Segment
X12 EDI Release 00303
To specify basic data about the claim
Elements
Code identifying the type of health insurance or program.
Codes (15)- BLBlue Cross/Blue Shield
- CHChampus
- CICommercial Insurance Co.
- FIFederal Employees Program
- HMHealth Maintenance Organization
- MAMedicare Part A
- MBMedicare Part B
- MCMedicaid
- MHManaged Care Non-HMO
- OFOther Federal Program
- SASelf-administered Group
- TVTitle V
- VAVeterans Affairs Plan
- WCWorkers' Compensation Health Claim
- ZZMutually Defined
Code identifying the type of provider or claim
Codes (15)- AMAmbulance
- CHChiropractic
- DDDentist or Dental
- DMDurable Medical Equipment Supplier
- EREmergency Room
- HSHospital
- ILIndependent Lab
- MDPhysician or Medical
- OCOccupational Therapy
- PDPodiatry
- PEParental or Enteral (PEN)
- PTPhysical Therapy
- RXPharmacy or Drug
- SNSkilled Nursing
- STSpeech or Language Therapy
Code indicating whether the provider has on file a signed statement by the patient authorizing the release of medical data to other organizations in order to adjudicate the claim
Codes (3)- MThe Provider has Limited or Restricted Ability to Release Data Related to a Claim
- NNo, Provider is Not Allowed to Release Data
- YYes, Provider has a Signed Statement Permitting Release of Medical Billing Data Related to a Claim
Code indicating how the patient or subscriber authorization signatures were obtained and how they are being retained by the provider
Codes (5)- BSigned signature authorization form or forms for both HCFA-1500 Claim Form block 12 and block 13 are on file
- CSigned HCFA-1500 Claim Form on file
- MSigned signature authorization form for HCFA-1500 Claim Form block 13 on file
- PSignature generated by provider because the patient was not physically present for services
- SSigned signature authorization form for HCFA-1500 Claim Form block 12 on file
Code indicating the Special Program under which the services rendered to the patient were performed
Codes (10)- 10Civilian Health and Medical Program of the Uniformed Services (CHAMPUS) External Partnership Program
- 01Early & Periodic Screening, Diagnosis, and Treatment (EPSDT) or Child Health Assessment Program (CHAP)
- 02Physically Handicapped Children's Program
- 03Special Federal Funding
- 04Family Planning
- 05Disability
- 06Pneumococcal Pneumonia Vaccine (PPV) or Medicare 100% Payment
- 07Induced Abortion - Danger to Life
- 08Induced Abortion - Rape or Incest
- 09Second Opinion or Surgery
Code specifying the level of service rendered
Codes (10)- LLimited Treatment
- 00Not specified
- 01Patient Consultation
- 02Home delivery
- 03Emergency
- 0424 Hour
- 05Patient Consultation Regarding Generic Product Selection
- 09Other
- F1Full Treatment - Phase One
- F2Full Treatment - Phase Two
Code indicating the type of agreement under which the provider is submitting this claim
Codes (7)- DManaged Dental Care Program
- ECivilian Health and Medical Program of the Uniformed Services (CHAMPUS) "External" Partnership Agreement
- HHealth Maintenance Organization (HMO) Agreement
- ICivilian Health and Medical Program of the Uniformed Services (CHAMPUS) "Internal" Partnership Agreement
- NNo Agreement
- PParticipation Agreement
- YPreferred Provider Organization (PPO) Agreement
Code identifying the status of an entire claim as assigned by the payor.
Codes (23)- 1Processed as Primary
- 2Processed as Secondary
- 3Processed as Tertiary
- 4Denied
- 5Pended
- 6Approved as amended
- 7Approved as submitted
- 8Cancelled due to inactivity
- 9Pending - under investigation
- 10Received, but not in process
- 11Rejected, duplicate claim
- 12Rejected, please resubmit with corrections
- 13Suspended
- 14Suspended - incomplete claim
- 15Suspended - investigation with field
- 16Suspended - return with material
- 17Suspended - review pending
- 18Suspended Product Registration
- 19Processed as Primary, Forwarded to Additional Payer(s)
- 20Processed as Secondary, Forwarded to Additional Payer(s)
- 21Processed as Tertiary, Forwarded to Additional Payer(s)
- 22Reversal of Previous Payment
- 23Not Our Claim, Forwarded to Additional Payer(s)