837P Health Care Claim: Professional (004010X098A1)
Providers and billing services send the 837P to submit professional claims, the electronic CMS-1500, to payers and clearinghouses. This is the standard X12 HIPAA 004010 spec, with 66 loops and 390 segment positions, as OpenEDI JSON, an ediFabric C# template and an ediFabric Native model. To change it for a trading partner, customize it in the EDI Spec Builder.
Use the 837P spec in your code
ediFabric .NET
Add the C# template and its common files to your project, or reference the template NuGet package, and read 837P files into TS837P objects. See ediFabric .NET.
ediFabric Native
Map version 004010X098A1 to the Native model with set_map, then parse 837P files to JSON from Python, Java, C or C#. See Convert between EDI and JSON.
OpenEDI
Select Customize in Spec Builder to copy the spec under your own name, change it for your partner, and parse files against it in EdiNation, ediFabric Native or ediFabric Cloud. Read about OpenEDI.
Generate 837P classes in Python, Java, Node.js, Go, Rust or C
ediFabric Native returns each 837P as JSON, with the property names of the OpenEDI schema. To work with that JSON as typed objects, generate classes from the OpenEDI file in your language and deserialize the JSON into TS837P. Serialize the objects back to JSON to build EDI with ediFabric Native. The classes keep the loops, segments, lengths and code lists, but not the EDI data formats, so validate files with ediFabric Native. Read more in Generate a class from OpenEDI.
Python: datamodel-code-generator. Node.js: openapi-typescript. Java, Go, Rust and C: OpenAPI Generator.
For a sample file, the same data as JSON, and code to parse, validate and generate the 837P, see the 837P transaction guide.
837P structure
Loops and segments of the standard 837P, with their usage and maximum repeats.
| ID | Name | Usage | Max use |
|---|---|---|---|
| ST | Transaction Set Header | Optional | 1 |
| BHT | Beginning Of Hierarchical Transaction | Mandatory | 1 |
| REF | Transmission Type Identification | Mandatory | 1 |
| Loop NM1 | Submitter Name | Mandatory | 1 |
| NM1 | Submitter Name | Mandatory | 1 |
| PER | Submitter EDI Contact Information | Mandatory | 2 |
| Loop NM1 | Receiver Name | Mandatory | 1 |
| NM1 | Receiver Name | Mandatory | 1 |
| Loop HL | Billing Payto Provider Hierarchical Level | Mandatory | >1 |
| HL | Billing Payto Provider Hierarchical Level | Mandatory | 1 |
| PRV | Billing Payto Provider Specialty Information | Optional | 1 |
| CUR | Foreign Currency Information | Optional | 1 |
| Loop NM1 | Billing Provider Name 2010AA | Mandatory | 1 |
| NM1 | Billing Provider Name 2010AA | Mandatory | 1 |
| N3 | Billing Provider Address 2010AA | Mandatory | 1 |
| N4 | Billing Provider City State ZIP Code 2010AA | Mandatory | 1 |
| REF | Billing Provider Secondary Identification 2010AA | Optional | 8 |
| REF | Credit Debit Card Billing Information 2010AA | Optional | 8 |
| PER | Billing Provider Contact Information 2010AA | Optional | 2 |
| Loop NM1 | Payto Provider Name 2010AB | Optional | 1 |
| NM1 | Payto Provider Name 2010AB | Mandatory | 1 |
| N3 | Payto Provider Address 2010AB | Mandatory | 1 |
| N4 | Payto Provider City State ZIP Code 2010AB | Mandatory | 1 |
| REF | Payto Provider Secondary Identification 2010AB | Optional | 5 |
| Loop HL | Subscriber Hierarchical Level | Mandatory | >1 |
| HL | Subscriber Hierarchical Level | Mandatory | 1 |
| SBR | Subscriber Information | Mandatory | 1 |
| PAT | Patient Information | Optional | 1 |
| Loop NM1 | Subscriber Name 2010BA | Mandatory | 1 |
| NM1 | Subscriber Name 2010BA | Mandatory | 1 |
| N3 | Subscriber Address 2010BA | Optional | 1 |
| N4 | Subscriber City State ZIP Code 2010BA | Optional | 1 |
| DMG | Subscriber Demographic Information 2010BA | Optional | 1 |
| REF | Subscriber Secondary Identification 2010BA | Optional | 4 |
| REF | Property And Casualty Claim Number 2010BA | Optional | 1 |
| Loop NM1 | Payer Name 2010BB | Mandatory | 1 |
| NM1 | Payer Name 2010BB | Mandatory | 1 |
| N3 | Payer Address 2010BB | Optional | 1 |
| N4 | Payer City State ZIP Code 2010BB | Optional | 1 |
| REF | Payer Secondary Identification 2010BB | Optional | 3 |
| Loop NM1 | Responsible Party Name 2010BC | Optional | 1 |
| NM1 | Responsible Party Name 2010BC | Mandatory | 1 |
| N3 | Responsible Party Address 2010BC | Mandatory | 1 |
| N4 | Responsible Party City State ZIP Code 2010BC | Mandatory | 1 |
| Loop NM1 | Credit Debit Card Holder Name 2010BD | Optional | 1 |
| NM1 | Credit Debit Card Holder Name 2010BD | Mandatory | 1 |
| REF | Credit Debit Card Information 2010BD | Optional | 2 |
| Loop CLM | Claim Information | Optional | 100 |
| CLM | Claim Information | Mandatory | 1 |
| DTP | Date Initial Treatment | Optional | 1 |
| DTP | Date Date Last Seen | Optional | 1 |
| DTP | Date Onset Of Current Illness Symptom | Optional | 1 |
| DTP | Date Acute Manifestation | Optional | 5 |
| DTP | Date Similar Illness Symptom Onset | Optional | 10 |
| DTP | Date Accident | Optional | 10 |
| DTP | Date Last Menstrual Period | Optional | 1 |
| DTP | Date Last Xray | Optional | 1 |
| DTP | Date Hearing And Vision Prescription Date | Optional | 1 |
| DTP | Date Disability Begin | Optional | 5 |
| DTP | Date Disability End | Optional | 5 |
| DTP | Date Last Worked | Optional | 1 |
| DTP | Date Authorized Return To Work | Optional | 1 |
| DTP | Date Admission | Optional | 1 |
| DTP | Date Discharge | Optional | 1 |
| DTP | Date Assumed And Relinquished Care Dates | Optional | 2 |
| PWK | Claim Supplemental Information | Optional | 10 |
| CN1 | Contract Information | Optional | 1 |
| AMT | Credit Debit Card Maximum Amount | Optional | 1 |
| AMT | Patient Amount Paid | Optional | 1 |
| AMT | Total Purchased Service Amount | Optional | 1 |
| REF | Service Authorization Exception Code | Optional | 1 |
| REF | Mandatory Medicare Section4081Crossover Indicator | Optional | 1 |
| REF | Mammography Certification Number | Optional | 1 |
| REF | Prior Authorization Or Referral Number | Optional | 2 |
| REF | Original Reference Number ICNDCN | Optional | 1 |
| REF | Clinical Laboratory Improvement Amendment CLIA Number | Optional | 3 |
| REF | Repriced Claim Number | Optional | 1 |
| REF | Adjusted Repriced Claim Number | Optional | 1 |
| REF | Investigational Device Exemption Number | Optional | 1 |
| REF | Claim Identification Number For Clearing Houses And Other Transmission Intermediaries | Optional | 1 |
| REF | Ambulatory Patient Group APG | Optional | 4 |
| REF | Medical Record Number | Optional | 1 |
| REF | Demonstration Project Identifier | Optional | 1 |
| K3 | File Information | Optional | 10 |
| NTE | Claim Note | Optional | 1 |
| CR1 | Ambulance Transport Information | Optional | 1 |
| CR2 | Spinal Manipulation Service Information | Optional | 1 |
| CRC | Ambulance Certification | Optional | 3 |
| CRC | Patient Condition Information Vision | Optional | 3 |
| CRC | Homebound Indicator | Optional | 1 |
| CRC | EPSDT Referral | Optional | 1 |
| HI | Health Care Diagnosis Code | Optional | 1 |
| HCP | Claim Pricing Repricing Information | Optional | 1 |
| Loop CR7 | Home Health Care Plan Information | Optional | 6 |
| CR7 | Home Health Care Plan Information | Mandatory | 1 |
| HSD | Health Care Services Delivery | Optional | 3 |
| Loop NM1 | Referring Provider Name | Optional | 2 |
| NM1 | Referring Provider Name | Mandatory | 1 |
| PRV | Referring Provider Specialty Information | Optional | 1 |
| REF | Referring Provider Secondary Identification | Optional | 5 |
| Loop NM1 | Rendering Provider Name | Optional | 1 |
| NM1 | Rendering Provider Name | Mandatory | 1 |
| PRV | Rendering Provider Specialty Information | Optional | 1 |
| REF | Rendering Provider Secondary Identification | Optional | 5 |
| Loop NM1 | Purchased Service Provider Name | Optional | 1 |
| NM1 | Purchased Service Provider Name | Mandatory | 1 |
| REF | Purchased Service Provider Secondary Identification | Optional | 5 |
| Loop NM1 | Service Facility Location | Optional | 1 |
| NM1 | Service Facility Location | Mandatory | 1 |
| N3 | Service Facility Location Address | Mandatory | 1 |
| N4 | Service Facility Location City State ZIP | Mandatory | 1 |
| REF | Service Facility Location Secondary Identification | Optional | 5 |
| Loop NM1 | Supervising Provider Name | Optional | 1 |
| NM1 | Supervising Provider Name | Mandatory | 1 |
| REF | Supervising Provider Secondary Identification | Optional | 5 |
| Loop SBR | Other Subscriber Information | Optional | 10 |
| SBR | Other Subscriber Information | Mandatory | 1 |
| CAS | Claim Level Adjustments | Optional | 5 |
| AMT | Coordination Of Benefits COB Payer Paid Amount | Optional | 1 |
| AMT | Coordination Of Benefits COB Approved Amount | Optional | 1 |
| AMT | Coordination Of Benefits COB Allowed Amount | Optional | 1 |
| AMT | Coordination Of Benefits COB Patient Responsibility Amount | Optional | 1 |
| AMT | Coordination Of Benefits COB Covered Amount | Optional | 1 |
| AMT | Coordination Of Benefits COB Discount Amount | Optional | 1 |
| AMT | Coordination Of Benefits COB Per Day Limit Amount | Optional | 1 |
| AMT | Coordination Of Benefits COB Patient Paid Amount | Optional | 1 |
| AMT | Coordination Of Benefits COB Tax Amount | Optional | 1 |
| AMT | Coordination Of Benefits COB Total Claim Before Taxes Amount | Optional | 1 |
| DMG | Subscriber Demographic Information | Optional | 1 |
| OI | Other Insurance Coverage Information | Mandatory | 1 |
| MOA | Medicare Outpatient Adjudication Information | Optional | 1 |
| Loop NM1 | Other Subscriber Name | Mandatory | 1 |
| NM1 | Other Subscriber Name | Mandatory | 1 |
| N3 | Other Subscriber Address | Optional | 1 |
| N4 | Other Subscriber City State ZIP Code | Optional | 1 |
| REF | Other Subscriber Secondary Identification | Optional | 3 |
| Loop NM1 | Other Payer Name | Mandatory | 1 |
| NM1 | Other Payer Name | Mandatory | 1 |
| PER | Other Payer Contact Information | Optional | 2 |
| DTP | Claim Adjudication Date | Optional | 1 |
| REF | Other Payer Secondary Identifier | Optional | 2 |
| REF | Other Payer Prior Authorization Or Referral Number | Optional | 2 |
| REF | Other Payer Claim Adjustment Indicator | Optional | 2 |
| Loop NM1 | Other Payer Patient Information | Optional | 1 |
| NM1 | Other Payer Patient Information | Mandatory | 1 |
| REF | Other Payer Patient Identification | Optional | 3 |
| Loop NM1 | Other Payer Referring Provider | Optional | 2 |
| NM1 | Other Payer Referring Provider | Mandatory | 1 |
| REF | Other Payer Referring Provider Identification | Mandatory | 3 |
| Loop NM1 | Other Payer Rendering Provider | Optional | 1 |
| NM1 | Other Payer Rendering Provider | Mandatory | 1 |
| REF | Other Payer Rendering Provider Secondary Identification | Mandatory | 3 |
| Loop NM1 | Other Payer Purchased Service Provider | Optional | 1 |
| NM1 | Other Payer Purchased Service Provider | Mandatory | 1 |
| REF | Other Payer Purchased Service Provider Identification | Mandatory | 3 |
| Loop NM1 | Other Payer Service Facility Location | Optional | 1 |
| NM1 | Other Payer Service Facility Location | Mandatory | 1 |
| REF | Other Payer Service Facility Location Identification | Mandatory | 3 |
| Loop NM1 | Other Payer Supervising Provider | Optional | 1 |
| NM1 | Other Payer Supervising Provider | Mandatory | 1 |
| REF | Other Payer Supervising Provider Identification | Mandatory | 3 |
| Loop LX | Service Line | Mandatory | 50 |
| LX | Service Line | Mandatory | 1 |
| SV1 | Professional Service | Mandatory | 1 |
| SV5 | Durable Medical Equipment Service | Optional | 1 |
| PWK | DMERCCMN Indicator | Optional | 1 |
| CR1 | Ambulance Transport Information | Optional | 1 |
| CR2 | Spinal Manipulation Service Information | Optional | 5 |
| CR3 | Durable Medical Equipment Certification | Optional | 1 |
| CR5 | Home Oxygen Therapy Information | Optional | 1 |
| CRC | Ambulance Certification | Optional | 3 |
| CRC | Hospice Employee Indicator | Optional | 1 |
| CRC | DMERC Condition Indicator | Optional | 2 |
| DTP | Date Service Date | Mandatory | 1 |
| DTP | Date Certification Revision Date | Optional | 1 |
| DTP | Date Begin Therapy Date | Optional | 1 |
| DTP | Date Last Certification Date | Optional | 1 |
| DTP | Date Date Last Seen | Optional | 1 |
| DTP | Date Test | Optional | 2 |
| DTP | Date Oxygen Saturation Arterial Blood Gas Test | Optional | 3 |
| DTP | Date Shipped | Optional | 1 |
| DTP | Date Onset Of Current Symptom Illness | Optional | 1 |
| DTP | Date Last Xray | Optional | 1 |
| DTP | Date Acute Manifestation | Optional | 1 |
| DTP | Date Initial Treatment | Optional | 1 |
| DTP | Date Similar Illness Symptom Onset | Optional | 1 |
| MEA | Test Result | Optional | 20 |
| CN1 | Contract Information | Optional | 1 |
| REF | Repriced Line Item Reference Number | Optional | 1 |
| REF | Adjusted Repriced Line Item Reference Number | Optional | 1 |
| REF | Prior Authorization Or Referral Number | Optional | 2 |
| REF | Line Item Control Number | Optional | 1 |
| REF | Mammography Certification Number | Optional | 1 |
| REF | Clinical Laboratory Improvement Amendment CLIA Identification | Optional | 1 |
| REF | Referring Clinical Laboratory Improvement Amendment CLIA Facility Identification | Optional | 1 |
| REF | Immunization Batch Number | Optional | 1 |
| REF | Ambulatory Patient Group APG | Optional | 4 |
| REF | Oxygen Flow Rate | Optional | 1 |
| REF | Universal Product Number UPN | Optional | 1 |
| AMT | Sales Tax Amount | Optional | 1 |
| AMT | Approved Amount | Optional | 1 |
| AMT | Postage Claimed Amount | Optional | 1 |
| K3 | File Information | Optional | 10 |
| NTE | Line Note | Optional | 1 |
| PS1 | Purchased Service Information | Optional | 1 |
| HSD | Health Care Services Delivery | Optional | 1 |
| HCP | Line Pricing Repricing Information | Optional | 1 |
| Loop LIN | Drug Identification | Optional | 25 |
| LIN | Drug Identification | Mandatory | 1 |
| CTP | Drug Pricing | Optional | 1 |
| REF | Prescription Number | Optional | 1 |
| Loop NM1 | Rendering Provider Name | Optional | 1 |
| NM1 | Rendering Provider Name | Mandatory | 1 |
| PRV | Rendering Provider Specialty Information | Optional | 1 |
| REF | Rendering Provider Secondary Identification | Optional | 5 |
| Loop NM1 | Purchased Service Provider Name | Optional | 1 |
| NM1 | Purchased Service Provider Name | Mandatory | 1 |
| REF | Purchased Service Provider Secondary Identification | Optional | 5 |
| Loop NM1 | Service Facility Location | Optional | 1 |
| NM1 | Service Facility Location | Mandatory | 1 |
| N3 | Service Facility Location Address | Mandatory | 1 |
| N4 | Service Facility Location City State ZIP | Mandatory | 1 |
| REF | Service Facility Location Secondary Identification | Optional | 5 |
| Loop NM1 | Supervising Provider Name | Optional | 1 |
| NM1 | Supervising Provider Name | Mandatory | 1 |
| REF | Supervising Provider Secondary Identification | Optional | 5 |
| Loop NM1 | Ordering Provider Name | Optional | 1 |
| NM1 | Ordering Provider Name | Mandatory | 1 |
| N3 | Ordering Provider Address | Optional | 1 |
| N4 | Ordering Provider City State ZIP Code | Optional | 1 |
| REF | Ordering Provider Secondary Identification | Optional | 5 |
| PER | Ordering Provider Contact Information | Optional | 1 |
| Loop NM1 | Referring Provider Name | Optional | 2 |
| NM1 | Referring Provider Name | Mandatory | 1 |
| PRV | Referring Provider Specialty Information | Optional | 1 |
| REF | Referring Provider Secondary Identification | Optional | 5 |
| Loop NM1 | Other Payer Prior Authorization Or Referral Number | Optional | 4 |
| NM1 | Other Payer Prior Authorization Or Referral Number | Mandatory | 1 |
| REF | Other Payer Prior Authorization Or Referral Number | Mandatory | 2 |
| Loop SVD | Line Adjudication Information | Optional | 25 |
| SVD | Line Adjudication Information | Mandatory | 1 |
| CAS | Line Adjustment | Optional | 99 |
| DTP | Line Adjudication Date | Mandatory | 1 |
| Loop LQ | Form Identification Code | Optional | 5 |
| LQ | Form Identification Code | Mandatory | 1 |
| FRM | Supporting Documentation | Mandatory | 99 |
| Loop HL | Patient Hierarchical Level | Optional | >1 |
| HL | Patient Hierarchical Level | Mandatory | 1 |
| PAT | Patient Information | Mandatory | 1 |
| Loop NM1 | Patient Name 2010CA | Mandatory | 1 |
| NM1 | Patient Name 2010CA | Mandatory | 1 |
| N3 | Patient Address 2010CA | Mandatory | 1 |
| N4 | Patient City State ZIP Code 2010CA | Mandatory | 1 |
| DMG | Patient Demographic Information 2010CA | Mandatory | 1 |
| REF | Subscriber Secondary Identification 2010BA | Optional | 4 |
| REF | Property And Casualty Claim Number 2010BA | Optional | 1 |
| Loop CLM | Claim Information | Mandatory | 100 |
| CLM | Claim Information | Mandatory | 1 |
| DTP | Date Initial Treatment | Optional | 1 |
| DTP | Date Date Last Seen | Optional | 1 |
| DTP | Date Onset Of Current Illness Symptom | Optional | 1 |
| DTP | Date Acute Manifestation | Optional | 5 |
| DTP | Date Similar Illness Symptom Onset | Optional | 10 |
| DTP | Date Accident | Optional | 10 |
| DTP | Date Last Menstrual Period | Optional | 1 |
| DTP | Date Last Xray | Optional | 1 |
| DTP | Date Hearing And Vision Prescription Date | Optional | 1 |
| DTP | Date Disability Begin | Optional | 5 |
| DTP | Date Disability End | Optional | 5 |
| DTP | Date Last Worked | Optional | 1 |
| DTP | Date Authorized Return To Work | Optional | 1 |
| DTP | Date Admission | Optional | 1 |
| DTP | Date Discharge | Optional | 1 |
| DTP | Date Assumed And Relinquished Care Dates | Optional | 2 |
| PWK | Claim Supplemental Information | Optional | 10 |
| CN1 | Contract Information | Optional | 1 |
| AMT | Credit Debit Card Maximum Amount | Optional | 1 |
| AMT | Patient Amount Paid | Optional | 1 |
| AMT | Total Purchased Service Amount | Optional | 1 |
| REF | Service Authorization Exception Code | Optional | 1 |
| REF | Mandatory Medicare Section4081Crossover Indicator | Optional | 1 |
| REF | Mammography Certification Number | Optional | 1 |
| REF | Prior Authorization Or Referral Number | Optional | 2 |
| REF | Original Reference Number ICNDCN | Optional | 1 |
| REF | Clinical Laboratory Improvement Amendment CLIA Number | Optional | 3 |
| REF | Repriced Claim Number | Optional | 1 |
| REF | Adjusted Repriced Claim Number | Optional | 1 |
| REF | Investigational Device Exemption Number | Optional | 1 |
| REF | Claim Identification Number For Clearing Houses And Other Transmission Intermediaries | Optional | 1 |
| REF | Ambulatory Patient Group APG | Optional | 4 |
| REF | Medical Record Number | Optional | 1 |
| REF | Demonstration Project Identifier | Optional | 1 |
| K3 | File Information | Optional | 10 |
| NTE | Claim Note | Optional | 1 |
| CR1 | Ambulance Transport Information | Optional | 1 |
| CR2 | Spinal Manipulation Service Information | Optional | 1 |
| CRC | Ambulance Certification | Optional | 3 |
| CRC | Patient Condition Information Vision | Optional | 3 |
| CRC | Homebound Indicator | Optional | 1 |
| CRC | EPSDT Referral | Optional | 1 |
| HI | Health Care Diagnosis Code | Optional | 1 |
| HCP | Claim Pricing Repricing Information | Optional | 1 |
| Loop CR7 | Home Health Care Plan Information | Optional | 6 |
| CR7 | Home Health Care Plan Information | Mandatory | 1 |
| HSD | Health Care Services Delivery | Optional | 3 |
| Loop NM1 | Referring Provider Name | Optional | 2 |
| NM1 | Referring Provider Name | Mandatory | 1 |
| PRV | Referring Provider Specialty Information | Optional | 1 |
| REF | Referring Provider Secondary Identification | Optional | 5 |
| Loop NM1 | Rendering Provider Name | Optional | 1 |
| NM1 | Rendering Provider Name | Mandatory | 1 |
| PRV | Rendering Provider Specialty Information | Optional | 1 |
| REF | Rendering Provider Secondary Identification | Optional | 5 |
| Loop NM1 | Purchased Service Provider Name | Optional | 1 |
| NM1 | Purchased Service Provider Name | Mandatory | 1 |
| REF | Purchased Service Provider Secondary Identification | Optional | 5 |
| Loop NM1 | Service Facility Location | Optional | 1 |
| NM1 | Service Facility Location | Mandatory | 1 |
| N3 | Service Facility Location Address | Mandatory | 1 |
| N4 | Service Facility Location City State ZIP | Mandatory | 1 |
| REF | Service Facility Location Secondary Identification | Optional | 5 |
| Loop NM1 | Supervising Provider Name | Optional | 1 |
| NM1 | Supervising Provider Name | Mandatory | 1 |
| REF | Supervising Provider Secondary Identification | Optional | 5 |
| Loop SBR | Other Subscriber Information | Optional | 10 |
| SBR | Other Subscriber Information | Mandatory | 1 |
| CAS | Claim Level Adjustments | Optional | 5 |
| AMT | Coordination Of Benefits COB Payer Paid Amount | Optional | 1 |
| AMT | Coordination Of Benefits COB Approved Amount | Optional | 1 |
| AMT | Coordination Of Benefits COB Allowed Amount | Optional | 1 |
| AMT | Coordination Of Benefits COB Patient Responsibility Amount | Optional | 1 |
| AMT | Coordination Of Benefits COB Covered Amount | Optional | 1 |
| AMT | Coordination Of Benefits COB Discount Amount | Optional | 1 |
| AMT | Coordination Of Benefits COB Per Day Limit Amount | Optional | 1 |
| AMT | Coordination Of Benefits COB Patient Paid Amount | Optional | 1 |
| AMT | Coordination Of Benefits COB Tax Amount | Optional | 1 |
| AMT | Coordination Of Benefits COB Total Claim Before Taxes Amount | Optional | 1 |
| DMG | Subscriber Demographic Information | Optional | 1 |
| OI | Other Insurance Coverage Information | Mandatory | 1 |
| MOA | Medicare Outpatient Adjudication Information | Optional | 1 |
| Loop NM1 | Other Subscriber Name | Mandatory | 1 |
| NM1 | Other Subscriber Name | Mandatory | 1 |
| N3 | Other Subscriber Address | Optional | 1 |
| N4 | Other Subscriber City State ZIP Code | Optional | 1 |
| REF | Other Subscriber Secondary Identification | Optional | 3 |
| Loop NM1 | Other Payer Name | Mandatory | 1 |
| NM1 | Other Payer Name | Mandatory | 1 |
| PER | Other Payer Contact Information | Optional | 2 |
| DTP | Claim Adjudication Date | Optional | 1 |
| REF | Other Payer Secondary Identifier | Optional | 2 |
| REF | Other Payer Prior Authorization Or Referral Number | Optional | 2 |
| REF | Other Payer Claim Adjustment Indicator | Optional | 2 |
| Loop NM1 | Other Payer Patient Information | Optional | 1 |
| NM1 | Other Payer Patient Information | Mandatory | 1 |
| REF | Other Payer Patient Identification | Optional | 3 |
| Loop NM1 | Other Payer Referring Provider | Optional | 2 |
| NM1 | Other Payer Referring Provider | Mandatory | 1 |
| REF | Other Payer Referring Provider Identification | Mandatory | 3 |
| Loop NM1 | Other Payer Rendering Provider | Optional | 1 |
| NM1 | Other Payer Rendering Provider | Mandatory | 1 |
| REF | Other Payer Rendering Provider Secondary Identification | Mandatory | 3 |
| Loop NM1 | Other Payer Purchased Service Provider | Optional | 1 |
| NM1 | Other Payer Purchased Service Provider | Mandatory | 1 |
| REF | Other Payer Purchased Service Provider Identification | Mandatory | 3 |
| Loop NM1 | Other Payer Service Facility Location | Optional | 1 |
| NM1 | Other Payer Service Facility Location | Mandatory | 1 |
| REF | Other Payer Service Facility Location Identification | Mandatory | 3 |
| Loop NM1 | Other Payer Supervising Provider | Optional | 1 |
| NM1 | Other Payer Supervising Provider | Mandatory | 1 |
| REF | Other Payer Supervising Provider Identification | Mandatory | 3 |
| Loop LX | Service Line | Mandatory | 50 |
| LX | Service Line | Mandatory | 1 |
| SV1 | Professional Service | Mandatory | 1 |
| SV5 | Durable Medical Equipment Service | Optional | 1 |
| PWK | DMERCCMN Indicator | Optional | 1 |
| CR1 | Ambulance Transport Information | Optional | 1 |
| CR2 | Spinal Manipulation Service Information | Optional | 5 |
| CR3 | Durable Medical Equipment Certification | Optional | 1 |
| CR5 | Home Oxygen Therapy Information | Optional | 1 |
| CRC | Ambulance Certification | Optional | 3 |
| CRC | Hospice Employee Indicator | Optional | 1 |
| CRC | DMERC Condition Indicator | Optional | 2 |
| DTP | Date Service Date | Mandatory | 1 |
| DTP | Date Certification Revision Date | Optional | 1 |
| DTP | Date Begin Therapy Date | Optional | 1 |
| DTP | Date Last Certification Date | Optional | 1 |
| DTP | Date Date Last Seen | Optional | 1 |
| DTP | Date Test | Optional | 2 |
| DTP | Date Oxygen Saturation Arterial Blood Gas Test | Optional | 3 |
| DTP | Date Shipped | Optional | 1 |
| DTP | Date Onset Of Current Symptom Illness | Optional | 1 |
| DTP | Date Last Xray | Optional | 1 |
| DTP | Date Acute Manifestation | Optional | 1 |
| DTP | Date Initial Treatment | Optional | 1 |
| DTP | Date Similar Illness Symptom Onset | Optional | 1 |
| MEA | Test Result | Optional | 20 |
| CN1 | Contract Information | Optional | 1 |
| REF | Repriced Line Item Reference Number | Optional | 1 |
| REF | Adjusted Repriced Line Item Reference Number | Optional | 1 |
| REF | Prior Authorization Or Referral Number | Optional | 2 |
| REF | Line Item Control Number | Optional | 1 |
| REF | Mammography Certification Number | Optional | 1 |
| REF | Clinical Laboratory Improvement Amendment CLIA Identification | Optional | 1 |
| REF | Referring Clinical Laboratory Improvement Amendment CLIA Facility Identification | Optional | 1 |
| REF | Immunization Batch Number | Optional | 1 |
| REF | Ambulatory Patient Group APG | Optional | 4 |
| REF | Oxygen Flow Rate | Optional | 1 |
| REF | Universal Product Number UPN | Optional | 1 |
| AMT | Sales Tax Amount | Optional | 1 |
| AMT | Approved Amount | Optional | 1 |
| AMT | Postage Claimed Amount | Optional | 1 |
| K3 | File Information | Optional | 10 |
| NTE | Line Note | Optional | 1 |
| PS1 | Purchased Service Information | Optional | 1 |
| HSD | Health Care Services Delivery | Optional | 1 |
| HCP | Line Pricing Repricing Information | Optional | 1 |
| Loop LIN | Drug Identification | Optional | 25 |
| LIN | Drug Identification | Mandatory | 1 |
| CTP | Drug Pricing | Optional | 1 |
| REF | Prescription Number | Optional | 1 |
| Loop NM1 | Rendering Provider Name | Optional | 1 |
| NM1 | Rendering Provider Name | Mandatory | 1 |
| PRV | Rendering Provider Specialty Information | Optional | 1 |
| REF | Rendering Provider Secondary Identification | Optional | 5 |
| Loop NM1 | Purchased Service Provider Name | Optional | 1 |
| NM1 | Purchased Service Provider Name | Mandatory | 1 |
| REF | Purchased Service Provider Secondary Identification | Optional | 5 |
| Loop NM1 | Service Facility Location | Optional | 1 |
| NM1 | Service Facility Location | Mandatory | 1 |
| N3 | Service Facility Location Address | Mandatory | 1 |
| N4 | Service Facility Location City State ZIP | Mandatory | 1 |
| REF | Service Facility Location Secondary Identification | Optional | 5 |
| Loop NM1 | Supervising Provider Name | Optional | 1 |
| NM1 | Supervising Provider Name | Mandatory | 1 |
| REF | Supervising Provider Secondary Identification | Optional | 5 |
| Loop NM1 | Ordering Provider Name | Optional | 1 |
| NM1 | Ordering Provider Name | Mandatory | 1 |
| N3 | Ordering Provider Address | Optional | 1 |
| N4 | Ordering Provider City State ZIP Code | Optional | 1 |
| REF | Ordering Provider Secondary Identification | Optional | 5 |
| PER | Ordering Provider Contact Information | Optional | 1 |
| Loop NM1 | Referring Provider Name | Optional | 2 |
| NM1 | Referring Provider Name | Mandatory | 1 |
| PRV | Referring Provider Specialty Information | Optional | 1 |
| REF | Referring Provider Secondary Identification | Optional | 5 |
| Loop NM1 | Other Payer Prior Authorization Or Referral Number | Optional | 4 |
| NM1 | Other Payer Prior Authorization Or Referral Number | Mandatory | 1 |
| REF | Other Payer Prior Authorization Or Referral Number | Mandatory | 2 |
| Loop SVD | Line Adjudication Information | Optional | 25 |
| SVD | Line Adjudication Information | Mandatory | 1 |
| CAS | Line Adjustment | Optional | 99 |
| DTP | Line Adjudication Date | Mandatory | 1 |
| Loop LQ | Form Identification Code | Optional | 5 |
| LQ | Form Identification Code | Mandatory | 1 |
| FRM | Supporting Documentation | Mandatory | 99 |
| SE | Transaction Set Trailer | Optional | 1 |