Department of Health & Human Services (DHHS) Centers for Medicare & Medicaid Services (CMS) Transmittal 1026 Date: January 26, 2012

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1 CMS Manual System Pub One-Time Notification Department of Health & Human Services (DHHS) Centers for Medicare & Medicaid Services (CMS) Transmittal 1026 Date: January 26, 2012 Change equest 7582 SUBJECT: Implementation of the HIPAA Version / Claim Status Edits July 2012 elease I. SUMMAY OF CHANGES: This Change equest (C) is related to the implementation of the July 2012 Edits for the Health Insurance Portability and Accountability Act (HIPAA) of 1996 for the Accredited Standards Committee (ASC) X12 Version Status equest and esponse (276/) transaction sets. EFFECTIVE DATE: July 1, 2012 IMPLEMENTATION DATE: July 2, 2012 Disclaimer for manual changes only: The revision date and transmittal number apply only to red italicized material. Any other material was previously published and remains unchanged. However, if this revision contains a table of contents, you will receive the new/revised information only, and not the entire table of contents. II. CHANGES IN MANUAL INSTUCTIONS: (N/A if manual is not updated) =EVISED, N=NEW, D=DELETED-Only One Per ow. /N/D N/A CHAPTE / SECTION / SUBSECTION / TITLE III. FUNDING: For Fiscal Intermediaries (FIs), egional Home Health Intermediaries (HHIs) and/or Carriers: No additional funding will be provided by CMS; Contractor activities are to be carried out within their operating budgets. For Medicare Administrative Contractors (MACs): The Medicare Administrative Contractor is hereby advised that this constitutes technical direction as defined in your contract. CMS does not construe this as a change to the MAC Statement of Work. The contractor is not obligated to incur costs in excess of the amounts allotted in your contract unless and until specifically authorized by the Contracting Officer. If the contractor considers anything provided, as described above, to be outside the current scope of work, the contractor shall withhold performance on the part(s) in question and immediately notify the Contracting Officer, in writing or by , and request formal directions regarding continued performance requirements. IV. ATTACHMENTS: One-Time Notification *Unless otherwise specified, the effective date is the date of service.

2 Attachment One-Time Notification Pub Transmittal: 1026 Date: January 26, 2012 Change equest: 7582 SUBJECT: Implementation of the HIPAA Version / Claim Status Edit July 2012 elease Effective Date: July 1, 2012 Implementation Date: July 2, 2012 I. GENEAL INFOMATION A. Background: This Change equest (C) is related to the implementation of the July 2012 Edits for the Health Insurance Portability and Accountability Act (HIPAA) of 1996 for the Accredited Standards Committee (ASC) X12 Version Status equest and esponse (276/) transaction sets. This C provides direction to the following stakeholders: 1. Shared System Maintainers (SSM) for: a. Fiscal Intermediary Standard System (FISS), b. Multi Carrier System (MCS), c. ViPS Medicare System (VMS), 2. The Durable Medical Equipment (DME) Common Electronic Data Interchange (CEDI) contractor, 3. The following Part A and Part B (A/B) Medicare Administrative Contractors (MACs) and their subcontractors as appropriate: a. Jurisdiction 1 Palmetto Government Benefits Administrator, b. Jurisdiction 3 Noridian Administrative Services, c. Jurisdiction 4 TrailBlazer Health Enterprise, d. Jurisdiction 5 Wisconsin Physicians Services, e. Jurisdiction 9 First Coast Service Options (FCSO), f. Jurisdiction 10 Cahaba Government Benefit Administrators, g. Jurisdiction 11 Palmetto Government Benefits Administrator, h. Jurisdiction 12 Highmark Medicare Services, i. Jurisdiction 13 National Government Services, j. Jurisdiction 14 National Heritage Insurance Corp, k. Jurisdiction 15 CGS Administrators, LLC. Additionally, this C addresses the Common Edits and Enhancement Module (CEM) software for the inbound Claim Status Inquiry process. The FISS Part A and MCS Part B Shared System Maintainer shall update any changes in the distribution process in order for the A/B MACs to retrieve, install and execute the CEM software and associated reference files for inbound claims status transactions at the Local Data Center. For the Durable Medical Equipment process the CEDI contractor shall be responsible for the creation of similar software within the CEDI processing environment.. This C also provides guidance to SSMs related to the following Cs: 1. All C 6940 Transmittal FISS C Transmittal MCS C 6411 Transmittal VMS C 6399 Transmittal 519

3 Estimates for this C should include a breakdown as part of the Level of Effort (LOE) response, utilizing the following table to be included in the Estimate-Specific Comments portion of the LOE template, to follow the Investment Lifecycle Phases. Investment Lifecycle Phase Total Hours Total Cost *Pre-Implementation/C eview* Design & Engineering Phase Development Phase Testing Phase Implementation Phase *Note that the Pre-Implementation/C eview costs will not be funded under the unique funding situation for the 5010/D.0 project, but instead out of the MAC s allotted hours for Pre-Implementation/C eview.* B. Policy: Health Insurance Portability and Accountability Act of 1996 (HIPAA), the Final ule as published in the Federal egister on January 16, 2009, by the Department of Health and Human Services, 45 CF Part 162, Subpart N- Status. II. BUSINESS EQUIEMENTS TABLE Use Shall" to denote a mandatory requirement Number equirement esponsibility (place an X in each applicable column) A / D M F I Shared- System OTH E B E Maintainers The A/B MAC, CEDI and the Shared System Maintainer shall insure that they comply with the CMS Edits Spreadsheet attached to this Change request for the 276/ transaction sets he A/B MAC, CEDI and the Shared System Maintainer shall address any findings uncovered during the installation and testing periods of the July 2012 release associated with the 276/ transaction sets The Shared System Maintainer shall perform analysis activity and costing information to begin providing Service Line Claim Status esponse information in the outbound Claim Status esponse transaction (). M A C M A C C A I E H H I F I S S M C S V M S C W F X X X CEDI CEM A CEM B X X X CEDI CEM A CEM B X CEM A

4 III. POVIDE EDUCATION TABLE Number equirement esponsibility (place an X in each applicable column) A / D M F I Shared- System OTH E B E Maintainers None M A C M A C C A I E H H I F I S S M C S V M S C W F IV. SUPPOTING INFOMATION Section A: For any recommendations and supporting information associated with listed requirements, use the box below: N/A Use "Should" to denote a recommendation. X-ef equirement Number ecommendations or other supporting information: Section B: For all other recommendations and supporting information, use this space: N/A V. CONTACTS Pre-Implementation Contact(s): Michael Cabral, (410) , michael.cabral@cms.hhs.gov Jason Jackson, (410) , jason.jackson3@cms.hhs.gov Post-Implementation Contact(s): Contact your Contracting Officer s Technical epresentative (COT) or Contractor Manager, and Pre-Implementation Contacts(s) as applicable. VI. FUNDING Section A: For Fiscal Intermediaries (FIs), egional Home Health Intermediaries (HHIs), and/or Carriers: No additional funding will be provided by CMS; Contractor activities are to be carried out within their operating budgets. Section B: For Medicare Administrative Contractors (MACs): The Medicare Administrative Contractor is hereby advised that this constitutes technical direction as defined in your contract. CMS does not construe this as a change to the MAC Statement of Work. The contractor is not obligated to incur costs in excess of the amounts allotted in your contract unless and until specifically authorized by the Contracting Officer. If the contractor considers anything provided, as described above, to be outside the current scope of work, the contractor shall withhold performance on the part(s) in question and immediately notify the Contracting Officer, in writing or by , and request formal directions regarding continued performance requirements.

5 If alternative formats of the 5010 Edits spreadsheet are required, please use the Submit Feedback feature at the bottom of the Te The Data Interchange Standards Association(DISA) holds a copyright on the T3 documents: Copyright (c) 2009, Data Interchange Standards Association on behalf of ASC X12. Format (c) 2009, Edit eference X212.C3..ISA.010 X212.C3..ISA.020 X212.C3..ISA X212.C3..ISA X212.C3..ISA X212.C3..ISA X212.C3..ISA ISA INTECHANGE CONTOL HEADE Max. eg. epeat 1 1 TA1 ISA TA1 ISA01 Authorization Information Qualifier ID 2-2 TA1 ISA01 TA1 ISA02 Authorization Information AN TA1 ISA0A1 ISA0A1 TA105: 024 "Invalid Interchange Content". TA105: 024 "Invalid Interchange Content". TA105: 010 "Invalid Authorization Information Qualifier. TA105: 010 "Invalid Authorization Information Qualifier. TA105: 011 "Invalid Authorization Information. TA105: 011 "Invalid Authorization Information. TA105: 011 "Invalid Authorization Information. ISA must be Only one iteration of ISA is allowed. ISA01 must be ISA must be Only one iteration of ISA is allowed. ISA01 must be ISA01 must be "00" or "03". ISA01 must be "00" or "03". ISA02 must be ISA02 must be 10 ISA02 must be populated with accepted AN ISA02 must be ISA02 must be 10 ISA02 must be populated with accepted AN Not X212.C3..ISA ISA03 Security Information Qualifier ID 2-2 TA1 TA105: 012 "Security Information Qualifier. ISA03 must be ISA03 must be X212.C3..ISA X212.C3..ISA X212.C3..ISA ISA03 TA1 ISA04 Security Information AN TA1 ISA04 TA1 TA105: 012 "Security Information Qualifier. TA105: 013 "Security Information. TA105: 013 "Security Information. ISA03 must be "00" or "01". ISA03 must be "00" or "01". ISA04 must be ISA04 must be 10 ISA04 must be ISA04 must be 10 X212.C3..ISA X212.C3..ISA X212.C3..ISA X212.C3..ISA X212.C3..ISA X212.C3..ISA X212.C3..ISA X212.C3..ISA X212.C3..ISA X212.C3..ISA X212.C3..ISA ISA04 TA1 ISA05 Interchange ID Qualifier ID 2-2 TA1 ISA05 TA1 ISA06 Interchange Sender ID AN TA1 ISA06 TA1 ISA07 Interchange ID Qualifier ID 2-2 TA1 ISA07 TA1 ISA08 Interchange eceiver ID AN TA1 ISA08 TA1 ISA09 Interchange Date DT 6-6 TA1 ISA09 TA1 TA105: 013 "Security Information. TA105: 005 "Invalid Interchange ID Qualifier for Sender". TA105: 005 "Invalid Interchange ID Qualifier for Sender". TA105: 006 "Invalid Interchange Sender ID". TA105: 006 "Invalid Interchange Sender ID". TA105: 007 "Invalid Interchange ID Qualifier for eceiver". TA105: 007 "Invalid Interchange ID Qualifier for eceiver". TA105: 008 "Invalid Interchange eceiver ID". TA105: 008 "Invalid Interchange eceiver ID". TA105: 014 "Invalid Interchange Date. TA105: 014 "Invalid Interchange Date. ISA04 must be populated with accepted AN ISA05 must be ISA05 must be valid values. ISA06 must be ISA06 must be a valid sender id. ISA07 must be ISA07 must be valid values. ISA08 must be ISA08 must be a valid receiver id. ISA09 must be ISA09 must be a valid date in YYMMDD format. ISA04 must be populated with accepted AN ISA05 must be ISA05 must be "ZZ". ISA06 must be ISA06 must be a valid sender id. ISA07 must be ISA07 must be "ZZ". ISA08 must be ISA08 must be a valid receiver id. ISA09 must be ISA09 must be a valid date in YYMMDD format. 04/09: 276 Companion Guide note needed. 04/09: Valid reference file required for this edit. 04/09: 276 Companion Guide note needed. 04/09: Valid reference file required for this edit. 276_ of 1026_OTN2.xlsx Page 1 evision Date: 12/12/2011

6 Edit eference Max. eg. epeat Not X212.C3..ISA X212.C3..ISA X212.C3..ISA X212.C3..ISA X212.C3..ISA X212.C3..ISA X212.C3..ISA ISA09 TA1 ISA10 Interchange Time TM 4-4 TA1 ISA10 TA1 ISA11 epetition Seperator AN 1-1 TA1 ISA11 TA1 ISA11 TA1 ISA12 Interchange Control Version Number ID 5-5 TA1 TA105: 014 "Invalid Interchange Date. TA105: 015 "Invalid Interchange Time. TA105: 015 "Invalid Interchange Time. TA105: 024 "Invalid Interchange Content". TA105: 024 "Invalid Interchange Content". TA105: 024 "Invalid Interchange Content". TA105: 017 "Invalid Interchange Version ID. ISA09 must be a the date of the interchange; must not be a future date. ISA10 must be ISA10 must be a valid time in HHMM format. ISA11 must be ISA11 must be 1 character. ISA11 must contain at least one non-space character. ISA12 must be ISA09 must be a the date of the interchange; must not be a future date. ISA10 must be ISA10 must be a valid time in HHMM format. ISA11 must be ISA11 must be 1 character. ISA11 must contain at least one non-space character. ISA12 must be X212.C3..ISA ISA1A1 TA105: 017 "Invalid Interchange Version ID. ISA12 must be "00501". ISA12 must be "00501". X212.C3..ISA ISA13 Interchange Control Number N0 9-9 TA1 TA105: 018 "Invalid Interchange Conrol Number. ISA13 must be ISA13 must be X212.C3..ISA ISA13 TA1 TA105: 018 "Invalid Interchange Conrol Number. ISA13 must be numeric. ISA13 must be numeric. X212.C3..ISA ISA13 TA1 TA105: 018 "Invalid Interchange Conrol Number. ISA13 must be 9 ISA13 must be 9 X212.C3..ISA ISA13 TA1 TA105: 018 "Invalid Interchange Conrol Number. ISA13 must be > 0. ISA13 must be > 0. X212.C3..ISA ISA13 TA1 TA105: 018 "Invalid Interchange Conrol Number. ISA13 must be unsigned. ISA13 must be unsigned. X212.C3..ISA ISA14 Acknowledgement equested ID 1-1 TA1 TA105: 019 "Invalid Acknowledgment equested ISA14 must be. ISA14 must be X212.C3..ISA ISA14 TA1 TA105: 019 "Invalid Acknowledgment equested ISA14 must be valid values.. ISA14 must be valid values. X212.C3..ISA ISA15 Usage Indicator ID 1-1 TA1 TA105: 020 "Invalid Test Indicator. ISA15 must be ISA15 must be X212.C3..ISA ISA15 TA1 TA105: 020 "Invalid Test Indicator. ISA15 must be"p" or "T". ISA15 must be"p" or "T". X212.C3..ISA ISA16 Component Separator AN 1-1 TA1 TA105: 027 "Invalid Component Separator" ISA16 must be ISA16 must be X212.C3..ISA ISA16 TA1 TA105: 027 "Invalid Component Separator" ISA16 must be 1 character. ISA16 must be 1 character. X212.C3..ISA ISA16 TA1 TA105: 027 "Invalid Component Separator" ISA16 must contain at least one non-space character. ISA16 must contain at least one non-space character. X212.C3..ISA ISA16 TA1 TA105: 027 "Invalid Component Separator" ISA16 must be populated with accepted AN ISA16 must be populated with accepted AN X212.C7..GS.010 GS FUNCTIONAL GOUP HEADE 1 >1 999 AK905: 1 "Functional Group Not Supported". GS must be present within a single Functional group boundary (GS-GE) pairing. GS must be present within a single Functional group boundary (GS-GE) pairing. 276_ of 1026_OTN2.xlsx Page 2 evision Date: 12/12/2011

7 Edit eference Max. eg. epeat Not X212.C7..GS.020 X212.C7..GS X212.C7..GS X212.C7..GS X212.C7..GS X212.C7..GS X212.C7..GS X212.C7..GS X212.C7..GS X212.C7..GS X212.C7..GS X212.C7..GS X212.C7..GS X212.C7..GS X212.C7..GS X212.C7..GS X212.C7..GS X212.C7..GS GS 999 GS01 Functional Identifier ID GS GS02 Application Sender AN GS GS03 Application eceiver AN GS GS04 Date DT 8-8 TA1 GS04 TA1 GS04 TA1 GS05 Time TM 4-8 TA1 GS05 TA1 GS06 Group Control Number N GS GS GS GS07 esponsible Agency ID 1-2 TA1 GS07 TA1 AK905: 1 "Functional Group Not Supported". AK905: 1 "Functional Group Not Supported". AK905: 1 "Functional Group Not Supported". AK905: 14 "Unknown Security Originator". AK905: 14 "Unknown Security Originator". AK905: 13 "Unknown Security ecipient". AK905: 13 "Unknown Security ecipient". TA105: 024 Invalid GS Segment TA105: 024 Invalid GS Segment TA105: 024 Invalid GS Segment TA105: 024 Invalid GS Segment TA105: 024 Invalid GS Segment AK905: 6 "Group Control Number Violates Syntax". AK905: 6 "Group Control Number Violates Syntax". AK905: 6 "Group Control Number Violates Syntax". AK905: 19 "Functional Group Control Number not Unique within Interchange. TA105: 024 Invalid GS Segment TA105: 024 Invalid GS Segment Only one iteration of GS is Only one iteration of GS is allowed within a single allowed within a single Functional group boundary (GS- Functional group boundary GE) pairing. (GS-GE) pairing. GS01 must be GS01 must be "H". GS02 must be GS02 must be a valid sender id. GS03 must be GS03 must be a valid receiver id. GS04 must be the date the functional group is created; must not be a future date. GS04 must be a valid date in CCYYMMDD format. GS04 must be a the date the functional group is created; must not be a future date. GS05 must be GS05 must be a valid time in a valid value format. GS06 must be GS06 must be numeric. GS06 must be > 0 and < =999,999,999 GS06 must be unique within the interchange. GS07 must be GS07 must be "X". GS01 must be GS01 must be "HN". GS02 must be GS02 must be a valid sender id. GS03 must be GS03 must be a valid receiver id. GS04 must be the date the functional group is created; must not be a future date. GS04 must be the current (system) date in CCYYMMDD format. GS05 must be GS05 must be the current (system) time in a valid value format. GS06 must be GS06 must be numeric. GS06 must be > 0 and < =999,999,999 GS06 must be unique within the interchange. GS07 must be GS07 must be "X". 04/09: 276 Companion Guide note needed. 04/09: Valid reference file required for this edit. 04/09: 276 Companion Guide note needed. 04/09: Valid reference file required for this edit. 3/24: s for this error are not in the standard but will be added in the next version. 3/24: s for this error are not in the standard but will be added in the next version. 3/24: s for this error are not in the standard but will be added in the next version. X212.C7..GS X212.C7..GS X212.36/106..ST.010 X212.36/106..ST.020 X212.36/106..ST GS08 Version Identifier AN GS ST TANSACTION SET HEADE 1 >1 999 ST 999 ST01 Transaction Set Identifier ID AK905: 2 "Functional Group Version Not Supported" AK905: 2 "Functional Group Version Not Supported" GS08 must be GS08 must be "005010X212". IK502: 1 "Transaction Set Not Supported". ST must be IK502: 1 "Transaction Set Only one iteration of ST is Not Supported". allowed. IK502: 6 "Missing or Invalid Transaction Set Identifier". ST01 must be GS08 must be GS08 must be "005010X212". ST must be Only one iteration of ST is allowed. ST01 must be 04/09: Type 2 errata doesn't change the version code, both errata are Type 2, so this value is correct. 276_ of 1026_OTN2.xlsx Page 3 evision Date: 12/12/2011

8 Edit eference Max. eg. epeat Not X212.36/106..ST ST IK502: 6 "Missing or Invalid Transaction Set Identifier". ST01 must be "276". ST01 must be "". X212.36/106..ST ST02 Transaction Set Control Number AN IK502: 7 "Missing or Invalid Transaction Set Control Number". ST02 must be ST02 must be X212.36/106..ST ST IK502: 7 "Missing or Invalid Transaction Set Control Number". ST02 must be 4-9 ST02 must be the concatenated value of three zeroes and a sequential number, the sequential portion will start with 1 and increment by 1. Example: "0001" followed by "0002".."0010". X212.36/106..ST ST IK502: 7 "Missing or Invalid Transaction Set Control Number". ST02 must contain at least four non-space X212.36/106..ST ST IK502: 7 "Missing or Invalid Transaction Set Control Number". ST02 must be populated with accepted AN X212.36/106..ST ST IK502: 23 "Transaction Set ST02 must be a unique number Control Number Not Unique within the ISA-IEA envelope. within the Functional Group". X212.36/106..ST ST03 Implementation Convention eference AN IK502: I6 "Implementation Convention Not Supported". ST03 must be ST03 must be X212.36/106..ST ST IK502: I6 "Implementation Convention Not Supported". ST03 must be "005010X212". ST03 must be "005010X212". 04/09: Type 2 errata doesn't change the version code, both errata are Type 2, so this value is correct. X212.37/107..BHT.010 BHT BEGINNING OF HIEACHICAL TANSACTION IK304 = 3: "equired Segment Missing" BHT must be BHT must be X212.37/107..BHT.020 X212.37/107..BHT X212.37/107..BHT X212.37/107..BHT X212.37/107..BHT X212.37/107..BHT X212.37/107..BHT X212.37/107..BHT X212.37/107..BHT X212.37/107..BHT X212.37/107..BHT X212.37/107..BHT BHT 999 BHT01 Hierarchical Structure ID BHT BHT02 Transaction Set Purpose ID BHT BHT03 eference Identification AN BHT BHT BHT BHT04 Transaction Set Creation Date DT IK304 = 5: "Segment Exceeds Maximum Use" IK403 = 5: "Data Too Long" BHT IK403 = 8: "Invalid Date" Only one iteration of BHT is allowed. BHT01 must be Only one iteration of BHT is allowed. BHT01 must be BHT01 must be "0010". BHT01 must be "0010". BHT02 must be BHT02 must be BHT02 must be "13". BHT02 must be "08". BHT03 must be BHT03 must be 1-50 BHT03 must contain at least one non-space character. BHT03 must be populated with accepted AN BHT04 must be BHT04 must be a valid date in CCYYMMDD format. BHT04 C CSC 510: "Future date" BHT04 must not be a future date. BHT03 must be BHT03 must be the cycle date in CCYYDDD Julian date format concatenated with value from ST02. Example: " " BHT04 must be BHT04 must be the current (system) date in CCYYMMDD format. 06/18: Cycle date is defined in other CMS instructions, available to all implementers. It will not be redefined as part of this task. 276_ of 1026_OTN2.xlsx Page 4 evision Date: 12/12/2011

9 Edit eference Max. eg. epeat Not X212.37/107..BHT X212.37/107..BHT X212.37/107..BHT BHT05 Transaction Set Creation Time TM BHT IK403 = 9: "Invalid Time" BHT06 Transaction Type ID 2-2 N/U 999 BHT05 must be BHT05 must a valid time in a valid time format. Must not be BHT05 must be BHT05 must be the current (system) time in HHMMSS format. BHT06 must be 6/16: edit revised. X212.37/107..BHT BHT06 BHT06 must be "DG". X212.39/ A.IS.010 IS Information Source 2000A >1 X212.39/ A.HL.010 HL INFOMATION SOUCE LEVEL A IK304 = 3: "equired Segment Missing" 2000A.HL must be 2000A.HL must be X212.39/ A.HL.020 HL 999 IK304 = 5: "Segment Exceeds Maximum Use" Only one iteration of 2000A.HL is allowed. Only one iteration of 2000A.HL is allowed. X212.39/ A.HL HL01 Hierarchical ID Number AN A.HL01 must be 2000A.HL01 must be X212.39/ A.HL HL IK403 = 5: "Data Too Long" 2000A.HL01 must be 1-12 X212.39/ A.HL X212.39/ A.HL X212.39/ A.HL HL HL HL02 Hierarchical Parent ID Number AN 1-12 N/U A.HL01 must be numeric. The first HL01 must be "1". The first HL01 must be "1". Must not be Must not be X212.39/ A.HL HL03 Hierarchical Level ID A.HL03 must be 2000A.HL03 must be X212.39/ A.HL HL A.HL03 must be "20". 2000A.HL03 must be "20". X212.39/ A.HL HL04 Hierarchical Child ID A.HL04 must be 2000A.HL04 must be X212.39/ A.HL HL A.HL04 must be "1'. 2000A.HL04 must be "1'. X212.41/ A.NM1.010 NM1 PAYE NAME A IK304 = 3: "equired Segment Missing" 2100A.NM1 must be 2100A.NM1 must be X212.41/ A.NM1.020 NM1 999 IK304 = 4: " Occurs Over Maximum Times" Only one iteration of 2100A.NM1 with NM101 "P" is allowed. Only one iteration of 2100A.NM1 with NM101 "P" is allowed. X212.41/ A.NM NM101 Entity Identifier ID A.NM101 must be 2100A.NM101 must be X212.41/ A.NM NM A.NM101 must be "P". 2100A.NM101 must be "P". 276_ of 1026_OTN2.xlsx Page 5 evision Date: 12/12/2011

10 Edit eference Max. eg. epeat Not X212.41/ A.NM NM102 Entity Type Qualifier ID A.NM102 must be 2100A.NM102 must be X212.41/ A.NM NM A.NM102 must be "2". 2100A.NM102 must be "2". X212.41/ A.NM NM103 Payer Name AN A.NM103 must be 2100A.NM103 must be X212.41/ A.NM NM IK403 = 5: "Data Too Long" 2100A.NM103 must be A.NM103 is pulled from the system reference file that designates the workload. X212.41/ A.NM NM A.NM103 must contain at least one non-space character. X212.41/ A.NM X212.41/ A.NM X212.41/ A.NM X212.41/ A.NM X212.41/ A.NM NM NM104 Name First AN 1-35 N/U 999 NM105 Name Middle AN 1-25 N/U 999 NM106 Name Prefix AN 1-10 N/U 999 NM107 Name Suffix AN 1-10 N/U A.NM103 must be populated with accepted AN Must not be Must not be Must not be Must not be Must not be Must not be Must not be Must not be X212.41/ A.NM NM108 Identification Qualifier ID A.NM108 must be 2100A..NM108 must be X212.41/ A.NM NM A.NM108 must be "PI". 2100A..NM108 must be "PI". X212.41/ A.NM NM109 Payer Identifier AN A.NM109 must be 2100A..NM109 must be X212.41/ A.NM X212.41/ A.NM X212.41/ A.NM X212.41/ A.NM NM109 T/C CSC26: "Entity not found" NM110 Entity elationship ID 2-2 N/U 999 NM111 Entity Identifier ID 2-3 N/U 999 NM112 Last Name AN 1-60 N/U A..NM109 must be a valid payer id according to the trading partner management system. Must not be Must not be Must not be 2100A..NM109 must be the Must not be Must not be Must not be 276_ of 1026_OTN2.xlsx Page 6 evision Date: 12/12/2011

11 Edit eference Max. eg. epeat Not X212.NA/ A.PE.010 PE PAYE CONTACT INFOMATION 1 S 2100A Only one iteration of 2100A.PE is allowed. 06/18: The telephone number will always be transmitted in the first communication number set, an address will be sent in the 2nd communication number set, if the information is applicable and available. The 3rd communication number set will not be transmitted. For DME the value "FX" will not be used X212.NA/ A.PE X212.NA/ A.PE X212.NA/ A.PE X212.NA/ A.PE X212.NA/ A.PE PE01 Contact Function ID 2-2 PE01 PE02 Payer Contact Name AN 1-60 S PE03 PE03 Communication Number Qualifier ID A.PE01 must be 2100A.PE01 must be "IC". For Part A: 2100A.PE02 must be the value in Parm For VMS A.PE02 must be the value in VANS/ Contact. For MCS A.PE02 must 2100A.PE03 must be 2100A.PE03 must be "TE". X212.NA/ A.PE X212.NA/ A.PE PE04 PE04 Communication Number AN A.PE04 must be 2100A.PE04 must be 10 digits. 06/18: The phone number must include the area code and phone number, in AAAPPPPPPP format. X212.NA/ A.PE X212.NA/ A.PE PE05 PE06 Communication Number Qualifier Communication Number ID 2-2 S 2100A.PE05 must be "EM". AN S If 2100A.PE06 is present, 2100A.PE05 must be X212.NA/ A.PE PE A.PE06 must be X212.NA/ A.PE PE07 Communication Number Qualifier ID 2-2 S Must not be X212.NA/ A.PE PE08 Communication Number AN S Must not be X212.NA/ A.PE PE09 Contact Inquiry eference AN 1-20 N/U Must not be X212.43/ B.I.010 I Information eceiver 2000B >1 276_ of 1026_OTN2.xlsx Page 7 evision Date: 12/12/2011

12 Edit eference Max. eg. epeat Not X212.43/ B.HL.010 HL INFOMATION ECEIVE LEVEL B IK304 = 3: "equired Segment Missing" 2000B.HL must be 2000B.HL must be X212.43/ B.HL.020 HL 999 IK304 = 5: "Segment Exceeds Maximum Use" Only one iteration of 2000B.HL is allowed. Only one iteration of 2000B.HL is allowed. X212.43/ B.HL HL01 Hierarchical ID Number AN B.HL01 must be 2000B.HL01 must be X212.43/ B.HL HL IK403 = 5: "Data Too Long" 2000B.HL01 must be 1-12 X212.43/ B.HL X212.43/ B.HL X212.43/ B.HL X212.43/ B.HL HL HL HL02 Hierarchical Parent ID Number AN HL IK403 = I12: "Implementation Pattern Match Failure" 2000B.HL01 must be numeric. 2000B.HL01 must equal the value of the previous HL01 plus one. 2000B.HL02 must be 2000B.HL02 must be equal the value of the HL01 (2000A.HL01) of the parent HL. 2000B.HL01 must equal the value of the previous HL01 plus one. 2000B.HL02 must be 2000B.HL02 must be equal the value of the HL01 (2000A.HL01) of the parent HL. X212.43/ B.HL HL03 Hierarchical Level ID B.HL03 must be 2000B.HL03 must be X212.43/ B.HL HL B.HL03 must be "21". 2000B.HL03 must be "21". X212.43/ B.HL X212.43/ B.HL X212.45/ B.NM1.010 X212.45/ B.NM1.020 HL04 Hierarchical Child ID HL NM1 INFOMATION ECEIVE NAME B NM1 999 IK304 = 3: "equired Segment Missing" IK304 = 4: " Occurs Over Maximum Times" 2000B.HL04 must be 2000B.HL04 must be "1". 2100B.NM1 must be Only one iteration of 2100B.NM1 is allowed with NM101="41". 2000B.HL04 must be 2000B.HL04 must be "0" when rejecting the status request for errors at the Information Source or Information eceiver levels. Otherwise, 2000B.HL04 must be "1" 2100B.NM1 must be Only one iteration of 2100B.NM1 is allowed with NM101="41". Triggering error example: 2100B.NM109 NE ISA06. X212.45/ B.NM X212.45/ B.NM NM101 Entity Identifier ID NM B.NM101 must be 2100B.NM101 must be "41". 2100B.NM101 must be 2100B.NM101 must be the X212.45/ B.NM X212.45/ B.NM NM102 Entity Type Qualifier ID NM B.NM102 must be 2100B.NM102 must be valid values 2100B.NM102 must be 2100B.NM102 must be the 276_ of 1026_OTN2.xlsx Page 8 evision Date: 12/12/2011

13 Edit eference Max. eg. epeat Not X212.45/ B.NM X212.45/ B.NM NM103 Information eceiver Last Name or Organization Name AN 1-60 S 999 NM IK403 = 5: "Data Too Long" 2100B.NM103 must be 2100B.NM103 must be B.NM103 must be 2100B.NM103 must be the X212.45/ B.NM X212.45/ B.NM NM NM B.NM103 must be populated with accepted A/N 2100B.NM103 must contain at least one non-space character. X212.45/ B.NM NM104 Information eceiver First Name AN 1-35 S 999 IK403 = I13: "Implementation Dependent 'not used' Data If 2100B.NM102 is "2", 2100B.NM104 must not be present 2100B.NM104 must be the X212.45/ B.NM NM104 C CSC 505: "Entity's First Name" If 2100B.NM102 is "1", 2100B.NM104 must be X212.45/ B.NM NM IK403 = 5: "Data Too Long" 2100B.NM104 must be 1-35 X212.45/ B.NM X212.45/ B.NM NM NM B.NM104 must contain at least one non-space character. 2100B.NM105 must be populated with accepted AN X212.45/ B.NM NM105 Information eceiver Middle Name AN 1-25 S 999 IK403 = I13: "Implementation Dependent 'not used' Data If 2100B.NM102 is "2", 2100B.NM105 must not be present 2100B.NM105 must be the X212.45/ B.NM NM IK403 = 5: "Data Too Long" 2100B.NM105 must be 1-25 X212.45/ B.NM NM B.NM105 must contain at least one non-space character. X212.45/ B.NM X212.45/ B.NM X212.45/ B.NM NM NM106 Name Prefix AN 1-10 N/U 999 NM107 Information eceiver Name Suffix AN 1-10 N/U B.NM105 must be populated with accepted AN Must not be Must not be Must not be Must not be X212.45/ B.NM X212.45/ B.NM NM108 Identification Qualifier ID NM B.NM108 must be 2100B.NM108 must be "46". 2100B.NM108 must be 2100B.NM108 must be the X212.45/ B.NM X212.45/ B.NM NM109 Information eceiver Identification Number AN NM109 T/C CSC26: "Entity not found" 2100B.NM109 must be 2100B.NM109 must be the same as GS B.NM109 must be 2100B.NM109 must be the Part A (T) Part B Either (PCF) T/C 276_ of 1026_OTN2.xlsx Page 9 evision Date: 12/12/2011

14 Edit eference X212.45/ B.NM X212.45/ B.NM X212.45/ B.NM X212.45/ B.NM X212.NA/ B.TN.010 Max. eg. epeat NM109 T/C NM110 Entity elationship ID 2-2 N/U 999 NM111 Entity Identifier ID 2-3 N/U 999 NM112 Last Name AN 1-60 N/U 999 TN eceiver CLAIM STATUS TACKING NUMBE 1 S 2200B 1 CSC 24: "Entity not approved as an electronic submitter " 2100B..NM109 must be a valid submitter id according to the trading partner management system. Must not be Must not be Must not be 2100A..NM109 must be the Must not be Must not be Must not be Translator level: When 2000B.HL04 = "0", one iteration of 2200B.TN is required. Otherwise, 2200B.TN is not allowed. Not Part A (T) Part B Either (PCF) T/C X212.NA/ B.TN TN01 Trace Type ID B.TN01 must be X212.NA/ B.TN TN B.TN01 must be "2". X212.NA/ B.TN X212.NA/ B.TN TN0race Number AN 1-50 TN B.TN02 must be 2200B.TN02 must be the BHT03 value from the X212.NA/ B.TN TN03 Originating Company Identifier AN N/U Must not be X212.NA/ B.TN TN04 eference Identifier AN 1-50 N/U Must not be X212.NA/ B.STC.010 STC INFOMATION ECEIVE STATUS INFOMATION B Translator level: When 2000B.HL04 = "0", one iteration of 2200B.STC is required. When not triggered, 2200B.STC is not allowed. 04/23: Medicare limitation: Up to five iterations of the STC will be allowed for all occurrences in these transactions. X212.NA/ B.STC X212.NA/ B.STC STC01 STC01-1 HEALTH CAE CLAIM STATUS Status Category AN B.STC01-1 must be "D0" or "E". Triggering error example: 2100B.NM109 NE ISA06 - STC01-1 = "E0" X212.NA/ B.STC X212.NA/ B.STC STC01-2 STC01-2 Status AN B.STC01-2 must be 2200B.STC01-2 must be a valid Claim Status. Triggering error example: 2100B.NM109 NE ISA06 - STC01-2 = "24" X212.NA/ B.STC STC01-3 Entity Identifier ID 2-3 S 2200B.STC01-3 must be "41". 276_ of 1026_OTN2.xlsx Page 10 evision Date: 12/12/2011

15 Edit eference Max. eg. epeat Not X212.NA/ B.STC X212.NA/ B.STC STC01-4 STC02 List Qualifier Status Information Effective Date ID 1-3 N/U Must not be DT B.STC02 must the current (system) date in CCYYMMDD format. X212.NA/ B.STC X212.NA/ B.STC X212.NA/ B.STC X212.NA/ B.STC X212.NA/ B.STC X212.NA/ B.STC X212.NA/ B.STC STC03 Action ID 1-2 N/U Must not be STC04 Monetary Amount 1-18 N/U Must not be STC05 Monetary Amount 1-18 N/U Must not be STC06 Date DT 8-8 N/U Must not be STC07 Payment Method ID 3-3 N/U Must not be STC08 Date DT 8-8 N/U Must not be STC09 Check Number AN 1-16 N/U Must not be X212.NA/ B.STC X212.NA/ B.STC STC10 STC10-1 HEALTH CAE CLAIM STATUS Status Category S AN B.STC10-1 may be present if 2200B.STC01-1 is present This "bucket" not used in this location. X212.NA/ B.STC STC B.STC01-1 must be "D0" or "E". X212.NA/ B.STC X212.NA/ B.STC STC10-2 STC10-2 Status AN B.STC10-2 must be 2200B.STC10-2 must be a valid Claim Status. Valid Claim Status equest reference must be available for this edit. X212.NA/ B.STC X212.NA/ B.STC STC10-3 Entity Identifier ID 2-3 S STC B.STC10-3 must be 2200B.STC10-3 must be valid values. X212.NA/ B.STC STC10-4 List Qualifier ID 1-3 N/U Must not be X212.NA/ B.STC X212.NA/ B.STC STC11 STC11-1 HEALTH CAE CLAIM STATUS Status Category S AN B.STC11-1 may be present if 2200B.STC01-1 is present This "bucket" not used in this location. 276_ of 1026_OTN2.xlsx Page 11 evision Date: 12/12/2011

16 Edit eference Max. eg. epeat Not X212.NA/ B.STC STC B.STC11-1 must be "D0" or "E". X212.NA/ B.STC X212.NA/ B.STC STC11-2 STC11-2 Status AN B.STC11-2 must be 2200B.STC11-2 must be a valid Claim Status. Valid Claim Status equest reference must be available for this edit. X212.NA/ B.STC X212.NA/ B.STC STC11-3 Entity Identifier ID 2-3 S STC B.STC11-3 must be 2200B.STC11-3 must be valid values. X212.NA/ B.STC STC11-4 List Qualifier ID 1-3 N/U Must not be X212.NA/ B.STC STC12 Free-Form Message Text AN N/U Must not be X212.47/ C.SP.010 SP Service Provider 2000C >1 X212.47/ C.HL.010 HL SEVICE POVIDE LEVEL C IK304 = 3: "equired Segment Missing" 2000C.HL must be 2000C.HL must be X212.47/ C.HL.020 HL 999 IK304 = 5: "Segment Exceeds Maximum Use" Only one iteration of 2000C.HL is allowed. Only one iteration of 2000C.HL is allowed. X212.47/ C.HL HL01 Hierarchical ID Number AN C.HL01 must be 2000C.HL01 must be X212.47/ C.HL HL IK403 = 5: "Data Too Long" 2000C.HL01 must be 1-12 X212.47/ C.HL X212.47/ C.HL X212.47/ C.HL X212.47/ C.HL HL HL HL02 Hierarchical Parent ID Number AN HL IK403 = I12: "Implementation Pattern Match Failure" 2000C.HL01 must be numeric. 2000C.HL01 must equal the value of the previous HL01 plus one. 2000C.HL02 must be 2000C.HL02 must equal the value of the HL01 (2000B.HL01) of the parent HL. 2000C.HL01 must equal the value of the previous HL01 plus one. 2000C.HL02 must be 2000C.HL02 must equal the value of the HL01 of the parent HL. X212.47/ C.HL HL03 Hierarchical Level ID C.HL03 must be 2000C.HL03 must be X212.47/ C.HL HL C.HL03 must be "19". 2000C.HL03 must be "19". X212.47/ C.HL HL04 Hierarchical Child ID C.HL04 must be 2000C.HL04 must be 276_ of 1026_OTN2.xlsx Page 12 evision Date: 12/12/2011

17 Edit eference Max. eg. epeat Not X212.47/ C.HL HL C.HL04 must be "1". 2000C.HL04 must be "0" when rejecting because the provider is not found. Otherwise, 2000C.HL04 must be "1". Triggering error example: 2100C.NM109 not matched in the internal system. X212.49/ C.PN.010 PN Provider Name 2100C 2 T CSCC - E4 "Trading partner agreement specific requirement not met: Data correction required: CSC: 504" Entity's Last Name " DE98 = 1P - Only one iteration of 2100C is Provider allowed. CSC: 505" Entity's First Name " DE98 = 1P - Provider CSC: 153" Entity's ID " DE98 = 1P - Provider 04/20: Medicare limitation, 276 Companion Guide note needed. X212.49/ C.NM1.010 X212.49/ C.NM1.020 NM1 POVIDE NAME C NM1 999 IK304 = 3: "equired Segment Missing" IK304 = 5: "Segment Exceeds Maximum Use" 2100C.NM1 must be Only one iteration of 2100C.NM1 is allowed with NM101="1P". 2100C.NM1 must be Only one iteration of 2100C.NM1 is allowed with NM101="1P". X212.49/ C.NM X212.49/ C.NM NM101 Entity Identifier ID NM C.NM101 must be 2100C.NM101 must be "1P". 2100C.NM101 must be 2100C.NM101 must be the X212.49/ C.NM X212.49/ C.NM NM102 Entity Type Qualifier ID NM C.NM102 must be 2100C.NM102 must be valid values 2100C.NM102 must be 2100C.NM102 must be the X212.49/ C.NM X212.49/ C.NM NM103 Provider Last or Organization Name AN 1-60 S 999 NM IK403 = 5: "Data Too Long" 2100C.NM103 must be 2100C.NM103 must be C.NM103 must be 2100C.NM103 must be the X212.49/ C.NM NM C.NM103 must contain at least one non-space character. X212.49/ C.NM NM C.NM103 must be populated with accepted AN X212.49/ C.NM NM104 Provider First Name AN 1-35 S 999 IK403 = I13: "Implementation Dependent 'not used' Data If 2100C.NM102 is "2" 2100C.NM104 must not be present 2100C.NM104 must be the X212.49/ C.NM NM104 T CSC 505: "Entity's First Name" If 2100C.NM102 is "1", 2100C.NM104 must be X212.49/ C.NM NM IK403 = 5: "Data Too Long" 2100C.NM104 must be _ of 1026_OTN2.xlsx Page 13 evision Date: 12/12/2011

18 Edit eference Max. eg. epeat Not X212.49/ C.NM NM C.NM104 must contain at least one non-space character. X212.49/ C.NM NM C.NM104 must be populated with accepted AN X212.49/ C.NM NM105 Provider Middle Name AN 1-25 S 999 IK403 = I13: "Implementation Dependent 'not used' Data If 2100C.NM102 is "2", 2100C.NM105 must not be present 2100C.NM105 must be the X212.49/ C.NM NM IK403 = 5: "Data Too Long" 2100C.NM105 must be 1-25 X212.49/ C.NM NM C.NM105 must contain at least one non-space character. X212.49/ C.NM X212.49/ C.NM NM NM106 Provider Name Prefix AN 1-10 N/U C.NM105 must be populated with accepted AN Must not be Must not be X212.49/ C.NM NM107 Provider Name Suffix AN 1-10 S 999 IK403 = I13: "Implementation Dependent 'not used' Data If 2100C.NM102 is "2", 2100C.NM107 must not be present 2100C.NM107 must be the X212.49/ C.NM NM IK403 = 5: "Data Too Long" 2100C.NM107 must be 1-10 X212.49/ C.NM X212.49/ C.NM NM NM C.NM107 must contain at least one non-space character. 2100C.NM107 must be populated with accepted AN X212.49/ C.NM NM108 Identification Qualifier ID C.NM108 must be 2100C.NM108 must be X212.49/ C.NM NM108 T/C CSCC - E4 "Trading partner agreement specific requirement not met: Data correction required: For everyone except VA, CSC:745 "Identifier qualifier" 2100C.NM108 must be "XX". & CSC 562: "Entity's National Provider Identifier (NPI)" & DE98 = 1P 2100C.NM108 must be the 04/21: 276: Everyone except VA. 276 Companion Guide note needed. NM108 T/C CSCC - E4 "Trading partner agreement specific requirement not met: Data correction required: For VA, 2100C.NM108 must be CSC:745 "Identifier qualifier" "XX" or "SV" & CSC 562: "Entity's National Provider Identifier (NPI)" & DE98 = 1P 04/21: 276: VA only exception. 276 Companion Guide note needed. X212.49/ C.NM _ of 1026_OTN2.xlsx Page 14 evision Date: 12/12/2011

19 Edit eference Max. eg. epeat Not X212.49/ C.NM X212.49/ C.NM NM109 Provider Identifier AN NM109 C IK403 = 2: "Conditional equired Data Missing" CSC 562: "Entity's National Provider Identifier (NPI)" 2100C.NM108 is present, 2100C.NM109 must be 2100C.NM109 must be valid according to the NPI algorithm. 2100C.NM109 must be 2100C.NM109 must be the If the NPI in the C NM109 is not found on the NPI crosswalk, then build the response up to and including 2200C TN and 2200C STC, do not build additional loops after the 2200C STC segment. X212.49/ C.NM NM109 C CSC 562: "Entity's National Provider Identifier (NPI)" The first position of 2100C.NM109 must be a "1". X212.49/ C.NM NM109 T/C CSCC - E4 "Trading partner agreement specific requirement not met: Data correction required:csc 562: "Entity's National Provider Identifier (NPI)" 2100C.NM109 must be a valid NPI on the Crosswalk. 04/21: new edit. Valid NPI Crosswalk source for the 276/ transaction sets in the Contractor Front End Service must be available for this edit. Part A (Trans) Part B (C) [40 is T/C B side CEM Edit] X212.49/ C.NM X212.49/ C.NM X212.49/ C.NM X212.49/ C.NM X212.NA/ C.TN.010 NM109 T/C NM110 Entity elationship ID 2-2 N/U 999 NM111 Entity Identifier ID 2-3 N/U 999 NM112 Last Name AN 1-60 N/U 999 TN Provider CLAIM STATUS TACKING NUMBE 1 S 2200C C..NM109 must be CSC 496: "Submitter not associated with a valid submitter approved for electronic claim from 2100B NM109 according to submission on behalf of this the trading partner management entity" system Must not be Must not be Must not be 2100A..NM109 must be the Must not be Must not be Must not be When 2000C.HL04 = "0", one iteration of 2200C.TN is allowed. Otherwise, 2200B.TN is not allowed. Part A (Trans) Part B (C) [40 is T/C B side CEM Edit] If reporting error status at this level, the 2000D and 2000E s related to this provider are not used. X212.NA/ C.TN TN01 Trace Type ID C.TN01 must be X212.NA/ C.TN TN C.TN01 must be "1". X212.NA/ C.TN TN0race Number AN C.TN02 must be 276_ of 1026_OTN2.xlsx Page 15 evision Date: 12/12/2011

20 Edit eference Max. eg. epeat Not X212.NA/ C.TN TN C.TN02 must be "0". X212.NA/ C.TN TN03 Originating Company Identifier AN N/U Must not be X212.NA/ C.TN TN04 eference Identifier AN 1-50 N/U Must not be X212.NA/ C.STC.010 STC Provider STATUS INFOMATION C When 2000C.HL04 = "0", 2200C.STC must be Otherwise, 2200C.STC is not allowed. If status is being provided at this level, the 2000D loop is not sent. X212.NA/ C.STC.020 STC Five iterations of 2200C.STC are allowed. 04/23: Medicare limitation: Up to five iterations of the STC will be allowed for all occurrences in these transactions. X212.NA/ C.STC X212.NA/ C.STC STC01 STC01-1 HEALTH CAE CLAIM STATUS Status Category AN C.STC01-1 must be "D0" or "E". Triggering error example: Provider not matched in the internal system. - STC01-1 = "D0" X212.NA/ C.STC X212.NA/ C.STC STC01-2 STC01-2 Status AN C.STC01-2 must be 2200C.STC01-2 must be a valid Claim Status. Triggering error example: 2100B.NM109 NE ISA06 - STC01-2 = "24" X212.NA/ C.STC STC01-3 Entity Identifier ID 2-3 S 2200C.STC01-3 must be "1P". X212.NA/ C.STC X212.NA/ C.STC STC01-4 STC02 List Qualifier Status Information Effective Date ID 1-3 N/U Must not be DT C.STC02 must the current (system) date in CCYYMMDD format. X212.NA/ C.STC X212.NA/ C.STC X212.NA/ C.STC X212.NA/ C.STC X212.NA/ C.STC X212.NA/ C.STC STC03 Action ID 1-2 N/U Must not be STC04 Monetary Amount 1-18 N/U Must not be STC05 Monetary Amount 1-18 N/U Must not be STC06 Date DT 8-8 N/U Must not be STC07 Payment Method ID 3-3 N/U Must not be STC08 Date DT 8-8 N/U Must not be 276_ of 1026_OTN2.xlsx Page 16 evision Date: 12/12/2011

21 Edit eference Max. eg. epeat Not X212.NA/ C.STC STC09 Check Number AN 1-16 N/U Must not be X212.NA/ C.STC X212.NA/ C.STC STC10 STC10-1 HEALTH CAE CLAIM STATUS Status Category S AN C.STC10-1 may be present if 2200C.STC01-1 is present X212.NA/ C.STC STC C.STC01-1 must be "D0" or "E". X212.NA/ C.STC X212.NA/ C.STC STC10-2 STC10-2 Status AN C.STC10-2 must be 2200C.STC10-2 must be a valid Claim Status. Valid Claim Status equest reference must be available for this edit. X212.NA/ C.STC STC10-3 Entity Identifier ID 2-3 S 2200C.STC10-3 must be valid values. X212.NA/ C.STC STC10-4 List Qualifier ID 1-3 N/U Must not be X212.NA/ C.STC X212.NA/ C.STC STC11 STC11-1 HEALTH CAE CLAIM STATUS Status Category S AN C.STC11-1 may be present if 2200C.STC10-1 is present X212.NA/ C.STC STC C.STC11-1 must be "D0" or "E". X212.NA/ C.STC X212.NA/ C.STC STC11-2 STC11-2 Status AN C.STC11-2 must be 2200C.STC11-2 must be a valid Claim Status. Valid Claim Status equest reference must be available for this edit. X212.NA/ C.STC STC11-3 Entity Identifier ID 2-3 S 2200C.STC11-3 must be valid values. X212.NA/ C.STC STC11-4 List Qualifier ID 1-3 N/U Must not be X212.NA/ C.STC STC12 Free-Form Message Text AN N/U Must not be X212.52/ D.Sub.010 Sub Subscriber 2000D >1 X212.52/ D.HL.010 HL SUBSCIBE LEVEL D IK304 = 3: "equired Segment Missing" 2000D.HL must be If status information was not reported in the 2200B or 2200C loop, 2000D.HL must be For Medicare, the patient is always the subscriber. 276_ of 1026_OTN2.xlsx Page 17 evision Date: 12/12/2011

22 Edit eference Max. eg. epeat Not X212.52/ D.HL.020 HL 999 IK304 = 5: "Segment Exceeds Maximum Use" Only one iteration of 2000D.HL is allowed. Only one iteration of 2000D.HL is allowed. X212.52/ D.HL HL01 Hierarchical ID Number AN D.HL01 must be 2000D.HL01 must be X212.52/ D.HL HL IK403 = 5: "Data Too Long" 2000D.HL01 must be 1-12 X212.52/ D.HL X212.52/ D.HL X212.52/ D.HL X212.52/ D.HL HL HL HL02 Hierarchical Parent ID Number AN HL IK403 = I12: "Implementation Pattern Match Failure" 2000D.HL01 must be numeric value. 2000D.HL01 must equal the value of the previous HL01 plus one. 2000D.HL02 must be 2000D.HL02 must be equal the value of the HL01 (2000C.HL01) of the parent HL. 2000D.HL01 must equal the value of the previous HL01 plus one. 2000D.HL02 must be 2000D.HL02 must be equal the value of the HL01 (2000C.HL01) of the parent HL. X212.52/ D.HL HL03 Hierarchical Level ID D.HL03 must be 2000D.HL03 must be X212.52/ D.HL HL D.HL03 must be "22". 2000D.HL03 must be "22". X212.52/ D.HL HL04 Hierarchical Child ID D.HL04 must be 2000D.HL04 must be X212.52/ D.HL X212.54/NA.2000D.DMG.010 HL DMG SUBSCIBE DEMOGAPHIC INFOMATION 1 S 2000D 999 IK304=5: "Segment Exceeds Maximum Use" 2000D.HL04 must be valid values. Only one iteration of 2000D.DMG is allowed. 2000D.HL04 must be "0". For Medicare, the 2000E loop is never used. X212.54/NA.2000D.DMG DMG01 Date Time Period Format Qualifier ID D.DMG01 must be X212.54/NA.2000D.DMG DMG D.DMG01 must be "D8". X212.54/NA.2000D.DMG X212.54/NA.2000D.DMG X212.54/NA.2000D.DMG DMG02 Subscriber Birth Date AN DMG IK403 = 8: "Invalid Date" DMG02 C CSC 510: "Future date" CSC 158: "Entity's date of birth" 2000D.DMG02 must be 2000D.DMG02 must be a valid date in format CCYYMMDD format. 2000D.DMG02 must not be a future date. X212.54/NA.2000D.DMG DMG03 Subscriber Gender ID 1-1 S D.DMG03 must be X212.54/NA.2000D.DMG DMG D.DMG03 must be valid values. 276_ of 1026_OTN2.xlsx Page 18 evision Date: 12/12/2011