NSF Plus New

Emdeon Business Services Technical Specifications NSF Plus
CHANGE LOG
Type* RT FLD Field Name Description of Change
M BA0 22.0 Billing Provider Specialty Code Added Requirement Note "Should be entered when
adjudication is known to be impacted by the
provider specialty."
Changed Validation Note to "If entered, should be

a valid code from Exhibit 3.
May only contain a value of 001-099, 301-308 or

N01-N07."
Changed Requirement to "S".
Changed Requirement Error Action to "None"
Changed Validation Error Action to "None".
M DA0 23.0 Insured Gender Changed Data Element Name to "Insured

Gender".
Changed Validation Note to "If entered, must

contain a valid code from the above list."
Changed Validation Error Action to "Reject Claim".
Changed Note to "Not Applicable".
M FB0 15.0 National Drug Code Changed Validation Note to "If entered, must be
11 numerics."
Changed Validation Error Action to "Reject Claim".
* A = Added Field; C = Code Values Changes; M = Modified Note, Definition, Validation or Requirment; D = Deleted Field
© 2002-2005, Emdeon Corporation. All Rights Reserved. Version 2.01 October 2007
Emdeon Business Services
EMDEON BUSINESS SERVICES NSF PLUS

TECHNICAL TRANSACTION SPECIFICATIONS
Professional Claims
October 2007
Version 2.01
©2003, Emdeon Business Services. All Rights Reserved

Emdeon Business Services Transaction Specifications NSF Plus Introduction
The information in this document is furnished for Emdeon Business Services and Trading
Partner use only. Changes are periodically made to the information in this document; these
changes will be incorporated in new editions of this publication. Emdeon Business Services
may make improvements and/or changes in the product and/or program described in this
publication at any time.
This document is the property of Emdeon Business Services, and furnished solely for use
pursuant to a license agreement giving the user the right to use the Emdeon Business
Services Commercial Claims Service(s) referenced in this document. All uses of this
document are subject to the terms of such license agreement. This document may not be
used except as permitted by such license agreement or changed, copied, photocopied,
reproduced, translated, or reduced to any electronic medium or machine readable form
without the prior consent of Emdeon Business Services.
© 2003, 2005 Emdeon Business Services, 26 Century Blvd., Suite 601, Nashville, TN
37214.
All Rights Reserved. Printed in the USA.
Last Update: October 2007
©2003 Emdeon Corporation, All Rights Reserved Version 2.01 October 2006
Overview
GENERAL
Emdeon Business Services believes that this transaction specification is accurate and
reliable. Emdeon Business Services will not be liable, however, for any losses or damages
arising out of the use of this material, including loss of profit, indirect, special, or
consequential damages. There are no warranties that extend beyond the Emdeon Business
Services Transaction Specifications.
The User should exercise care to assure that use of the application package is in full
compliance with all applicable laws and regulations of the jurisdictions with respect to which
it is used.
The use of proprietary Data Elements contained within this document without a participation
agreement between Emdeon Business Services and the User is prohibited by law.
PURPOSE
This is the transaction specification for version 2.1 of Emdeon Business Services proprietary
NSF Plus transaction for professional claims and/or encounters. This transaction
specification provides data requirements and content for all clients submitting claims and/or
encounters through Emdeon Business Services. This specification contains detailed
explanation of the data structure and content, valid code lists, and applicable values for
electronic claims payment.
SPECIFICATION UPDATES
Updates to the transaction processing system are usually made annually. Typically, updates
will be implemented in conjunction with updates to the applicable HIPAA Implementation
Guides. Updated specifications, reflecting the system changes, are distributed to contracted
users.
A change log provided with each update package explains the changes contained therein.
CONVENTIONS
Emdeon Business Services clientele perform a broad variety of functions in the healthcare
and healthcare insurance industries. Some entities act as both a claim receiver and
submitter in the claim process.
The generic titles “claim submitter” and “claim receiver” are used throughout this
specification in an attempt to include all parties who might be affected by any given action
described herein.
©2003 Emdeon Corporation, All Rights Reserved Version 2.01 March 2006
Claim Submitter
An entity that sends a claim directly to Emdeon Business Services is called a submitter.
Claim submitters include but are not limited to:
• Physicians
• Hospitals
• Dentists
• Healthcare Providers
• Healthcare Suppliers
• Laboratories
• Billing Services
• Managed Care Organizations (MCOs)
• Third Party Organizations (TPOs)
• Vendors
Claim Receiver
Any company that receives claims from Emdeon Business Services is called a receiver.
Claim receivers include but are not limited to:
• Commercial Insurance Companies

• Blue Cross / Blue Shield Organizations
• CHAMPUS (Military)
• Medicare (Federal)
• Medicaid (State)
• Third Party Organizations (TPOs)
• Third Party Administrators (TPAs)
• Preferred-Provider Organizations (PPOs)
Business Summary
ELECTRONIC DATA INTERCHANGE
Electronic Data Interchange, or EDI, is a way of sending information electronically from one
computer to another. EDI helps providers and payers maintain a flow of vital information by
enabling the transmission of claims and managed care transactions. That means no more
filling out paperwork by hand, waiting for the post office to deliver claims or spending time
holding on the phone.
FUNDAMENTALS OF EDI
EDI connects providers and payers and other healthcare partners using computers, modems
and ordinary phone lines. It allows you to send and receive vital healthcare information
electronically. Information is sent from your billing or practice management system to an
EDI network where it is verified for accuracy and then sent straight through to the payer's
computer.
At Emdeon Business Services, we partner with hundreds of practice management

system vendors to bring you connectivity to our network. Upon request, we can supply
you with a list of our Networked Partners.
BENEFITS OF USING EDI
EDI delivers a wide array of benefits for healthcare providers. It eliminates the need for
your office staff to prepare claims manually or enter repetitive transaction information. In
fact, there are no paper forms, no envelopes and no stamps. Your staff can work more
efficiently, saving you time and money.
With EDI, claims are processed quickly, efficiently and more accurately. Fewer rejected
claims means better cash flow for your practice.
A recent study of healthcare providers, sponsored by the State of New Jersey, showed the
tremendous savings available when using EDI:
• Physicians save an average of $1.50 or 35 percent per claim by using EDI

instead of paper.
• Physicians report 21 percent less rejected initial claims and 20 percent less
rejected follow-up claims.
• Physicians save an average of 30 days in collecting accounts receivable for
electronic claims or 52 percent improvement in cash flow vs. paper claims.
In addition, the study found physicians using EDI improved their efficiency, productivity and
data accuracy through improved payment turnaround time, reduced rejected claims and
improved patient relations.
Time Savings
Processing claims electronically is much faster than the traditional way. In fact, there's just
no contest.
Processing claims the old way requires claims to be filled out manually by hand, typewriter
or word processor. A file copy is made, and then the envelope must be addressed, stuffed,
postage added and finally mailed. When the payer receives the claim, it is opened,
microfilmed, sorted and sent for data entry.
At every step, there's a potential for human error and delays -- and that can put a dent in
your cash flow. Processing claims the EDI way is easy. Submit claims with just a few
keystrokes. The claim is automatically checked for accuracy and electronically delivered to
the appropriate payer. There's no paper -- no postage -- no delays in the mail -- no lost use
of your money.
Claims are turned around quicker, so you get your money faster. If your claims are rejected
or pended, you are notified within 24 hours instead of the weeks it takes with paper claims.
EDI virtually eliminates human errors and delay.
Emdeon Business Services Network Advantages
An EDI network acts as your gateway to the healthcare information highway. It not only
routes the flow of information between your practice and the payer, it automatically
reconfigures your data into the correct format for each payer -- so nothing gets lost in the
translation. But, not all EDI networks are created equal, so make sure you get the details
before you sign up.
Emdeon Business Services is connected to most payers who accept electronic claims. You
can submit all your claims to a single source because Emdeon Business Services will convert
and submit paper claims to all other payers for you. You send everything electronically and
we do all the sorting and transmission. Emdeon Business Services is able to translate your
claims into the format accepted by each individual payer. In addition, Emdeon Business
Services offers patient eligibility and benefit information, reports on claim status, and offers
value-added services including electronic remittance advice and financial transactions.
Emdeon Business Services also offers referral and authorization capabilities to help you
manage managed care rules.
BATCH CLAIM PROCESSING

Emdeon Business Services electronic claims processing takes all the paper and most of the
work out of insurance claims. By filing your claims electronically, you eliminate the review,
data entry and follow-up steps required by paper claims. You'll find claims are submitted
more efficiently and with fewer errors and omissions. That means faster turn around time
and fewer returned or denied claims because of manual data entry mistakes.
HOW BATCH PROCESSING WORKS
Emdeon Business Services takes a batch claim file; our computers sort the information and
electronically submit it to the appropriate payers. Emdeon Business Services automatically
checks for clerical errors and omissions, then "clean" claims are routed to the individual
payer the same day. Electronic verification and confirmation is sent back to you for each
claim submitted to Emdeon Business Services. As a further convenience, we'll even print
and mail your claim forms to insurance companies that don't yet accept electronic claims.
You have the convenience, accuracy and efficiency of electronic submissions. We'll handle
the bothersome paper functions.
Benefits of Batch Claims:
• Simplifies procedures
• Decreases time spent preparing claims
• Reduces errors and omissions
• Speeds submission and processing of claims
• Expedites reimbursement
• Eliminates worry about paper or mailing hassles
• Reduces rejected claims
• Increases administrative efficiency
• Electronically edits for accuracy
• Improves productivity
• Expedites claims processing
DESCRIPTION
NSF Plus version 2.1 is a computerized system format developed by Emdeon Business
Services to collect, validate and distribute professional claims between claim submitters and
receivers. The format consists of a series of 320-byte physical records (Record Types).
These records are structured in four levels:
• File Level
• Batch Level
• Claim Level
• Service Line Level
File Level Records
These records contain identification information for the submitter and receiver of the file. A
file may include between one and 9,999 batches. The file header record details the
applicable identification data. The file trailer record consists of batch, claim, record and
service line counts and total charges in the file.
Batch Level Records
These records consist of billing provider or pay-to provider identification data for the claims
contained within the given batch. Each batch can contain up to 5,000 claims. Identification
information is cited in the batch header records, while the batch trailer record holds claim,
record and service line counts and total charges for the batch.
Claim Level Records
Patient, insured party and payer information, and high-level claim details are contained in
the claim level records. Each claim may include between one and fifty service lines. The
Claim Trailer Record lists record and service line counts, and the total charges for the claim.
Service Line Level Records
This record level contains detailed information about each procedure performed and
reported in a claim.
File Transaction Layout
Record Type Description Repeats Required

File Level
AA0 File Header Submitter Data 1 R
Batch Level R-9999
BA0 Batch Header Provider Data 1 1 R
BA1 Batch Header Provider Data 2 1 R
BB0 Pay-to Provider Information 1 S
Claim Level R-5000
CA0 Patient Data 1 R
CA1 Indian Health Services Data 1 S
CB0 Legal Representative Data 1 S
Insurance Information R-5
DA0 Payer Data 1 1 R
DA1 Payer Data 2 1 S
DA2 Payer Data 3 1 S
DA3 Payer Adjustment Data 5 S
DA@ Additional Payer Data 1 S
EA0 Claim Data 1 R
EA1 Claim Data 2 1 S
EA3 Supplement Claim Data 1 S
EA@ Additional Claim Detail 1 S
Service Line Level R-50
FA0 Service Line Detail 1 R
FA@ Additional Provider Information 1 S
FB0 Medical Segment 1 1 S
Service Line Adjudication Information S-5
FB3 Service Line Adjudication Information 1 S
FB4 Service Line Adjustment Information 25 S
FE0 Third Party Organization 1 S
GA0 Ambulance Certification Record 1 S
GC0 Chiropractic Certification Record 1 S
GD@ Durable Medical Equipment Information 1 S
GU0 Certification Record: DMEPOS Items 1 S
GX0 Certification Record: Medical Necessity for Oxygen 1 S
GX2 Certification Record: Facility Information for 1 S
Oxygen
HA0 Narrative 1 S
XA0 Claim Trailer Claim Summary 1 R
YA0 Batch Trailer Batch Summary 1 R
ZA0 File Trailer Record 1 R
VALIDATION
When claim files are received by Emdeon Business Services, specific tests are applied to
each claim file. These tests evaluate the adherence of all claims to the rules defined for data
pertaining to patients, providers and payers and services. After validation, only claim data
which has successfully passed all checks is forwarded to the receivers.
File Level Validation
Every file must begin with a File Header (Record Type AA0) and end with a File Trailer
(Record Type ZA0). The validation checks performed at this level are as follows:
• Duplicate File Checks

• Old File Checks (three months or older)
• Submitter Information Checks
• File Totaling Checks
If a file does not pass File Level Validation, the entire file is rejected at Emdeon Business
Services.
Batch Level Validation
A file may contain multiple batches of claims and, in fact, there may be multiple batches per
provider. Every batch must begin with a Batch Header (Record Type BA0) and end with a
Batch Trailer (Record Type YA0). The validation checks performed at this level are:
• Provider Information Checks (minimum)

• Batch Sequencing Checks (files are re-batched on output to receivers)
• Batch Totaling Checks
If a batch does not pass Batch Level Validation, all claims within the batch are rejected at
Emdeon Business Services.
Claim Level Validation
A batch may contain multiple claims. Every claim must contain a minimum number of
records, must begin with a Claim Header (Record Type CA0), and must end with a Claim
Trailer (Record Type XA0). The validation checks performed at this level are as follows:
• Duplicate Claim Checks (Duplicate claims received the same day)

• Requirement Checks
• Field Length Checks
• Alphanumeric Checks
• Code Validation
• Relational Checks
• Payer-Specific Edits
If a claim does not pass Claim Level Validation, it is rejected at Emdeon Business Services.
Claims are accepted by the Emdeon Business Services systems after they pass all of the
validation checks. Accepted claims from each submitter are re-batched, by provider. They
are distributed to the appropriate receiver as designated by the data element entitled PAYER
ORGANIZATION ID.
VERSION AND RELEASE

This transaction specification is based on the February 2006 release of Emdeon Business
Services Proprietary NSF Plus version 2.1.
PAYER LISTS
The Batch Payer Lists for Commercial, Medicare, Medicaid and Blue Cross/Blue Shield Payers
indicate which carriers receive claim data through Emdeon Business Services. The current
Payer Lists are included in the installation package for submitters. The Payer Lists are
frequently updated as we add connections to more carriers. You can also download the
latest Payer Lists from the Emdeon Business Services Internet web site. The payer lists are
in Adobe® Acrobat format. The web site address is:
http://www.emdeon.com/PayerLists/payerlists.php
DAILY PROCESSING SCHEDULE
Claim files can be submitted at any time of the day or night except for Sunday from 12:00
a.m. to 6:00 a.m. (Eastern Time), which is used for downtime maintenance.
The Daily process runs five times a week, Monday through Friday. All output is available
after 4:00 a.m. (Eastern Time) Tuesday through Saturday.
Data is accumulated until cutoff time. Cutoff time has been established at 9:30 p.m.
(Eastern Time) Monday through Friday.
When the cutoff time is reached, all data files completely received will be formatted for
batch production processing. Data entered or received after the cutoff time, including files
partially received before cutoff, will be accumulated until the next scheduled production
run. Claim files submitted on Friday after cutoff time, Saturday, or Sunday will be
processed the following Monday evening.
Technical support is available Monday through Friday from 8:00 a.m. to 8:00 p.m. (Eastern
Time).
Transaction Specifications
UNDERSTANDING THE TRANSACTION SPECIFICATIONS MANUAL
Each Record Type contains a general overview as the first page of the record. This is called
the Record Summary and includes the purpose of the record and the overall record
requirements and validations. The words “data element” and “field” are used
interchangeably.
A SITUATIONAL NOTE is considered a requirement edit.

INITIALIZATION is also considered a requirement edit.
Data Element names are capitalized (e.g., PAYER ORGANIZATION ID) within the body (text)
of the specification page for easy reference. The Alphabetic Index in the front of this
transaction specification can be used to locate data elements by name.
If a given numeric field is required, VALIDATION will include the verbiage: “Must be
numeric.”
Code lists that are large, used by multiple data elements or that are updated frequently will
appear as Exhibits in the back of the transaction specifications manual.
RECORDS
Every record is 320 bytes (positions) in length. The number of data elements contained
within each record varies, as does the field length of these data elements.
There are three (3) types of specification pages assigned to each Record Type. The
different types of specification pages are reviewed in detail on the following pages. The
sequence of appearance for these pages within each record is:
1. Record Summary
Identifies the Record Type and provides information regarding its use. See
Figure 2.
2. File and Record Specifications.

Summarizes the data elements contained within each Record Type. See Figure 3.
3. Data Elements.
Contains the requirements, code values (if applicable) and validations associated
with a given data element.
Record Summary Page

The following is an explanation of the information found on each “Record Summary” page.
1
2
3
4
5 6
7
8
9
Figure 2. Record Summary Page.
CALLOUT/HEADING DESCRIPTION
1. RECORD TYPE The three byte abbreviation assigned to the record.
2. RECORD NAME This is the functional name of the record.
3. RECORD LEVEL Identifies the level of validation to be performed on the

record (File, Batch, or Claim).
4. RECORD PURPOSE Indicates why the record exists and the kind of
information it should contain. For example: “Identifies
the insured to the payer”.
5. PRECEDING RECORD(S) Reflects the placement of the record within the file by
stating what Record Type(s) may precede it.
6. FOLLOWING RECORD(S) Shows the placement of the record within the file by
stating what Record Type(s) may follow it.
7. REQUIREMENTS Indicates when a record is required for a particular type

of claim (medical or dental) for a specific type of
validation criteria (commercial vs. Medicare):
R REQUIRED. The record must be entered at all

times
C CONDITIONAL. The record must be entered

under certain conditions (explained in the
conditional note)
N NOT APPLICABLE. The record should not be

entered for this type of payer.
8. CONDITIONAL NOTE Lists the conditions under which the record must be
entered.
9. NOTES Provides additional information that may be helpful in the

coding process.
Record Layout Page
3 5 6 7 8
2 4
Figure 3. Record Layout Page
1. RECORD TYPE The three byte abbreviation assigned to the record.
2. RT The three byte abbreviation assigned to the record.
3. FIELD The sequential number assigned to a data element

indicating the position within the record.
4. FIELD NAME The literal name of the data element.
5. DT (DATA TYPE) The attribute of the data element.
X Alphanumeric
9 Numeric
9v9 Numeric value with one decimal position.
9v99 Numeric value with two decimal positions.
6. LEN (LENGTH) The total number of bytes required for each

data element. If the content is less than the required
length it must be space or zero filled based on the
initialization of the field.
7. FRM (FROM) The start position of the data element within the
Record Type.
8. THR (THROUGH) The end position of the data element within

the Record Type.
Data Element Page
1
2
3 4 5 6 7 8 9 10
11
12
13
14
15
16
Figure 4. Data Element Page.
1. DATA ELEMENT The literal name assigned to the data field.
2. DEFINITION The business description of the data element usage.
3. RECORD Indicates the Record (Type) in which each field is to be

entered.
4. FIELD Identifies the field number assigned to the data element

to indicate the field position within the record.
5. DATA TYPE Identifies the attributes of the data element.
X Alphanumeric
9 Numeric
9v9 Numeric value with one decimal position
9v99 Numeric value with two decimal positions
6. LENGTH The total number of bytes contained within the field or

data element.
7. JUSTIFY The justification is defined by the Data Type L – Left

Justified. R – Right Justified. Single character data
elements and “filler” (empty space) fields are not
justified.
8. INITIALIZE Identifies the “initial” (or starting) contents of the field

before data is entered. Alphanumeric (“X”) fields are
always initially spaces, while numeric (“9”) fields are
always initially zeros. If no data is entered, the field
retains its initial value. If the content is less than the
required length it must be space or zero filled based on
the initialization of the field.
9. FROM The start position of the data element within the Record
Type.
10. THRU The end position of the data element within the Record
Type.
11. REQUIREMENTS Indicates whether the data element is required.
R REQUIRED – The data element must be entered at

all times.
S SITUATIONAL – The data element must be

entered under certain situations (See
SITUATIONAL NOTE)
N NOT APPLICABLE – The data element should

not be entered for this type of payer.
O OPTIONAL – The data element is not required,

but may be entered.
D DESIRABLE – The data is not required, but

should be entered, if applicable, to help in the
adjudication process.
12. SITUATIONAL NOTE Identifies the conditions under which the data element is
required (must be entered).
13. CODE VALUES Identifies the code values (if applicable) associated with
the data element.
14. VALIDATION Indicates the criteria that must be met for the data
element (Code value verification, relational checks, etc).
15. ERROR ACTION Shows the type of error message the system will produce
if requirement or validation checks are not met.
REJECT The system will produce a “rejection”

message identifying the error(s) and the
claim/batch/file will not be forwarded to
the indicated receiver.
NONE The system will perform validation checks

(if specified) but will not issue any
messages. And claim/batch/file will be
forwarded to the indicated receiver.
16. NOTES Provides additional information that may be helpful in the

coding process. Provides validation considerations
(requirements) of other fields in relation to the current
data element.
EXHIBITS
Exhibit 1 – Standard Date & Time Checks
This exhibit contains format and validation requirements for entering data into date fields
and code values for entering time data.
Exhibit 1A – Accident Hour

This exhibit lists accident hour values and their corresponding time span.
Exhibit 2 – Standard Address Checks

This exhibit consists of validation and sequencing rules for entering address information in
NSF Plus fields. State, zip and area codes are also provided, along with an extensive list of
standard abbreviations.
Exhibit 3 – Provider Specialty Codes

This exhibit lists Provider Specialties by category and, within each category; specialties are
listed in alphabetical order. These codes apply to all Billing and Rendering Provider Specialty
Code fields. This exhibit also contains the HIPAA Standard Taxonomy Codes that will be
used when sending to a receiver of the HIPAA transactions.
Exhibit 11 – NSF DMERC Form Matrix to GU0 Record/Field

This matrix is designed to assist submitters in entering DMERC form data in Record Type
GU0.
Exhibit 97 - Duplicate Claims Editing

This exhibit lists edits that will be performed by Emdeon Business Services to eliminate
duplicate submission of claims to Emdeon Business Services on the same processing day. If
these fields contain the same values as a claim previously submitted on the same day, the
claim will be rejected for “duplicate claim”.
Emdeon Business Services Technical Specifications NSF Plus AA0
RECORD SUMMARY
RECORD TYPE: AA0
RECORD NAME: File Header Record: Submitter Data
RECORD LEVEL: File
RECORD PURPOSE: To identify the submitter of the claim file. This can be a
provider, a vendor, a billing agency, etc.
To identify the receiver of the claim file. This is WebMD

Envoy on input, and the Payer (or claim receiver) on output.
To uniquely identify the claim file.
REQUIREMENTS: PRECEDING RECORD(S): FOLLOWING RECORD(S):
R None BA0
COMMERCIAL HMO/PPO BCBS CHAMPUS MEDICAID MEDICARE

REQUIREMENTS R R R R R R
CONDITIONAL NOTE:
NOTES: Must be the first record of a claim file.
Only one (1) Record Type AA0 may be entered per file.
If CREATION DATE (fld-15.0) and SUBMISSION/SERIAL

NUMBER (fld-05.0) contain the same values as a previously
submitted file, the entire file will be rejected for "duplicate
claim file".
When a claim file is rejected at the file level, batch level and
claim level editing will not occur.
© 2002-2005 Emdeon Corporation. All Rights Reserved. Version 2.01 March 2006
Emdeon Business Services Technical Specifications NSF Plus BA0
RECORD SUMMARY
RECORD TYPE: BA0
RECORD NAME: Batch Header: Provider Data 1
RECORD LEVEL: Batch
RECORD PURPOSE: To identify the billing provider or billing agency for the
claims contained within this batch.
R AA0 or YA0 BA1

CONDITIONAL NOTE:
NOTES: Only one BA0 record is allowed for each batch.
Must be the first record of a batch of claims.
A maximum of 9,999 batches may be entered per file.
All batches must be sorted by three (3) variables: BILLING

PROVIDER TAX ID & BILLING PROVIDER SITE ID (flds-06.0,
07.0) AND BATCH TYPE (fld-03.0).
When a claim file is rejected on a batch level, claim level

editing will not occur.
RECORD SUMMARY
RECORD TYPE: BA1
RECORD LEVEL: Batch
RECORD PURPOSE: Additional record to identify the billing provider or billing

agency for the claims contained within this batch.
R BA0 CA0

CONDITIONAL NOTE:
NOTES: Only one (1) Record Type BA1 may be entered per batch.
Emdeon Business Services Technical Specifications NSF Plus BB0
RECORD SUMMARY
RECORD TYPE: BB0
RECORD NAME: Pay-to Provider Information
RECORD LEVEL: Batch
RECORD PURPOSE: To identify the pay-to provider or pay-to billing agency for
the claims contained within this batch.
S BA1 CA0

REQUIREMENTS C C C C C C
CONDITIONAL NOTE:
NOTES: Only one (1) Record Type BB0 may be entered per batch.
Emdeon Business Services Technical Specifications NSF Plus CA0
RECORD SUMMARY
RECORD TYPE: CA0
RECORD NAME: Claim Header: Patient Data
RECORD LEVEL: Claim
RECORD PURPOSE: To identify the patient that received the services indicated in
the claim.
To provide demographic and admission/discharge

information on the patient.
R BA1, BB0 or XA0 CA1, CB0, DA0

CONDITIONAL NOTE:
NOTES: Must be the first record of a claim.
A maximum of 5,000 claims may be entered per batch.
Only one (1) CA0 Record may be entered per claim.
All Records following Record Type CA0, up to and including

Record Type XA0, must contain the same PATIENT CONTROL
NUMBER (fld-03.0).
RECORD SUMMARY
RECORD TYPE: CA1
RECORD NAME: Indian Health Services Patient Data
RECORD LEVEL: Claim
RECORD PURPOSE: To identify and provide information regarding the patient

who received the services indicated in this claim. This data
is specific to Indian Health Services/Contract Health
Services.
S CA0 CB0 or DA0

CONDITIONAL NOTE: Should only be entered for Indian Health Services/Contract

Health Services.
NOTES: Must be entered for every Indian Health Services/Contract

Health Services claim.
Only one (1) Record Type CA1 may be entered per claim.
Emdeon Business Services Technical Specifications NSF Plus CB0
RECORD SUMMARY
RECORD TYPE: CB0
RECORD NAME: Claim Header: Legal Representative Data
RECORD LEVEL: Claim
RECORD PURPOSE: To identify the legal representative or guardian responsible

for a patient that may be mentally or physically unable to
file a claim.
S CA0 or CA1 DA0

CONDITIONAL NOTE: Must be entered if the patient is the insured, and is mentally
or physically unable to file a claim.
NOTES: Only one (1) Record Type CB0 may be entered per claim.
Emdeon Business Services Technical Specifications NSF Plus DA0
RECORD SUMMARY
RECORD TYPE: DA0
RECORD NAME: Insurance Information: Payer Data 1
RECORD LEVEL: Claim
RECORD PURPOSE: To identify the Payer(s) responsible for claim payment.
To identify the insured individual and to provide the

insured's coverage information.
To identify the Payer(s) that have already paid a portion of

the claim.
R CA0, CA1, CB0, DA0, DA0, DA1, DA2, DA3,

DA1, DA2, DA3, DA@ DA@ or EA0

CONDITIONAL NOTE:
NOTES: Multiple DA0 records should be sequenced according to

national and state coordination of benefits rules. The
primary payer should always be first regardless of whether
payment is being requested at this time. The order of
records should always be: Primary insurance followed by
Secondary insurance (if applicable), and then Tertiary
insurance (if applicable).
PAYER ID (fld-07.0) should be used to direct the claim to the

appropriate payer(s).
A maximum of one (1) Record Type DA0, with a CLAIM

FILING INDICATOR of P, may be present on a claim.
A Record containing a CLAIM FILING INDICATOR of P, will be

subject to full validation.
Records without a CLAIM FILING INDICATOR of P, will be

treated as "informational" and will not be edited.
RECORD SUMMARY
RECORD TYPE: DA1
RECORD LEVEL: Claim
RECORD PURPOSE: To supply additional information for identifying the Payer

and/or to provide prior adjudication status information from
primary Payers.
S DA0 DA0, DA2, DA3, DA@ or

EA0

CONDITIONAL NOTE: When filing "secondary" claims, CHAMPUS claims, and All-
Payer claims, a Record Type DA1 is required for every Payer
who has received and/or processed the claim prior to this
submission.
Record Type DA1 is also required when filing claims

designated as "paper" claims, i.e., claims to be printed by
WebMD Envoy and mailed on the Submitter/Provider's behalf
to the designated payer.
This Record should only be created if there is data other

than fields DA1-01.0, DA1-02.0, DA1-03.0 or filler.
NOTES: This Record must be created if PAYER ORGANIZATION ID

(RT DA0,flds-07.0) in the corresponding DA0 Record
contains a value of 06126 or SPRNT or CPRNT and the CLAIM
FILING INDICATOR (RT DA0,fld-04.0) in the corresponding
DA0 Record contains a value of P.
When used, this Record Type DA1 must have the same
SEQUENCE NUMBER (fld-02.0) as the Record Type DA0
associated with this payer.
Only one (1) Record Type DA1 may be entered per DA0.
RECORD SUMMARY
RECORD TYPE: DA2
RECORD LEVEL: Claim
RECORD PURPOSE: To identify the mailing address of the insured individual.
To identify the employer of the insured individual.
S DA0 or DA1 DA0, DA3, DA@ or EA0

CONDITIONAL NOTE: Should be entered if:
The insured has a different mailing address from the patient;
OR
The insured is covered by a plan of insurance that involves

multiple employers or one employer operating from multiple
locations.

NOTES: When used, this Record Type DA2 must have the same
RECORD SUMMARY
RECORD TYPE: DA3
RECORD NAME: Claim Adjustment Information
RECORD LEVEL: Claim
RECORD PURPOSE: Provides the Claim Adjustment Information from the Non-
destination Payer (cross walked from the Remittance
Advice).
S DA0, DA1, DA2, DA3 DA0, DA3 or EA0

CONDITIONAL NOTE: This Record should only be created if there is data other
than fields DA3-01.0, DA3-02.0, DA3-03.0, DA3-04.0 or filler.
A maximum of five (5) DA3 Records per DA0 packet may be

entered.
Emdeon Business Services Technical Specifications NSF Plus DA@
RECORD SUMMARY
RECORD TYPE: DA@
RECORD NAME: Additional Insurance Information
RECORD LEVEL: Claim
RECORD PURPOSE: To provide additional insurance information not included in

the previous record(s).
S DA0, DA1, DA2, DA3 DA0 or EA0

REQUIREMENTS N N C N N N
CONDITIONAL NOTE: Must be entered if Blue Cross/Blue Shield payer requires a

plan code.

than fields DA@-01.0, DA@-02.0, DA@-03.0 or filler.
NOTES: May only be entered if SOURCE OF PAYMENT (RT DA0,fld-

05.0) contains a value of G or P and CLAIM FILING
INDICATOR (RT DA0,fld-04.0) contains a value of M or P.
When used, this Record Type DA@ must have the same
Only one (1) Record Type DA@ may be entered per DA0.
Emdeon Business Services Technical Specifications NSF Plus EA0
RECORD SUMMARY
RECORD TYPE: EA0
RECORD NAME: Claim Record: Claim Data
RECORD LEVEL: Claim
RECORD PURPOSE: To provide information necessary to adjudicate the claim.
R DA0, DA1, DA2, DA3 or EA1, EA3, EA@ or FA0

DA@

CONDITIONAL NOTE:
NOTES: A maximum of one (1) Record Type EA0 may be entered per
claim.
RECORD SUMMARY
RECORD TYPE: EA1
RECORD NAME: Claim Record: Claim Data 2
RECORD LEVEL: Claim
RECORD PURPOSE: To identify additional claim level information.
S EA0 EA3, EA@ or FA0

CONDITIONAL NOTE: Should only be submitted in LABORATORY INDICATOR (RT

EA0, fld-28.0) contains a value of Y or if PLACE OF SERVICE
(RT FA0, fld-07.0) does not contain a value of 11 (office) or
12 (home).

than fields EA1-01.0, EA1-03.0 or filler.
NOTES: Only one (1) Record Type EA1 is allowed per claim.
RECORD SUMMARY
RECORD TYPE: EA2
RECORD NAME:
RECORD LEVEL:
RECORD PURPOSE:

REQUIREMENTS
CONDITIONAL NOTE:
NOTES:
RECORD SUMMARY
RECORD TYPE: EA3
RECORD NAME: Claim Supplemental Information
RECORD LEVEL: Claim
RECORD PURPOSE: Provides additional information applicable to the entire claim.
S EA0 or EA1 EA@ or FA0

than fields EA3-01.0, EA3-03.0 or filler present.
RECORD SUMMARY
RECORD TYPE: EA4
RECORD NAME:
RECORD LEVEL:
RECORD PURPOSE:

REQUIREMENTS
CONDITIONAL NOTE:
NOTES:
Emdeon Business Services Technical Specifications NSF Plus EA@
RECORD SUMMARY
RECORD TYPE: EA@
RECORD NAME: Claim Detail - Additional Claim Detail
RECORD LEVEL: Claim
RECORD PURPOSE: To provide additional CHAMPUS, Medicaid and

rendering/referring provider insurance information not
included in the previous record(s).
S EA0, EA1, EA3 FA0

CONDITIONAL NOTE: Should be entered if the Rendering Provider information is

different than the Billing Provider.
Applies to the entire claim unless a Rendering Provider is

sent in the FA@ Record.

than fields EA@-01.0, EA@-03.0 or filler.
NOTES: Only one (1) Record Type EA@ is allowed per claim.
Emdeon Business Services Technical Specifications NSF Plus FA0
RECORD SUMMARY
RECORD TYPE: FA0
RECORD NAME: Claim - Service Line Detail
RECORD LEVEL: Service Line
RECORD PURPOSE: To provide information pertaining to the medical services

rendered.
R EA0, EA1, EA3, EA@, FA0, FA@, FB0, FB1, FB2, FB3,
FA@, FB0, FB1, FB2, FB3, FB4, FE0, GA0, GC0,
FB4, FE0, GA0, GC0, GD@, GU0, GX0, GX2,
GD@, GU0, GX0, GX2, HA0, XA0
HA0

CONDITIONAL NOTE:
NOTES: There must be at least one (1) Record Type FA0 entered for
every claim.
The SEQUENCE NUMBER (fld-02.0) for each additional

Record Type FA0 must contain a value one (1) greater than
the previous Record Type FA0.
All applicable "F" type records must be grouped as FA0,

FA@, FB0, FB1, FB2, FB3, FB4 and FE0, followed by any
applicable Certification record(s) and/or Narrative record(s)
by Sequence Number.
A maximum of (50) sequences of Record Type FA0 may be

entered per claim.
Emdeon Business Services Technical Specifications NSF Plus FA@
RECORD SUMMARY
RECORD TYPE: FA@
RECORD NAME: Additional Provider Information
RECORD PURPOSE: To identify rendering provider information required for the

processing and payment of (all) claims.
To identify the referring provider and authorization

information especially pertinent to indemnity claims.
To identify managed care and PPO network information.
S FA0 FA0, FB0, FB1, FB2, FB3,

FB4, FE0, GA0, GC0,
GD@, GU0, GX0, GX2,
HA0, XA0

CONDITIONAL NOTE: Applies to the the corresponding service line and should only
be sent when different than the Rendering Provider reported
in the EA@ Record, or when different than the Billing
Provider reported in the BA0 Record.

than fields FA@-01.0, FA@-02.0, FA@-03.0 or filler.
NOTES: When used, this Record Type FA@ must have the same
SEQUENCE NUMBER (fld-02.0) as the Record Type FA0
related to this service.
Only one (1) Record Type FA@ may be entered per FA0.

applicable Certification record(s) and/or narrative record(s)
by Sequence Number.
Emdeon Business Services Technical Specifications NSF Plus FB0
RECORD SUMMARY
RECORD TYPE: FB0
RECORD NAME: Claim - Medical Segment 1
RECORD PURPOSE: To provide informtion related to the medical services

rendered to the patient by the provider.
S FA0, FA@ FA0, FB1, FB2, FB3, FB4,

FE0, GA0, GC0, GD@,
GU0, GX0, GX2, HA0, XA0

than fields FB0-01.0, FB0-02.0, FB0-03.0 or filler.
NOTES: When used, this Record Type FB0 must have the same

by Sequence Number.
RECORD SUMMARY
RECORD TYPE: FB1
RECORD PURPOSE: To provide information related to the medical services

S FA0, FA@, FB0 FA0, FB2, FB3, FB4, FE0,

GA0, GC0, GD@, GU0,
GX0, GX2, HA0, XA0


by Sequence Number.
RECORD SUMMARY
RECORD TYPE: FB2
RECORD PURPOSE: To provide additional provider address information.
S FA0, FA@, FB0, FB1 FA0, FB3, FB4, FE0, GA0,

GC0, GD@, GU0, GX0,
GX2, HA0, XA0


by Sequence Number.
If more than three (3) provider address sets (flds-06.0-10.0)

are needed, claim must be split into separate claims.
RECORD SUMMARY
RECORD TYPE: FB3
RECORD NAME: Service Line Payment Information
RECORD PURPOSE: To provide service line payment information from the non-
destination payer (crosswalked from the remittance advice).
S FA0, FA@, FB1, FB2, FB3 FA0, FB3, FB4, FE0, GA0,
GC0, GD@, GU0, GX0,
GX2, HA0, XA0


by Sequence Number.
A maximum of five (5) sequences of Record Type FB3 may

be entered per Record Type FA0.
RECORD SUMMARY
RECORD TYPE: FB4
RECORD NAME: Service Line Adjustment Information
RECORD PURPOSE: To provide service line adjustment information from the non-
S FB3, FB4 FA0, FB4, FE0, GA0, GC0,

GD@, GU0, GX0, GX2,
HA0, XA0


by Sequence Number.
A maximum of twenty-five (25) sequences of Record Type

FB4 may be entered per Record Type FB3.
Emdeon Business Services Technical Specifications NSF Plus FE0
RECORD SUMMARY
RECORD TYPE: FE0
RECORD NAME: Claim - Third Party Organization Segment
RECORD PURPOSE: To provide repricing and review information to the

destination payer.
S FA0, FA@, FB0, FB1, FB2 FA0, GA0, GC0, GD@,


REQUIREMENTS C C C C C N
than fields FE0-01.0, FE0-02.0, FE0-03.0 or filler.
NOTES: When used, this Record Type FE0 must have the same

by Sequence Number.
Emdeon Business Services Technical Specifications NSF Plus GA0
RECORD SUMMARY
RECORD TYPE: GA0
RECORD NAME: Ambulance Certification Record
RECORD PURPOSE: To provide additional information related to the ambulance

service rendered to the patient.
S FA0, FB0, FB1, FB2, FB3, FA0, HA0, XA0

FB4, FE0

CONDITIONAL NOTE:
NOTES: When used, this Record Type GA0 must have the same
When used, this record must follow the FA0, FA@, FB1, FB2,
FB3 or FB4 record related to this service.
Emdeon Business Services Technical Specifications NSF Plus GC0
RECORD SUMMARY
RECORD TYPE: GC0
RECORD NAME: Chiropractic Certification Record
RECORD PURPOSE: To provide additional information related to the chiropractic

S FA0, FA@, FB0, FB1, FB2, FA0, HA0, XA0

FB3, FB4, FE0

REQUIREMENTS N N N N N C
than fields GC0-01.0, GC0-02.0, GC0-03.0 or filler.
NOTES: When used, this Record Type GC0 must have the same
FB2, FB3, FB4 or FE0 record related to this service.
Emdeon Business Services Technical Specifications NSF Plus GD@
RECORD SUMMARY
RECORD TYPE: GD@
RECORD NAME: Durable Medical Equipment (DME) Information
RECORD PURPOSE: To provide information relevant to the sale and/or rental of

durable medical equipment.

FB3, FB4, FE0

than fields GD@-01.0, GD@-02.0, GD@-03.0 or filler.
Must be entered if this is the initial claim for the rental/sale

of durable medical equipment.
May not be entered for Medicare claims.
NOTES: When used, this Record Type GD@ must have the same
FB3, FB4 or FE0 record related to this service.
Emdeon Business Services Technical Specifications NSF Plus GU0
RECORD SUMMARY
RECORD TYPE: GU0
RECORD NAME: "DMEPOS ITEMS" Certification Record
RECORD PURPOSE: To provide information regarding certification of medical

necessity for DMEPOS items.

FB3, FB4

than fields GU0-01.0, GU0-02.0, GU0-03.0 or filler.
If required by the payer, this record must be submitted for

the initial certification, revised certification or renewal
certification when billing for DMEPOS ITEMS on Medicare
Claims.
NOTES: When used, this Record Type GU0 must have the same
See Exhibit 11 (NSF GU0 Field to DMERC Form Question

Matrix) to determine appropriate placement of DMERC form
responses for Record Type GU0 (flds-26.0-70.0).
Emdeon Business Services Technical Specifications NSF Plus GV0
RECORD SUMMARY
RECORD TYPE: GV0
RECORD NAME: Drug Identification Information
RECORD PURPOSE: To provide information regarding drugs dispensed at the

service line.

FB3, FB4

than fields GV0-01.0, GV0-02.0, GV0-03.0, GV0-04.0 or filler.
NOTES: When used, this Record Type GV0 must have the same
Emdeon Business Services Technical Specifications NSF Plus GX0
RECORD SUMMARY
RECORD TYPE: GX0
RECORD NAME: Oxygen Certification Record
RECORD PURPOSE: To provide information regarding attending physician's

certification of medical necessity
S FA0, FA@, FB0, FB1, FB2, FA0, GX2, HA0, XA0

FB3, FB4, FE0

than fields GX0-01.0, GX0-02.0, GX0-03.0 or filler.

certification when billing for home oxygen therapy on
Medicare Claims.
NOTES: When used, this Record Type GX0 must have the same
RECORD SUMMARY
RECORD TYPE: GX2
RECORD NAME: Facility Information for Oxygen
RECORD PURPOSE: To provide information regarding where the test was

performed or where the patient resides if other than home.
S GX0 FA0, HA0, XA0


Medicare Claims.
Emdeon Business Services Technical Specifications NSF Plus HA0
RECORD SUMMARY
RECORD TYPE: HA0
RECORD NAME: Narrative Record
RECORD PURPOSE: To provide additional information related to the service

S FA0, FA@, FB0, FB1, FB2, FA0, XA0

FB3, FB4, FE0, GA0, GC0,
GD@, GU0, GX0, GX2

than fields HA0-01.0, HA0-02.0, HA0-03.0 or filler.
NOTES: When used, this Record Type HA0 must have the same
Emdeon Business Services Technical Specifications NSF Plus XA0
RECORD SUMMARY
RECORD TYPE: XA0
RECORD NAME: Claim Trailer Record: Claim Summary
RECORD LEVEL: Claim
RECORD PURPOSE: To provide a summary of the total number of records and

record types within the claim as well as providing the total
dollar amounts.
To provide free text information.
R FA0, FA@, FB0, FB1, FB2, CA0, YA0

GD@, GU0, GX0, GX2,
HA0

CONDITIONAL NOTE:
NOTES: Only one (1) Record Type XA0 may be entered per claim.
Emdeon Business Services Technical Specifications NSF Plus YA0
RECORD SUMMARY
RECORD TYPE: YA0
RECORD NAME: Batch Trailer Record
RECORD LEVEL: Batch
RECORD PURPOSE: To provide a summary of claims and claim totals within a

batch.
R XA0 BA0, ZA0

CONDITIONAL NOTE:
NOTES: Must be the last record within a batch of claims.
BILLING PROVIDER TAX ID (fld-06.0) must be identical to

the BILLING PROVIDER TAX ID in Record Type BA0 (fld-
06.0).
BATCH TYPE (fld-03.0) must be identical to BATCH TYPE in

Record Type BA0 (fld-03.0).
Emdeon Business Services Technical Specifications NSF Plus ZA0
RECORD SUMMARY
RECORD TYPE: ZA0
RECORD NAME: File Trailer Record
RECORD LEVEL: File
RECORD PURPOSE: To provide a summary of batches and batch totals within a

file.
R YA0 None

CONDITIONAL NOTE:
NOTES: Must be the last record of a claim file.
The SUBMITTER ID (fld-02.0) must be identical to the

SUBMITTER ID in Record Type AA0 (fld-02.0).
The RECEIVER ID and SUB-ID (flds-04.0a-04.0b) must be

identical to the RECEIVER ID and SUB-ID in Record Type
AA0 (flds-17.0a-17.0b).
RECORD LAYOUT
Record Type: AA0
RT FIELD FIELD NAME DT LEN FRM THR

AA0 01.0 Record Type 'AA0' X 03 01 03
AA0 02.0 Submitter ID X 16 04 19
AA0 03.0 Reserved Filler X 09 20 28
AA0 05.0 Submission/Serial Number X 06 35 40
AA0 06.0 Submitter Name X 33 41 73
AA0 07.0 Submitter Street Address 1 X 30 74 103
AA0 09.0 Submitter City X 20 134 153
AA0 10.0 Submitter State X 02 154 155
AA0 11.0 Submitter Zip Code X 09 156 164
AA0 12.0 Submitter Region X 05 165 169
AA0 13.0 Submitter Contact X 33 170 202
AA0 14.0 Submitter Telephone Number X 10 203 212
AA0 15.0 Creation Date 9 08 213 220
AA0 16.0 Submission Time X 06 221 226
AA0 17.0 Receiver ID X 05 227 231
AA0 17.0 Receiver Sub-ID X 11 232 242
AA0 18.0 Receiver Type Code X 01 243 243
AA0 19.0 Version Code - National 9v99 05 244 248
AA0 20.0 Version Code - Local 9v99 05 249 253
AA0 21.0 Test/Production Indicator X 04 254 257
AA0 22.0 Software Issuer ID/Vendor ID X 08 258 265
AA0 23.0 (Re)transmission Status X 01 266 266
AA0 24.0 Original Submitter ID X 16 267 282
AA0 25.0 Vendor Application Category X 01 283 283
AA0 26.0 Vendor Software Version X 05 284 288
AA0 27.0 Vendor Software Update X 02 289 290
AA0 28.0 Filler - National X 02 291 292
AA0 29.0 Filler - Local X 28 293 320
© 2002-2005 Emdeon Corporation. All Rights Reserved. Version 2.01, March 2006
RECORD LAYOUT
Record Type: BA0

BA0 01.0 Record Type 'BA0' X 03 01 03
BA0 02.0 EMC Provider ID X 15 04 18
BA0 03.0 Batch Type X 03 19 21
BA0 04.0 Batch Sequence Number 9 04 22 25
BA0 05.0 Batch ID X 06 26 31
BA0 06.0 Billing Provider Tax ID X 09 32 40
BA0 07.0 Billing Provider Site ID X 06 41 46
BA0 08.0 Billing Provider Tax ID Type X 01 47 47
BA0 09.0 Billing Provider Medicare Number X 15 48 62
BA0 10.0 Billing Provider UPIN X 06 63 68
BA0 11.0 Billing Provider USIN X 06 69 74
BA0 12.0 Billing Provider Medicaid Number X 15 75 89
BA0 13.0 Billing Provider CHAMPUS Number X 15 90 104
BA0 14.0 Billing Provider Blue Shield Number X 15 105 119
BA0 15.0 Billing Provider Commercial Number X 15 120 134
BA0 16.0 Billing Provider Secondary ID X 15 135 149
BA0 17.0 Billing Provider NPI X 15 150 164
BA0 18.0 Billing Provider Organization Name X 33 165 197
BA0 19.0 Billing Provider Last Name X 20 198 217
BA0 20.0 Billing Provider First Name X 12 218 229
BA0 21.0 Billing Provider Middle Name X 01 230 230
BA0 22.0 Billing Provider Specialty Code X 03 231 233
BA0 23.0 Billing Provider Specialty License Number X 15 234 248
BA0 24.0 Billing Provider State License Number X 15 249 263
BA0 25.0 Billing Provider Dentist License Number X 15 264 278
BA0 26.0 Billing Provider Anesthesia License Number X 15 279 293
BA0 27.0 Filler - National X 03 294 296
BA0 28.0 Billing Provider Taxonomy X 10 297 306
BA0 29.0 Billing Provider Secondary ID Qualifier X 02 307 308
BA0 30.0 Filler X 10 309 318
BA0 31.0 Reserved Filler X 01 319 319
BA0 32.0 Rendering Provider Flag X 01 320 320
RECORD LAYOUT
Record Type: BA1

BA1 05.0 Batch ID X 06 26 31
BA1 06.0 Provider Type Organization X 03 32 34
BA1 07.0 Provider Service Address 1 X 30 35 64
BA1 09.0 Provider Service City X 20 95 114
BA1 10.0 Provider Service State X 02 115 116
BA1 11.0 Provider Service Zip Code X 09 117 125
BA1 12.0 Provider Service Phone Number X 10 126 135
BA1 13.0 Billing Provider Address 1 X 30 136 165
BA1 15.0 Billing Provider City X 20 196 215
BA1 16.0 Billing Provider State X 02 216 217
BA1 17.0 Billing Provider Zip Code X 09 218 226
BA1 18.0 Billing Provider Phone Number X 10 227 236
BA1 19.0 Billing Provider Contact Name X 60 237 296
BA1 20.0 Filler - Local X 24 297 320
RECORD LAYOUT
Record Type: BB0

BB0 01.0 Record Type ‘BB0’ X 03 01 03
BB0 02.0 EMC Provider ID X 15 4 18
BB0 03.0 Batch Type X 3 19 21
BB0 04.0 Batch Sequence Number 9 4 22 25
BB0 05.0 Batch ID X 6 26 31
BB0 06.0 Pay-to Provider Tax ID Type X 1 32 32
BB0 07.0 Pay-to Provider Tax ID X 9 33 41
BB0 08.0 Filler X 3 42 44
BB0 09.0 Pay-to Provider Entity Type Code X 1 45 45
BB0 10.0 Pay-to Provider Organization /Last Name X 35 46 80
BB0 11.0 Pay-to Provider First Name X 12 81 92
BB0 12.0 Pay-to Provider Middle Name X 1 93 93
BB0 13.0 Pay-to Provider Suffix X 10 94 103
BB0 14.0 Pay-to Provider NPI X 10 104 113
BB0 15.0 Pay-to Provider Secondary ID Qualifier X 2 114 115
BB0 16.0 Pay-to Provider Secondary ID X 15 116 130
BB0 17.0 Filler X 36 131 166
BB0 18.0 Pay-to Provider Taxonomy Code X 10 167 176
BB0 19.0 Pay-to Provider Address 1 X 30 177 206
BB0 21.0 Pay-to Provider City X 20 237 256
BB0 22.0 Pay-to Provider State X 2 257 258
BB0 23.0 Pay-to Provider Zip Code X 9 259 267
BB0 24.0 Filler X 53 268 320
RECORD LAYOUT
Record Type: CA0

CA0 01.0 Record Type 'CA0' X 03 01 03
CA0 02.0 TPO Participation Indicator X 01 04 04
CA0 02.0 Type of Transaction X 01 05 05
CA0 03.0 Patient Control Number X 17 06 22
CA0 04.0 Patient Last Name X 20 23 42
CA0 05.0 Patient First Name X 12 43 54
CA0 06.0 Patient Middle Initial X 01 55 55
CA0 07.0 Patient Generation X 03 56 58
CA0 08.0 Patient Date of Birth 9 08 59 66
CA0 09.0 Patient Sex X 01 67 67
CA0 10.0 Patient Type of Residence X 01 68 68
CA0 11.0 Patient Address 1 X 30 69 98
CA0 13.0 Patient City X 20 129 148
CA0 14.0 Patient State X 02 149 150
CA0 15.0 Patient Zip Code X 09 151 159
CA0 16.0 Patient Telephone Number X 10 160 169
CA0 17.0 Patient Marital Status X 01 170 170
CA0 18.0 Patient Student Status X 01 171 171
CA0 19.0 Patient Employment Status X 01 172 172
CA0 20.0 Patient Death Indicator X 01 173 173
CA0 21.0 Date of Death 9 08 174 181
CA0 22.0 Other Insurance Indicator X 01 182 182
CA0 23.0 Claim Adjudication - Receiver Type X 01 183 183
CA0 24.0 Type Claim Indicator X 02 184 185
CA0 25.0 Legal Representative Indicator X 01 186 186
CA0 26.0 Origin Code X 09 187 195
CA0 27.0 Payer Claim Control Number X 17 196 212
CA0 28.0 Provider Number X 15 213 227
CA0 29.0 Claim ID Number X 06 228 233
CA0 30.0 Patient Weight X 04 234 237
CA0 31.0 Pregnancy Indicator X 01 238 238
CA0 32.0 Patient ID Qualifier X 02 239 240
CA0 33.0 Filler X 24 241 264
CA0 34.0 Patient Secondary ID Qualifier X 02 265 266
CA0 35.0 Patient Secondary ID X 30 267 296
CA0 36.0 Claim Sequence Number X 14 297 310
CA0 37.0 Patient ID X 10 311 320
RECORD LAYOUT
Record Type: CA1

CA1 02.0 Reserved Filler X 02 04 05
CA1 04.0 Purchase Order Number X 10 23 32
CA1 05.0 Tribe 9 03 33 35
CA1 06.0 Residency Code 9 07 36 42
CA1 07.0 Patient Health Record Number 9 06 43 48
CA1 08.0 Authorizing Facility Number X 09 49 57
CA1 09.0 Multiple Claim Indicator X 01 58 58
CA1 10.0 Filler - National X 262 59 320
RECORD LAYOUT
Record Type: CB0

CB0 01.0 Record Type 'CB0' X 03 01 03
CB0 02.0 Reserved Filler X 02 04 05
CB0 03.0 Patient Control Number X 17 06 22
CB0 04.0 Responsible Person Last Name X 20 23 42
CB0 05.0 Responsible Person First Name X 12 43 54
CB0 06.0 Responsible Person Middle Initial X 01 55 55
CB0 07.0 Responsible Person Address 1 X 30 56 85
CB0 09.0 Responsible Person City X 20 116 135
CB0 10.0 Responsible Person State X 02 136 137
CB0 11.0 Responsible Person Zip Code X 09 138 146
CB0 12.0 Responsible Person Telephone Number X 10 147 156
CB0 13.0 Filler - National X 82 157 238
CB0 14.0 Filler - Local X 82 239 320
RECORD LAYOUT
Record Type: DA0

DA0 01.0 Record Type 'DA0' X 03 01 03
DA0 02.0 Payer Responsibility 9 02 04 05
DA0 03.0 Patient Control Number X 17 06 22
DA0 04.0 Claim Filing Indicator X 01 23 23
DA0 05.0 Source of Payment X 01 24 24
DA0 06.0 Insurance Type Code X 02 25 26
DA0 07.0 Payer Organization ID X 05 27 31
DA0 08.0 Payer Claim Office Number X 04 32 35
DA0 09.0 Payer Name X 33 36 68
DA0 10.0 Group Number X 20 69 88
DA0 11.0 Group Name X 33 89 121
DA0 12.0 PPO/HMO Indicator X 01 122 122
DA0 13.0 PPO ID X 15 123 137
DA0 14.0 Prior Authorization Number X 15 138 152
DA0 15.0 Assignment of Benefits Indicator X 01 153 153
DA0 16.0 Patient Signature Source X 01 154 154
DA0 17.0 Patient Relationship to Insured 9 02 155 156
DA0 18.0 Insured ID Number X 25 157 181
DA0 19.0 Insured Last Name X 20 182 201
DA0 20.0 Insured First Name X 12 202 213
DA0 21.0 Insured Middle Initial X 01 214 214
DA0 22.0 Insured Generation X 03 215 217
DA0 23.0 Insured Sex X 01 218 218
DA0 24.0 Insured Date of Birth 9 08 219 226
DA0 25.0 Insured Employment Status X 01 227 227
DA0 26.0 Supplemental Insurance Indicator X 01 228 228
DA0 27.0 Insurance Location ID X 07 229 235
DA0 28.0 Medicaid ID Number X 25 236 260
DA0 29.0 Other Payer Patient ID X 10 261 270
DA0 30.0 Other Payer Patient ID Qualifier X 02 271 272
DA0 31.0 Payer Secondary ID Qualifier X 02 273 274
DA0 32.0 Payer Secondary ID X 15 275 289
DA0 33.0 Obligated to Accept Amount 9v99 7 290 296
DA0 34.0 Filler X 24 297 320
RECORD LAYOUT
Record Type: DA1

DA1 04.0 Payer Address Line 1 X 30 23 52
DA1 06.0 Payer City X 20 83 102
DA1 07.0 Payer State X 02 103 104
DA1 08.0 Payer Zip X 09 105 113
DA1 09.0 Disallowed Cost Containment Amount 9v99 7 114 120
DA1 10.0 Disallowed Other Amount 9v99 07 121 127
DA1 11.0 Allowed Amount 9v99 07 128 134
DA1 12.0 Deductible Amount X 07 135 141
DA1 13.0 Coinsurance Amount X 07 142 148
DA1 14.0 Payer Amount Paid 9v99 07 149 155
DA1 15.0 Zero Pay Indicator X 01 156 156
DA1 16.0 Adjudication Indicator 1 X 02 157 158
DA1 19.0 CHAMPUS Sponsor Branch X 01 163 163
DA1 20.0 CHAMPUS Sponsor Grade X 02 164 165
DA1 21.0 CHAMPUS Sponsor Status X 01 166 166
DA1 22.0 Insurance Card Effect Date 9 08 167 174
DA1 23.0 Insurance Card Term Date 9 08 175 182
DA1 24.0 Balance Due 9v99 07 183 189
DA1 25.0 Claim Adjudication Date 9 08 190 197
DA1 26.0 Claim Adjustment Indicator 1 X 01 198 198
DA1 28.0 Approved Amount 9v99 08 200 207
DA1 29.0 Patient Responsibility Amount 9v99 08 208 215
DA1 30.0 Covered Amount 9v99 08 216 223
DA1 31.0 Discount Amount 9v99 08 224 231
DA1 32.0 Per Day Limit Amount 9v99 08 232 239
DA1 33.0 Amount Paid to Patient 9v99 08 240 247
DA1 34.0 Tax Amount 9v99 08 248 255
DA1 35.0 Total Claim Before Taxes 9v99 08 256 263
DA1 36.0 MOA Reimbursement Amount 9v99 08 264 271
DA1 37.0 MOA HCPCS Payable Amount 9v99 08 272 279
DA1 38.0 MOA Claim Payment Remark 1 X 05 280 284
DA1 43.0 MOA ESRD Payable Amount 9v99 08 305 312
DA1 44.0 MOA Nonpayable Professional Component Billed Amount 9v99 08 313 320
RECORD LAYOUT
Record Type: DA2

DA2 04.0 Insured Address Line 1 X 30 23 52
DA2 06.0 Insured City X 20 83 102
DA2 07.0 Insured State X 02 103 104
DA2 08.0 Insured Zip Code X 09 105 113
DA2 09.0 Insured Telephone Number X 10 114 123
DA2 10.0 Insured Retirement Date 9 08 124 131
DA2 11.0 Insured Spouse Retirement Date 9 08 132 139
DA2 12.0 Insured Employer Name X 33 140 172
DA2 13.0 Insured Employer Address 1 X 30 173 202
DA2 15.0 Insured Employer City X 20 233 252
DA2 16.0 Insured Employer State X 02 253 254
DA2 17.0 Insured Employer Zip Code X 09 255 263
DA2 18.0 Employer Identification Number X 12 264 275
DA2 19.0 Original Reference Number X 30 276 305
DA2 20.0 Filler - Local X 15 306 320
RECORD LAYOUT
Record Type: DA3

DA3 03.0 Sub Sequence Number 9 02 06 07
DA3 04.0 Filler X 03 08 10
DA3 06.0 Filler X 17 28 44
DA3 07.0 CAS Group X 02 45 46
DA3 08.0 CAS Code 1 X 05 47 51
DA3 09.0 CAS Amount 1 9v99 08 52 59
DA3 10.0 CAS Quantity 1 9 10 60 69
DA3 11.0 CAS Code 2 X 05 70 74
DA3 12.0 CAS Amount 2 9v99 08 75 82
DA3 13.0 CAS Quantity 2 9 10 83 92
DA3 14.0 CAS Code 3 X 05 93 97
DA3 15.0 CAS Amount 3 9v99 08 98 105
DA3 16.0 CAS Quantity 3 9 10 106 115
DA3 17.0 CAS Code 4 X 05 116 120
DA3 18.0 CAS Amount 4 9v99 08 121 128
DA3 19.0 CAS Quantity 4 9 10 129 138
DA3 20.0 CAS Code 5 X 05 139 143
DA3 21.0 CAS Amount 5 9v99 08 144 151
DA3 22.0 CAS Quantity 5 9 10 152 161
DA3 23.0 CAS Code 6 X 05 162 166
DA3 24.0 CAS Amount 6 9v99 08 167 174
DA3 25.0 CAS Quantity 6 9 10 175 184
DA3 26.0 Filler X 136 185 320
RECORD LAYOUT
Record Type: DA@

DA@ 01.0 Record Type 'DA@' X 03 01 03
DA@ 02.0 Payer Responsibility 9 02 04 05
DA@ 03.0 Patient Control Number X 17 06 22
DA@ 04.0 BC/BS Plan Code X 05 23 27
DA@ 05.0 Filler - Local X 293 28 320
RECORD LAYOUT
Record Type: EA0

EA0 01.0 Record Type 'EA0' X 03 01 03
EA0 02.0 Reserved Filler X 02 04 05
EA0 03.0 Patient Control Number X 17 06 22
EA0 04.0 Employment Related Indicator X 01 23 23
EA0 05.0 Accident Indicator X 01 24 24
EA0 06.0 Symptom Indicator X 01 25 25
EA0 07.0 Accident/Symptom Date 9 08 26 33
EA0 08.0 External Cause of Accident X 05 34 38
EA0 09.0 Responsibility Indicator X 01 39 39
EA0 10.0 Accident State X 02 40 41
EA0 11.0 Accident Hour X 02 42 43
EA0 12.0 Abuse Indicator X 01 44 44
EA0 13.0 Release of Information Indicator X 01 45 45
EA0 14.0 Release of Information Date 9 08 46 53
EA0 15.0 Same/Similar Symptom Indicator X 01 54 54
EA0 16.0 Same/Similar Symptom Date 9 08 55 62
EA0 17.0 Disability Type X 01 63 63
EA0 18.0 Disability From Date 9 08 64 71
EA0 19.0 Disability To Date 9 08 72 79
EA0 20.0 Referring Provider Tax ID X 15 80 94
EA0 20.1 Referring Provider Tax ID Qualifier X 01 95 95
EA0 21.1 Diagnosis Code 5 X 5 100 104
EA0 22.0 Referring Provider Last Name X 20 120 139
EA0 23.0 Referring Provider First Name X 12 140 151
EA0 24.0 Referring Provider Middle Initial X 01 152 152
EA0 25.0 Referring Provider State X 02 153 154
EA0 26.0 Admission Date - 1 9 08 155 162
EA0 27.0 Discharge Date - 1 9 08 163 170
EA0 28.0 Laboratory Indicator X 01 171 171
EA0 29.0 Laboratory Charges 9v99 07 172 178
EA0 34.0 Provider Assignment Indicator X 01 199 199
EA0 35.0 Provider Signature Indicator X 01 200 200
EA0 36.0 Provider Signature Date 9 08 201 208
EA0 37.0 Facility/Laboratory Name X 33 209 241
EA0 38.0 Documentation Indicator X 01 242 242
EA0 39.0 Type of Documentation X 01 243 243
EA0 40.0 Functional Status Code X 02 244 245
EA0 41.0 Special Program Indicator X 02 246 247
EA0 42.0 CHAMPUS Non-Available Indicator X 01 248 248
EA0 43.0 Supervising Provider Indicator X 01 249 249
EA0 44.0 Resubmission Code X 02 250 251
EA0 45.0 Resubmission Reference Number X 15 252 266
EA0 46.0 Date Last Seen 9 08 267 274
EA0 47.0 Date Documentation Sent 9 08 275 282
EA0 48.0 Homebound Indicator X 01 283 283
EA0 49.0 Claim Place of Service X 02 284 285
EA0 50.0 Claim Frequency Code X 01 286 286
EA0 51.0 IDE Number X 15 287 301
EA0 52.0 Referring Provider NPI X 10 302 311
EA0 53.0 Filler X 08 312 319
EA0 54.0 Emergency/Urgent Indicator X 01 320 320
RECORD LAYOUT
Record Type: EA1

EA1 04.0 Facility/Lab Tax ID X 15 23 37
EA1 04.1 Facility/Lab Tax ID Qualifier X 01 38 38
EA1 05.0 Supervising Provider Tax ID Qualifier X 01 39 39
EA1 05.1 Supervising Provider Tax ID X 09 40 48
EA1 07.0 Facility Type Qualifier X 02 51 52
EA1 08.0 Facility/Lab Address - 1 X 30 53 82
EA1 10.0 Facility/Lab City X 20 113 132
EA1 11.0 Facility/Lab State X 02 133 134
EA1 12.0 Facility/Lab Zip X 09 135 143
EA1 13.0 Medical Record Number X 17 144 160
EA1 14.0 Return to Work Date 9 08 161 168
EA1 15.0 First Consult/Surgery Date 9 08 169 176
EA1 16.0 Admission Date 2 9 08 177 184
EA1 17.0 Discharge Date 2 9 08 185 192
EA1 18.0 Supervising Provider Secondary ID X 15 193 207
EA1 18.1 Supervising Provider Secondary ID Qualifier X 02 208 209
EA1 19.0 Supervising Provider NPI X 10 210 219
EA1 19.1 Filler X 03 220 222
EA1 20.0 Supervising Provider Last Name X 20 223 242
EA1 21.0 Supervising Provider First Name X 12 243 254
EA1 22.0 Supervising Provider Middle Initial X 01 255 255
EA1 23.0 Supervising Provider State X 02 256 257
EA1 24.0 EMT/Paramedic Last Name X 20 258 277
EA1 25.0 EMT/Paramedic First Name X 12 278 289
EA1 26.0 EMT/Paramedic Middle Initial X 01 290 290
EA1 27.0 Facility/Lab Provider NPI X 10 291 300
EA1 28.0 Facility/Lab Secondary ID Qualifier X 02 301 302
EA1 29.0 Facility/Lab Secondary ID X 15 303 317
EA1 30.0 Filler - Local X 03 318 320
RECORD LAYOUT
Record Type: EA3

EA3 02.0 Filler X 02 04 5
EA3 04.0 Referral Number X 15 23 37
EA3 05.0 Referring Provider Taxonomy X 11 38 48
EA3 06.0 Delay Reason Code X 02 49 50
EA3 07.0 Relinquished Care Date 9 08 51 58
EA3 08.0 Assumed Care Date 9 08 59 66
EA3 09.0 Filler X 04 67 70
EA3 10.0 Total Purchased Service Amount 9v99 06 71 76
EA3 11.0 Mammography Certification Number X 15 77 91
EA3 12.0 CLIA Number X 15 92 106
EA3 13.0 Auto Accident Country Code X 03 107 109
EA3 14.0 Participation Agreement Code X 01 110 110
EA3 15.0 Hearing/Vision Rx Date 9 08 111 118
EA3 16.0 Date Last Worked 9 08 119 126
EA3 17.0 Attachment Control Number X 35 127 161
EA3 18.0 Service Authorization Exception Code X 01 162 162
EA3 19.0 EPSDT Referral Certification Indicator X 01 163 163
EA3 20.0 EPSDT Referral Condition Code 1 X 02 164 165
EA3 25.0 Purchased Service Provider Tax ID Type X 01 174 174
EA3 26.0 Purchased Service Provider Tax ID X 09 175 183
EA3 27.0 Vision Category X 02 184 185
EA3 28.0 Vision Certification Indicator X 01 186 186
EA3 29.0 Vision Condition Code 1 X 02 187 188
EA3 48.0 Filler - Reserved X 98 223 320
RECORD LAYOUT
Record Type: EA@

EA@ 01.0 Record Type 'EA@' X 03 01 03
EA@ 02.0 Reserved X 02 04 05
EA@ 03.0 Patient Control Number X 17 06 22
EA@ 04.0 Champus Responsible Person Last Name X 20 23 42
EA@ 05.0 Champus Responsible First Name X 15 43 57
EA@ 06.0 Champus Responsible Middle Initial X 01 58 58
EA@ 07.0 Military Accident Indicator X 01 59 59
EA@ 08.0 Non-Avail Statement Number X 11 60 70
EA@ 09.0 Special Process Indicator X 01 71 71
EA@ 10.0 Zero Other Health Insurance Payment Reason X 02 72 73
EA@ 11.0 Program for Handicapped Indicator X 02 74 75
EA@ 12.0 Filler X 25 76 100
EA@ 13.0 Provider Certification Statement Indicator X 01 101 101
EA@ 14.0 Claim Adjustment Code X 01 102 102
EA@ 15.0 Billing Exception Code X 02 103 104
EA@ 16.0 Filler X 06 105 110
EA@ 17.0 Type of Attachment X 02 111 112
EA@ 18.0 Reject Claim CRN X 10 113 122
EA@ 19.0 Reject Claim RA X 02 123 124
EA@ 20.0 Medicaid Type of Claim X 03 125 127
EA@ 21.0 Claim Processor Specific 1 X 08 128 135
EA@ 24.0 Filler X 03 152 154
EA@ 24.1 Rendering Provider Tax ID Qualifier X 01 155 155
EA@ 25.0 Rendering Provider Tax ID 9 09 156 164
EA@ 26.0 Rendering Provider Name Qualifier X 01 165 165
EA@ 27.0 Rendering Provider Organization/Last Name X 17 166 182
EA@ 28.0 Rendering Provider Qualification Degree X 03 183 185
EA@ 29.0 Rendering Provider First Name X 10 186 195
EA@ 30.0 Rendering Provider Middle Initial X 01 196 196
EA@ 31.0 Rendering Provider Specialty Code X 03 197 199
EA@ 32.0 Rendering Provider Secondary ID X 15 200 214
EA@ 33.0 Referring Provider Secondary ID X 15 215 229
EA@ 34.0 Referring Provider Phone Number 9 10 230 239
EA@ 35.0 Referral Number X 15 240 254
EA@ 36.0 Authorization Number X 15 255 269
EA@ 37.0 HMO Code X 03 270 272
EA@ 38.0 Claim Type Indicator 9 01 273 273
EA@ 39.0 Rendering Provider Taxonomy X 10 274 283
EA@ 40.0 Referring Provider Secondary ID Qualifier X 02 284 285
EA@ 41.0 Rendering Provider NPI X 10 286 295
EA@ 42.0 Rendering Provider Secondary ID Qualifier X 2 296 297
EA@ 43.0 Filler X 23 298 320
RECORD LAYOUT
Record Type: FA0

FA0 01.0 Record Type 'FA0' X 03 01 03
FA0 02.0 Sequence Number 9 02 04 05
FA0 03.0 Patient Control Number X 17 06 22
FA0 04.0 Line Item Control Number X 17 23 39
FA0 05.0 Service From Date 9 08 40 47
FA0 06.0 Service To Date 9 08 48 55
FA0 07.0 Place of Service X 02 56 57
FA0 08.0 Type of Service X 02 58 59
FA0 09.0 HCPCS Procedure Code X 05 60 64
FA0 10.0 HCPCS Modifier 1 X 02 65 66
FA0 13.0 Line Charges 9v99 07 71 77
FA0 14.0 Diagnosis Code Pointer 1 X 01 78 78
FA0 18.0 Units of Service 9v9 04 82 85
FA0 19.0 Anesthesia/Oxygen Minutes 9 04 86 89
FA0 20.0 Emergency Indicator X 01 90 90
FA0 21.0 COB Indicator X 01 91 91
FA0 22.0 HPSA Indicator X 01 92 92
FA0 23.0 Rendering Provider ID X 15 93 107
FA0 24.0 Referring Provider ID X 15 108 122
FA0 25.0 Referring Provider State X 02 123 124
FA0 26.0 Purchase Service Indicator X 01 125 125
FA0 27.0 Disallowed Cost Containment 9v99 07 126 132
FA0 28.0 Disallowed Other 9v99 07 133 139
FA0 29.0 Review by Code Indicator X 01 140 140
FA0 30.0 Multiple Procedure Indicator X 01 141 141
FA0 31.0 Mammography Certification Number X 10 142 151
FA0 32.0 Class Findings X 09 152 160
FA0 33.0 Podiatry Service Condition X 03 161 163
FA0 34.0 CLIA ID Number X 15 164 178
FA0 35.0 Primary Paid Amount 9v99 07 179 185
FA0 37.0 Provider Specialty X 03 188 190
FA0 38.0 Podiatry Therapy Indicator X 01 191 191
FA0 39.0 Podiatry Therapy Type X 01 192 192
FA0 40.0 Hospice Employed Provider Indicator X 01 193 193
FA0 41.0 HGB/HCT Date 9 08 194 201
FA0 42.0 Hemoglobin Result 9 03 202 204
FA0 43.0 Hematocrit Result 9 02 205 206
FA0 44.0 Patient Weight 9 03 207 209
FA0 45.0 Epoetin Dosage 9 03 210 212
FA0 46.0 Serum Creatine Date 9 08 213 220
FA0 47.0 Creatine Result 9 03 221 223
FA0 48.0 Obligated to Accept Amount 9v99 07 224 230
FA0 49.0 Drug Discount Amount 9v99 07 231 237
FA0 50.0 UPN X 14 238 251
FA0 51.0 Vendor Product Number X 14 252 265
FA0 52.0 Date Last Seen 9 08 266 273
FA0 53.0 Sales Tax Amount 9v99 07 274 280
FA0 54.0 Referring CLIA Number X 14 281 294
FA0 55.0 Filler X 26 295 320
RECORD LAYOUT
Record Type: FA@

FA@ 01.0 Record Type 'FA@' X 03 01 03
FA@ 02.0 Sequence Number 9 02 04 05
FA@ 03.0 Patient Control Number X 17 06 22
FA@ 04.0 Line Item Control Number X 17 23 39
FA@ 05.0 Rendering Provider Tax ID 9 09 40 48
FA@ 06.0 Rendering Provider Name Qualifier X 01 49 49
FA@ 07.0 Rendering Provider Organization/Last Name X 17 50 66
FA@ 08.0 Rendering Provider First Name X 10 67 76
FA@ 09.0 Rendering Provider Middle Initial X 01 77 77
FA@ 10.0 Rendering Provider Qualification Degree X 03 78 80
FA@ 11.0 Rendering Provider Specialty Code X 03 81 83
FA@ 12.0 Rendering Provider Secondary ID X 15 84 98
FA@ 13.0 Rendering Provider Address X 18 99 116
FA@ 14.0 Rendering Provider City X 15 117 131
FA@ 15.0 Rendering Provider State X 02 132 133
FA@ 16.0 Rendering Provider Zip Code 9 09 134 142
FA@ 17.0 Rendering Provider Taxonomy X 10 143 152
FA@ 18.0 Rendering Provider NPI X 10 153 162
FA@ 19.0 Rendering Provider Tax ID Qualifier X 01 163 163
FA@ 20.0 Rendering Provider Secondary ID Qualifier X 02 164 165
FA@ 21.0 Filler - Local X 155 166 320
RECORD LAYOUT
Record Type: FB0

FB0 01.0 Record Type 'FB0' X 03 01 03
FB0 02.0 Sequence Number 9 02 04 05
FB0 03.0 Patient Control Number X 17 06 22
FB0 04.0 Line Item Control Number X 17 23 39
FB0 05.0 Purchase Service Charge 9v99 07 40 46
FB0 06.0 Allowed Amount 9v99 07 47 53
FB0 07.0 Deductible Amount 9v99 07 54 60
FB0 08.0 Coinsurance Amount 9v99 07 61 67
FB0 09.0 Ordering Provider NPI X 10 68 77
FB0 09.1 Filler X 05 78 82
FB0 10.0 Ordering Provider State X 02 83 84
FB0 11.0 Purchase Service Provider NPI X 10 85 94
FB0 11.1 Filler X 05 95 99
FB0 12.0 Purchase Service State X 02 100 101
FB0 13.0 PEN Grams of Protein 9 04 102 105
FB0 14.0 PEN Calories 9 04 106 109
FB0 15.0 National Drug Code X 11 110 120
FB0 16.0 National Drug Units 9v99 07 121 127
FB0 17.0 Prescription Number X 15 128 142
FB0 18.0 Prescription Date 9 08 143 150
FB0 19.0 Prescription Number of Months 9 02 151 152
FB0 20.0 Special Pricing Indicator X 01 153 153
FB0 21.0 Copay Status Indicator X 01 154 154
FB0 22.0 EPSDT Indicator X 01 155 155
FB0 23.0 Family Planning Indicator X 01 156 156
FB0 24.0 DME Charge Indicator X 01 157 157
FB0 25.0 HPSA Facility ID X 15 158 172
FB0 26.0 HPSA Facility Zip Code X 09 173 181
FB0 27.0 Purchase Service Name X 33 182 214
FB0 28.0 Purchase Service Address 1 X 30 215 244
FB0 30.0 Purchase Service City X 20 275 294
FB0 31.0 Purchase Service Zip Code X 09 295 303
FB0 32.0 Purchase Service Phone X 10 304 313
FB0 33.0 Drug Days Supply 9 03 314 316
FB0 34.0 Filler - National X 02 317 318
FB0 35.0 Filler - Local X 02 319 320
RECORD LAYOUT
Record Type: FB1

FB1 05.0 Place of Service Name X 33 40 72
FB1 06.0 Ordering Provider Last Name X 20 73 92
FB1 07.0 Ordering Provider First Name X 12 93 104
FB1 08.0 Ordering Provider Middle Initial X 01 105 105
FB1 09.0 Ordering Provider Secondary ID X 15 106 120
FB1 10.0 Referring Provider Last Name X 20 121 140
FB1 11.0 Referring Provider First Name X 12 141 152
FB1 12.0 Referring Provider Middle Initial X 01 153 153
FB1 13.0 Referring Provider Secondary ID X 15 154 168
FB1 14.0 Rendering Provider Last Name X 20 169 188
FB1 15.0 Rendering Provider First Name X 12 189 200
FB1 16.0 Rendering Provider Middle Initial X 01 201 201
FB1 17.0 Rendering Provider UPIN X 15 202 216
FB1 18.0 Supervising Provider Last Name X 20 217 236
FB1 19.0 Supervising Provider First Name X 12 237 248
FB1 20.0 Supervising Provider Middle Initial X 01 249 249
FB1 21.0 Supervising Provider NPI X 10 250 259
FB1 21.1 Filler X 05 260 264
FB1 22.0 Supervising Provider Secondary ID X 15 265 279
FB1 23.0 Ordering Provider Secondary ID Qualifier X 02 280 281
FB1 24.0 Referring Provider Secondary ID Qualifier X 02 282 283
FB1 25.0 Supervising Provider Secondary ID Qualifier X 02 284 285
FB1 26.0 Purchased Service Provider Secondary ID Qualifier X 02 286 287
FB1 27.0 Purchased Service Provider Secondary ID X 15 288 302
FB1 28.0 Referring Provider NPI X 10 303 312
FB1 29.0 Filler - Local X 08 313 320
RECORD LAYOUT
Record Type: FB2

FB2 05.0 Provider Type Indicator A X 02 40 41
FB2 06.0 Provider A Address 1 X 30 42 71
FB2 08.0 Provider A City X 20 102 121
FB2 09.0 Provider A State X 02 122 123
FB2 10.0 Provider A Zip Code X 09 124 132
FB2 11.0 Provider Type Indicator B X 02 133 134
FB2 12.0 Provider B Address 1 X 30 135 164
FB2 14.0 Provider B City X 20 195 214
FB2 15.0 Provider B State X 02 215 216
FB2 16.0 Provider B Zip Code X 09 217 225
FB2 17.0 Provider Type Indicator C X 02 226 227
FB2 18.0 Provider C Address 1 X 30 228 257
FB2 20.0 Provider C City X 20 288 307
FB2 21.0 Provider C State X 02 308 309
FB2 22.0 Provider C Zip Code X 09 310 318
RECORD LAYOUT
Record Type: FB3

FB3 03.0 Sub Sequence Number 9 02 06 07
FB3 04.0 Filler X 01 08 08
FB3 07.0 Payer ID X 05 43 47
FB3 08.0 Procedure Code Qualifier X 02 48 49
FB3 09.0 Procedure Code X 05 50 54
FB3 10.0 Filler X 02 55 56
FB3 11.0 Procedure Code Modifier 1 X 02 57 58
FB3 15.0 Procedure Code Description X 80 65 144
FB3 16.0 Paid Units of Service 9v9 15 145 159
FB3 17.0 Bundled Line Number X 06 160 165
FB3 18.0 Adjudication or Payment Date 9 08 166 173
FB3 19.0 Service Line Paid Amount 9v99 08 174 181
FB3 20.0 Filler X 139 182 320
RECORD LAYOUT
Record Type: FB4

FB4 04.0 Filler X 01 08 08
FB4 05.0 CAS Record Counter X 02 09 10
FB4 08.0 CAS Group X 02 45 46
FB4 09.0 CAS Code 1 X 05 47 51
FB4 10.0 CAS Amount 1 9v99 08 52 59
FB4 11.0 CAS Quantity 1 9 10 60 69
FB4 12.0 CAS Code 2 X 05 70 74
FB4 13.0 CAS Amount 2 9v99 08 75 82
FB4 14.0 CAS Quantity 2 9 10 83 92
FB4 15.0 CAS Code 3 X 05 93 97
FB4 16.0 CAS Amount 3 9v99 08 98 105
FB4 17.0 CAS Quantity 3 9 10 106 115
FB4 18.0 CAS Code 4 X 05 116 120
FB4 19.0 CAS Amount 4 9v99 08 121 128
FB4 20.0 CAS Quantity 4 9 10 129 138
FB4 21.0 CAS Code 5 X 05 139 143
FB4 22.0 CAS Amount 5 9v99 08 144 151
FB4 23.0 CAS Quantity 5 9 10 152 161
FB4 24.0 CAS Code 6 X 05 162 166
FB4 25.0 CAS Amount 6 9v99 08 167 174
FB4 26.0 CAS Quantity 6 9 10 175 184
FB4 27.0 Filler X 136 185 320
RECORD LAYOUT
Record Type: FE0

FE0 01.0 Record Type 'FE0' X 03 01 03
FE0 02.0 Sequence Number 9 02 04 05
FE0 03.0 Patient Control Number X 17 06 22
FE0 04.0 Line Item Control Number X 17 23 39
FE0 05.0 TPO Identification Number X 09 40 48
FE0 06.0 TPO Reference Number X 15 49 63
FE0 07.0 Pricing Methodology X 02 64 65
FE0 08.0 Allowed Amount 9v99 07 66 72
FE0 09.0 Savings Amount 9v99 07 73 79
FE0 10.0 Approved Procedure Code X 05 80 84
FE0 11.0 Approved Units 9v9 04 85 88
FE0 12.0 Rejection Message X 02 89 90
FE0 13.0 Authorization Number X 20 91 110
FE0 14.0 Policy Compliance Code X 02 111 112
FE0 15.0 Exception Code X 02 113 114
FE0 16.0 Adjusted Repriced Claim Number X 15 115 129
FE0 17.0 Filler - National X 191 130 320
RECORD LAYOUT
Record Type: GA0

GA0 01.0 Record Type 'GA0' X 03 01 03
GA0 02.0 Sequence Number 9 02 04 05
GA0 03.0 Patient Control Number X 17 06 22
GA0 04.0 Reserved Filler X 17 23 39
GA0 05.0 Patient Weight 9 03 40 42
GA0 06.0 Hospital Admit X 01 43 43
GA0 07.0 Type of Transport X 01 44 44
GA0 08.0 Bed Confined-Before X 01 45 45
GA0 09.0 Bed Confined-After X 01 46 46
GA0 10.0 Moved by Stretcher X 01 47 47
GA0 11.0 Unconscious/Shock X 01 48 48
GA0 12.0 Emergency Situation X 01 49 49
GA0 13.0 Physical Restraints X 01 50 50
GA0 14.0 Visible Hemorrhaging X 01 51 51
GA0 15.0 Transported To/For X 01 52 52
GA0 16.0 Medically Necessary X 01 53 53
GA0 17.0 Miles X 04 54 57
GA0 18.0 Origin Information X 40 58 97
GA0 19.0 Destination Information X 40 98 137
GA0 20.0 Purpose of Round Trip X 80 138 217
GA0 21.0 Purpose of Stretcher X 80 218 297
GA0 22.0 Patient Discharged X 01 298 298
GA0 23.0 Patient Admitted X 01 299 299
GA0 24.0 Services Available X 01 300 300
GA0 25.0 Filler - National X 07 301 307
GA0 26.0 Filler - Local X 13 308 320
RECORD LAYOUT
Record Type: GC0

GC0 01.0 Record Type 'GC0' X 03 01 03
GC0 02.0 Sequence Number 9 02 04 05
GC0 03.0 Patient Control Number X 17 06 22
GC0 04.0 Reserved Filler X 17 23 39
GC0 05.0 Initial Treatment Date 9 08 40 47
GC0 06.0 Date of Last X-Ray 9 08 48 55
GC0 07.0 Number in Series X 07 56 62
GC0 08.0 Level of Subluxation X 07 63 69
GC0 09.0 Treatment Months/Years for this Series X 03 70 72
GC0 10.0 Number of Treatments - This Month X 02 73 74
GC0 11.0 Nature of Condition X 01 75 75
GC0 12.0 Date of Acute Manifestation 9 08 76 83
GC0 13.0 Complication Indicator X 01 84 84
GC0 14.0 Symptoms Description X 160 85 244
GC0 15.0 X-Ray Indicator X 01 245 245
GC0 16.0 Filler - National X 37 246 282
GC0 17.0 Filler - Local X 38 283 320
RECORD LAYOUT
Record Type: GD@

GD@ 01.0 Record Type 'GD@' X 03 01 03
GD@ 02.0 Sequence Number 9 02 04 05
GD@ 03.0 Patient Control Number X 17 06 22
GD@ 04.0 Line Item Control Number X 17 23 39
GD@ 05.0 Length of Medical Necessity 9 03 40 42
GD@ 06.0 DME Purchase Price 9v99 06 43 48
GD@ 07.0 Purchased Equipment Indicator X 01 49 49
GD@ 08.0 DME Rental Unit Price Indicator X 01 50 50
GD@ 09.0 DME Rental Price 9v99 06 51 56
GD@ 10.0 Procedure Code X 05 57 61
GD@ 11.0 Prescription/Medical Necessity Documentation Indicator X 01 62 62
GD@ 12.0 Equipment Warranty Indicator X 01 63 63
GD@ 13.0 Comments X 100 64 163
GD@ 14.0 Filler X 157 164 320
RECORD LAYOUT
Record Type: GU0

GU0 01.0 Record Type 'GU0' X 03 01 03
GU0 02.0 Sequence Number 9 02 04 05
GU0 03.0 Patient Control Number X 17 06 22
GU0 04.0 Certification Type X 01 23 23
GU0 05.0 Place of Service X 02 24 25
GU0 06.0 Replacement Item X 01 26 26
GU0 07.0 HCPCS Procedure Code X 05 27 31
GU0 08.0 HCPCS Modifier X 02 32 33
GU0 09.0 Warranty Reply X 01 34 34
GU0 10.0 Warranty Length X 02 35 36
GU0 11.0 Warranty Type X 01 37 37
GU0 12.0 Diagnosis Code-1 X 05 38 42
GU0 16.0 Patient Height 9 02 58 59
GU0 17.0 Patient Weight 9 03 60 62
GU0 18.0 Date of Last Medical Exam 9 08 63 70
GU0 19.0 Initial Date 9 08 71 78
GU0 20.0 Revision or Recertification Date 9 08 79 86
GU0 21.0 Length of Need 9 02 87 88
GU0 22.0 Date of Physician's Signature 9 08 89 96
GU0 23.0 Ordering Physician's Telephone Number X 10 97 106
GU0 24.0 Certification on File X 01 107 107
GU0 25.0 Certification Form Number 9v99 04 108 111
GU0 26.0 Reply ALN L01 N01 X 01 112 112
GU0 27.0 Reply ALN L01 N02 X 01 113 113
GU0 28.0 Reply ALN L01 N03 X 01 114 114
GU0 29.0 Reply ALN L01 N04 X 01 115 115
GU0 30.0 Reply ALN L01 N05 X 01 116 116
GU0 31.0 Reply ALN L01 N06 X 01 117 117
GU0 32.0 Reply ALN L01 N07 X 01 118 118
GU0 33.0 Reply ALN L01 N08 X 01 119 119
© 2002-2005 Emdeon Corporation. All Rights Reserved. Version 2.01, July 2006
GU0 34.0 Reply ALN L01 N09 X 01 120 120
GU0 35.0 Reply ALN L01 N10 X 01 121 121
GU0 36.0 Reply ALN L01 N11 X 01 122 122
GU0 37.0 Reply ALN L01 N12 X 01 123 123
GU0 38.0 Reply ALN L01 N13 X 01 124 124
GU0 39.0 Reply ALN L01 N14 X 01 125 125
GU0 40.0 Reply ALN L01 N15 X 01 126 126
GU0 41.0 Reply ALN L01 N16 X 01 127 127
GU0 42.0 Reply ALN L01 N17 X 01 128 128
GU0 43.0 Reply ALN L01 N18 X 01 129 129
GU0 44.0 Reply ALN L01 N19 X 01 130 130
GU0 45.0 Reply ALN L01 N20 X 01 131 131
GU0 46.0 Reply ALN L01 N21 X 01 132 132
GU0 47.0 Reply ALN L01 N22 X 01 133 133
GU0 48.0 Reply ALN L01 N23 X 01 134 134
GU0 49.0 Reply ALN L01 N24 X 01 135 135
GU0 50.0 Reply ALN L05 N01 X 05 136 140
GU0 51.0 Reply ALN L05 N02 X 05 141 145
GU0 52.0 Reply ALN L05 N03 X 05 146 150
GU0 53.0 Reply ALN L08 N01 9 08 151 158
GU0 54.0 Reply ALN L08 N02 9 08 159 166
GU0 55.0 Reply ALN L08 N03 9 08 167 174
GU0 56.0 Reply ALN L08 N04 9 08 175 182
GU0 57.0 Reply ALN L20 N01 X 20 183 202
GU0 58.0 Reply ALN L30 N01 X 30 203 232
GU0 58.1 Reply ALN L30 N02 X 30 233 262
GU0 59.0 Reply NUM L01 N01 9 01 263 263
GU0 60.0 Reply NUM L01 N02 9 01 264 264
GU0 61.0 Reply NUM L01 N03 9 01 265 265
GU0 62.0 Reply NUM L04 N01 9 04 266 269
GU0 63.0 Reply NUM L04 N02 9 04 270 273
GU0 64.0 Reply NUM L04 N03 9 04 274 277
GU0 65.0 Reply NUM L04 N04 9 04 278 281
GU0 66.0 Reply NUM L04 N05 9 04 282 285
GU0 67.0 Reply NUM L04 N06 9 04 286 289
GU0 68.0 Reply NUM L04 N07 9 04 290 293
GU0 69.0 Reply PCT L04 N01 9v9 04 294 297
GU0 70.0 Reply PCT L04 N02 9v9 04 298 301
GU0 71.0 Reply PCT L04 N03 9v9 04 302 305
GU0 72.0 DMERC CMN Indicator X 02 306 307
GU0 73.0 Filler - National X 06 308 313
GU0 74.0 Filler - Local X 07 314 320
Emdeon Business Services Technical Specifications NSF Plus GV0
RECORD LAYOUT
Record Type: GV0

GV0 01.0 Record Type 'GV0' X 3 01 03
GV0 02.0 Sequence Number X 2 04 05
GV0 03.0 Sub-Sequence Number X 2 06 07
GV0 04.0 Patient's Account Number X 17 08 24
GV0 05.0 Drug Prescription Number 1 X 30 25 54
GV0 06.1 NDC Code Qualifier 1 X 2 55 56
GV0 06.2 NDC Code 1 X 11 57 67
GV0 07.0 NDC Unit Price 1 9v99 8 68 75
GV0 08.1 NDC Unit Qualifier 1 X 2 76 77
GV0 08.2 NDC Unit 1 9v9 7 78 84
GV0 10.2 NDC Code 2 X 11 117 127
GV0 12.2 NDC Unit 2 9v9 7 138 144
GV0 14.2 NDC Code 3 X 11 177 187
GV0 16.2 NDC Unit 3 9v9 7 198 204
GV0 18.2 NDC Code 4 X 11 237 247
GV0 20.2 NDC Unit 4 9v9 7 258 264
GV0 21.0 Filler X 56 265 320
RECORD LAYOUT
Record Type: GX0

GX0 01.0 Record Type 'GX0' X 03 01 03
GX0 02.0 Sequence Number 9 02 04 05
GX0 03.0 Patient Control Number X 17 06 22
GX0 04.0 Certification Type X 01 23 23
GX0 05.0 Oxygen System X 01 24 24
GX0 06.0 Length of Need X 02 25 26
GX0 07.0 Equipment Type 1 X 01 27 27
GX0 09.0 Equipment Reason X 64 29 92
GX0 10.0 Prescribed From Date 9 08 93 100
GX0 11.0 Prescribed To Date 9 08 101 108
GX0 12.0 Date Oxygen Prescribed 9 08 109 116
GX0 13.0 Date Evaluated 9 08 117 124
GX0 14.0 Oxygen Flow Rate X 03 125 127
GX0 15.0 Frequency of Use X 02 128 129
GX0 16.0 Duration X 02 130 131
GX0 17.0 Arterial Blood Gas 4 LMP 99v9 03 132 134
GX0 18.0 Oximetry 4 LMP 99v9 03 135 137
GX0 19.0 Date Tested 4 LMP 9 08 138 145
GX0 20.0 Inpatient/Outpatient Indicator X 01 146 146
GX0 21.1 Ordering Provider Contact Name X 35 147 181
GX0 21.2 Filler X 30 182 211
GX0 22.0 Arterial Blood Gas 99v9 03 212 214
GX0 23.0 Oximetry 99v9 03 215 217
GX0 24.0 Date Tested 9 08 218 225
GX0 25.0 Test Facility Name X 33 226 258
GX0 26.0 Test Conditions X 01 259 259
GX0 27.0 Clinical Findings X 03 260 262
GX0 28.0 Portable Oxygen Flow Rate 99v9 03 263 265
GX0 29.0 Filler X 15 266 280
GX0 30.0 Ordering Provider Telephone Number X 10 281 290
GX0 31.0 Diagnosis Code-1 X 05 291 295
GX0 34.0 Diagnosis Code 4 X 05 306 310
GX0 35.0 Certification on File X 01 311 311
GX0 36.0 Delivery System Type X 01 312 312
GX0 37.0 DMERC CMN Indicator X 02 313 314
GX0 38.0 Filler - National X 06 315 320
RECORD LAYOUT
Record Type: GX2

GX2 04.0 Test Facility Address 1 X 30 23 52
GX2 06.0 Test Facility City X 20 83 102
GX2 07.0 Test Facility State X 02 103 104
GX2 08.0 Test Facility Zip X 09 105 113
GX2 09.0 Filler X 124 114 237
GX2 10.0 Test Facility Qualifier X 02 238 239
GX2 11.0 Test Facility NPI X 10 240 249
GX2 12.0 Test Facility Secondary ID Qualifier X 02 250 251
GX2 13.0 Test Facility Secondary ID X 15 252 266
GX2 14.0 Filler - Local X 54 267 320
RECORD LAYOUT
Record Type: HA0

HA0 01.0 Record Type 'HA0' X 03 01 03
HA0 02.0 Sequence Number 9 02 04 05
HA0 03.0 Patient Control Number X 17 06 22
HA0 04.0 Line Item Control Number X 17 23 39
HA0 05.0 Extra Narrative Data X 281 40 320
RECORD LAYOUT
Record Type: XA0

XA0 01.0 Record Type 'XA0' X 03 01 03
XA0 02.0 Reserved Filler X 02 04 05
XA0 03.0 Patient Control Number X 17 06 22
XA0 04.0 Record Type Cxx Count 9 02 23 24
XA0 05.0 Record Type Dxx Count 9 02 25 26
XA0 06.0 Record Type Exx Count 9 02 27 28
XA0 07.0 Record Type Fxx Count 9 04 29 32
XA0 08.0 Record Type Gxx Count 9 02 33 34
XA0 09.0 Record Type Hxx Count 9 02 35 36
XA0 10.0 Claim Record Count 9 04 37 40
XA0 12.0 Total Claim Charges 9v99 07 78 84
XA0 13.0 Total Disallowed Cost Containment Charges 9v99 07 85 91
XA0 14.0 Total Disallowed Other Charges 9v99 07 92 98
XA0 15.0 Total Allowed Amount 9v99 07 99 105
XA0 16.0 Total Deductible Amount 9v99 07 106 112
XA0 17.0 Total Coinsurance Amount 9v99 07 113 119
XA0 18.0 Total Payer Amount Paid 9v99 07 120 126
XA0 19.0 Patient Amount Paid 9v99 07 127 133
XA0 20.0 Total Purchase Service Charges 9v99 07 134 140
XA0 21.0 Provider Discount Information X 16 141 156
XA0 22.0 Remarks X 103 157 259
XA0 23.0 Filler - National X 31 260 290
XA0 24.0 Filler - Local X 15 291 305
XA0 25.0 Clearinghouse ID 9 15 306 320
RECORD LAYOUT
Record Type: YA0

YA0 01.0 Record Type 'YA0' X 03 01 03
YA0 02.0 EMC Provider ID X 15 04 18
YA0 03.0 Batch Type X 03 19 21
YA0 04.0 Batch Number 9 04 22 25
YA0 05.0 Batch ID X 06 26 31
YA0 06.0 Billing Provider Tax ID X 09 32 40
YA0 07.0 Reserved Filler X 06 41 46
YA0 08.0 Batch Service Line Count 9 07 47 53
YA0 09.0 Batch Record Count 9 07 54 60
YA0 10.0 Batch Claim Count 9 07 61 67
YA0 11.0 Batch Total Charges 9v99 09 68 76
YA0 12.0 Filler - National X 121 77 197
YA0 13.0 Filler - Local X 114 198 311
YA0 14.0 Original Submitter ID 9 09 312 320
RECORD LAYOUT
Record Type: ZA0

ZA0 01.0 Record Type 'ZA0' X 03 01 03
ZA0 02.0 Submitter ID X 16 04 19
ZA0 03.0 Reserved Filler X 09 20 28
ZA0 04.0 Receiver ID X 05 29 33
ZA0 04.0 Receiver Sub-ID X 11 34 44
ZA0 05.0 File Service Line Count 9 07 45 51
ZA0 06.0 File Record Count 9 07 52 58
ZA0 07.0 File Claim Count 9 07 59 65
ZA0 08.0 Batch Count 9 04 66 69
ZA0 09.0 File Total Charges 9v99 11 70 80
ZA0 10.0 Filler - National X 120 81 200
ZA0 11.0 Filler - Local X 120 201 320
RECORD SUMMARY
RECORD TYPE: AA0
RECORD NAME: File Header Record: Submitter Data
RECORD LEVEL: File
RECORD PURPOSE: To identify the submitter of the claim file. This can be a
provider, a vendor, a billing agency, etc.
To identify the receiver of the claim file. This is WebMD

Envoy on input, and the Payer (or claim receiver) on output.
To uniquely identify the claim file.
R None BA0

CONDITIONAL NOTE:
NOTES: Must be the first record of a claim file.
Only one (1) Record Type AA0 may be entered per file.
If CREATION DATE (fld-15.0) and SUBMISSION/SERIAL

NUMBER (fld-05.0) contain the same values as a previously
submitted file, the entire file will be rejected for "duplicate
claim file".
When a claim file is rejected at the file level, batch level and
claim level editing will not occur.
RECORD LAYOUT
Record Type: AA0

AA0 01.0 Record Type 'AA0' X 03 01 03
AA0 02.0 Submitter ID X 16 04 19
AA0 05.0 Submission/Serial Number X 06 35 40
AA0 06.0 Submitter Name X 33 41 73
AA0 09.0 Submitter City X 20 134 153
AA0 10.0 Submitter State X 02 154 155
AA0 11.0 Submitter Zip Code X 09 156 164
AA0 12.0 Submitter Region X 05 165 169
AA0 13.0 Submitter Contact X 33 170 202
AA0 14.0 Submitter Telephone Number X 10 203 212
AA0 15.0 Creation Date 9 08 213 220
AA0 16.0 Submission Time X 06 221 226
AA0 17.0 Receiver ID X 05 227 231
AA0 17.0 Receiver Sub-ID X 11 232 242
AA0 18.0 Receiver Type Code X 01 243 243
AA0 19.0 Version Code - National 9v99 05 244 248
AA0 20.0 Version Code - Local 9v99 05 249 253
AA0 21.0 Test/Production Indicator X 04 254 257
AA0 22.0 Software Issuer ID/Vendor ID X 08 258 265
AA0 23.0 (Re)transmission Status X 01 266 266
AA0 24.0 Original Submitter ID X 16 267 282
AA0 25.0 Vendor Application Category X 01 283 283
AA0 26.0 Vendor Software Version X 05 284 288
AA0 27.0 Vendor Software Update X 02 289 290
AA0 28.0 Filler - National X 02 291 292
AA0 29.0 Filler - Local X 28 293 320
Emdeon Business Services Technical Specifications NSF Plus AA0 - 01.0
DATA ELEMENT: Record Type 'AA0'
DEFINITION: A field used to identify the "File Header: Submitter Data" record.
RECORD FIELD DATA TYPE LENGTH JUSTIFY INITIALIZE FROM THRU
AA0 01.0 X 03 L Spaces 01 03
REQUIREMENTS: COMMERCIAL HMO/PPO BC/BS CHAMPUS MEDICAID MEDICARE

R R R R R R
SITUATIONAL NOTE: Not Applicable.
CODE VALUES:
VALIDATION: Must contain a value of AA0.
ERROR ACTION: REQUIREMENT VALIDATION

Reject File Reject File
NOTES: Not Applicable.
© 2002-2003, Emdeon Corporation. All Rights Reserved. Version 2.01 March 2006
DATA ELEMENT: Submitter ID
DEFINITION: The federally assigned Tax Identification Number (TIN) of the

submitter. This can also be the Employer Identification number
(EIN).
AA0 02.0 X 16 L Spaces 04 19

R R R R R R
CODE VALUES:
VALIDATION: Must be numeric.
INPUT: Must be identical to an entry on the WebMD Envoy

Submitter file.
OUTPUT: Will contain a value of '133052274'.

NOTES: Positions 13-19 will not be mapped by WebMD Envoy.
Must be identical to the SUBMITTER ID entered in Record Type ZA0

(fld-02.0).
SUBMITTER ID is one of several fields which are compared for

"duplicate" processing. If these fields contain the same values as a
claim previously submitted on the same day, the claim will be
rejected for "duplicate claim". See Exhibit 97 for detailed
information.
DATA ELEMENT: Reserved Filler
DEFINITION: Unused record space reserved by WebMD
AA0 03.0 X 09 L Spaces 20 28

R R R R R R
CODE VALUES:
VALIDATION: Not Applicable.

None None
AA0 04.0 X 06 L Spaces 29 34

R R R R R R
CODE VALUES:

None None
DATA ELEMENT: Submission/Serial Number
DEFINITION: The inventory file number assigned by the submitter for the current
claim file being submitted.
AA0 05.0 X 06 L Spaces 35 40

R R R R R R
CODE VALUES:
VALIDATION: INPUT: Must be unique from previously submitted files.
OUTPUT: Will contain the destination payer's RECEIVER ID (fld-

17.0a) in positions 1-5 plus the last digit of the payer's RECEIVER
SUB-ID (fld-17.0b) in position 6.

NOTES: The SERIAL NUMBER, CREATION DATE (fld-15.0) and FILE TOTAL
CHARGES (RT ZA0, fld-07.0) must not contain the same information
as that of a file submitted within the last three (3) months of
submission. This will cause a "Duplicate Transmission" error.
DATA ELEMENT: Submitter Name
DEFINITION: The name of the organization/provider that is submitting the file.
AA0 06.0 X 33 L Spaces 41 73

R R R R R R
CODE VALUES:
VALIDATION: Must be entered if required by receiver.

Submitter file.
OUTPUT: Will contain a value of "WebMD"
See Standard Name and Address Checks in Exhibit 2 for field

validation.

Reject File None
DATA ELEMENT: Submitter Street Address 1
DEFINITION: The mailing address of the organization/provider that is submitting

the file.
AA0 07.0 X 30 L Spaces 74 103

R R R R R R
CODE VALUES:
VALIDATION: See Standard Name and Address Checks in Exhibit 2 for field
validation.

Submitter file.
OUTPUT: Will contain WebMD Envoy's mailing address.

None None
DATA ELEMENT: Submitter Street Address 2

the file.
AA0 08.0 X 30 L Spaces 104 133

S S S S S S
SITUATIONAL NOTE: Should be entered if a second address line is necessary to provide

a complete mailing address.
CODE VALUES:
VALIDATION: If entered, see Standard Name and Address Checks in Exhibit 2 for
field validation.

Submitter file.

None None
DATA ELEMENT: Submitter City

the file.
AA0 09.0 X 20 L Spaces 134 153

R R R R R R
CODE VALUES:
validation.

Submitter file.

None None
DATA ELEMENT: Submitter State

the file.
AA0 10.0 X 02 L Spaces 154 155

R R R R R R
CODE VALUES:
validation.

Submitter file.

None None
DATA ELEMENT: Submitter Zip Code

the file.
AA0 11.0 X 09 L Spaces 156 164

R R R R R R
CODE VALUES:
validation.

Submitter file.

None None
DATA ELEMENT: Submitter Region
DEFINITION: A receiver defined field that identifies the region submitting the
claim. To be used for future regional processing.
AA0 12.0 X 05 L Spaces 165 169

R R R R R R
CODE VALUES:
VALIDATION: May only contain spaces.

None None
DATA ELEMENT: Submitter Contact
DEFINITION: Identifies an individual responsible for issues that may arise

concerning this submission.
AA0 13.0 X 33 L Spaces 170 202

R R R R R R
CODE VALUES:

None None
DATA ELEMENT: Submitter Telephone Number
DEFINITION: The telephone number, including the area code, at which the
organization/provider that is submitting the claim file may be
contacted.
AA0 14.0 X 10 L Spaces 203 212

R R R R R R
CODE VALUES:
Must be in format XXXyyyZZZZ, where:

XXX = Area code
yyy = Exchange
ZZZZ = Station number
INPUT: Must contain the submitter's telephone number.
OUTPUT: Will contain WebMD's telephone number: 6158853700.

None None
DATA ELEMENT: Creation Date
DEFINITION: The date the submitter prepares the file for transmission to WebMD
Envoy.
AA0 15.0 9 08 R Zeroes 213 220

R R R R R R
CODE VALUES:
Must be in the format CCYYMMDD.
See Standard Date and Time Checks in Exhibit 1 for field validation.
INPUT: Must be less than or equal to the date the file is received
by WebMD.
Must be less than three months prior to the date WebMD

receives
the file.
OUTPUT: Will contain WebMD's production cycle date.

NOTES: The CREATION DATE and SUBMISSION/SERIAL NUMBER (fld-05.0)

and FILE TOTAL CHARGES (RT ZA0, fld-09.0) must not contain the
same data as a file submitted within the last three (3) months. This
will cause a "Duplicate Transmission" error.
DATA ELEMENT: Submission Time
DEFINITION: Identifies the time of day that the submitter created the file.
AA0 16.0 X 06 L Spaces 221 226

R R R R R R
CODE VALUES:

None None
Emdeon Business Services Technical Specifications NSF Plus AA0 - 17.0a
DATA ELEMENT: Receiver ID
DEFINITION: A number used to identify the organization designated to receive the

file.
AA0 17.0a X 05 L Spaces 227 231

R R R R R R
CODE VALUES:
INPUT: Must contain a value of 13305.
OUTPUT: Will contain the destination payer's ID. This field is

WebMD Envoy defined.

NOTES: Must be identical to the RECEIVER ID entered in Record Type ZA0

(fld-04.0a).
Emdeon Business Services Technical Specifications NSF Plus AA0 - 17.0b
DATA ELEMENT: Receiver Sub-ID
DEFINITION: A number used to identify the specific location, within the receiver's
organization, designated to receive the file.
AA0 17.0b X 11 L Spaces 232 242

R R R R R R
CODE VALUES:
INPUT: Must contain a value of 2274.
OUTPUT: Will contain the destination payer's Sub-ID. This field is

WebMD Envoy defined.

NOTES: Must be identical to the RECEIVER SUB ID entered in Record Type

ZA0 (fld-04.0b).
DATA ELEMENT: Receiver Type Code
DEFINITION: A code indicating the type of organization designated to receive this

file.
AA0 18.0 X 01 L Spaces 243 243

R R R R R R
CODE VALUES: A Self-Pay

B Workers Comp
C Medicare
D Medicaid
E Other Federal Program
F Commercial Insurance Company
G Blue Cross/Blue Shield
H Champus
I Other
Z Multiple Principal Source of Payment
VALIDATION: Must be a valid code from the above list.
INPUT: Must contain a value of 'Z'.
OUTPUT: Will be a valid code from the above list other than 'Z'.

DATA ELEMENT: Version Code - National
DEFINITION: A code indicating the specification version being used. This is

restricted to National use.
AA0 19.0 9v99 05 R Zeroes 244 248

R R R R R R
CODE VALUES:
VALIDATION: Must contain a value of 00201.

None Reject File
NOTES: The first three (3) digits before the implied decimal will indicate
changes in record format or any new or deleted records. It is the
VERSION of the specifications.
The last two (2) digits after the implied decimal will indicate changes
in editing. It is the UPDATE NUMBER of the specifications.
DATA ELEMENT: Version Code - Local
DEFINITION: A code indicating the specification version being used. This is

restricted to Local use and applies to the LOCAL FILLER only.
AA0 20.0 9v99 05 R Zeroes 249 253

N N N N N N
CODE VALUES:

None Reject File
DATA ELEMENT: Test/Production Indicator
DEFINITION: A code indicating whether the file is to be used for test or production
purposes.
AA0 21.0 X 04 L Spaces 254 257

R R R R R R
CODE VALUES: PROD Production Indicator

TEST Test Indicator

None None
DATA ELEMENT: Software Issuer ID/Vendor ID
DEFINITION: A vendor ID assigned by WebMD Envoy used for billing purposes.
AA0 22.0 X 08 L Spaces 258 265

R R R R R R
CODE VALUES:

None None
DATA ELEMENT: (Re)transmission Status
DEFINITION: A code used to indicate the type of transmission and the inventory
file number assigned by the submitter for the current claim file being
submitted.
AA0 23.0 X 01 L Spaces 266 266

R R R R R R
CODE VALUES: 0 Normal Transmission

8 Non-Chargeable Retransmission
9 Chargeable Retransmission
INPUT: Must contain a value of zero(0).
OUTPUT: Will be a valid code from the above list.

None None
DATA ELEMENT: Original Submitter ID
DEFINITION: Identifies the original submitter of claims in this file.
AA0 24.0 X 16 L Spaces 267 282

N N N N N N
CODE VALUES:

None None
DATA ELEMENT: Vendor Application Category
DEFINITION: The category that applies to the vendor who created this file.
AA0 25.0 X 01 L Spaces 283 283

N N N N N N
CODE VALUES:

None None
DATA ELEMENT: Vendor Software Version
DEFINITION: A code used to indicate the version number and version subrelease
of the specification format being used.
AA0 26.0 X 05 L Spaces 284 288

R R R R R R
CODE VALUES:
VALIDATION: Positions 284-286 must contain a value of 002.
Position 287 must contain a value of 1.
Position 288 is not used.

DATA ELEMENT: Vendor Software Update
DEFINITION: A code used to indicate the update number and update subrelease of
the specification format being used.
AA0 27.0 X 02 L Spaces 289 290

R R R R R R
CODE VALUES:
VALIDATION: Must contain the value 00.

NOTES: This field relates to any special "fixes" or updates to the version
reported in Record Type AA0 (fld-26.0).
DATA ELEMENT: Filler - National
AA0 28.0 X 02 L Spaces 291 292

R R R R R R
CODE VALUES:

None None
DATA ELEMENT: Filler - Local
AA0 29.0 X 28 L Spaces 293 320

R R R R R R
CODE VALUES:

None None
RECORD SUMMARY
RECORD TYPE: BA0
RECORD LEVEL: Batch
RECORD PURPOSE: To identify the billing provider or billing agency for the
claims contained within this batch.
R AA0 or YA0 BA1

CONDITIONAL NOTE:
NOTES: Only one BA0 record is allowed for each batch.
Must be the first record of a batch of claims.
A maximum of 9,999 batches may be entered per file.
All batches must be sorted by three (3) variables: BILLING

PROVIDER TAX ID & BILLING PROVIDER SITE ID (flds-06.0,
07.0) AND BATCH TYPE (fld-03.0).
When a claim file is rejected on a batch level, claim level

editing will not occur.
RECORD LAYOUT
Record Type: BA0

BA0 05.0 Batch ID X 06 26 31
BA0 06.0 Billing Provider Tax ID X 09 32 40
BA0 07.0 Billing Provider Site ID X 06 41 46
BA0 08.0 Billing Provider Tax ID Type X 01 47 47
BA0 09.0 Billing Provider Medicare Number X 15 48 62
BA0 10.0 Billing Provider UPIN X 06 63 68
BA0 11.0 Billing Provider USIN X 06 69 74
BA0 12.0 Billing Provider Medicaid Number X 15 75 89
BA0 13.0 Billing Provider CHAMPUS Number X 15 90 104
BA0 14.0 Billing Provider Blue Shield Number X 15 105 119
BA0 15.0 Billing Provider Commercial Number X 15 120 134
BA0 16.0 Billing Provider Secondary ID X 15 135 149
BA0 17.0 Billing Provider NPI X 15 150 164
BA0 18.0 Billing Provider Organization Name X 33 165 197
BA0 19.0 Billing Provider Last Name X 20 198 217
BA0 20.0 Billing Provider First Name X 12 218 229
BA0 21.0 Billing Provider Middle Name X 01 230 230
BA0 22.0 Billing Provider Specialty Code X 03 231 233
BA0 23.0 Billing Provider Specialty License Number X 15 234 248
BA0 24.0 Billing Provider State License Number X 15 249 263
BA0 25.0 Billing Provider Dentist License Number X 15 264 278
BA0 26.0 Billing Provider Anesthesia License Number X 15 279 293
BA0 27.0 Filler - National X 03 294 296
BA0 28.0 Billing Provider Taxonomy X 10 297 306
BA0 29.0 Billing Provider Secondary ID Qualifier X 02 307 308
BA0 30.0 Filler X 10 309 318
BA0 31.0 Reserved Filler X 01 319 319
BA0 32.0 Rendering Provider Flag X 01 320 320
Emdeon Business Services Technical Specifications NSF Plus BA0 - 01.0
DATA ELEMENT: Record Type 'BA0'
DEFINITION: The field used to identify the "Provider Data 1" record.
BA0 01.0 X 03 L Spaces 01 03

R R R R R R
CODE VALUES:
VALIDATION: Must contain a value of BA0.

Reject Batch Reject Batch
DATA ELEMENT: EMC Provider ID
DEFINITION: The unique number assigned to the billing provider for EMC
identification purposes by the payer/receiver.
BA0 02.0 X 15 L Spaces 04 18

S S S S S S
SITUATIONAL NOTE: Must be entered if required by the payer/receiver.
CODE VALUES:

None None
NOTES: Must be identical to the EMC PROVIDER ID in the corresponding

Record Type BA1 (fld-02.0) and Record Type YA0 (fld-02.0).
DATA ELEMENT: Batch Type
DEFINITION: This field indicates the type of claims that are included within this
batch.
BA0 03.0 X 03 L Spaces 19 21

R R R R R R
CODE VALUES: 100 Medical
VALIDATION: May only contain a value of 100.

NOTES: Must be identical to the BATCH TYPE entered in Record Type BA1
(fld-03.0) and Record Type YA0 (fld-03.0).
DATA ELEMENT: Batch Sequence Number
DEFINITION: A sequential number assigned by the submitter to each batch of

claims.
BA0 04.0 9 04 R Zeroes 22 25

R R R R R R
CODE VALUES:
First occurrence must be 0001.
Whenever BILLING PROVIDER TAX ID (fld-06.0) or BATCH TYPE

(fld-03.0) or BILLING PROVIDER SITE ID (fld-07.0), changes from
those previously entered, BATCH SEQUENCE NUMBER must be
reset to 0001.
If the previous BILLING PROVIDER TAX ID (fld-06.0) or BATCH

TYPE (fld-03.0) or BILLING PROVIDER SITE ID (fld-07.0) are
identical with those currently being processed, the BATCH
SEQUENCE NUMBER must be one (1) greater than the previous
BATCH SEQUENCE NUMBER.

DATA ELEMENT: Batch ID
DEFINITION: The identifier assigned by the submitter/provider to identify a batch

within his own system.
BA0 05.0 X 06 L Spaces 26 31

N N N N N N
CODE VALUES:

None None
NOTES: Must be identical to the BATCH ID in the corresponding Record Type

BA1 (fld-05.0) and Record Type YA0 (fld-05.0).
DATA ELEMENT: Billing Provider Tax ID
DEFINITION: The federally assigned Tax Identification number (TIN) of the billing
provider. This can be either the Employer Identification Number
(EIN) or the Social Security Number (SSN).
BA0 06.0 X 09 L Spaces 32 40

R R R R R R
CODE VALUES:

NOTES: Must be identical to the PROVIDER TAX ID entered in Record Type

YA0 (fld-06.0).
BILLING PROVIDER TAX ID is one of several fields which are

compared for "duplicate claim" processing. If these fields contain
the same values as a claim previously submitted on the same day,
the claim will be rejected for "duplicate claim". See Exhibit 97 for
detailed information.
DATA ELEMENT: Billing Provider Site ID
DEFINITION: A code assigned by the submitter used to identify the provider's

specific billing location.
BA0 07.0 X 06 L Spaces 41 46

R R R R R R
CODE VALUES:
VALIDATION: Must only contain a value of A-Z or 0-9. No special characters or

spaces are allowed.

NOTES: In order to distribute claims to their appropriate output destinations

(payers), a rebatching process is necessary. An important part of the
rebatching process is the retrieval of provider name and address
information from the WebMD Provider Table.
BACKGROUND: The information in the WebMD Provider Table is

updated through a process known as "automatic enrollment". In this
process, the provider information received (RT BA0) is used to
update the WebMD Provider Table. If Provider Tax ID and Provider
Site ID match an existing entry on the table, but the provider name
and/or address information is different, the Table will be updated
with the new information.
For this reason, it is necessary to use unique Provider Site ID

numbers for each provider.
RAMIFICATIONS: If Provider Tax ID and Site ID are used for

different hospitals within a multi-hospital system, the last provider
entered will update the WebMD Provider Table and will be used to
create the output claim file to the destination payer - regardless of
how many other providers submitted claims previously using that
Provider Tax ID and Site ID.
Example: Assume two providers with the same Provider Tax ID and
Site ID are submitting claims on the same day. After the first batch
has been added to the WebMD Provider Table, the Table will be
updated again with the second batch's provider name when the
second batch is encountered. Because the identification numbers are
the same for both providers, the second provider name replaces the
first.
At the time of output distribution, the second batch's provider name

will be the provider name that is sent to the destination payer for all
claims submitted, including the claims submitted by the first
provider. This, in turn, will cause the payer to pay the second
provider for claims submitted by the first.
It is therefore imperative that Provider Site ID always contain a

unique number to insure that correct information is being passed on
to the destination payer.
Provider Site ID is one of several fields which are compared for

"duplicate claim" processing. If these fields contain the same values
as a claim previously submitted on the same day, the claim will be
rejected for "duplicate claim". See Exhibit 97 for detailed information.
DATA ELEMENT: Billing Provider Tax ID Type
DEFINITION: A code used to indicate the type of tax identification number entered
in BILLING PROVIDER TAX ID.
BA0 08.0 X 01 L Spaces 47 47

R R R R R R
CODE VALUES: E Employer Identification Number

S Social Security Number (also used when a
Corporate name is entered, but a Social
Security Number is the Tax ID)

NOTES: If BILLING PROVIDER TAX ID TYPE contains a value of E, then

BILLING PROVIDER ORGANIZATION NAME (fld-18.0) must be
entered.
If BILLING PROVIDER TAX ID TYPE contains a value of S, then

BILLING PROVIDER LAST NAME (fld-19.0) and BILLING PROVIDER
FIRST NAME (fld-20.0) must be entered.
DATA ELEMENT: Billing Provider Medicare Number
DEFINITION: The number assigned with the billing provider that is assigned by the
Medicare intermediary for identification purposes.
BA0 09.0 X 15 L Spaces 48 62

O O O O O S
SITUATIONAL NOTE: MEDICARE: Must be entered if the CLAIM FILING INDICATOR (RT-
DA0, fld-04.0) contains a value of P, and SOURCE OF PAYMENT
CODE (RT-DA0,fld-05.0) contains a value of C (Medicare).
CODE VALUES:
VALIDATION: Must be identical to the Medicare Provider Number on the WebMD

Envoy Provider File.

Reject Batch None
DATA ELEMENT: Billing Provider UPIN
DEFINITION: The number assigned to the billing provider by the National Registry
for Medicare Identification purposes.
BA0 10.0 X 06 L Spaces 63 68

S S S S S S
SITUATIONAL NOTE: Must be entered if applicable.
CODE VALUES:

None None
DATA ELEMENT: Billing Provider USIN
DEFINITION: The number assigned to the billing provider by the National Registry
for Medicare Identification purposes.
BA0 11.0 X 06 L Spaces 69 74

S S S S S S
SITUATIONAL NOTE: Must be entered if applicable.
CODE VALUES:

None None
DATA ELEMENT: Billing Provider Medicaid Number
DEFINITION: The number associated with the billing provider that is assigned by a
Medicaid State Agency for identification purposes.
BA0 12.0 X 15 L Spaces 75 89

O O O O R O
SITUATIONAL NOTE: MEDICAID: Must be entered if CLAIM FILING INDICATOR (RT-

DA0,fld-04.0) contains a value of P, and SOURCE OF PAYMENT (RT-
DA0,fld-05.0) contains a value of D (Medicaid).
CODE VALUES:

Reject Batch None
DATA ELEMENT: Billing Provider CHAMPUS Number
DEFINITION: The number assigned to the billing provider by the CHAMPUS payer
for identification purposes.
BA0 13.0 X 15 L Spaces 90 104

O O O R O O
SITUATIONAL NOTE: CHAMPUS: Must be entered if CLAIM FILING INDICATOR (RT-

DA0,fld-05.0) contains a value of H (CHAMPUS).
CODE VALUES:

Reject Batch None
DATA ELEMENT: Billing Provider Blue Shield Number
DEFINITION: The number assigned to the billing provider that is assigned by the
Blue Cross/Blue Shield for identification purposes.
BA0 14.0 X 15 L Spaces 105 119

O O S O O O
SITUATIONAL NOTE: BLUE SHIELD: Must be entered if CLAIM FILING INDICATOR (RT-
DA0,fld-05.0) contains a value of G or P (Blue Shield).
CODE VALUES:

None None
DATA ELEMENT: Billing Provider Commercial Number
DEFINITION: The number assigned to the billing provider by the Commercial payer
for identification purposes.
BA0 15.0 X 15 L Spaces 120 134

O O O O O O
CODE VALUES:

None None
DATA ELEMENT: Billing Provider Secondary ID
DEFINITION: The number assigned to the billing provider by the receiver for other
identification purposes.
BA0 16.0 X 15 L Spaces 135 149

O O O O O O
CODE VALUES:

None None
DATA ELEMENT: Billing Provider NPI
DEFINITION: The National Provider Identifier assigned to the billing provider.
BA0 17.0 X 15 L Spaces 150 164

O O O O O O
SITUATIONAL NOTE: Should be entered if the provider has been assigned a National
Provider Identifier (NPI).
CODE VALUES:

None None
DATA ELEMENT: Billing Provider Organization Name
DEFINITION: The name of the billing (provider) organization to whom payment is

to be sent.
BA0 18.0 X 33 L Spaces 165 197

S S S S S S
SITUATIONAL NOTE: Must be entered if the BILLING PROVIDER TAX ID TYPE (fld-08.0)
contains a value of E.
CODE VALUES:
VALIDATION: Must be present if BILLING PROVIDER LAST NAME (fld-19.0) has

not been entered.
See Standard Address Checks in Exhibit 2 for field validation.

None None
DATA ELEMENT: Billing Provider Last Name
DEFINITION: The last name of the individual billing provider to whom payment is
to be sent.
BA0 19.0 X 20 L Spaces 198 217

S S S S S S
SITUATIONAL NOTE: Must be entered if the BILLING PROVIDER ORGANIZATION NAME

(fld-18.0) has not been entered.
Must be entered if BILLING PROVIDER TAX ID TYPE (fld-08.0)

contains a value of S.
CODE VALUES:
VALIDATION: Must be present if BILLING PROVIDER FIRST NAME (fld-20.0) has

been entered.

Reject Batch None
NOTES: If BILLING PROVIDER LAST NAME and FIRST NAME are entered,
BILLING PROVIDER ORGANIZATION NAME (fld-18.0) should not be
entered.
DATA ELEMENT: Billing Provider First Name
DEFINITION: The first name of the individual billing provider to whom payment is
to be sent.
BA0 20.0 X 12 L Spaces 218 229

S S S S S S
SITUATIONAL NOTE: Must be entered if the BILLING PROVIDER ORGANIZATION NAME

CODE VALUES:
VALIDATION: BILLING PROVIDER FIRST NAME may only be entered if BILLING

PROVIDER LAST NAME (fld-19.0) has been entered.
See Standard Address Checks on Exhibit 2 for field validation.

Reject Batch None
NOTES: If BILLING PROVIDER LAST NAME and FIRST NAME are entered,
BILLING PROVIDER ORGANIZATION NAME (fld-18.0) should not be
entered.
DATA ELEMENT: Billing Provider Middle Name
DEFINITION: The middle initial of the individual billing provider to whom payment
is to be sent.
BA0 21.0 X 01 L Spaces 230 230

D D D D D D
CODE VALUES:
VALIDATION: May only contain a value of A-Z or space. No other special

characters are allowed.
May only be entered if BILLING PROVIDER LAST NAME (fld-19.0)

and BILLING PROVIDER FIRST NAME (fld-20.0) have been entered.

None None
DATA ELEMENT: Billing Provider Specialty Code
DEFINITION: A code used to indicate the primary specialty of the billing provider.
BA0 22.0 X 03 L Spaces 231 233

S S S S S S
SITUATIONAL NOTE: Should be entered when adjudication is known to be impacted by

the provider specialty.
CODE VALUES:
VALIDATION: If entered, should be a valid code from Exhibit 3.
May only contain a value of 001-099, 301-308 or N01-N07.

None None
NOTES: If BILLING PROVIDER SPECIALTY CODE contains a value of 069,

071, 072, 095, or N06, then PATIENT ADDRESS, CITY, STATE, and
ZIP CODE (RT-CA0, flds-11.0-15.0) are not required.
DATA ELEMENT: Billing Provider Specialty License Number
DEFINITION: The Specialty License Number of the provider rendering services, as

assigned by the licensing board of that specialty.
BA0 23.0 X 15 L Spaces 234 248

S S S S S S
SITUATIONAL NOTE: May be required by payer.
CODE VALUES:

None None
DATA ELEMENT: Billing Provider State License Number
DEFINITION: The state license number of the provider.
BA0 24.0 X 15 L Spaces 249 263

S S S S S S
CODE VALUES:

None None
DATA ELEMENT: Billing Provider Dentist License Number
DEFINITION: The license number of the dentist providing the services.
BA0 25.0 X 15 L Spaces 264 278

S S S S S S
CODE VALUES:

None None
DATA ELEMENT: Billing Provider Anesthesia License Number
DEFINITION: The state license number of the anesthesiologist.
BA0 26.0 X 15 L Spaces 279 293

S S S S S S
CODE VALUES:

None None
BA0 27.0 X 03 L Spaces 294 296

R R R R R R
CODE VALUES:

None None
DATA ELEMENT: Billing Provider Taxonomy
DEFINITION: The applicable taxonomy (specialty) code for this provider.
BA0 28.0 X 10 L Spaces 297 306

S S S S S S
SITUATIONAL NOTE: Should be entered if known.
CODE VALUES: * Source:

BCBS Association and ASC X12N TG2 WG15
Available From:
Washington Publishing Company
http://www.wpc-edi.com
VALIDATION: If entered, must be a valid code from the above list.

None Reject Batch
DATA ELEMENT: Billing Provider Secondary ID Qualifier
DEFINITION: A code used to indicate the type of identification number entered in

BILLING PROVIDER SECONDARY ID (fld-16.0).
BA0 29.0 X 02 L Spaces 307 308

S S S S S S
SITUATIONAL NOTE: Must be entered if BILLING PROVIDER SECONDARY ID (fld-16.0)

has been entered.
CODE VALUES: 1A Blue Cross

1J Facility ID Number
B3 Preferred Provider Organization Number
BQ Health Maintenance Organization Code Number
FH Clinic Number
LU Location Number
X5 State Industrial Accident Provider Number

DATA ELEMENT: Filler
BA0 30.0 X 10 L Spaces 309 318

R R R R R R
CODE VALUES:

None None
BA0 31.0 X 01 L Spaces 319 319

R R R R R R
CODE VALUES:

None None
DATA ELEMENT: Rendering Provider Flag
DEFINITION: A code used to indicate whether the billing provider's name and
address is the same as the rendering provider's name and address.
Rendering provider is defined as the primary care, attending, or
consulting provider that has rendered the service(s). Rendering
provider's address is defined as the office/site/clinic location where
services were performed.
BA0 32.0 X 01 L Spaces 320 320

R R R R R N
CODE VALUES: N No, the billing provider's address is different

from the rendering provider's service address.
Y Yes, the billing provider's address is the same
as the rendering provider's service address.

NOTES: PROVIDER SERVICE ADDRESS (RT BA1, flds-07.0-11.0),

RENDERING PROVIDER NAME (RT FB1, FLDS-14.0-16.0), and
PROVIDER SPECIALTY (RT FA0, FLD-37.0) must be entered if
RENDERING PROVIDER FLAG has been entered.
RECORD SUMMARY
RECORD TYPE: BA1
RECORD LEVEL: Batch
RECORD PURPOSE: Additional record to identify the billing provider or billing

agency for the claims contained within this batch.
R BA0 CA0

CONDITIONAL NOTE:
NOTES: Only one (1) Record Type BA1 may be entered per batch.
RECORD LAYOUT
Record Type: BA1

BA1 05.0 Batch ID X 06 26 31
BA1 06.0 Provider Type Organization X 03 32 34
BA1 09.0 Provider Service City X 20 95 114
BA1 10.0 Provider Service State X 02 115 116
BA1 11.0 Provider Service Zip Code X 09 117 125
BA1 12.0 Provider Service Phone Number X 10 126 135
BA1 15.0 Billing Provider City X 20 196 215
BA1 16.0 Billing Provider State X 02 216 217
BA1 17.0 Billing Provider Zip Code X 09 218 226
BA1 18.0 Billing Provider Phone Number X 10 227 236
BA1 19.0 Billing Provider Contact Name X 60 237 296
BA1 20.0 Filler - Local X 24 297 320
DATA ELEMENT: Record Type 'BA1'
DEFINITION: A field used to identify the "Provider Data 2" record.
BA1 01.0 X 03 L Spaces 01 03

R R R R R R
CODE VALUES:
VALIDATION: Must contain a value of BA1.

Reject Batch None
DEFINITION: The unique number assigned to the provider for EMC identification
purposes by the payer/receiver.
BA1 02.0 X 15 L Spaces 04 18

S S S S S S
SITUATIONAL NOTE: Must be entered if required by payer/receiver.
CODE VALUES:
VALIDATION: Must be identical to the EMC PROVIDER ID in the preceding Record

Type BA0 (fld-02.0) and Record Type YA0 (fld-02.0).

None None
batch.
BA1 03.0 X 03 L Spaces 19 21

R R R R R R
VALIDATION: Must contain a value code value from the above list.
Must be equal to the BATCH TYPE in Record Type BA0 (fld-03.0)

and Record Type YA0 (fld-03.0).

DEFINITION: This is a sequential number assigned by the submitter to each batch

of claims.
BA1 04.0 9 04 R Zeroes 22 25

R R R R R R
CODE VALUES: 0001-0099
First occurrence must be 0001.
Whenever BILLING PROVIDER TAX ID (RT BA0, fld-06.0) or BATCH

TYPE (RT BA0, fld-03.0) or BILLING PROVIDER SITE ID (RT BA0,
fld-07.0) changes from those previously entered, BATCH
SEQUENCE NUMBER must be reset to 0001.
If the previous BILLING PROVIDER TAX ID (RT BA0, fld-06.0) or

BATCH TYPE (RT BA0, fld-03.0) or BILLING PROVIDER SITE ID (RT
BA0, fld-07.0) are identical to those currently being processed, the
BATCH SEQUENCE NUMBER must be one (1) greater than the
previous BATCH SEQUENCE NUMBER.
Must be identical to the BATCH SEQUENCE NUMBER in the

corresponding Record Type BA0 (fld-04.0) and Record Type YA0
(fld-04.0).


BA1 05.0 X 06 L Spaces 26 31

N N N N N N
CODE VALUES:
VALIDATION: Must be identical to the BATCH ID in the preceding Record Type


None None
DATA ELEMENT: Provider Type Organization
DEFINITION: The organizational structure of the billing provider of service.
BA1 06.0 X 03 L Spaces 32 34

S S S S S S
SITUATIONAL NOTE: Should be entered if required by payer.
CODE VALUES: 001 Solo Practice

002 Partnership
003 Professional Association
004 Clinic
005 One Facility/Hospital
006 Distinct Part of Facility/Hospital
007 Individual
008 Corporation
VALIDATION: If entered, should be a valid code form the above list.

None None
DATA ELEMENT: Provider Service Address 1
DEFINITION: The office, site, or clinic location where services were rendered.
BA1 07.0 X 30 L Spaces 35 64

S S S S S S
SITUATIONAL NOTE: Should be entered, if available, to facilitate claim adjudication.
COMMERCIAL: Must be entered if RENDERING PROVIDER FLAG

(RT-BA0-32.0) contains a value of N.
MEDICARE: Must be entered if Chiropractic Certification (GC0)

records have been submitted.
CODE VALUES:
VALIDATION: See Standard Address Checks in Exhibit 2 for field validation.

None Reject Batch
NOTES: RENDERING PROVIDER'S SERVICE ADDRESS should not contain a

Post Office (P.O.) Box.
If RENDERING PROVIDER'S SERVICE ADDRESS is different per line

item, then separate batches must be submitted.
DATA ELEMENT: Provider Service Address 2
BA1 08.0 X 30 L Spaces 65 94

S S S S S S


CODE VALUES:
VALIDATION: If entered, see Standard Address Checks in Exhibit 2 for field

validation.

None Reject Batch
DATA ELEMENT: Provider Service City
BA1 09.0 X 20 L Spaces 95 114

S S S S S S


CODE VALUES:

None Reject Batch


DATA ELEMENT: Provider Service State
BA1 10.0 X 02 L Spaces 115 116

S S S S S S


CODE VALUES:

None Reject Batch


DATA ELEMENT: Provider Service Zip Code
BA1 11.0 X 09 L Spaces 117 125

S S S S S S


CODE VALUES:

None Reject Batch


DATA ELEMENT: Provider Service Phone Number
DEFINITION: The telephone number, including area code, at which the provider
can be contacted (where services were rendered).
BA1 12.0 X 10 L Spaces 126 135

S S S S S S
CODE VALUES:
VALIDATION: If entered, must be in the format: XXXyyyZZZZ where:

XXX = Area Code
yyy = Exchange

None None
DATA ELEMENT: Billing Provider Address 1
DEFINITION: The mailing address of the billing organization/provider to which

payment is to be sent.
BA1 13.0 X 30 L Spaces 136 165

R R R R R R
CODE VALUES:

DATA ELEMENT: Billing Provider Address 2

payment is to be sent.`
BA1 14.0 X 30 L Spaces 166 195

S S S S S S

CODE VALUES:
VALIDATION: If entered, See Standard Name and Address checks in Exhibit 2 for
field validation.

None Reject Batch
DATA ELEMENT: Billing Provider City

BA1 15.0 X 20 L Spaces 196 215

R R R R R R
CODE VALUES:

DATA ELEMENT: Billing Provider State

BA1 16.0 X 02 L Spaces 216 217

R R R R R R
CODE VALUES:

DATA ELEMENT: Billing Provider Zip Code

BA1 17.0 X 09 L Spaces 218 226

R R R R R R
CODE VALUES:

DATA ELEMENT: Billing Provider Phone Number
DEFINITION: The telephone number, including area code, at which the billing
organization/provider may be contacted.
BA1 18.0 X 10 L Spaces 227 236

R R R R R R
CODE VALUES:
VALIDATION: Must be in the format: XXXyyyZZZZ where:

XXX = Area Code
yyy = Exchange

None None
DATA ELEMENT: Billing Provider Contact Name
DEFINITION: Identifies the primary contact for the Billing Provider.
BA1 19.0 X 60 L Spaces 237 296

S S S S S S
SITUATIONAL NOTE: Should be entered if a billing provider telephone number has been
entered.
CODE VALUES:

None None
BA1 20.0 X 24 L Spaces 297 320

R R R R R R
CODE VALUES:

None None
RECORD SUMMARY
RECORD TYPE: BB0
RECORD NAME: Pay-to Provider Information
RECORD LEVEL: Batch
RECORD PURPOSE: To identify the pay-to provider or pay-to billing agency for
the claims contained within this batch.
S BA1 CA0

CONDITIONAL NOTE:
NOTES: Only one (1) Record Type BB0 may be entered per batch.
RECORD LAYOUT
Record Type: BB0

BB0 01.0 Record Type ‘BB0’ X 03 01 03
BB0 02.0 EMC Provider ID X 15 4 18
BB0 03.0 Batch Type X 3 19 21
BB0 04.0 Batch Sequence Number 9 4 22 25
BB0 05.0 Batch ID X 6 26 31
BB0 06.0 Pay-to Provider Tax ID Type X 1 32 32
BB0 07.0 Pay-to Provider Tax ID X 9 33 41
BB0 08.0 Filler X 3 42 44
BB0 09.0 Pay-to Provider Entity Type Code X 1 45 45
BB0 10.0 Pay-to Provider Organization /Last Name X 35 46 80
BB0 11.0 Pay-to Provider First Name X 12 81 92
BB0 12.0 Pay-to Provider Middle Name X 1 93 93
BB0 13.0 Pay-to Provider Suffix X 10 94 103
BB0 14.0 Pay-to Provider NPI X 10 104 113
BB0 15.0 Pay-to Provider Secondary ID Qualifier X 2 114 115
BB0 16.0 Pay-to Provider Secondary ID X 15 116 130
BB0 17.0 Filler X 36 131 166
BB0 18.0 Pay-to Provider Taxonomy Code X 10 167 176
BB0 21.0 Pay-to Provider City X 20 237 256
BB0 22.0 Pay-to Provider State X 2 257 258
BB0 23.0 Pay-to Provider Zip Code X 9 259 267
BB0 24.0 Filler X 53 268 320
Emdeon Business Services Technical Specifications NSF Plus BB0 - 01.0
DATA ELEMENT: Record Type ‘BB0’
DEFINITION: A field used to identify the "Pay-to Provider Information" record.
BB0 01.0 X 03 L Spaces 01 03

R R R R R R
CODE VALUES:
VALIDATION: Must contain a value of BB0.

Reject Batch None
DEFINITION: The unique number assigned to the billing provider for EMC
identification purposes by the payer/receiver.
BB0 02.0 X 15 L Spaces 4 18

S S S S S S
SITUATIONAL NOTE: Must be entered if required by payer/receiver.
CODE VALUES:
VALIDATION: Must be identical to the EMC PROVIDER ID in the preceding Record

Type BA0 (fld-02.0) and Record Type YA0 (fld-02.0).

None None
batch.
BB0 03.0 X 3 L Spaces 19 21

R R R R R R
VALIDATION: Must contain a value code value from the above list.
Must be equal to the BATCH TYPE in Record Type BA0 (fld-03.0)

and Record Type YA0 (fld-03.0).

DEFINITION: This is a sequential number assigned by the submitter to each batch

of claims.
BB0 04.0 9 4 R Zeroes 22 25

R R R R R R
Must be identical to the BATCH SEQUENCE NUMBER in the

corresponding Record Type BA0 (fld-04.0) and Record Type YA0
(fld-04.0).


BB0 05.0 X 6 L Spaces 26 31

N N N N N N
CODE VALUES:
VALIDATION: Must be identical to the BATCH ID in the preceding Record Type


None None
DATA ELEMENT: Pay-to Provider Tax ID Type
DEFINITION: Indicates the type of tax identification number entered in the PAY-TO
PROVIDER TAX ID (fld-07.0)
BB0 06.0 X 1 L Spaces 32 32

S S S S S S
SITUATIONAL NOTE: Must be entered if PAY-TO PROVIDER TAX ID (fld-07.0) has been
entered.
CODE VALUES: E Employer Identification Number

S Social Security Number

Reject Claim Reject Claim
DATA ELEMENT: Pay-to Provider Tax ID
DEFINITION: The federally-assigned Tax Identification Number (TIN) of the pay-to

provider.
BB0 07.0 X 9 L Spaces 33 41

S S S S S S
SITUATIONAL NOTE: Must be entered if the PAY-TO PROVIDER TAX ID TYPE (fld-06.0)
has been entered.
CODE VALUES:

Reject Claim None
BB0 08.0 X 3 L Spaces 42 44

R R R R R R
CODE VALUES:

None None
DATA ELEMENT: Pay-to Provider Entity Type Code
DEFINITION: Indicates whether the PAY-TO PROVIDER ORGANIZATION/LAST

NAME contains an organization or individual provider's last name.
BB0 09.0 X 1 L Spaces 45 45

S S S S S S
SITUATIONAL NOTE: Must be entered if PAY-TO PROVIDER ORGANIZATION/LAST NAME

(fld-10.0) has been entered.
CODE VALUES: L Individual Provider

O Organization

Reject Claim None
DATA ELEMENT: Pay-to Provider Organization /Last Name
DEFINITION: The last name or organization name of the pay-to provider.
BB0 10.0 X 35 L Spaces 46 80

S S S S S S
SITUATIONAL NOTE: Must be entered if the PAY-TO PROVIDER ENTITY TYPE CODE (fld-
09.0) has been entered.
CODE VALUES:

Reject Claim None
DATA ELEMENT: Pay-to Provider First Name
DEFINITION: The first name of the pay-to provider to whom payment is to be sent.
BB0 11.0 X 12 L Spaces 81 92

S S S S S S
SITUATIONAL NOTE: Must be entered if PAY-TO PROVIDER ENTITY TYPE CODE (fld-
09.0) contains a value of 'L'.
CODE VALUES:

Reject Claim None
DATA ELEMENT: Pay-to Provider Middle Name
DEFINITION: The middle intial of the pay-to provider to whom payment is to be

sent.
BB0 12.0 X 1 L Spaces 93 93

D D D D D D
CODE VALUES:

None None
DATA ELEMENT: Pay-to Provider Suffix
DEFINITION: The generation of the pay-to provider (I, II, III, IV, JR or SR).
BB0 13.0 X 10 L Spaces 94 103

N N N N N N
CODE VALUES:

None None
DATA ELEMENT: Pay-to Provider NPI
DEFINITION: The National Provider Identifier assigned to the pay-to provider.
BB0 14.0 X 10 L Spaces 104 113

N N N N N N
CODE VALUES:

None None
DATA ELEMENT: Pay-to Provider Secondary ID Qualifier

PAY-TO PROVIDER SECONDARY ID (fld-16.0).
BB0 15.0 X 2 L Spaces 114 115

S S S S S S
SITUATIONAL NOTE: Must be entered if PAY-TO PROVIDER SECONDARY ID (fld-16.0)

has been entered.
CODE VALUES: 0B State License Number

1A Blue Cross Provider Number
1B Blue Shield Provider Number
1C Medicare Provider Number
1D Medicaid Provider Number
1G Provider UPIN Number
1H Champus Identification Number
1J Facility ID Number
B3 Preferred Provider Organization Number
BQ Health Maintenance Organization Code Number
EI Employer's Identification Number
FH Clinic Number
G2 Provider Commercial Number
G5 Provider Site Number
LU Location Number
SY Social Security Number
U3 Unique Supplier Identification Number (USIN)

DATA ELEMENT: Pay-to Provider Secondary ID
DEFINITION: The number assigned to the pay-to provider by the receiver for other
identification purposes.
BB0 16.0 X 15 L Spaces 116 130

O O O O O O
CODE VALUES:

None None
BB0 17.0 X 36 L Spaces 131 166

R R R R R R
CODE VALUES:

None None
DATA ELEMENT: Pay-to Provider Taxonomy Code
BB0 18.0 X 10 L Spaces 167 176

S S S S S S

Available From:

None Reject Batch
DATA ELEMENT: Pay-to Provider Address 1
DEFINITION: The mailing address of the pay-to organization/provider to which

BB0 19.0 X 30 L Spaces 177 206

R R R R R R
CODE VALUES:

DATA ELEMENT: Pay-to Provider Address 2

payment is to be sent.`
BB0 20.0 X 30 L Spaces 207 236

S S S S S S

CODE VALUES:
VALIDATION: If entered, See Standard Name and Address checks in Exhibit 2 for
field validation.

None Reject Batch
DATA ELEMENT: Pay-to Provider City

BB0 21.0 X 20 L Spaces 237 256

R R R R R R
CODE VALUES:

DATA ELEMENT: Pay-to Provider State

BB0 22.0 X 2 L Spaces 257 258

R R R R R R
CODE VALUES:

DATA ELEMENT: Pay-to Provider Zip Code

BB0 23.0 X 9 L Spaces 259 267

R R R R R R
CODE VALUES:

BB0 24.0 X 53 L Spaces 268 320

R R R R R R
CODE VALUES:

None None
RECORD SUMMARY
RECORD TYPE: CA0
RECORD NAME: Claim Header: Patient Data
RECORD LEVEL: Claim
RECORD PURPOSE: To identify the patient that received the services indicated in
the claim.
To provide demographic and admission/discharge

information on the patient.
R BA1, BB0 or XA0 CA1, CB0, DA0

CONDITIONAL NOTE:
NOTES: Must be the first record of a claim.
A maximum of 5,000 claims may be entered per batch.
Only one (1) CA0 Record may be entered per claim.
All Records following Record Type CA0, up to and including

Record Type XA0, must contain the same PATIENT CONTROL
NUMBER (fld-03.0).
RECORD LAYOUT
Record Type: CA0

CA0 02.0 TPO Participation Indicator X 01 04 04
CA0 02.0 Type of Transaction X 01 05 05
CA0 04.0 Patient Last Name X 20 23 42
CA0 05.0 Patient First Name X 12 43 54
CA0 06.0 Patient Middle Initial X 01 55 55
CA0 07.0 Patient Generation X 03 56 58
CA0 08.0 Patient Date of Birth 9 08 59 66
CA0 09.0 Patient Sex X 01 67 67
CA0 10.0 Patient Type of Residence X 01 68 68
CA0 13.0 Patient City X 20 129 148
CA0 14.0 Patient State X 02 149 150
CA0 15.0 Patient Zip Code X 09 151 159
CA0 16.0 Patient Telephone Number X 10 160 169
CA0 17.0 Patient Marital Status X 01 170 170
CA0 18.0 Patient Student Status X 01 171 171
CA0 19.0 Patient Employment Status X 01 172 172
CA0 20.0 Patient Death Indicator X 01 173 173
CA0 21.0 Date of Death 9 08 174 181
CA0 22.0 Other Insurance Indicator X 01 182 182
CA0 23.0 Claim Adjudication - Receiver Type X 01 183 183
CA0 24.0 Type Claim Indicator X 02 184 185
CA0 25.0 Legal Representative Indicator X 01 186 186
CA0 26.0 Origin Code X 09 187 195
CA0 27.0 Payer Claim Control Number X 17 196 212
CA0 28.0 Provider Number X 15 213 227
CA0 29.0 Claim ID Number X 06 228 233
CA0 30.0 Patient Weight X 04 234 237
CA0 31.0 Pregnancy Indicator X 01 238 238
CA0 32.0 Patient ID Qualifier X 02 239 240
CA0 33.0 Filler X 24 241 264
CA0 34.0 Patient Secondary ID Qualifier X 02 265 266
CA0 35.0 Patient Secondary ID X 30 267 296
CA0 36.0 Claim Sequence Number X 14 297 310
CA0 37.0 Patient ID X 10 311 320
Emdeon Business Services Technical Specifications NSF Plus CA0 - 01.0
DATA ELEMENT: Record Type 'CA0'
DEFINITION: A field used to identify the "Patient Data" record.
CA0 01.0 X 03 L Spaces 01 03

R R R R R R
CODE VALUES:
VALIDATION: Must contain a value of CA0.

Emdeon Business Services Technical Specifications NSF Plus CA0 - 02.0a
DATA ELEMENT: TPO Participation Indicator
DEFINITION: A flag used to indicate the destination payer's participation status.
CA0 02.0a X 01 L Spaces 04 04

O O O O O N
SITUATIONAL NOTE: Should be submitted if applicable or required by payer.
CODE VALUES: A WebMD participating payer

B Non-WebMD participating payer
VALIDATION: If entered, must contain a valid code from the above list.

NOTES: If TPO PARTICIPATION INDICATOR contains a value of B, the claim

will NOT be edited.
TPO PARTICIPATION INDICATOR may contain spaces if TPO claims

are being submitted to WebMD Envoy participating payers.
Emdeon Business Services Technical Specifications NSF Plus CA0 - 02.0b
DATA ELEMENT: Type of Transaction
DEFINITION: A code used to define the transaction type.
CA0 02.0b X 01 L Spaces 05 05

R R R R R R
CODE VALUES: 1 Claim

2 Encounter
VALIDATION: Must contain a valid code from the above list.

None None
DATA ELEMENT: Patient Control Number
DEFINITION: A unique number assigned by the provider to facilitate retrieval of

individual patient records and payment posting.
CA0 03.0 X 17 L Spaces 06 22

R R R R R R
CODE VALUES:
VALIDATION: Must contain A-Z, 0-9, slash (/), period (.), comma (,), or hyphen
(-). No other special characters are allowed.

NOTES: All Records between Record Type CA0, up to and including Record
Type XA0, must contain the same PATIENT CONTROL NUMBER.
Although up to seventeen characters are allowed, not all payers'

systems will record and return seventeen characters on remittance
advices or other documents.
PATIENT CONTROL NUMBER is one of several fields which are

compared for "duplicate claim" processing. If these fields contain the
same values as a claim previously submitted on the same day, the
claim will be rejected for "Duplicate claim". See Exhibit 97 for
DATA ELEMENT: Patient Last Name
DEFINITION: The last name of the patient.
CA0 04.0 X 20 L Spaces 23 42

R R R R R R
CODE VALUES:
validation.

NOTES: PATIENT LAST NAME is one of several fields which are compared for
"duplicate claim" processing. If this field contains the same value as
a claim previously submitted on the same day, the claim will be
information.
DATA ELEMENT: Patient First Name
DEFINITION: The first name of the patient.
CA0 05.0 X 12 L Spaces 43 54

R R R R R R
CODE VALUES:
validation.
PATIENT FIRST NAME may only be entered if PATIENT LAST NAME

has been entered.

NOTES: PATIENT FIRST NAME is one of several fields which are compared for
"duplicate claim" processing. If this field contains the same value as
a claim previously submitted on the same day, the claim will be
information..
DATA ELEMENT: Patient Middle Initial
DEFINITION: The middle initial of the patient.
CA0 06.0 X 01 L Spaces 55 55

D D D D D D
CODE VALUES:
VALIDATION: If entered, may only contain a value of A-Z or space. No other

special characters are allowed.
PATIENT MIDDLE INITIAL may only be entered if PATIENT LAST

NAME (fld-04.0) and PATIENT FIRST NAME (fld-05.0) have been
entered.

None None
DATA ELEMENT: Patient Generation
DEFINITION: The generation of the patient, such as I, II, III, IV, JR, SR.
CA0 07.0 X 03 L Spaces 56 58

D D D D D D
CODE VALUES:
VALIDATION: If entered, should only contain a value of I, II, III, IV, JR, SR.

None None
DATA ELEMENT: Patient Date of Birth
DEFINITION: The patient's date of birth.
CA0 08.0 9 08 R Zeroes 59 66

R R R R R D
CODE VALUES:
VALIDATION: Must be entered except for Medicare claims.
Must be numeric.
May not be greater than SERVICE FROM DATE (RT FA0, fld-05.0).
Must be in the format of CCYYMMDD.
MEDICARE: May not contain a value of 00 for Month or Day.
ALL OTHERS: If Month or Day is unknown, a value of 00 may be

entered.

DATA ELEMENT: Patient Sex
DEFINITION: A code used to identify the gender of the patient.
CA0 09.0 X 01 L Spaces 67 67

R R R R R R
CODE VALUES: F Female

M Male
U* Unknown
VALIDATION: Must be valid code from the above list.

NOTES: *Codes added to accommodate HIPAA
DATA ELEMENT: Patient Type of Residence
DEFINITION: A code which indicates patient place of residence.
CA0 10.0 X 01 L Spaces 68 68

S S S S S S
SITUATIONAL NOTE: Must be entered if required by the payer.
CODE VALUES: N Nursing Home

P Private Home
R Resident Treatment Ctr
S Skill Nursing facility
VALIDATION: If entered, should contain a valid code from the above list.

None None
DATA ELEMENT: Patient Address 1
DEFINITION: The mailing address of the patient as recorded in the provider's

records.
CA0 11.0 X 30 L Spaces 69 98

S S S S S R
SITUATIONAL NOTE: If BILLING PROVIDER SPECIALTY CODE (RT-BA0, fld-22.0)

contains a value of 069, 071, 072, 095 or N06, then PATIENT
ADDRESS 1 is not required.
CODE VALUES:

DATA ELEMENT: Patient Address 2

records.
CA0 12.0 X 30 L Spaces 99 128

N N N N N N
CODE VALUES:
VALIDATION: Should be entered if a second address line is required to provide a

complete mailing address.

None Reject Claim
DATA ELEMENT: Patient City

records.
CA0 13.0 X 20 L Spaces 129 148

S S S S S R

contains a value of 069, 071, 072, 095 or N06, then PATIENT CITY
is not required.
CODE VALUES:

DATA ELEMENT: Patient State

records.
CA0 14.0 X 02 L Spaces 149 150

S S S S S R

contains a value of 069, 071, 072, 095 or N06, then PATIENT
STATE is not required.
CODE VALUES:

DATA ELEMENT: Patient Zip Code

records.
CA0 15.0 X 09 L Spaces 151 159

S S S S S R

contains a value of 069, 071, 072, 095 or N06, then PATIENT ZIP
CODE is not required.
CODE VALUES:

DATA ELEMENT: Patient Telephone Number
DEFINITION: The telephone number, including area code, at which the patient
may be contacted.
CA0 16.0 X 10 L Spaces 160 169

D D D D D S
SITUATIONAL NOTE: MEDICARE: Should be entered for claims containing Certification

and Chiropractic services.
CODE VALUES:
VALIDATION: If entered, should be numeric.
If entered, should be in format: XXXyyyZZZZ, where:

XXX = Area code
yyy = Exchange

None None
DATA ELEMENT: Patient Marital Status
DEFINITION: A code used to identify the marital status of the patient.
CA0 17.0 X 01 L Spaces 170 170

D D D D D S
SITUATIONAL NOTE: MEDICARE: Should be entered if patient age is 65 - 69.
CODE VALUES: D Divorced

M Married
P Partner
S Single
U Unknown
W Widowed
X Legally Separated

None None
DATA ELEMENT: Patient Student Status
DEFINITION: A code used to indicate the student status of the patient.
CA0 18.0 X 01 L Spaces 171 171

S S S S S R
SITUATIONAL NOTE: MEDICARE: Must be entered if patient is over 19, not handicapped,
and is a dependent of the insured.
CODE VALUES: F Full Time Student

N Not a Student
P Part Time Student

DATA ELEMENT: Patient Employment Status
DEFINITION: A code used to indicate the employment status of the patient.
CA0 19.0 X 01 L Spaces 172 172

S S S S S R
SITUATIONAL NOTE: Must be entered if required by payer.
CODE VALUES: 1 Employed Full Time

2 Employed Part Time
3 Not employed
4 Self employed
5 Retired
6 On active military duty
9 Unknown
VALIDATION: MEDICARE: May only contain a value of 1, 2, 3, or 5.
ALL OTHERS: Should contain a valid code from the above list

NOTES: If the patient is not the insured and is over 19, it is important that
payers know whether the patient is employed and potentially
covered by another health plan.
DATA ELEMENT: Patient Death Indicator
DEFINITION: A code used to indicate if the patient is deceased.
CA0 20.0 X 01 L Spaces 173 173

D D D D D D
CODE VALUES: D Patient is deceased

N Patient is not deceased

None None
DATA ELEMENT: Date of Death
DEFINITION: The date the patient expired.
CA0 21.0 9 08 R Zeroes 174 181

S S S S S S
SITUATIONAL NOTE: Must be entered if the first position of PAYER ORGANIZATION ID

(RT DA0, fld-07.0) contains a value of S and PATIENT DEATH
INDICATOR (fld-20.0) contains a value of D.
CODE VALUES:
VALIDATION: If entered, must be numeric.
If entered, must be in the format CCYYMMDD.
See Standard Date Time Checks in Exhibit 1 for field validation.

NOTES: If PATIENT DATE OF DEATH is entered, then RESPONSIBLE PERSON

LAST NAME and FIRST NAME (RT-CB0, flds-05.0,06.0) must be
entered.
DATA ELEMENT: Other Insurance Indicator
DEFINITION: A code used to indicate whether the patient has additional health
insurance which is not reflected within the claim.
CA0 22.0 X 01 L Spaces 182 182

S S S S S R
SITUATIONAL NOTE: Must be entered if required by payer.
CODE VALUES: 1 Yes, patient has other insurance

2 Yes, patient has other insurance not reflected
on this claim.
3 No, patient does not have other insurance.

NOTES: 1 = Patient has declared that he/she has other insurance which may
pay a portion of this claim and provided the necessary insurance
information. (Not all insurance companies require that the other
insurance fields be completed.)
2 = Patient has declared that he/she has other insurance which may
pay a portion of this claim, but did not furnish the insurance
information for this claim.
3 = The provider has asked the patient if he/she has other

insurance, and the patient has stated that they do not.
If OTHER INSURANCE INDICATOR contains a value of 1, a second

sequence of Record Type DA0 should be entered to expedite the
claim adjudication process.
DATA ELEMENT: Claim Adjudication - Receiver Type
DEFINITION: A code assigned by the receiver to determine the adjudication

program.
CA0 23.0 X 01 L Spaces 183 183

S S S S S S
CODE VALUES: A Self Pay

B Worker's Compensation
C Medicare
D Medicaid
F Commercial Insurance
G BC/BS
H Champus
I HMO
J FEP
K Central Certification
L Self Administered
M Family or Friends
P PPO
Z Other

None None
DATA ELEMENT: Type Claim Indicator
DEFINITION: A code which indicated the type of claim.
CA0 24.0 X 02 L Spaces 184 185

S S S S S S
CODE VALUES: A Ambulance

B Anesthesia
C Chiropractic
D Dental
E DME
F Medical
G Occupational Therapy
H Oxygen
J Parenteral/Enteral
K Podiatry
L Physical Therapy
M Speech Therapy
N Surgery
O Other
Z Multiple Service Types

None None
DATA ELEMENT: Legal Representative Indicator
DEFINITION: A code used to indicate whether a patient who is mentally or

physically unable to file his/her own claim has a legal representative.
CA0 25.0 X 01 L Spaces 186 186

S S S S S R
SITUATIONAL NOTE: Must be entered if SOURCE OF PAYMENT (D0-04) = C.
CODE VALUES: N No, the patient does not have a legal

representative
Y Yes, the patient has a legal representative

NOTES: If the LEGAL REPRESENTATIVE INDICATOR contains a value of 'Y'

then the name and address of the legal representative (RT CB0, flds-
04.0-11.0) must be entered.
DATA ELEMENT: Origin Code
DEFINITION: A code to denote the geographic area where the service(s) being
submitted on this claim was/were performed.
CA0 26.0 X 09 L Spaces 187 195

S S S S S S
CODE VALUES:
VALIDATION: If entered, should contain a valid code value from Exhibit 2.

None None
DATA ELEMENT: Payer Claim Control Number
DEFINITION: A number assigned by the Payer/Receiver to identify the claim.
CA0 27.0 X 17 L Spaces 196 212

S S S S S S
SITUATIONAL NOTE: Should be entered if a payer assigns a unique identification number

to the claim.
CODE VALUES:

None None
DATA ELEMENT: Provider Number
DEFINITION: An identification number assigned to the provider by the payer

indicated in this payer record.
CA0 28.0 X 15 L Spaces 213 227

S S S S S N
CODE VALUES:

None None
NOTES: Position 226 and 227 are not mapped by WebMD Envoy.
DATA ELEMENT: Claim ID Number
DEFINITION: Unique number of identification assigned to the claim by the sender.
CA0 29.0 X 06 L Spaces 228 233

O O O O O O
CODE VALUES:

None None
DATA ELEMENT: Patient Weight
DEFINITION: The weight (in pounds) of the patient at the time the services were
rendered.
CA0 30.0 X 04 L Spaces 234 237

S S S S S S
SITUATIONAL NOTE: Should be entered for EPOETIN claims for patients on dialysis.
Should be entered for Durable Medical Equipment Regional
Carrier's (DMERC CMN) certificate of medical necessity.
CODE VALUES:

None None
DATA ELEMENT: Pregnancy Indicator
DEFINITION: A code to indicate whether the patient is pregnant.
CA0 31.0 X 01 L Spaces 238 238

S S S S S S
SITUATIONAL NOTE: Should be entered when required by State Law, such as Indiana
Medicaid.
CODE VALUES: Y Patient is Pregnant

None Reject Claim
DATA ELEMENT: Patient ID Qualifier

PATIENT ID for the destination payer.
CA0 32.0 X 02 L Spaces 239 240

S S S S S S
SITUATIONAL NOTE: Should be entered if PATIENT ID has been entered.
CODE VALUES: MI Member Identification Number

ZZ HIPAA Individual Identifier

None Reject Claim
CA0 33.0 X 24 L Spaces 241 264

R R R R R R
CODE VALUES:

None None
DATA ELEMENT: Patient Secondary ID Qualifier
DEFINITION: Should be entered when a secondary number is necessary to identify

patient for the destination payer.
CA0 34.0 X 02 L Spaces 265 266

S S S S S S
SITUATIONAL NOTE: Must be entered if PATIENT SECONDARY ID (fld-35.0) has been

entered.
CODE VALUES: 1W Member Identification Number

23 Client Number
IG Insurance Policy Number

DATA ELEMENT: Patient Secondary ID
DEFINITION: A secondary number used when necessary to identify the patient.
CA0 35.0 X 30 L Spaces 267 296

D D D D D D
CODE VALUES:

None None
DATA ELEMENT: Claim Sequence Number
DEFINITION: A control number that is sequentially assigned by the submitter.
CA0 36.0 X 14 L Spaces 297 310

O O O O O O
CODE VALUES:
If entered, the first occurrence must contain a value of 0001.

Subsequent occurrences must be increased sequentially by one (1).

None None
DATA ELEMENT: Patient ID
DEFINITION: The identification number, usually the Social Security Number (SSN)
of the patient (if not the insured) for the destination payer. This is
not the patient control number or the medical record number.
CA0 37.0 X 10 L Spaces 311 320

S S S S S N
SITUATIONAL NOTE: Should be entered if the destination payer requires patient

identification for claim processing.
CODE VALUES:

None None
NOTES: Non-Destination Payer Patient ID numbers are located in Record

Type DA0 (flds-29.0, 30.0).
RECORD SUMMARY
RECORD TYPE: CA1
RECORD NAME: Indian Health Services Patient Data
RECORD LEVEL: Claim
RECORD PURPOSE: To identify and provide information regarding the patient

who received the services indicated in this claim. This data
is specific to Indian Health Services/Contract Health
Services.
S CA0 CB0 or DA0

CONDITIONAL NOTE: Should only be entered for Indian Health Services/Contract

Health Services.
NOTES: Must be entered for every Indian Health Services/Contract

Health Services claim.
Only one (1) Record Type CA1 may be entered per claim.
RECORD LAYOUT
Record Type: CA1

CA1 02.0 Reserved Filler X 02 04 05
CA1 04.0 Purchase Order Number X 10 23 32
CA1 05.0 Tribe 9 03 33 35
CA1 06.0 Residency Code 9 07 36 42
CA1 07.0 Patient Health Record Number 9 06 43 48
CA1 08.0 Authorizing Facility Number X 09 49 57
CA1 09.0 Multiple Claim Indicator X 01 58 58
CA1 10.0 Filler - National X 262 59 320
DATA ELEMENT: Record Type 'CA1'
DEFINITION: A field used to identify the "Indian Health Services Patient Data"
record.
CA1 01.0 X 03 L Spaces 01 03

R R R R R R
CODE VALUES:
VALIDATION: Must contain a value of CA1.

CA1 02.0 X 02 L Spaces 04 05

R R R R R R
CODE VALUES:

None None

CA1 03.0 X 17 L Spaces 06 22

R R R R R R
CODE VALUES:

NOTES: All Records from Record Type CA0 up to and including Record Type
XA0 must contain the same PATIENT CONTROL NUMBER.
DATA ELEMENT: Purchase Order Number
DEFINITION: A number assigned to a Purchase Order issued by Indian Health

Services (IHS) to confirm that a patient has received service
authorization and IHS intends to pay all or part of the services
rendered.
CA1 04.0 X 10 L Spaces 23 32

S S S S S S
SITUATIONAL NOTE: Should be entered if available.
CODE VALUES:
VALIDATION: Position 1 may only contain a zero (0).

Position 2 may only contain a value of 0-9.
Position 3 may only contain a value of A-D, L, N-Q, S, U, or X.
Positions 4 through 10 may only contain a value of 0-9.

None Reject Claim
NOTES: This number is obtained from the authorizing IHS Service Unit which
referred the patient for services and approved use of Contract Health
Services (CHS) funds to pay for all or part of the services.
PURCHASE ORDER NUMBER is valid for specific dates of service and

dollar amounts, as designated by the IHS Service Unit. Multiple
visits may involve multiple purchase order numbers.
DATA ELEMENT: Tribe
DEFINITION: A code used to identify the patient's federally recognized tribal

affiliation.
CA1 05.0 9 03 R Zeroes 33 35

S S S S S S
CODE VALUES:
May only contain a value of 000-999.

None None
referred the patient for services.
DATA ELEMENT: Residency Code
DEFINITION: A code used to identify a patient's place of residence by geographical

area, designated by community, county, and state.
CA1 06.0 9 07 R Zeroes 36 42

S S S S S S
CODE VALUES:
Positions 1-3 must contain a valid 3-digit Community code.

Positions 4-5 must contain a valid 2-digit County code.
Positions 6-7 must contain a valid 2-digit State code.

None None
NOTES: These number is obtained from the authorizing IHS Service Unit
which referred the patient for services.
DATA ELEMENT: Patient Health Record Number
DEFINITION: A unique number assigned to identify a patient at the IHS

Authorizing Service Unit Facility.
CA1 07.0 9 06 R Zeroes 43 48

R R R R R R
CODE VALUES:
May contain 1-6 digits.
Must be greater than zero (0).

None Reject Claim
referred the patient for services. This number will vary for each
Service Unit. This is the equivalent of a patient's medical record
number at the IHS Service Unit.
DATA ELEMENT: Authorizing Facility Number
DEFINITION: A unique number assigned to identify the IHS Authorizing Service

Unit.
CA1 08.0 X 09 L Spaces 49 57

S S S S S S
CODE VALUES:
VALIDATION: Positions 1-3 may only contain a value of CHS.

Positions 4-5 must contain a valid IHS National Area code.
Positions 6-7 must contain a valid IHS Authorizing Service Unit
code.
Positions 8-9 must contain a valid IHS Facility (IHS hospital or
clinic) code.

None None
NOTES: These number is obtained from the authorizing IHS Service Unit
which referred the patient for services.
DATA ELEMENT: Multiple Claim Indicator
DEFINITION: A code to indicate simultaneous claim submission of a HCFA-1450

form for facility charges and a HCFA-1500 form for physician
charges, authorized under the same Purchase Order.
CA1 09.0 X 01 L Spaces 58 58

S S S S S S
SITUATIONAL NOTE: Must contain a value of Y if multiple claims have been submitted
under a single Purchase Order Number.
CODE VALUES: N or Space Single claim or Purchase Order

Y Multiple Claim on Purchase Order

None Reject Claim
NOTES: This field is applicable only for facility providers which also bill
professional fees.
CA1 10.0 X 262 L Spaces 59 320

R R R R R R
CODE VALUES:

None None
RECORD SUMMARY
RECORD TYPE: CB0
RECORD NAME: Claim Header: Legal Representative Data
RECORD LEVEL: Claim
RECORD PURPOSE: To identify the legal representative or guardian responsible

for a patient that may be mentally or physically unable to
file a claim.
S CA0 or CA1 DA0

CONDITIONAL NOTE: Must be entered if the patient is the insured, and is mentally
or physically unable to file a claim.
NOTES: Only one (1) Record Type CB0 may be entered per claim.
RECORD LAYOUT
Record Type: CB0

CB0 01.0 Record Type 'CB0' X 03 01 03
CB0 02.0 Reserved Filler X 02 04 05
CB0 03.0 Patient Control Number X 17 06 22
CB0 04.0 Responsible Person Last Name X 20 23 42
CB0 05.0 Responsible Person First Name X 12 43 54
CB0 06.0 Responsible Person Middle Initial X 01 55 55
CB0 09.0 Responsible Person City X 20 116 135
CB0 10.0 Responsible Person State X 02 136 137
CB0 11.0 Responsible Person Zip Code X 09 138 146
CB0 12.0 Responsible Person Telephone Number X 10 147 156
CB0 13.0 Filler - National X 82 157 238
CB0 14.0 Filler - Local X 82 239 320
Emdeon Business Services Technical Specifications NSF Plus CB0 - 01.0
DATA ELEMENT: Record Type 'CB0'
DEFINITION: A code used to identify the "Legal Representative Data" record.
CB0 01.0 X 03 L Spaces 01 03

R R R R R R
CODE VALUES:
VALIDATION: Must contain a value of CB0.

CB0 02.0 X 02 L Spaces 04 05

R R R R R R
CODE VALUES:

None None

CB0 03.0 X 17 L Spaces 06 22

R R R R R R
CODE VALUES:
VALIDATION: Must contain A-Z, 0-9, slash (/), comma (,), or hyphen (-). No
other special characters are allowed.

DATA ELEMENT: Responsible Person Last Name
DEFINITION: The last name of the legally responsible party if the patient is
mentally or physically unable to file his/her own claim.
CB0 04.0 X 20 L Spaces 23 42

N N N N N S
SITUATIONAL NOTE: Must be entered if the LEGAL REPRESENTATIVE INDICATOR (RT

CA0, fld-25.0) contains a value of Y.
CODE VALUES:
VALIDATION: Must contain A-Z, period (.), comma (,), hyphen (-), and trailing
spaces.
No other special characters or embedded spaces are allowed.

validation.

DATA ELEMENT: Responsible Person First Name
DEFINITION: The first name of the legally responsible party if the patient is
CB0 05.0 X 12 L Spaces 43 54

N N N N N S
SITUATIONAL NOTE: Must be entered if the LEGAL REPRESENTATIVE INDICATOR (RT

CA0, fld-25.0) contains a value of Y.
CODE VALUES:
VALIDATION: Must contain A-Z, period (.), comma (,), hyphen (-), and trailing
spaces.

validation.

DATA ELEMENT: Responsible Person Middle Initial
DEFINITION: The middle initial of the legally responsible party if the patient is
CB0 06.0 X 01 L Spaces 55 55

N N N N N D
CODE VALUES:
VALIDATION: Should only contain a value of A-Z or space. No other special

characters allowed.
RESPONSIBLE PARTY MIDDLE INITIAL may only be entered if

RESPONSIBLE PERSON LAST NAME (fld-04.0) and RESPONSIBLE
PERSON FIRST NAME (fld-05.0) have been entered.

None None
DATA ELEMENT: Responsible Person Address 1
DEFINITION: The address of the legally responsible party if the patient is mentally
or physically unable to file his/her own claim.
CB0 07.0 X 30 L Spaces 56 85

N N N N N S
SITUATIONAL NOTE: Must be entered if the LEGAL REPRENTATIVE INDICATOR (RT CA0,
fld-25.0) contains a value of Y.
CODE VALUES:
VALIDATION: If entered, See Standard Address Checks in Exhibit 2 for field

validation.

DATA ELEMENT: Responsible Person Address 2
CB0 08.0 X 30 L Spaces 86 115

N N N N N S
SITUATIONAL NOTE: Should be entered if a second address line is required to provide a

CODE VALUES:

validation.

None Reject Claim
DATA ELEMENT: Responsible Person City
CB0 09.0 X 20 L Spaces 116 135

N N N N N S
CODE VALUES:

validation.

DATA ELEMENT: Responsible Person State
CB0 10.0 X 02 L Spaces 136 137

N N N N N S
CODE VALUES:

validation.

DATA ELEMENT: Responsible Person Zip Code
CB0 11.0 X 09 L Spaces 138 146

N N N N N S
CODE VALUES:

validation.

DATA ELEMENT: Responsible Person Telephone Number
DEFINITION: The telephone number of the legally responsible party if the patient
is mentally or physically unable to file his/her own claim.
CB0 12.0 X 10 L Spaces 147 156

N N N N N N
CODE VALUES:
VALIDATION: If entered, should be in the format XXXyyyZZZZ where:

XXX = Area Code
yyy = Exchange
ZZZZ = Station Number

None None
CB0 13.0 X 82 L Spaces 157 238

R R R R R R
CODE VALUES:

None None
CB0 14.0 X 82 L Spaces 239 320

R R R R R R
CODE VALUES:

None None
RECORD SUMMARY
RECORD TYPE: DA0
RECORD LEVEL: Claim
RECORD PURPOSE: To identify the Payer(s) responsible for claim payment.
To identify the insured individual and to provide the

insured's coverage information.
To identify the Payer(s) that have already paid a portion of

the claim.
R CA0, CA1, CB0, DA0, DA0, DA1, DA2, DA3,

DA1, DA2, DA3, DA@ DA@ or EA0

CONDITIONAL NOTE:
NOTES: Multiple DA0 records should be sequenced according to

national and state coordination of benefits rules. The
primary payer should always be first regardless of whether
payment is being requested at this time. The order of
records should always be: Primary insurance followed by
Secondary insurance (if applicable), and then Tertiary
insurance (if applicable).
PAYER ID (fld-07.0) should be used to direct the claim to the

appropriate payer(s).
A maximum of one (1) Record Type DA0, with a CLAIM

FILING INDICATOR of P, may be present on a claim.
A Record containing a CLAIM FILING INDICATOR of P, will be

subject to full validation.
Records without a CLAIM FILING INDICATOR of P, will be

treated as "informational" and will not be edited.
RECORD LAYOUT
Record Type: DA0

DA0 04.0 Claim Filing Indicator X 01 23 23
DA0 05.0 Source of Payment X 01 24 24
DA0 06.0 Insurance Type Code X 02 25 26
DA0 07.0 Payer Organization ID X 05 27 31
DA0 08.0 Payer Claim Office Number X 04 32 35
DA0 09.0 Payer Name X 33 36 68
DA0 10.0 Group Number X 20 69 88
DA0 11.0 Group Name X 33 89 121
DA0 12.0 PPO/HMO Indicator X 01 122 122
DA0 13.0 PPO ID X 15 123 137
DA0 14.0 Prior Authorization Number X 15 138 152
DA0 15.0 Assignment of Benefits Indicator X 01 153 153
DA0 16.0 Patient Signature Source X 01 154 154
DA0 17.0 Patient Relationship to Insured 9 02 155 156
DA0 18.0 Insured ID Number X 25 157 181
DA0 19.0 Insured Last Name X 20 182 201
DA0 20.0 Insured First Name X 12 202 213
DA0 21.0 Insured Middle Initial X 01 214 214
DA0 22.0 Insured Generation X 03 215 217
DA0 23.0 Insured Sex X 01 218 218
DA0 24.0 Insured Date of Birth 9 08 219 226
DA0 25.0 Insured Employment Status X 01 227 227
DA0 26.0 Supplemental Insurance Indicator X 01 228 228
DA0 27.0 Insurance Location ID X 07 229 235
DA0 28.0 Medicaid ID Number X 25 236 260
DA0 29.0 Other Payer Patient ID X 10 261 270
DA0 30.0 Other Payer Patient ID Qualifier X 02 271 272
DA0 31.0 Payer Secondary ID Qualifier X 02 273 274
DA0 32.0 Payer Secondary ID X 15 275 289
DA0 33.0 Obligated to Accept Amount 9v99 7 290 296
DA0 34.0 Filler X 24 297 320
Emdeon Business Services Technical Specifications NSF Plus DA0 - 01.0
DATA ELEMENT: Record Type 'DA0'
DEFINITION: A field used to identify the "Payer Data 1" Record.
DA0 01.0 X 03 L Spaces 01 03

R R R R R R
CODE VALUES:
VALIDATION: Must contain a value of DA0

DATA ELEMENT: Payer Responsibility
DEFINITION: A sequential number from 01-05 assigned to individual records

within the same specific Record Type to indicate the sequence of
each physical record.
DA0 02.0 9 02 R Zeroes 04 05

R R R R R R
CODE VALUES:
Must be a valid code from the above list.
If only one (1) Record Type DA0 is entered, SEQUENCE NUMBER

must contain a value of 01. Each additional Record Type DA0
entered must have a SEQUENCE NUMBER one (1) greater than the
previous Record Type DA0.
MEDICARE: Up to three (3) sequences of Record Type DA0 are

allowed.
ALL OTHERS: Up to five (5) sequences of Record Type DA0 are

allowed.

NOTES: The SEQUENCE NUMBER for Record Type DA0 must be identical to
the SEQUENCE NUMBER of the corresponding Record Types DA1,
DA2, and DA3 (fld-02.0).
The primary payer should be reported in the first sequence of the

claim and the secondary payer should be reported in the second
sequence.

DA0 03.0 X 17 L Spaces 06 22

R R R R R R
CODE VALUES:

DATA ELEMENT: Claim Filing Indicator
DEFINITION: A code used to indicate whether the information in this payer record
should be fully validated and the claim forwarded to the indicated
payer.
or
whether the information in this payer record is for informational
purposes.
DA0 04.0 X 01 L Spaces 23 23

R R R R R R
CODE VALUES: I Payment is not being requested of this payer.

The claim is being submitted for information
purposes only.
P Payment requested of this payer only
If CLAIM FILING INDICATOR contains a value of P, PAYER

ORGANIZATION ID (fld-07.0) must be a valid code from the
WebMD Payer List.
A claim must have one (1) and only one Record Type DA0 with a P.

NOTES: For every payer record containing a CLAIM FILING INDICATOR of P,

a copy of the claim, in its entirety, will be forwarded to the payer
indicated within that payer record.
DATA ELEMENT: Source of Payment
DEFINITION: A code used to indicate the source of payment for the claim
associated with this payer record.
DA0 05.0 X 01 L Spaces 24 24

R R R R R R
CODE VALUES: 1 Liability Medical

2 Health Maintenance Organization-Medicare Risk
3 Automobile Medical
4 Mutually Defined
5 Disability
A Self Pay
B Workers Compensation
C Medicare
D Medicaid
F Commercial Insurance Co.
G Blue Cross/Blue Shield
H Champus
I HMO
J Federal Employees Program
K Central Certification
L Self-Administrated
M Family and Friends
N Managed Care Non-HMO
P Blue Cross
Q Point of Service
R Exclusive Provider Organization (EPO)
S Indemnity Insurance
© 2002-2003, Emdeon Corporation. All Rights Reserved. Version 2.01 November 2006
T Title V
V Veteran's Administration Plan
W Liability
X Preferred Provider Organization
Z Other/Other Non Federal Programs
Every claim must have at least one (1) Record Type DA0
containing a SOURCE OF PAYMENT with a value of C, F, G, or H and
a CLAIM FILING INDICATOR (fld-04.0) of P.

NOTES: PROVIDER MEDICARE NUMBER (RT BA0, fld-09.0) must be entered if

SOURCE OF PAYMENT contains a value of C.
PROVIDER MEDICAID NUMBER (RT BA0, fld-12.0) must be entered if

SOURCE OF PAYMENT contains a value of D.
PROVIDER CHAMPUS NUMBER (RT BA0, fld-13.0) must be entered if

SOURCE OF PAYMENT contains a value of H.
PROVIDER BLUE SHIELD NUMBER (RT BA0, fld-14.0) must be

entered if SOURCE OF PAYMENT contains a value of G or P.
© 2002-2003, Emdeon Corporation. All Rights Reserved. Version 2.01 November 2006
DATA ELEMENT: Insurance Type Code
DEFINITION: Identifies the type of insurance (policy).
DA0 06.0 X 02 L Spaces 25 26

S S S S S S
SITUATIONAL NOTE: Should be entered if required by the payer.
CODE VALUES: 12 Medicare Secondary, Working Aged

Beneficiary/Spouse with EGHP
13 Medicare Secondary, ESRD Beneficiary in 12
Month Period with EGHP
14 Medicare Secondary, No Fault Insurance,
Including Auto is Primary
15 Medicare Secondary, Workers Comp
16 Medicare Secondary, PHS and Other Federal
Agencies
41 Medicare Secondary, Black Lung
42 Medicare Secondary, Veterans Administration
43 Medicare Secondary, Disabled Beneficiary
Under Age 65 With LGHP
47 Medicare Secondary, Other Liability Insurance
is Primary
AP Auto Insurance Policy
GP Group Policy
IP Individual Policy
LD Long Term Policy
LT Litigation
MG Medigap Part B
MP Medicare Primary
OT Other
PP Personal Payment (Cash - No Insurance)
SP Supplemental Policy

None Reject Claim
NOTES: MEDICARE: If the first occurrence of RT-DA0 contains a SOURCE OF

PAYMENT (fld-05.0) of C, the associated occurrence of INSURANCE
TYPE CODE must contain a value of MP.
DATA ELEMENT: Payer Organization ID
DEFINITION: The number used to identify each payer organization from which the
provider expects or receives some reimbursement for this claim.
DA0 07.0 X 05 L Spaces 27 31

S S S S S S
SITUATIONAL NOTE: Must be entered if the CLAIM FILING INDICATOR contains a value
of P.
CODE VALUES:
VALIDATION: If entered, and if the CLAIM FILING INDICATOR = P, must contain

a valid Payer ID on the WebMD Payer List posted on the WebMD
Envoy website.

NOTES: All-Payer Program submitters must have a signed addendum with

WebMD before submitting claims to non-participating Payers or Print
Claims.
PAYER NAME (fld-09.0) must be entered if PAYER ORGANIZATION ID

identifies medical or dental All-Payer status.
PAYER ID is one of several fields which are compared for duplicate

claim processing. If these fields contain the same values as a claim
previously submitted on the same day, the claim will be rejected for
duplicate claims. See Exhibit 97 for detailed information.
DATA ELEMENT: Payer Claim Office Number
DEFINITION: The number, assigned by the payer, used to identify the specific
location which the payer has designated to receive this claim.
DA0 08.0 X 04 L Spaces 32 35

S S S S S S
SITUATIONAL NOTE: Must be entered if the CLAIM FILING INDICATOR contains a value
of P.
CODE VALUES:
VALIDATION: If entered, and if the CLAIM FILING INDICATOR = P, must contain

a valid PAYER CLAIM OFFICE NUMBER on the WebMD Payer List
posted on the WebMD Envoy website.

NOTES: Many Payers participate in WebMD Cardless claims processing where

the payer CLAIM OFFICE ID should contain a value of NOCD. For a
list of these payers, see the WebMD Payer List found on the WebMD
Envoy website.
For PARTICIPATING PAYERS: If payer CLAIM OFFICE ID contains

invalid data, WebMD will NOT reject the claim, but will replace the
data with a value of NOCD.
For NON PARTICIPATING PAYERS: The payer CLAIM OFFICE ID may
be found on the Payer's Insurance Card (appears as the last four
digits of the PAYER ID).
DATA ELEMENT: Payer Name
DEFINITION: The name of the payer organization from which the provider expects
or receives some reimbursement for this claim.
DA0 09.0 X 33 L Spaces 36 68

S R R R R R
SITUATIONAL NOTE: Must be entered if the PAYER ID (fld-07.0) contains a value of

SPRNT, CPRNT, PPRNT or 06126 and the CLAIM FILING
INDICATOR (fld-04.0) contains a value of P.
CODE VALUES:
VALIDATION: Must contain A-Z, 0-9, slash(/), space, hyphen (-) or ampersand
(&).
No other Special Characters are allowed.

DATA ELEMENT: Group Number
DEFINITION: An identification number, control number, or code assigned by the

payer or administrator used to identify the group under which the
insured is covered.
DA0 10.0 X 20 L Spaces 69 88

S S S N N N
SITUATIONAL NOTE: Must be entered if SOURCE OF PAYMENT (fld-05.0) contains a

value of D, F, G, H, I, or X, and CLAIM FILING INDICATOR (fld-
04.0) contains a value of P.
CODE VALUES:
VALIDATION: Must contain A-Z, 0-9, slash (/), period (.), comma (,) or hyphen (-
). No other special characters are allowed.
Must NOT contain the same value as the INSURED ID.
Must NOT contain all zero's.
Must NOT contain 1234567890.
Must not contain any of the following literals:

NONE UNKNOWN
INDIVIDUAL SELF

NOTES: Many Payers participate in WebMD Cardless claims processing

where the GROUP POLICY/PLAN NUMBER may contain a value of
999999. For a list of these payers, see the WebMD Payer List on the
WebMD Envoy website.
For PARTICIPATING PAYERS: If GROUP POLICY/PLAN NUMBER

contains invalid data, WebMD will NOT reject the claim, but will
replace the data with a value of 999999.
For NON PARTICIPATING PAYERS: The GROUP POLICY/PLAN

NUMBER may be found on the Payer's Insurance Card.
DATA ELEMENT: Group Name
DEFINITION: The name of the group or plan through which the insurance is
provided to the insured individual.
DA0 11.0 X 33 L Spaces 89 121

D D D D D N
SITUATIONAL NOTE: Should be entered if the subscriber's payer identification includes a

group or plan name.
CODE VALUES:
VALIDATION: Should only contain A-Z, 0-9, slash (/), period (.), hyphen (-),
ampersand (&), apostrophe (') or space.
No other special characters should be used.

None None
DATA ELEMENT: PPO/HMO Indicator
DEFINITION: An indicator that the provider is submitting this claim to or has

submitted this claim to the indicated payer under a Special
Processing Agreement.
DA0 12.0 X 01 L Spaces 122 122

S S S S S S
SITUATIONAL NOTE: Should be entered if applicable and required by payer.
CODE VALUES: C Champus "CAM Charleston" Partnership

Agreement
E Champus "External Partnership" Agreement
G Champus Army CAM Demonstration
H Champus Navy CAM Demonstration
I Champus "Internal" Partnership Agreement
J Champus Air Force CAM Demonstration
N HMO or PPO Claim
O Champus MCSP PPO Agreement
P Champus MCSP Prime Agreement
T Champus Tricare MCSP Extra Agreement
U Champus Tricare MCSP HMO Agreement
X Champus Cooperative Care Claim
Y HMO/PPO Agreement
VALIDATION: Should be a valid code from the above list.

None None
DATA ELEMENT: PPO ID
DEFINITION: The identification number assigned to the PPO/HMO by the payer.
DA0 13.0 X 15 L Spaces 123 137

S S S S S S
SITUATIONAL NOTE: Must be entered if PPO/HMO INDICATOR (fld-12.0) contains a

value of C, E, G, H, I, J, O, P, T, U or X.
CODE VALUES:
VALIDATION: CHAMPUS: Should contain the military treatment facility ID when

filing CHAMPUS partnership claims.

Reject Claim None
DATA ELEMENT: Prior Authorization Number
DEFINITION: A number, assigned by the payer, used to indicate prior

authorization.
DA0 14.0 X 15 L Spaces 138 152

S S S S S S
SITUATIONAL NOTE: Should be entered if the provider has a prior authorization number
from the payer.
CODE VALUES:

None None
DATA ELEMENT: Assignment of Benefits Indicator
DEFINITION: A code used to indicate whether the provider has a signed form
authorizing the payer to pay the provider, and whether the provider
accepts such a payment arrangement.
DA0 15.0 X 01 L Spaces 153 153

R R R R R R
CODE VALUES: N No, benefits are not assigned

Y Yes, benefits are assigned

DATA ELEMENT: Patient Signature Source
DEFINITION: A code used to indicate whether the provider has a signature from
the patient on file.
DA0 16.0 X 01 L Spaces 154 154

S S S S S R
SITUATIONAL NOTE: Must be entered if the SOURCE OF PAYMENT (fld-05.0) contains a

value of C.
CODE VALUES: B Authorization Form - Block 12 & 13

C Signed HCFA 1500 on file
M Authorization Form - Block 13
P Provider Signed
S Authorization Form - Block 12

DATA ELEMENT: Patient Relationship to Insured
DEFINITION: A code used to indicate the relationship of the patient to the insured
individual.
DA0 17.0 9 02 R Zeroes 155 156

R R R R R R
CODE VALUES: 01 Self - Patient is Insured

02 Spouse
03 Natural child / insured has financial
responsibility
04 Natural child / insured has no financial
responsibility
05 Stepson or Stepdaughter
06 Foster Child
07 Ward of the Court
08 Employee
09 Unknown
10 Handicapped Dependent
11 Organ Donor
12 Cadaver Donor
13 Grandson or Granddaughter
14 Nephew or Niece
15 Injured Plaintiff
16 Sponsored Dependent
17 Dependent of a Minor Dependent
18 Father or Mother
19 Grandfather or Grandmother
20* Life Partner
21* Emancipated Minor
22* Significant Other
24* Adopted Child
25* Other Adult
99 Other Relationship
Must contain a valid code from the above list.

NOTES: If PATIENT RELATIONSHIP TO INSURED does not contain a value of

01 (self), INSURED LAST NAME (fld-19.0) and INSURED FIRST
NAME (fld-20.0) must be entered.
If a value of 99 is entered, an explanation should be entered in

REMARKS (RT XA0, fld-22.0).
*Codes added to accommodate HIPAA
DATA ELEMENT: Insured ID Number
DEFINITION: A code used to identify the insured. This may be a code assigned by
the payer or the Social Security Number (SSN) of the insured. In
the case of Medicare, it will be the Health Insurance Card (HIC)
Number.
DA0 18.0 X 25 L Spaces 157 181

S S S S S S
SITUATIONAL NOTE: Must be entered if CLAIM FILING INDICATOR (fld-04.0) contains a

value of P.
CODE VALUES:
VALIDATION: Must contain A-Z, 0-9, slash(/), space or hyphen (-). No other
Special Characters are allowed.
Must not contain the same values and the GROUP NUMBER (fld-
10.0).
The first 5 bytes must not be the same as the PAYER

ORGANIZATION ID (FLD-07.0).
Must not contain ALL 1's, 2's, 3's. 4's, 5's, 6's, 7's, 8's, 9's, or 0's.
May not contain any of the following literals:
1234567890 NONE UNKNOWN

INDIVIDUAL SELF 123456789

NOTES: INSURED ID is one of several fields which are compared for duplicate
claim processing. If these fields contain the same values as a claim
previously submitted on the same day, the claim will be rejected for
duplicate claims. See Exhibit 97 for detailed information.
DATA ELEMENT: Insured Last Name
DEFINITION: The last name of the insured.
DA0 19.0 X 20 L Spaces 182 201

S S S S S S
SITUATIONAL NOTE: Must be entered if PATIENT RELATIONSHIP TO INSURED (fld-17.0)

does not contain a value of 01.
CODE VALUES:
VALIDATION: The first character must contain A-Z.
The remainder must contain A-Z, period (.), comma (,), hyphen (-)
and trailing spaces.

DATA ELEMENT: Insured First Name
DEFINITION: The first name of the insured.
DA0 20.0 X 12 L Spaces 202 213

S S S S S S
SITUATIONAL NOTE: Must be entered if PATIENT RELATIONSHIP TO INSURED (fld-17.0)

does not contain a value of 01.
CODE VALUES:
VALIDATION: The first character must contain A-Z.
The remainder must contain A-Z, period (.), comma (,), hyphen (-)
and trailing spaces.
The INSURED FIRST NAME must be entered if the INSURED LAST

NAME (D0-11) has been entered.

DATA ELEMENT: Insured Middle Initial
DEFINITION: The middle initial of the insured.
DA0 21.0 X 01 L Spaces 214 214

D D D D D D
CODE VALUES:
VALIDATION: If entered should only contain a value of A-Z, no other special

Should only be entered if INSURED LAST NAME (fld-19.0) and

INSURED FIRST NAME (fld-20.0) have been entered.

None None
DATA ELEMENT: Insured Generation
DEFINITION: The generation of the insured, such as I, II, III, IV, JR, or SR.
DA0 22.0 X 03 L Spaces 215 217

D D D D D D
CODE VALUES:
VALIDATION: If entered, should only contain a value of I, II, III, IV, JR, SR.

None None
DATA ELEMENT: Insured Gender
DEFINITION: A code used to identify the gender of the insured.
DA0 23.0 X 01 L Spaces 218 218

D D D D D D
CODE VALUES: F Female

M Male
U Unknown

None Reject Claim
DATA ELEMENT: Insured Date of Birth
DEFINITION: The date of birth of the insured individual.
DA0 24.0 9 08 R Zeroes 219 226

D D D D D D
CODE VALUES:
If entered, must be in format CCYYMMDD.

None Reject Claim
NOTES: This information is especially important for Coordination of Benefits if

the patient is a dependent child of the insured. Failure to enter this
information in these instances may result in a delay of claim
processing.
DATA ELEMENT: Insured Employment Status
DEFINITION: Code to indicate employment status of the insured individual.
DA0 25.0 X 01 L Spaces 227 227

N N N N N N
CODE VALUES: 1 Employed Full-Time

2 Employed Part-Time
3 Not Employed
4 Self-Employed
5 Retired
6 On Active Military Duty
7 Reserved for National Assignment
8 Reserved for Local Assignment
9 Unknown
VALIDATION: If entered, should be a valid code from the above list.

None None
DATA ELEMENT: Supplemental Insurance Indicator
DEFINITION: Indicates whether patient is carrying other insurance, or is eligible

for Medicaid or is eligible for Medicare.
DA0 26.0 X 01 L Spaces 228 228

S S S S S S
SITUATIONAL NOTE: Should be entered if required by the payer in the associated D0

Record.
CODE VALUES: I Eligible for Medicare

M Medicaid
P Primary Payer in MSP
S Supplemental Medigap
W Medicaid & MSP
X Medicaid & Medigap
Y Medicaid, Medigap & MSP
Z MSP & Medigap

None None
DATA ELEMENT: Insurance Location ID
DEFINITION: A code to identify the location, Title XIX coverage, branch number,
HMO Satellite, etc.
DA0 27.0 X 07 L Spaces 229 235

S S S S S S
SITUATIONAL NOTE: Should be entered if required by payer/receiver.
CODE VALUES:

None None
DATA ELEMENT: Medicaid ID Number
DEFINITION: Insured's unique Medicaid identification number.
DA0 28.0 X 25 L Spaces 236 260

S S S S S S
SITUATIONAL NOTE: Should be entered if SUPPLEMENTAL INSURANCE INDICATOR (fld-

26.0) contains a value of M (Medicaid).
CODE VALUES:
VALIDATION: Should NOT contain all zero's.
Should NOT contain 1234567890.
Should not contain any of the following literals:

NONE UNKNOWN
INDIVIDUAL SELF

None None
DATA ELEMENT: Other Payer Patient ID
DEFINITION: The identification number, usually the Social Security Number (SSN)
of the patient (if not the insured). This is not the patient control
number or the medical record number.
DA0 29.0 X 10 L Spaces 261 270

S S S S S S
CODE VALUES:

None None
DATA ELEMENT: Other Payer Patient ID Qualifier

OTHER PAYER PATIENT ID.
DA0 30.0 X 02 L Spaces 271 272

S S S S S S
SITUATIONAL NOTE: Should be entered if OTHER PAYER PATIENT ID has been entered.
CODE VALUES: MI Member Identification Number

ZZ HIPAA Individual Identifier

None Reject Claim
DATA ELEMENT: Payer Secondary ID Qualifier
DEFINITION: A code used to qualify the PAYER SECONDARY ID (fld-32.0).
DA0 31.0 X 02 L Spaces 273 274

S S S S S S
SITUATIONAL NOTE: Must be entered if PAYER SECONDARY ID (fld-32.0) has been

entered.
CODE VALUES: 2U Payer Identification Number

FY Claim Office Number
NF National Association of Insurance
Commissioners (NAIC) Code
TJ Federal Taxpayer's Identification Number

DATA ELEMENT: Payer Secondary ID
DEFINITION: A secondary number used when necessary to identify the payer.
DA0 32.0 X 15 L Spaces 275 289

S S S S S S
SITUATIONAL NOTE: Must be entered if PAYER SECONDARY ID QUALIFIER (fld-31.0)

has been entered.
CODE VALUES:

Reject Claim None
DATA ELEMENT: Obligated to Accept Amount
DEFINITION: The amount the provider agreed to accept as payment in full, under
the provisions of the contract.
DA0 33.0 9v99 7 R Zeroes 290 296

S S S S S S
SITUATIONAL NOTE: Should be entered if applicable.
CODE VALUES:

None Reject Claim
DA0 34.0 X 24 L Spaces 297 320

R R R R R R
CODE VALUES:

None None
RECORD SUMMARY
RECORD TYPE: DA1
RECORD LEVEL: Claim
RECORD PURPOSE: To supply additional information for identifying the Payer

and/or to provide prior adjudication status information from
primary Payers.
S DA0 DA0, DA2, DA3, DA@ or

EA0

CONDITIONAL NOTE: When filing "secondary" claims, CHAMPUS claims, and All-
Payer claims, a Record Type DA1 is required for every Payer
who has received and/or processed the claim prior to this
submission.
Record Type DA1 is also required when filing claims

designated as "paper" claims, i.e., claims to be printed by
WebMD Envoy and mailed on the Submitter/Provider's behalf
to the designated payer.

NOTES: This Record must be created if PAYER ORGANIZATION ID

(RT DA0,flds-07.0) in the corresponding DA0 Record
contains a value of 06126 or SPRNT or CPRNT and the CLAIM
FILING INDICATOR (RT DA0,fld-04.0) in the corresponding
DA0 Record contains a value of P.
When used, this Record Type DA1 must have the same
RECORD LAYOUT
Record Type: DA1

DA1 06.0 Payer City X 20 83 102
DA1 07.0 Payer State X 02 103 104
DA1 08.0 Payer Zip X 09 105 113
DA1 09.0 Filler X 7 114 120
DA1 10.0 Filler X 07 121 127
DA1 11.0 Allowed Amount 9v99 07 128 134
DA1 12.0 Filler X 07 135 141
DA1 13.0 Filler X 07 142 148
DA1 14.0 Payer Amount Paid 9v99 07 149 155
DA1 15.0 Zero Pay Indicator X 01 156 156
DA1 16.0 Filler X 02 157 158
DA1 17.0 Filler X 02 159 160
DA1 18.0 Filler X 02 161 162
DA1 19.0 CHAMPUS Sponsor Branch X 01 163 163
DA1 20.0 CHAMPUS Sponsor Grade X 02 164 165
DA1 21.0 CHAMPUS Sponsor Status X 01 166 166
DA1 22.0 Insurance Card Effect Date 9 08 167 174
DA1 23.0 Insurance Card Term Date 9 08 175 182
DA1 24.0 Balance Due 9v99 07 183 189
DA1 25.0 Claim Adjudication Date 9 08 190 197
DA1 28.0 Approved Amount 9v99 08 200 207
DA1 29.0 Patient Responsibility Amount 9v99 08 208 215
DA1 30.0 Covered Amount 9v99 08 216 223
DA1 31.0 Discount Amount 9v99 08 224 231
DA1 32.0 Per Day Limit Amount 9v99 08 232 239
DA1 33.0 Amount Paid to Patient 9v99 08 240 247
© 2002-2005 Emdeon Corporation. All Rights Reserved. Version 2.01, June 2006
DA1 34.0 Tax Amount 9v99 08 248 255
DA1 35.0 Total Claim Before Taxes 9v99 08 256 263
DA1 36.0 MOA Reimbursement Amount 9v99 08 264 271
DA1 37.0 MOA HCPCS Payable Amount 9v99 08 272 279
DA1 43.0 MOA ESRD Payable Amount 9v99 08 305 312
DA1 44.0 MOA Nonpayable Professional Component Billed Amount 9v99 08 313 320
DA1 01.0 X 03 L Spaces 01 03

R R R R R R
CODE VALUES:
VALIDATION: Must contain a value of DA1.

DEFINITION: A sequential number from 01-05 assigned to correspond to its

associated Record Type DA0 and DA2.
DA1 02.0 9 02 R Zeroes 04 05

R R R R R R
CODE VALUES:
VALIDATION: Must be entered.
Must be numeric.
Must be identical to the SEQUENCE NUMBER in the preceding

Record Type DA0 (fld-02.0).

NOTES: The primary payer should be reported in the first sequence of the
sequence.

DA1 03.0 X 17 L Spaces 06 22

R R R R R R
CODE VALUES:

DATA ELEMENT: Payer Address Line 1
DEFINITION: The current street address of the payer in the corresponding Record
Type DA0.
DA1 04.0 X 30 L Spaces 23 52

S S S S S S
SITUATIONAL NOTE: Required when the PAYER ORGANIZATION ID (RT DA0, fld-07.0)
contains a value of SPRNT, CPRNT, PPRNT, or 06126 and the
CLAIM FILING INDICATOR (RT DA0, fld-04.0) contains a value of P.
CODE VALUES:

DATA ELEMENT: Payer Address Line 2
DEFINITION: The additional street address of the payer in the corresponding

Record Type DA0.
DA1 05.0 X 30 L Spaces 53 82

N N N N N N

CODE VALUES:

None Reject Claim
DATA ELEMENT: Payer City
DEFINITION: The city of the payer in the corresponding Record Type DA0.
DA1 06.0 X 20 L Spaces 83 102

S S S S S S
CODE VALUES:

DATA ELEMENT: Payer State
DEFINITION: The state of the payer in the corresponding Record Type DA0.
DA1 07.0 X 02 L Spaces 103 104

S S S S S S
CODE VALUES:

DATA ELEMENT: Payer Zip
DEFINITION: The zip code of the payer in the corresponding Record Type DA0.
DA1 08.0 X 09 L Spaces 105 113

S S S S S S
CODE VALUES:

DA1 09.0 X 7 L Spaces 114 120

R R R R R R
CODE VALUES:

None None
NOTES: Disallowed Cost Containment Amount information should be

submitted using the DA3 (Claim Adjustment Information) Record.
Information submitted in this field will not be forwarded to the payer.
© 2002-2003, Emdeon Corporation. All Rights Reserved. Version 2.01 June 2006
DA1 10.0 X 07 L Spaces 121 127

R R R R R R
CODE VALUES:

None None
NOTES: Disallowed Other Amount information should be submitted using the

DA3 (Claim Adjustment Information) Record. Information submitted
in this field will not be forwarded to the payer.
DATA ELEMENT: Allowed Amount
DEFINITION: The maximum amount determined by the payer due as being

'allowable under the provisions of the contract prior to the
determination of actual payment.
DA1 11.0 9v99 07 R Zeroes 128 134

S S S S S S
SITUATIONAL NOTE: Should be entered if applicable and the payer in the associated
DA0 Record requires the information for the filing of secondary
claims.
CODE VALUES:
If entered, must equal the sum of all line level ALLOWED AMOUNTs
in Record Type FB0 (fld-06.0) if CLAIM FILING INDICATOR (RT
DA0, fld-04.0) contains a value of P.

None Reject Claim
NOTES: Only positive numeric dollar amounts are acceptable at this time;
negative values are not allowed.
DA1 12.0 X 07 L Spaces 135 141

R R R R R R
CODE VALUES:

None None
NOTES: Deductible Amount information should be submitted using the DA3

(Claim Adjustment Information) Record. Information submitted in
this field will not be forwarded to the payer.
DA1 13.0 X 07 L Spaces 142 148

R R R R R R
CODE VALUES:

None None
NOTES: Coinsurance Amount information should be submitted using the DA3

(Claim Adjustment Information) Record. Information submitted in
this field will not be forwarded to the payer.
DATA ELEMENT: Payer Amount Paid
DEFINITION: The amount paid by the payer on this claim.
DA1 14.0 9v99 07 R Zeroes 149 155

S S S S S S
claims.
CODE VALUES:

None Reject Claim
DATA ELEMENT: Zero Pay Indicator
DEFINITION: An indicator showing that the claim has been filed with to the payer,
that the payer has processed the claim and that the PAYER AMOUNT
PAID (RT DA1, fld-14.0) is the entire amount paid by the payer on
this claim.
DA1 15.0 X 01 L Spaces 156 156

S S S S S S
claims.
CODE VALUES: N Payment Greater than Zero

Space Not Filed/Not Received
Z Zero Payment

None None
NOTES: The purpose of this indicator is to allow payers to process secondary

claims with zero payments by the primary payer without having to
obtain an EOB from the payer or insured.
The provider is certifying that he has filed the claim to the indicated
payer; the payer has processed the claim to completion, informed
the provider of the results of that processing and that the amount
shown in PAYER AMOUNT PAID (RT DA1, fld-14.0) is the actual
amount that the payer paid on the claim.
DA1 16.0 X 02 L Spaces 157 158

R R R R R R
CODE VALUES:

None None
NOTES: Claim Adjustment information should be reported in the DA3 (Claim

Adjustment Information) Record. Information submitted in this field
will not be forwarded to the payer.
DA1 17.0 X 02 L Spaces 159 160

R R R R R R
CODE VALUES:

None None

DA1 18.0 X 02 L Spaces 161 162

R R R R R R
CODE VALUES:

None None

DATA ELEMENT: CHAMPUS Sponsor Branch
DEFINITION: CHAMPUS sponsor's military branch of service obtained from the

military identification card.
DA1 19.0 X 01 L Spaces 163 163

N N N S N N
SITUATIONAL NOTE: Must be entered if the SOURCE OF PAYMENT (RT DA0, fld-05.0)
contains a value of H (CHAMPUS) and CLAIM FILING INDICATOR
(RT DA0, fld-04.0) contains a value of P.
CODE VALUES: 1 Army

2 Air Force
3 Marine
4 Navy
5 Coast Guard
6 Public Health Service
7 NOAA

Reject Claim None
DATA ELEMENT: CHAMPUS Sponsor Grade
DEFINITION: CHAMPUS sponsor's military grade obtained from the military

identification card.
DA1 20.0 X 02 L Spaces 164 165

N N N S N N
contains a value of 'H' (CHAMPUS) and CLAIM FILING INDICATOR
CODE VALUES: E1-E9 Enlisted

G1 General/Admiral
O1-O9 Officer
S1 Security Agent
T1 NATO
VA CHAMPVA
W1-W4 Warrant Officer

Reject Claim None
DATA ELEMENT: CHAMPUS Sponsor Status
DEFINITION: CHAMPUS sponsor's military status obtained from the military

identification card.
DA1 21.0 X 01 L Spaces 166 166

N N N S N N
CODE VALUES: 1 Active Military

2 Retired Military
3 Deceased

Reject Claim None
DATA ELEMENT: Insurance Card Effect Date
DEFINITION: The effective date as obtained from the insurance identification card.
DA1 22.0 9 08 R Zeroes 167 174

N N N S N N
CODE VALUES:
If entered, must be in the format of CCYYMMDD.

DATA ELEMENT: Insurance Card Term Date
DEFINITION: The termination date as obtained from the insurance identification

card.
DA1 23.0 9 08 R Zeroes 175 182

N N N S N N
CODE VALUES:
If entered, it must be in the format of CCYYMMDD.
If entered, must not be greater than the CREATION DATE (RT

AA0, fld-15.0).
If entered, may not be less than the corresponding SERVICE FROM

DATE (fld-05.0).

DATA ELEMENT: Balance Due
DEFINITION: Amount of total charges remaining if partial payment is made by the

patient.
DA1 24.0 9v99 07 R Zeroes 183 189

S S S S S S
CODE VALUES:

None Reject Claim
DATA ELEMENT: Claim Adjudication Date
DEFINITION: The date that the claim was finalized in the adjudication system.
DA1 25.0 9 08 R Zeroes 190 197

S S S S S S
SITUATIONAL NOTE: Should be entered if the claim has been adjudicated by the payer
in this packet.
CODE VALUES:
VALIDATION: If entered must be numeric.
If entered must be in the format CCYYMMDD.

None Reject Claim
DATA ELEMENT: Claim Adjustment Indicator 1
DEFINITION: Other payer claim adjustment indicator.
DA1 26.0 X 01 L Spaces 198 198

N N N N N N
CODE VALUES: Y Yes, an adjustment to a prior claim

None Reject Claim
DATA ELEMENT: Claim Adjustment Indicator 2
DEFINITION: Other payer claim adjustment indicator.
DA1 27.0 X 01 L Spaces 199 199

N N N N N N
CODE VALUES: Y Yes, an adjustment to a prior claim

None Reject Claim
DATA ELEMENT: Approved Amount
DEFINITION: The amount approved for all service lines in the claim according to
the payer identified in the preceding Record Type DA0.
DA1 28.0 9v99 08 R Zeroes 200 207

S S S S S S
SITUATIONAL NOTE: Should only be entered if the claim has been adjudicated by the
payer in this packet.
CODE VALUES:

None Reject Claim
NOTES: Providers do not usually complete this information but may do so if

the information is available.
DATA ELEMENT: Patient Responsibility Amount
DEFINITION: The amount of money which is the responsibility of the patient

according to the payer identified in the preceding Record Type DA0.
DA1 29.0 9v99 08 R Zeroes 208 215

S S S S S S
CODE VALUES:

None Reject Claim
DATA ELEMENT: Covered Amount
DEFINITION: The covered amount equals the amount for the total claim that was
covered by the payer identified in the preceding Record Type DA0.
DA1 30.0 9v99 08 R Zeroes 216 223

S S S S S S
CODE VALUES:

None Reject Claim
DATA ELEMENT: Discount Amount
DEFINITION: The discount amount equals the amount for the total claim that was
discounted by the payer identified in the preceding Record Type DA0.
DA1 31.0 9v99 08 R Zeroes 224 231

S S S S S S
CODE VALUES:

None Reject Claim
DATA ELEMENT: Per Day Limit Amount
DEFINITION: The per day limit amount equals the amount of the day limit as
recorded by the payer identified in the preceding Record Type DA0.
DA1 32.0 9v99 08 R Zeroes 232 239

S S S S S S
CODE VALUES:

None Reject Claim
DATA ELEMENT: Amount Paid to Patient
DEFINITION: The amount paid to the patient as recorded by the payer identified in
the preceding Record Type DA0.
DA1 33.0 9v99 08 R Zeroes 240 247

S S S S S S
CODE VALUES:

None Reject Claim
DATA ELEMENT: Tax Amount
DEFINITION: The tax amount equals the amount of the tax as recorded by the
payer identified in the preceding Record Type DA0.
DA1 34.0 9v99 08 R Zeroes 248 255

S S S S S S
CODE VALUES:

None Reject Claim
DATA ELEMENT: Total Claim Before Taxes
DEFINITION: The pre-tax amount equals the amount of the pre-tax as recorded
by the payer identified in the preceding Record Type DA0.
DA1 35.0 9v99 08 R Zeroes 256 263

S S S S S S
CODE VALUES:

None Reject Claim
DATA ELEMENT: MOA Reimbursement Amount
DEFINITION: Medicare outpatient adjustment reimbursement percent rate as

recorded by the payer identified in the preceding Record Type DA0.
DA1 36.0 9v99 08 R Zeroes 264 271

S S S S S S
payer in this packet, and this information has been returned in the
remittance advice.
CODE VALUES:

None Reject Claim
DATA ELEMENT: MOA HCPCS Payable Amount
DEFINITION: Medicare outpatient adjustment HCPCS Payable amount as recorded

by the payer identified in the preceding Record Type DA0.
DA1 37.0 9v99 08 R Zeroes 272 279

S S S S S S
remittance advice.
CODE VALUES:

None Reject Claim
DATA ELEMENT: MOA Claim Payment Remark 1
DEFINITION: Medicare outpatient adjustment remarks.
DA1 38.0 X 05 L Spaces 280 284

S S S S S S
remittance advice.
CODE VALUES:

None None
DA1 39.0 X 05 L Spaces 285 289

S S S S S S
remittance advice.
CODE VALUES:

None None
DA1 40.0 X 05 L Spaces 290 294

S S S S S S
remittance advice.
CODE VALUES:

None None
DA1 41.0 X 05 L Spaces 295 299

S S S S S S
remittance advice.
CODE VALUES:

None None
DA1 42.0 X 05 L Spaces 300 304

S S S S S S
remittance advice.
CODE VALUES:

None None
DATA ELEMENT: MOA ESRD Payable Amount
DEFINITION: The amount paid on ESRD as recorded by the payer.
DA1 43.0 9v99 08 R Zeroes 305 312

S S S S S S
remittance advice.
CODE VALUES:

None Reject Claim
DATA ELEMENT: MOA Nonpayable Professional Component Billed Amount
DEFINITION: The amount paid on professional component as recorded by the

payer.
DA1 44.0 9v99 08 R Zeroes 313 320

S S S S S S
remittance advice.
CODE VALUES:

None Reject Claim
RECORD SUMMARY
RECORD TYPE: DA2
RECORD LEVEL: Claim
RECORD PURPOSE: To identify the mailing address of the insured individual.
To identify the employer of the insured individual.
S DA0 or DA1 DA0, DA3, DA@ or EA0

CONDITIONAL NOTE: Should be entered if:
The insured has a different mailing address from the patient;
OR
The insured is covered by a plan of insurance that involves

multiple employers or one employer operating from multiple
locations.

RECORD LAYOUT
Record Type: DA2

DA2 06.0 Insured City X 20 83 102
DA2 07.0 Insured State X 02 103 104
DA2 08.0 Insured Zip Code X 09 105 113
DA2 09.0 Insured Telephone Number X 10 114 123
DA2 10.0 Insured Retirement Date 9 08 124 131
DA2 11.0 Insured Spouse Retirement Date 9 08 132 139
DA2 12.0 Insured Employer Name X 33 140 172
DA2 15.0 Insured Employer City X 20 233 252
DA2 16.0 Insured Employer State X 02 253 254
DA2 17.0 Insured Employer Zip Code X 09 255 263
DA2 18.0 Employer Identification Number X 12 264 275
DA2 19.0 Original Reference Number X 30 276 305
DA2 20.0 Filler - Local X 15 306 320
DA2 01.0 X 03 L Spaces 01 03

R R R R R R
CODE VALUES:


associated Record Type DA0.
DA2 02.0 9 02 R Zeroes 04 05

R R R R R R
CODE VALUES:


sequence.

DA2 03.0 X 17 L Spaces 06 22

R R R R R R
CODE VALUES:

DATA ELEMENT: Insured Address Line 1
DEFINITION: The address line 1 of the current mailing address of the insured
individual when different from the patient's.
DA2 04.0 X 30 L Spaces 23 52

S S S S S S
SITUATIONAL NOTE: Should be entered if insured's mailing address is different from the
patient's address (RT CA0, fld-11.0 -15.0).
CODE VALUES:

validation.

None Reject Claim
DATA ELEMENT: Insured Address Line 2
DEFINITION: The address line 2 of the current mailing address of the insured
individual when different from the patient's.
DA2 05.0 X 30 L Spaces 53 82

N N N N N N

CODE VALUES:

validation.

None Reject Claim
DATA ELEMENT: Insured City
DEFINITION: The city of the current mailing address of the insured individual when
different from the patient's.
DA2 06.0 X 20 L Spaces 83 102

S S S S S S
CODE VALUES:

validation.

None Reject Claim
DATA ELEMENT: Insured State
DEFINITION: The state of the current mailing address of the insured individual
when different from the patient's.
DA2 07.0 X 02 L Spaces 103 104

S S S S S S
CODE VALUES:

validation.

None Reject Claim
DATA ELEMENT: Insured Zip Code
DEFINITION: The zip of the current mailing address of the insured individual when
different from the patient's.
DA2 08.0 X 09 L Spaces 105 113

S S S S S S
CODE VALUES:

validation.

None Reject Claim
DATA ELEMENT: Insured Telephone Number
DEFINITION: The telephone number, including area code, at which the insured
may be contacted.
DA2 09.0 X 10 L Spaces 114 123

D D D D D D
CODE VALUES:
If entered, should be in the format XXXyyyZZZZ where:
XXX = Area Code

yyy = Exchange

None None
DATA ELEMENT: Insured Retirement Date
DEFINITION: The retirement date of the insured.
DA2 10.0 9 08 R Zeroes 124 131

N N N N N S
SITUATIONAL NOTE: Should be entered if SOURCE OF PAYMENT (RT DA0, fld-05.0)

equals C (Medicare).
CODE VALUES:
VALIDATION: If, entered, must be numeric.

None Reject Claim
DATA ELEMENT: Insured Spouse Retirement Date
DEFINITION: The retirement date of the insured's spouse.
DA2 11.0 9 08 R Zeroes 132 139

N N N N N S

equals C (Medicare).
CODE VALUES:
VALIDATION: If, entered, must be numeric.


None Reject Claim
DATA ELEMENT: Insured Employer Name
DEFINITION: The name of the insured individual's current employer.
DA2 12.0 X 33 L Spaces 140 172

S S S S S S
SITUATIONAL NOTE: Should be entered if the insured's employer operates out of

multiple locations or the employer is an affiliated group (e.g.,
Chicago Area Automobile Association).
CODE VALUES:

None None
DATA ELEMENT: Insured Employer Address 1
DEFINITION: Address line 1 of the mailing address of the insured individual's

current employer.
DA2 13.0 X 30 L Spaces 173 202

S S S S S S

CODE VALUES:

validation.

None None
DATA ELEMENT: Insured Employer Address 2
DEFINITION: Address line 2 of the mailing address of the insured individual's

current employer.
DA2 14.0 X 30 L Spaces 203 232

N N N N N N

CODE VALUES:

validation.

None None
DATA ELEMENT: Insured Employer City
DEFINITION: City of the mailing address of the insured individual's current

employer.
DA2 15.0 X 20 L Spaces 233 252

S S S S S S

CODE VALUES:

validation.

None None
DATA ELEMENT: Insured Employer State
DEFINITION: State of the mailing address of the insured individual's current

employer.
DA2 16.0 X 02 L Spaces 253 254

S S S S S S

CODE VALUES:

validation.

None None
DATA ELEMENT: Insured Employer Zip Code
DEFINITION: Zip of the mailing address of the insured individual's current

employer.
DA2 17.0 X 09 L Spaces 255 263

S S S S S S

CODE VALUES:

validation.

None None
DATA ELEMENT: Employer Identification Number
DEFINITION: The identification number assigned by the employer to the employee.
DA2 18.0 X 12 L Spaces 264 275

D D D D D D
CODE VALUES:

None None
DATA ELEMENT: Original Reference Number
DEFINITION: A reference number assigned by payer to the original claim.
DA2 19.0 X 30 L Spaces 276 305

S S S S S S
SITUATIONAL NOTE: Should be entered if the claim is a resubmission.
CODE VALUES:

None None
DA2 20.0 X 15 L Spaces 306 320

R R R R R R
SITUATIONAL NOTE: Not Applicable
CODE VALUES:

None None
RECORD SUMMARY
RECORD TYPE: DA3
RECORD NAME: Claim Adjustment Information
RECORD LEVEL: Claim
RECORD PURPOSE: Provides the Claim Adjustment Information from the Non-
destination Payer (cross walked from the Remittance
Advice).
S DA0, DA1, DA2, DA3 DA0, DA3 or EA0

than fields DA3-01.0, DA3-02.0, DA3-03.0, DA3-04.0 or filler.
A maximum of five (5) DA3 Records per DA0 packet may be

entered.
RECORD LAYOUT
Record Type: DA3

DA3 03.0 Sub Sequence Number 9 02 06 07
DA3 04.0 Filler X 03 08 10
DA3 06.0 Filler X 17 28 44
DA3 07.0 CAS Group X 02 45 46
DA3 08.0 CAS Code 1 X 05 47 51
DA3 09.0 CAS Amount 1 9v99 08 52 59
DA3 10.0 CAS Quantity 1 9 10 60 69
DA3 11.0 CAS Code 2 X 05 70 74
DA3 12.0 CAS Amount 2 9v99 08 75 82
DA3 13.0 CAS Quantity 2 9 10 83 92
DA3 14.0 CAS Code 3 X 05 93 97
DA3 15.0 CAS Amount 3 9v99 08 98 105
DA3 16.0 CAS Quantity 3 9 10 106 115
DA3 17.0 CAS Code 4 X 05 116 120
DA3 18.0 CAS Amount 4 9v99 08 121 128
DA3 19.0 CAS Quantity 4 9 10 129 138
DA3 20.0 CAS Code 5 X 05 139 143
DA3 21.0 CAS Amount 5 9v99 08 144 151
DA3 22.0 CAS Quantity 5 9 10 152 161
DA3 23.0 CAS Code 6 X 05 162 166
DA3 24.0 CAS Amount 6 9v99 08 167 174
DA3 25.0 CAS Quantity 6 9 10 175 184
DA3 26.0 Filler X 136 185 320
DEFINITION: A field used to identify the "Claim Level Adjustment" Record.
DA3 01.0 X 03 L Spaces 01 03

R R R R R R
CODE VALUES:


associated Record Type DA0.
DA3 02.0 9 02 R Zeroes 04 5

R R R R R R
CODE VALUES:

Record type DA0 (fld-02.0).

sequence.
DATA ELEMENT: Sub Sequence Number
DEFINITION: A sequential number from 01 to 05 assigned to individual records

within a group of Records to indicate the sequence of each physical
record.
DA3 03.0 9 02 R Zeroes 06 07

R R R R R R
CODE VALUES: 01-05

NOTES: Up to five (5) Record Type DA3 are allowed per payer.
DA3 04.0 X 03 L Spaces 08 10

R R R R R R
CODE VALUES:

None None

individual records and payment posting.
DA3 05.0 X 17 L Spaces 11 27

R R R R R R
CODE VALUES:

DA3 06.0 X 17 L Spaces 28 44

R R R R R R
CODE VALUES:

None None
DATA ELEMENT: CAS Group
DEFINITION: A code identifying the general category of payment adjustment.
DA3 07.0 X 02 L Spaces 45 46

R R R R R R
CODE VALUES: CO Contractual Obligations

CR Correction and Reversals
OA Other Adjustments
PI Payer Initiated Reductions
PR Patient Responsibility

DATA ELEMENT: CAS Code 1
DEFINITION: A code identifying the detailed reason why the adjustment was made.
DA3 08.0 X 05 L Spaces 47 51

R R R R R R

National Health Care Claim Payment/Advise
Committee Bulletins
Available From:
Blue Cross/Blue Shield Association
Interplan Teleprocessing Services Division
676 N. St. Clair Street
Chicago, IL 60611

Reject Claim None
DATA ELEMENT: CAS Amount 1
DEFINITION: The amount of adjustment made on the claim.
DA3 09.0 9v99 08 R Zeroes 52 59

R R R R R R
CODE VALUES:

DATA ELEMENT: CAS Quantity 1
DEFINITION: The units of service being adjusted.
DA3 10.0 9 10 R Zeroes 60 69

S S S S S S
SITUATIONAL NOTE: Must be entered if CAS CODE (fld-08.0) has been entered and CAS
AMOUNT (fld-09.0) has not been entered.
CODE VALUES:

DA3 11.0 X 05 L Spaces 70 74

S S S S S S
SITUATIONAL NOTE: Must be entered if either CAS AMOUNT (fld-12.0) or CAS

QUANTITY (fld-13.0) has been entered.

Committee Bulletins
Available From:
Chicago, IL 60611

Reject Claim None
DA3 12.0 9v99 08 R Zeroes 75 82

S S S S S S
QUANTITY (fld-13.0) has not been entered.
CODE VALUES:

DA3 13.0 9 10 R Zeroes 83 92

S S S S S S
CODE VALUES:

DA3 14.0 X 05 L Spaces 93 97

S S S S S S


Committee Bulletins
Available From:
Chicago, IL 60611

Reject Claim None
DA3 15.0 9v99 08 R Zeroes 98 105

S S S S S S
CODE VALUES:

DA3 16.0 9 10 R Zeroes 106 115

S S S S S S
CODE VALUES:

DA3 17.0 X 05 L Spaces 116 120

S S S S S S


Committee Bulletins
Available From:
Chicago, IL 60611

Reject Claim None
DA3 18.0 9v99 08 R Zeroes 121 128

S S S S S S
CODE VALUES:

DA3 19.0 9 10 R Zeroes 129 138

S S S S S S
CODE VALUES:

DA3 20.0 X 05 L Spaces 139 143

S S S S S S


Committee Bulletins
Available From:
Chicago, IL 60611

Reject Claim None
DA3 21.0 9v99 08 R Zeroes 144 151

S S S S S S
CODE VALUES:

DA3 22.0 9 10 R Zeroes 152 161

S S S S S S
CODE VALUES:

DA3 23.0 X 05 L Spaces 162 166

S S S S S S


Committee Bulletins
Available From:
Chicago, IL 60611

Reject Claim None
DA3 24.0 9v99 08 R Zeroes 167 174

S S S S S S
CODE VALUES:

DA3 25.0 9 10 R Zeroes 175 184

S S S S S S
CODE VALUES:

DA3 26.0 X 136 L Spaces 185 320

R R R R R R
CODE VALUES:

None None
RECORD SUMMARY
RECORD TYPE: DA@
RECORD NAME: Additional Insurance Information
RECORD LEVEL: Claim
RECORD PURPOSE: To provide additional insurance information not included in

the previous record(s).
S DA0, DA1, DA2, DA3 DA0 or EA0

REQUIREMENTS N N C N N N
CONDITIONAL NOTE: Must be entered if Blue Cross/Blue Shield payer requires a

plan code.

than fields DA@-01.0, DA@-02.0, DA@-03.0 or filler.
NOTES: May only be entered if SOURCE OF PAYMENT (RT DA0,fld-

05.0) contains a value of G or P and CLAIM FILING
INDICATOR (RT DA0,fld-04.0) contains a value of M or P.
When used, this Record Type DA@ must have the same
Only one (1) Record Type DA@ may be entered per DA0.
RECORD LAYOUT
Record Type: DA@

DA@ 01.0 Record Type 'DA@' X 03 01 03
DA@ 02.0 Payer Responsibility 9 02 04 05
DA@ 03.0 Patient Control Number X 17 06 22
DA@ 04.0 BC/BS Plan Code X 05 23 27
DA@ 05.0 Filler - Local X 293 28 320
Emdeon Business Services Technical Specifications NSF Plus DA@ - 01.0
DATA ELEMENT: Record Type 'DA@'
DEFINITION: A field used to identify the "Additional Insurance Information" Record.
DA@ 01.0 X 03 L Spaces 01 03

N N R N N N
CODE VALUES:
VALIDATION: Must contain a value of DA@.


associated Record Type DA0 and Record Type DA1 and/or Record
Type DA2.
DA@ 02.0 9 02 R Zeroes 04 05

N N R N N N
CODE VALUES:

MEDICARE: Up to three (3) sequences of Record Type DA@ are

allowed.
ALL OTHERS: Up to five (5) sequences of Record Type DA@ are

allowed.

sequence.

DA@ 03.0 X 17 L Spaces 06 22

N N R N N N
CODE VALUES:

DATA ELEMENT: BC/BS Plan Code
DEFINITION: A code used to indicate that coverage is with an out-of-state

insurance plan.
DA@ 04.0 X 05 L Spaces 23 27

N N S N N N
CODE VALUES:

None None
NOTES: BC/BS PLAN CODE is used for Blue Cross/Blue Shield plans with
reciprocity agreements. It is NOT used for Central Certification or
FEP out-of-state Blue Shield plans.
DA@ 05.0 X 293 L Spaces 28 320

N N R N N N
CODE VALUES:

None None
RECORD SUMMARY
RECORD TYPE: EA0
RECORD NAME: Claim Record: Claim Data
RECORD LEVEL: Claim
RECORD PURPOSE: To provide information necessary to adjudicate the claim.
R DA0, DA1, DA2, DA3 or EA1, EA3, EA@ or FA0

DA@

CONDITIONAL NOTE:
NOTES: A maximum of one (1) Record Type EA0 may be entered per
claim.
RECORD LAYOUT
Record Type: EA0

EA0 04.0 Employment Related Indicator X 01 23 23
EA0 05.0 Accident Indicator X 01 24 24
EA0 06.0 Symptom Indicator X 01 25 25
EA0 07.0 Accident/Symptom Date 9 08 26 33
EA0 08.0 External Cause of Accident X 05 34 38
EA0 09.0 Responsibility Indicator X 01 39 39
EA0 10.0 Accident State X 02 40 41
EA0 11.0 Accident Hour X 02 42 43
EA0 12.0 Abuse Indicator X 01 44 44
EA0 13.0 Release of Information Indicator X 01 45 45
EA0 14.0 Release of Information Date 9 08 46 53
EA0 15.0 Same/Similar Symptom Indicator X 01 54 54
EA0 16.0 Same/Similar Symptom Date 9 08 55 62
EA0 17.0 Disability Type X 01 63 63
EA0 18.0 Disability From Date 9 08 64 71
EA0 19.0 Disability To Date 9 08 72 79
EA0 20.0 Referring Provider Tax ID X 15 80 94
EA0 20.1 Referring Provider Tax ID Qualifier X 01 95 95
EA0 22.0 Referring Provider Last Name X 20 120 139
EA0 23.0 Referring Provider First Name X 12 140 151
EA0 24.0 Referring Provider Middle Initial X 01 152 152
EA0 25.0 Referring Provider State X 02 153 154
EA0 26.0 Admission Date - 1 9 08 155 162
EA0 27.0 Discharge Date - 1 9 08 163 170
EA0 28.0 Laboratory Indicator X 01 171 171
EA0 29.0 Laboratory Charges 9v99 07 172 178
EA0 34.0 Provider Assignment Indicator X 01 199 199
EA0 35.0 Provider Signature Indicator X 01 200 200
EA0 36.0 Provider Signature Date 9 08 201 208
EA0 37.0 Facility/Laboratory Name X 33 209 241
EA0 38.0 Documentation Indicator X 01 242 242
EA0 39.0 Type of Documentation X 01 243 243
EA0 40.0 Functional Status Code X 02 244 245
EA0 41.0 Special Program Indicator X 02 246 247
EA0 42.0 CHAMPUS Non-Available Indicator X 01 248 248
EA0 43.0 Supervising Provider Indicator X 01 249 249
EA0 44.0 Resubmission Code X 02 250 251
EA0 45.0 Resubmission Reference Number X 15 252 266
EA0 46.0 Date Last Seen 9 08 267 274
EA0 47.0 Date Documentation Sent 9 08 275 282
EA0 48.0 Homebound Indicator X 01 283 283
EA0 49.0 Claim Place of Service X 02 284 285
EA0 50.0 Claim Frequency Code X 01 286 286
EA0 51.0 IDE Number X 15 287 301
EA0 52.0 Referring Provider NPI X 10 302 311
EA0 53.0 Filler X 08 312 319
EA0 54.0 Emergency/Urgent Indicator X 01 320 320
Emdeon Business Services Technical Specifications NSF Plus EA0 - 01.0
DATA ELEMENT: Record Type 'EA0'
DEFINITION: A field used to identify the "Claim Data" record.
EA0 01.0 X 03 L Spaces 01 03

R R R R R R
CODE VALUES:
VALIDATION: Must contain a value of EA0.

EA0 02.0 X 02 L Spaces 04 05

R R R R R R
CODE VALUES:

None None

EA0 03.0 X 17 L Spaces 06 22

R R R R R R
CODE VALUES:

DATA ELEMENT: Employment Related Indicator
DEFINITION: A code used to indicate whether the patient alleges that his/her
medical condition is due to the environment or events resulting from
employment.
EA0 04.0 X 01 L Spaces 23 23

R R R R R R
CODE VALUES: N No, the medical condition is not employment

related
U Unknown if the medical condition is
employment related
Y Yes, the medical condition is employment
related

DATA ELEMENT: Accident Indicator
DEFINITION: A code used to indicate whether the services performed were

treatment for injuries received as a result of an automobile or other
accident.
EA0 05.0 X 01 L Spaces 24 24

S S S S S S
SITUATIONAL NOTE: Should be entered if the services performed were related to an

accident.
CODE VALUES: A Injuries were received as the result of an

automobile accident
N Injuries were not received as the result of an
accident
O Injuries were received as the result of a non
automobile accident

None Reject Claim
NOTES: If ACCIDENT INDICATOR contains a value of A or O,

ACCIDENT/SYMPTOM DATE (fld-07.0), EXTERNAL CAUSE OF
ACCIDENT (fld-08.0), RESPONSIBILITY INDICATOR (fld-09.0), and
ACCIDENT STATE (fld-10.0) must be entered.
DATA ELEMENT: Symptom Indicator
DEFINITION: A code used to indicate the type of (first) symptom or illness being
reported.
EA0 06.0 X 01 L Spaces 25 25

D D D D D D
CODE VALUES: 0 No Symptom Date

1 First Symptom/Illness
2 Last Menstrual Period (LMP)

None None
DATA ELEMENT: Accident/Symptom Date
DEFINITION: The date that symptoms were first experienced or the date of last
menstrual period (LMP) if treatment is the result of pregnancy.
Or
The date when the accident occurred for services being submitted in
this claim.
EA0 07.0 9 08 R Zeroes 26 33

S S S S S S
SITUATIONAL NOTE: Should be entered if ACCIDENT INDICATOR (fld-05.0) has been

entered or SYMPTOM INDICATOR (fld-06.0) contains a value of 1
or 2.
CODE VALUES:

None Reject Claim
DATA ELEMENT: External Cause of Accident
DEFINITION: A code from the Supplemental Classification of External Causes of

Injury and Poisoning section of the ICD-9-CM manual.
EA0 08.0 X 05 L Spaces 34 38

S S S S S S
SITUATIONAL NOTE: Should be entered if ACCIDENT INDICATOR (fld-05.0) contains a

value of O.
CODE VALUES:
VALIDATION: Must be a valid ICD-9-CM code with a first digit of E.
May not contain decimal points.

None Reject Claim
NOTES: Decimal points are implied and should not be included in the code
entered.
DATA ELEMENT: Responsibility Indicator
DEFINITION: A code used to indicate whether or not the accident or illness was
caused by another party.
EA0 09.0 X 01 L Spaces 39 39

S S S S S S

value of A or O.
CODE VALUES: N No, accident or illness was not caused by

another party
Y Yes, accident or illness was caused by another
party

None None
DATA ELEMENT: Accident State
DEFINITION: The two-character state abbreviation identifying the state in which

the automobile accident occurred.
EA0 10.0 X 02 L Spaces 40 41

S S S S S S

value of A.
CODE VALUES:

validation.

None None
DATA ELEMENT: Accident Hour
DEFINITION: A code used to indicate the hour when the accident that necessitated
treatment occurred.
EA0 11.0 X 02 L Spaces 42 43

S S S S S S

value of A or O.
CODE VALUES:
VALIDATION: If entered, see Standard Date and Time Check in Exhibit 1 for field
validation.

None None
DATA ELEMENT: Abuse Indicator
DEFINITION: A code used to indicate whether the patient's condition, in the

provider's opinion, may be the result of abuse.
EA0 12.0 X 01 L Spaces 44 44

N N N N N D
CODE VALUES: N No, patient's condition is not the result of

abuse
Y Yes, patient's condition may be the result of
abuse

None None
DATA ELEMENT: Release of Information Indicator
DEFINITION: A code used to indicate whether the provider has a signed statement
on file permitting the release of medical data or other organizations
in order to adjudicate the claim.
EA0 13.0 X 01 L Spaces 45 45

R R R R R R
CODE VALUES: A* Appropriate Release of Information on File at

Health Care Service Provider or at Utilization
Review Organization.
I* Informed Consent to Release Medical
Information for Conditions or Diagnoses
Regulated by Federal Statutes.
M Modified or Restricted Release
N No Release
O* On file at Payer or at Plan Sponsor
Y Yes, Provider has a Signed Statement
Permitting Release of Medical Billing Data
Related to a Claim.
VALIDATION: Must contain a valid code from the above list.

DATA ELEMENT: Release of Information Date
DEFINITION: The date that the Release of Information was signed by the patient.
EA0 14.0 9 08 R Zeroes 46 53

S S S S S S
SITUATIONAL NOTE: Should be entered if RELEASE OF INFORMATION INDICATOR (fld-

13.0) contains a value of Y or M.
CODE VALUES:

None Reject Claim
DATA ELEMENT: Same/Similar Symptom Indicator
DEFINITION: A code used to indicate whether the patient has reported previously
experiencing identical or similar symptoms to those reported in the
claim.
EA0 15.0 X 01 L Spaces 54 54

D D D D D D
CODE VALUES: N No, Symptoms were not Previously

Experienced
Y Yes, Symptoms were Previously Experienced

None None
DATA ELEMENT: Same/Similar Symptom Date
DEFINITION: The previous date that the patient experienced symptoms similar or
identical to those for which services submitted on this claim were
rendered.
EA0 16.0 9 08 R Zeroes 55 62

S S S S S S
SITUATIONAL NOTE: Should be entered if SAME/SIMILAR INDICATOR (fld-15.0)

contains a value of Y.
CODE VALUES:

None Reject Claim
DATA ELEMENT: Disability Type
DEFINITION: An indicator to describe the type of disability.
EA0 17.0 X 01 L Spaces 63 63

S S S S S S
CODE VALUES: 1 Short Term

2 Long Term
3 Permanent
4 No Disability

None None
DATA ELEMENT: Disability From Date
DEFINITION: The beginning date the patient, in the physician's opinion, was or will
be unable to perform the duties normally associated with his/her
work.
EA0 18.0 9 08 R Zeroes 64 71

S S S S S S
SITUATIONAL NOTE: Should be entered if DISABILITY TYPE (fld-17.0) contains a value

of 1 or 2.
CODE VALUES:

None Reject Claim
DATA ELEMENT: Disability To Date
DEFINITION: The ending date the patient, in the physician's opinion, was or will be
unable to perform the duties normally associated with his/her work.
EA0 19.0 9 08 R Zeroes 72 79

S S S S S S
SITUATIONAL NOTE: Should be entered if DISABILITY TYPE (fld-17.0) contains a value

of 1 or 2.
CODE VALUES:

None Reject Claim
DATA ELEMENT: Referring Provider Tax ID
DEFINITION: The tax identification number of the referring provider.
EA0 20.0 X 15 L Spaces 80 94

S S S S S S
SITUATIONAL NOTE: Should be entered if the REFERRING PROVIDER TAX ID QUALIFIER

CODE VALUES:

None Reject Claim
DATA ELEMENT: Referring Provider Tax ID Qualifier

REFERRING PROVIDER TAX ID (fld-20.0).
EA0 20.1 X 01 L Spaces 95 95

S S S S S S
SITUATIONAL NOTE: Should be entered if REFERRING PROVIDER TAX ID (fld-20.0) has

been entered.
CODE VALUES: E Employer's Identification Number (EIN)

S Social Security Number (SSN)

None Reject Claim
DATA ELEMENT: Diagnosis Code 5
DEFINITION: ICD-9-CM primary diagnosis code for the illness or injury which was
the reason for treatment.
EA0 21.1 X 5 L Spaces 100 104

N N N N N N
CODE VALUES:
VALIDATION: If entered, must be a valid Diagnosis ICD-9-CM Code.
If entered, must be the most specific/precise 3-digit, 4-digit or 5-

digit code allowed for in the ICD-9-CM coding format.
OTHER DIAGNOSIS CODE may only be entered if TERTIARY
DIAGNOSIS CODE (fld-33.0) has been entered.

None Reject Claim
NOTES: Decimal points are implied and should not be included in the
diagnosis code.
PRIMARY and SECONDARY DIAGNOSIS CODEs are two of several

fields which are compared for "duplicate claim processing". If these
fields contain the same values as a claim previously submitted on
the same day, the claim will be rejected for "duplicate claim". See
Exhibit 97 for detailed information.
EA0 21.2 X 5 L Spaces 105 109

N N N N N N
CODE VALUES:

DIAGNOSIS CODE (fld-21.a) has been entered.

None Reject Claim
diagnosis code.

EA0 21.3 X 5 L Spaces 110 114

N N N N N N
CODE VALUES:

DIAGNOSIS CODE (fld-21.0b) has been entered.

None Reject Claim
diagnosis code.

EA0 21.4 X 5 L Spaces 115 119

N N N N N N
CODE VALUES:

DIAGNOSIS CODE (fld-21.0C) has been entered.

None Reject Claim
diagnosis code.

EA0 21.5 X 4 L Spaces 96 99

R R R R R R
CODE VALUES:

None None
DATA ELEMENT: Referring Provider Last Name
DEFINITION: The last name of the provider (or surrogate) who referred the
patient to the billing provider.
EA0 22.0 X 20 L Spaces 120 139

S S S S S S
SITUATIONAL NOTE: Must be entered for lab claims when PRIMARY DIAGNOSIS CODE
CODE VALUES:
VALIDATION: If entered, the first character should contain a value of A-Z, the
remainder of the field should contain A-Z, space, comma, or
period. No other special characters are allowed.

Reject Claim None
DATA ELEMENT: Referring Provider First Name
DEFINITION: The first name of the provider (or surrogate) who referred the
EA0 23.0 X 12 L Spaces 140 151

S S S S S S
SITUATIONAL NOTE: Must be entered for lab claims when PRIMARY DIAGNOSIS CODE
CODE VALUES:

Reject Claim None
DATA ELEMENT: Referring Provider Middle Initial
DEFINITION: The middle initial of the provider (or surrogate) who referred the
EA0 24.0 X 01 L Spaces 152 152

D D D D D D
CODE VALUES:
VALIDATION: Should only contain a value of A-Z or a space.
Should only be entered if RENDERING PROVIDER FIRST NAME (fld-


None None
DATA ELEMENT: Referring Provider State
DEFINITION: The state in which the referring provider is located.
EA0 25.0 X 02 L Spaces 153 154

S S S S S S
SITUATIONAL NOTE: Should be entered if REFERRING PROVIDER LAST AND FIRST

NAME (flds-22.0-23.0) have been entered.
CODE VALUES:

validation.

None None
DATA ELEMENT: Admission Date - 1
DEFINITION: The beginning confinement date for services performed in a health

care facility.
EA0 26.0 9 08 R Zeroes 155 162

D D D D D S
SITUATIONAL NOTE: Should be entered if durable medical equipment (DME) was

prescribed and/or used while patient was admitted.
CODE VALUES:

None Reject Claim
DATA ELEMENT: Discharge Date - 1
DEFINITION: The ending confinement date for services performed in a health care
facility.
EA0 27.0 9 08 R Zeroes 163 170

D D D D D S
SITUATIONAL NOTE: Should be entered if durable medical equipment (DME) was

prescribed and/or used while patient was admitted.
CODE VALUES:

None Reject Claim
DATA ELEMENT: Laboratory Indicator
DEFINITION: A code used to indicate whether or not the laboratory work was
performed outside the provider's office.
EA0 28.0 X 01 L Spaces 171 171

S S S S S S
CODE VALUES: N Claim does not contain laboratory services

performed outside of the providers office
Y Claim contains laboratory services performed
outside of the providers office
VALIDATION: If entered, should be valid code from the above list.

None None
DATA ELEMENT: Laboratory Charges
DEFINITION: Charges billed to the provider by the Independent Laboratory.
EA0 29.0 9v99 07 R Zeroes 172 178

S S S S S S
SITUATIONAL NOTE: Should be entered if the LABORATORY INDICATOR (fld-28.0)

CODE VALUES:
Position 172 must contain a value of zero (0).

None Reject Claim
EA0 30.0 X 05 L Spaces 179 183

R R R R R R
CODE VALUES:
VALIDATION: Must be a valid Diagnosis ICD-9 Code.
The first character of PRIMARY DIAGNOSIS CODE may not contain

a value of E.
The first character may contain a value of V, if appropriate.
If PRRIMARY DIAGNOSIS CODE (RT-EA0, fld-30.0) entered

indicates sex specificity, then sex must match PATIENT SEX (RT
CA0, fld-09.0).

diagnosis code.

DEFINITION: ICD-9-CM secondary diagnosis code for the illness or injury which
was the reason for treatment.
EA0 31.0 X 05 L Spaces 184 188

N N N N N N
CODE VALUES:

SECONDARY DIAGNOSIS CODE may only be entered if PRIMARY


None Reject Claim
diagnosis code.
DEFINITION: ICD-9-CM tertiary diagnosis code for the illness or injury which was
EA0 32.0 X 05 L Spaces 189 193

N N N N N N
CODE VALUES:

TERTIARY DIAGNOSIS CODE may only be entered if SECONDARY


None Reject Claim
diagnosis code.
DEFINITION: ICD-9-CM other diagnosis code for the illness or injury which was
EA0 33.0 X 05 L Spaces 194 198

N N N N N N
CODE VALUES:


None Reject Claim
diagnosis code.
DATA ELEMENT: Provider Assignment Indicator
DEFINITION: A code used to indicate whether the provider and the beneficiary
have a signed mutual agreement authorizing the Medicare carrier to
pay the provider.
EA0 34.0 X 01 L Spaces 199 199

N N N N N R
SITUATIONAL NOTE: Must be entered if SOURCE OF PAYMENT (RT DA0, fld-05.0)

contains a value of C.
CODE VALUES: A Assigned

B Clinical Lab Only
N Not Assigned
P Patient refuses to assign benefits

DATA ELEMENT: Provider Signature Indicator
DEFINITION: The signature of the provider of service(s) reported on this claim

which acknowledges the performance of the service(s) and
authorizes payment is on file in the provider's office.
EA0 35.0 X 01 L Spaces 200 200

N N N N N S
CODE VALUES: N No, service provider's signature on file

Y Yes, service provider's signature on file

None None
DATA ELEMENT: Provider Signature Date
DEFINITION: The date the claim was signed by the provider.
EA0 36.0 9 08 R Zeroes 201 208

S S S S S S
SITUATIONAL NOTE: Must be entered if PROVIDER SIGNATURE INDICATOR (fld-35.0)

CODE VALUES:
VALIDATION: If entered must be numeric.
If entered must be in the format CCYYMMDD.

DATA ELEMENT: Facility/Laboratory Name
DEFINITION: The name of the facility other than the patient's home or the
provider's office, where services were rendered, such as hospital,
clinic, or laboratory.
EA0 37.0 X 33 L Spaces 209 241

S S S S S S
SITUATIONAL NOTE: Should be entered if LABORATORY INDICATOR (fld-28.0) contains

a value of Y.
CODE VALUES:
VALIDATION: If entered, the first character must contain a value of A-Z, the
remainder of the field must contain A-Z, space, comma, or period.
No other special characters are allowed.

None None
DATA ELEMENT: Documentation Indicator
DEFINITION: A code used to indicate that documentation pertaining to this claim

will be forwarded to the payer by the provider.
EA0 38.0 X 01 L Spaces 242 242

S S S S S S
SITUATIONAL NOTE: Should be entered if additional information is being forwarded to

the payer.
CODE VALUES: 1 By Mail

2 By Fax
3 Available on Request at Provider Site
E* E-Mail
L* Electronically Only

None None
NOTES: Code values 4, 5, 6 and 9 have been moved to the DMERC CMN
INDICATOR fields in Record Type GU0 (fld-72.0) and Record Type
GX0 (fld-37.0)
If DOCUMENTATION INDICATOR contains a value of 1, 2, 4, or 6,

DATE DOCUMENTATION SENT (fld-47.0) should be entered to
expedite the claim adjudication.
If DOCUMENTATION INDICATOR is entered and does not contain a

value of 3, TYPE OF DOCUMENTATION (fld-39.0) should be entered
to expedite the claim processing.
DATA ELEMENT: Type of Documentation
DEFINITION: A code used to indicate the type of documentation being submitted

by the provider.
EA0 39.0 X 01 L Spaces 243 243

S S S S S S
SITUATIONAL NOTE: Should be entered if DOCUMENTATION INDICATOR (fld-38.0)

contains a value of 1-6.
CODE VALUES: 9* Support Data for Verification REFERRAL: Use

this code to indicate a completed referral form
A DME Prescription
B Explanation of Benefits (Coordination of
Benefits or Medicare Secondary Payer)
C Diagnostic Report
D Operative Note
E PEN Certification
F Ambulance Certification
G Physical Therapy Certification
H Chiropractic Justification
I Prosthetics or Orthotic Certification
J Oxygen Prescription
K* Admission Summary
L* Prescription
M* Physician Order
N* Referral Form
O* Certification
P* Dental Models
Q* Discharge Summary
R* Models
S* Nursing Notes
T* Support Data for Claim
U* Physical Therapy Notes
V* Radiology Films
W* Radiology Report
X* Report of Tests and Analysis Report
Y Multiple Documentation Items
Z Other

None None
DATA ELEMENT: Functional Status Code
DEFINITION: A code based on the Karnofsky Scale to describe the patient's level
of disability.
EA0 40.0 X 02 L Spaces 244 245

N N N N N D
CODE VALUES: 00 Deceased

10 Moribund
20 Very Sick, Hospitalization Necessary
30 Severely Disabled, Hospitalization is Indicated
Although Death is not Imminent
40 Unable to Care for Self, Requires Institutional
or Hospital Care, Disease Maybe Progressing
Rapidly
50 Requires Considerable Assistance and
Frequent Medical Care
60 Requires Occasional Assistance but is Able to
Care for Most Needs
70 Unable to Work, Able to Work at Home and
Care for Most Needs, Varying Amount of
Assistance is Needed
80 Normal Activity with Effort, Some Signs or
Symptoms of Disease
90 Able to Carry on Normal Activity, Minor Signs
or Symptoms of Disease
99 Able to Carry on Normal Activity, No Special
Care Needed, Normal, No Complaints, No
Evidence of Disease

None None
DATA ELEMENT: Special Program Indicator
DEFINITION: A code used to indicate whether the services included within the
claim are related to a special program.
EA0 41.0 X 02 L Spaces 246 247

S S S S S S
SITUATIONAL NOTE: Should be entered when a special program may provider benefits
toward this claim.
CODE VALUES: 02 Physically Handicapped Children's Program

03 Special Federal Funding/Planning
05 Disability
06 PPV/Medicare
07 Induced Abortion - Danger to Life
08 Induced Abortion - Rape or Incest
09 Early & Periodic Screening, Diagnosis, and
Treatment (EPSDT) or Child Health
Assessment Program (CHAP)
10 Family Planning
A Champus Program for the Handicapped
(Patient is Sponsor)
B Champus Program for the Handicapped
(Patient is Spouse)
C1-C9 Champus Program for the Handicapped
(Patient is a Child, up to nine PFTH Suffix(s)
are Available for Assignment When More than
one Child From the Same Family is Enrolled in
the Program)
D Champus Program for the Handicapped
(Patient is Widow of Sponsor)
W Champus Program for the Handicapped
(Patient is a Child, However, the individual's
Assigned PFTH Suffix is Unknown)
Z* Second Opinion or Surgery

None Reject Claim
DATA ELEMENT: CHAMPUS Non-Available Indicator
DEFINITION: A code to indicate whether or not the provider has a signed

CHAMPUS statement of non-availability on file (statement indicates
the service was not available at a Military Treatment Facility).
EA0 42.0 X 01 L Spaces 248 248

N N N S N S

contains a value of H and CLAIM FILING INDICATOR (RT DA0, fld-
CODE VALUES: N No, the Provider does not have a Signed

Champus Non-Availability Statement on File
Y Yes, the Provider has a Signed Champus Non-
Availability Statement on File

None None
DATA ELEMENT: Supervising Provider Indicator
DEFINITION: A code to indicate whether any service billed on this claim was
supervised by a provider other than the rendering provider.
EA0 43.0 X 01 L Spaces 249 249

N N N N N S
SITUATIONAL NOTE: Should be entered if there is supervising provider information to be

reported.
CODE VALUES: N Service Billed was not Supervised by Other

Provider
Y Service Billed was Supervised by Other
Provider

None None
NOTES: If SUPERVISING PROVIDER INDICATOR contains a value of Y,

SUPERVISING PROVIDER NAME (RT EA1, flds-20.0,21.0),
SUPERVISING PROVIDER STATE (RT EA1, fld-23.0), SUPERVISING
PROVIDER TAX ID QUALIFIER and TAX ID (RT EA1, flds-05.0, 05.1)
should be entered.
DATA ELEMENT: Resubmission Code
DEFINITION: A code to indicate the reason for the resubmission of this claim.
EA0 44.0 X 02 L Spaces 250 251

S S S S S S
CODE VALUES: 01 Lack of Information to adjudicate the claim

None None
DATA ELEMENT: Resubmission Reference Number
DEFINITION: A reference number assigned by payer to the original claim.
EA0 45.0 X 15 L Spaces 252 266

S S S S S S
SITUATIONAL NOTE: Should be entered if the claim is a resubmission.
CODE VALUES:

None None
DATA ELEMENT: Date Last Seen
DEFINITION: The date the patient was last seen by the referring/ordering
physician for a claim billed by an independent physical therapist or
podiatrist.
EA0 46.0 9 08 R Zeroes 267 274

N N N N N D
CODE VALUES:

None Reject Claim
DATA ELEMENT: Date Documentation Sent
DEFINITION: The date that the documentation noted in DOCUMENTATION

INDICATOR (fld-38.0) was sent to the payer.
EA0 47.0 9 08 R Zeroes 275 282

N N N N N S
SITUATIONAL NOTE: Should be entered if DOCUMENTATION INDICATOR (fld-38.0)

contains a value of 1, 2, 4 or 6 to expedite claim adjudication.
CODE VALUES:

None Reject Claim
DATA ELEMENT: Homebound Indicator
DEFINITION: A code used to indicate whether an independent lab rendered

services to a homebound patient.
EA0 48.0 X 01 L Spaces 283 283

D D D D D D
CODE VALUES: N Patient is not homebound

Y Patient is homebound

None None
DATA ELEMENT: Claim Place of Service
DEFINITION: A code used to identify where the services were performed. If more
than one place of service code applies to the claim, it will be
overridden at the service line level.
EA0 49.0 X 02 L Spaces 284 285

N N N N N N
CODE VALUES: * Source: Codes are Maintained by the Centers

for Medicare and Medicaid
The Place of Service Code List is located at:
http://www.cms.hhs.gov/states/poshome.asp

None Reject Claim
NOTES: *Codes added to accommodate HIPAA.
DATA ELEMENT: Claim Frequency Code
DEFINITION: A code specifying the frequency of the claim. (This is the 3rd
position of the Uniform Billing Claim Form Bill Type)
EA0 50.0 X 01 L Spaces 286 286

N N N N N N

National Uniform Billing Data Element
Specifications Type of Bill Position 3
Available From:
National Uniform Billing Committee
American Hospital Association
840 Lake Shore Drive
Chicago, IL 60694

None None
DATA ELEMENT: IDE Number
DEFINITION: A code used to identify an FDA assigned Investigational Device

Exemption Number (IDE).
EA0 51.0 X 15 L Spaces 287 301

S S S S S S
SITUATIONAL NOTE: Should be entered if a claim involves an FDA assigned

investigational device number.
CODE VALUES:

None None
DATA ELEMENT: Referring Provider NPI
DEFINITION: The National Provider Identifier assigned to the provider.
EA0 52.0 X 10 L Spaces 302 311

N N N N N N
CODE VALUES:

None None
EA0 53.0 X 08 L Spaces 312 319

R R R R R R
CODE VALUES:

None None
DATA ELEMENT: Emergency/Urgent Indicator
DEFINITION: Indicates whether the patient required immediate medical attention

as a result of a physical or mental disorder, or severe and possibly
life threatening conditions.
EA0 54.0 X 01 L Spaces 320 320

D D D D D D
CODE VALUES: N No, the patient did not require immediate

attention
Y Yes, the patient required immediate attention

None None
RECORD SUMMARY
RECORD TYPE: EA1
RECORD NAME: Claim Record: Claim Data 2
RECORD LEVEL: Claim
RECORD PURPOSE: To identify additional claim level information.
S EA0 EA3, EA@ or FA0

CONDITIONAL NOTE: Should only be submitted in LABORATORY INDICATOR (RT

EA0, fld-28.0) contains a value of Y or if PLACE OF SERVICE
(RT FA0, fld-07.0) does not contain a value of 11 (office) or
12 (home).

than fields EA1-01.0, EA1-03.0 or filler.
RECORD LAYOUT
Record Type: EA1

EA1 04.0 Facility/Lab Tax ID X 15 23 37
EA1 04.1 Facility/Lab Tax ID Qualifier X 01 38 38
EA1 05.0 Supervising Provider Tax ID Qualifier X 01 39 39
EA1 05.1 Supervising Provider Tax ID X 09 40 48
EA1 07.0 Facility Type Qualifier X 02 51 52
EA1 10.0 Facility/Lab City X 20 113 132
EA1 11.0 Facility/Lab State X 02 133 134
EA1 12.0 Facility/Lab Zip X 09 135 143
EA1 13.0 Medical Record Number X 17 144 160
EA1 14.0 Return to Work Date 9 08 161 168
EA1 15.0 First Consult/Surgery Date 9 08 169 176
EA1 16.0 Admission Date 2 9 08 177 184
EA1 17.0 Discharge Date 2 9 08 185 192
EA1 18.0 Supervising Provider Secondary ID X 15 193 207
EA1 18.1 Supervising Provider Secondary ID Qualifier X 02 208 209
EA1 19.0 Supervising Provider NPI X 10 210 219
EA1 19.1 Filler X 03 220 222
EA1 20.0 Supervising Provider Last Name X 20 223 242
EA1 21.0 Supervising Provider First Name X 12 243 254
EA1 22.0 Supervising Provider Middle Initial X 01 255 255
EA1 23.0 Supervising Provider State X 02 256 257
EA1 24.0 EMT/Paramedic Last Name X 20 258 277
EA1 25.0 EMT/Paramedic First Name X 12 278 289
EA1 26.0 EMT/Paramedic Middle Initial X 01 290 290
EA1 27.0 Facility/Lab Provider NPI X 10 291 300
EA1 28.0 Facility/Lab Secondary ID Qualifier X 02 301 302
EA1 29.0 Facility/Lab Secondary ID X 15 303 317
EA1 30.0 Filler - Local X 03 318 320
DEFINITION: A field used to identify the "Claim Detail" record.
EA1 01.0 X 03 L Spaces 01 03

R R R R R R
CODE VALUES:

EA1 02.0 X 02 L Spaces 04 05

R R R R R R
CODE VALUES:

None None

EA1 03.0 X 17 L Spaces 06 22

R R R R R R
CODE VALUES:

DATA ELEMENT: Facility/Lab Tax ID
DEFINITION: The Tax Identification number of the Service Facility Provider.
EA1 04.0 X 15 L Spaces 23 37

S S S S S S
SITUATIONAL NOTE: Should be entered if LABORATORY INDICATOR (RT EA0, fld-28.0)

Must be entered if FACILITY/LAB TAX ID QUALIFIER has been

entered.
CODE VALUES:

Reject Claim None
DATA ELEMENT: Facility/Lab Tax ID Qualifier
DEFINITION: A code used to indicate what type of tax identification number is

present in FACILITY/LAB TAX ID (fld-04.0).
EA1 04.1 X 01 L Spaces 38 38

S S S S S S
SITUATIONAL NOTE: Must be entered if FACILITY/LAB TAX ID NUMBER has been

entered.


DATA ELEMENT: Supervising Provider Tax ID Qualifier
DEFINITION: A code used to indicate what type of tax identification number is

present in SUPERVISING PROVIDER TAX ID (fld-05.1).
EA1 05.0 X 01 L Spaces 39 39

S S S S S S
SITUATIONAL NOTE: Must be entered if SUPERVISING PROVIDER ID (fld-05.1) has been

entered.


DATA ELEMENT: Supervising Provider Tax ID
DEFINITION: The Tax Identification number of the Supervising Provider.
EA1 05.1 X 09 L Spaces 40 48

S S S S S S
SITUATIONAL NOTE: Must be entered if SUPERVISING PROVIDER TAX ID QUALIFIER has

been entered.
CODE VALUES:

Reject Claim None
EA1 06.0 X 02 L Spaces 49 50

R R R R R R
CODE VALUES:

None None
DATA ELEMENT: Facility Type Qualifier
DEFINITION: A code used to indicate what type of facility information is entered in

Record Type EA1 .
EA1 07.0 X 02 L Spaces 51 52

S S S S S S
SITUATIONAL NOTE: Must be entered if FACILITY/LAB ADDRESS (flds-08.0-12.0),

FACILITY TAX ID (fld-04.0), FACILITY PROVIDER NPI (fld-27.0),
or FACILITY/LAB NAME (RT EA0, fld-37.0) has been entered.
CODE VALUES: 77 Service Location

FA Facility
LI Independent Laboratory
TL Testing Laboratory

DATA ELEMENT: Facility/Lab Address - 1
DEFINITION: The street address of the facility, other than the patients' home or
provider's office, where services were rendered, such as a hospital,
EA1 08.0 X 30 L Spaces 53 82

S S S S S S
SITUATIONAL NOTE: Should be entered if the location of the health care service is
different than that specified in the Billing Provider address
information.
CODE VALUES:

validation.

None Reject Claim
DATA ELEMENT: Facility/Lab Address - 2
DEFINITION: The additional street address of the facility, other than the patients'
home or provider's office, where services were rendered, such as a
hospital, clinic, or laboratory.
EA1 09.0 X 30 L Spaces 83 112

N N N N N N
SITUATIONAL NOTE: Should be entered if a second street address is necessary to

convey a complete mailing address.
CODE VALUES:

validation.

None Reject Claim
DATA ELEMENT: Facility/Lab City
DEFINITION: The city of the facility, other than the patients' home or provider's
office, where services were rendered, such as a hospital, clinic, or
laboratory.
EA1 10.0 X 20 L Spaces 113 132

S S S S S S
information.
CODE VALUES:

validation.

None Reject Claim
DATA ELEMENT: Facility/Lab State
DEFINITION: The state of the facility, other than the patients' home or provider's
office, where services were rendered, such as a hospital, clinic, or
laboratory.
EA1 11.0 X 02 L Spaces 133 134

S S S S S S
information.
CODE VALUES:

validation.

None Reject Claim
DATA ELEMENT: Facility/Lab Zip
DEFINITION: The zip code of the facility, other than the patients' home or
provider's office, where services were rendered, such as a hospital,
EA1 12.0 X 09 L Spaces 135 143

S S S S S S
information.
CODE VALUES:

validation.

None Reject Claim
DATA ELEMENT: Medical Record Number
DEFINITION: A number assigned by the provider to identify the patient's medical

record.
EA1 13.0 X 17 L Spaces 144 160

N N N N N D
CODE VALUES:

None None
DATA ELEMENT: Return to Work Date
DEFINITION: The date the patient, in the provider's opinion, will be able to resume
the performance of the duties normally associated with his/her work.
EA1 14.0 9 08 R Zeroes 161 168

S S S S S S
SITUATIONAL NOTE: Should be entered if DISABILITY TYPE (RT EA0, fld-17.) contains a
value of 1 or 2.
CODE VALUES:

None Reject Claim
DATA ELEMENT: First Consult/Surgery Date
DEFINITION: The date the patient first consulted the provider for the condition
reported in this claim.
EA1 15.0 9 08 R Zeroes 169 176

D D D D D D
CODE VALUES:

None Reject Claim
DATA ELEMENT: Admission Date 2
DEFINITION: The beginning second confinement date for services performed in a

health care facility.
EA1 16.0 9 08 R Zeroes 177 184

S S S S S S
SITUATIONAL NOTE: Should be entered if multiple admissions to a health care facility

occurred during the service period of this claim.
CODE VALUES:
ADMISSION DATE 2 may not be greater than DISCHARGE DATE 2.

None Reject Claim
DATA ELEMENT: Discharge Date 2
DEFINITION: The ending second confinement date for services performed in a

health care facility.
EA1 17.0 9 08 R Zeroes 185 192

S S S S S S
SITUATIONAL NOTE: Should be entered if multiple admissions to a health care facility

occurred during the service period of this claim.
CODE VALUES:
DISCHARGE DATE 2 may not be less than ADMISSION DATE 2.

None Reject Claim
DATA ELEMENT: Supervising Provider Secondary ID
DEFINITION: The identification number assigned by the payer to the Supervising

Provider.
EA1 18.0 X 15 L Spaces 193 207

S S S S S S
SITUATIONAL NOTE: Should be entered if SUPERVISING PROVIDER ID QUALIFIER (fld-

CODE VALUES:

None None
DATA ELEMENT: Supervising Provider Secondary ID Qualifier
DEFINITION: A code used to qualify the SUPERVISING PROVIDER SECONDARY ID

in the preceding field.
EA1 18.1 X 02 L Spaces 208 209

S S S S S S
SITUATIONAL NOTE: Must be entered if SUPERVISING PROVIDER SECONDARY ID (fld-


LU Location Number
N5 Provider Plan Network ID

DATA ELEMENT: Supervising Provider NPI
EA1 19.0 X 10 L Spaces 210 219

N N N N N N
CODE VALUES:

None None
EA1 19.1 X 03 L Spaces 220 222

R R R R R R
CODE VALUES:

None None
DATA ELEMENT: Supervising Provider Last Name
DEFINITION: The last name of the provider who supervised the rendering of a
service on this claim.
EA1 20.0 X 20 L Spaces 223 242

N N N N N S
SITUATIONAL NOTE: Should be entered if SUPERVISING PROVIDER INDICATOR (RE

EA0, fld-43.0) contains a value of Y.
CODE VALUES:

None None
DATA ELEMENT: Supervising Provider First Name
DEFINITION: The first name of the provider who supervised the rendering of a
EA1 21.0 X 12 L Spaces 243 254

N N N N N S

CODE VALUES:

None None
DATA ELEMENT: Supervising Provider Middle Initial
DEFINITION: The middle initial of the provider who supervised the rendering of a
EA1 22.0 X 01 L Spaces 255 255

N N N N N S

CODE VALUES:
Should only be entered if PROVIDER FIRST NAME is entered.

None None
DATA ELEMENT: Supervising Provider State
DEFINITION: The state postal code abbreviation of the supervising provider.
EA1 23.0 X 02 L Spaces 256 257

N N N N N S

CODE VALUES:

validation.

None None
DATA ELEMENT: EMT/Paramedic Last Name
DEFINITION: The last name of the emergency medical technician/paramedic on

the ambulance run sheet.
EA1 24.0 X 20 L Spaces 258 277

D D D D D D
CODE VALUES:
VALIDATION: If entered, the first character should contain a value of A-Z. The
remainder should contain A-Z, A-9, period (.), comma (,),hyphen (-
), and trailing spaces.
No other special character should be entered.

None None
DATA ELEMENT: EMT/Paramedic First Name
DEFINITION: The first name of the emergency medical technician/paramedic on

EA1 25.0 X 12 L Spaces 278 289

D D D D D D
SITUATIONAL NOTE: Should only be entered if the EMT/PARAMEDIC LAST NAME (fld-
CODE VALUES:
VALIDATION: If entered, the first character should contain a value of A-Z. The
remainder should contain A-Z, A-9, period (.), comma (,),hyphen (-
), and trailing spaces.
No other special character should be entered.

None None
DATA ELEMENT: EMT/Paramedic Middle Initial
DEFINITION: The middle initial of the emergency medical technician/paramedic on

EA1 26.0 X 01 L Spaces 290 290

D D D D D D
SITUATIONAL NOTE: Should only be entered if the EMT/PARAMEDIC LAST NAME (fld-
22.0) and EMT/PARAMEDIC FIRST NAME(fld-23.0) has been
entered.
CODE VALUES:
VALIDATION: If entered, should contain a value of A-Z.

None None
DATA ELEMENT: Facility/Lab Provider NPI
EA1 27.0 X 10 L Spaces 291 300

N N N N N N
CODE VALUES:

None None
DATA ELEMENT: Facility/Lab Secondary ID Qualifier
DEFINITION: A code used to qualify the FACILTY/LAB SECONDARY ID (FLD-29.0).
EA1 28.0 X 02 L Spaces 301 302

S S S S S S
SITUATIONAL NOTE: Must be entered if FACILITY/LAB SECONDARY ID (fld-29.0) has

been entered.

LU Location Number
TJ Tax Identification Number
X4 Clinical Laboratory Improvement Amendment
Number (CLIA)

DATA ELEMENT: Facility/Lab Secondary ID
DEFINITION: The identification number assigned by the payer to the Facility/Lab

Provider.
EA1 29.0 X 15 L Spaces 303 317

S S S S S S
SITUATIONAL NOTE: Should be entered if FACILITY/LAB PROVIDER ID QUALIFIER (fld-

CODE VALUES:

None None
EA1 30.0 X 03 L Spaces 318 320

R R R R R R
CODE VALUES:

None None
RECORD SUMMARY
RECORD TYPE: EA3
RECORD NAME: Claim Supplemental Information
RECORD LEVEL: Claim
RECORD PURPOSE: Provides additional information applicable to the entire claim.
S EA0 or EA1 EA@ or FA0

than fields EA3-01.0, EA3-03.0 or filler present.
RECORD LAYOUT
Record Type: EA3

EA3 02.0 Filler X 02 04 5
EA3 04.0 Referral Number X 15 23 37
EA3 05.0 Referring Provider Taxonomy X 11 38 48
EA3 06.0 Delay Reason Code X 02 49 50
EA3 07.0 Relinquished Care Date 9 08 51 58
EA3 08.0 Assumed Care Date 9 08 59 66
EA3 09.0 Filler X 04 67 70
EA3 10.0 Total Purchased Service Amount 9v99 06 71 76
EA3 11.0 Mammography Certification Number X 15 77 91
EA3 12.0 CLIA Number X 15 92 106
EA3 13.0 Auto Accident Country Code X 03 107 109
EA3 14.0 Participation Agreement Code X 01 110 110
EA3 15.0 Hearing/Vision Rx Date 9 08 111 118
EA3 16.0 Date Last Worked 9 08 119 126
EA3 17.0 Attachment Control Number X 35 127 161
EA3 18.0 Service Authorization Exception Code X 01 162 162
EA3 19.0 EPSDT Referral Certification Indicator X 01 163 163
EA3 25.0 Purchased Service Provider Tax ID Type X 01 174 174
EA3 26.0 Purchased Service Provider Tax ID X 09 175 183
EA3 48.0 Filler - Reserved X 98 223 320
DEFINITION: A field used to identify the "Claim Supplemental Information" record.
EA3 01.0 X 03 L Spaces 01 03

R R R R R R
CODE VALUES:

EA3 02.0 X 02 L Spaces 04 5

R R R R R R
CODE VALUES:

None None

EA3 03.0 X 17 L Spaces 06 22

R R R R R R
CODE VALUES:

DATA ELEMENT: Referral Number
DEFINITION: A unique number assigned by the payer to authorize the services

prior to it being performed.
EA3 04.0 X 15 L Spaces 23 37

N N N N N N
CODE VALUES:

None None
DATA ELEMENT: Referring Provider Taxonomy
EA3 05.0 X 11 L Spaces 38 48

S S S S S S

Available From:

None Reject Claim
DATA ELEMENT: Delay Reason Code
DEFINITION: A code used to identify the reason why a request was delayed..
EA3 06.0 X 02 L Spaces 49 50

S S S S S S
SITUATIONAL NOTE: Should be entered if the claim is submitted late and any of the
code values below apply.
CODE VALUES: 1 Proof of Eligibility Unknown or Unavailable

10 Administration Delay in the Prior Approval
Process
11 Other
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

None Reject Claim
DATA ELEMENT: Relinquished Care Date
DEFINITION: The date the care of the patient was assumed by another physician.
EA3 07.0 9 08 R Zeroes 51 58

S S S S S S
SITUATIONAL NOTE: Should be entered on claims where providers share post-operative

care.
CODE VALUES:

None Reject Claim
DATA ELEMENT: Assumed Care Date
DEFINITION: The date the care of the patient was assumed by another physician.
EA3 08.0 9 08 R Zeroes 59 66

S S S S S S
SITUATIONAL NOTE: Should be entered on claims where providers share post-operative

care.
CODE VALUES:

None Reject Claim
DEFINITION: Unused record space reserved by WebMD Envoy.
EA3 09.0 X 04 L Spaces 67 70

R R R R R R
CODE VALUES:

None None
DATA ELEMENT: Total Purchased Service Amount
DEFINITION: The dollar amount associated with the charges for services
performed outside of the provider's office. These charges are
actually included in the corresponding line charge.
EA3 10.0 9v99 06 R Zeroes 71 76

S S S S S S
SITUATIONAL NOTE: Should be entered if the LABORATORY INDICATOR (RT EA0, fld-
28.0) contains a value of 'Y'.
CODE VALUES:

None Reject Claim
DATA ELEMENT: Mammography Certification Number
DEFINITION: CMS assigned Certification Number of the certified mammography

screening center.
EA3 11.0 X 15 L Spaces 77 91

S S S S S S
SITUATIONAL NOTE: Should be entered on Medicare claims for all mammography

services.
CODE VALUES:

None None
DATA ELEMENT: CLIA Number
DEFINITION: The CLIA (Clinical Laboratory Improvement Amendments of 1988

Identification number) Certificate of Waiver or Certificate of
Registration identification number assigned to the laboratory testing
site that rendered this service.
EA3 12.0 X 15 L Spaces 92 106

S S S S S S
SITUATIONAL NOTE: Should be entered on Medicare and Medicaid claims for any lab
performing tests covered by the CLIA act.
CODE VALUES:

None None
DATA ELEMENT: Auto Accident Country Code
DEFINITION: The code indicating the geographic location of the auto accident if
outside of the U.S.
EA3 13.0 X 03 L Spaces 107 109

N N N N N N
SITUATIONAL NOTE: Should be entered if the auto accident occurred outside of the U.S.
CODE VALUES:

None None
DATA ELEMENT: Participation Agreement Code
DEFINITION: Code indicating type of agreement under which the provider is

submitting the claim.
EA3 14.0 X 01 L Spaces 110 110

N N N N N N
SITUATIONAL NOTE: Should be entered if a non-participating provider is submitting a

participating claim/encounter.
CODE VALUES: P Participation Agreement
VALIDATION: If entered, must be a valid code from above list.

None Reject Claim
DATA ELEMENT: Hearing/Vision Rx Date
DEFINITION: A field used to indicate the date the prescription was written for
hearing devices or vision frames and lenses.
EA3 15.0 9 08 R Zeroes 111 118

D D D D D D
CODE VALUES:

None Reject Claim
DATA ELEMENT: Date Last Worked
DEFINITION: A field used to indicate the date the patient last worked.
EA3 16.0 9 08 R Zeroes 119 126

D D D D D D
SITUATIONAL NOTE: Should be entered when required by payer.
CODE VALUES:

None Reject Claim
NOTES: Should only be entered for worker's compensation claims.
DATA ELEMENT: Attachment Control Number
DEFINITION: A number assigned to the attachment documentation.
EA3 17.0 X 35 L Spaces 127 161

S S S S S S
SITUATIONAL NOTE: Must be entered if DOCUMENTATION INDICATOR (RT-EA0,fld-

38.0) contains a value of 1, 2, E or L.
CODE VALUES:

Reject Claim None
DATA ELEMENT: Service Authorization Exception Code
DEFINITION: A code used to identify the reason authorization was not obtained.
EA3 18.0 X 01 L Spaces 162 162

D D D D D D
SITUATIONAL NOTE: Should be entered when required by payer.
CODE VALUES: 1 Immediate/Urgent Care

2 Services rendered in a retroactive period
3 Emergency Care
4 Client as temporary Medicaid
5 Request from County for second opinion to
recipient can work
6 Request for override pending
7 Special handling

None Reject Claim
DATA ELEMENT: EPSDT Referral Certification Indicator
DEFINITION: A code used to indicate whether an EPSDT Referral was done for the
patient.
EA3 19.0 X 01 L Spaces 163 163

S S S S S S
SITUATIONAL NOTE: Must be entered if any EPSDT REFERRAL CONDITION CODE 1-5
(flds-20.0-24.0) have been entered.
CODE VALUES: N No
Y Yes

DATA ELEMENT: EPSDT Referral Condition Code 1
DEFINITION: A code used to indicate the conditions which apply to the EPSDT
Referral.
EA3 20.0 X 02 L Spaces 164 165

S S S S S S
SITUATIONAL NOTE: Must be entered if EPSDT REFERRAL CERTIFICATION INDICATOR

CODE VALUES: AV Available - Not Used

NU Not Used
S2 Under Treatment
ST New Services Requested

Referral.
EA3 21.0 X 02 L Spaces 166 167

S S S S S S
SITUATIONAL NOTE: Should be entered when applicable.

NU Not Used
S2 Under Treatment

None Reject Claim
Referral.
EA3 22.0 X 02 L Spaces 168 169

S S S S S S

NU Not Used
S2 Under Treatment

None Reject Claim
Referral.
EA3 23.0 X 02 L Spaces 170 171

S S S S S S

NU Not Used
S2 Under Treatment

None Reject Claim
Referral.
EA3 24.0 X 02 L Spaces 172 173

S S S S S S

NU Not Used
S2 Under Treatment

None Reject Claim
DATA ELEMENT: Purchased Service Provider Tax ID Type
DEFINITION: Indicates the type of tax identification number entered in the

PURCHASED SERVICE PROVIDER TAX ID (fld-26.0)
EA3 25.0 X 01 L Spaces 174 174

S S S S S S
SITUATIONAL NOTE: Must be entered if PURCHASED SERVICE PROVIDER TAX ID (fld-



DATA ELEMENT: Purchased Service Provider Tax ID
DEFINITION: The federally-assigned Tax Identification Number (TIN) of the

purchased service provider.
EA3 26.0 X 09 L Spaces 175 183

S S S S S S
SITUATIONAL NOTE: Should be entered if purchased services rendered for this claim.
CODE VALUES:

None None
DATA ELEMENT: Vision Category
DEFINITION: A code used to indicate the type of vision certification being

submitted on this claim.
EA3 27.0 X 02 L Spaces 184 185

S S S S S S
SITUATIONAL NOTE: Must be entered if VISION CERTIFICATION INDICATOR (fld-28.0)

has been entered
CODE VALUES: E1 Spectacle Lenses

E2 Contact Lenses
E3 Spectacle Frames

DATA ELEMENT: Vision Certification Indicator
DEFINITION: A code used to indicate whether a vision certification was done for
the patient.
EA3 28.0 X 01 L Spaces 186 186

S S S S S S
SITUATIONAL NOTE: Must be entered if any VISION CONDITION CODE 1-5 (flds-29.0-
CODE VALUES: N No
Y Yes

DATA ELEMENT: Vision Condition Code 1
DEFINITION: A code used to indicate the conditions which apply to the vision lense
or frame replacement.
EA3 29.0 X 02 L Spaces 187 188

S S S S S S

has been entered.
CODE VALUES: L1 General Standard of 20 Degree or .5 Diopter

Sphere or Cylinder Change Met
L2 Replacement Due to Loss or Theft
L3 Replacement Due to Breakage or Damage
L4 Replacement Due to Patient Preference
L5 Replacement Due to Medical Reasons

EA3 30.0 X 02 L Spaces 189 190

S S S S S S


None Reject Claim
EA3 31.0 X 02 L Spaces 191 192

S S S S S S


None Reject Claim
EA3 32.0 X 02 L Spaces 193 194

S S S S S S


None Reject Claim
EA3 33.0 X 02 L Spaces 195 196

S S S S S S


None Reject Claim

EA3 34.0 X 02 L Spaces 197 198

S S S S S S

has been entered

E2 Contact Lenses
E3 Spectacle Frames

the patient.
EA3 35.0 X 01 L Spaces 199 199

S S S S S S
CODE VALUES: N No
Y Yes

EA3 36.0 X 02 L Spaces 200 201

S S S S S S

has been entered.


EA3 37.0 X 02 L Spaces 202 203

S S S S S S


None Reject Claim
EA3 38.0 X 02 L Spaces 204 205

S S S S S S


None Reject Claim
EA3 39.0 X 02 L Spaces 206 207

S S S S S S


None Reject Claim
EA3 40.0 X 02 L Spaces 208 209

S S S S S S


None Reject Claim

EA3 41.0 X 02 L Spaces 210 211

S S S S S S

has been entered

E2 Contact Lenses
E3 Spectacle Frames

the patient.
EA3 42.0 X 01 L Spaces 212 212

S S S S S S
CODE VALUES: N No
Y Yes

EA3 43.0 X 02 L Spaces 213 214

S S S S S S

has been entered.


EA3 44.0 X 02 L Spaces 215 216

S S S S S S


None Reject Claim
EA3 45.0 X 02 L Spaces 217 218

S S S S S S


None Reject Claim
EA3 46.0 X 02 L Spaces 219 220

S S S S S S


None Reject Claim
EA3 47.0 X 02 L Spaces 221 222

S S S S S S


None Reject Claim
DATA ELEMENT: Filler - Reserved
DEFINITION: Unused record space reserved by WebMD Envoy.
EA3 48.0 X 98 L Spaces 223 320

R R R R R R
CODE VALUES:

None None
RECORD SUMMARY
RECORD TYPE: EA@
RECORD NAME: Claim Detail - Additional Claim Detail
RECORD LEVEL: Claim
RECORD PURPOSE: To provide additional CHAMPUS, Medicaid and

rendering/referring provider insurance information not
included in the previous record(s).
S EA0, EA1, EA3 FA0

CONDITIONAL NOTE: Should be entered if the Rendering Provider information is

different than the Billing Provider.
Applies to the entire claim unless a Rendering Provider is

sent in the FA@ Record.

than fields EA@-01.0, EA@-03.0 or filler.
NOTES: Only one (1) Record Type EA@ is allowed per claim.
RECORD LAYOUT
Record Type: EA@

EA@ 01.0 Record Type 'EA@' X 03 01 03
EA@ 02.0 Reserved X 02 04 05
EA@ 03.0 Patient Control Number X 17 06 22
EA@ 04.0 Champus Responsible Person Last Name X 20 23 42
EA@ 05.0 Champus Responsible First Name X 15 43 57
EA@ 06.0 Champus Responsible Middle Initial X 01 58 58
EA@ 07.0 Military Accident Indicator X 01 59 59
EA@ 08.0 Non-Avail Statement Number X 11 60 70
EA@ 09.0 Special Process Indicator X 01 71 71
EA@ 10.0 Zero Other Health Insurance Payment Reason X 02 72 73
EA@ 11.0 Program for Handicapped Indicator X 02 74 75
EA@ 12.0 Filler X 25 76 100
EA@ 13.0 Provider Certification Statement Indicator X 01 101 101
EA@ 14.0 Claim Adjustment Code X 01 102 102
EA@ 15.0 Billing Exception Code X 02 103 104
EA@ 16.0 Filler X 06 105 110
EA@ 17.0 Type of Attachment X 02 111 112
EA@ 18.0 Reject Claim CRN X 10 113 122
EA@ 19.0 Reject Claim RA X 02 123 124
EA@ 20.0 Medicaid Type of Claim X 03 125 127
EA@ 24.0 Filler X 03 152 154
EA@ 24.1 Rendering Provider Tax ID Qualifier X 01 155 155
EA@ 25.0 Rendering Provider Tax ID 9 09 156 164
EA@ 26.0 Rendering Provider Name Qualifier X 01 165 165
EA@ 27.0 Rendering Provider Organization/Last Name X 17 166 182
EA@ 28.0 Rendering Provider Qualification Degree X 03 183 185
EA@ 29.0 Rendering Provider First Name X 10 186 195
EA@ 30.0 Rendering Provider Middle Initial X 01 196 196
EA@ 31.0 Rendering Provider Specialty Code X 03 197 199
EA@ 32.0 Rendering Provider Secondary ID X 15 200 214
EA@ 33.0 Referring Provider Secondary ID X 15 215 229
EA@ 34.0 Referring Provider Phone Number 9 10 230 239
EA@ 35.0 Referral Number X 15 240 254
EA@ 36.0 Authorization Number X 15 255 269
EA@ 37.0 HMO Code X 03 270 272
EA@ 38.0 Claim Type Indicator 9 01 273 273
EA@ 39.0 Rendering Provider Taxonomy X 10 274 283
EA@ 40.0 Referring Provider Secondary ID Qualifier X 02 284 285
EA@ 41.0 Rendering Provider NPI X 10 286 295
EA@ 42.0 Rendering Provider Secondary ID Qualifier X 2 296 297
EA@ 43.0 Filler X 23 298 320
Emdeon Business Services Technical Specifications NSF Plus EA@ - 01.0
DATA ELEMENT: Record Type 'EA@'
DEFINITION: A field used to identify the "Additional Claim Detail" record.
EA@ 01.0 X 03 L Spaces 01 03

R R R R R R
CODE VALUES:
VALIDATION: Must contain a value of EA@.

DATA ELEMENT: Reserved
EA@ 02.0 X 02 L Spaces 04 05

R R R R R R
CODE VALUES:

None None

EA@ 03.0 X 17 L Spaces 06 22

R R R R R R
CODE VALUES:

DATA ELEMENT: Champus Responsible Person Last Name
DEFINITION: The last name of the individual authorized to sign the claim
(responsible for the bill) if the patient is younger than eighteen (18)
years of age.
EA@ 04.0 X 20 L Spaces 23 42

N N N S N N

CODE VALUES:
field validation.

None None
DATA ELEMENT: Champus Responsible First Name
DEFINITION: The first name of the individual authorized to sign the claim
years of age.
EA@ 05.0 X 15 L Spaces 43 57

N N N S N N

CODE VALUES:
field validation.
CHAMPUS RESPONSIBLE PERSON FIRST NAME should only be

entered if CHAMPUS RESPONSIBLE PERSON LAST NAME has been
entered.

None None
DATA ELEMENT: Champus Responsible Middle Initial
DEFINITION: The middle initial of the individual authorized to sign the claim
years of age.
EA@ 06.0 X 01 L Spaces 58 58

N N N D N N
CODE VALUES:
VALIDATION: Should only contain a value of A - Z and space. No other special

Should only be entered if CHAMPUS RESPONSIBLE PERSON LAST

NAME (fld-04.0) and CHAMPUS RESPONSIBLE PERSON FIRST
NAME (fld-05.0) have been entered.

None None
DATA ELEMENT: Military Accident Indicator
DEFINITION: An indicator identifying whether the services performed were

treatment as a result of a military accident.
EA@ 07.0 X 01 L Spaces 59 59

N N N S N N
SITUATIONAL NOTE: Should be entered if the SOURCE OF PAYMENT (RT DA0, fld-05.0)
contains a value of H and the CLAIM FILING INDICATOR (RT DA0,
fld-04.0) contains a value of P.
CODE VALUES: space Not Applicable

Y Military Accident

None None
DATA ELEMENT: Non-Avail Statement Number
DEFINITION: A field used to identify the number on a Non-Availability Statement.
EA@ 08.0 X 11 L Spaces 60 70

N N N S N N
SITUATIONAL NOTE: Must be entered if the NON-AVAILABLITY INDICATOR (RT EA0, fld-
42.0) contains a value of Y; SOURCE OF PAYMENT (RT DA0, fld-
05.0) contains a value of H and the CLAIM FILING INDICATOR (RT
DA0, fld-04.0) contains a value of P.
CODE VALUES:

Reject Claim None
DATA ELEMENT: Special Process Indicator
DEFINITION: A field indicating that special processing of the claim is required.
EA@ 09.0 X 01 L Spaces 71 71

S S S S S S
CODE VALUES:

None None
DATA ELEMENT: Zero Other Health Insurance Payment Reason
DEFINITION: A field indicating why the other health insurance paid nothing on this
claim.
EA@ 10.0 X 02 L Spaces 72 73

S S S S S S
CODE VALUES: A Service Excluded on Prime Policy

B Total Other Health Insurance Payment Applied
to Deductible
C Patient has Met Lifetime Maximum for Services
D Other Health Insurance no in Effect at Time of
Service
E Supplemental Coverage

None None
DATA ELEMENT: Program for Handicapped Indicator
DEFINITION: A code indicating a program for a handicapped dependent.
EA@ 11.0 X 02 L Spaces 74 75

S S S S S S
SITUATIONAL NOTE: Must be entered if SPECIAL PROGRAM INDICATOR (RT EA0, fld-
CODE VALUES: 02 Physically Handicapped Children's Program

03 Special Federal Funding/Planning
05 Disability
06 PPV/Medicare
07 Induced Abortion - Danger to Life
08 Induced Abortion - Rape or Incest
09 Early & Periodic Screening, Diagnosis, and
Treatment (EPSDT) or Child Health
Assessment Program (CHAP)
10 Family Planning
A Champus Program for the Handicapped
(Patient is Sponsor)
B Champus Program for the Handicapped
(Patient is Spouse)
C1-C9 Champus Program for the Handicapped
(Patient is a Child, up to nine PFTH Suffix(s)
are Available for Assignment When More than
one Child From the Same Family is Enrolled in
the Program)
D Champus Program for the Handicapped
(Patient is Widow of Sponsor)
W Champus Program for the Handicapped
(Patient is a Child, However, the individual's
Assigned PFTH Suffix is Unknown)
Z* Second Opinion or Surgery
VALIDATION: If entered should be a valid code from the above list

VALIDATION:

Reject Claim None
EA@ 12.0 X 25 L Spaces 76 100

R R R R R R
CODE VALUES:

None None
DATA ELEMENT: Provider Certification Statement Indicator
DEFINITION: A field used to indicate whether the provider has certification on file.
EA@ 13.0 X 01 L Spaces 101 101

N N N N S N

contains a value of 'D' and the CLAIM FILING INDICATOR (RT DA0,
fld-04.0) contains a value of P.
CODE VALUES: N No, Provider does not have Certification on File

Y Yes, Provider has Certification on File

None None
DATA ELEMENT: Claim Adjustment Code
DEFINITION: A field used to indicate that this claim is reporting adjustment data
to a claim which has already been submitted to Medicaid.
EA@ 14.0 X 01 L Spaces 102 102

N N N N S N
CODE VALUES: 0 Not an Adjustment

1 Adjustment

None None
DATA ELEMENT: Billing Exception Code
DEFINITION: The two-month billing limit exception code if the claim is over the
billing imitation.
EA@ 15.0 X 02 L Spaces 103 104

N N N N S N
CODE VALUES:

None None
EA@ 16.0 X 06 L Spaces 105 110

R R R R R R
CODE VALUES:

None None
DATA ELEMENT: Type of Attachment
DEFINITION: A code indicating the type of attachment correlating to the invoice.
EA@ 17.0 X 02 L Spaces 111 112

N N N N S N
CODE VALUES: 9* Support Data for Verification REFERRAL: Use

this code to indicate a completed referral form
A DME Prescription
B Explanation of Benefits (Coordination of
Benefits or Medicare Secondary Payer)
C Diagnostic Report
D Operative Note
E PEN Certification
F Ambulance Certification
G Physical Therapy Certification
H Chiropractic Justification
I Prosthetics or Orthotic Certification
J Oxygen Prescription
K* Admission Summary
L* Prescription
M* Physician Order
N* Referral Form
O* Certification
P* Dental Models
Q* Discharge Summary
R* Models
S* Nursing Notes
T* Support Data for Claim
U* Physical Therapy Notes
V* Radiology Films
W* Radiology Report
X* Report of Tests and Analysis Report
Y Multiple Documentation Items
Z Other

None None
DATA ELEMENT: Reject Claim CRN
DEFINITION: The unique number assigned by Medicaid to the rejected claim.
EA@ 18.0 X 10 L Spaces 113 122

N N N N S N
CODE VALUES:

None None
DATA ELEMENT: Reject Claim RA
DEFINITION: The number of the remittance advice cycle in which the rejected
claim appeared.
EA@ 19.0 X 02 L Spaces 123 124

N N N N S N
CODE VALUES:

None None
DATA ELEMENT: Medicaid Type of Claim
DEFINITION: The code indicating the type of claim where a Medicaid processor
accepts multiple claim types.
EA@ 20.0 X 03 L Spaces 125 127

N N N N S N
CODE VALUES:

None None
DATA ELEMENT: Claim Processor Specific 1
DEFINITION: This field is used to contain specific information by the carrier

identified in Record Type DA0. This information will be supplied to
the provider by the claim processor.
EA@ 21.0 X 08 L Spaces 128 135

N N N N S N
CODE VALUES:

None None

EA@ 22.0 X 08 L Spaces 136 143

N N N N S N
CODE VALUES:

None None

EA@ 23.0 X 08 L Spaces 144 151

N N N N S N
CODE VALUES:

None None
EA@ 24.0 X 03 L Spaces 152 154

R R R R R R
CODE VALUES:

None None
DATA ELEMENT: Rendering Provider Tax ID Qualifier

RENDERING PROVIDER TAX ID.
EA@ 24.1 X 01 L Spaces 155 155

S S S S S S
SITUATIONAL NOTE: Should be entered if RENDERING PROVIDER TAX ID has been

entered.


None Reject Claim
DATA ELEMENT: Rendering Provider Tax ID
DEFINITION: The Tax ID of the primary care, attending, or consulting provider

that has rendered the service(s).
EA@ 25.0 9 09 R Zeroes 156 164

S S S S S S
SITUATIONAL NOTE: Should be entered if the RENDERING PROVIDER TAX ID QUALIFIER

(EA@-24.1) has been entered.
CODE VALUES:

None Reject Claim
DATA ELEMENT: Rendering Provider Name Qualifier
DEFINITION: A code used to indicate whether the following field is an organization

name or an individual provider's last name.
EA@ 26.0 X 01 L Spaces 165 165

S S S S S S
SITUATIONAL NOTE: Should be entered if a Rendering Provider name is reported

because the Rendering Provider's name is different from the billing
provider (RT BA0, fld-19.0 - 21.0).
CODE VALUES: L Individual's Last Name

O Organizational Name
VALIDATION: Must be valid code from the above list.

None Reject Claim
NOTES: If RENDERING PROVIDER NAME QUALIFIER contains a value of O,

then RENDERING PROVIDER ORGANIZATION NAME OR LAST NAME
(fld-27.0) will contain the Provider's organization name and
RENDERING PROVIDER FIRST NAME (fld-29.0) will not be entered.
If RENDERING PROVIDER NAME QUALIFIER contains a value of L,

then RENDERING PROVIDER ORGANIZATION NAME OR LAST NAME
(fld-27.0) will contain the Provider's last name and RENDERING
PROVIDER FIRST NAME (fld-29.0) will be entered.
DATA ELEMENT: Rendering Provider Organization/Last Name
DEFINITION: The organization or last name of the primary care, attending, or

consulting provider that has rendered the service(s). This includes
providers that have responsibility for servicing practitioners that are
in his/her employ, i.e., RN's, PA's, technicians, etc.
EA@ 27.0 X 17 L Spaces 166 182

S S S S S S
SITUATIONAL NOTE: Must be entered if RENDERING PROVIDER NAME QUALIFIER (fld-

CODE VALUES:
VALIDATION: If entered, and the RENDERING PROVIDER NAME QUALIFIER (fld-

26.0) contains a value of L, the first character must contain a value
of A-Z, the remainder of the field must contain A-Z, space, comma,
or period. No other special characters are allowed.

NOTES: Will contain an organization name if RENDERING PROVIDER NAME

QUALIFIER (fld-26.0) contains a value of O.
Will contain an individual provider's last name if RENDERING

PROVIDER NAME QUALIFIER (fld-26.0) contains a value of L.
DATA ELEMENT: Rendering Provider Qualification Degree
DEFINITION: The Qualification Degree of the primary care, attending, or

consulting provider that has rendered the service(s). This includes
in his/her employ, i.e., RN's, PA's, technicians, etc.
EA@ 28.0 X 03 L Spaces 183 185

O O O O O O
CODE VALUES:

None None
DATA ELEMENT: Rendering Provider First Name
DEFINITION: The first name of the primary care, attending, or consulting provider
that has rendered the service(s). This includes providers that have
responsibility for servicing practitioners that are in his/her employ,
i.e., RN's, PA's, technicians, etc.
EA@ 29.0 X 10 L Spaces 186 195

S S S S S S

26.0) contains a value of L.
CODE VALUES:
VALIDATION: If entered, the first character must contain a value of A-Z. The
remainder of the field must contain A-Z, space, comma, or period.
No other special characters are allowed.

DATA ELEMENT: Rendering Provider Middle Initial
DEFINITION: The middle initial of the primary care, attending, or consulting

provider that has rendered the service(s). This includes providers
that have responsibility for servicing practitioners that are in his/her
employ.
EA@ 30.0 X 01 L Spaces 196 196

D D D D D D
SITUATIONAL NOTE: Should be entered if Provider middle initial is known and the
RENDERING PROVIDER NAME QUALIFIER (fld-26.0) contains a
value of L.
CODE VALUES:
Should only be entered if PROVIDER FIRST NAME is entered.

None None
DATA ELEMENT: Rendering Provider Specialty Code
DEFINITION: A code used to indicate the primary specialty of the rendering

provider.
EA@ 31.0 X 03 L Spaces 197 199

S S S S S S
SITUATIONAL NOTE: Should be entered if Provider TAXONOMY CODE (fld-39.0) is not

entered.
CODE VALUES:
VALIDATION: See Exhibit 3 for valid code values.

None Reject Claim
DATA ELEMENT: Rendering Provider Secondary ID
DEFINITION: A reference number used when necessary to further identify the

Rendering Provider.
EA@ 32.0 X 15 L Spaces 200 214

S S S S S S
SITUATIONAL NOTE: Should be entered if RENDERING PROVIDER ID QUALIFIER (fld-

CODE VALUES:

None None
DATA ELEMENT: Referring Provider Secondary ID

Referring Provider.
EA@ 33.0 X 15 L Spaces 215 229

S S S S S S
SITUATIONAL NOTE: Should be entered if REFERRING PROVIDER ID QUALIFIER (fld-

CODE VALUES:

None None
DATA ELEMENT: Referring Provider Phone Number
DEFINITION: The telephone number, including area code, at which the referring
provider may be contacted.
EA@ 34.0 9 10 R Zeroes 230 239

D D D D D D
CODE VALUES:
XXX = Area Code

yyy = Exchange

None Reject Claim
DATA ELEMENT: Referral Number
DEFINITION: A unique number, assigned by a healthcare network, authorizing a

referral, by the primary care physician, to a specialist.
EA@ 35.0 X 15 L Spaces 240 254

S S S S S S
SITUATIONAL NOTE: Should be entered for Managed Care Claims submitted by a

Specialist authorized to provide medical services.
CODE VALUES:

None None
NOTES: This referral number is associated with the destination payer in the
preceding Record Type DA0.
DATA ELEMENT: Authorization Number
DEFINITION: A unique number, assigned by the referring provider, authorizing

treatment/surgery for the procedure(s) indicated on this claim.
EA@ 36.0 X 15 L Spaces 255 269

S S S S S S
SITUATIONAL NOTE: Should be entered if the provider has obtained a pre-authorization

number from the payer.
CODE VALUES:

None None
NOTES: This authorization number is associated with the destination payer in

the preceding Record Type DA0.
DATA ELEMENT: HMO Code
DEFINITION: A unique number assigned to each individual HMO health insurance

plan.
EA@ 37.0 X 03 L Spaces 270 272

S S S S S S
SITUATIONAL NOTE: Should be entered if the claim is covered under an HMO health
insurance plan.
CODE VALUES:
VALIDATION: Should only contain a value of A-Z, 0-9 and trailing spaces. No
other special characters or embedded spaces are allowed.

None Reject Claim
DATA ELEMENT: Claim Type Indicator
DEFINITION: A code used to identify the type of claim being submitted.
EA@ 38.0 9 01 R Zeroes 273 273

D D D D D D
CODE VALUES:

None Reject Claim
DATA ELEMENT: Rendering Provider Taxonomy
EA@ 39.0 X 10 L Spaces 274 283

S S S S S S

provider taxonomy code.

Available From:

None Reject Claim
DATA ELEMENT: Referring Provider Secondary ID Qualifier

REFERRING PROVIDER SECONDARY ID.
EA@ 40.0 X 02 L Spaces 284 285

S S S S S S
SITUATIONAL NOTE: Must be entered if REFERRING PROVIDER ID (RT EA@, fld-33.0)

has been entered.

LU Location Number

DATA ELEMENT: Rendering Provider NPI
DEFINITION: The National Provider Identifier assigned to the rendering provider.
EA@ 41.0 X 10 L Spaces 286 295

N N N N N N
CODE VALUES:

None None
DATA ELEMENT: Rendering Provider Secondary ID Qualifier

RENDERING PROVIDER SECONDARY ID.
EA@ 42.0 X 2 L Spaces 296 297

S S S S S S
SITUATIONAL NOTE: Must be entered if RENDERING PROVIDER SECONDARY ID (RT

EA@, fld-32.0) has been entered.

LU Location Number

EA@ 43.0 X 23 L Spaces 298 320

R R R R R R
CODE VALUES:

None None
RECORD SUMMARY
RECORD TYPE: FA0
RECORD NAME: Claim - Service Line Detail
RECORD PURPOSE: To provide information pertaining to the medical services

rendered.
R EA0, EA1, EA3, EA@, FA0, FA@, FB0, FB1, FB2, FB3,
FA@, FB0, FB1, FB2, FB3, FB4, FE0, GA0, GC0,
FB4, FE0, GA0, GC0, GD@, GU0, GX0, GX2,
GD@, GU0, GX0, GX2, HA0, XA0
HA0

CONDITIONAL NOTE:
NOTES: There must be at least one (1) Record Type FA0 entered for
every claim.
The SEQUENCE NUMBER (fld-02.0) for each additional

Record Type FA0 must contain a value one (1) greater than
the previous Record Type FA0.

by Sequence Number.
A maximum of (50) sequences of Record Type FA0 may be

entered per claim.
RECORD LAYOUT
Record Type: FA0

FA0 01.0 Record Type 'FA0' X 03 01 03
FA0 02.0 Sequence Number 9 02 04 05
FA0 03.0 Patient Control Number X 17 06 22
FA0 04.0 Line Item Control Number X 17 23 39
FA0 05.0 Service From Date 9 08 40 47
FA0 06.0 Service To Date 9 08 48 55
FA0 07.0 Place of Service X 02 56 57
FA0 08.0 Type of Service X 02 58 59
FA0 09.0 HCPCS Procedure Code X 05 60 64
FA0 13.0 Line Charges 9v99 07 71 77
FA0 18.0 Units of Service 9v9 04 82 85
FA0 19.0 Anesthesia/Oxygen Minutes 9 04 86 89
FA0 20.0 Emergency Indicator X 01 90 90
FA0 21.0 COB Indicator X 01 91 91
FA0 22.0 HPSA Indicator X 01 92 92
FA0 23.0 Rendering Provider ID X 15 93 107
FA0 24.0 Referring Provider ID X 15 108 122
FA0 25.0 Referring Provider State X 02 123 124
FA0 26.0 Purchase Service Indicator X 01 125 125
FA0 27.0 Filler X 07 126 132
FA0 28.0 Filler X 07 133 139
FA0 29.0 Review by Code Indicator X 01 140 140
FA0 30.0 Multiple Procedure Indicator X 01 141 141
FA0 31.0 Mammography Certification Number X 10 142 151
FA0 32.0 Class Findings X 09 152 160
FA0 33.0 Podiatry Service Condition X 03 161 163
FA0 34.0 CLIA ID Number X 15 164 178
FA0 35.0 Filler X 07 179 185
FA0 37.0 Provider Specialty X 03 188 190
FA0 38.0 Podiatry Therapy Indicator X 01 191 191
FA0 39.0 Podiatry Therapy Type X 01 192 192
FA0 40.0 Hospice Employed Provider Indicator X 01 193 193
FA0 41.0 HGB/HCT Date 9 08 194 201
FA0 42.0 Hemoglobin Result 9 03 202 204
FA0 43.0 Hematocrit Result 9 02 205 206
FA0 44.0 Patient Weight 9 03 207 209
FA0 45.0 Epoetin Dosage 9 03 210 212
FA0 46.0 Serum Creatine Date 9 08 213 220
FA0 47.0 Creatine Result 9 03 221 223
FA0 48.0 Obligated to Accept Amount 9v99 07 224 230
FA0 49.0 Drug Discount Amount 9v99 07 231 237
FA0 50.0 UPN X 14 238 251
FA0 51.0 Vendor Product Number X 14 252 265
FA0 52.0 Date Last Seen 9 08 266 273
FA0 53.0 Sales Tax Amount 9v99 07 274 280
FA0 54.0 Referring CLIA Number X 14 281 294
FA0 55.0 Filler X 26 295 320
Emdeon Business Services Technical Specifications NSF Plus FA0 - 01.0
DATA ELEMENT: Record Type 'FA0'
DEFINITION: A field used to identify the "Service Line Detail" record.
FA0 01.0 X 03 L Spaces 01 03

R R R R R R
CODE VALUES:
VALIDATION: Must contain a value of FA0.

DATA ELEMENT: Sequence Number

within the same specific Record type to indicate the sequence of
FA0 02.0 9 02 R Zeroes 04 05

R R R R R R
CODE VALUES: 01-50
If only one (1) Record Type FA0 is entered, SEQUENCE NUMBER

must contain a value of 01. Each additional Record type FA0
entered must have a SEQUENCE NUMBER one (1) greater than the
previous Record Type FA0.

NOTES: All "F" records must be grouped as FA0, FA@, FB0, FB1, FB2, FB3,
FB4 followed by any applicable Certification records and/or Narrative
records by Sequence Number.

FA0 03.0 X 17 L Spaces 06 22

R R R R R R
CODE VALUES:

DATA ELEMENT: Line Item Control Number
DEFINITION: An identifier assigned by the submitter/provider to this line item.
FA0 04.0 X 17 L Spaces 23 39

S S S S S S
CODE VALUES:
VALIDATION: Should be in consecutive ascending order.

None None
NOTES: All Fxx, Gxx and HA0 records between this FA0 and the next FA0
record must contain the same LINE ITEM CONTROL NUMBER.
DATA ELEMENT: Service From Date
DEFINITION: The start date, or service date, for each consultation, service or
performed procedure.
FA0 05.0 9 08 R Zeroes 40 47

R R R R R R
CODE VALUES:
Must not be greater than the CREATION DATE (RT AA0, fld-15.0).
Must not be less than the PATIENT DATE OF BIRTH (RT CA0, fld-
08.0).
Must not be less than FIRST CONSULT/SURGERY DATE (RT EA1,

fld-15.0).

NOTES: If SERVICE FROM DATE is entered, the following fields must be

entered.
UNITS OF SERVICE (fld-18.0)

PLACE OF SERVICE (fld-07.0)
TYPE OF SERVICE (fld-08.0)
HCPCS PROCEDURE CODE (fld-09.0)
DIAGNOSIS CODE POINTER (fld-14.0)
LINE CHARGES (fld-13.0)
SERVICE FROM DATE is one of several fields which are compared for
information.
DATA ELEMENT: Service To Date
DEFINITION: The end date for each consultation, service or performed procedure
if the service end date is different from the service start date.
FA0 06.0 9 08 R Zeroes 48 55

S S S S S R
SITUATIONAL NOTE: Should be entered if the services span more than one date of
service.
CODE VALUES:
If entered, it must be in the format of CCYYMMDD.

AA0, fld-15.0).
If entered, may not be less than the corresponding SERVICE FROM

DATE (fld-05.0).

None Reject Claim
NOTES: SERVICE TO DATE is one of several fields which are compared for
information.
DATA ELEMENT: Place of Service
DEFINITION: A code used to identify where services were performed.
FA0 07.0 X 02 L Spaces 56 57

R R R R R R
CODE VALUES: 03* School

04* Homeless Shelter
05* Indian Health Service Free-Standing Facility
06* Indian Health Service Provider Based Facility
07* Tribal 638 Free-Standing Facility
08* Tribal 638 Provider-Based Facility
11 Office
12 Patient's Home
13* Assisted Living Facility
14* Group Home
15* Mobile Unit
20* Urgent Care Facility
21 Inpatient Hospital
22 Outpatient Hospital
23 Emergency Room - Hospital
24 Ambulatory Surgical Center
25 Birthing Center
26 Military Treatment Facility
31 Skilled Nursing Facility
32 Nursing Facility
33 Custodial Care Facility
34 Hospice
41 Ambulance - Land
42 Ambulance - Air or Water
49* Independent Clinic
50* Federal Qualified Health Center
51 Psychiatric Facility - Inpatient
52 Psychiatric Facility - Partial Hospitalization
53 Community Mental Health Center
54 Intermediate Care Facility/Mentally Retarded
55 Residential Substance Abuse Treatment Facility
56 Psychiatric Facility - Residential Treatment
Center
57* Non-Residential Substance Abuse Treatment
Facility
60* Mass Immunization Center
61 Comprehensive Inpatient Rehabilitation Facility
62 Comprehensive Outpatient Rehabilitation
Facility
65 End Stage Renal Disease Treatment Facility
71 State or Local Public Health Clinic
72 Rural Health Clinic
81 Independent Laboratory
99 Other Place of Service

DATA ELEMENT: Type of Service
DEFINITION: A code used to classify the service, supply, or procedure rendered.
FA0 08.0 X 02 L Spaces 58 59

R R R R R R
CODE VALUES: 01 Medical Care

02 Surgery
03 Consultation
04 Diagnostic Radiology
05 Diagnostic Laboratory
06 Radiation Therapy
07 Anesthesia
08 Surgical Assistance
09 Other Medical Service
10 Blood Charges
11 Used DME
12 DME Purchase
13 Ambulatory Surgery Center
14 Renal Supplies in the Home
15 Alternate Method Dialysis Payment
16 CRD Equipment
17 Pre-Admission Testing
18 DME Rental
19 Pneumonia Vaccine
20 Second Opinion on Elective Surgery
21 Third Opinion on Elective Surgery
99 Other

DATA ELEMENT: HCPCS Procedure Code
DEFINITION: A code from the HCPCS/CPT-4 uniform classification system used to

identify the procedure performed, service rendered, or supplies
furnished.
FA0 09.0 X 05 L Spaces 60 64

R R R R R R

Heatlhcare Common Procedure Coding System
Level II (HCPCS)
Current Procedural Terminolgy (CPT)
VALIDATION: Must be a valid HCPCS/CPT procedure code.

procedure code entered.
HCPCS PROCEDURE CODE is one of several fields which are

the same values as a claim previously submitted on the same day,
the claim will be rejected for "duplicate claim". See Exhibit 97 for
DATA ELEMENT: HCPCS Modifier 1
DEFINITION: A modifier code from the HCFA uniform classification system that
identifies special circumstances associated with the corresponding
Procedure Code entered.
FA0 10.0 X 02 L Spaces 65 66

S S S S S S
SITUATIONAL NOTE: Should be entered if the HCPCS PROCEDURE CODE (fld-09.0)

requires modifiers to properly define the services being rendered.

Level II (HCPCS)
VALIDATION: If entered, must contain a valid HCPCS Procedure Code Modifier.

None Reject Claim
NOTES: HCPCS MODIFIER 1 is one of several fields which are compared for
information.
FA0 11.0 X 02 L Spaces 67 68

S S S S S S


Level II (HCPCS)

None Reject Claim
NOTES: HCPCS MODIFIER 2 is one of several fields which are compared for
information.
FA0 12.0 X 02 L Spaces 69 70

S S S S S S


Level II (HCPCS)

None Reject Claim
DATA ELEMENT: Line Charges
DEFINITION: The dollar amount associated with the performed procedure or

service.
FA0 13.0 9v99 07 R Zeroes 71 77

R R R R R R
CODE VALUES:

negative values are not allowed. Any unsigned values are assumed
to be positive.
DATA ELEMENT: Diagnosis Code Pointer 1
DEFINITION: A code used to identify that the provided service was treatment for
one or more of the reported diagnosis codes.
FA0 14.0 X 01 L Spaces 78 78

S S S S S S
SITUATIONAL NOTE: Must be entered if PRIMARY DIAGNOSIS CODE-1 (RT EA0, fld-
CODE VALUES: 1-4 Points to appropriate Diagnosis code(s) for the

service line
VALIDATION: If entered, must contain a value of 1 through 4
Code values 1 - 4 may only be entered if the corresponding

DIAGNOSIS CODES (RT EA0, flds-30.0-33.0) have been entered.

FA0 15.0 X 01 L Spaces 79 79

O O O O O O

service line


None Reject Claim
FA0 16.0 X 01 L Spaces 80 80

O O O O O O

service line


None Reject Claim
FA0 17.0 X 01 L Spaces 81 81

O O O O O O

service line


None Reject Claim
DATA ELEMENT: Units of Service
DEFINITION: A quantitative measure of:

identical medical or surgical services performed;
the supply units provided for the corresponding procedure code.
FA0 18.0 9v9 04 R Zeroes 82 85

S S S S S S
SITUATIONAL NOTE: Must be entered if TYPE OF SERVICE (fld-08.0) does not contain a
value of 07.
CODE VALUES:
VALIDATION: Must be greater than zero.

DATA ELEMENT: Anesthesia/Oxygen Minutes
DEFINITION: The number of minutes the patient was administered anesthesia or

oxygen.
FA0 19.0 9 04 R Zeroes 86 89

S S S S S N
SITUATIONAL NOTE: Must be entered if TYPE OF SERVICE (fld-08.0) contains a value of

07.
CODE VALUES:
Must be greater than zero.
Must not be greater than three (3) positions.
Position 86 must contain a zero (0).

DATA ELEMENT: Emergency Indicator
DEFINITION: An indicator of whether emergency care was rendered in response to

the sudden and unexpected onset of a medical condition; a severe
injury; or an acute exacerbation of a chronic condition which was
threatening to life, limb, or sight, and which required immediate
medical or surgical treatment.
FA0 20.0 X 01 L Spaces 90 90

S S S S S S
SITUATIONAL NOTE: Should be entered if required by payer,
CODE VALUES: N No, Not Emergency Related

Y Yes, Emergency Related

None None
DATA ELEMENT: COB Indicator
DEFINITION: A code used to indicate the liability of the primary carrier.
FA0 21.0 X 01 L Spaces 91 91

N N N N N N
CODE VALUES: 0-9 Reserved for Local Assignment

A-Z Reserved for National Assignment

None None
DATA ELEMENT: HPSA Indicator
DEFINITION: A code that identifies a Health Professional Shortage Area (HPSA).
FA0 22.0 X 01 L Spaces 92 92

N N N N N S
CODE VALUES: 1-4

None None
DATA ELEMENT: Rendering Provider ID
DEFINITION: A code or name (Last Name, First Name, Middle Initial) used to
identify the provider performing this service.
FA0 23.0 X 15 L Spaces 93 107

S S S S S S
SITUATIONAL NOTE: Should be entered if the performing provider is a member of a

group or clinic and has a unique identifier to report for claim
adjudication.
CODE VALUES:

None None
NOTES: RENDERING PROVIDER ID is one of several fields which are

the same values as a claim previously submitted on the same
processing day, the claim will be rejected for "duplicate claim"
processing. See Exhibit 97 for detailed information.
DATA ELEMENT: Referring Provider ID
DEFINITION: The identifier assigned by the payer to the physician who referred
the service.
FA0 24.0 X 15 L Spaces 108 122

S S S S S S
SITUATIONAL NOTE: Must be entered if REFERRING PROVIDER NAME (RT FB1, fld-10.0-
CODE VALUES:

Reject Claim None
DATA ELEMENT: Referring Provider State
DEFINITION: The referring provider's state code.
FA0 25.0 X 02 L Spaces 123 124

D D D D D S
CODE VALUES:

validation.

None None
DATA ELEMENT: Purchase Service Indicator
DEFINITION: An indicator that the service was purchased by another entity.
FA0 26.0 X 01 L Spaces 125 125

N N N N N S
CODE VALUES: N No, Service was not purchased by another

entity
Y Yes, Service was purchased by another entity

None None
FA0 27.0 X 07 L Spaces 126 132

R R R R R R
CODE VALUES:

None None
NOTES: Disallowed Cost Containment Amount information should be

submitted using the FB4 (Service Line Adjustment Information)
Record. Information submitted in this field will not be forwarded to
the payer.
FA0 28.0 X 07 L Spaces 133 139

R R R R R R
CODE VALUES:

None None
NOTES: Disallowed Other Amount information should be submitted using the

FB4 (Service Line Adjustment Information) Record. Information
submitted in this field will not be forwarded to the payer.
DATA ELEMENT: Review by Code Indicator
DEFINITION: A code used to indicate extenuating circumstances or justifications

which might assist in any review of the medical necessity for this
service.
FA0 29.0 X 01 L Spaces 140 140

N N N N N S
CODE VALUES: A Case Turned Over to a Consultant

B Pre-Admission Testing
C X-Ray/Lab Procedure Related to a Covered
Surgery
D Provider/Supplies determined Service not
Covered, Patient Requesting Review by Payer
E Beneficiary Notified Item Might not be
Considered Medically Necessary, Agreed in
Writing to Pay for Item
F Beneficiary Notified Item Might not be
Considered Medically Necessary, has not
Agreed to Pay for Item

None None
DATA ELEMENT: Multiple Procedure Indicator
DEFINITION: A code used to indicate the procedure (primary or secondary)

described in this claim for cases involving multiple surgical
procedures during the same surgical session.
FA0 30.0 X 01 L Spaces 141 141

N N N N N S
CODE VALUES: P Primary

S Secondary
Space Not multiple procedure

None None
DATA ELEMENT: Mammography Certification Number
DEFINITION: The HCFA-assigned Certification Number of the mammography

screening center.
FA0 31.0 X 10 L Spaces 142 151

N N N N N S
SITUATIONAL NOTE: Should be entered when mammography services have been

rendered by a certified mammography provider.
CODE VALUES:

None None
DATA ELEMENT: Class Findings
DEFINITION: A code used to describe class findings for routine foot care. One
Class A, two Class B, or one Class B + two Class C findings may be
included on a clam.
FA0 32.0 X 09 L Spaces 152 160

N N N N N S
CODE VALUES: A10 Non-Traumatic Amputation of Foot or Integral

Skeletal Portion There-of
B10 Absent Posterior Tibial Pulse
B20 Absent Dorsalis Pedis Pulse
B31 Hair Growth Nail Changes Pigmentary
Changes Skin Texture Skin Color
C10 Claudication
C20 Temperature Changes
C30 Paresthesia
C40 Burning
C50 Edema

None None
DATA ELEMENT: Podiatry Service Condition
DEFINITION: A code used to indicate the condition justifying necessity of foot care.
FA0 33.0 X 03 L Spaces 161 163

N N N N N S
CODE VALUES: A01 Condition is of Such Severity that it Markedly

Limits Patient's Ability to Ambulate and
Treatment Would Allow Improvement
B01 Patient is Non-Ambulatory and if Condition is
Left Untreated it will Likely Result in Serious
Medical Complications
E01 Amputation - Leg, Foot or Part of Foot
E02 ASO
E03 Arteriosclerosis - Lower Extremities
E04 ASO of Feet or Just ASO
E05 Buerger's Disease - Lower Extremities
E06 Generalized Arteriosclerosis
E07 Lumbosacral Syringomyelia
E08 Occlusive Peripheral Arteriosclerosis
E09 Carcinoma
E10 Hereditary Disorders
E11 Leprosy
E12 Neurosyphilis
E13 Traumatic Injury
E20 Chronic Phlebitis
E21 Chronic Thrombophlebitis
E22 Diabetes (non-specified)
E23 Diabetes Mellitus
E24 Peripheral Neuropathies involving the Feet
Associated with Diabetes (non-specified)
Associated with Diabetes Mellitus
Associated with - Drugs
Associated with - Malnutrition and Vitamin
Deficiency
Associated with - Multiple Sclerosis
Associated with - Uremia (Chronic Renal
Disease)
Associated with - Toxins
Associated with - Peripheral Vascular Disease
Associated with- PVD of the Foot or Toes
Associated with - Acute Thrombophlebitis
Associated with - Acute Phlebitis
H01 Arterial Insufficiency
H02 Blockage of Leg Vessels
H03 Chronic Vascular Disease
H04 Circulatory Deficiency
H05 Circulatory Impairment
H07 Clot in Leg
H08 Impaired Arterial Circulation
H09 Peripheral Arterial Insufficiency
H10 Peripheral Neuritis
H11 Peripheral Occlusive Disease
H12 Peripheral Vascular Disease (non-specified)

None None
DATA ELEMENT: CLIA ID Number
DEFINITION: The CLIA Certificate of Waiver or Certificate of Registration

identification number assigned to the laboratory testing site that
rendered this service.
FA0 34.0 X 15 L Spaces 164 178

S S S S S S
CODE VALUES:
VALIDATION: If entered, should be a valid CLIA number as issued by HCFA.

None None
FA0 35.0 X 07 L Spaces 179 185

R R R R R R
CODE VALUES:

None None
NOTES: Primary Paid Amount information should be submitted using the FB3
(Service Line Payment Information) Record. Information submitted
in this field will not be forwarded to the payer.
FA0 36.0 X 02 L Spaces 186 187

S S S S S S


Level II (HCPCS)

None Reject Claim
DATA ELEMENT: Provider Specialty

provider.
FA0 37.0 X 03 L Spaces 188 190

N N N N N S
SITUATIONAL NOTE: Should be entered if RENDERING PROVIDER TAXONOMY CODE (fld-

17.0) is not entered.
CODE VALUES: * See Exhibit 3

None None
DATA ELEMENT: Podiatry Therapy Indicator
DEFINITION: A code used to indicate whether the podiatry patient is receiving anti-
fungal therapy.
FA0 38.0 X 01 L Spaces 191 191

N N N N N S
CODE VALUES: N No, Patient is not Receiving Anti-Fungal

Therapy
Y Yes, Patient is Receiving Anti-Fungal Therapy

None None
DATA ELEMENT: Podiatry Therapy Type
DEFINITION: A code used to indicate the type of anti-fungal therapy the podiatry
patient is receiving.
FA0 39.0 X 01 L Spaces 192 192

N N N N N S
CODE VALUES: O Oral

T Topical
Should be entered if PODIATRY THERAPY INDICATOR (fld-38.0)

has been entered.

None None
DATA ELEMENT: Hospice Employed Provider Indicator
DEFINITION: A code used to indicate whether the treatment in the hospice was
rendered by a hospice-employed physician.
FA0 40.0 X 01 L Spaces 193 193

S S S S S S
CODE VALUES: N No, Physician is not Employed by Hospice

Y Yes, Physician is Employed by Hospice

None None
DATA ELEMENT: HGB/HCT Date
DEFINITION: The date of the most recent hemoglobin/hematocrit.
FA0 41.0 9 08 R Zeroes 194 201

S S S S S S
SITUATIONAL NOTE: Should be entered for initial Epoetin therapy claims. It is not
required for subsequent claims.
CODE VALUES:

None Reject Claim
DATA ELEMENT: Hemoglobin Result
DEFINITION: The result, in grams, of the hemoglobin test.
FA0 42.0 9 03 R Zeroes 202 204

S S S S S S
CODE VALUES:

None Reject Claim
DATA ELEMENT: Hematocrit Result
DEFINITION: The result (percentage) of the hematocrit test.
FA0 43.0 9 02 R Zeroes 205 206

S S S S S S
CODE VALUES:

None Reject Claim
DEFINITION: The patient's current weight in kilograms.
FA0 44.0 9 03 R Zeroes 207 209

S S S S S S
CODE VALUES:

None Reject Claim
DATA ELEMENT: Epoetin Dosage
DEFINITION: The starting dosage of Epoetin in units per kilograms.
FA0 45.0 9 03 R Zeroes 210 212

S S S S S S
CODE VALUES:

None Reject Claim
DATA ELEMENT: Serum Creatine Date
DEFINITION: The date of the most recent serum creatin.
FA0 46.0 9 08 R Zeroes 213 220

S S S S S S
CODE VALUES:

None Reject Claim
DATA ELEMENT: Creatine Result
DEFINITION: The results of the creatine to the nearest tenth.
FA0 47.0 9 03 R Zeroes 221 223

S S S S S S
CODE VALUES:

None Reject Claim
DATA ELEMENT: Obligated to Accept Amount
DEFINITION: The amount the provider agreed to accept as payment in full, under
the provisions of the contract.
FA0 48.0 9v99 07 R Zeroes 224 230

S S S S S S
CODE VALUES:

None Reject Claim
DATA ELEMENT: Drug Discount Amount
DEFINITION: The discount drug amount (HCPCS "J" codes) that the provider
received.
FA0 49.0 9v99 07 R Zeroes 231 237

S S S S S S
CODE VALUES:

None Reject Claim
DATA ELEMENT: UPN
DEFINITION: Universal Product Code Number
FA0 50.0 X 14 L Spaces 238 251

S S S S S S
SITUATIONAL NOTE: Should be entered when an item/supply being billed has an

associated product number in the Health Care Uniform Code
Council system.
CODE VALUES:

None None
DATA ELEMENT: Vendor Product Number
DEFINITION: Vendor Product Code number
FA0 51.0 X 14 L Spaces 252 265

S S S S S S
SITUATIONAL NOTE: Should be entered when an item/supply being billed has an

associated product number in the Health Industry Business
Communications Council system.
CODE VALUES:

None None
DATA ELEMENT: Date Last Seen
DEFINITION: Date the patient was last seen.
FA0 52.0 9 08 R Zeroes 266 273

S S S S S S
SITUATIONAL NOTE: Should be entered on Physical Therapy; Occupational Therapy or

Podiatric Claims if it is different from the DATE LAST SEEN in
Record Type EA0 (fld-46.0).
CODE VALUES:

None Reject Claim
DATA ELEMENT: Sales Tax Amount
DEFINITION: A tax amount that applies to the service line.
FA0 53.0 9v99 07 R Zeroes 274 280

S S S S S S
SITUATIONAL NOTE: Should be entered when sales tax applies to the service line.
CODE VALUES:

None Reject Claim
DATA ELEMENT: Referring CLIA Number
DEFINITION: The CLIA number of the laboratory that referred tests out to another
laboratory.
FA0 54.0 X 14 L Spaces 281 294

N N N N N S
SITUATIONAL NOTE: Should be entered if the SOURCE OF PAYMENT (RT DA0, fld-05.0)
value is C, and the test was referred out to another lab covered
under the CLIA act.
CODE VALUES:

None None
FA0 55.0 X 26 L Spaces 295 320

R R R R R R
CODE VALUES:

None None
RECORD SUMMARY
RECORD TYPE: FA@
RECORD NAME: Additional Provider Information
RECORD PURPOSE: To identify rendering provider information required for the

processing and payment of (all) claims.
To identify the referring provider and authorization

information especially pertinent to indemnity claims.
To identify managed care and PPO network information.
S FA0 FA0, FB0, FB1, FB2, FB3,

FB4, FE0, GA0, GC0,
GD@, GU0, GX0, GX2,
HA0, XA0

CONDITIONAL NOTE: Applies to the the corresponding service line and should only
be sent when different than the Rendering Provider reported
in the EA@ Record, or when different than the Billing
Provider reported in the BA0 Record.

than fields FA@-01.0, FA@-02.0, FA@-03.0 or filler.
NOTES: When used, this Record Type FA@ must have the same
Only one (1) Record Type FA@ may be entered per FA0.

applicable Certification record(s) and/or narrative record(s)
by Sequence Number.
RECORD LAYOUT
Record Type: FA@

FA@ 01.0 Record Type 'FA@' X 03 01 03
FA@ 02.0 Sequence Number 9 02 04 05
FA@ 03.0 Patient Control Number X 17 06 22
FA@ 04.0 Line Item Control Number X 17 23 39
FA@ 05.0 Rendering Provider Tax ID 9 09 40 48
FA@ 06.0 Rendering Provider Name Qualifier X 01 49 49
FA@ 07.0 Rendering Provider Organization/Last Name X 17 50 66
FA@ 08.0 Rendering Provider First Name X 10 67 76
FA@ 09.0 Rendering Provider Middle Initial X 01 77 77
FA@ 10.0 Rendering Provider Qualification Degree X 03 78 80
FA@ 11.0 Rendering Provider Specialty Code X 03 81 83
FA@ 12.0 Rendering Provider Secondary ID X 15 84 98
FA@ 13.0 Rendering Provider Address X 18 99 116
FA@ 14.0 Rendering Provider City X 15 117 131
FA@ 15.0 Rendering Provider State X 02 132 133
FA@ 16.0 Rendering Provider Zip Code 9 09 134 142
FA@ 17.0 Rendering Provider Taxonomy X 10 143 152
FA@ 18.0 Rendering Provider NPI X 10 153 162
FA@ 19.0 Rendering Provider Tax ID Qualifier X 01 163 163
FA@ 20.0 Rendering Provider Secondary ID Qualifier X 02 164 165
FA@ 21.0 Filler - Local X 155 166 320
Emdeon Business Services Technical Specifications NSF Plus FA@ - 01.0
DATA ELEMENT: Record Type 'FA@'
DEFINITION: A field used to identify the "Additional Provider Information" record.
FA@ 01.0 X 03 L Spaces 01 03

R R R R R R
CODE VALUES:
VALIDATION: Must contain a value of FA@.


FA@ 02.0 9 02 R Zeroes 04 05

R R R R R R
CODE VALUES: 01-50

Record Type FA0 (fld-02.0).

NOTES: The total number of Fxx (all "F" type) records may not exceed 50 for
each claim.
All "F" records must be grouped by FA0, FA@, FB0, FB1, FB2, FB3,

FA@ 03.0 X 17 L Spaces 06 22

R R R R R R
CODE VALUES:

FA@ 04.0 X 17 L Spaces 23 39

S S S S S S
SITUATIONAL NOTE: Should be entered if the preceding Record Type FA0 contains a
LINE ITEM CONTROL NUMBER.
CODE VALUES:
VALIDATION: Should be identical to the LINE ITEM CONTROL NUMBER in the

preceding Record Type FA0 (fld-04.0).

None None
DATA ELEMENT: Rendering Provider Tax ID
DEFINITION: The Tax ID of the primary care, attending or consulting provider that
has rendered the service(s).
FA@ 05.0 9 09 R Zeroes 40 48

S S S S S S
SITUATIONAL NOTE: Should be entered if the RENDERING PROVIDER TAX ID QUALIFIER

CODE VALUES:

None Reject Claim
DATA ELEMENT: Rendering Provider Name Qualifier
DEFINITION: A code used to indicate whether the following field is an organization

name or an individual provider's last name.
FA@ 06.0 X 01 L Spaces 49 49

S S S S S S
SITUATIONAL NOTE: Should be entered if a Rendering Provider name is to be reported

because the Rendering Provider's name is different from the Billing
Provider (RT BA0, fld-18.0-21.0).
CODE VALUES: L Last Name

O Organization Name

None Reject Claim
NOTES: If RENDERING PROVIDER NAME QUALIFIER contains a value of O,

then RENDERING PROVIDER ORGANZATION/LAST NAME (fld-07.0)
will contain a rendering provider's organization name and the
RENDERING PROVIDER FIRST NAME (fld-08.0) will not be present.
If RENDERING PROVIDER NAME QUALIFIER contains a value of L,

then RENDERING PROVIDER ORGANZATION/LAST NAME (fld-07.0)
will contain a rendering provider's last name and the RENDERING
PROVIDER FIRST NAME (fld-08.0) will be present.
DATA ELEMENT: Rendering Provider Organization/Last Name
DEFINITION: The organization/last name of the primary care, attending or

consulting provider that has rendered the services(s). This includes
in his/her employ, i.e.., RN's PA's, technicians, etc.
FA@ 07.0 X 17 L Spaces 50 66

S S S S S S

07.0) contains a value of O or L.
CODE VALUES:
remainder of the field must contain A-Z, space, comma, or period,
no other special characters are allowed.

NOTES: Must contain an organization name if RENDRING PROVIDER NAME

QUALIFIER (fld-06.0) contains a value of O.
Must contain an individual provider's last name if RENDERING

PROVIDER NAME QUALIFIER (fld-06.0) contains a value of L.
DEFINITION: The first name of the primary care, attending or consulting provider
who has rendered the service(s). This includes providers that have
responsibility for servicing practitioners in his/her employ (e.g..
RN's, PA's, technicians, etc.).
FA@ 08.0 X 10 L Spaces 67 76

S S S S S S

07.0) contains a value of L.
CODE VALUES:
remainder of the field must contain A-Z, space, comma, or period,
no other special characters are allowed.

DEFINITION: The middle initial of the primary care, attending or consulting

provider that has rendered the services(s). This includes providers
employ, i.e.., RN's PA's, technicians, etc.
FA@ 09.0 X 01 L Spaces 77 77

D D D D D D
CODE VALUES:
Should only be entered if RENDRING PROVIDER FIRST NAME (fld-

08.0) is entered.

None None
DATA ELEMENT: Rendering Provider Qualification Degree
DEFINITION: The Qualification Degree of the primary care, attending or consulting

provider that has rendered the services(s). This includes providers
employ, i.e.., RN's PA's, technicians, etc.
FA@ 10.0 X 03 L Spaces 78 80

O O O O O O
CODE VALUES:

None None
DATA ELEMENT: Rendering Provider Specialty Code

provider.
FA@ 11.0 X 03 L Spaces 81 83

S S S S S S
SITUATIONAL NOTE: Should be entered if RENDERING PROVIDER TAXONOMY (fld-17.0)

is not entered.
CODE VALUES: * See Exhibit 3

None Reject Claim
DATA ELEMENT: Rendering Provider Secondary ID

Rendering Provider.
FA@ 12.0 X 15 L Spaces 84 98

S S S S S S
SITUATIONAL NOTE: Should be entered if RENDERING PROVIDER SECONDARY ID

QUALIFIER (fld-20.0) is entered.
CODE VALUES:

None None
DATA ELEMENT: Rendering Provider Address
DEFINITION: The street address of the office, site or clinic location where services
were rendered.
FA@ 13.0 X 18 L Spaces 99 116

S S S S S S
different than that specified in the Billing Provider or Pay-To
Provider address information.
CODE VALUES:

validation.

None Reject Claim
DATA ELEMENT: Rendering Provider City
DEFINITION: The city of the office, site or clinic location where services were
rendered.
FA@ 14.0 X 15 L Spaces 117 131

S S S S S S
CODE VALUES:

validation.

None Reject Claim
DATA ELEMENT: Rendering Provider State
DEFINITION: The state of the office, site or clinic location where services were
rendered.
FA@ 15.0 X 02 L Spaces 132 133

S S S S S S
CODE VALUES:

validation.

None Reject Claim
DATA ELEMENT: Rendering Provider Zip Code
DEFINITION: The zip of the office, site or clinic location where services were
rendered.
FA@ 16.0 9 09 R Zeroes 134 142

S S S S S S
CODE VALUES:

validation.

None Reject Claim
DATA ELEMENT: Rendering Provider Taxonomy
FA@ 17.0 X 10 L Spaces 143 152

S S S S S S

provider taxonomy code.

Available From:

None Reject Claim
DATA ELEMENT: Rendering Provider NPI
FA@ 18.0 X 10 L Spaces 153 162

N N N N N N
CODE VALUES:

None None
DATA ELEMENT: Rendering Provider Tax ID Qualifier

RENDERING PROVIDER TAX ID fld-05.0).
FA@ 19.0 X 01 L Spaces 163 163

S S S S S S
SITUATIONAL NOTE: Should be entered if the RENDERING PROVIDER TAX ID (fld-05.0)

has been entered.
CODE VALUES: E Employer's Identification Number

S Social Security Number

None Reject Claim
DATA ELEMENT: Rendering Provider Secondary ID Qualifier

RENDERING PROVIDER SECONDARY ID.
FA@ 20.0 X 02 L Spaces 164 165

S S S S S S
SITUATIONAL NOTE: Must be entered if the RENDERING PROVIDER SECONDARY ID (fld-


LU Location Number

FA@ 21.0 X 155 L Spaces 166 320

R R R R R R
CODE VALUES:

None None
RECORD SUMMARY
RECORD TYPE: FB0
RECORD PURPOSE: To provide informtion related to the medical services

S FA0, FA@ FA0, FB1, FB2, FB3, FB4,

FE0, GA0, GC0, GD@,


by Sequence Number.
RECORD LAYOUT
Record Type: FB0

FB0 05.0 Purchase Service Charge 9v99 07 40 46
FB0 06.0 Allowed Amount 9v99 07 47 53
FB0 07.0 Filler X 07 54 60
FB0 08.0 Filler X 07 61 67
FB0 09.0 Ordering Provider NPI X 10 68 77
FB0 09.1 Filler X 05 78 82
FB0 10.0 Ordering Provider State X 02 83 84
FB0 11.0 Purchase Service Provider NPI X 10 85 94
FB0 11.1 Filler X 05 95 99
FB0 12.0 Purchase Service State X 02 100 101
FB0 13.0 PEN Grams of Protein 9 04 102 105
FB0 14.0 PEN Calories 9 04 106 109
FB0 15.0 National Drug Code X 11 110 120
FB0 16.0 National Drug Units 9v99 07 121 127
FB0 17.0 Prescription Number X 15 128 142
FB0 18.0 Prescription Date 9 08 143 150
FB0 19.0 Prescription Number of Months 9 02 151 152
FB0 20.0 Special Pricing Indicator X 01 153 153
FB0 21.0 Copay Status Indicator X 01 154 154
FB0 22.0 EPSDT Indicator X 01 155 155
FB0 23.0 Family Planning Indicator X 01 156 156
FB0 24.0 DME Charge Indicator X 01 157 157
FB0 25.0 HPSA Facility ID X 15 158 172
FB0 26.0 HPSA Facility Zip Code X 09 173 181
FB0 27.0 Purchase Service Name X 33 182 214
FB0 30.0 Purchase Service City X 20 275 294
FB0 31.0 Purchase Service Zip Code X 09 295 303
FB0 32.0 Purchase Service Phone X 10 304 313
FB0 33.0 Drug Days Supply 9 03 314 316
FB0 35.0 Filler - Local X 02 319 320
Emdeon Business Services Technical Specifications NSF Plus FB0 - 01.0
DATA ELEMENT: Record Type 'FB0'
DEFINITION: A field used to identify the "Medical Segment 1" Record.
FB0 01.0 X 03 L Spaces 01 03

R R R R R R
CODE VALUES:
VALIDATION: Must contain a value of FB0.


FB0 02.0 9 02 R Zeroes 04 05

R R R R R R
CODE VALUES: 01-50
Must be identical to the SEQUENCE NUMBER (fld-02.0) submitted

in the preceding Record Type FA0.


FB0 03.0 X 17 L Spaces 06 22

R R R R R R
CODE VALUES:

FB0 04.0 X 17 L Spaces 23 39

S S S S S S
CODE VALUES:
VALIDATION: Should be identical to the LINE ITEM CONTROL NUMBER submitted

in the preceding Record Type FA0 (fld-04.0).

None None
DATA ELEMENT: Purchase Service Charge
DEFINITION: The net cost for the purchased service.
FB0 05.0 9v99 07 R Zeroes 40 46

S S S S S S
SITUATIONAL NOTE: Should be entered if CLAIM FILING INDICATOR (RT DA0, fld-04.0)
contains a value of P and HCPCS MODIFIER 1,2 (RT FA0, flds-
10.0,11.0) contains a value of WU.
CODE VALUES:

None Reject Claim
DEFINITION: The maximum amount determined by the payer as being "allowable"

under the provisions of the contract prior to the determination of
actual payment.
FB0 06.0 9v99 07 R Zeroes 47 53

S S S S S S
SITUATIONAL NOTE: Should be entered if applicable or required by payer.
CODE VALUES:

None Reject Claim
NOTES: Only positive dollar amounts are acceptable at this time; negative
values are not allowed.
The accumulated total of ALLOWED AMOUNT fields must equal the

amount entered in ALLOWED AMOUNT in Record Type DA1 (fld-11.0)
when CLAIM FILING INDICATOR (RT DA0, fld-04.0) contains a value
of P.
FB0 07.0 X 07 L Spaces 54 60

R R R R R R
CODE VALUES:

None None
NOTES: Deductible Amount information should be submitted using the FB4

(Service Line Adjustment Information) Record. Information
FB0 08.0 X 07 L Spaces 61 67

R R R R R R
CODE VALUES:

None None
NOTES: Coinsurance Amount information should be submitted using the FB4

(Service Line Adjustment Information) Record. Information
DATA ELEMENT: Ordering Provider NPI
FB0 09.0 X 10 L Spaces 68 77

N N N N N N
CODE VALUES:

None None
FB0 09.1 X 05 L Spaces 78 82

R R R R R R
CODE VALUES:

None None
DATA ELEMENT: Ordering Provider State
DEFINITION: US Postal Service Abbreviation Code of the State of the ordering

provider.
FB0 10.0 X 02 L Spaces 83 84

S S S S S S
CODE VALUES:

validation.

None None
DATA ELEMENT: Purchase Service Provider NPI
FB0 11.0 X 10 L Spaces 85 94

N N N N N N
CODE VALUES:

None None
FB0 11.1 X 05 L Spaces 95 99

R R R R R R
CODE VALUES:

None None
DATA ELEMENT: Purchase Service State
DEFINITION: US Postal Service abbreviation code of the state in which the service
was purchased.
FB0 12.0 X 02 L Spaces 100 101

N N N N N S
SITUATIONAL NOTE: Should be entered if CLAIM FILING INDICATOR (RT DA0, fld-04.0)
contains a value of P and HCPCS MODIFIER1,2 (RT FA0, flds-
10.0,11.0) contains a value of WU.
CODE VALUES:

validation.

None None
DATA ELEMENT: PEN Grams of Protein
DEFINITION: The grams of amino acids prescribed per day.
FB0 13.0 9 04 R Zeroes 102 105

N N N N N S
CODE VALUES:

None Reject Claim
NOTES: PEN GRAMS OF PROTEIN should be entered to facilitate adjudication

of parenteral claims.
DATA ELEMENT: PEN Calories
DEFINITION: The number of calories prescribed per day.
FB0 14.0 9 04 R Zeroes 106 109

N N N N N S
CODE VALUES:

None Reject Claim
NOTES: PEN CALORIES should be entered to facilitate adjudication of enteral

claims.
DATA ELEMENT: National Drug Code
DEFINITION: The national drug identification number assigned by the Federal

Drug Administration (FDA).
FB0 15.0 X 11 L Spaces 110 120

N N N N N S
CODE VALUES:
VALIDATION: If entered, must be 11 numerics.

None Reject Claim
DATA ELEMENT: National Drug Units
DEFINITION: The dispensing quantity, based upon the unit of measure as defined
by the NDC Number (RT-FB0, fld-15.0).
FB0 16.0 9v99 07 R Zeroes 121 127

N N N N N S
CODE VALUES:

None Reject Claim
DATA ELEMENT: Prescription Number
DEFINITION: The unique identification number assigned by the pharmacy or

supplier.
FB0 17.0 X 15 L Spaces 128 142

N N N N N S
CODE VALUES:

None None
DATA ELEMENT: Prescription Date
DEFINITION: The date the prescription was issued by the referring physician.
FB0 18.0 9 08 R Zeroes 143 150

N N N N N S
CODE VALUES:

None Reject Claim
DATA ELEMENT: Prescription Number of Months
DEFINITION: The number of months the prescription will be in effect.
FB0 19.0 9 02 R Zeroes 151 152

N N N N N S
CODE VALUES:

None Reject Claim
DATA ELEMENT: Special Pricing Indicator
DEFINITION: This indicator is used to meet additional or special medical

requirements as required by the Medicare claim processor.
FB0 20.0 X 01 L Spaces 153 153

N N N N N S
CODE VALUES:

None None
DATA ELEMENT: Copay Status Indicator
DEFINITION: A code used to indicate whether co-payment requirements were met

on a line by line basis.
FB0 21.0 X 01 L Spaces 154 154

S S S S S S
CODE VALUES: 0 Copay Exempt

1 Recipient Did Not Pay When Asked
2 Recipient Did Pay When Asked
3 Recipient was Not Asked
VALIDATION: If entered, should be a code from the above list.

None None
DATA ELEMENT: EPSDT Indicator
DEFINITION: A code used to indicate whether Early and Periodic Screen for
Diagnosis and Treatment of Children services are involved with this
detail line.
FB0 22.0 X 01 L Spaces 155 155

S S S S S S
CODE VALUES: N No, EPSDT was not Involved

Y Yes, EPSDT was Involved

None None
DATA ELEMENT: Family Planning Indicator
DEFINITION: A code used to indicate whether Family Planning Services are

involved with this detail line.
FB0 23.0 X 01 L Spaces 156 156

S S S S S S
CODE VALUES: N No, Family Planning is not Involved

Y Yes, Family Planning is Involved

None None
DATA ELEMENT: DME Charge Indicator
DEFINITION: A code used to indicate whether a charge for Durable Medical

Equipment is being submitted for the first time.
FB0 24.0 X 01 L Spaces 157 157

S S S S S N
CODE VALUES: 0 Not a DME Rental, Repeat DME Purchase or

PEN
1 First Charge for DME Rental, or DME Repeat
Purchase
2 Subsequent Charge for DME Rental, Purchase
or PEN
3 Re-Certified PEN Claim or a PEN Claim
Containing new Caloric Values

None None
DATA ELEMENT: HPSA Facility ID
DEFINITION: The identifier assigned by the payer to the Healthcare Professional

Shortage Area facility.
FB0 25.0 X 15 L Spaces 158 172

N N N N N S
CODE VALUES:

None None
DATA ELEMENT: HPSA Facility Zip Code
DEFINITION: The zip code of the HPSA facility location.
FB0 26.0 X 09 L Spaces 173 181

N N N N N S
CODE VALUES:

validation.

None None
DATA ELEMENT: Purchase Service Name
DEFINITION: The name of the entity from which service was purchased.
FB0 27.0 X 33 L Spaces 182 214

S S S S S S
SITUATIONAL NOTE: Should be entered if HCPCS MODIFIER 1,2 (RT FA0, flds-10.0,11.0)
contain a value of WU.
CODE VALUES:
period, no other special characters are allowed.

None None
DATA ELEMENT: Purchase Service Address 1
DEFINITION: The street address of the entity from which service was purchased.
FB0 28.0 X 30 L Spaces 215 244

S S S S S S
CODE VALUES:

validation.

None Reject Claim
DATA ELEMENT: Purchase Service Address 2
DEFINITION: The second street address of the entity from which service was
purchased.
FB0 29.0 X 30 L Spaces 245 274

N N N N N N
SITUATIONAL NOTE: Should be entered if a second address line needed to convey a

CODE VALUES:

validation.

None Reject Claim
DATA ELEMENT: Purchase Service City
DEFINITION: The city of the entity from which service was purchased.
FB0 30.0 X 20 L Spaces 275 294

S S S S S S
CODE VALUES:

validation.

None Reject Claim
DATA ELEMENT: Purchase Service Zip Code
DEFINITION: The zip code of the entity from which service was purchased.
FB0 31.0 X 09 L Spaces 295 303

S S S S S S
CODE VALUES:

validation.

None Reject Claim
DATA ELEMENT: Purchase Service Phone
DEFINITION: The phone number of the entity from which service was purchased.
FB0 32.0 X 10 L Spaces 304 313

S S S S S S
CODE VALUES:

XXX = Area code
yyy = Exchange

None None
DATA ELEMENT: Drug Days Supply
DEFINITION: The number of days' supply, from 1 to 99, currently dispensed with
this prescription service.
FB0 33.0 9 03 R Zeroes 314 316

S S S S S S
SITUATIONAL NOTE: Must be entered if NATIONAL DRUG CODE (fld-15.0) has been
entered and TYPE OF SERVICE (RT FA0, fld-08.0) contains a value
of 99 (Other).
If entered, should be a valid code from the above list.

FB0 34.0 X 02 L Spaces 317 318

R R R R R R
CODE VALUES:

None None
FB0 35.0 X 02 L Spaces 319 320

R R R R R R
CODE VALUES:

None None
RECORD SUMMARY
RECORD TYPE: FB1
RECORD PURPOSE: To provide information related to the medical services

S FA0, FA@, FB0 FA0, FB2, FB3, FB4, FE0,

GA0, GC0, GD@, GU0,
GX0, GX2, HA0, XA0


by Sequence Number.
RECORD LAYOUT
Record Type: FB1

FB1 05.0 Place of Service Name X 33 40 72
FB1 06.0 Ordering Provider Last Name X 20 73 92
FB1 07.0 Ordering Provider First Name X 12 93 104
FB1 08.0 Ordering Provider Middle Initial X 01 105 105
FB1 09.0 Ordering Provider Secondary ID X 15 106 120
FB1 10.0 Referring Provider Last Name X 20 121 140
FB1 11.0 Referring Provider First Name X 12 141 152
FB1 12.0 Referring Provider Middle Initial X 01 153 153
FB1 13.0 Referring Provider Secondary ID X 15 154 168
FB1 14.0 Rendering Provider Last Name X 20 169 188
FB1 15.0 Rendering Provider First Name X 12 189 200
FB1 16.0 Rendering Provider Middle Initial X 01 201 201
FB1 17.0 Rendering Provider UPIN X 15 202 216
FB1 18.0 Supervising Provider Last Name X 20 217 236
FB1 19.0 Supervising Provider First Name X 12 237 248
FB1 20.0 Supervising Provider Middle Initial X 01 249 249
FB1 21.0 Supervising Provider NPI X 10 250 259
FB1 21.1 Filler X 05 260 264
FB1 22.0 Supervising Provider Secondary ID X 15 265 279
FB1 23.0 Ordering Provider Secondary ID Qualifier X 02 280 281
FB1 24.0 Referring Provider Secondary ID Qualifier X 02 282 283
FB1 25.0 Supervising Provider Secondary ID Qualifier X 02 284 285
FB1 26.0 Purchased Service Provider Secondary ID Qualifier X 02 286 287
FB1 27.0 Purchased Service Provider Secondary ID X 15 288 302
FB1 28.0 Referring Provider NPI X 10 303 312
FB1 29.0 Filler - Local X 08 313 320
DEFINITION: A field used to identify the "Medical Segment 2" Record.
FB1 01.0 X 03 L Spaces 01 03

R R R R R R
CODE VALUES:

None None

FB1 02.0 9 02 R Zeroes 04 05

R R R R R R
CODE VALUES: 01-50



FB1 03.0 X 17 L Spaces 06 22

R R R R R R
CODE VALUES:

FB1 04.0 X 17 L Spaces 23 39

S S S S S S
CODE VALUES:


None None
DATA ELEMENT: Place of Service Name
DEFINITION: The name of the place of service.
FB1 05.0 X 33 L Spaces 40 72

S S S S S S
CODE VALUES:

None None
DATA ELEMENT: Ordering Provider Last Name
DEFINITION: The last name of the ordering provider.
FB1 06.0 X 20 L Spaces 73 92

S S S S S S
CODE VALUES:

None None
DATA ELEMENT: Ordering Provider First Name
DEFINITION: The first name of the ordering provider.
FB1 07.0 X 12 L Spaces 93 104

S S S S S S
CODE VALUES:

None None
DATA ELEMENT: Ordering Provider Middle Initial
DEFINITION: The middle initial of the ordering provider.
FB1 08.0 X 01 L Spaces 105 105

D D D D D D
CODE VALUES:
Should only be entered if ORDERING PROVIDER LAST NAME (fld-

06.0) ORDERING PROVIDER FIRST NAME (fld-07.0) is entered.

None None
DATA ELEMENT: Ordering Provider Secondary ID

Ordering Provider.
FB1 09.0 X 15 L Spaces 106 120

S S S S S S
SITUATIONAL NOTE: Should be entered if ORDERING PROVIDER SECONDARY ID

QUALIFIER (fld-23.0) has been entered.
CODE VALUES:

None None
DATA ELEMENT: Referring Provider Last Name
DEFINITION: The last name of the referring provider.
FB1 10.0 X 20 L Spaces 121 140

N N N N N S
CODE VALUES:

None None
DATA ELEMENT: Referring Provider First Name
DEFINITION: The first name of the referring provider.
FB1 11.0 X 12 L Spaces 141 152

N N N N N S
CODE VALUES:

None None
DATA ELEMENT: Referring Provider Middle Initial
DEFINITION: The middle initial of the referring provider.
FB1 12.0 X 01 L Spaces 153 153

N N N N N D
CODE VALUES:
Should only be entered if REFERRING PROVIDER LAST NAME (fld-

10.0) and REFERRING PROVIDER FIRST NAME (fld-11.0) is
entered.

None None
DATA ELEMENT: Referring Provider Secondary ID

Referring Provider.
FB1 13.0 X 15 L Spaces 154 168

S S S S S S
SITUATIONAL NOTE: Should be entered if REFERRING PROVIDER SECONDARY ID

CODE VALUES:

None None
DATA ELEMENT: Rendering Provider Last Name
DEFINITION: The last name of the primary care, attending or consulting provider
responsibility for servicing practitioners that are in his /her employ,
i.e.., RN's, PA's, technicians, etc.
FB1 14.0 X 20 L Spaces 169 188

N N N N N S

CODE VALUES:

None None
DEFINITION: The first name of the primary care, attending or consulting provider
responsibility for servicing practitioners that are in his /her employ,
eye., RN's, PA's, technicians, etc.
FB1 15.0 X 12 L Spaces 189 200

N N N N N S

CODE VALUES:

None None
DEFINITION: The middle initial of the primary care, attending or consulting

provider that has rendered the service(s). This includes providers
that have responsibility for servicing practitioners that are in his /her
employ, eye., RN's, PA's, technicians, etc.
FB1 16.0 X 01 L Spaces 201 201

N N N N N D
CODE VALUES:
Should only be entered if RENDERING PROVIDER LAST NAME (fld-

14.0) and RENDERING PROVIDER FIRST NAME (fld-15.0) is
entered.

None None
DATA ELEMENT: Rendering Provider UPIN
DEFINITION: The rendering physician's Unique Physician Identification Number.
FB1 17.0 X 15 L Spaces 202 216

S S S S S S
CODE VALUES:
VALIDATION: Should only contain a value of A-Z, 0-9 and trailing spaces. Not

None None
DATA ELEMENT: Supervising Provider Last Name
DEFINITION: The last name of the supervising provider.
FB1 18.0 X 20 L Spaces 217 236

S S S S S S
CODE VALUES:

None None
DATA ELEMENT: Supervising Provider First Name
DEFINITION: The first name of the supervising provider.
FB1 19.0 X 12 L Spaces 237 248

S S S S S S
CODE VALUES:

None None
DATA ELEMENT: Supervising Provider Middle Initial
DEFINITION: The middle initial of the supervising provider.
FB1 20.0 X 01 L Spaces 249 249

D D D D D D
CODE VALUES:
Should only be entered if SUPERVISING PROVIDER LAST NAME (fld-

18.0) and SUPERVISING PROVIDER FIRST NAME (fld-19.0) is
entered.

None None
DATA ELEMENT: Supervising Provider NPI
DEFINITION: The National Provider Identifier assigned to the provider
FB1 21.0 X 10 L Spaces 250 259

N N N N N N
CODE VALUES:

None None
FB1 21.1 X 05 L Spaces 260 264

R R R R R R
CODE VALUES:

None None
DATA ELEMENT: Supervising Provider Secondary ID

Supervising Provider.
FB1 22.0 X 15 L Spaces 265 279

S S S S S S
SITUATIONAL NOTE: Should be entered if SUPERVISING PROVIDER SECONDARY ID

CODE VALUES:

None None
DATA ELEMENT: Ordering Provider Secondary ID Qualifier
DEFINITION: A code used to qualify the ORDERING PROVIDER SECONDARY ID

NUMBER in (RT FB1,fld-09.0)
FB1 23.0 X 02 L Spaces 280 281

S S S S S S
SITUATIONAL NOTE: Must be entered if ORDERING PROVIDER SECONDARY ID (fld-


LU Location Number

DATA ELEMENT: Referring Provider Secondary ID Qualifier
DEFINITION: A code used to qualify the REFERRING PROVIDER SECONDARY ID

FB1 24.0 X 02 L Spaces 282 283

S S S S S S
SITUATIONAL NOTE: Must be entered if REFERRING PROVIDER SECONDARY ID (fld-


LU Location Number

DATA ELEMENT: Supervising Provider Secondary ID Qualifier
DEFINITION: A code used to qualify the SUPERVISING PROVIDER SECONDARY ID

FB1 25.0 X 02 L Spaces 284 285

S S S S S S
SITUATIONAL NOTE: Must be entered if SUPERVISING PROVIDER SECONDARY ID (fld-


LU Location Number

DATA ELEMENT: Purchased Service Provider Secondary ID Qualifier
DEFINITION: A code used to qualify the PURCHASED SERVICE PROVIDER

SECONDARY ID NUMBER in (fld-27.0)
FB1 26.0 X 02 L Spaces 286 287

S S S S S S
SITUATIONAL NOTE: Must be entered if PURCHASED SERVICE PROVIDER ID NUMBER


LU Location Number
U3 Unique Supplier Identification Number (USIN)

DATA ELEMENT: Purchased Service Provider Secondary ID

Purchased Service Provider.
FB1 27.0 X 15 L Spaces 288 302

S S S S S S
SITUATIONAL NOTE: Should be entered if PURCHASED SERVICE PROVIDER SECONDARY

ID QUALIFIER (fld-26.0) has been entered.
CODE VALUES:

None None
DATA ELEMENT: Referring Provider NPI
FB1 28.0 X 10 L Spaces 303 312

N N N N N N
CODE VALUES:

None None
FB1 29.0 X 08 L Spaces 313 320

R R R R R R
CODE VALUES:

None None
RECORD SUMMARY
RECORD TYPE: FB2
RECORD PURPOSE: To provide additional provider address information.
S FA0, FA@, FB0, FB1 FA0, FB3, FB4, FE0, GA0,

GC0, GD@, GU0, GX0,
GX2, HA0, XA0


by Sequence Number.
If more than three (3) provider address sets (flds-06.0-10.0)

are needed, claim must be split into separate claims.
RECORD LAYOUT
Record Type: FB2

FB2 05.0 Provider Type Indicator A X 02 40 41
FB2 08.0 Provider A City X 20 102 121
FB2 09.0 Provider A State X 02 122 123
FB2 10.0 Provider A Zip Code X 09 124 132
FB2 11.0 Provider Type Indicator B X 02 133 134
FB2 14.0 Provider B City X 20 195 214
FB2 15.0 Provider B State X 02 215 216
FB2 16.0 Provider B Zip Code X 09 217 225
FB2 17.0 Provider Type Indicator C X 02 226 227
FB2 20.0 Provider C City X 20 288 307
FB2 21.0 Provider C State X 02 308 309
FB2 22.0 Provider C Zip Code X 09 310 318
DEFINITION: A field used to identify the "Medical Segment 3" Record
FB2 01.0 X 03 L Spaces 01 03

R R R R R R
CODE VALUES:


FB2 02.0 9 02 R Zeroes 04 05

R R R R R R
CODE VALUES: 01-50



FB2 03.0 X 17 L Spaces 06 22

R R R R R R
CODE VALUES:

FB2 04.0 X 17 L Spaces 23 39

S S S S S S
CODE VALUES:


None None
DATA ELEMENT: Provider Type Indicator A
DEFINITION: A code used to indicate the type of provider to whom the address
information in fields 06.0-10.0 applies.
FB2 05.0 X 02 L Spaces 40 41

S S S S S S
CODE VALUES: AP Attending Provider

CP Consulting Provider
OD Ordering Provider
OO Other Ordering Provider
RF Referring Provider
SP Supervising Provider
SU Surrogate Provider

None None
DATA ELEMENT: Provider A Address 1
DEFINITION: The street address of the provider identified in PROVIDER TYPE

INDICATOR A (fld-05.0).
FB2 06.0 X 30 L Spaces 42 71

S S S S S S
CODE VALUES:

validation.

None Reject Claim
DATA ELEMENT: Provider A Address 2
DEFINITION: The second street address of the provider identified in PROVIDER

TYPE INDICATOR A (fld-05.0).
FB2 07.0 X 30 L Spaces 72 101

N N N N N N
SITUATIONAL NOTE: Should be entered if a second address is needed to convey a

complete address.
CODE VALUES:

validation.

None Reject Claim
DATA ELEMENT: Provider A City
DEFINITION: The city of the provider identified in PROVIDER TYPE INDICATOR A

(fld-05.0).
FB2 08.0 X 20 L Spaces 102 121

S S S S S S
CODE VALUES:

validation.

None Reject Claim
DATA ELEMENT: Provider A State
DEFINITION: The state of the provider identified in PROVIDER TYPE INDICATOR A

(fld-05.0).
FB2 09.0 X 02 L Spaces 122 123

S S S S S S
CODE VALUES:

validation.

None Reject Claim
DATA ELEMENT: Provider A Zip Code
DEFINITION: The zip code of the provider identified in PROVIDER TYPE

INDICATOR A (fld-05.0).
FB2 10.0 X 09 L Spaces 124 132

S S S S S S
CODE VALUES:

validation.

None Reject Claim
DATA ELEMENT: Provider Type Indicator B
FB2 11.0 X 02 L Spaces 133 134

S S S S S S


None None
DATA ELEMENT: Provider B Address 1

INDICATOR B (fld-11.0).
FB2 12.0 X 30 L Spaces 135 164

S S S S S S
CODE VALUES:

validation.

None Reject Claim
DATA ELEMENT: Provider B Address 2

TYPE INDICATOR B (fld-11.0).
FB2 13.0 X 30 L Spaces 165 194

N N N N N N

complete address.
CODE VALUES:

validation.

None Reject Claim
DATA ELEMENT: Provider B City
DEFINITION: The city of the provider identified in PROVIDER TYPE INDICATOR B

(fld-11.0).
FB2 14.0 X 20 L Spaces 195 214

S S S S S S
CODE VALUES:

validation.

None Reject Claim
DATA ELEMENT: Provider B State
DEFINITION: The state of the provider identified in PROVIDER TYPE INDICATOR B

(fld-11.0).
FB2 15.0 X 02 L Spaces 215 216

S S S S S S
CODE VALUES:

validation.

None Reject Claim
DATA ELEMENT: Provider B Zip Code

INDICATOR B (fld-11.0).
FB2 16.0 X 09 L Spaces 217 225

S S S S S S
CODE VALUES:

validation.

None Reject Claim
DATA ELEMENT: Provider Type Indicator C
FB2 17.0 X 02 L Spaces 226 227

S S S S S S


None None
DATA ELEMENT: Provider C Address 1

INDICATOR C (fld-17.0).
FB2 18.0 X 30 L Spaces 228 257

S S S S S S
CODE VALUES:

validation.

None Reject Claim
DATA ELEMENT: Provider C Address 2

TYPE INDICATOR C (fld-17.0).
FB2 19.0 X 30 L Spaces 258 287

N N N N N N

complete address.
CODE VALUES:

validation.

None Reject Claim
DATA ELEMENT: Provider C City
DEFINITION: The city of the provider identified in PROVIDER TYPE INDICATOR C

(fld-17.0).
FB2 20.0 X 20 L Spaces 288 307

S S S S S S
CODE VALUES:

validation.

None Reject Claim
DATA ELEMENT: Provider C State
DEFINITION: The state of the provider identified in PROVIDER TYPE INDICATOR C

(fld-17.0).
FB2 21.0 X 02 L Spaces 308 309

S S S S S S
CODE VALUES:

validation.

None Reject Claim
DATA ELEMENT: Provider C Zip Code

INDICATOR C (fld-17.0).
FB2 22.0 X 09 L Spaces 310 318

S S S S S S
CODE VALUES:

validation.

None Reject Claim
FB2 23.0 X 02 L Spaces 319 320

R R R R R R
CODE VALUES:

None None
RECORD SUMMARY
RECORD TYPE: FB3
RECORD NAME: Service Line Payment Information
RECORD PURPOSE: To provide service line payment information from the non-
S FA0, FA@, FB1, FB2, FB3 FA0, FB3, FB4, FE0, GA0,
GC0, GD@, GU0, GX0,
GX2, HA0, XA0


by Sequence Number.
A maximum of five (5) sequences of Record Type FB3 may

be entered per Record Type FA0.
RECORD LAYOUT
Record Type: FB3

FB3 04.0 Filler X 01 08 08
FB3 07.0 Payer ID X 05 43 47
FB3 08.0 Procedure Code Qualifier X 02 48 49
FB3 09.0 Procedure Code X 05 50 54
FB3 10.0 Filler X 02 55 56
FB3 15.0 Procedure Code Description X 80 65 144
FB3 16.0 Paid Units of Service 9v9 15 145 159
FB3 17.0 Bundled Line Number X 06 160 165
FB3 18.0 Adjudication or Payment Date 9 08 166 173
FB3 19.0 Service Line Paid Amount 9v99 08 174 181
FB3 20.0 Filler X 139 182 320
DEFINITION: A field used to identify the "Service Line Payment Information"

record.
FB3 01.0 X 03 L Spaces 01 03

R R R R R R
CODE VALUES:

DEFINITION: The sequence number of the Record Type FA0 Service Line Record
being adjusted.
FB3 02.0 9 02 R Zeroes 04 5

R R R R R R
CODE VALUES: 01-50
Must be identical to a SEQUENCE NUMBER entered in the preceding

Record Type FA0.

DEFINITION: A sequence number assigned to individual records within the same

specific Record Type to indicate the sequence of each physical record.
FB3 03.0 9 02 R Zeroes 06 07

R R R R R R
CODE VALUES: 01-05
Must be a valid value of 01-05.

FB3 04.0 X 01 L Spaces 08 08

R R R R R R
CODE VALUES:

None None

FB3 05.0 X 17 L Spaces 9 25

R R R R R R
CODE VALUES:

DEFINITION: An identifier assigned by the submitter/provider to the line item

being adjusted.
FB3 06.0 X 17 L Spaces 26 42

S S S S S S
CODE VALUES:


None None
DATA ELEMENT: Payer ID
DEFINITION: Other Payer Primary ID Number
FB3 07.0 X 05 L Spaces 43 47

R R R R R R
CODE VALUES:
VALIDATION: Must be identical to a PAYER ORGANIZATION ID entered in a

preceding Record Type DA0 (fld-07.0).

DATA ELEMENT: Procedure Code Qualifier
DEFINITION: A code used to identify the type of Procedure Code entered in RT

FB3, fld-09.0.
FB3 08.0 X 02 L Spaces 48 49

N N N N N N
CODE VALUES: HC HCPCS - Health Care Financing Administration

Common Procedural Coding System Codes.
IV HIEC - Home Infusion EDI Coalition
Product/Service Code
ZZ Mutually Defined - Worker Compensation
Claims Only
VALIDATION: Should contain a value of HC.

None None
DATA ELEMENT: Procedure Code
DEFINITION: A code used to identify the procedure code that was used to pay this
service line.
FB3 09.0 X 05 L Spaces 50 54

R R R R R R
CODE VALUES:

FB3 10.0 X 02 L Spaces 55 56

R R R R R R
CODE VALUES:

None None
DATA ELEMENT: Procedure Code Modifier 1
DEFINITION: A modifier code from the HCPCS uniform classification system used
to identify special circumstances associated with the corresponding
PROCEDURE CODE (fld-09.0) entered.
FB3 11.0 X 02 L Spaces 57 58

S S S S S S
SITUATIONAL NOTE: Should be entered if the PROCEDURE CODE requires modifiers to

properly define the services being rendered.
CODE VALUES:
VALIDATION: If entered, should contain a valid HCPCS/CPT Procedure Code

Modifier.

None None
FB3 12.0 X 02 L Spaces 59 60

S S S S S S

CODE VALUES:

Modifier.

None None
FB3 13.0 X 02 L Spaces 61 62

S S S S S S

CODE VALUES:

Modifier.

None None
FB3 14.0 X 02 L Spaces 63 64

S S S S S S

CODE VALUES:

Modifier.

None None
DATA ELEMENT: Procedure Code Description
DEFINITION: A description from the American Medical Association that is

associated with the corresponding PROCEDURE CODE (fld-09.0)
entered.
FB3 15.0 X 80 L Spaces 65 144

S S S S S S
SITUATIONAL NOTE: Should be entered if the PROCEDURE CODE requires clarification.
CODE VALUES:
VALIDATION: None

None None
DATA ELEMENT: Paid Units of Service
DEFINITION: The units provided for the corresponding procedure code that was
used to pay this service line.
FB3 16.0 9v9 15 R Zeroes 145 159

R R R R R R
CODE VALUES:

DATA ELEMENT: Bundled Line Number
DEFINITION: Number assigned for differentiation within a transaction set, used for
bundling of service lines.
FB3 17.0 X 06 L Spaces 160 165

S S S S S S
SITUATIONAL NOTE: Should be entered if the payer bundled or unbundled this service
line.
CODE VALUES:

None Reject Claim
DATA ELEMENT: Adjudication or Payment Date
DEFINITION: The date the line was adjudicated or the payment was made.
FB3 18.0 9 08 R Zeroes 166 173

S S S S S S
SITUATIONAL NOTE: Should be entered if this service line has adjustments applied to it.
CODE VALUES:

None Reject Claim
DATA ELEMENT: Service Line Paid Amount
DEFINITION: Amount paid for this service line.
FB3 19.0 9v99 08 R Zeroes 174 181

R R R R R R
CODE VALUES:

FB3 20.0 X 139 L Spaces 182 320

R R R R R R
CODE VALUES:

None None
RECORD SUMMARY
RECORD TYPE: FB4
RECORD NAME: Service Line Adjustment Information
RECORD PURPOSE: To provide service line adjustment information from the non-
S FB3, FB4 FA0, FB4, FE0, GA0, GC0,

GD@, GU0, GX0, GX2,
HA0, XA0


by Sequence Number.
A maximum of twenty-five (25) sequences of Record Type

FB4 may be entered per Record Type FB3.
RECORD LAYOUT
Record Type: FB4

FB4 04.0 Filler X 01 08 08
FB4 05.0 CAS Record Counter X 02 09 10
FB4 08.0 CAS Group X 02 45 46
FB4 09.0 CAS Code 1 X 05 47 51
FB4 10.0 CAS Amount 1 9v99 08 52 59
FB4 11.0 CAS Quantity 1 9 10 60 69
FB4 12.0 CAS Code 2 X 05 70 74
FB4 13.0 CAS Amount 2 9v99 08 75 82
FB4 14.0 CAS Quantity 2 9 10 83 92
FB4 15.0 CAS Code 3 X 05 93 97
FB4 16.0 CAS Amount 3 9v99 08 98 105
FB4 17.0 CAS Quantity 3 9 10 106 115
FB4 18.0 CAS Code 4 X 05 116 120
FB4 19.0 CAS Amount 4 9v99 08 121 128
FB4 20.0 CAS Quantity 4 9 10 129 138
FB4 21.0 CAS Code 5 X 05 139 143
FB4 22.0 CAS Amount 5 9v99 08 144 151
FB4 23.0 CAS Quantity 5 9 10 152 161
FB4 24.0 CAS Code 6 X 05 162 166
FB4 25.0 CAS Amount 6 9v99 08 167 174
FB4 26.0 CAS Quantity 6 9 10 175 184
FB4 27.0 Filler X 136 185 320
DEFINITION: A field used to identify the "Service Line Adjustment" Record.
FB4 01.0 X 03 L Spaces 01 03

R R R R R R
CODE VALUES:

DEFINITION: The sequence number of the Record Type FA0 Service Line Record
being adjusted.
FB4 02.0 9 02 R Zeroes 04 05

R R R R R R
CODE VALUES: 1-50
Must be identical to a SEQUENCE NUMBER entered in the preceding

Record Type FA0.

DEFINITION: A sequential number assigned to individual records within a group of

Records to indicate the sequence of each physical record.
FB4 03.0 9 02 R Zeroes 06 07

R R R R R R
CODE VALUES: 01-25
Must be identical to the SUB SEQUENCE NUMBER entered in the

preceding Record Type FB3 (fld-03.0).

FB4 04.0 X 01 L Spaces 08 08

R R R R R R
CODE VALUES:

None None
DATA ELEMENT: CAS Record Counter
DEFINITION: The sequential number assigned to the repeat of the FB4 record
within the FB3 Records.
FB4 05.0 X 02 L Spaces 09 10

R R R R R R
CODE VALUES:
VALIDATION: Must be a valid value 01-25.


FB4 06.0 X 17 L Spaces 11 27

R R R R R R
CODE VALUES:

DEFINITION: An identifier assigned by the submitter/provider to the line item

being adjusted.
FB4 07.0 X 17 L Spaces 28 44

S S S S S S
CODE VALUES:


None None
DATA ELEMENT: CAS Group
DEFINITION: A code identifying the general category of payment adjustment.
FB4 08.0 X 02 L Spaces 45 46

R R R R R R
CODE VALUES: CO Contractual Obligations

CR Correction and Reversals
OA Other Adjustments
PI Payer Initiated Reductions
PR Patient Responsibility

FB4 09.0 X 05 L Spaces 47 51

R R R R R R

Committee Bulletins
Available from:
Chicago, IL 60611

Reject Claim None
FB4 10.0 9v99 08 R Zeroes 52 59

R R R R R R
CODE VALUES:

FB4 11.0 9 10 R Zeroes 60 69

S S S S S S
CODE VALUES:

FB4 12.0 X 05 L Spaces 70 74

S S S S S S


Committee Bulletins
Available from:
Chicago, IL 60611

Reject Claim None
FB4 13.0 9v99 08 R Zeroes 75 82

S S S S S S
QUANTITY (fld-14.0_ has not been entered.
CODE VALUES:

FB4 14.0 9 10 R Zeroes 83 92

S S S S S S
CODE VALUES:

FB4 15.0 X 05 L Spaces 93 97

S S S S S S


Committee Bulletins
Available from:
Chicago, IL 60611

Reject Claim None
FB4 16.0 9v99 08 R Zeroes 98 105

S S S S S S
QUANTITY (fld -17.0) has not been entered.
CODE VALUES:

FB4 17.0 9 10 R Zeroes 106 115

S S S S S S
CODE VALUES:

FB4 18.0 X 05 L Spaces 116 120

S S S S S S


Committee Bulletins
Available from:
Chicago, IL 60611

Reject Claim None
FB4 19.0 9v99 08 R Zeroes 121 128

S S S S S S
SITUATIONAL NOTE: Must be entered if CAS CODE (Fld-18.0) has been entered and CAS
CODE VALUES:

FB4 20.0 9 10 R Zeroes 129 138

S S S S S S
CODE VALUES:

FB4 21.0 X 05 L Spaces 139 143

S S S S S S


Committee Bulletins
Available from:
Chicago, IL 60611

Reject Claim None
FB4 22.0 9v99 08 R Zeroes 144 151

S S S S S S
CODE VALUES:

FB4 23.0 9 10 R Zeroes 152 161

S S S S S S
CODE VALUES:

FB4 24.0 X 05 L Spaces 162 166

S S S S S S


Committee Bulletins
Available from:
Chicago, IL 60611

Reject Claim None
FB4 25.0 9v99 08 R Zeroes 167 174

S S S S S S
CODE VALUES:

FB4 26.0 9 10 R Zeroes 175 184

S S S S S S
CODE VALUES:

FB4 27.0 X 136 L Spaces 185 320

R R R R R R
CODE VALUES:

None None
RECORD SUMMARY
RECORD TYPE: FE0
RECORD NAME: Claim - Third Party Organization Segment
RECORD PURPOSE: To provide repricing and review information to the

destination payer.
S FA0, FA@, FB0, FB1, FB2 FA0, GA0, GC0, GD@,


than fields FE0-01.0, FE0-02.0, FE0-03.0 or filler.
NOTES: When used, this Record Type FE0 must have the same

by Sequence Number.
RECORD LAYOUT
Record Type: FE0

FE0 01.0 Record Type 'FE0' X 03 01 03
FE0 02.0 Sequence Number 9 02 04 05
FE0 03.0 Patient Control Number X 17 06 22
FE0 04.0 Line Item Control Number X 17 23 39
FE0 05.0 TPO Identification Number X 09 40 48
FE0 06.0 TPO Reference Number X 15 49 63
FE0 07.0 Pricing Methodology X 02 64 65
FE0 08.0 Allowed Amount 9v99 07 66 72
FE0 09.0 Savings Amount 9v99 07 73 79
FE0 10.0 Approved Procedure Code X 05 80 84
FE0 11.0 Approved Units 9v9 04 85 88
FE0 12.0 Rejection Message X 02 89 90
FE0 13.0 Authorization Number X 20 91 110
FE0 14.0 Policy Compliance Code X 02 111 112
FE0 15.0 Exception Code X 02 113 114
FE0 16.0 Adjusted Repriced Claim Number X 15 115 129
FE0 17.0 Filler - National X 191 130 320
Emdeon Business Services Technical Specifications NSF Plus FE0 - 01.0
DATA ELEMENT: Record Type 'FE0'
DEFINITION: A field used to identify the "Third Party Organization Segment"

record.
FE0 01.0 X 03 L Spaces 01 03

R R R R R N
CODE VALUES:
VALIDATION: Must contain a value of FE0.


FE0 02.0 9 02 R Zeroes 04 05

R R R R R N
CODE VALUES: 01-50
Must be identical to the SEQUENCE NUMBER (fld-02.0) in the



FE0 03.0 X 17 L Spaces 06 22

R R R R R N
CODE VALUES:

FE0 04.0 X 17 L Spaces 23 39

S S S S S N
CODE VALUES:


None None
DATA ELEMENT: TPO Identification Number
DEFINITION: A number used to identify the Third Party Organization from which
the claim is being returned after pricing and /or review.
FE0 05.0 X 09 L Spaces 40 48

R R R R R N
CODE VALUES:
VALIDATION: Must be a valid TPO ID on the WebMD Payer List posted on the
WebMD Envoy website.

DATA ELEMENT: TPO Reference Number
DEFINITION: An internal control number, assigned by the TPO, used for tracking
purposes.
FE0 06.0 X 15 L Spaces 49 63

S S S S S N
SITUATIONAL NOTE: Should be entered if the TPO assigns an internal control number.
CODE VALUES:

None None
DATA ELEMENT: Pricing Methodology
DEFINITION: A code used to identify the method of pricing being applied to the
line item claim.
FE0 07.0 X 02 L Spaces 64 65

R R R R R N
CODE VALUES: 00 Zero Pricing (Not Covered Under Contract)

01 Priced as Billed at 100%
02 Priced at the Standard Fee Schedule
03 Priced at Contractual Percentage
04 Bundled Pricing
05 Peer Review Pricing
06 Per Diem Pricing
07 Flat Rate Pricing
08 Combination Pricing
09 Maternity Pricing
10 Other Pricing
11 Lower of Cost
12 Ratio of Cost
13 Cost Reimbursed
14 Adjustment Repricing

DEFINITION: The dollar amount allowed for this line item.
FE0 08.0 9v99 07 R Zeroes 66 72

R R R R R N
CODE VALUES:

DATA ELEMENT: Savings Amount
DEFINITION: The dollar amount that represents the difference between the total
amount charged and the TPO amount allowed.
FE0 09.0 9v99 07 R Zeroes 73 79

D D D D D N
CODE VALUES:

None Reject Claim
DATA ELEMENT: Approved Procedure Code
DEFINITION: The procedure code the TPO has "approved" for payment. This will
be different from the procedure code entered in the original line item.
FE0 10.0 X 05 L Spaces 80 84

S S S S S N
SITUATIONAL NOTE: Should be entered if a change was made to the reported procedure
code.
CODE VALUES:
VALIDATION: If entered, must be a valid HCPCS/CPT Code.

None Reject Claim
procedure code entered.
DATA ELEMENT: Approved Units
DEFINITION: The service units "approved" for payment by the TPO. This will be
different from the service units entered in the original line item.
FE0 11.0 9v9 04 R Zeroes 85 88

S S S S S N
SITUATIONAL NOTE: Should be entered if a change was made to the reported service
units.
CODE VALUES:

None Reject Claim
DATA ELEMENT: Rejection Message
DEFINITION: An indicator used to identify reasons a TPO may not be able to

provide pricing information.
FE0 12.0 X 02 L Spaces 89 90

S S S S S N
SITUATIONAL NOTE: Should be entered if the TPO cannot price the claim because:
The indicated provider/payer/insured is not part of the TPO

contract;
The provider has not submitted sufficient information for pricing.
CODE VALUES: T1 Cannot Identify Provider as TPO Participant

T2 Cannot Identify Payer as TPO Participant
T3 Cannot Identify Insured as TPO Participant
T4 Payer Name or Identifier Missing
T5 Certification Information Missing
T6 Claim Does Not Contain Enough Information
for Repricing

None Reject Claim
NOTES: If REJECTION MESSAGE INDICATOR contains a value of T1-T3, the

claim will be forwarded to the payer indicated in Record Type DA0.
If REJECTION MESSAGE INDICATOR contains a value of T4-T6, the

claim will NOT be forwarded to the payer indicated in Record Type
DA0; but instead, the rejection message will be returned to the
provider through the WebMD Envoy Unprocessed Claim system.
DATA ELEMENT: Authorization Number
DEFINITION: A number, assigned by the payer or TPO, used to indicate that the
treatment in the corresponding line item has been authorized.
FE0 13.0 X 20 L Spaces 91 110

D D D D D N
CODE VALUES:

None None
DATA ELEMENT: Policy Compliance Code
DEFINITION: A code specifying policy compliance.
FE0 14.0 X 02 L Spaces 111 112

S S S S S N
CODE VALUES: 01 Procedure Followed (Compliance)

02 Not Followed - Call Not Made (Non-Compliance
Call Not Made)
03 Not Medically Necessary (Non-Compliance Non-
Medically Necessary)
04 Not Followed Other (Non-Compliance Other)
05 Emergency Admit To Non-Network Hospital

None Reject Claim
DATA ELEMENT: Exception Code
DEFINITION: The exception code generated by a third party organization.
FE0 15.0 X 02 L Spaces 113 114

S S S S S N
CODE VALUES: 01 Non-Network Professional Provider in Network

Hospital
02 Emergency Care
03 Services or Specialist not in Network
04 Out -of- Service Area
05 State Mandates
06 Other

None Reject Claim
DATA ELEMENT: Adjusted Repriced Claim Number
DEFINITION: Identifies the adjusted repriced claim reference number.
FE0 16.0 X 15 L Spaces 115 129

N N N N N N
CODE VALUES:

None None
FE0 17.0 X 191 L Spaces 130 320

R R R R R N
CODE VALUES:

None None
RECORD SUMMARY
RECORD TYPE: GA0
RECORD NAME: Ambulance Certification Record
RECORD PURPOSE: To provide additional information related to the ambulance

S FA0, FB0, FB1, FB2, FB3, FA0, HA0, XA0

FB4, FE0

CONDITIONAL NOTE:
NOTES: When used, this Record Type GA0 must have the same
RECORD LAYOUT
Record Type: GA0

GA0 01.0 Record Type 'GA0' X 03 01 03
GA0 02.0 Sequence Number 9 02 04 05
GA0 03.0 Patient Control Number X 17 06 22
GA0 04.0 Reserved Filler X 17 23 39
GA0 05.0 Patient Weight 9 03 40 42
GA0 06.0 Hospital Admit X 01 43 43
GA0 07.0 Type of Transport X 01 44 44
GA0 08.0 Bed Confined-Before X 01 45 45
GA0 09.0 Bed Confined-After X 01 46 46
GA0 10.0 Moved by Stretcher X 01 47 47
GA0 11.0 Unconscious/Shock X 01 48 48
GA0 12.0 Emergency Situation X 01 49 49
GA0 13.0 Physical Restraints X 01 50 50
GA0 14.0 Visible Hemorrhaging X 01 51 51
GA0 15.0 Transported To/For X 01 52 52
GA0 16.0 Medically Necessary X 01 53 53
GA0 17.0 Miles X 04 54 57
GA0 18.0 Origin Information X 40 58 97
GA0 19.0 Destination Information X 40 98 137
GA0 20.0 Purpose of Round Trip X 80 138 217
GA0 21.0 Purpose of Stretcher X 80 218 297
GA0 22.0 Patient Discharged X 01 298 298
GA0 23.0 Patient Admitted X 01 299 299
GA0 24.0 Services Available X 01 300 300
GA0 25.0 Filler - National X 07 301 307
GA0 26.0 Filler - Local X 13 308 320
Emdeon Business Services Technical Specifications NSF Plus GA0 - 01.0
DATA ELEMENT: Record Type 'GA0'
DEFINITION: A field used to identify the "Ambulance Certification" record.
GA0 01.0 X 03 L Spaces 01 03

R R R R R R
CODE VALUES:
VALIDATION: Must contain a value of GA0.

NOTES: Not Applicable
DEFINITION: A sequential from 01-50 assigned to individual records within the

same specific Record type to indicate the sequence of each physical
record.
GA0 02.0 9 02 R Zeroes 04 05

R R R R R R
CODE VALUES: 01-50



GA0 03.0 X 17 L Spaces 06 22

R R R R R R
CODE VALUES:

GA0 04.0 X 17 L Spaces 23 39

R R R R R R
CODE VALUES:
VALIDATION: Not Applicable

None None
DEFINITION: The weight of the patient at time of transport.
GA0 05.0 9 03 R Zeroes 40 42

N N N N N N
CODE VALUES:

None Reject Claim
DATA ELEMENT: Hospital Admit
DEFINITION: A code used to indicate if the patient was admitted to a hospital.
GA0 06.0 X 01 L Spaces 43 43

N N N N N N
CODE VALUES: N Patient not admitted.

Y Patient admitted.

None None
DATA ELEMENT: Type of Transport
DEFINITION: A code used to indicate the type of transport.
GA0 07.0 X 01 L Spaces 44 44

N N N N N N
CODE VALUES: I Initial Trip

R Return Trip
T Transfer Trip
X Round Trip

None None
DATA ELEMENT: Bed Confined-Before
DEFINITION: A code used to indicate whether the patient was bed confined before
the ambulance service.
GA0 08.0 X 01 L Spaces 45 45

N N N N N N
CODE VALUES: N Patient was not bed confined

Y Patient was bed confined

None None
DATA ELEMENT: Bed Confined-After
DEFINITION: A code used to indicate whether the patient was bed confined after
the ambulance transport.
GA0 09.0 X 01 L Spaces 46 46

N N N N N N
CODE VALUES: N Patient was not bed confined

Y Patient was bed confined

None None
DATA ELEMENT: Moved by Stretcher
DEFINITION: A code used to indicate whether the patient was moved by stretcher.
GA0 10.0 X 01 L Spaces 47 47

N N N N N N
CODE VALUES: N Patient was not moved by stretcher

Y Patient was moved by stretcher

None None
DATA ELEMENT: Unconscious/Shock
DEFINITION: A code used to indicate whether the patient was unconscious or in

shock.
GA0 11.0 X 01 L Spaces 48 48

N N N N N N
CODE VALUES: N No, the patient was not unconscious or in

shock
Y Yes, the patient was unconscious or in shock

None None
DATA ELEMENT: Emergency Situation
DEFINITION: A code used to indicate whether the patient was transported in an

emergency situation.
GA0 12.0 X 01 L Spaces 49 49

N N N N N N
CODE VALUES: N Not an emergency situation

Y Emergency situation

None None
DATA ELEMENT: Physical Restraints
DEFINITION: A code used to indicate whether the patient had to be physically

restrained.
GA0 13.0 X 01 L Spaces 50 50

N N N N N N
CODE VALUES: N No physical restraints used

Y Physical restraints needed

None None
DATA ELEMENT: Visible Hemorrhaging
DEFINITION: A code used to indicate whether the patient had visible

hemorrhaging.
GA0 14.0 X 01 L Spaces 51 51

N N N N N N
CODE VALUES: N No visible hemorrhaging noted

Y Visible hemorrhaging noted

None None
DATA ELEMENT: Transported To/For
DEFINITION: A code used to indicate whether the patient was transported to the
nearest facility or for other considerations.
GA0 15.0 X 01 L Spaces 52 52

N N N N N N
CODE VALUES: A Patient was transported to nearest facility for

care of symptoms, complaints, or both
B Patient was transported for the benefit of a
preferred physician
C Patient was transported for the nearness of
family members
D Patient was transported for the care of a
specialist or for availability of specialized
equipment

None None
DATA ELEMENT: Medically Necessary
DEFINITION: A code used to indicate whether the ambulance service was

medically necessary.
GA0 16.0 X 01 L Spaces 53 53

N N N N N N
CODE VALUES: N Not medically necessary

Y Medically necessary

None None
DATA ELEMENT: Miles
DEFINITION: Number of miles traveled during this ambulance service.
GA0 17.0 X 04 L Spaces 54 57

N N N N N N
CODE VALUES:

None None
DATA ELEMENT: Origin Information
DEFINITION: Free form description to indicate address, etc.
GA0 18.0 X 40 L Spaces 58 97

N N N N N N
CODE VALUES:

None None
DATA ELEMENT: Destination Information
DEFINITION: Free form description to indicate address, etc.
GA0 19.0 X 40 L Spaces 98 137

N N N N N N
CODE VALUES:

None None
DATA ELEMENT: Purpose of Round Trip
DEFINITION: Free form description to indicate the purpose for the round trip
ambulance service.
GA0 20.0 X 80 L Spaces 138 217

N N N N N N
SITUATIONAL NOTE: Should be entered if TYPE OF TRANSPORT (fld-07.0) contains a

value of 'X'.
CODE VALUES:

None None
DATA ELEMENT: Purpose of Stretcher
DEFINITION: Free form description to indicate the purpose for the usage of a
stretcher during the ambulance service.
GA0 21.0 X 80 L Spaces 218 297

N N N N N N
CODE VALUES:

None None
DATA ELEMENT: Patient Discharged
DEFINITION: A code used to indicate if the patient was discharged from the first
facility.
GA0 22.0 X 01 L Spaces 298 298

N N N N N N
CODE VALUES: N No, patient was not discharged

Y Yes, patient was discharged

None None
DATA ELEMENT: Patient Admitted
DEFINITION: A code used to indicate if the patient was admitted to the second
facility.
GA0 23.0 X 01 L Spaces 299 299

N N N N N N
CODE VALUES: N No, the patient was not admitted

Y Yes, the patient was admitted

None None
DATA ELEMENT: Services Available
DEFINITION: A code used to indicate if the services provided at the second facility
were available at the first facility.
GA0 24.0 X 01 L Spaces 300 300

N N N N N N
CODE VALUES: N No, the services were not available at the first
facility
Y Yes, the services were available at the first
facility

None None
GA0 25.0 X 07 L Spaces 301 307

R R R R R R
CODE VALUES:

None None
GA0 26.0 X 13 L Spaces 308 320

R R R R R R
CODE VALUES:

None None
RECORD SUMMARY
RECORD TYPE: GC0
RECORD NAME: Chiropractic Certification Record
RECORD PURPOSE: To provide additional information related to the chiropractic


FB3, FB4, FE0

than fields GC0-01.0, GC0-02.0, GC0-03.0 or filler.
NOTES: When used, this Record Type GC0 must have the same
FB2, FB3, FB4 or FE0 record related to this service.
RECORD LAYOUT
Record Type: GC0

GC0 01.0 Record Type 'GC0' X 03 01 03
GC0 02.0 Sequence Number 9 02 04 05
GC0 03.0 Patient Control Number X 17 06 22
GC0 04.0 Reserved Filler X 17 23 39
GC0 05.0 Initial Treatment Date 9 08 40 47
GC0 06.0 Date of Last X-Ray 9 08 48 55
GC0 07.0 Number in Series X 07 56 62
GC0 08.0 Level of Subluxation X 07 63 69
GC0 09.0 Treatment Months/Years for this Series X 03 70 72
GC0 10.0 Number of Treatments - This Month X 02 73 74
GC0 11.0 Nature of Condition X 01 75 75
GC0 12.0 Date of Acute Manifestation 9 08 76 83
GC0 13.0 Complication Indicator X 01 84 84
GC0 14.0 Symptoms Description X 160 85 244
GC0 15.0 X-Ray Indicator X 01 245 245
GC0 16.0 Filler - National X 37 246 282
GC0 17.0 Filler - Local X 38 283 320
Emdeon Business Services Technical Specifications NSF Plus GC0 - 01.0
DATA ELEMENT: Record Type 'GC0'
DEFINITION: A field used to identify the "Chiropractic Certification" record.
GC0 01.0 X 03 L Spaces 01 03

N N N N N R
CODE VALUES:
VALIDATION: Must contain a value of GC0.


GC0 02.0 9 02 R Zeroes 04 05

N N N N N R
CODE VALUES: 01-50



GC0 03.0 X 17 L Spaces 06 22

N N N N N R
CODE VALUES:

GC0 04.0 X 17 L Spaces 23 39

N N N N N R
CODE VALUES:

None None
DATA ELEMENT: Initial Treatment Date
DEFINITION: The date that the patient initially sought treatment for this condition.
GC0 05.0 9 08 R Zeroes 40 47

N N N N N D
CODE VALUES:

None Reject Claim
DATA ELEMENT: Date of Last X-Ray
DEFINITION: The date of the patient's last X-Ray.
GC0 06.0 9 08 R Zeroes 48 55

N N N N N D
CODE VALUES:

None Reject Claim
NOTES: Enter the date of most recent x-ray done for the patient. Must be
proximate to the initial date of the treatment period for this series of
manipulations.
DATA ELEMENT: Number in Series
DEFINITION: The number in the series of treatment being submitted on this

service line.
GC0 07.0 X 07 L Spaces 56 62

N N N N N D
CODE VALUES:
VALIDATION: Position 59 may only contain a dash (-).
The remaining positions may only contain a value 0-9.

None None
NOTES: The number to the left side of the dash (-) represents the number of
treatments currently rendered. The number to the right of the dash
represents the total number of treatments prescribed, (e.g., 004-
020. This is the fourth treatment rendered within a prescribed
twenty treatments).
DATA ELEMENT: Level of Subluxation
DEFINITION: A code or codes to identify the specific level of subluxation.
GC0 08.0 X 07 L Spaces 63 69

N N N N N S
CODE VALUES: C1 Cervical 1

C2 Cervical 2
C3 Cervical 3
C4 Cervical 4
C5 Cervical 5
C6 Cervical 6
C7 Cervical 7
CO Coccyx
IL Ilium
L1 Lumbar 1
L2 Lumbar 2
L3 Lumbar 3
L4 Lumbar 4
L5 Lumbar 5
OC Occiput
SA Sacrum
T1 Thoracic 1
T10 Thoracic 10
T11 Thoracic 11
T12 Thoracic 12
T2 Thoracic 2
T3 Thoracic 3
T4 Thoracic 4
T5 Thoracic 5
T6 Thoracic 6
T7 Thoracic 7
T8 Thoracic 8
T9 Thoracic 9
To report consecutive codes, position 66 must contain a dash (-);

otherwise, should contain a space.

None None
NOTES: Enter specific level of subluxation per x-ray report and beneficiary
complaint/physical findings.
DATA ELEMENT: Treatment Months/Years for this Series
DEFINITION: The months of years involved in this series of treatments.
GC0 09.0 X 03 L Spaces 70 72

N N N N N S
CODE VALUES: 01-99 Position 71-72

M or Y Position 70 - Months/Years
VALIDATION: Positions 71-72 may only contain a value of 01-12 if position 70

contains a value of M.
Positions 71-72 may only contain a value of 01-99 if position 70


None Reject Claim
DATA ELEMENT: Number of Treatments - This Month
DEFINITION: The number of treatments rendered to the patient during this

current month.
GC0 10.0 X 02 L Spaces 73 74

N N N N N D
CODE VALUES:

None None
DATA ELEMENT: Nature of Condition
DEFINITION: A code to indicate the nature of the patient's condition.
GC0 11.0 X 01 L Spaces 75 75

N N N N N S
CODE VALUES: A Acute Condition

C Chronic Condition
D* Non-Acute Condition
E* Non-Life Threatening
F* Routine
G* Symptomatic
M Acute Manifestation of a Chronic Condition

None None
NOTES: This field validates x-ray date and initiation of treatment for
proximation and reimbursement. Failure to provide necessary
information could result in denial of payment.
DATA ELEMENT: Date of Acute Manifestation
DEFINITION: The date of acute manifestation of a chronic condition.
GC0 12.0 9 08 R Zeroes 76 83

N N N N N S
SITUATIONAL NOTE: Should be entered if NATURE OF CONDITION (fld-11.0) contains a

value of M.
CODE VALUES:

None Reject Claim
DATA ELEMENT: Complication Indicator
DEFINITION: A code to indicate whether the patient's condition is complicated or

uncomplicated.
GC0 13.0 X 01 L Spaces 84 84

N N N N N S
SITUATIONAL NOTE: Should be entered if utilization parameters have been exceeded.
CODE VALUES: C Complicated Condition

U Uncomplicated Condition
VALIDATION: If entered, should be a code from the above list.

None None
DATA ELEMENT: Symptoms Description
DEFINITION: A free form description of the patient's condition.
GC0 14.0 X 160 L Spaces 85 244

N N N N N S
SITUATIONAL NOTE: Should be entered if utilization parameters have been exceeded.
CODE VALUES:

None None
NOTES: Information entered in this field should include initial beneficiary

complaints and physical findings pertinent to those complaints.
Should be indicative of subluxation and symptomology.
Additional, x-ray results may be entered in Record Type HA0 (fld-

05.0) to support the treatment plan.
DATA ELEMENT: X-Ray Indicator
DEFINITION: An indicator of whether X-rays are on file for chiropractic spinal

manipulation.
GC0 15.0 X 01 L Spaces 245 245

N N N N N S
SITUATIONAL NOTE: Should be entered of required by payer.
CODE VALUES: N No, X-Rays are not Maintained and not

Available for Review
Y Yes, X-Rays are on File, Maintained and Ready
for Review

None None
GC0 16.0 X 37 L Spaces 246 282

N N N N N R
CODE VALUES:

None None
GC0 17.0 X 38 L Spaces 283 320

N N N N N R
CODE VALUES:

None None
RECORD SUMMARY
RECORD TYPE: GD@
RECORD NAME: Durable Medical Equipment (DME) Information
RECORD PURPOSE: To provide information relevant to the sale and/or rental of

durable medical equipment.

FB3, FB4, FE0

than fields GD@-01.0, GD@-02.0, GD@-03.0 or filler.
Must be entered if this is the initial claim for the rental/sale

of durable medical equipment.
May not be entered for Medicare claims.
NOTES: When used, this Record Type GD@ must have the same
FB3, FB4 or FE0 record related to this service.
RECORD LAYOUT
Record Type: GD@

GD@ 01.0 Record Type 'GD@' X 03 01 03
GD@ 02.0 Sequence Number 9 02 04 05
GD@ 03.0 Patient Control Number X 17 06 22
GD@ 04.0 Line Item Control Number X 17 23 39
GD@ 05.0 Length of Medical Necessity 9 03 40 42
GD@ 06.0 DME Purchase Price 9v99 06 43 48
GD@ 07.0 Purchased Equipment Indicator X 01 49 49
GD@ 08.0 DME Rental Unit Price Indicator X 01 50 50
GD@ 09.0 DME Rental Price 9v99 06 51 56
GD@ 10.0 Procedure Code X 05 57 61
GD@ 11.0 Prescription/Medical Necessity Documentation Indicator X 01 62 62
GD@ 12.0 Equipment Warranty Indicator X 01 63 63
GD@ 13.0 Comments X 100 64 163
GD@ 14.0 Filler X 157 164 320
Emdeon Business Services Technical Specifications NSF Plus GD@ - 01.0
DATA ELEMENT: Record Type 'GD@'
DEFINITION: A field used to identify the "Durable Medical Equipment (DME)

Information" record.
GD@ 01.0 X 03 L Spaces 01 03

R R R R R N
CODE VALUES:
VALIDATION: Must contain a value of GD@.


within the same specific Record Type to indicate the sequence of
GD@ 02.0 9 02 R Zeroes 04 05

R R R R R N
CODE VALUES: 01-50



GD@ 03.0 X 17 L Spaces 06 22

R R R R R N
CODE VALUES:

GD@ 04.0 X 17 L Spaces 23 39

S S S S S N
CODE VALUES:


None None
DATA ELEMENT: Length of Medical Necessity
DEFINITION: The period of medical necessity, in days, for Durable Medical

Equipment as established by the prescribing physician.
GD@ 05.0 9 03 R Zeroes 40 42

R R R R R N
CODE VALUES:

DATA ELEMENT: DME Purchase Price
DEFINITION: The price at which the supplier sells this piece of equipment.
GD@ 06.0 9v99 06 R Zeroes 43 48

R R R R R N
CODE VALUES:

DATA ELEMENT: Purchased Equipment Indicator
DEFINITION: A code used to indicate whether the DME item was purchased new or
purchased used.
GD@ 07.0 X 01 L Spaces 49 49

S S S S S N
SITUATIONAL NOTE: Must be entered if TYPE OF SERVICE CODE (RT FA0, fld-08.0)
contains a value of D, for the purchased DME.
CODE VALUES: N Purchased new

U Purchased used
VALIDATION: If entered, must contain a value code from the above list.

DATA ELEMENT: DME Rental Unit Price Indicator
DEFINITION: A code used to indicate how the total DME Rental Price is being billed.
GD@ 08.0 X 01 L Spaces 50 50

S S S S S N
SITUATIONAL NOTE: Must be entered if TYPE OF SERVICE CODE (RT-FA0, fld-08.0)

contains a value of R.
CODE VALUES: D DME is rented on a daily basis

M DME is rented on a monthly basis
W DME is rented on a weekly basis

NOTES: DME RENTAL UNIT PRICE INDICATOR should be entered if DME

RENTAL PRICE (fld-09.0) has been entered.
DATA ELEMENT: DME Rental Price
DEFINITION: The total monthly rental price for this piece of equipment.
GD@ 09.0 9v99 06 R Zeroes 51 56

S S S S S N
SITUATIONAL NOTE: Must be entered if DME RENTAL UNIT PRICE INDICATOR (fld-07.0)
has been entered.
CODE VALUES:

DME RENTAL PRICE should be entered if the durable medical

equipment can be either rented or purchased.
DATA ELEMENT: Procedure Code
DEFINITION: A code from the HCFA uniform classification system used to identify
the procedure performed, medical service rendered, or supplies
furnished.
GD@ 10.0 X 05 L Spaces 57 61

R R R R R N
CODE VALUES:
VALIDATION: Must be a valid HCPC/CPT procedure code.

DATA ELEMENT: Prescription/Medical Necessity Documentation Indicator
DEFINITION: A code used to indicate that the DME provider has the prescriptive
statement on file containing the diagnosis, length of medical
necessity and equipment prescribed by the referring physician.
GD@ 11.0 X 01 L Spaces 62 62

R R R R R N
CODE VALUES: N No, the Provider does not have the

Prescriptive Statement on File
Y Yes, the Provider has the Prescriptive
Statement on File

DATA ELEMENT: Equipment Warranty Indicator
DEFINITION: A code used to indicate whether the purchased equipment is under

warranty.
GD@ 12.0 X 01 L Spaces 63 63

D D D D D N
CODE VALUES: N Purchased equipment is not under warranty

Y Purchased equipment under warranty

None Reject Claim
DATA ELEMENT: Comments
DEFINITION: A free form area designed to be used in those situations where

supplementary data would be helpful in processing this claim.
GD@ 13.0 X 100 L Spaces 64 163

O O O O O N
SITUATIONAL NOTE: Should be entered when supplementary information would be

helpful in processing this claim.
CODE VALUES:

None None
GD@ 14.0 X 157 L Spaces 164 320

R R R R R N
CODE VALUES:

None None
RECORD SUMMARY
RECORD TYPE: GU0
RECORD NAME: "DMEPOS ITEMS" Certification Record
RECORD PURPOSE: To provide information regarding certification of medical

necessity for DMEPOS items.

FB3, FB4

than fields GU0-01.0, GU0-02.0, GU0-03.0 or filler.

certification when billing for DMEPOS ITEMS on Medicare
Claims.
NOTES: When used, this Record Type GU0 must have the same
See Exhibit 11 (NSF GU0 Field to DMERC Form Question

Matrix) to determine appropriate placement of DMERC form
responses for Record Type GU0 (flds-26.0-70.0).
RECORD LAYOUT
Record Type: GU0

GU0 01.0 Record Type 'GU0' X 03 01 03
GU0 02.0 Sequence Number 9 02 04 05
GU0 03.0 Patient Control Number X 17 06 22
GU0 04.0 Certification Type X 01 23 23
GU0 05.0 Place of Service X 02 24 25
GU0 06.0 Replacement Item X 01 26 26
GU0 07.0 HCPCS Procedure Code X 05 27 31
GU0 08.0 HCPCS Modifier X 02 32 33
GU0 09.0 Warranty Reply X 01 34 34
GU0 10.0 Warranty Length X 02 35 36
GU0 11.0 Warranty Type X 01 37 37
GU0 16.0 Patient Height 9 02 58 59
GU0 17.0 Patient Weight 9 03 60 62
GU0 18.0 Date of Last Medical Exam 9 08 63 70
GU0 19.0 Initial Date 9 08 71 78
GU0 20.0 Revision or Recertification Date 9 08 79 86
GU0 21.0 Length of Need 9 02 87 88
GU0 22.0 Date of Physician's Signature 9 08 89 96
GU0 23.0 Ordering Physician's Telephone Number X 10 97 106
GU0 24.0 Certification on File X 01 107 107
GU0 25.0 Certification Form Number 9v99 04 108 111
GU0 26.0 Reply ALN L01 N01 X 01 112 112
GU0 27.0 Reply ALN L01 N02 X 01 113 113
GU0 28.0 Reply ALN L01 N03 X 01 114 114
GU0 29.0 Reply ALN L01 N04 X 01 115 115
GU0 30.0 Reply ALN L01 N05 X 01 116 116
GU0 31.0 Reply ALN L01 N06 X 01 117 117
GU0 32.0 Reply ALN L01 N07 X 01 118 118
GU0 33.0 Reply ALN L01 N08 X 01 119 119
GU0 34.0 Reply ALN L01 N09 X 01 120 120
GU0 35.0 Reply ALN L01 N10 X 01 121 121
GU0 36.0 Reply ALN L01 N11 X 01 122 122
GU0 37.0 Reply ALN L01 N12 X 01 123 123
GU0 38.0 Reply ALN L01 N13 X 01 124 124
GU0 39.0 Reply ALN L01 N14 X 01 125 125
GU0 40.0 Reply ALN L01 N15 X 01 126 126
GU0 41.0 Reply ALN L01 N16 X 01 127 127
GU0 42.0 Reply ALN L01 N17 X 01 128 128
GU0 43.0 Reply ALN L01 N18 X 01 129 129
GU0 44.0 Reply ALN L01 N19 X 01 130 130
GU0 45.0 Reply ALN L01 N20 X 01 131 131
GU0 46.0 Reply ALN L01 N21 X 01 132 132
GU0 47.0 Reply ALN L01 N22 X 01 133 133
GU0 48.0 Reply ALN L01 N23 X 01 134 134
GU0 49.0 Reply ALN L01 N24 X 01 135 135
GU0 50.0 Reply ALN L05 N01 X 05 136 140
GU0 51.0 Reply ALN L05 N02 X 05 141 145
GU0 52.0 Reply ALN L05 N03 X 05 146 150
GU0 53.0 Reply ALN L08 N01 9 08 151 158
GU0 54.0 Reply ALN L08 N02 9 08 159 166
GU0 55.0 Reply ALN L08 N03 9 08 167 174
GU0 56.0 Reply ALN L08 N04 9 08 175 182
GU0 57.0 Reply ALN L20 N01 X 20 183 202
GU0 58.0 Reply ALN L30 N01 X 30 203 232
GU0 58.1 Reply ALN L30 N02 X 30 233 262
GU0 59.0 Reply NUM L01 N01 9 01 263 263
GU0 60.0 Reply NUM L01 N02 9 01 264 264
GU0 61.0 Reply NUM L01 N03 9 01 265 265
GU0 62.0 Reply NUM L04 N01 9 04 266 269
GU0 63.0 Reply NUM L04 N02 9 04 270 273
GU0 64.0 Reply NUM L04 N03 9 04 274 277
GU0 65.0 Reply NUM L04 N04 9 04 278 281
GU0 66.0 Reply NUM L04 N05 9 04 282 285
GU0 67.0 Reply NUM L04 N06 9 04 286 289
GU0 68.0 Reply NUM L04 N07 9 04 290 293
GU0 69.0 Reply PCT L04 N01 9v9 04 294 297
GU0 70.0 Reply PCT L04 N02 9v9 04 298 301
GU0 71.0 Reply PCT L04 N03 9v9 04 302 305
GU0 72.0 DMERC CMN Indicator X 02 306 307
GU0 73.0 Filler - National X 06 308 313
GU0 74.0 Filler - Local X 07 314 320
Emdeon Business Services Technical Specifications NSF Plus GU0 - 01.0
DATA ELEMENT: Record Type 'GU0'
DEFINITION: A field used to identify the "Universal DMEPOS Item Certification"

record.
GU0 01.0 X 03 L Spaces 01 03

N N N N N R
CODE VALUES:
VALIDATION: Must contain a value of GU0.


GU0 02.0 9 02 R Zeroes 04 05

N N N N N R
CODE VALUES: 01-50
VALIDATION: Must be identical to the SEQUENCE NUMBER (fld-02.0) submitted



GU0 03.0 X 17 L Spaces 06 22

N N N N N R
CODE VALUES:
Must be identical to the PATIENT CONTROL NUMBER in Record

Type CA0 (fld-03.0).

DATA ELEMENT: Certification Type
DEFINITION: A code used to identify the type of durable medical equipment

certification.
GU0 04.0 X 01 L Spaces 23 23

N N N N N R
CODE VALUES: 1 Initial Certification

2 Revision
3 Renewal

NOTES: This code value should correspond to the certification type box
checked in Section A of the DMERC CMN form.
DATA ELEMENT: Place of Service
DEFINITION: The code that identifies where the service was performed.
GU0 05.0 X 02 L Spaces 24 25

N N N N N R

Codes are maintained by the Centers for
Medicare & Medicaid Services.
The Place of Service Code List is located at:
http://www.cms.hhs.gov/MedHCPCSGenInfo/
Must match the PLACE OF SERVICE submitted in the preceding


© 2002-2003, Emdeon Corporation. All Rights Reserved. Version 2.01 July 2006
DATA ELEMENT: Replacement Item
DEFINITION: Indicates that this certification is for an item replacing a previously

purchased item.
GU0 06.0 X 01 L Spaces 26 26

N N N N N S
SITUATIONAL NOTE: Must be entered for all CMNs except DMERC form 08.02.
CODE VALUES: N No
Y Yes

DATA ELEMENT: HCPCS Procedure Code
DEFINITION: The HCPCS code describing the certified item.
GU0 07.0 X 05 L Spaces 27 31

N N N N N R

Level II (HCPCS)
VALIDATION: Must be a valid HCPCS/CPT procedure code.
Must match HCPCS PROCEDURE CODE submitted in the preceding


DATA ELEMENT: HCPCS Modifier
DEFINITION: The code that identifies special circumstances related to the

equipment or supply.
GU0 08.0 X 02 L Spaces 32 33

N N N N N S

CODE VALUES:
VALIDATION: If entered, must match HCPCS MODIFIER 1 submitted in the


None Reject Claim
DATA ELEMENT: Warranty Reply
DEFINITION: Code indicating whether the item is covered by warranty.
GU0 09.0 X 01 L Spaces 34 34

N N N N N S
CODE VALUES: D Does not apply

N No
Y Yes

None Reject Claim
NOTES: Form Location:

All DMERC CMNs, Section A, except form 05.02 (not currently in use)
and 08.02.
This response is implied on hardcopy CMNs when the warranty

length and type are completed. However, it must be indicated
electronically.
DATA ELEMENT: Warranty Length
DEFINITION: Length of warranty period in months.
GU0 10.0 X 02 L Spaces 35 36

N N N N N S
SITUATIONAL NOTE: Must be entered if WARRANTY REPLY (fld-09.0) is equal to 'Y'. Not
required for DMERC forms 05.02 and 08.02.
CODE VALUES: 01-99


All DMERC CMNs, Section A, except 05.02 and 08.02.
DATA ELEMENT: Warranty Type
DEFINITION: Code indicating the warranty type and coverage.
GU0 11.0 X 01 L Spaces 37 37

N N N N N S
SITUATIONAL NOTE: Must be entered if WARRANTY REPLY (fld-09.0) is equal to 'Y'.

Must be blank for DMERC forms 05.02 and 08.02.
CODE VALUES: 1 Full replacement

2 Pro-rated replacement
3 Parts and Labor
4 Parts only


All DMERC CMNs, Section A, except 05.02 and 08.02.
DATA ELEMENT: Diagnosis Code-1
DEFINITION: The ICD-9-CM diagnosis code identifying a diagnosed medical

condition resulting in the medical necessity for this item.
GU0 12.0 X 05 L Spaces 38 42

N N N N N R
CODE VALUES:
VALIDATION: Must be a valid ICD-9-CM code.
Must be the most specific/precise 3 digit, 4 digit, or 5 digit code

allowed for in the ICD-9-CM coding format.
Must match PRIMARY DIAGNOSIS CODE submitted in the preceding

Record Type EA0 (fld-30.0).


All DMERC CMNs, Section B
Decimal points are implied and should not be included in the

diagnosis code.

GU0 13.0 X 05 L Spaces 43 47

N N N N N N
CODE VALUES:
VALIDATION: If entered, must be a valid ICD-9-CM code.
If entered, must be the most specific/precise 3 digit, 4 digit, or 5

If entered must match SECONDARY DIAGNOSIS CODE submitted in

the preceding Record Type EA0 (fld-31.0).

None Reject Claim


diagnosis code.

GU0 14.0 X 05 L Spaces 48 52

N N N N N N
CODE VALUES:

If entered must match TERTIARY DIAGNOSIS CODE submitted in

the preceding Record Type EA0 (fld-32.0).

None Reject Claim


diagnosis code.

GU0 15.0 X 05 L Spaces 53 57

N N N N N N
CODE VALUES:

If entered must match OTHER DIAGNOSIS CODE submitted in the

preceding Record Type EA0 (fld-33.0).

None Reject Claim


diagnosis code.
DATA ELEMENT: Patient Height
DEFINITION: Patient height in inches.
GU0 16.0 9 02 R Zeroes 58 59

N N N N N S
SITUATIONAL NOTE: Must be entered for DMERC form 10.02
CODE VALUES:


All DMERC CMNs, except 08.02.
DEFINITION: Patient weight in pounds.
GU0 17.0 9 03 R Zeroes 60 62

N N N N N S
SITUATIONAL NOTE: Must be entered for DMERC form 02.02 and 10.02
CODE VALUES:
If entered, should match the PATIENT WEIGHT submitted in the

preceding Record Type CA0 (fld-30.0).


All DMERC CMNs, except 08.02.
DATA ELEMENT: Date of Last Medical Exam
DEFINITION: The date that the patient was last seen by the certifying physician.
GU0 18.0 9 08 R Zeroes 63 70

N N N N N N
CODE VALUES:

None Reject Claim
DATA ELEMENT: Initial Date
DEFINITION: The beginning date of certified period of medical necessity.
GU0 19.0 9 08 R Zeroes 71 78

N N N N N R
CODE VALUES:


All DMERC CMNs, Section A
DATA ELEMENT: Revision or Recertification Date
DEFINITION: The effective date of the revision or recertification provided by the

certifying physician.
GU0 20.0 9 08 R Zeroes 79 86

N N N N N S
SITUATIONAL NOTE: Must be entered if CERTIFICATION TYPE (fld-04.0) contains a value

of 2 or 3.
CODE VALUES:

AA0, fld-15.0).
If entered, must not be less than the corresponding SERVICE

FROM DATE (RT FA0,fld-05.0).


All DMERC CMNs, Section A
DATA ELEMENT: Length of Need
DEFINITION: The number of months of medical necessity certified by the physician.
GU0 21.0 9 02 R Zeroes 87 88

N N N N N S
SITUATIONAL NOTE: Must be entered for all DMERC forms except form 08.02.
CODE VALUES: 01-99


All DMERC CMNs, Section B, except 08.02 and 09.03.
DATA ELEMENT: Date of Physician's Signature
DEFINITION: The date the certificate of medical necessity was completed and
signed by the ordering physician.
GU0 22.0 9 08 R Zeroes 89 96

N N N N N R
CODE VALUES:


All DMERC CMNs, Section D.
DATA ELEMENT: Ordering Physician's Telephone Number
DEFINITION: The telephone number of the ordering physician who prescribed this
item.
GU0 23.0 X 10 L Spaces 97 106

N N N N N R
CODE VALUES:

Reject Claim None

All DMERC CMNs, Section A.
DATA ELEMENT: Certification on File
DEFINITION: The supplier's guarantee that a copy of the paper certification,

signed and dated by the physician, is on file at the supplier's office.
GU0 24.0 X 01 L Spaces 107 107

N N N N N R
CODE VALUES: N No
Y Yes

NOTES: A "N" response will cause the claim to reject as there must be a
signed, dated CMN on file with the supplier in order for the claim to
be adjudicated.
DATA ELEMENT: Certification Form Number
DEFINITION: Form Number of the DMERC Certification of Medical Necessity used

as the source of input to this DMEPOS Certification record.
GU0 25.0 9v99 04 R Zeroes 108 111

N N N N N R
CODE VALUES: 01.02 Hospital Bed and Support Services

02.03 Manual and Motorized Wheelchairs
03.02 Continuous Positive Airway Pressure System
04.03 Lymphedema Pump, Osteogenesis Stimulator
(Obsolete 1/1/07)
04.04 Pneumatic Compression Devices and
Osteogenesis Stimulators (Effective 10/1/06)
05.02 Reserved for future use
06.02 TENS (Obsolete 1/1/07)
06.03 Transcutaneous Electrical Nerve Stimulator
(TENS) (Effective 10/1/06)
07.02 Seat Lift Mechanisms and Power Operated
Vehicle (POV) (Obsolete 1/1/07)
07.03 Seat Lift Mechanisms (Effective 10/1/06)
08.02 Immunosuppressive Drugs
09.02 External Infusion Pump (Obsolete 1/1/07)
09.03 External Infusion Pumps (Effective 10/1/06)
10.02 Parenteral and Enteral Nutrition (Obsolete
1/1/07)
10.03 Enteral & Parenteral Nutrition (Effective
10/1/06)
Must be a valid code from the above list.

DMERC Certification Form
DATA ELEMENT: Reply ALN L01 N01
DEFINITION: Reply to the first question on any DMERC Certification of Medical

necessity for that requires a one position alphanumeric response.
GU0 26.0 X 01 L Spaces 112 112

N N N N N S

N No
Y Yes

None Reject Claim

DMERC 01.02, Question 1
DMERC 04.03, Question 1 (Lymphedema Pumps)
DEFINITION: Reply to the second question on any DMERC Certification of Medical

GU0 27.0 X 01 L Spaces 113 113

N N N N N S

N No
Y Yes

None Reject Claim

DEFINITION: Reply to the third question on any DMERC Certification of Medical

GU0 28.0 X 01 L Spaces 114 114

N N N N N S
CODE VALUES: 1 Headache (DMERC form 06.02)

1 Central Line (DMERC form 10.02)
2 Visceral abdominal pain (DMERC form 06.02)
3 Pelvic Pain (DMERC form 06.02)
3 Hemodialysis Access Line (DMERC form 10.02)
4 Temporomandibular Joint (TMJ) Pain (DMERC
form 06.02)
5 None of the above (DMERC form 06.02)
7 Peripherally Inserted Catheter (PIC) Line
(DMERC form 10.02)
D Does not Apply (DMERC forms 01.02, 02.03,
04.03 07.02 and 07.03)
N No (DMERC forms 01.02, 02.03, 04.03, 04.04,
06.03, 07.03 and 10.03)
Y Yes (DMERC forms 01.02, 02.03, 04.03,
04.04, 06.03, 07.03 and 10.03)

None Reject Claim

DEFINITION: Reply to the fourth question on any DMERC Certification of Medical

GU0 29.0 X 01 L Spaces 115 115

N N N N N S

N No
Y Yes

None Reject Claim

DEFINITION: Reply to the fifth question on any DMERC Certification of Medical

GU0 30.0 X 01 L Spaces 116 116

N N N N N S

N No
Y Yes

None Reject Claim

DMERC 02.03, Question 6 (Motorized Wheelchairs)
DEFINITION: Reply to the sixth question on any DMERC Certification of Medical

GU0 31.0 X 01 L Spaces 117 117

N N N N N S
CODE VALUES: 1 Daily (DMERC form 06.02)

2 3 to 6 days per week (DMERC form 06.02)
3 2 or less days per week (DMERC form 06.02)
D Does not Apply (DMERC forms 01.02, 02.03,
04.03, 07.02)
N No (DMERC forms 01.02, 02.03, 04.03, 07.02,
and 10.02)
Y Yes (DMERC forms 01.02, 02.03, 04.03,
07.02, and 10.02)

None Reject Claim

DMERC 02.03, Question 7 (Motorized Wheelchairs)
DMERC 04.03, Question 6A (Osteogenesis Stimulator)
DEFINITION: Reply to the seventh question on any DMERC Certification of Medical

GU0 32.0 X 01 L Spaces 118 118

N N N N N S

N No
Y Yes

None Reject Claim

DMERC 04.03, Question 7A
DEFINITION: Reply to the eighth question on any DMERC Certification of Medical

GU0 33.0 X 01 L Spaces 119 119

N N N N N S
CODE VALUES: 1 Syringe (DMERC form 10.02)

2 Gravity (DMERC form 10.02)
2 2 leads (DMERC form 06.02)
3 Pump (DMERC form 10.02)
4 Does not apply (DMERC form 10.02)
4 4 leads (DMER form 06.02)
D Does not Apply (DMERC form 04.04 and 07.02)
N No (DMERC form 02.03, 04.02, 04.04 and
07.02)
Y Yes (DMERC form 02.03, 04.02, 04.04 and
07.02)

None Reject Claim

DEFINITION: Reply to the ninth question on any DMERC Certification of Medical

GU0 34.0 X 01 L Spaces 120 120

N N N N N S

N No
Y Yes

None Reject Claim

DEFINITION: Reply to the tenth question on any DMERC Certification of Medical

GU0 35.0 X 01 L Spaces 121 121

N N N N N S

N No
Y Yes

None Reject Claim

DEFINITION: Reply to the eleventh question on any DMERC Certification of Medical

GU0 36.0 X 01 L Spaces 122 122

N N N N N S

N No
Y Yes

None Reject Claim

DEFINITION: Reply to the twelfth question on any DMERC Certification of Medical

GU0 37.0 X 01 L Spaces 123 123

N N N N N S

N No
Y Yes

None Reject Claim

DEFINITION: Reply to the thirteenth question on any DMERC Certification of

Medical necessity for that requires a one position alphanumeric
response.
GU0 38.0 X 01 L Spaces 124 124

N N N N N S

N No
Y Yes

None Reject Claim

DEFINITION: Reply to the fourteenth question on any DMERC Certification of

response.
GU0 39.0 X 01 L Spaces 125 125

N N N N N S

N No
Y Yes

None Reject Claim

DEFINITION: Reply to the fifteenth question on any DMERC Certification of Medical

GU0 40.0 X 01 L Spaces 126 126

N N N N N S

N No
Y Yes

None Reject Claim

DEFINITION: Reply to the sixteenth question on any DMERC Certification of

response.
GU0 41.0 X 01 L Spaces 127 127

N N N N N N
CODE VALUES:

None None
NOTES: Reserved for future use.
DEFINITION: Reply to the seventeenth question on any DMERC Certification of

response.
GU0 42.0 X 01 L Spaces 128 128

N N N N N N
CODE VALUES:

None None
DEFINITION: Reply to the eighteenth question on any DMERC Certification of

response.
GU0 43.0 X 01 L Spaces 129 129

N N N N N S

N No
Y Yes

None Reject Claim

DEFINITION: Reply to the nineteenth question on any DMERC Certification of

response.
GU0 44.0 X 01 L Spaces 130 130

N N N N N S

N No
Y Yes

None Reject Claim

DEFINITION: Reply to the twentieth question on any DMERC Certification of

Medical necessity for that requires a one position numeric response.
GU0 45.0 X 01 L Spaces 131 131

N N N N N S
CODE VALUES: 1 Improved

2 Remained Same
3 Worsened

None Reject Claim

DEFINITION: Reply to the twenty-first question on any DMERC Certification of

response.
GU0 46.0 X 01 L Spaces 132 132

N N N N N N
CODE VALUES:

None None
DEFINITION: Reply to the twenty-second question on any DMERC Certification of

response.
GU0 47.0 X 01 L Spaces 133 133

N N N N N N
CODE VALUES:

None None
DEFINITION: Reply to the twenty-third question on any DMERC Certification of

response.
GU0 48.0 X 01 L Spaces 134 134

N N N N N N
CODE VALUES:

None None
DEFINITION: Reply to the twenty-fourth question on any DMERC Certification of

response.
GU0 49.0 X 01 L Spaces 135 135

N N N N N N
CODE VALUES:

None None

necessity for that requires a five position alphanumeric response.
GU0 50.0 X 05 L Spaces 136 140

N N N N N S
CODE VALUES:
VALIDATION: If entered, must be a valid HCPCS code.

None Reject Claim

DMERC 09.02: HCPCS code for drug that requires use of pump.
DMERC 10.03: HCPCS code of product.

GU0 51.0 X 05 L Spaces 141 145

N N N N N S
CODE VALUES:

None None

DMERC 09.03, Question 1B
DMERC 08.02: U.S Postal Service State abbreviation for the state
which the transplant operation was performed.
DMERC 10.03: HCPCS code of product.

GU0 52.0 X 05 L Spaces 146 150

N N N N N N
CODE VALUES:

None None

DMERC 09.03, Question 1C

necessity for that requires an eight position alphanumeric response.
GU0 53.0 9 08 R Zeroes 151 158

N N N N N S
CODE VALUES:

None Reject Claim

DMERC 06.02: Date of surgery resulting in acute post-operative

pain.
DMERC 06.03: Date that patient was re-evaluated at the end of the
trial period.

GU0 54.0 9 08 R Zeroes 159 166

N N N N N S
CODE VALUES:

None Reject Claim

DMERC 06.02: Start date of TENS trial.

DMERC 08.02: Date patient discharged from hospital following
transplant surgery.

GU0 55.0 9 08 R Zeroes 167 174

N N N N N S
CODE VALUES:

None Reject Claim

DMERC 06.02: Ending date of TENS trial.
DEFINITION: Reply to the fourth question on any DMERC Certification of Medical

GU0 56.0 9 08 R Zeroes 175 182

N N N N N S
CODE VALUES:

None Reject Claim

DMERC 06.02: Date that ordering physician saw and evaluated

patient following TENS unit trial.

necessity for that requires a twenty position alphanumeric response.
GU0 57.0 X 20 L Spaces 183 202

N N N N N S
CODE VALUES:

None None

DMERC 08.02: City where transplant facility located.

DMERC 09.02: Name of drug with non-specific HCPCS code.
DMERC 09.03: Name of drug with non-specific HCPCS code.
DMERC 10.02: Product name.

necessity for that requires a thirty position alphanumeric response.
GU0 58.0 X 30 L Spaces 203 232

N N N N N S
CODE VALUES:

None None

DMERC 08.02: Name of transplant facility (max. 30 characters)

DMERC 09.03: Name of drug for non-specific HCPCS code.
DMERC 10.02: Additional information when required by policy.

necessity for that requires a thirty position alphanumeric response.
GU0 58.1 X 30 L Spaces 233 262

N N N N N S
CODE VALUES:

None None

DMERC 09.03: Name of drug for non-specific HCPCS code.
DATA ELEMENT: Reply NUM L01 N01
DEFINITION: Reply to the first DMERC Certification form question that requires a
one position numeric answer.
GU0 59.0 9 01 R Zeroes 263 263

N N N N N S
CODE VALUES: 1 Headache (DMERC 06.03)

1 Heart (DMERC form 08.02)
1 Intravenous (DMERC 09.03)
1 Stage One (DMERC form 01.02)
1 Syring (DMERC 10.03)
1 External infusion pump - non-disposable
(DMERC form 09.02)
1-7 (DMERC form 10.02)
2 Visceral Abdominal Pain (DMERC 06.03)
2 Gravity (DMERC 10.03)
2 Implantable infusion pump (DMERC form
09.02)
2 Liver (DMERC form 08.02)
2 Stage Two (DMERC form 01.02)
2 Subcutaneous (DMERC 09.03)
3 Epidural (DMERC 09.03)
3 Kidney (DMERC form 08.02)
3 Pelvic Pain (DMERC 06.03)
3 Pump (DMERC 10.03)
3 Stage Three (DMERC form 01.02)
3 Disposable infusion pump (DMERC form 09.02)
4 Bone Marrow (DMERC form 08.02)
4 Oral (DMERC 10.03)
4 Other (DMERC 09.03)
4 Stage Four (DMERC form 01.02)
4 Temporomandibular Joint (TMJ) Pain (DMERC
06.03)
5 Lung (DMERC form 08.02)
5 None of the above (DMERC 06.03)
9 No Ulcer or Pressure Area (DMERC form 01.02)
If entered, must be a valid code from the above list.

None Reject Claim

DMERC 01.02: Stage of pressure area/ulcer #1.

DMERC 06.03: Conditions for which TENS is prescribed.
DMERC 08.02: Transplanted organ code #1.
DMERC 09.02: Type of prescribed pump code.
DMERC 09.03: Route of administration.
DMERC 10.02: Days per week infused.
DMERC 10.03: Method of administration.
DEFINITION: Reply to the second DMERC Certification form question that requires
a one position numeric answer.
GU0 60.0 9 01 R Zeroes 264 264

N N N N N S
CODE VALUES: 1 Intravenous (DMERC form 09.02)

1 Heart (DMERC form 08.02)
1 Continuous (DMERC 09.03)
1-4 (DMERC firm 01.02)
1-7 (DMERC form 10.02 and 10.03)
2 Intermittent (DMERC 09.03)
3 Epidural (DMERC form 09.02)
4 Subcutaneous (DMERC form 09.02)

None Reject Claim


DMERC 10.02: Days per week administered.
DMERC 10.03: Days per week administered.
DEFINITION: Reply to the third DMERC Certification form question that requires a
one position numeric answer.
GU0 61.0 9 01 R Zeroes 265 265

N N N N N S
CODE VALUES: 1 Heart (DMERC form 08.02)

1 Continuous (DMERC form 09.02)
1 Central Line (DMERC 10.03)
1-4 (DMERC form 01.02)
2 Intermittent (DMERC form 09.02)
2 Hemodialysis Access Line (DMERC 10.03)
3 Peritoneal Catheter (DMERC 10.03)
3 Bolus (DMERC form 09.02)

None Reject Claim


four position numeric answer.
GU0 62.0 9 04 R Zeroes 266 269

N N N N N S
CODE VALUES: 0000-9999 DMERC forms 03.02, 08.02, 10.02 and 10.03
0001-0024 DMERC forms 02.03 and 09.02
0001-0099 DMERC forms 04.03, 04.04, 06.02 and 06.03

None Reject Claim

DMERC 04.03, Question 6B (Osteogenesis Stimulators)
DMERC 02.03: Hours per day patient usually spends in the

wheelchair.
DMERC 03.02: Number of episodes apnea lasting more than 10
seconds in seven hours or less.
DMERC 04.03: Number of months prior to ordering device did
patient sustain the fracture.
DMERC 04.04: Number of months prior to ordering device did
patient have the previously failed fusion.
DMERC 06.02: Number of months patient has had intractable pain.
DMERC 06.03: Number of months patient has had intractable pain.
DMERC 08.02: Milligram dosage of each drug administered.
DMERC 09.02: Number of hours of drug infusion per day.
DMERC 10.02: Milliliters per day of amino acid.
DMERC 10.03: Calories per day.
a four position numeric answer.
GU0 63.0 9 04 R Zeroes 270 273

N N N N N S
CODE VALUES: 0000-0999 DMERC form 10.02

0000-9999 DMERC forms 01.02, 08.02 and 10.03
0001-0099 DMERC forms 04.03 and 04.04

None Reject Claim

DMERC 01.02, Question 21D
DMERC 01.02: Maximum length in centimeters of pressure

area/ulcer #1.
DMERC 04.03: Number of months, prior to ordering the device, did
the patient have the fusion (other than spine).
the patient have the fusioin.
DMERC 08.02: Times per day of drug administration.
DMERC 10.02: Grams of protein per day.
GU0 64.0 9 04 R Zeroes 274 277

N N N N N S
CODE VALUES: 0000-9999 DMERC forms 01.02, 10.02 and 10.03

0001-0099 DMERC form 04.03 and 04.04

None Reject Claim

DMERC 01.02, Question 21G
DMERC 01.02: Maximum width in centimeters of pressure

area/ulcer #1.
the patient have the spinal fusion.
the patient have repeat fusion.
DMERC 10.02: Milliliters per day of Dextrose.
DMERC 10.03: Milliiters per day of Amino Acid.
DEFINITION: Reply to the fourth DMERC Certification form question that requires a
GU0 65.0 9 04 R Zeroes 278 281

N N N N N S

0000-9999 DMERC forms 01.02 and 10.02
0001-0099 DMERC forms 04.03 and 04.04

None Reject Claim

DMERC 01.02, Question 21E
DMERC 10.02, Question 4F

area/ulcer #2.
the patient have the repeat fusion.
the patient have a previously failed fusion.
DMERC 10.02: Milliliters per day of lipids.
DMERC 10.03: Grams per day of Protein.
DEFINITION: Reply to the fifth DMERC Certification form question that requires a
GU0 66.0 9 04 R Zeroes 282 285

N N N N N S

0000-9999 DMERC forms 01.02 and 10.03
0001-0099 DMERC form 04.03

None Reject Claim

DMERC 01.02, Question 21H

area/ulcer #2.
the patient have the previouly failed fusion.
DMERC 10.02: Days per week lipids administered.
DMERC 10.03: Milliliters per day of Dextrose.
DEFINITION: Reply to the sixth DMERC Certification form question that requires a
GU0 67.0 9 04 R Zeroes 286 289

N N N N N S
CODE VALUES: 0000-9999 DMERC forms 01.02, 10.02 and 10.03

0001-0099 DMERC form 04.03

None Reject Claim


area/ulcer #3.
the patient have the multi-level fusion.
DMERC 10.03: Milliliters per day of Lipids.
DEFINITION: Reply to the seventh DMERC Certification form question that requires
a four position numeric answer.
GU0 68.0 9 04 R Zeroes 290 293

N N N N N S

None Reject Claim

DMERC 01.02, Question 21.I

area/ulcer #3.
DMERC 10.03: Days per week of Lipids.
DATA ELEMENT: Reply PCT L04 N01
four position numeric percentage answer containing an implied
decimal place.
GU0 69.0 9v9 04 R Zeroes 294 297

N N N N N S
CODE VALUES: 000.0-099. DMERC form 10.02

None Reject Claim

DMERC 10.02: Amino acid percentage of concentration.

DMERC 10.03: Amino acid percentage of concentration.
a four position numeric percentage answer containing an implied
decimal place.
GU0 70.0 9v9 04 R Zeroes 298 301

N N N N N S

None Reject Claim

DMERC 10.02: Dextrose percentage of concentration.

DMERC 10.03: Dextrose percentage of concentration.
four position numeric percentage answer containing an implied
decimal place.
GU0 71.0 9v9 04 R Zeroes 302 305

N N N N N S

None Reject Claim

DMERC 10.02: Lipids percentage of concentration.

DMERC 10.03: Lipids percentage of concentration.
DATA ELEMENT: DMERC CMN Indicator
DEFINITION: A code used to indicate the type of transmission used to submit the
attachment information.
GU0 72.0 X 02 L Spaces 306 307

N N N N N S

contains a value of C and certification information applies to the
claim.
CODE VALUES: AB Previously Submitted to Payer

AD Certification Included in this Claim
AF Narrative Segment Included in this Claim
AG No Documentation is Required
NS Not Specified

GU0 73.0 X 06 L Spaces 308 313

N N N N N R
CODE VALUES:

None None
GU0 74.0 X 07 L Spaces 314 320

N N N N N R
CODE VALUES:

None None
RECORD SUMMARY
RECORD TYPE: GX0
RECORD NAME: Oxygen Certification Record
RECORD PURPOSE: To provide information regarding attending physician's

certification of medical necessity
S FA0, FA@, FB0, FB1, FB2, FA0, GX2, HA0, XA0

FB3, FB4, FE0


Medicare Claims.
RECORD LAYOUT
Record Type: GX0

GX0 04.0 Certification Type X 01 23 23
GX0 05.0 Oxygen System X 01 24 24
GX0 06.0 Length of Need X 02 25 26
GX0 09.0 Equipment Reason X 64 29 92
GX0 10.0 Prescribed From Date 9 08 93 100
GX0 11.0 Prescribed To Date 9 08 101 108
GX0 12.0 Date Oxygen Prescribed 9 08 109 116
GX0 13.0 Date Evaluated 9 08 117 124
GX0 14.0 Oxygen Flow Rate X 03 125 127
GX0 15.0 Frequency of Use X 02 128 129
GX0 16.0 Duration X 02 130 131
GX0 17.0 Arterial Blood Gas 4 LMP 99v9 03 132 134
GX0 18.0 Oximetry 4 LMP 99v9 03 135 137
GX0 19.0 Date Tested 4 LMP 9 08 138 145
GX0 20.0 Inpatient/Outpatient Indicator X 01 146 146
GX0 21.1 Ordering Provider Contact Name X 35 147 181
GX0 21.2 Filler X 30 182 211
GX0 22.0 Arterial Blood Gas 99v9 03 212 214
GX0 23.0 Oximetry 99v9 03 215 217
GX0 24.0 Date Tested 9 08 218 225
GX0 25.0 Test Facility Name X 33 226 258
GX0 26.0 Test Conditions X 01 259 259
GX0 27.0 Clinical Findings X 03 260 262
GX0 28.0 Portable Oxygen Flow Rate 99v9 03 263 265
GX0 29.0 Filler X 15 266 280
GX0 30.0 Ordering Provider Telephone Number X 10 281 290
GX0 34.0 Diagnosis Code 4 X 05 306 310
GX0 35.0 Certification on File X 01 311 311
GX0 36.0 Delivery System Type X 01 312 312
GX0 37.0 DMERC CMN Indicator X 02 313 314
GX0 38.0 Filler - National X 06 315 320
Emdeon Business Services Technical Specifications NSF Plus GX0 - 01.0
DATA ELEMENT: Record Type 'GX0'
DEFINITION: A field used to identify the "Home Health Information" record.
GX0 01.0 X 03 L Spaces 01 03

N N N N N R
CODE VALUES:
VALIDATION: Must contain a value of GX0.


GX0 02.0 9 02 R Zeroes 04 05

N N N N N R
CODE VALUES: 01-50



GX0 03.0 X 17 L Spaces 06 22

N N N N N R
CODE VALUES:


DATA ELEMENT: Certification Type
DEFINITION: A code used to identify the type of certification.
GX0 04.0 X 01 L Spaces 23 23

N N N N N S
CODE VALUES: I Initial

R Renewal
S Revised

None Reject Claim

DMERC 484.2, Section A
DATA ELEMENT: Oxygen System
DEFINITION: A code used to indicate if the patient is mobile within the home when
ordering portable oxygen.
GX0 05.0 X 01 L Spaces 24 24

N N N N N S

N No
Y Yes

None Reject Claim

DATA ELEMENT: Length of Need
DEFINITION: Estimate of length of time (in months) oxygen therapy will be

required.
GX0 06.0 X 02 L Spaces 25 26

N N N N N S
CODE VALUES:

None None

DMERC 484.2, Section B
DMERC 484.03, Section B
Enter the number of months covered by this certification. If lifetime,

enter 99.
DATA ELEMENT: Equipment Type 1
DEFINITION: A code used to indicate the specific type of equipment being

prescribed for the delivery of oxygen.
GX0 07.0 X 01 L Spaces 27 27

N N N N N S
CODE VALUES: A Concentrator

B Liquid Stationary
C Gaseous Stationary
D Liquid Portable
E Gaseous Portable
O Other

None Reject Claim
NOTES: If the prescribing physician ordered both a portable and stationary

system, or a concentrator with a system, enter the second system in
EQUIPMENT TYPE 2 (fld-08.0)
DATA ELEMENT: Equipment Type 2
DEFINITION: A code used to indicate the specific type of equipment being

prescribed for the delivery of oxygen.
GX0 08.0 X 01 L Spaces 28 28

N N N N N S
CODE VALUES: A Concentrator

B Liquid Stationary
C Gaseous Stationary
D Liquid Portable
E Gaseous Portable
O Other

None Reject Claim
DATA ELEMENT: Equipment Reason
DEFINITION: The reasons why a particular system or piece of equipment is

required.
GX0 09.0 X 64 L Spaces 29 92

N N N N N S
CODE VALUES:

None None
DATA ELEMENT: Prescribed From Date
DEFINITION: The from date for which oxygen was prescribed.
GX0 10.0 9 08 R Zeroes 93 100

N N N N N S
CODE VALUES:

None Reject Claim

DATA ELEMENT: Prescribed To Date
DEFINITION: The to date for which oxygen was prescribed.
GX0 11.0 9 08 R Zeroes 101 108

N N N N N S
CODE VALUES:

None Reject Claim

DATA ELEMENT: Date Oxygen Prescribed
DEFINITION: The date oxygen was prescribed. On renewal prescriptions, enter

the date the physician signed the renewal.
GX0 12.0 9 08 R Zeroes 109 116

N N N N N S
CODE VALUES:

None Reject Claim

DMERC 484.2, Section D
DMERC 484.03, Section D
DATA ELEMENT: Date Evaluated
DEFINITION: The date the patient was last examined by the physician to
determine the need for oxygen therapy.
GX0 13.0 9 08 R Zeroes 117 124

N N N N N S
CODE VALUES:

None Reject Claim
DATA ELEMENT: Oxygen Flow Rate
DEFINITION: The oxygen flow rate (stationary equipment liters per minute).
GX0 14.0 X 03 L Spaces 125 127

N N N N N S
CODE VALUES: 001-999 Liters per minute

00X Less than 1 liter per minute

None None

For oxygen concentrator, the concentrator supplied must

accommodate, the flow rate prescribed by the physician. If billing
oxygen in excess of 4LPM, or less than 1 LPM, the prescription must
support the liter flow output.
If billing oxygen is greater than 4LPM also enter the date the test
was performed (fld-19.0)
Claims with flow rate of more than 2 liters per minute usually require
review by the insurance carrier's medical staff.
DATA ELEMENT: Frequency of Use
DEFINITION: The number of times per day the patient must use oxygen.
GX0 15.0 X 02 L Spaces 128 129

N N N N N S
CODE VALUES:

None None
NOTES: This field is normally used only if the physician has prescribed
oxygen for a particular period of use (i.e. during exercise,
nocturnally, etc.)
DATA ELEMENT: Duration
DEFINITION: The hours per period of use.
GX0 16.0 X 02 L Spaces 130 131

N N N N N S
CODE VALUES:

None None
DATA ELEMENT: Arterial Blood Gas 4 LMP
DEFINITION: The arterial blood gas test results taken on 4 Liters Per Minute
(LMP).
GX0 17.0 99v9 03 R Zeroes 132 134

N N N N N S
CODE VALUES:

None Reject Claim

DATA ELEMENT: Oximetry 4 LMP
DEFINITION: The oxygen saturation test results taken on 4 Liters Per Minute
(LMP).
GX0 18.0 99v9 03 R Zeroes 135 137

N N N N N S
CODE VALUES:

None Reject Claim

DATA ELEMENT: Date Tested 4 LMP
DEFINITION: Date patient was tested for arterial blood gas and/or oxygen
saturation on 4 LMP.
GX0 19.0 9 08 R Zeroes 138 145

N N N N N S
CODE VALUES:

None Reject Claim

DATA ELEMENT: Inpatient/Outpatient Indicator
DEFINITION: A code used to indicate if the tests were performed within one day of
discharge from an inpatient facility to home or with the patient in a
chronic stable state as an outpatient.
GX0 20.0 X 01 L Spaces 146 146

N N N N N S
CODE VALUES: N No
Y Yes

None Reject Claim

DATA ELEMENT: Ordering Provider Contact Name
DEFINITION: The name of the contact person for the Ordering Provider.
GX0 21.1 X 35 L Spaces 147 181

S S S S S S
SITUATIONAL NOTE: Should be entered if the ORDERING PROVIDER TELEPHONE

NUMBER (fld-30.0) has been entered.
CODE VALUES:

None None
GX0 21.2 X 30 L Spaces 182 211

R R R R R R
CODE VALUES:

None None
DATA ELEMENT: Arterial Blood Gas
DEFINITION: The arterial blood gas results.
GX0 22.0 99v9 03 R Zeroes 212 214

N N N N N S
CODE VALUES:

None Reject Claim

DATA ELEMENT: Oximetry
DEFINITION: The oxygen saturation results.
GX0 23.0 99v9 03 R Zeroes 215 217

N N N N N S
CODE VALUES:

None Reject Claim

DATA ELEMENT: Date Tested
DEFINITION: The date oxygen saturation test was performed.
GX0 24.0 9 08 R Zeroes 218 225

N N N N N S
CODE VALUES:

None Reject Claim

DATA ELEMENT: Test Facility Name
DEFINITION: The name of the entity who performed the ABG and/or oximetry
tests.
GX0 25.0 X 33 L Spaces 226 258

N N N N N S
CODE VALUES:

None None

DATA ELEMENT: Test Conditions
DEFINITION: A code used to identify the conditions under a patient was tested.
GX0 26.0 X 01 L Spaces 259 259

N N N N N S
CODE VALUES: 1 At rest on room air

2 Exercising
3 Sleeping

None Reject Claim

DATA ELEMENT: Clinical Findings
DEFINITION: A code used if a patient's arterial PO2 is over 55mm Hg and under
60mm Hg, or if the oxygen saturation is over 88%, to indicate
whether the patient has one of the conditions listed below.
GX0 27.0 X 03 L Spaces 260 262

N N N N N S
Enter Y, N, or blank to the following questions:
Position 1 = Dependent edema due to congestive heart failure

Position 2 = "P" pulmonale on electrocardiogram (EKG)
Position 3 = Erythrocythemia with a hematocrit greater than 56%
CODE VALUES: N No
space Does not apply
Y Yes

None Reject Claim

DMERC 484.2, Questions 8, 9, 10
DMERC 484.03, Questions 7, 8, 9
Up to three codes can be entered in this field. For example, if 1 and

3 are applicable, enter "Y Y". A space means 'does not apply'.
DATA ELEMENT: Portable Oxygen Flow Rate
DEFINITION: The oxygen flow rate (liters per minute) LMP for a portable oxygen
system.
GX0 28.0 99v9 03 R Zeroes 263 265

N N N N N S
CODE VALUES:

None Reject Claim
GX0 29.0 X 15 L Spaces 266 280

N N N N N R
CODE VALUES:

None None
DATA ELEMENT: Ordering Provider Telephone Number
DEFINITION: The telephone number of the ordering physician who prescribed the
oxygen.
GX0 30.0 X 10 L Spaces 281 290

N N N N N R
SITUATIONAL NOTE: Should be entered if the ORDERING PROVIDER CONTACT NAME

CODE VALUES:

None None

condition resulting in the prescription for oxygen.
GX0 31.0 X 05 L Spaces 291 295

N N N N N S
CODE VALUES:

If entered, must match the diagnosis code reported in Record Type

EA0 (fld-30.0).

None Reject Claim
diagnosis code.

GX0 32.0 X 05 L Spaces 296 300

N N N N N S
CODE VALUES:


EA0 (fld-31.0).

None Reject Claim
diagnosis code.

GX0 33.0 X 05 L Spaces 301 305

N N N N N S
CODE VALUES:


EA0 (fld-32.0).

None Reject Claim
diagnosis code.

GX0 34.0 X 05 L Spaces 306 310

N N N N N S
CODE VALUES:


EA0 (fld-33.0).

None Reject Claim
diagnosis code.
DATA ELEMENT: Certification on File
DEFINITION: A code used to identify whether a copy of signed certification is on

file.
GX0 35.0 X 01 L Spaces 311 311

N N N N N S
CODE VALUES: N No
Y Yes

None Reject Claim
DATA ELEMENT: Delivery System Type
DEFINITION: A code used to identify if a particular form of delivery was prescribed.
GX0 36.0 X 01 L Spaces 312 312

N N N N N R
CODE VALUES: A Nasal Cannula

B O2 Conserving Device
C O2 Conserving Device with Pulse O2 System
D O2 Conserving Device with Reservoir System
E Transtracheal Catheter

None Reject Claim
DATA ELEMENT: DMERC CMN Indicator
DEFINITION: A code used to indicate the type of transmission used to submit the
attachment information.
GX0 37.0 X 02 L Spaces 313 314

N N N N N S

contains a value of C and certification information applies to the
claim.
CODE VALUES: AB Previously Submitted to Payer

AD Certification Included in this Claim
AF Narrative Segment Included in this Claim
AG No Documentation is Required
NS Not Specified

GX0 38.0 X 06 L Spaces 315 320

N N N N N R
CODE VALUES:

None None
RECORD SUMMARY
RECORD TYPE: GX2
RECORD NAME: Facility Information for Oxygen
RECORD PURPOSE: To provide information regarding where the test was

performed or where the patient resides if other than home.
S GX0 FA0, HA0, XA0


Medicare Claims.
RECORD LAYOUT
Record Type: GX2

GX2 06.0 Test Facility City X 20 83 102
GX2 07.0 Test Facility State X 02 103 104
GX2 08.0 Test Facility Zip X 09 105 113
GX2 09.0 Filler X 124 114 237
GX2 10.0 Test Facility Qualifier X 02 238 239
GX2 11.0 Test Facility NPI X 10 240 249
GX2 12.0 Test Facility Secondary ID Qualifier X 02 250 251
GX2 13.0 Test Facility Secondary ID X 15 252 266
GX2 14.0 Filler - Local X 54 267 320
DATA ELEMENT: Record Type 'GX2'
DEFINITION: A field used to identify the "Facility for Oxygen" record.
GX2 01.0 X 03 L Spaces 01 03

N N N N N R
CODE VALUES:
VALIDATION: Must contain a value of GX2.


GX2 02.0 9 02 R Zeroes 04 05

N N N N N R
CODE VALUES: 01-50
VALIDATION: Must be identical to the SEQUENCE NUMBER (fld-02.0) submitted



GX2 03.0 X 17 L Spaces 06 22

N N N N N R
CODE VALUES:


DATA ELEMENT: Test Facility Address 1
DEFINITION: The street address of the laboratory, office, facility or clinic where
services were rendered.
GX2 04.0 X 30 L Spaces 23 52

N N N N N S
CODE VALUES:

validation.

None Reject Claim

DATA ELEMENT: Test Facility Address 2
DEFINITION: Additional address information for the laboratory, office, facility or

clinic where services were rendered.
GX2 05.0 X 30 L Spaces 53 82

N N N N N S
CODE VALUES:

validation.

None Reject Claim

DATA ELEMENT: Test Facility City
DEFINITION: The city address of the laboratory, office, facility or clinic where
GX2 06.0 X 20 L Spaces 83 102

N N N N N S
CODE VALUES:

validation.

None Reject Claim

DATA ELEMENT: Test Facility State
DEFINITION: The state address of the laboratory, office, facility or clinic where
GX2 07.0 X 02 L Spaces 103 104

N N N N N S
CODE VALUES:

validation.

None Reject Claim

DATA ELEMENT: Test Facility Zip
DEFINITION: The U.S. Postal Service zip code for the laboratory, office, facility or
clinic where services were rendered.
GX2 08.0 X 09 L Spaces 105 113

N N N N N S
CODE VALUES:

validation.

None Reject Claim

GX2 09.0 X 124 L Spaces 114 237

N N N N N R
CODE VALUES:

None None
DATA ELEMENT: Test Facility Qualifier
DEFINITION: A code used to indicate what type of test facility information is

entered in TEST FACILITY NAME (RT GX0, fld-25.0).
GX2 10.0 X 02 L Spaces 238 239

N N N N N N
SITUATIONAL NOTE: Should be entered if TEST FACILITY NAME (RT GX0, fld-25.0) has
been entered.
CODE VALUES: FA Facility

LI Independent Laboratory
TL Testing Laboratory

None None
DATA ELEMENT: Test Facility NPI
GX2 11.0 X 10 L Spaces 240 249

N N N N N N
CODE VALUES:

None None
DATA ELEMENT: Test Facility Secondary ID Qualifier
DEFINITION: A code used to qualify the TEST FACILITY SECONDARY ID NUMBER

in the next field.
GX2 12.0 X 02 L Spaces 250 251

N N N N N S
SITUATIONAL NOTE: Must be entered if TEST FACILITY SECONDARY ID (fld.13.0) has

been entered.

LU Location Number
TJ Tax Identification Number
X4 Clinical Laboratory Improvement Amendment
Number (CLIA)

DATA ELEMENT: Test Facility Secondary ID
DEFINITION: A number, assigned by the payer, used to identify the test facility
provider.
GX2 13.0 X 15 L Spaces 252 266

N N N N N S
SITUATIONAL NOTE: Should be entered if TEST FACILITY SECONDARY ID QUALIFIER

CODE VALUES:

None None
GX2 14.0 X 54 L Spaces 267 320

N N N N N R
CODE VALUES:

None None
RECORD SUMMARY
RECORD TYPE: HA0
RECORD NAME: Narrative Record
RECORD PURPOSE: To provide additional information related to the service

S FA0, FA@, FB0, FB1, FB2, FA0, XA0

GD@, GU0, GX0, GX2

than fields HA0-01.0, HA0-02.0, HA0-03.0 or filler.
NOTES: When used, this Record Type HA0 must have the same
RECORD LAYOUT
Record Type: HA0

HA0 01.0 Record Type 'HA0' X 03 01 03
HA0 02.0 Sequence Number 9 02 04 05
HA0 03.0 Patient Control Number X 17 06 22
HA0 04.0 Line Item Control Number X 17 23 39
HA0 05.0 Extra Narrative Data X 281 40 320
Emdeon Business Services Technical Specifications NSF Plus HA0 - 01.0
DATA ELEMENT: Record Type 'HA0'
DEFINITION: A field used to identify the "Narrative Record - HA0".
HA0 01.0 X 03 L Spaces 01 03

R R R R R R
CODE VALUES:
VALIDATION: Must contain a value of HA0.


associated Record Type FA0.
HA0 02.0 9 02 R Zeroes 04 05

R R R R R R
CODE VALUES: 01-50
Must be identical to SEQUENCE NUMBER (fld-02.0) submitted in

the preceding Record Type FA0.


HA0 03.0 X 17 L Spaces 06 22

R R R R R R
CODE VALUES:

DEFINITION: An identifier assigned by the submitter/provider to this line item
HA0 04.0 X 17 L Spaces 23 39

S S S S S S
CODE VALUES:


None None
DATA ELEMENT: Extra Narrative Data
DEFINITION: Free form narrative record to submit additional information that may
assist in the adjudication of the associated SERVICE LINE ITEM.
HA0 05.0 X 281 L Spaces 40 320

S S S S S S
SITUATIONAL NOTE: Should be entered if additional information is needed to adjudicate

the claim.
CODE VALUES:

None None
RECORD SUMMARY
RECORD TYPE: XA0
RECORD NAME: Claim Trailer Record: Claim Summary
RECORD LEVEL: Claim
RECORD PURPOSE: To provide a summary of the total number of records and

record types within the claim as well as providing the total
dollar amounts.
To provide free text information.
R FA0, FA@, FB0, FB1, FB2, CA0, YA0

GD@, GU0, GX0, GX2,
HA0

CONDITIONAL NOTE:
NOTES: Only one (1) Record Type XA0 may be entered per claim.
RECORD LAYOUT
Record Type: XA0

XA0 01.0 Record Type 'XA0' X 03 01 03
XA0 03.0 Patient Control Number X 17 06 22
XA0 04.0 Record Type Cxx Count 9 02 23 24
XA0 05.0 Record Type Dxx Count 9 02 25 26
XA0 06.0 Record Type Exx Count 9 02 27 28
XA0 07.0 Record Type Fxx Count 9 04 29 32
XA0 08.0 Record Type Gxx Count 9 02 33 34
XA0 09.0 Record Type Hxx Count 9 02 35 36
XA0 10.0 Claim Record Count 9 04 37 40
XA0 12.0 Total Claim Charges 9v99 07 78 84
XA0 13.0 Total Disallowed Cost Containment Charges 9v99 07 85 91
XA0 14.0 Total Disallowed Other Charges 9v99 07 92 98
XA0 15.0 Total Allowed Amount 9v99 07 99 105
XA0 16.0 Total Deductible Amount 9v99 07 106 112
XA0 17.0 Total Coinsurance Amount 9v99 07 113 119
XA0 18.0 Total Payer Amount Paid 9v99 07 120 126
XA0 19.0 Patient Amount Paid 9v99 07 127 133
XA0 20.0 Total Purchase Service Charges 9v99 07 134 140
XA0 21.0 Provider Discount Information X 16 141 156
XA0 22.0 Remarks X 103 157 259
XA0 23.0 Filler - National X 31 260 290
XA0 24.0 Filler - Local X 15 291 305
XA0 25.0 Clearinghouse ID 9 15 306 320
Emdeon Business Services Technical Specifications NSF Plus XA0 - 01.0
DATA ELEMENT: Record Type 'XA0'
DEFINITION: A field used to identify the "Claim Trailer Record: Claim Summary"
record.
XA0 01.0 X 03 L Spaces 01 03

R R R R R R
CODE VALUES:
VALIDATION: Must contain a value of XA0.

XA0 02.0 X 02 L Spaces 04 05

R R R R R R
CODE VALUES:

None None

XA0 03.0 X 17 L Spaces 06 22

R R R R R R
CODE VALUES:

DATA ELEMENT: Record Type Cxx Count
DEFINITION: A summarization by individual record type.
XA0 04.0 9 02 R Zeroes 23 24

R R R R R R
CODE VALUES:
Must equal the computed sum of all Record Types Cxx included
within this claim.

DATA ELEMENT: Record Type Dxx Count
XA0 05.0 9 02 R Zeroes 25 26

R R R R R R
CODE VALUES:
Must equal the computed sum of all Record Types Dxx included
within this claim.

DATA ELEMENT: Record Type Exx Count
XA0 06.0 9 02 R Zeroes 27 28

R R R R R R
CODE VALUES:
Must equal the computed sum of all Record Types Exx included
within this claim.

DATA ELEMENT: Record Type Fxx Count
XA0 07.0 9 04 R Zeroes 29 32

R R R R R R
CODE VALUES:
Must equal the computed sum of all Record Types Fxx included
within this claim.

DATA ELEMENT: Record Type Gxx Count
XA0 08.0 9 02 R Zeroes 33 34

S S S S S S
CODE VALUES:
If entered, must equal the computed sum of all Record Types Gxx
included within this claim.

None Reject Claim
DATA ELEMENT: Record Type Hxx Count
XA0 09.0 9 02 R Zeroes 35 36

S S S S S S
CODE VALUES:
If entered, must equal the computed sum of all Record Types Hxx
included within this claim.

None Reject Claim
DATA ELEMENT: Claim Record Count
DEFINITION: The total number of records submitted in this claim excluding this
record.
XA0 10.0 9 04 R Zeroes 37 40

R R R R R R
CODE VALUES:
Must equal the computed sum of all records processed from the
CLAIM HEADER RECORD (RT CA0) up to, but not including this
CLAIM TRAILER RECORD (RT XA0).

XA0 11.0 X 37 L Spaces 41 77

R R R R R R
CODE VALUES:

None None
DATA ELEMENT: Total Claim Charges
DEFINITION: The sum of all line items included within this claim.
XA0 12.0 9v99 07 R Zeroes 78 84

R R R R R R
CODE VALUES:
Must equal the sum of all LINE CHARGES (RT FA0,fld-13.0)

included within the claim.

NOTES: TOTAL CLAIM CHARGES is one of several fields which are compared
for "duplicate claim" processing. If these fields contain the same
values as a claim previously submitted on the same day, the claim
will be rejected for "duplicate claim". See Exhibit 97 for detailed
information.
Only positive numeric dollar amounts are acceptable at this time;

negative values are not allowed. Any unsigned values are assumed
to be positive.
DATA ELEMENT: Total Disallowed Cost Containment Charges
DEFINITION: The sum of all the disallowed cost containment charges associated
with this claim.
XA0 13.0 9v99 07 R Zeroes 85 91

R R R R R R
CODE VALUES:
Must be the computed sum of all DISALLOWED COST

CONTAINMENT CHARGES fields (RT FA0, fld-27.0) included in this
claim.

DATA ELEMENT: Total Disallowed Other Charges
DEFINITION: The sum of all additional disallowed charges associated with this
claim.
XA0 14.0 9v99 07 R Zeroes 92 98

R R R R R R
CODE VALUES:
Must be the computed sum of all DISALLOWED OTHER CHARGES

fields (RT FA0, fld-28.0) included in this claim.

DATA ELEMENT: Total Allowed Amount
DEFINITION: The sum of all allowed charges associated with this claim.
XA0 15.0 9v99 07 R Zeroes 99 105

R R R R R R
CODE VALUES:
Must be the computed sum of all ALLOWED AMOUNT fields (RT

DA1, fld-11.0) included in this claim.
If Record Type DA1 is not present, must be the computed sum of

all repriced ALLOWED AMOUNT fields (RT FE0, fld-08.0) included in
this claim.

DATA ELEMENT: Total Deductible Amount
DEFINITION: The total amount applied to the patient's deductible by previous

payer(s).
XA0 16.0 9v99 07 R Zeroes 106 112

R R R R R R
CODE VALUES:
Must be the computed sum of all DEDUCTIBLE AMOUNT fields (RT

FB0, fld-07.0) included in this claim.

DATA ELEMENT: Total Coinsurance Amount
DEFINITION: The total amount applied toward the patient's coinsurance by

previous payer(s).
XA0 17.0 9v99 07 R Zeroes 113 119

R R R R R R
CODE VALUES:
Must be the computed sum of all COINSURANCE AMOUNT fields

(RT FB0, fld-08.0) included in this claim.

DATA ELEMENT: Total Payer Amount Paid
DEFINITION: The amount the provider has received from the payer(s) toward
payment of this claim.
XA0 18.0 9v99 07 R Zeroes 120 126

R R R R R R
CODE VALUES:
Must be the computed sum of all PAYER AMOUNT PAID fields (RT
DA1, fld-14.0) included in this claim.
Must not exceed TOTAL CLAIM CHARGES (fld-12.0).

DATA ELEMENT: Patient Amount Paid
DEFINITION: The amount the provider has received from the patient or insured
toward payment of this claim.
XA0 19.0 9v99 07 R Zeroes 127 133

S S S S S S
SITUATIONAL NOTE: Should be entered if any payment has been made to the provider
for this claim.
CODE VALUES:
If entered, must not be greater than TOTAL CHARGES - CLAIM

(RT XA0,fld-12.0).

None Reject Claim
PATIENT AMOUNT PAID is one of several fields which are compared

for "duplicate claim" processing. If these fields contain the same
values as a claim previously submitted on the same day, the claim
will be rejected for "duplicate claim". See Exhibit 97 for detailed
information.
DATA ELEMENT: Total Purchase Service Charges
DEFINITION: The sum of all purchase service charges associated with this claim.
XA0 20.0 9v99 07 R Zeroes 134 140

R R R R R R
CODE VALUES:
Must be the computed sum of all PURCHASE SERVICE CHARGES

fields (RT FB0, fld-05.0) included in this claim.

DATA ELEMENT: Provider Discount Information
DEFINITION: Details on a prompt payment discount program offered by the

provider.
XA0 21.0 X 16 L Spaces 141 156

S N N N N S
SITUATIONAL NOTE: Should be entered, if applicable, to facilitate claim adjudication.
CODE VALUES:

None None
DATA ELEMENT: Remarks
DEFINITION: A free form area designed to be used in those situations where

supplementary data would be helpful in processing a claim.
XA0 22.0 X 103 L Spaces 157 259

S S S S S S
SITUATIONAL NOTE: Should be entered when supplementary information is required

from providers.
CODE VALUES:

None None
XA0 23.0 X 31 L Spaces 260 290

R R R R R R
CODE VALUES:

None None
XA0 24.0 X 15 L Spaces 291 305

R R R R R R
CODE VALUES:

None None
DATA ELEMENT: Clearinghouse ID
DEFINITION: A WebMD Envoy generated control number used to uniquely identify

a claim.
XA0 25.0 9 15 R Zeroes 306 320

R R R R R R
CODE VALUES:
SUBMITTER: Should contain zeros (0's)
RECEIVER: Will contain a fifteen digit Claim ID generated by

WebMD.
Positions 1-6 will contain the WebMD processing date, position 7

will contain a value of 5; positions 8-15 will be a sequential number
assigned to the incoming claims.

None Reject Batch
RECORD SUMMARY
RECORD TYPE: YA0
RECORD NAME: Batch Trailer Record
RECORD LEVEL: Batch
RECORD PURPOSE: To provide a summary of claims and claim totals within a

batch.
R XA0 BA0, ZA0

CONDITIONAL NOTE:
NOTES: Must be the last record within a batch of claims.
BILLING PROVIDER TAX ID (fld-06.0) must be identical to

the BILLING PROVIDER TAX ID in Record Type BA0 (fld-
06.0).
BATCH TYPE (fld-03.0) must be identical to BATCH TYPE in

RECORD LAYOUT
Record Type: YA0

YA0 01.0 Record Type 'YA0' X 03 01 03
YA0 02.0 EMC Provider ID X 15 04 18
YA0 03.0 Batch Type X 03 19 21
YA0 04.0 Batch Number 9 04 22 25
YA0 05.0 Batch ID X 06 26 31
YA0 06.0 Billing Provider Tax ID X 09 32 40
YA0 07.0 Reserved Filler X 06 41 46
YA0 08.0 Batch Service Line Count 9 07 47 53
YA0 09.0 Batch Record Count 9 07 54 60
YA0 10.0 Batch Claim Count 9 07 61 67
YA0 11.0 Batch Total Charges 9v99 09 68 76
YA0 12.0 Filler - National X 121 77 197
YA0 13.0 Filler - Local X 114 198 311
YA0 14.0 Original Submitter ID 9 09 312 320
Emdeon Business Services Technical Specifications NSF Plus YA0 - 01.0
DATA ELEMENT: Record Type 'YA0'
DEFINITION: A field used to identify the "Batch Trailer Record" record.
YA0 01.0 X 03 L Spaces 01 03

R R R R R R
CODE VALUES:
VALIDATION: Must contain a value of YA0.

DEFINITION: Identifies the provider as defined by the receiver.
YA0 02.0 X 15 L Spaces 04 18

R R R R R R
CODE VALUES:
VALIDATION: Must be identical to the EMC PROVIDER IDENTIFIER (fld-02.0) in

the preceding Record Types BA0 and BA1.

None None
DEFINITION: A codes used to indicate the type of claims included within the batch.
YA0 03.0 X 03 L Spaces 19 21

R R R R R R
CODE VALUES:
VALIDATION: Must contain a value of 100.
Must be identical to the BATCH TYPE submitted in the preceding


DATA ELEMENT: Batch Number
DEFINITION: A sequential number assigned by the submitter to each batch of

claims.
YA0 04.0 9 04 R Zeroes 22 25

R R R R R R
CODE VALUES:
VALIDATION: Must be identical to the BATCH SEQUENCE NUMBER submitted in

the preceding Record Type BA0 (fld-04.0).

None Reject Batch
DEFINITION: An identifier assigned by the provider/submitter to identify a batch in

its own system.
YA0 05.0 X 06 L Spaces 26 31

N N N N N N
CODE VALUES:
VALIDATION: If entered, should be identical to the BATCH ID in the preceding


None None
DATA ELEMENT: Billing Provider Tax ID

provider. This can be either the Employer Identification Number
(EIN) or the Social Security Number (SSN).
YA0 06.0 X 09 L Spaces 32 40

R R R R R R
CODE VALUES:
Must be identical to the BILLING PROVIDER TAX ID submitted in


YA0 07.0 X 06 L Spaces 41 46

R R R R R R
CODE VALUES:

None None
DATA ELEMENT: Batch Service Line Count
DEFINITION: The number of line items included in this batch.
YA0 08.0 9 07 R Zeroes 47 53

R R R R R R
CODE VALUES:
Must be the computed sum of all Record Type FA0's within this
batch.

DATA ELEMENT: Batch Record Count
DEFINITION: The number of records included in this batch.
YA0 09.0 9 07 R Zeroes 54 60

R R R R R R
CODE VALUES:
Must be the computed sum of all Record type BA0 through YA0.

DATA ELEMENT: Batch Claim Count
DEFINITION: The count of the number of claims included within the batch.
YA0 10.0 9 07 R Zeroes 61 67

R R R R R R
CODE VALUES:
Must equal the sum of all Record Type CA0's included between the
preceding Record Type BA0 and Record Type YA0.

DATA ELEMENT: Batch Total Charges
DEFINITION: The sum of all charges included within the batch.
YA0 11.0 9v99 09 R Zeroes 68 76

R R R R R R
CODE VALUES:
Must equal the sum of all TOTAL CLAIM CHARGES (RT XA0-fld-
12.0) , included between the preceding Record Type BA0 and
Record Type YA0.

YA0 12.0 X 121 L Spaces 77 197

R R R R R R
CODE VALUES:

None None
YA0 13.0 X 114 L Spaces 198 311

R R R R R R
CODE VALUES:

None None
DATA ELEMENT: Original Submitter ID

submitter. This can also be the Employer Identification Number
(EIN).
YA0 14.0 9 09 R Zeroes 312 320

R R R R R R
CODE VALUES:
SUBMITTER: Must contain a value of all Zeros (0's).
RECEIVER: Will contain the original SUBMITTER ID (A0-02) of the

organization that submitted the batch.

RECORD SUMMARY
RECORD TYPE: ZA0
RECORD NAME: File Trailer Record
RECORD LEVEL: File
RECORD PURPOSE: To provide a summary of batches and batch totals within a

file.
R YA0 None

CONDITIONAL NOTE:
NOTES: Must be the last record of a claim file.
The SUBMITTER ID (fld-02.0) must be identical to the

SUBMITTER ID in Record Type AA0 (fld-02.0).
The RECEIVER ID and SUB-ID (flds-04.0a-04.0b) must be

identical to the RECEIVER ID and SUB-ID in Record Type
AA0 (flds-17.0a-17.0b).
RECORD LAYOUT
Record Type: ZA0

ZA0 01.0 Record Type 'ZA0' X 03 01 03
ZA0 02.0 Submitter ID X 16 04 19
ZA0 03.0 Reserved Filler X 09 20 28
ZA0 04.0 Receiver ID X 05 29 33
ZA0 04.0 Receiver Sub-ID X 11 34 44
ZA0 05.0 File Service Line Count 9 07 45 51
ZA0 06.0 File Record Count 9 07 52 58
ZA0 07.0 File Claim Count 9 07 59 65
ZA0 08.0 Batch Count 9 04 66 69
ZA0 09.0 File Total Charges 9v99 11 70 80
ZA0 10.0 Filler - National X 120 81 200
ZA0 11.0 Filler - Local X 120 201 320
Emdeon Business Services Technical Specifications NSF Plus ZA0 - 01.0
DATA ELEMENT: Record Type 'ZA0'
DEFINITION: A field used to identify the "File Trailer Record" record.
ZA0 01.0 X 03 L Spaces 01 03

R R R R R R
CODE VALUES:
VALIDATION: Must contain a value of ZA0.

DATA ELEMENT: Submitter ID

submitter. This can also be the Employer Identification Number
(EIN).
ZA0 02.0 X 16 L Spaces 04 19

R R R R R R
CODE VALUES:
VALIDATION: Must be identical to the SUBMITTER ID submitted in the preceding

Record Type AA0 (fld-02.0).

ZA0 03.0 X 09 L Spaces 20 28

R R R R R R
CODE VALUES:

None None
Emdeon Business Services Technical Specifications NSF Plus ZA0 - 04.0a
DATA ELEMENT: Receiver ID
DEFINITION: A number used to identify the organization designated to receive this

file.
ZA0 04.0a X 05 L Spaces 29 33

R R R R R R
CODE VALUES:
Must be identical to the RECEIVER ID entered in Record Type AA0

(fld-17.0a).

Emdeon Business Services Technical Specifications NSF Plus ZA0 - 04.0b
DATA ELEMENT: Receiver Sub-ID
DEFINITION: A number used to identify the specific location, within the receiver's
organization, designated to receive the file.
ZA0 04.0b X 11 L Spaces 34 44

R R R R R R
CODE VALUES:
Must be identical to the RECEIVER SUB-ID entered in Record Type

AA0 (fld-17.0b).

DATA ELEMENT: File Service Line Count
DEFINITION: The number of service line included in this file.
ZA0 05.0 9 07 R Zeroes 45 51

R R R R R R
CODE VALUES:
Must be the computed sum of all BATCH SERVICE LINE COUNT

fields (RT YA0, fld-08.0) included within this file.

DATA ELEMENT: File Record Count
DEFINITION: The number of records included in this file.
ZA0 06.0 9 07 R Zeroes 52 58

R R R R R R
CODE VALUES:
Must be the computed sum of all BATCH RECORD COUNT fields (RT-
YA0, fld-09.0) included within this file.

DATA ELEMENT: File Claim Count
DEFINITION: The number of claims included in this file.
ZA0 07.0 9 07 R Zeroes 59 65

R R R R R R
CODE VALUES:
Must be the computed sum of all BATCH CLAIM COUNT fields (RT-
YA0, fld-10.0) included within this file.

DATA ELEMENT: Batch Count
DEFINITION: The number of batches included within the file.
ZA0 08.0 9 04 R Zeroes 66 69

R R R R R R
CODE VALUES:
Must equal the sum of all Record Type BA0's included between
Record Type AA0 and this Record Type ZA0.

DATA ELEMENT: File Total Charges
DEFINITION: The sum of all charges included within the file.
ZA0 09.0 9v99 11 R Zeroes 70 80

R R R R R R
CODE VALUES:
Must equal the computed sum of all BATCH TOTAL CHARGES (RT-
YA0, fld-11.0) included between the preceding Record Type AA0
and this Record Type ZA0.

ZA0 10.0 X 120 L Spaces 81 200

R R R R R R
CODE VALUES:

None None
ZA0 11.0 X 120 L Spaces 201 320

R R R R R R
CODE VALUES:

None None
Emdeon Business Services Technical Specifications Exhibit 1
Standard Date and Time Check

FORMAT RULES
DATE fields are depicted as "CCYYMMDD"
CC = Century
YY = Year
MM = Month
DD = Day
TIME fields are depicted as "HHMMSS" or "HHMM"

HH = Hours
MM = Minutes
SS = Seconds
VALIDATION RULE
MONTH (MM)
Must contain a value of 01 - 12.
DAY (DD)
Must contain 01-31 MONTH DAY
04, 06, 09. or 11 01-30
01, 03, 05, 07, 08, 10, or 12 01-31
02 (When not a leap year)* 01-28
02 (When a leap year)* 01-29
*Leap Year is any year

divisible by 4 including 2000
(except for all other years
divisible by 400)
CENTURY (CC)
Must contain a value of 19 or 20 for all dates except dates of birth.
Must contain a value of 18, 19, or 20 for date of birth fields.
YEAR (YY)
Must contain a value of 00 - 99
HOUR (HH)
MINUTE (MM)
SECOND (SS)
© 2002, Emdeon Corporation. All Rights Reserve Updated, March 2006

Emdeon Business Services Technical Specifications Exhibit 1A
Accident Hour
CODE TIME SPAN
00 12:00 Midnight - 12:59 am

01 01:00 - 01:59 am
02 02:00 - 02:59 am
03 03:00 - 03:59 am
04 04:00 - 04:59 am
05 05:00 - 05:59 am
06 06:00 - 06:59 am
07 07:00 - 07:59 am
08 08:00 - 08:59 am
09 09:00 - 09:59 am
10 10:00 - 10:59 am
11 11:00 - 11:59 am
12 12:00 Noon - 12:59 pm
13 01:00 - 01:59 pm
14 02:00 - 02:59 pm
15 03:00 - 03:59 pm
16 04:00 - 04:59 pm
17 05:00 - 05:59 pm
18 06:00 - 06:59 pm
19 07:00 - 07:59 pm
20 08:00 - 08:59 pm
21 09:00 - 09:59 pm
22 10:00 - 10:59 pm
23 11:00 - 11:59 pm

Standard Address Check
ORDER
ADDRESS fields occur in the following order:
ADDRESS-a
ADDRESS-b (optional)
CITY
STATE or PROVINCE CODE
POSTAL CODE
COUNTRY CODE (optional)
VALIDATION RULE
ADDRESS-a, ADDRESS-b:
Must only contain a value of A-Z, 0-9, space, comma, period, ampersand (&), pound sign (#),
hyphen (-), or forward slash (/). No other special characters are allowed.
ADDRESS-b must only be entered if ADDRESS-a has been entered.
CITY:
Must only contain a value of A-Z, 0-9, space, comma, period, ampersand (&), pound sign (#) or
forward slash (/). No other special characters are allowed.
Must only be entered if ADDRESS-a has been entered.
Must not be less than two (2) characters in length.
STATE OR PROVINCE:
Must be a valid United States State Code or Canadian Province Code from External Code Source:
ISO-3166 (Codes for Representation of Names of Countries)
Available from:
American National Standards Institute
11 West 42nd Street, 13th Floor
New York, NY 10036
Must only be entered if CITY has been entered.
POSTAL CODE:
If the STATE CODE is a U.S. STATE CODE then the POSTAL CODE must be 5 or 9 numerics.
If all nine (9) digits are known, enter all nine digits.
If all nine (9) digits are not known:

-- the first five (5) positions must contain the POSTAL CODE
-- the last four (4) positions may contain spaces or zeros.
Must only be entered if STATE or Province code has been entered.

Exhibit 02 - Page 1
Standard Address Check
COUNTRY CODE
Should be a valid COUNTRY CODE from External Code Source: National Zip Code and Post Office
Directory
Available from:
U.S. Postal Service
National Information Data Center
P.O. Box 2977
Washington, DC 20013
Should not be entered if country is in U.S.

Exhibit 02 - Page 2
_________________________________________________________________________________
DMERC Form Number and Corresponding GU0

Record/Field
_________________________________________________________________________________
©2001-2005, Emdeon Corporation. All Rights Reserved. Updated, March 2006
_________________________________________________________________________________
Duplicate Claims Check
The following edits will be performed to eliminate duplicate submission of

claims to Emdeon Business Services on the same processing day. This is
specific to claim files submitted from the same submitter on the same day.
1. Compare the data elements listed on page 2 of this exhibit.
2. If all data elements match, the first claim in a set of duplicates will be
accepted and forwarded to the payer. Subsequent duplicate claims will be
rejected and transmitted back to the original submitter of the claim.
3. If all data elements do not match, the claim will be forwarded on to the
appropriate destination payer.
_________________________________________________________________________________
Exhibit 97 page 1
_________________________________________________________________________________
Duplicate Claims Editing
Name RT-FLD Comments

Submitter ID AA0-02.0
Billing Provider Tax ID BA0-06.0
Billing Provider Site ID BA0-07.0
Patient Control Number CA0-03.0
Patient Last Name CA0-04.0
Patient First Name CA0-05.0
Payer Organization ID DA0-07.0
Insured ID Number DA0-18.0
Patient Relation to Insured DA0.17.0
Diagnosis Code 1 EA0-30.0
Diagnosis Code 2 EA0-31.0
Service From Date FA0-05.0 The earliest service date (from all Procedure
lines) will be used.
Service To Date FA0-06.0 The latest service date (from all Procedure
lines) will be used.
Procedure Code FA0-09.0
Modifier 1 FA0-10.0 If a Modifier field contains a value of 76 or 77,
the claim will not reject if the PROCEDURE
CODE is the same as a previous PROCEDURE
CODE.
CODE.
CODE.
Rendering Provider ID FA0-23.0
Total Claim Charges XA0-12.0
_________________________________________________________________________________
Exhibit 97 page 2

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Emdeon Business Services Technical Specifications NSF Plus

Changed Validation Note to "If entered, should be

May only contain a value of 001-099, 301-308 or

Changed Requirement to "S".

Changed Requirement Error Action to "None"

Changed Validation Error Action to "None".

M DA0 23.0 Insured Gender Changed Data Element Name to "Insured

Changed Validation Note to "If entered, must

Changed Validation Error Action to "Reject Claim".

Changed Note to "Not Applicable".

Changed Validation Error Action to "Reject Claim".

EMDEON BUSINESS SERVICES NSF PLUS

©2003, Emdeon Business Services. All Rights Reserved

All Rights Reserved. Printed in the USA.

Last Update: October 2007

• Commercial Insurance Companies

At Emdeon Business Services, we partner with hundreds of practice management

BENEFITS OF USING EDI

• Physicians save an average of $1.50 or 35 percent per claim by using EDI

Emdeon Business Services Network Advantages

BATCH CLAIM PROCESSING

HOW BATCH PROCESSING WORKS

Benefits of Batch Claims:

File Level Records

Batch Level Records

Claim Level Records

Service Line Level Records

File Transaction Layout

Record Type Description Repeats Required

File Level Validation

• Duplicate File Checks

Batch Level Validation

• Provider Information Checks (minimum)

Claim Level Validation

• Duplicate Claim Checks (Duplicate claims received the same day)

VERSION AND RELEASE

DAILY PROCESSING SCHEDULE

A SITUATIONAL NOTE is considered a requirement edit.

2. File and Record Specifications.

Record Summary Page

Figure 2. Record Summary Page.

1. RECORD TYPE The three byte abbreviation assigned to the record.

2. RECORD NAME This is the functional name of the record.

3. RECORD LEVEL Identifies the level of validation to be performed on the

7. REQUIREMENTS Indicates when a record is required for a particular type

R REQUIRED. The record must be entered at all

C CONDITIONAL. The record must be entered

N NOT APPLICABLE. The record should not be

9. NOTES Provides additional information that may be helpful in the

Record Layout Page

Figure 3. Record Layout Page

1. RECORD TYPE The three byte abbreviation assigned to the record.

2. RT The three byte abbreviation assigned to the record.

3. FIELD The sequential number assigned to a data element

4. FIELD NAME The literal name of the data element.

5. DT (DATA TYPE) The attribute of the data element.

9v9 Numeric value with one decimal position.

9v99 Numeric value with two decimal positions.

6. LEN (LENGTH) The total number of bytes required for each

8. THR (THROUGH) The end position of the data element within

Data Element Page

Figure 4. Data Element Page.

1. DATA ELEMENT The literal name assigned to the data field.

2. DEFINITION The business description of the data element usage.