber

2320

lines

Service lines

List of InstLineCsv

2400

Service Line

Loop: 2400 Open API Schema
NameDescriptionTypeEDI Reference

controlNumber

Control number

String

REF02*6R

revenueCode

Revenue code

View codes and descriptions

Code

Required

SV201

procedure

Procedure

View codes and descriptions

Procedure

SV202*HC
SV202*AD
SV202*WK
SV202*IV

chargeAmount

Charge amount

Number

Required

SV203

unitType

Unit type

String

Required

SV204

unitCount

Unit count

Number

Required

SV205

nonCoveredAmount

Non covered amount

Number

SV207

serviceDateFrom

Service period start date

Date

DTP03*472
DTP03*150

serviceDateTo

Service period end date. If not provided in EDI (single day), it is set to 'serviceDateFrom'

Date

DTP03*151

repricedReferenceNumber

Repriced reference number

String

REF02*9B

adjustedRepricedReferenceNumber

Adjusted repriced reference number

String

REF02*9D

serviceTaxAmount

Service tax amount

Number

AMT02*GT

facilityTaxAmount

Facility tax amount

Number

AMT02*N8

thirdPartyNote

Third party note

String

NTE02

drug

Drug

View codes and descriptions

Code

LIN03

drugQuantity

Drug quantity

Number

CTP04

drugUnitType

Drug unit type

String

CTP05-1

prescriptionNumber

Prescription number

String

REF02*XZ

attachments

Attachments

List of Attachment

PWK

operatingPhysician

Operating physician

Provider

NM1*72

otherOperatingPhysician

Other operating physician

Party

NM1*ZZ

renderingProvider

Rendering provider

Provider

NM1*82

referringProvider

Referring provider

Party

NM1*DN

Subscriber

Open API Schema
NameDescriptionTypeEDI Reference

payerResponsibilitySequence

Payer responsibility sequence

Values:

EIGHT(E), ELEVEN(H), FIVE(B), FOUR(A), NINE(F), PRIMARY(P), SECONDARY(S), SEVEN(D), SIX(C), TEN(G), TERTIARY(T), UNCONFIRMED(N), UNKNOWN(U)

String (enum)

Required

SBR01

relationshipType

Relationship type

Values:

CADAVER_DONOR(40), CHILD(19), EMPLOYEE(20), LIFE_PARTNER(53), ORGAN_DONOR(39), OTHER(G8), SELF(18), SPOUSE(1), UNKNOWN(21)

String (enum)

SBR02
PAT01

groupOrPolicyNumber

Group or policy number

String

SBR03

groupName

Group name

String

SBR04

claimFilingIndicatorCode

Claim filing indicator code

String

SBR09

insurancePlanType

Insurance plan type

Values:

AUTOMOBILE_MEDICAL(AM), BCBS(BL), CHAMPUS(CH), COMMERCIAL(CI), EPO(14), FEDERAL_EMPLOYEE_PROGRAM(FI), HMO(HM), HMO_MEDICARE(16), INDEMNITY_INSURANCE(15), MEDICAID(MC), MEDICARE_A(MA), MEDICARE_B(MB), MUTUALLY_DEFINED(ZZ), OTHER_FEDERAL(OF), OTHER_NON_FEDERAL(11), POS(13), PPO(12), VETERAN_AFFAIRS(VA), WORKERS_COMPENSATION(WC)

String (enum)

SBR09

person

Person

PersonWithDemographic

NM1

deathDate

Death date

Date

PAT06

weight

Patient weight in pounds

Number

PAT08

pregnancyIndicator

Pregnancy indicator

String

PAT09

propertyCasualtyClaimNumber

Property casualty claim number

String

REF02*Y4

payer

Payer

Party

2330B

NM1*PR

Patient

Open API Schema
NameDescriptionTypeEDI Reference

relationshipType

Relationship type

Values:

CADAVER_DONOR(40), CHILD(19), EMPLOYEE(20), LIFE_PARTNER(53), ORGAN_DONOR(39), OTHER(G8), SELF(18), SPOUSE(1), UNKNOWN(21)

String (enum)

SBR02
PAT01

person

Person

PersonWithDemographic

NM1

deathDate

Death date

Date

PAT06

weight

Patient weight in pounds

Number

PAT08

pregnancyIndicator

Pregnancy indicator

String

PAT09

Other Subscriber

Open API Schema
NameDescriptionTypeEDI Reference

payerResponsibilitySequence

Payer responsibility sequence

Values:

EIGHT(E), ELEVEN(H), FIVE(B), FOUR(A), NINE(F), PRIMARY(P), SECONDARY(S), SEVEN(D), SIX(C), TEN(G), TERTIARY(T), UNCONFIRMED(N), UNKNOWN(U)

String (enum)

Required

SBR01

relationshipType

Relationship type

Values:

CADAVER_DONOR(40), CHILD(19), EMPLOYEE(20), LIFE_PARTNER(53), ORGAN_DONOR(39), OTHER(G8), SELF(18), SPOUSE(1), UNKNOWN(21)

String (enum)

SBR02
PAT01

groupOrPolicyNumber

Group or policy number

String

SBR03

groupName

Group name

String

SBR04

coordinationOfBenefitsCode

Coordination of benefits code, post-adjudicated claims only

String

SBR06

claimFilingIndicatorCode

Claim filing indicator code

String

SBR09

insurancePlanType

Insurance plan type

Values:

AUTOMOBILE_MEDICAL(AM), BCBS(BL), CHAMPUS(CH), COMMERCIAL(CI), EPO(14), FEDERAL_EMPLOYEE_PROGRAM(FI), HMO(HM), HMO_MEDICARE(16), INDEMNITY_INSURANCE(15), MEDICAID(MC), MEDICARE_A(MA), MEDICARE_B(MB), MUTUALLY_DEFINED(ZZ), OTHER_FEDERAL(OF), OTHER_NON_FEDERAL(11), POS(13), PPO(12), VETERAN_AFFAIRS(VA), WORKERS_COMPENSATION(WC)

String (enum)

SBR09

person

Person

PersonWithDemographic

NM1

adjustments

Claim-level adjustments from this payer

List of Adjustment

CAS

payerPaidAmount

Payer paid amount

Number

AMT02*D

nonCoveredAmount

Non covered amount

Number

AMT02*A8

remainingPatientLiabilityAmount

Remaining patient liability amount

Number

AMT02*EAF

outpatientAdjudication

Outpatient adjudication

OutpatientAdjudication

MOA

payerPriorAuthorizationNumber

Payer prior authorization number

String

REF02*G1

payerReferralNumber

Payer referral number

String

REF02*9F

payerClaimControlNumber

Payer claim control number

String

REF02*F8

payer

Payer

Party

2330B

NM1*PR

patient

Patient's information; post-adjudicated claims only

Party

2330C

NM1*QC

providers

Other payer's providers

List of Party

NM1

Organization Or Person ID and Name

Open API Schema
NameDescriptionTypeEDI Reference

entityRole

Entity role

View codes and descriptions

String

Required

NM101
N101

entityType

Type of this entity: 'BUSINESS' for organization, 'INDIVIDUAL' for person

Values:

BUSINESS(2), INDIVIDUAL(1)

String (enum)

Required

NM102

identificationType

Identification type, e.g., NPI or EIN. This is a qualifier code translated to a string constant (enum)

View codes and descriptions

String

NM108
N103

identifier

Identifier

String

NM109
N104

taxId

Tax id

String

REF02*TJ
REF02*SY
REF02*EI

lastNameOrOrgName

Organization name or person last name

String

NM103
N102

firstName

First name

String

NM104

middleName

Middle name

String

NM105

Organization or Person (Party)

Open API Schema
Extends: PartyIdName
NameDescriptionTypeEDI Reference

address

Address

Address

contacts

Contacts

List of ContactInfo

additionalIds

Other identifications

List of Reference

REF

Provider

Open API Schema
Extends: Party
NameDescriptionTypeEDI Reference

providerTaxonomy

Provider's specialty information (taxonomy). Populated only for billing, rendering, operating providers.

View codes and descriptions

Code

PRV

Person with Demographic Info

Open API Schema
Extends: Party
NameDescriptionTypeEDI Reference

birthDate

Birth date

Date

DMG02

gender

Gender

Values:

FEMALE(F), MALE(M), UNKNOWN(U)

String (enum)

DMG03

Address

Open API Schema
NameDescriptionTypeEDI Reference

line

Line

String

Required

N301

line2

Line2

String

N302

city

City

String

Required

N401

stateCode

State code

String

N402

zipCode

Zip code

String

N403

countryCode

Country code

String

N404

Contact Info

Segment: PER Open API Schema
NameDescriptionTypeEDI Reference

functionCode

Function code

String

Required

PER01

name

Name

String

PER02

contactNumbers

Contact numbers

List of ContactNumber

Contact Number

Segment: PER Open API Schema
NameDescriptionTypeEDI Reference

type

Type of contact number

Values:

ALTERNATE_PHONE, BEEPER, CELL_PHONE, EMAIL, EXTENSION, FAX, HOME_PHONE, PHONE, UNKNOWN, URL, WORK_PHONE

String (enum)

Required

PER03
PER05
PER07

number

Number

String

Required

PER04
PER06
PER08

Diagnosis

Open API Schema
Extends: Code
NameDescriptionTypeEDI Reference

presentOnAdmissionIndicator

Present on admission indicator

String

HI01-9

Procedure

Procedure code with description and optional modifiers
Segment: HI,SV1,SV2,SV3,SVC Open API Schema
Extends: Code
NameDescriptionTypeEDI Reference

modifiers

Modifiers

List of Code

837P:SV101-3-6
837I:SV201-3-6
835:SVC01-3-6
277:SVC01-3-6

Code with Date

The date is provided for procedures at a claim level and for occurrence codes.

Open API Schema
Extends: Code
NameDescriptionTypeEDI Reference

occurrenceDate

Occurrence date

Date

Required

HI01-4

Code

Code and description
Open API Schema
NameDescriptionType

subType

Healthcare code subtype, such as CPT, HCPCS, ICD_10, NDC

String

code

Healthcare code

String

Required

desc

Code description

String

Attachment

Segment: PWK Open API Schema
NameDescriptionTypeEDI Reference

reportTypeCode

Report type code

String

Required

PWK01

reportTransmissionCode

Report transmission code

String

Required

PWK02

controlNumber

Control number

String

PWK06

Reference Identifications

Segment: REF Open API Schema
NameDescriptionTypeEDI Reference

qualifierCode

Code qualifying the reference identification

String

Required

REF01

type

Type of reference; qualifier code as a string constant (enum)

View codes and descriptions

String

REF01

identification

Reference identification

String

Required

REF02