837P Health Care Claim: Professional (005010X222)
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 005010 before the errata spec, with 65 loops and 380 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 005010X222 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 |
| 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 Provider Hierarchical Level | Mandatory | >1 |
| HL | Billing Provider Hierarchical Level | Mandatory | 1 |
| PRV | Billing Provider Specialty Information | Optional | 1 |
| CUR | Foreign Currency Information | Optional | 1 |
| Loop NM1 | Billing Provider Name | Mandatory | 1 |
| NM1 | Billing Provider Name | Mandatory | 1 |
| N3 | Billing Provider Address | Mandatory | 1 |
| N4 | Billing Provider City State ZIP Code | Mandatory | 1 |
| REF | Billing Provider Tax Identification | Mandatory | 1 |
| REF | Billing Provider UPIN License Information | Optional | 2 |
| PER | Billing Provider Contact Information | Optional | 2 |
| Loop NM1 | Pay Address Name | Optional | 1 |
| NM1 | Pay Address Name | Mandatory | 1 |
| N3 | Pay To Address ADDRESS | Mandatory | 1 |
| N4 | Pay Address City State ZIP Code | Mandatory | 1 |
| Loop NM1 | Pay To Plan Name | Optional | 1 |
| NM1 | Pay To Plan Name | Mandatory | 1 |
| N3 | Pay To Plan Address | Mandatory | 1 |
| N4 | Pay To Plan City State ZIP Code | Mandatory | 1 |
| REF | Pay To Plan Secondary Identification | Optional | 1 |
| REF | Pay To Plan Tax Identification Number | Mandatory | 1 |
| 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 | Mandatory | 1 |
| NM1 | Subscriber Name | Mandatory | 1 |
| N3 | Subscriber Address | Optional | 1 |
| N4 | Subscriber City State ZIP Code | Mandatory | 1 |
| DMG | Subscriber Demographic Information | Optional | 1 |
| REF | Subscriber Secondary Identification | Optional | 1 |
| REF | Propertyand Casualty Claim Number | Optional | 1 |
| PER | Propertyand Casualty Subscriber Contact Information | Optional | 1 |
| Loop NM1 | Payer Name | Mandatory | 1 |
| NM1 | Payer Name | Mandatory | 1 |
| N3 | Payer Address | Optional | 1 |
| N4 | Payer City State ZIP Code | Mandatory | 1 |
| REF | Payer Secondary Identification | Optional | 3 |
| REF | Billing Provider Secondary Identification | Optional | 2 |
| Loop CLM | Claim Information | Optional | 100 |
| CLM | Claim Information | Mandatory | 1 |
| DTP | Date Onsetof Current Illnessor Symptom | Optional | 1 |
| DTP | Date Initial Treatment Date | Optional | 1 |
| DTP | Date Last Seen Date | Optional | 1 |
| DTP | Date Acute Manifestation | Optional | 1 |
| DTP | Date Accident | Optional | 1 |
| DTP | Date Last Menstrual Period | Optional | 1 |
| DTP | Date Last X Date | Optional | 1 |
| DTP | Date Hearingand Vision Prescription Date | Optional | 1 |
| DTP | Date Disability Dates | Optional | 1 |
| DTP | Date Last Worked | Optional | 1 |
| DTP | Date Authorized Returnto Work | Optional | 1 |
| DTP | Date Admission | Optional | 1 |
| DTP | Date Discharge | Optional | 1 |
| DTP | Date Assumedand Relinquished Care Dates | Optional | 2 |
| DTP | Propertyand Casualty Dateof First Contact | Optional | 1 |
| DTP | Date Repricer Received Date | Optional | 1 |
| PWK | Claim Supplemental Information | Optional | 10 |
| CN1 | Contract Information | Optional | 1 |
| AMT | Patient Amount Paid | Optional | 1 |
| REF | Service Authorization Exception Code | Optional | 1 |
| REF | Mandatory Medicare Section4081 Crossover Indicator | Optional | 1 |
| REF | Mammography Certification Number | Optional | 1 |
| REF | Referral Number | Optional | 1 |
| REF | Prior Authorization | Optional | 1 |
| REF | Payer Claim Control Number | Optional | 1 |
| REF | Clinical Laboratory Improvement Amendment CLIA Number | Optional | 1 |
| REF | Repriced Claim Number | Optional | 1 |
| REF | Adjusted Repriced Claim Number | Optional | 1 |
| REF | Investigational Device Exemption Number | Optional | 1 |
| REF | Claim Identifier For Transmission Intermediaries | Optional | 1 |
| REF | Medical Record Number | Optional | 1 |
| REF | Demonstration Project Identifier | Optional | 1 |
| REF | Care Plan Oversight | 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 | Mandatory | 1 |
| HI | Anesthesia Related Procedure | Optional | 1 |
| HI | Condition Information | Optional | 2 |
| HCP | Claim Pricing Repricing Information | Optional | 1 |
| Loop NM1 | Referring Provider Name | Optional | 2 |
| NM1 | Referring Provider Name | Mandatory | 1 |
| REF | Referring Provider Secondary Identification | Optional | 3 |
| 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 | 4 |
| Loop NM1 | Service Facility Location Name | Optional | 1 |
| NM1 | Service Facility Location Name | Mandatory | 1 |
| N3 | Service Facility Location Address | Mandatory | 1 |
| N4 | Service Facility Location City State ZIP Code | Mandatory | 1 |
| REF | Service Facility Location Secondary Identification | Optional | 3 |
| PER | Service Facility Contact Information | Optional | 1 |
| Loop NM1 | Supervising Provider Name | Optional | 1 |
| NM1 | Supervising Provider Name | Mandatory | 1 |
| REF | Supervising Provider Secondary Identification | Optional | 4 |
| Loop NM1 | Ambulance Pick Location | Optional | 1 |
| NM1 | Ambulance Pick Location | Mandatory | 1 |
| N3 | Ambulance Pick Location Address | Mandatory | 1 |
| N4 | Ambulance Pick Location City State Zip Code | Mandatory | 1 |
| Loop NM1 | Ambulance Drop Location | Optional | 1 |
| NM1 | Ambulance Drop Location | Mandatory | 1 |
| N3 | Ambulance Drop Location Address | Mandatory | 1 |
| N4 | Ambulance Drop Location City State Zip Code | Mandatory | 1 |
| Loop SBR | Other Subscriber Information | Optional | 10 |
| SBR | Other Subscriber Information | Mandatory | 1 |
| CAS | Claim Level Adjustments | Optional | 5 |
| AMT | Coordinationof Benefits COB Payer Paid Amount | Optional | 1 |
| AMT | Coordinationof Benefits COB Total Non Amount | Optional | 1 |
| AMT | Remaining Patient Liability | Optional | 1 |
| OI | Other Insurance Coverage Information | Mandatory | 1 |
| MOA | 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 | Mandatory | 1 |
| REF | Other Subscriber Secondary Identification | Optional | 1 |
| Loop NM1 | Other Payer Name | Mandatory | 1 |
| NM1 | Other Payer Name | Mandatory | 1 |
| N3 | Other Payer Address | Optional | 1 |
| N4 | Other Payer City State ZIP Code | Mandatory | 1 |
| DTP | Claim Checkor Remittance Date | Optional | 1 |
| REF | Other Payer Secondary Identifier | Optional | 2 |
| REF | Other Payer Prior Authorization Number | Optional | 1 |
| REF | Other Payer Referral Number | Optional | 1 |
| REF | Other Payer Claim Adjustment Indicator | Optional | 1 |
| REF | Other Payer Claim Control Number | Optional | 1 |
| Loop NM1 | Other Payer Referring Provider | Optional | 2 |
| NM1 | Other Payer Referring Provider | Mandatory | 1 |
| REF | Other Payer Referring Provider Secondary 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 Service Facility Location | Optional | 1 |
| NM1 | Other Payer Service Facility Location | Mandatory | 1 |
| REF | Other Payer Service Facility Location Secondary Identification | Mandatory | 3 |
| Loop NM1 | Other Payer Supervising Provider | Optional | 1 |
| NM1 | Other Payer Supervising Provider | Mandatory | 1 |
| REF | Other Payer Supervising Provider Secondary Identification | Mandatory | 3 |
| Loop NM1 | Other Payer Billing Provider | Optional | 1 |
| NM1 | Other Payer Billing Provider | Mandatory | 1 |
| REF | Other Payer Billing Provider Secondary Identification | Mandatory | 2 |
| Loop LX | Service Line Number | Mandatory | 50 |
| LX | Service Line Number | Mandatory | 1 |
| SV1 | Professional Service | Mandatory | 1 |
| SV5 | Durable Medical Equipment Service | Optional | 1 |
| PWK | Line Supplemental Information | Optional | 10 |
| PWK | Durable Medical Equipment Certificateof Medical Necessity Indicator | Optional | 1 |
| CR1 | Ambulance Transport Information | Optional | 1 |
| CR3 | Durable Medical Equipment Certification | Optional | 1 |
| CRC | Ambulance Certification | Optional | 3 |
| CRC | Hospice Employee Indicator | Optional | 1 |
| CRC | Condition Indicator Durable Medical Equipment | Optional | 1 |
| DTP | Date Service Date | Mandatory | 1 |
| DTP | Date Prescription Date | Optional | 1 |
| DTP | DATE Certification Revision Recertification Date | Optional | 1 |
| DTP | Date Begin Therapy Date | Optional | 1 |
| DTP | Date Last Certification Date | Optional | 1 |
| DTP | Date Last Seen Date | Optional | 1 |
| DTP | Date Test Date | Optional | 2 |
| DTP | Date Shipped Date | Optional | 1 |
| DTP | Date Last X Date | Optional | 1 |
| DTP | Date Initial Treatment Date | Optional | 1 |
| QTY | Ambulance Patient Count | Optional | 1 |
| QTY | Obstetric Anesthesia Additional Units | Optional | 1 |
| MEA | Test Result | Optional | 5 |
| 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 | Optional | 5 |
| REF | Line Item Control Number | Optional | 1 |
| REF | Mammography Certification Number | Optional | 1 |
| REF | Clinical Laboratory Improvement Amendment CLIA Number | Optional | 1 |
| REF | Referring Clinical Laboratory Improvement Amendment CLIA Facility Identification | Optional | 1 |
| REF | Immunization Batch Number | Optional | 1 |
| REF | Referral Number | Optional | 5 |
| AMT | Sales Tax Amount | Optional | 1 |
| AMT | Postage Claimed Amount | Optional | 1 |
| K3 | File Information | Optional | 10 |
| NTE | Line Note | Optional | 1 |
| NTE | Third Party Organization Notes | Optional | 1 |
| PS1 | Purchased Service Information | Optional | 1 |
| HCP | Line Pricing Repricing Information | Optional | 1 |
| Loop LIN | Drug Identification | Optional | 1 |
| LIN | Drug Identification | Mandatory | 1 |
| CTP | Drug Quantity | Mandatory | 1 |
| REF | Prescriptionor Compound Drug Association 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 | 20 |
| Loop NM1 | Purchased Service Provider Name | Optional | 1 |
| NM1 | Purchased Service Provider Name | Mandatory | 1 |
| REF | Purchased Service Provider Secondary Identification | Optional | 20 |
| 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 Code | Mandatory | 1 |
| REF | Service Facility Location Secondary Identification | Optional | 3 |
| Loop NM1 | Supervising Provider Name | Optional | 1 |
| NM1 | Supervising Provider Name | Mandatory | 1 |
| REF | Supervising Provider Secondary Identification | Optional | 20 |
| 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 | Mandatory | 1 |
| REF | Ordering Provider Secondary Identification | Optional | 20 |
| PER | Ordering Provider Contact Information | Optional | 1 |
| Loop NM1 | Referring Provider Name | Optional | 2 |
| NM1 | Referring Provider Name | Mandatory | 1 |
| REF | Referring Provider Secondary Identification | Optional | 20 |
| Loop NM1 | Ambulance Pick Location | Optional | 1 |
| NM1 | Ambulance Pick Location | Mandatory | 1 |
| N3 | Ambulance Pick Location Address | Mandatory | 1 |
| N4 | Ambulance Pick Location City State Zip Code | Mandatory | 1 |
| Loop NM1 | Ambulance Drop Location | Optional | 1 |
| NM1 | Ambulance Drop Location | Mandatory | 1 |
| N3 | Ambulance Drop Location Address | Mandatory | 1 |
| N4 | Ambulance Drop Location City State Zip Code | Mandatory | 1 |
| Loop SVD | Line Adjudication Information | Optional | 15 |
| SVD | Line Adjudication Information | Mandatory | 1 |
| CAS | Line Adjustment | Optional | 5 |
| DTP | Line Checkor Remittance Date | Mandatory | 1 |
| AMT | Remaining Patient Liability | Optional | 1 |
| Loop LQ | Form Identification Code | Optional | >1 |
| 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 | Mandatory | 1 |
| NM1 | Patient Name | Mandatory | 1 |
| N3 | Patient Address | Mandatory | 1 |
| N4 | Patient City State ZIP Code | Mandatory | 1 |
| DMG | Patient Demographic Information | Mandatory | 1 |
| REF | Propertyand Casualty Claim Number | Optional | 1 |
| PER | Propertyand Casualty Patient Contact Information | Optional | 1 |
| Loop CLM | Claim Information | Mandatory | 100 |
| CLM | Claim Information | Mandatory | 1 |
| DTP | Date Onsetof Current Illnessor Symptom | Optional | 1 |
| DTP | Date Initial Treatment Date | Optional | 1 |
| DTP | Date Last Seen Date | Optional | 1 |
| DTP | Date Acute Manifestation | Optional | 1 |
| DTP | Date Accident | Optional | 1 |
| DTP | Date Last Menstrual Period | Optional | 1 |
| DTP | Date Last X Date | Optional | 1 |
| DTP | Date Hearingand Vision Prescription Date | Optional | 1 |
| DTP | Date Disability Dates | Optional | 1 |
| DTP | Date Last Worked | Optional | 1 |
| DTP | Date Authorized Returnto Work | Optional | 1 |
| DTP | Date Admission | Optional | 1 |
| DTP | Date Discharge | Optional | 1 |
| DTP | Date Assumedand Relinquished Care Dates | Optional | 2 |
| DTP | Propertyand Casualty Dateof First Contact | Optional | 1 |
| DTP | Date Repricer Received Date | Optional | 1 |
| PWK | Claim Supplemental Information | Optional | 10 |
| CN1 | Contract Information | Optional | 1 |
| AMT | Patient Amount Paid | Optional | 1 |
| REF | Service Authorization Exception Code | Optional | 1 |
| REF | Mandatory Medicare Section4081 Crossover Indicator | Optional | 1 |
| REF | Mammography Certification Number | Optional | 1 |
| REF | Referral Number | Optional | 1 |
| REF | Prior Authorization | Optional | 1 |
| REF | Payer Claim Control Number | Optional | 1 |
| REF | Clinical Laboratory Improvement Amendment CLIA Number | Optional | 1 |
| REF | Repriced Claim Number | Optional | 1 |
| REF | Adjusted Repriced Claim Number | Optional | 1 |
| REF | Investigational Device Exemption Number | Optional | 1 |
| REF | Claim Identifier For Transmission Intermediaries | Optional | 1 |
| REF | Medical Record Number | Optional | 1 |
| REF | Demonstration Project Identifier | Optional | 1 |
| REF | Care Plan Oversight | 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 | Mandatory | 1 |
| HI | Anesthesia Related Procedure | Optional | 1 |
| HI | Condition Information | Optional | 2 |
| HCP | Claim Pricing Repricing Information | Optional | 1 |
| Loop NM1 | Referring Provider Name | Optional | 2 |
| NM1 | Referring Provider Name | Mandatory | 1 |
| REF | Referring Provider Secondary Identification | Optional | 3 |
| 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 | 4 |
| Loop NM1 | Service Facility Location Name | Optional | 1 |
| NM1 | Service Facility Location Name | Mandatory | 1 |
| N3 | Service Facility Location Address | Mandatory | 1 |
| N4 | Service Facility Location City State ZIP Code | Mandatory | 1 |
| REF | Service Facility Location Secondary Identification | Optional | 3 |
| PER | Service Facility Contact Information | Optional | 1 |
| Loop NM1 | Supervising Provider Name | Optional | 1 |
| NM1 | Supervising Provider Name | Mandatory | 1 |
| REF | Supervising Provider Secondary Identification | Optional | 4 |
| Loop NM1 | Ambulance Pick Location | Optional | 1 |
| NM1 | Ambulance Pick Location | Mandatory | 1 |
| N3 | Ambulance Pick Location Address | Mandatory | 1 |
| N4 | Ambulance Pick Location City State Zip Code | Mandatory | 1 |
| Loop NM1 | Ambulance Drop Location | Optional | 1 |
| NM1 | Ambulance Drop Location | Mandatory | 1 |
| N3 | Ambulance Drop Location Address | Mandatory | 1 |
| N4 | Ambulance Drop Location City State Zip Code | Mandatory | 1 |
| Loop SBR | Other Subscriber Information | Optional | 10 |
| SBR | Other Subscriber Information | Mandatory | 1 |
| CAS | Claim Level Adjustments | Optional | 5 |
| AMT | Coordinationof Benefits COB Payer Paid Amount | Optional | 1 |
| AMT | Coordinationof Benefits COB Total Non Amount | Optional | 1 |
| AMT | Remaining Patient Liability | Optional | 1 |
| OI | Other Insurance Coverage Information | Mandatory | 1 |
| MOA | 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 | Mandatory | 1 |
| REF | Other Subscriber Secondary Identification | Optional | 1 |
| Loop NM1 | Other Payer Name | Mandatory | 1 |
| NM1 | Other Payer Name | Mandatory | 1 |
| N3 | Other Payer Address | Optional | 1 |
| N4 | Other Payer City State ZIP Code | Mandatory | 1 |
| DTP | Claim Checkor Remittance Date | Optional | 1 |
| REF | Other Payer Secondary Identifier | Optional | 2 |
| REF | Other Payer Prior Authorization Number | Optional | 1 |
| REF | Other Payer Referral Number | Optional | 1 |
| REF | Other Payer Claim Adjustment Indicator | Optional | 1 |
| REF | Other Payer Claim Control Number | Optional | 1 |
| Loop NM1 | Other Payer Referring Provider | Optional | 2 |
| NM1 | Other Payer Referring Provider | Mandatory | 1 |
| REF | Other Payer Referring Provider Secondary 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 Service Facility Location | Optional | 1 |
| NM1 | Other Payer Service Facility Location | Mandatory | 1 |
| REF | Other Payer Service Facility Location Secondary Identification | Mandatory | 3 |
| Loop NM1 | Other Payer Supervising Provider | Optional | 1 |
| NM1 | Other Payer Supervising Provider | Mandatory | 1 |
| REF | Other Payer Supervising Provider Secondary Identification | Mandatory | 3 |
| Loop NM1 | Other Payer Billing Provider | Optional | 1 |
| NM1 | Other Payer Billing Provider | Mandatory | 1 |
| REF | Other Payer Billing Provider Secondary Identification | Mandatory | 2 |
| Loop LX | Service Line Number | Mandatory | 50 |
| LX | Service Line Number | Mandatory | 1 |
| SV1 | Professional Service | Mandatory | 1 |
| SV5 | Durable Medical Equipment Service | Optional | 1 |
| PWK | Line Supplemental Information | Optional | 10 |
| PWK | Durable Medical Equipment Certificateof Medical Necessity Indicator | Optional | 1 |
| CR1 | Ambulance Transport Information | Optional | 1 |
| CR3 | Durable Medical Equipment Certification | Optional | 1 |
| CRC | Ambulance Certification | Optional | 3 |
| CRC | Hospice Employee Indicator | Optional | 1 |
| CRC | Condition Indicator Durable Medical Equipment | Optional | 1 |
| DTP | Date Service Date | Mandatory | 1 |
| DTP | Date Prescription Date | Optional | 1 |
| DTP | DATE Certification Revision Recertification Date | Optional | 1 |
| DTP | Date Begin Therapy Date | Optional | 1 |
| DTP | Date Last Certification Date | Optional | 1 |
| DTP | Date Last Seen Date | Optional | 1 |
| DTP | Date Test Date | Optional | 2 |
| DTP | Date Shipped Date | Optional | 1 |
| DTP | Date Last X Date | Optional | 1 |
| DTP | Date Initial Treatment Date | Optional | 1 |
| QTY | Ambulance Patient Count | Optional | 1 |
| QTY | Obstetric Anesthesia Additional Units | Optional | 1 |
| MEA | Test Result | Optional | 5 |
| 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 | Optional | 5 |
| REF | Line Item Control Number | Optional | 1 |
| REF | Mammography Certification Number | Optional | 1 |
| REF | Clinical Laboratory Improvement Amendment CLIA Number | Optional | 1 |
| REF | Referring Clinical Laboratory Improvement Amendment CLIA Facility Identification | Optional | 1 |
| REF | Immunization Batch Number | Optional | 1 |
| REF | Referral Number | Optional | 5 |
| AMT | Sales Tax Amount | Optional | 1 |
| AMT | Postage Claimed Amount | Optional | 1 |
| K3 | File Information | Optional | 10 |
| NTE | Line Note | Optional | 1 |
| NTE | Third Party Organization Notes | Optional | 1 |
| PS1 | Purchased Service Information | Optional | 1 |
| HCP | Line Pricing Repricing Information | Optional | 1 |
| Loop LIN | Drug Identification | Optional | 1 |
| LIN | Drug Identification | Mandatory | 1 |
| CTP | Drug Quantity | Mandatory | 1 |
| REF | Prescriptionor Compound Drug Association 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 | 20 |
| Loop NM1 | Purchased Service Provider Name | Optional | 1 |
| NM1 | Purchased Service Provider Name | Mandatory | 1 |
| REF | Purchased Service Provider Secondary Identification | Optional | 20 |
| 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 Code | Mandatory | 1 |
| REF | Service Facility Location Secondary Identification | Optional | 3 |
| Loop NM1 | Supervising Provider Name | Optional | 1 |
| NM1 | Supervising Provider Name | Mandatory | 1 |
| REF | Supervising Provider Secondary Identification | Optional | 20 |
| 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 | Mandatory | 1 |
| REF | Ordering Provider Secondary Identification | Optional | 20 |
| PER | Ordering Provider Contact Information | Optional | 1 |
| Loop NM1 | Referring Provider Name | Optional | 2 |
| NM1 | Referring Provider Name | Mandatory | 1 |
| REF | Referring Provider Secondary Identification | Optional | 20 |
| Loop NM1 | Ambulance Pick Location | Optional | 1 |
| NM1 | Ambulance Pick Location | Mandatory | 1 |
| N3 | Ambulance Pick Location Address | Mandatory | 1 |
| N4 | Ambulance Pick Location City State Zip Code | Mandatory | 1 |
| Loop NM1 | Ambulance Drop Location | Optional | 1 |
| NM1 | Ambulance Drop Location | Mandatory | 1 |
| N3 | Ambulance Drop Location Address | Mandatory | 1 |
| N4 | Ambulance Drop Location City State Zip Code | Mandatory | 1 |
| Loop SVD | Line Adjudication Information | Optional | 15 |
| SVD | Line Adjudication Information | Mandatory | 1 |
| CAS | Line Adjustment | Optional | 5 |
| DTP | Line Checkor Remittance Date | Mandatory | 1 |
| AMT | Remaining Patient Liability | Optional | 1 |
| Loop LQ | Form Identification Code | Optional | >1 |
| LQ | Form Identification Code | Mandatory | 1 |
| FRM | Supporting Documentation | Mandatory | 99 |
| SE | Transaction Set Trailer | Optional | 1 |