277U Structure and Data Sources

ISA

Interchange Control Header

1

O

ISA01

Authorization Information Qualifier

1

M

ID

2-2

00 no authorization information present

ISA02

Authorization Information

1

M

AN

10-10

Blank (ten spaces)

ISA03

Security Information Qualifier

1

M

ID

2-2

00 no authorization information present

ISA04

Security Information

1

M

AN

10-10

Blank (ten spaces)

ISA05

Interchange ID Qualifier

1

M

ID

2-2

From initiating transaction’s ISA07

ISA06

Interchange Sender ID

1

M

AN

15-15

From initiating transaction’s ISA08

ISA07

Interchange ID Qualifier

1

M

ID

2-2

From initiating transaction’s ISA05

ISA08

Interchange Receiver ID

1

M

AN

15-15

From initiating transaction’s ISA06

ISA09

Interchange Date

1

M

DT

6-6

Current date in YYMMDD format

ISA10

Interchange Time

1

M

TM

4-4

Current time in HHMM format

ISA11

Repetition Separator

1

M

ID

1-1

^ - Default

ISA12

Interchange Control Version Number

1

M

ID

5-5

00501

ISA13

Interchange Control Number

1

M

N0

9-9

Specified interchange control number, zero-filled, starting at “000000001”, and increments by 1 for each Control Number

ISA14

Acknowledgment Requested

1

M

ID

1-1

0 - No acknowledgment requested

ISA15

Usage Indicator

1

M

ID

1-1

P - Production Data

GS01

Functional Identifier Code

1

M

ID

2-2

HN

GS02

Application Sender's Code

1

M

AN

2-15

From initiating transaction’s GS03

GS03

Application Receiver's Code

1

M

AN

2-15

From initiating transaction’s GS02

GS04

Date

1

M

DT

8-8

Current date in YYYYMMDD format

GS05

Time

1

M

TM

4-8

Current time in HHMMSS format

GS06

Group Control Number

1

M

N0

1-9

Specified Group Control Number

GS07

Responsible Agency Code

1

M

ID

1-2

X Accredited Standards Committee X12

GS08

Version / Release / Industry Identifier Code

1

M

AN

1-12

For details, refer GS08    480    Version/Release/Industry Identifier Code.

ST

Transaction Set Header

1

M

ST01

Transaction Set Identifier Code

1

M

ID

3-3

277

ST02

Transaction Set Control Number

1

M

AN

4-9

Specified transaction control number, zero-filled, starting at “0001”, and increments by 1 for each transaction control number.

ST03

Implementation Convention Reference

1

O

AN

1-35

For details, refer GS08    480    Version/Release/Industry Identifier Code.

BHT

Beginning of Hierarchical Transaction

1

M

BHT01

Hierarchical Structure Code

1

M

ID

4-4

0010

BHT02

Transaction Set Purpose Code

1

M

ID

2-2

08

BHT03

Reference Identification

1

O

AN

1-30

See ST02 definition

BHT04

Date

1

O

DT

8-8

Current date in YYYYMMDD format

BHT05

Time

1

O

TM

4-8

Not Used

HL01

Hierarchical ID Number

1

M

AN

1-12

Generated internally by Response Generator

HL02

Hierarchical Parent ID Number

1

O

AN

1-12

Not used in 2000A (parent loop)

HL03

Hierarchical Level Code

1

M

ID

2-2

20 (Information Source)

HL04

Hierarchical Child Code

1

M

ID

1-1

1 (2000A loop has child nodes)

2100A

NM

Payer Name

M

NM101

Entity Identifier Code

1

M

ID

2-3

PR (Payer)

NM102

Entity Type Qualifier

1

M

ID

1-1

2 (Non-Person Entity)

NM103

Name (Last) or Organization Name

1

O

AN

1-35

837 Receiver NM103. Detail file ZRP record refers to NM1 segment passed along in 1000B.

NM108

Identification Code Qualifier

1

X

ID

1-2

837 Receiver NM108. Detail file ZRP record refers to NM1 segment passed along in 1000B.

NM109

Identification Code

1

X

AN

2-80

837 Receiver NM109. Detail file ZRP record refers to NM1 segment passed along in 1000B.

2000B

HL

Information Receiver Level

M

HL01

Hierarchical ID Number

1

M

AN

1-12

Generated internally by Response Generator

HL02

Hierarchical Parent ID Number

1

O

AN

1-12

Generated internally by Response Generator

HL03

Hierarchical Level Code

1

M

ID

2-2

21 (Information Receiver)

NM101

Entity Identifier Code

1

M

ID

2-3

41 (Submitter)

NM102

Entity Type Qualifier

1

M

ID

1-1

837 Submitter NM102. Detail file ZRT record refers to NM1 segment passed along in 1000A.

NM103

Name (Last) or Organization Name

1

O

AN

1-35

837 Submitter NM103. Detail file ZRT record refers to NM1 segment passed along in 1000A.

NM104

Name First

1

O

AN

1-25

837 Submitter NM104. Detail file ZRT record refers to NM1 segment passed along in 1000A.

NM105

Name Middle

1

O

AN

1-25

837 Submitter NM105. Detail file ZRT record refers to NM1 segment passed along in 1000A.

NM106

Name Prefix

1

O

AN

1-25

837 Submitter NM106. Detail file ZRT record refers to NM1 segment passed along in 1000A.

NM107

Name Suffix

1

O

AN

1-25

837 Submitter NM107. Detail file ZRT record refers to NM1 segment passed along in 1000A.

NM108

Identification Code Qualifier

1

X

ID

1-2

837 Submitter NM108. Detail file ZRT record refers to NM1 segment passed along in 1000A.

NM109

Identification Code

1

X

AN

2-80

837 Receiver NM109. Detail file ZRT record refers to NM1 segment passed along in 1000A.

2000C

HL

Service Provider Level

M

HL01

Hierarchical ID Number

1

M

AN

1-12

Generated internally by Response Generator

HL02

Hierarchical Parent ID Number

1

O

AN

1-12

Generated internally by Response Generator

HL03

Hierarchical Level Code

1

M

ID

2-2

19 (Provider of Service)

NM101

Entity Identifier Code

1

M

ID

2-3

1P (Provider)

NM102

Entity Type Qualifier

1

M

ID

1-1

837 Provider NM102

NM103

Name (Last) or Organization Name

1

O

AN

1-35

837 Provider NM103

NM104

Name First

1

O

AN

1-25

837 Provider NM104

NM105

Name Middle

1

O

AN

1-25

837 Provider NM105

NM107

Name Prefix

1

O

AN

1-25

837 Provider NM106

NM107

Name Suffix

1

O

AN

1-25

837 Provider NM107

NM108

Identification Code Qualifier

1

X

ID

1-2

837 Provider NM108

NM109

Identification Code

1

X

AN

2-80

837 Provider NM109

2000D

HL

Subscriber Level

M

HL01

Hierarchical ID Number

1

M

AN

1-12

Generated internally by Response Generator

HL02

Hierarchical Parent ID Number

1

O

AN

1-12

Generated internally by Response Generator

HL03

Hierarchical Level Code

1

M

ID

2-2

22 (Subscriber)

HL04

Hierarchical Child Code

1

M

ID

1-1

0 if no Dependent loop exists, 1 if one does exist

DMG

Subscriber Demographic Information

1

O

DMG01

Date Time Period Format Qualifier

1

X

ID

2-3

837 Subscriber DMG01. Detail file ZRSG record refers to DMG segment passed along in 2010BA.

DMG02

Date Time Period

1

X

AN

1-35

837 Subscriber DMG02. Detail file ZRSG record refers to DMG segment passed along in 2010BA.

NM101

Entity Identifier Code

1

M

ID

2-3

IL (Subscriber/Insured)

NM102

Entity Type Qualifier

1

M

ID

1-1

837 Subscriber NM102. Detail file 0003 record refers to NM1 segment passed along in 2010BA.

NM103

Name (Last) or Organization Name

1

O

AN

1-35

837 Subscriber NM103. Detail file 0003 record refers to NM1 segment passed along in 2010BA.

NM104

Name First

1

O

AN

1-25

837 Subscriber NM104. Detail file 0003 record refers to NM1 segment passed along in 2010BA.

NM105

Name Middle

1

O

AN

1-25

837 Subscriber NM105. Detail file 0003 record refers to NM1 segment passed along in 2010BA.

NM106

Name Prefix

1

O

AN

1-25

837 Subscriber NM106. Detail file 0003 record refers to NM1 segment passed along in 2010BA.

NM107

Name Suffix

1

O

AN

1-25

837 Subscriber NM107. Detail file 0003 record refers to NM1 segment passed along in 2010BA.

NM108

Identification Code Qualifier

1

X

ID

1-2

837 Subscriber NM108. Detail file 0003 record refers to NM1 segment passed along in 2010BA.

NM109

Identification Code

1

X

AN

2-80

837 Subscriber NM109. Detail file 0003 record refers to NM1 segment passed along in 2010BA.

2200D

TRN

Claim Submitter Trace Number

M

TRN01

Trace Type Code

1

M

ID

1-2

2 (Referenced Transaction Trace Numbers)

STC01.01

Industry Code

1

M

AN

1-30

A3

STC01.02

Industry Code

1

M

AN

1-30

The STC code value from the DTL record. Default is 21.

STC01.03

Entity Identifier Code

1

O

ID

2-3

Not used

STC02

Date

1

O

DT

8-8

Current date in YYYYMMDD format

STC03

Not used.

STC04

Monetary Amount

1

0

R

1-10

837 Subscriber Claim CLM02. Detail file S009 record refers to CLM segment passed along in Subscriber 2300.

STC05

Monetary Amount

1

0

R

1-10

0

STC06

Date

1

O

DT

8-8

Not used

STC07

Payment Method Code

1

O

ID

3-3

Not used

STC08

Date

1

O

DT

8-8

Not used

STC09

Check Number

1

O

AN

1-16

Not used

STC10.01

Industry Code

1

M

AN

1-30

A3

STC10.02

Industry Code

1

M

AN

1-30

Generated by ResponseGen from 837 Subscriber Claim detail file error records. Used if a second claim status is needed.

STC10.03

Entity Identifier Code

1

O

ID

2-3

Not used

STC11.01

Industry Code

1

M

AN

1-30

A3

STC11.02

Industry Code

1

M

AN

1-30

Generated by ResponseGen from 837 Subscriber Claim detail file error records. Used if a third claim status is needed.

STC11.03

Entity Identifier Code

1

O

ID

2-3

Not used

REF

Payer Claim Identification Number

1

O

REF01

Reference Identification Qualifier

1

M

ID

2-3

1K (Payor's claim number)

REF01

Reference Identification Qualifier

1

M

ID

2-3

BLT (Billing Type)

REF02

Reference Identification

1

X

AN

1-30

837 Subscriber Claim CLM05.1 and CLM05.3 concatenated together as a single value. Detail file record S009 refers to the Subscriber Claim CLM segment.

REF

Medical Record Identification

1

O

REF01

Reference Identification Qualifier

1

M

ID

2-3

EA (Medical Record Identification Number)

REF02

Reference Identification

1

X

AN

1-30

837 Subscriber Claim REF EA REF02. Detail file record ZRSM refers to the Subscriber Claim REF EA segment.

REF

Claim ID Number for Clearinghouses and Other Transmission Intermediaries

1

O

REF01

Reference Identification Qualifier

1

M

ID

2-3

D9 (Claim Number)

REF02

Reference Identification

1

X

AN

1-30

REF02 where REF01=D9

DTP

Claim Service Date

1

O

DTP01

Date/Time Qualifier

1

M

ID

3-3

232 (Claim Statement Period Start)

DTP02

Date Time Period Format Qualifier

1

M

ID

2-3

RD8 (Range of dates expressed in YYYYMMDD-YYYYMMDD format)

DTP03

Date Time Period

1

M

AN

1-35

837 Subscriber Claim Service Date range from DTP 435. Detail file record S010 refers to the Subscriber Claim DTP 435 segment.

2220D

SVC

Service Line Information

O

SVC01

Composite Medical Procedure Identifier

1

M

C003

Read from 837 Subscriber Claim SV1 or SV2 segments. Detail file record S011 refers to the Subscriber Claim SV1 or SV2 segment.

SVC02

Monetary Amount

1

M

R

1-10

Read from 837 Subscriber Claim SV102 or SV203. Detail file record S011 refers to the Subscriber Claim SV1 or SV2 segment.

SVC03

Monetary Amount

1

O

R

1-10

0

SVC04

Product/Service ID

1

O

AN

1-48

Read from 837 Subscriber Claim SV1 or SV2 segments. Detail file record S011 refers to the Subscriber Claim SV1 or SV2 segment.

SVC05

Not used

SVC06

Not used

SVC07

Quantity

1

Read from 837 Subscriber Claim SV1 or SV2 segments. Detail file record S011 refers to the Subscriber Claim SV1 or SV2 segment.

STC

Service Line Status Information

1

M

STC01.01

Industry Code

1

M

AN

1-30

A3

STC01.02

Industry Code

1

M

AN

1-30

Generated by ResponseGen from 837 Subscriber Claim detail file error records

STC01.03

Entity Identifier Code

1

O

ID

2-3

Not used

STC02

Date

1

O

DT

8-8

Current date in YYYYMMDD format

STC03

Not used.

STC04

Monetary Amount

1

0

R

1-10

Read from 837 Subscriber Claim SV102 or SV203. Detail file record S011 refers to the Subscriber Claim SV1 or SV2 segment.

STC05

Monetary Amount

1

0

R

1-10

0

STC06

Date

1

O

DT

8-8

Not used.

STC07

Payment Method Code

1

O

ID

3-3

Not used.

STC08

Date

1

O

DT

8-8

Not used.

STC09

Check Number

1

O

AN

1-16

Not used.

STC10.01

Industry Code

1

M

AN

1-30

A3

STC10.02

Industry Code

1

M

AN

1-30

Generated by ResponseGen from 837 Subscriber Claim detail file error records. Used if a second claim status is needed.

STC10.03

Entity Identifier Code

1

O

ID

2-3

Not used

STC11.01

Industry Code

1

M

AN

1-30

A3

STC11.02

Industry Code

1

M

AN

1-30

Generated by ResponseGen from 837 Subscriber Claim detail file error records. Used if a third claim status is needed.

REF01

Reference Identification Qualifier

1

M

ID

2-3

FJ (Line Item Control Number)

REF02

Reference Identification

1

X

AN

1-30

837 Subscriber Claim Service Line LX01 value. Detail file record 0007refers to this LX segment

DTP

Service Line Date

1

O

DTP01

Date/Time Qualifier

1

M

ID

3-3

472 (Service)

DTP02

Date Time Period Format Qualifier

1

M

ID

2-3

RD8 (Range of dates expressed in YYYYMMDD-YYYYMMDD format)

DTP03

Date Time Period

1

M

AN

1-35

837 Subscriber Claim Service Line Date range from DTP 472. Detail file record ZRSV refers to this DTP segment.

2000E

HL

Dependent Level

M

HL01

Hierarchical ID Number

1

M

AN

1-12

Generated internally by Response Generator

HL02

Hierarchical Parent ID Number

1

O

AN

1-12

Generated internally by Response Generator

HL03

Hierarchical Level Code

1

M

ID

2-2

23 (Dependent Patient)

HL04

Hierarchical Child Code

1

M

ID

1-1

Not used (No subordinate loops)

DMG

Dependent Demographic Information

1

O

DMG01

Date Time Period Format Qualifier

1

X

ID

2-3

837 Dependent DMG01. Detail file ZRDG record refers to DMG segment passed along in 2010BA.

DMG02

Date Time Period

1

X

AN

1-35

837 Dependent DMG02. Detail file ZRDG record refers to DMG segment passed along in 2010CA.

NM101

Entity Identifier Code

1

M

ID

2-3

QC (Dependent)

NM102

Entity Type Qualifier

1

M

ID

1-1

837 Dependent NM102. Detail file 0006 record refers to NM1 segment passed along in 2010BA.

NM103

Name (Last) or Organization Name

1

O

AN

1-35

837 Dependent NM103. Detail file 0006 record refers to NM1 segment passed along in 2010BA.

NM104

Name First

1

O

AN

1-25

837 Dependent NM104. Detail file 0006 record refers to NM1 segment passed along in 2010BA.

NM105

Name Middle

1

O

AN

1-25

837 Dependent NM105. Detail file 0006 record refers to NM1 segment passed along in 2010BA.

NM106

Name Prefix

1

O

AN

1-25

837 Dependent NM106. Detail file 0006 record refers to NM1 segment passed along in 2010BA.

NM107

Name Suffix

1

O

AN

1-25

837 Dependent NM107. Detail file 0006 record refers to NM1 segment passed along in 2010BA.

NM108

Identification Code Qualifier

1

X

ID

1-2

837 Dependent NM108. Detail file 0006 record refers to NM1 segment passed along in 2010BA.

NM109

Identification Code

1

X

AN

2-80

837 Dependent NM109. Detail file 0006 record refers to NM1 segment passed along in 2010BA.

2200E

TRN

Claim Submitter Trace Number

M

TRN01

Trace Type Code

1

M

ID

1-2

2 (Referenced Transaction Trace Numbers)

STC01

Health Care Claim Status

1

M

CO43

N/A

Generated by ResponseGen from 837 Dependent Claim detail file error records

STC02

Date

1

O

DT

8-8

Current date in YYYYMMDD format

STC03

Not used.

STC04

Monetary Amount

1

0

R

1-10

837 Dependent Claim CLM02. Detail file P009 record refers to CLM segment passed along in Dependent 2300.

STC05

Monetary Amount

1

0

R

1-10

0

STC06

Date

1

O

DT

8-8

Not used

STC07

Payment Method Code

1

O

ID

3-3

Not used

STC08

Date

1

O

DT

8-8

Not used

STC09

Check Number

1

O

AN

1-16

Not used

STC10

Health Care Claim Status

1

O

C043

N/A

Generated by ResponseGen from 837 Dependent Claim detail file error records. Used if a second claim status is needed.

STC11

Health Care Claim Status

1

O

C043

N/A

Generated by ResponseGen from 837 Dependent Claim detail file error records. Used if a third claim status is needed.

REF

Payer Claim Identification Number

1

O

REF01

Reference Identification Qualifier

1

M

ID

2-3

1K (Payor's claim number)

REF02

Reference Identification

1

X

AN

1-30

If 837 Dependent Claim REF F8 exists, its REF02 is used, otherwise CLM01 (ClaimID) is used. Detail file record ZRPI refers to the Dependent Claim REF F8 segment.

REF

Institutional Bill    Type Identification

1

O

REF01

Reference Identification Qualifier

1

M

ID

2-3

BLT (Billing Type)

REF01

Reference Identification Qualifier

1

M

ID

2-3

EA (Medical Record Identification Number)

REF02

Reference Identification

1

X

AN

1-30

837 Dependent Claim REF EA REF02. Detail file record ZRPM refers to the Dependent Claim REF EA segment.

DTP

Claim Service Date

1

O

DTP01

Date/Time Qualifier

1

M

ID

3-3

232 (Claim Statement Period Start)

DTP02

Date Time Period Format Qualifier

1

M

ID

2-3

RD8 (Range of dates expressed in YYYYMMDD-YYYYMMDD format)

DTP03

Date Time Period

1

M

AN

1-35

837 Dependent Claim Service Date range from DTP 435. Detail file record P010 refers to the Dependent Claim DTP 435 segment.

2220E

SVC

Service Line Information

O

SVC01

Composite Medical Procedure Identifier

1

M

C003

Read from 837 Dependent Claim SV1 or SV2 segments. Detail file record P011 refers to the Dependent Claim SV1 or SV2 segment.

SVC02

Monetary Amount

1

M

R

1-10

Read from 837 Dependent Claim SV102 or SV203. Detail file record P011 refers to the Dependent Claim SV1 or SV2 segment.

SVC03

Monetary Amount

1

O

R

1-10

0

SVC04

Product/Service ID

1

O

AN

1-48

Read from 837 Dependent Claim SV1 or SV2 segments. Detail file record P011 refers to the Dependent Claim SV1 or SV2 segment.

SVC05

Not used

SVC06

Not used

STC01

Health Care Claim Status

1

M

CO43

N/A

Generated by ResponseGen from 837 Dependent Claim detail file error records.

STC02

Date

1

O

DT

8-8

Current date in YYYYMMDD format.

STC03

Not used.

STC04

Monetary Amount

1

0

R

1-10

Read from 837 Dependent Claim SV102 or SV203. Detail file record P011 refers to the Dependent Claim SV1 or SV2 segment.

STC05

Monetary Amount

1

0

R

1-10

0

STC06

Date

1

O

DT

8-8

Not used

STC07

Payment Method Code

1

O

ID

3-3

Not used

STC08

Date

1

O

DT

8-8

Not used

STC09

Check Number

1

O

AN

1-16

Not used

STC10

Health Care Claim Status

1

O

C043

N/A

Generated by ResponseGen from 837 Dependent Claim detail file error records. Used if a second claim status is needed

STC11

Health Care Claim Status

1

O

C043

N/A

Generated by ResponseGen from 837 Dependent Claim detail file error records. Used if a third claim status is needed.

REF

Service Line Item Identification

1

O

REF01

Reference Identification Qualifier

1

M

ID

2-3

FJ (Line Item Control Number)

REF02

Reference Identification

1

X

AN

1-30

837 Dependent Claim Service Line LX01 value. Detail file record 0005 refers to this LX segment.

DTP

Service Line Date

1

O

DTP01

Date/Time Qualifier

1

M

ID

3-3

472 (Service)

DTP02

Date Time Period Format Qualifier

1

M

ID

2-3

RD8 (Range of dates expressed in YYYYMMDD-YYYYMMDD format)

DTP03

Date Time Period

1

M

AN

1-35

837 Dependent Claim Service Line Date range from DTP 472. Detail file record ZRPV refers to this DTP segment.

SE

Transaction Set Trailer

1

M

SE01

Number of Included Segments

1

M

N0

1-10

Count of Segments in output transaction

SE02

Transaction Set Control Number

1

M

AN

4-9

Matches ST02 of output transaction

GE

Functional Group Trailer

1

O

GE01

Number of Transaction Sets Included

1

M

N0

1-6

Count of ST/SEs in output transaction

GE02

Group Control Number

1

M

N0

1-9

Matches GS06 of output transaction

IEA

Interchange Control Trailer

1

O

IEA01

Number of Included Functional Groups

1

M

N0

1-5

Count of GS/GEs in output transaction