5010 Gap Analysis for Institutional Claims. Based on ASC X v5010 TR3 X223A2 Version 2.0 August 2010

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1 5010 Gap Analysis for Institutional Claims Based on ASC X v5010 T3 X223A2 Version 2.0 August 2010

2 This information is provided by Emdeon for education and awareness use only. Even though Emdeon believes that all the information in this document is correct as of August 2010, Emdeon does not warrant the accuracy, completeness, or fitness for any particular purpose of this information. All use is at the reader s own risk. The information provided here is for reference use only and does not constitute the rendering of legal, financial, or other professional advice or recommendations by Emdeon. 2010, Emdeon Business Services LLC, 3055 Lebanon Pike Suite 1000, Nashville, TN All ights eserved. Printed in the USA.

3 PUPOSE The purpose of this document is to provide a high-level gap analysis between the current HIPAA-mandated Health Care Claim: Institutional X096A1 837 version 4010 and the HIPAA-mandated Health Care Claim: Institutional X223A2 837 version 5010 that has a compliance date of January 1, This document should be used along with the X Institutional T3 X223A2. To obtain your copy of the T3 visit the X12 Web Site at: Health Care Claims: Institutional 837 ASC X (005010X223A2) OVEALL GAP ANALYSIS EPOT NEW CONTENT EPOT DELETED CONTENT EPOT USE CHANGE EPOT SIZING CHANGE EPOT CODE CHANGE EPOT The Overall Gap Analysis eport provides a list of all content changes in the order of the T3. Changes that were considered non-substantive are not listed in this report. The Change Comment gives a brief summary of the change, and the columns listed to the right indicate the type of change. The New Content eport provides a list of NEW data elements added in the 5010 version of the transaction. The Deleted Content eport provides a list of the data elements EMOVED in the 5010 version of the transaction. The Use Change eport provides a list of data elements where the T3 usage changed from Situational to equired; equired to Situational; or the Situational Note changed. The Sizing Change eport provides a list of data elements where the min/max requirements changed in the The Code Change eport provides a list of data elements where the code values within the data element were changed in 5010.

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5 5010 Gap Analysis Institutional Claims X223A2 Gap Analysis Items in ed are flagged as Transitions Challenges. Highlighted Items indicate Errata Changes. Loop Segment Qualifier Description Change Comment New Del elocate T3 Use Code Qualifier X12 Use X12 Size Header ISA11 epetition Separator Element changed from Interchange Control Standards Identifier to epetition Separator. Header ISA12 Interchange Control Version Number Code value changed to Header GS08 Version / elease Industry ID Code X223A2: Code value changed to X223A2. X223A1: Code value changed to X223A1. Header ST03 Implementation Convention eference X223A2: Code value is X223A2 X223A1: Added ST03 to replace the Table 1 EF. Code value is X223A1 Header BHT03 Originator Application Transaction Identifier For the purposes of the implementation the maximum field length is 30. Min/Max changed from 1/30 to 1/50. Header BHT06 Claim or Encounter Identifier Code Value 31 (Subrogation Demand) was added. Header EF01 87 eference Number Qualifier Moved the Transmission Type to ST03. Header EF02 Transmission Type Code Moved the Transmission Type to ST A NM103 Submitter Last/Org Name X12 Attribute changed from Optional (O) to Conditional (X). Min/Max changed from 1/35 to 1/ A NM104 Submitter First Name equired when NM102 equals 1 and the person has a first name. Min/Max changed from 1/25 to 1/ A PE02 Submitter Contact Name Changed from equired to Situational. 1000A PE04 Communication Number Min/Max changed from 1/80 to 1/ A PE04 ED Submitter EDI Number Deleted in 5010 due to lack of business requirement. 1000A PE04 EM Submitter E mail Min/Max changed from 1/80 to 1/256. Page 2 of 47

6 Loop Segment Qualifier Description Change Comment New Del elocate T3 Use Code Qualifier X12 Use X12 Size 1000A PE04 FX Submitter FAX Min/Max changed from 1/80 to 1/ A PE04 TE Submitter Telephone Number Min/Max changed from 1/80 to 1/ A PE06 Communication Number Min/Max changed from 1/80 to 1/ A PE06 ED Submitter EDI Number Deleted in 5010 due to lack of business requirement. 1000A PE06 EM Submitter Min/Max changed from 1/80 to 1/ A PE06 FX Submitter FAX Min/Max changed from 1/80 to 1/ A PE06 TE Submitter Telephone Number Min/Max changed from 1/80 to 1/ A PE06 EX Submitter Telephone Extension Min/Max changed from 1/80 to 1/ A PE08 Communication Number Min/Max changed from 1/80 to 1/ A PE08 ED Submitter EDI Number Deleted in 5010 due to lack of business requirement. 1000A PE08 EM Submitter Min/Max changed from 1/80 to 1/ A PE08 FX Submitter FAX Min/Max changed from 1/80 to 1/ A PE08 TE Submitter Telephone Number Min/Max changed from 1/80 to 1/ A PE08 EX Submitter Telephone Extension Min/Max changed from 1/80 to 1/ B NM103 eceiver Last/Org Name X12 Attribute changed from Optional (O) to Conditional (X). Min/Max changed from 1/35 to 1/ A PV01 Provider Code Qualifier PT was deleted. 2000A PV02 PXC eference Number Qualifier Qualifier ZZ changed to PXC. X12 Attribute changed from Mandatory (M) to Conditional (X) with the condition if either PV02 or PV03 is present the other is required. 2000A PV03 BI Billing Provider Taxonomy Code X12 Attribute changed from Mandatory (M) to Conditional (X) with the condition if either PV02 or PV03 is present the other is required. Min/Max changed from 1/30 to 1/ A PV03 PT Pay To Provider Taxonomy Code Deleted Taxonomy Code as this is now Address Information only. 2010AA NM103 Billing Provider Last/Org Name X12 Attribute changed from Optional (O) to Conditional (X). Min/Max changed from 1/35 to 1/60. Page 3 of 47

7 Loop Segment Qualifier Description Change Comment New Del elocate T3 Use Code Qualifier X12 Use X12 Size 2010AA NM108 Identification Code Qualifier Changed from equired to Situational. equired when the Provider is eligible for an NPI. Qualifiers 24 and 34 were deleted. Due to NPI mandate, NPI (XX) is the only valid qualifier. 2010AA NM109 Billing Provider Primary Identification Number Changed from equired to Situational. Situational ule added NPI is required when provider is eligible for an NPI. 2010AA NM Billing Provider Employer's Identification Number Employer Identification Number (Qualifier 24) was relocated to a EF segment in the 2010AA Loop. The usage changed from equired to Situational. equired when the Provider is eligible for an NPI. 2010AA NM Billing Provider Social Security Number Social Security Number (Qualifier 34) was relocated to a EF segment in the 2010AA Loop. The usage changed from equired to Situational. equired when the Provider is eligible for an NPI. 2010AA N402 Billing Provider State / Province Code Changed from equired to Situational. equired when US or it's territories or Canada. X12 Attribute changed from Optional (O) to Conditional (X). Only one of N402 or N407 may be present. 2010AA N403 Billing Provider Postal Zone or Zip Code Changed from equired to Situational. equired when US or it's territories or Canada. When reporting zip codes for US addresses the full nine digit zip code must be provided. 2010AA N404 Billing Provider Country Code X12 Attribute changed from Optional (O) to Conditional (X). If N407 is present then N404 is required. Clarification added to use ISO 1366 Part 1 Alpha list. 2010AA N407 Billing Provider Country Subdivision Code Only one of N402 or N407 may be present. If N407 is present then N404 is required. 2010AA EF01 BILLING POVIDE TAX IDENTIFICATION Billing Provider Tax Identification moved into a required EF segment specifically for Tax Identification Number. 2010AA EF02 Billing Provider Tax Identification Number Billing Provider Tax Identification moved into a required EF segment specifically for Tax Identification Number. Min/Max changed from 1/30 to 1/ AA EF02 EI Employer Identification Number Qualifier note restricts to 9 numeric no hyphens. Min/Max changed from 1/30 to 1/ AA EF01 eference Number Qualifier 2010AA EF02 Billing Provider Secondary Identifiers Page 4 of 47

8 Loop Segment Qualifier Description Change Comment New Del elocate T3 Use Code Qualifier X12 Use X12 Size 2010AA EF02 0B Billing Provider State License Number 2010AA EF02 1A Billing Provider Blue Cross Number 2010AA EF02 1B Billing Provider Blue Shield Number 2010AA EF02 1C Billing Provider Medicare Number 2010AA EF02 1D Billing Provider Medicaid Number 2010AA EF02 1G Billing Provider Medicaid Number 2010AA EF02 1H Billing Provider CHAMPUS Id Number 2010AA EF02 1G Billing Provider UPIN 2010AA EF02 1J Billing Provider Facility ID Number 2010AA EF02 B3 Billing Provider PPO Number 2010AA EF02 BQ Billing Provider HMO Code Number 2010AA EF02 EI Billing Provider Employer Identification Number 2010AA EF02 FH Billing Provider Clinic Number 2010AA EF02 G2 Billing Provider Commercial Number 2010AA EF02 G5 Billing Provider Site Number Deleted in However, Emdeon will continue to allow providers to use this for reporting purposes. The information will not be passed on to the payer. 2010AA EF02 LU Billing Provider Location Number 2010AA EF02 SY Billing Provider Social Security Number 2010AA EF02 X5 Billing Provider State industrial Acc Number 2010AA EF01 eference Number Qualifier 2010AA EF02 Billing Provider Credit Card Identifier 2010AA EF02 06 System Number 2010AA EF02 8U Bank Assigned Security Identifier 2010AA EF02 EM Electronic Payment eference Number 2010AA EF02 IJ Standard Industry Classification (SIC) 2010AA EF02 LU Location Number Page 5 of 47

9 Loop Segment Qualifier Description Change Comment New Del elocate T3 Use Code Qualifier X12 Use X12 Size 2010AA EF02 B ate Code Number 2010AA EF02 ST Store Number 2010AA EF02 TT Terminal Code 2010AA PE02 Contact Name Changed from equired to Situational. Clarification: the requirement of this element on the second repeat of the PE Segment. 2010AA PE04 Communication Number Min/Max changed from 1/80 to 1/ AA PE04 EM Billing Provider Min/Max changed from 1/80 to 1/ AA PE04 FX Billing Provider FAX Min/Max changed from 1/80 to 1/ AA PE04 TE Billing Provider Telephone Min/Max changed from 1/80 to 1/ AA PE06 EM Billing Provider Min/Max changed from 1/80 to 1/ AA PE06 EX Billing Provider Telephone Extension Min/Max changed from 1/80 to 1/ AA PE06 FX Billing Provider FAX Min/Max changed from 1/80 to 1/ AA PE06 TE Billing Provider Telephone Min/Max changed from 1/80 to 1/ AA PE08 EM Billing Provider Min/Max changed from 1/80 to 1/ AA PE08 EX Billing Provider Telephone Extension Min/Max changed from 1/80 to 1/ AA PE08 FX Billing Provider FAX Min/Max changed from 1/80 to 1/ AA PE08 TE Billing Provider Telephone Min/Max changed from 1/80 to 1/ AB NM103 Pay To Provider Last/Org Name 2010AB NM108 Identification Code Qualifier 2010AB NM109 Pay To Primary Identifier 2010AB NM109 XX Pay To National Identifier 2010AB NM Pay To Employer Identification Number 2010AB NM Pay To Social Security Number 2010AB N301 Pay To Address AB N302 Pay To Address AB N401 Pay To City Name Page 6 of 47

10 Loop Segment Qualifier Description Change Comment New Del elocate T3 Use Code Qualifier X12 Use X12 Size 2010AB N402 Pay To State/Province Code Changed from equired to Situational. equired when US or it's territories or Canada. X12 Attribute changed from Optional (O) to Conditional (X). Only one of N402 or N407 may be present. 2010AB N403 Pay To Zip Code Changed from equired to Situational. equired when US or it's territories or Canada. 2010AB N404 Pay To Country Code X12 Attribute changed from Optional (O) to Conditional (X). If N407 is present then N404 is required. Clarification added to use ISO 1366 Part 1 Alpha list. 2010AB N407 Pay To Country Subdivision Code Only one of N402 or N407 may be present. If N407 is present then N404 is required. 2010AB EF01 eference Number Qualifier 2010AB EF02 Pay To Secondary Identifiers 2010AB EF02 0B Pay To State License Number 2010AB EF02 1A Pay To Blue Cross Provider Number 2010AB EF02 1B Pay To Blue Shield Provider Number 2010AB EF02 1C Pay To Medicare Number 2010AB EF02 1D Pay To Medicaid Number 2010AB EF02 1G Pay To UPIN Number 2010AB EF02 1H Pay To CHAMPUS ID Number 2010AB EF02 1J Pay To Facility Identification Number 2010AB EF02 B3 Pay To PPO Number 2010AB EF02 BQ Pay To HMO Number 2010AB EF02 EI Pay To Employer's Identification Number 2010AB EF02 FH Pay To Clinic Number 2010AB EF02 G2 Pay To Commercial Number 2010AB EF02 G5 Pay To Site Number 2010AB EF02 LU Pay To Location Number 2010AB EF02 SY Pay To Social Security Number Page 7 of 47

11 Loop Segment Qualifier Description Change Comment New Del elocate T3 Use Code Qualifier X12 Use X12 Size 2010AB EF02 U3 Pay To USIN Number 2010AB EF02 X5 Pay To State Industrial Accident Number 2010AC NM101 PE Name Qualifier 2010AC NM102 2 Entity Type Qualifier 2010AC NM103 Pay To Plan Organization Name 2010AC NM108 List Identification Code Qualifier 2010AC NM109 Pay To Plan Primary Identifier 2010AC NM109 PI Pay To Plan Payer ID 2010AC NM109 XV Pay To Plan CMS PlanID 2010AC N301 Pay To Plan Address AC N302 Pay To Plan Address AC N401 Pay To Plan City Name 2010AC N402 Pay To Plan State or Province Code 2010AC N403 Pay To Plan Postal Zone or Zip Code 2010AC N404 Pay To Plan Country Code If N407 is present then N404 is required. 2010AC N407 Pay To Plan Country Subdivision Code Only one of N402 or N407 may be present. If N407 is present then N404 is required. 2010AC EF01 List eference Number Qualifier 2010AC EF02 Pay To Plan Secondary Identifiers 2010AC EF02 2U Pay To Plan Payer ID 2010AC EF02 FY Pay To Plan Claim Office Number 2010AC EF02 NF Pay To Plan National Association of Insurance Commissioners (NAIC) Number 2010AC EF01 eference Number Qualifier 2010AC EF02 EI Pay To Plan Tax Identification Number Qualfier note restricts to 9 numerics no hyphens. 2000B SB01 Payer esponsibility Sequence Number Code Code Values A H and U were added to support payers Provider Products should not allow U as a valid value since this is for Payer to Payer COB only. Page 8 of 47

12 Loop Segment Qualifier Description Change Comment New Del elocate T3 Use Code Qualifier X12 Use X12 Size 2000B SB03 Subscriber Group or Policy Number Industry Name changed from insured to subscriber. Min/Max changed from 1/30 to 1/ B SB09 Claim Filing Indicator Code Code Values 09, 10, LI were deleted. Code Values 17 and FI were added. Code descriptions for VA and ZZ were modified (nonsubstantive). 2010BA NM103 Subscriber Last Name X12 Attribute changed from Optional (O) to Conditional (X). Min/Max changed from 1/35 to 1/ BA NM104 Subscriber First Name equired when NM102 equals 1 and the person has a first name. Min/Max changed from 1/25 to 1/ BA NM108 List Identification Code Qualifier X223A2: Changed from equired to Situational to accommodate Workers' Compensation. equired when NM102=1. X223A1: Qualifier II replaced ZZ for Standard Unique Health Identifier. Changed from Situational to equired to support the new definition of subscriber. 2010BA NM109 Subscriber Primary Identifier X223A2: Changed from equired to Situational to accommodate Workers' Compensation. equired when NM102 = BA NM109 ZZ Mutually Defined X223A1: Changed from Situational to equired to support the new definition of subscriber. 2010BA N4 SUBSCIBE CITY/STATE/ZIP CODE X223A2: Changed from equired to Situational. equired when the patient is the subscriber or considered to be the subscriber. X223A1: Changed from Situational to equired. The X12 Portal for HIPAA Interpretations addresses this information in HI BA N402 Subscriber State Code Changed from equired to Situational. equired when US or it's territories or Canada. X12 Attribute changed from Optional (O) to Conditional (X). Only one of N402 or N407 may be present. 2010BA N403 Subscriber Postal Zone or Zip Code Changed from equired to Situational. equired when US or it's territories or Canada. Page 9 of 47

13 Loop Segment Qualifier Description Change Comment New Del elocate T3 Use Code Qualifier X12 Use X12 Size 2010BA N404 Subscriber Country Code X12 Attribute changed from Optional (O) to Conditional (X). If N407 is present then N404 is required. Clarification added to use ISO 1366 Part 1 Alpha list. 2010BA N407 Subscriber Country Subdivision Code Only one of N402 or N407 may be present. If N407 is present then N404 is required. 2010BA EF01 List eference Number Qualifier Qualifiers 1W, 23 and IG were deleted. emoved Note that SY may not be used for Medicare. Hyphens should be stripped from the value prior to sending. 2010BA EF02 Subscriber Supplemental Identifier Min/Max changed from 1/30 to 1/ BA EF02 23 Subscriber IHS Health ecord Number 2010BA EF02 1W Subscriber Member ID 2010BA EF02 IG Subscriber Insurance Policy Number 2010BA EF02 SY Subscriber Social Security Number Qualifier note restricts to 9 numeric no hyphens. Min/Max changed from 1/30 to 1/ BA EF02 Property Casualty Claim Number Min/Max changed from 1/30 to 1/ BB NM101 AO Name Qualifier 2010BB NM102 Entity Type Qualifier 2010BB NM103 Credit/Debit Cardholder Last or Organization Name 2010BB NM104 Credit /Debit Cardholder First Name 2010BB NM105 Credit /Debit Cardholder Middle Name or Initial 2010BB NM107 Credit /Debit Cardholder Name Suffix 2010BB NM108 MI Identification Code Qualifier 2010BB NM109 Credit or Debit Card Number 2010BB EF01 List eference Number Qualifier 2010BB EF02 AB Credit/Debit Card Authorization Number 2010BB EF02 BB Credit/Debit Card Acceptable Source Purchaser ID 2010BB NM103 Payer Name X12 Attribute changed from Optional (O) to Conditional (X). Min/Max changed from 1/35 to 1/60. Page 10 of 47

14 Loop Segment Qualifier Description Change Comment New Del elocate T3 Use Code Qualifier X12 Use X12 Size 2010BB N4 PAYE CITY/STATE/ZIP CODE X223A2: Changed to Situational. equired when the payer address is available to the submitter and the submitter intends for the claim to be printed at the next EDI location. X223A1: Changed from Situational to equired. The X12 Portal for HIPAA Interpretations addresses this information in HI BB N402 Payer State/Provider Code Changed from equired to Situational. equired when US or it's territories or Canada. X12 Attribute changed from Optional (O) to Conditional (X). Only one of N402 or N407 may be present. 2010BB N403 Payer Postal Zone or Zip Code Changed from equired to Situational. equired when US or it's territories or Canada. 2010BB N404 Payer Country Code X12 Attribute changed from Optional (O) to Conditional (X). If N407 is present then N404 is required. Clarification added to use ISO 1366 Part 1 Alpha list. 2010BB N407 Payer Country Subdivision Code Only one of N402 or N407 may be present. If N407 is present then N404 is required. 2010BB EF01 List eference Number Qualifier Qualifier TJ was deleted. Qualifier EI was added. 2010BB EF02 Payer Secondary Identifier Min/Max changed from 1/30 to 1/ BB EF02 2U Payer Identification Min/Max changed from 1/30 to 1/ BB EF02 EI Payer Employer's Identification Number Qualifier note restricts to 9 numeric no hyphens. 2010BB EF02 FY Payer Claim Office Number Min/Max changed from 1/30 to 1/ BB EF02 NF Payer National Association of Insurance Commissioners (NAIC) Number 2010BB EF02 TJ Payer Federal Taxpayer's Identification Number Min/Max changed from 1/30 to 1/ BB EF01 eference Number Qualifier Qualifiers G2 and LU are the only valid Qualifiers. 2010BB EF02 List Billing Provider Secondary Identifier emaining Secondary Provider Identifiers were removed from the 2010AA Loop and moved to the Payer Loop. Min/Max changed from 1/30 to 1/ BB EF02 G2 Payer Assigned ID emaining Secondary Provider Identifiers were removed from the 2010AA Loop and moved to the Payer Loop. Min/Max changed from 1/30 to 1/50. Page 11 of 47

15 Loop Segment Qualifier Description Change Comment New Del elocate T3 Use Code Qualifier X12 Use X12 Size 2010BB EF02 LU Location Number emaining Secondary Provider Identifiers were removed from the 2010AA Loop and moved to the Payer Loop. Min/Max changed from 1/30 to 1/ BD NM101 QD Name Qualifier 2010BD NM102 Entity Type Qualifier 2010BD NM103 esponsible Party Last/Org Name 2010BD NM104 esponsible Party First Name 2010BD NM105 esponsible Party Middle Name or Initial 2010BD NM107 esponsible Party Suffix 2010BD N301 esponsible Party Address BD N302 esponsible Party Address BD N401 esponsible Party City Name 2010BD N402 esponsible Party State or Province Code 2010BD N403 esponsible Party Postal Zone or Zip Code 2010BD N404 esponsible Party Country Code 2000C PAT01 Individual elationship Code Code Values 01, 19, 20, 21, 39, 40, 53 and G8 are the only remaining values. All other code values were deleted. 2010CA NM103 Patient Last Name X12 Attribute changed from Optional (O) to Conditional (X). Min/Max changed from 1/35 to 1/ CA NM104 Patient First Name Changed from equired to Situational. equired when NM102 equals 1 and the person has a first name. Min/Max changed from 1/25 to 1/ CA NM108 List Identification Code Qualifier Deleted in If patient has a unique identifier then the patient is reported in the subscriber information. 2010CA NM109 Patient Primary Identifier 2010CA NM109 MI Patient Member Identification Number Deleted in If patient has a unique identifier then the patient is reported in the subscriber information. 2010CA NM109 ZZ Patient HIPAA Individual Identifier Page 12 of 47

16 Loop Segment Qualifier Description Change Comment New Del elocate T3 Use Code Qualifier X12 Use X12 Size 2010CA N402 Patient State or Province Code Changed from equired to Situational. equired when US or it's territories or Canada. X12 Attribute changed from Optional (O) to Conditional (X). Only one of N402 or N407 may be present. 2010CA N403 Patient Postal Zone or Zip Code Changed from equired to Situational. equired when US or it's territories or Canada. 2010CA N404 Patient Country Code X12 Attribute changed from Optional (O) to Conditional (X). If N407 is present then N404 is required. Clarification added to use ISO 1366 Part 1 Alpha list. 2010CA N407 Patient Country Subdivision Code Only one of N402 or N407 may be present. If N407 is present then N404 is required. 2010CA EF01 eference Number Qualifier 2010CA EF02 Patient Secondary Identifiers 2010CA EF02 23 Patient Indian Health Service Number 2010CA EF02 1W Patient Member Identification Number 2010CA EF02 IG Patient Insurance Policy Number 2010CA EF02 SY Patient Social Security Number 2010CA EF POPETY AND CASUALTY PATIENT IDENTIFIE X223A2: This Segment was added to accommodate Workers' Compensation in lieu of the removal of the Patient Secondary Identification Segment. 2010CA EF01 eference Number Qualifier 2010CA EF02 Patient Secondary Identifiers 2010CA EF02 1W Patient Member Identification Number 2010CA EF02 SY Patient Social Security Number 2010CA EF02 Property Casualty Claim Number Min/Max changed from 1/30 to 1/ CLM02 Total Claim Charge Amount Clarification: total claim charge amount cannot be less than zero. Maximum length note was added to be 11 characters 2300 CLM06 Provider or Supplier Signature Indicator Changed from equired to Not Used. Page 13 of 47

17 Loop Segment Qualifier Description Change Comment New Del elocate T3 Use Code Qualifier X12 Use X12 Size 2300 CLM07 Assignment or Plan Participation Code Code Value P was deleted. Code Values A, B and C are the only remaining values. Usage of this field changed and is no longer limited to Medicare Assignment. This could be a significant change to provider software and products if a payer is requiring the use of this field to define their relationship with the provider submitting claims CLM08 Benefits Assignment Certification Indicator Code value W added to replace CLM07 Provider Accept Assignment Indicator code value P 'Patient refuses to assign benefits' CLM09 elease of Information Code Code values A, M, N, O were deleted. Code values remaining are I and Y CLM18 Explanation of Benefits Indicator Changed from equired to Not Used CLM20 Delay eason Code Code Value 15 was added. Example was removed to eliminate confusion in use of the element DTP02 D8 DTP Format Qualifier Qualifier D8 was deleted DTP02 List DTP Format Qualifier Qualifier D8 was added DTP DTP Qualifier 2300 DTP02 D8 DTP Format Qualifier 2300 DTP03 epricer eceived Date 2300 CL101 Admission Type Code X223A2: Changed from Situational to equired. Implementation Name changed to Priority (Type) of Admission or Visit CL103 Patient Status Code Changed from Situational to equired PWK01 List Attachment eport Type Code Code Values 03, 04, 05, 06, 07, 08, 09, 10, 11, 13, 15, 21 A3, A4, AM, B, BS, BT, CB, CK, D2, DB, DJ, HC, H, I5, I, LA, M1, OC, OD, OE, OX, P4, P5, PE, PQ, PY, X, SG, V5, XP were added PWK02 List Attachment Transmission Code Code Value FT was added PWK06 Attachment Control Number A realistic maximum of 50 was added to the notes PWK07 Attachment Description 2300 CN102 Contract Amount Maximum length note was added to be 11 characters 2300 CN104 Contract Code Min/Max changed from 1/30 to 1/50. Page 14 of 47

18 Loop Segment Qualifier Description Change Comment New Del elocate T3 Use Code Qualifier X12 Use X12 Size 2300 AMT01 C5 Amount Qualifier Code 2300 AMT02 Estimated Claim Due Amount 2300 AMT02 Patient esponsibility Amount Maximum length note was added to be 11 characters 2300 AMT01 F5 Amount Qualifier Code 2300 AMT02 Patient Amount Paid 2300 AMT01 MA Amount Qualifier Code 2300 AMT02 Credit or Debit Card Maximum Amount 2300 EF02 List Service Authorization Exception Code Min/Max changed from 1/30 to 1/ EF01 List eference Number Qualifier 2300 EF02 9F eferral Number 2300 EF02 G1 Prior Authorization Number 2300 EF01 9F eference Number Qualifier 2300 EF02 eferral Number Min/Max changed from 1/30 to 1/ EF01 G1 eference Number Qualifier 2300 EF02 Prior Authorization Number Min/Max changed from 1/30 to 1/ EF02 Payer Claim Control Number Min/Max changed from 1/30 to 1/ EF02 epriced Claim eference Number Min/Max changed from 1/30 to 1/ EF02 Adjusted epriced Claim eference Number Min/Max changed from 1/30 to 1/ EF02 Investigational Device Exemption Identifier Min/Max changed from 1/30 to 1/ EF02 Value Added Network Trace Number Min/Max changed from 1/30 to 1/50. Maximum length note was added to be 20 characters EF01 LU eference Number Qualifier 2300 EF02 Auto Accident State Code 2300 EF02 Medical ecord Number Min/Max changed from 1/30 to 1/ EF02 Demonstration Project Identifier Min/Max changed from 1/30 to 1/ EF02 Peer eview Authorization Number Min/Max changed from 1/30 to 1/50. Page 15 of 47

19 Loop Segment Qualifier Description Change Comment New Del elocate T3 Use Code Qualifier X12 Use X12 Size 2300 EF01 DD eference Number Qualifier 2300 EF02 Document Control Identifier 2300 C601 Prognosis Indicator 2300 C602 Service From Date 2300 C603 Date Time Period Format Qualifier 2300 C604 Home Health Certification Period 2300 C605 Diagnosis Date 2300 C606 Skilled Nursing Facility Indicator 2300 C607 Medicare Coverage Indicator 2300 C608 Certification Type Indicator 2300 C609 Surgery Date 2300 C610 Surgical Procedure Type Code 2300 C611 Surgical Procedure Code 2300 C612 Provider Order Date 2300 C613 Last Visit Date 2300 C614 Provider Contact Date 2300 C615 Date Time Period Format Qualifier 2300 C616 Last Discharge Date 2300 C616 Last Admission Date 2300 C617 Patient Discharge Facility Type Code 2300 C618 Diagnosis Date C619 Diagnosis Date C620 Diagnosis Date C621 Diagnosis Date CC01 75 Functional Limitations 2300 CC02 Certification Condition Indicator Page 16 of 47

20 Loop Segment Qualifier Description Change Comment New Del elocate T3 Use Code Qualifier X12 Use X12 Size 2300 CC03 Functional Limitation Code 2300 CC04 Functional Limitation Code (epeat 4) 2300 CC05 Functional Limitation Code 2300 CC06 Functional Limitation Code 2300 CC07 Functional Limitation Code 2300 CC ACTIVITIES PEMITTED INFOMATION (EPEAT 3) Deleted due to lack of business requirements CC01 76 Activities Condition Certification Code 2300 CC02 Activities Permitted Certification Condition Indicator 2300 CC03 Activities Permitted Code 2300 CC04 Activities Permitted Code 2300 CC05 Activities Permitted Code 2300 CC06 Activities Permitted Code 2300 CC07 Activities Permitted Code 2300 CC01 77 Certification Condition Indicator 2300 CC02 Home Health Mental Status Certification Conditions Indicator 2300 CC03 Mental Status Code 2300 CC04 Additional Mental Status Code (epeat 4) 2300 CC05 Mental Status Code 2300 CC06 Mental Status Code 2300 CC07 Mental Status Code 2300 CC01 ZZ Code Category 2300 CC02 List Certification Condition Indicator 2300 CC03 List EPSDT Condition Code 2300 CC04 List Condition Indicator 2300 CC05 List Condition Indicator 2300 HI01 1 List Code List Qualifier Code Code Value ABK was added to support ICD 10. Page 17 of 47

21 Loop Segment Qualifier Description Change Comment New Del elocate T3 Use Code Qualifier X12 Use X12 Size 2300 HI01 9 List Present on Admission Indicator (epeat 1 Principal Diagnosis) 2300 HI01 Health Care Code Information 2300 HI01 1 List Code List Qualifier Code Code Value ABJ was added to support ICD HI01 2 Admitting Diagnosis 2300 HI01 Health Care Code Information 2300 HI01 1 List Code List Qualifier Code Code Value AP was added to support ICD HI01 2 Patient eason for Visit 2300 HI02 Health Care Code Information 2300 HI02 1 List Code List Qualifier Code 2300 HI02 2 Patient eason for Visit 2300 HI03 Health Care Code Information 2300 HI03 1 List Code List Qualifier Code 2300 HI03 2 Patient eason for Visit 2300 HI01 Health Care Code Information 2300 HI01 1 List Code List Qualifier Code Code Value ABN was added to support ICD HI01 2 External Cause of Injury Code 2300 HI01 9 List Present on Admission Indicator (epeat 12 External Cause of Injury) 2300 HI02 Health Care Code Information 2300 HI02 1 List Code List Qualifier Code 2300 HI02 2 External Cause of Injury Code 2300 HI02 9 List Present on Admission Indicator 2300 HI03 Health Care Code Information 2300 HI03 1 List Code List Qualifier Code 2300 HI03 2 External Cause of Injury Code 2300 HI03 9 List Present on Admission Indicator Page 18 of 47

22 Loop Segment Qualifier Description Change Comment New Del elocate T3 Use Code Qualifier X12 Use X12 Size 2300 HI04 Health Care Code Information 2300 HI04 1 List Code List Qualifier Code 2300 HI04 2 External Cause of Injury Code 2300 HI04 9 List Present on Admission Indicator 2300 HI05 Health Care Code Information 2300 HI05 1 List Code List Qualifier Code 2300 HI05 2 External Cause of Injury Code 2300 HI05 9 List Present on Admission Indicator 2300 HI06 Health Care Code Information 2300 HI06 1 List Code List Qualifier Code 2300 HI06 2 External Cause of Injury Code 2300 HI06 9 List Present on Admission Indicator 2300 HI07 Health Care Code Information 2300 HI07 1 List Code List Qualifier Code 2300 HI07 2 External Cause of Injury Code 2300 HI07 9 List Present on Admission Indicator 2300 HI08 Health Care Code Information 2300 HI08 1 List Code List Qualifier Code 2300 HI08 2 External Cause of Injury Code 2300 HI08 9 List Present on Admission Indicator 2300 HI09 Health Care Code Information 2300 HI09 1 List Code List Qualifier Code 2300 HI09 2 External Cause of Injury Code 2300 HI09 9 List Present on Admission Indicator 2300 HI10 Health Care Code Information 2300 HI10 1 List Code List Qualifier Code Page 19 of 47

23 Loop Segment Qualifier Description Change Comment New Del elocate T3 Use Code Qualifier X12 Use X12 Size 2300 HI10 2 External Cause of Injury Code 2300 HI10 9 List Present on Admission Indicator 2300 HI11 Health Care Code Information 2300 HI11 1 List Code List Qualifier Code 2300 HI11 2 External Cause of Injury Code 2300 HI11 9 List Present on Admission Indicator 2300 HI12 Health Care Code Information 2300 HI12 1 List Code List Qualifier Code 2300 HI12 2 External Cause of Injury Code 2300 HI012 9 List Present on Admission Indicator 2300 HI01 1 List Code List Qualifier Code Code Value ABF was added to support ICD HI01 9 List Present on Admission Indicator (epeat 24 Other Diagnosis) 2300 HI02 1 List Code List Qualifier Code Code Value ABF was added to support ICD HI02 9 List Present on Admission Indicator 2300 HI03 1 List Code List Qualifier Code Code Value ABF was added to support ICD HI03 9 List Present on Admission Indicator 2300 HI04 1 List Code List Qualifier Code Code Value ABF was added to support ICD HI04 9 List Present on Admission Indicator 2300 HI05 1 List Code List Qualifier Code Code Value ABF was added to support ICD HI05 9 List Present on Admission Indicator 2300 HI06 1 List Code List Qualifier Code Code Value ABF was added to support ICD HI06 9 List Present on Admission Indicator 2300 HI07 1 List Code List Qualifier Code Code Value ABF was added to support ICD HI07 9 List Present on Admission Indicator 2300 HI08 1 List Code List Qualifier Code Code Value ABF was added to support ICD HI08 9 List Present on Admission Indicator Page 20 of 47

24 Loop Segment Qualifier Description Change Comment New Del elocate T3 Use Code Qualifier X12 Use X12 Size 2300 HI09 1 List Code List Qualifier Code Code Value ABF was added to support ICD HI09 9 List Present on Admission Indicator 2300 HI10 1 List Code List Qualifier Code Code Value ABF was added to support ICD HI10 9 List Present on Admission Indicator 2300 HI11 1 List Code List Qualifier Code Code Value ABF was added to support ICD HI11 9 List Present on Admission Indicator 2300 HI12 1 List Code List Qualifier Code Code Value ABF was added to support ICD HI012 9 List Present on Admission Indicator 2300 HI01 1 List Code List Qualifier Code Code values BB and CAH were added. Code Value BP was deleted because ICD is the only valid code set for inpatient procedures HI01 3 D8 DTP Format Qualifier Changed from Situational to equired HI01 4 Principal Procedure Date Changed from Situational to equired HI01 1 List Code List Qualifier Code Code Value BBQ was added HI01 3 D8 Date Time Period Format Qualifier Changed from Situational to equired HI01 4 Procedure Date Changed from Situational to equired HI02 1 List Code List Qualifier Code Code Value BBQ was added HI02 3 D8 Date Time Period Format Qualifier Changed from Situational to equired HI02 4 Procedure Date Changed from Situational to equired HI03 1 List Code List Qualifier Code Code Value BBQ was added HI03 3 D8 Date Time Period Format Qualifier Changed from Situational to equired HI03 4 Procedure Date Changed from Situational to equired HI04 1 List Code List Qualifier Code Code Value BBQ was added HI04 3 D8 Date Time Period Format Qualifier Changed from Situational to equired HI04 4 Procedure Date Changed from Situational to equired HI05 1 List Code List Qualifier Code Code Value BBQ was added HI05 3 D8 Date Time Period Format Qualifier Changed from Situational to equired. Page 21 of 47

25 Loop Segment Qualifier Description Change Comment New Del elocate T3 Use Code Qualifier X12 Use X12 Size 2300 HI05 4 Procedure Date Changed from Situational to equired HI06 1 List Code List Qualifier Code Code Value BBQ was added HI06 3 D8 Date Time Period Format Qualifier Changed from Situational to equired HI06 4 Procedure Date Changed from Situational to equired HI07 1 List Code List Qualifier Code Code Value BBQ was added HI07 3 D8 Date Time Period Format Qualifier Changed from Situational to equired HI07 4 Procedure Date Changed from Situational to equired HI08 1 List Code List Qualifier Code Code Value BBQ was added HI08 3 D8 Date Time Period Format Qualifier Changed from Situational to equired HI08 4 Procedure Date Changed from Situational to equired HI09 1 List Code List Qualifier Code Code Value BBQ was added HI09 3 D8 Date Time Period Format Qualifier Changed from Situational to equired HI09 4 Procedure Date Changed from Situational to equired HI10 1 List Code List Qualifier Code Code Value BBQ was added HI10 3 D8 Date Time Period Format Qualifier Changed from Situational to equired HI10 4 Procedure Date Changed from Situational to equired HI11 1 List Code List Qualifier Code Code Value BBQ was added HI11 3 D8 Date Time Period Format Qualifier Changed from Situational to equired HI11 4 Procedure Date Changed from Situational to equired HI12 1 List Code List Qualifier Code Code Value BBQ was added HI12 3 D8 Date Time Period Format Qualifier Changed from Situational to equired HI12 4 Procedure Date Changed from Situational to equired HI01 5 Value Code Amount Maximum length note was added to be 11 characters 2300 HI02 5 Value Code Amount Maximum length note was added to be 11 characters 2300 HI03 5 Value Code Amount Maximum length note was added to be 11 characters Page 22 of 47

26 Loop Segment Qualifier Description Change Comment New Del elocate T3 Use Code Qualifier X12 Use X12 Size 2300 HI04 5 Value Code Amount Maximum length note was added to be 11 characters 2300 HI05 5 Value Code Amount Maximum length note was added to be 11 characters 2300 HI06 5 Value Code Amount Maximum length note was added to be 11 characters 2300 HI07 5 Value Code Amount Maximum length note was added to be 11 characters 2300 HI08 5 Value Code Amount Maximum length note was added to be 11 characters 2300 HI09 5 Value Code Amount Maximum length note was added to be 11 characters 2300 HI10 5 Value Code Amount Maximum length note was added to be 11 characters 2300 HI11 5 Value Code Amount Maximum length note was added to be 11 characters 2300 HI12 5 Value Code Amount Maximum length note was added to be 11 characters 2300 QTY01 Quantity Qualifier 2300 QTY02 CA Covered Days 2300 QTY02 CD Coinsurance Days 2300 QTY02 LA Lifetime eserve Days 2300 QTY02 NA Non covered Days 2300 QTY03 Composite Unit of Measure 2300 QTY03 1 DA Unit or Basis for Measurement Code 2300 HCP02 epriced Allowed Amount Maximum length note was added to be 11 characters 2300 HCP03 epriced Savings Amount Maximum length note was added to be 11 characters 2300 HCP04 epricing Organization Identifier Min/Max changed from 1/30 to 1/ HCP05 epricing Per Diem or Flat ate Amount 2300 HCP06 epriced Approved DG Code Min/Max changed from 1/30 to 1/50. Page 23 of 47

27 Loop Segment Qualifier Description Change Comment New Del elocate T3 Use Code Qualifier X12 Use X12 Size 2300 HCP07 epriced Approved Amount Maximum length note was added to be 11 characters 2300 HCP09 HC Product/Service ID Qualifier 2300 HCP10 epriced Approved HCPCS Code 2300 HCP12 epriced Approved Service Unit Count Maximum length was defined at 9 including a decimal position in the guide. The maximum number of positions allowed to the right of the decimal is three C701 Home Health Discipline Type Code 2305 C702 Visits Prior to ecertification Date Count 2305 C703 Total Visits Projected This Certification Count 2305 HSD01 Visits 2305 HSD02 Home Health Number of Visits 2305 HSD03 Home Health Frequency Period 2305 HSD04 Home Health Frequency Count 2305 HSD05 Home Health Duration of Visits Units 2305 HSD06 Duration of Visits, Number of Units 2305 HSD07 Home Health Ship, Delivery or Calendar Pattern Code 2305 HSD08 Home Health Delivery Pattern Time Code 2310A NM102 1 Entity Type Qualifier Code Value 2 was deleted. 2310A NM103 Attending Physician Last Name Min/Max changed from 1/35 to 1/60. X12 Attribute changed from Optional (O) to Conditional (X). 2310A NM104 Attending Physician First Name equired when NM102 equals 1 and the person has a first name. Min/Max changed from 1/25 to 1/ A NM108 Identification Code Qualifier Changed from equired to Situational. Qualifiers 24 and 34 were deleted. Due to NPI mandate, NPI (XX) is the only valid qualifier. 2310A NM109 Attending Physician Primary Identifier Changed from equired to Situational. Situational ule added NPI is required when provider is eligible for an NPI. 24 and 34 were removed. Page 24 of 47

28 Loop Segment Qualifier Description Change Comment New Del elocate T3 Use Code Qualifier X12 Use X12 Size 2310A NM Attending Physician Employer's Identification Number 2310A NM Attending Physician Social Security Number 2310A PV01 AT Provider Code Code value SU was deleted. 2310A PV02 PXC eference Identification Qualifier Qualifier ZZ changed to PXC. X12 Attribute changed from Mandatory (M) to Conditional (X) with the condition if either PV02 or PV03 is present the other is required. 2310A PV03 Provider Taxonomy Code Min/Max changed from 1/30 to 1/50. X12 Attribute changed from Mandatory (M) to Conditional (X) with the condition if either PV02 or PV03 is present the other is required. 2310A EF01 List eference Number Qualifier Qualifiers 0B, 1G, G2 and LU are the only remaining values. 2310A EF02 Attending Physician Secondary Identifier Min/Max changed from 1/30 to 1/ A EF02 0B Attending Physician State License Number Min/Max changed from 1/30 to 1/ A EF02 1A Attending Physician Blue Cross Provider Number 2310A EF02 1B Attending Physician Blue Shield Number 2310A EF02 1C Attending Physician Medicare Number 2310A EF02 1D Attending Physician Medicaid Number 2310A EF02 1G Attending Physician UPIN Min/Max changed from 1/30 to 1/ A EF02 1H Attending Physician CHAMPUS Number 2310A EF02 EI Attending Physician Employer's Identification Number 2310A EF02 G2 Attending Physician Commercial Number Min/Max changed from 1/30 to 1/ A EF02 LU Attending Physician Location Number Min/Max changed from 1/30 to 1/ A EF02 N5 Attending Physician Network Identification Number 2310A EF02 SY Attending Physician Social Security Number 2310A EF02 X5 Attending Physician State Industrial Acc Number 2310B NM103 Operating Physician Last Name Min/Max changed from 1/35 to 1/60. X12 Attribute changed from Optional (O) to Conditional (X). Page 25 of 47

29 Loop Segment Qualifier Description Change Comment New Del elocate T3 Use Code Qualifier X12 Use X12 Size 2310B NM104 Operating Physician First Name Changed from equired to Situational. equired when NM102 equals 1 and the person has a first name. Min/Max changed from 1/25 to 1/ B NM108 Identification Code Qualifier Changed from equired to Situational. Qualifiers 24 and 34 were deleted. Due to NPI mandate, NPI (XX) is the only valid qualifier. 2310B NM109 Operating Physician Primary Identifier Changed from equired to Situational. Situational ule added NPI is required when provider is eligible for an NPI. 2310B NM Operating Physician Employer's Identification Number 2310B NM Operating Physician Social Security Number 2310B EF01 List eference Number Qualifier Qualifiers 0B, 1G, G2 and LU are the only remaining values. 2310B EF02 Operating Physician Secondary Identifier Min/Max changed from 1/30 to 1/ B EF02 0B Operating Physician State License Number Min/Max changed from 1/30 to 1/ B EF02 1A Operating Physician Blue Cross Number 2310B EF02 1B Operating Physician Blue Shield Number 2310B EF02 1C Operating Physician Medicare Number 2310B EF02 1D Operating Physician Medicaid Number 2310B EF02 1G Operating Physician UPIN Min/Max changed from 1/30 to 1/ B EF02 1H Operating Physician CHAMPUS Number 2310B EF02 EI Operating Physician Employer Identification Number 2310B EF02 G2 Operating Physician Commercial Number Min/Max changed from 1/30 to 1/ B EF02 LU Operating Physician Location Number Min/Max changed from 1/30 to 1/ B EF02 N5 Operating Physician Network Identification Number 2310B EF02 SY Operating Physician Social Security Number 2310B EF02 X5 Operating Physician State Industrial Accident Number 2310C NM Name Qualifier 2310C NM102 List Entity Type Qualifier Page 26 of 47

30 Loop Segment Qualifier Description Change Comment New Del elocate T3 Use Code Qualifier X12 Use X12 Size 2310C NM103 Other Provider Last Name 2310C NM104 Other Provider First Name 2310C NM105 Other Provider Middle Name 2310C NM107 Other Provider Name Suffix 2310C NM108 Identification Code Qualifier 2310C NM109 List Other Provider Secondary Identifier 2310C NM Other Provider Employer's Identification Number 2310C NM Other Provider Social Security Number 2310C NM109 XX Other Provider NPI 2310C EF01 List eference Number Qualifier 2310C EF02 Other Provider Secondary Identifier 2310C EF02 0B Other Provider State License Number 2310C EF02 1A Other Provider Blue Cross Provider Number 2310C EF02 1B Other Provider Blue Shield Number 2310C EF02 1C Other Provider Medicare Number 2310C EF02 1D Other Provider Medicaid Number 2310C EF02 1G Other Provider UPIN 2310C EF02 1H Other Provider CHAMPUS Number 2310C EF02 EI Other Provider EIN 2310C EF02 G2 Other Provider Physician Commercial Number 2310C EF02 LU Other Provider Location Number 2310C EF02 N5 Other Provider Network Identification Number 2310C EF02 SY Other Provider SSN 2310C EF02 X5 Other Provider State Industrial Accident Number 2310C NM101 ZZ Name Qualifier 2310C NM102 1 Entity Type Qualifier Page 27 of 47

31 Loop Segment Qualifier Description Change Comment New Del elocate T3 Use Code Qualifier X12 Use X12 Size 2310C NM103 Other Operating Physician Last Name 2310C NM104 Other Operating Physician First Name equired when NM102 equals 1 and the person has a first name. 2310C NM105 Other Operating Physician Middle Name or Initial 2310C NM107 Other Operating Physician Name Suffix 2310C NM108 Identification Code Qualifier 2310C NM109 Other Operating Physician Primary Identifier 2310C NM109 XX Other Operating Physician NPI 2310C EF01 List eference Number Qualifier 2310C EF02 Other Operating Physician Secondary Identifier 2310C EF02 0B Other Operating Physician State License Number 2310C EF02 1G Other Operating Physician UPIN Number 2310C EF02 G2 Other Operating Physician Commercial Number 2310C EF02 LU Other Operating Physician Number 2310D NM Name Qualifier 2310D NM102 1 Entity Type Qualifier 2310D NM103 endering Provider Last Name 2310D NM104 endering Provider Physician First Name equired when NM102 equals 1 and the person has a first name. 2310D NM105 endering Provider Middle Name or Initial 2310D NM107 endering Provider Name Suffix 2310D NM108 Identification Code Qualifier 2310D NM109 endering Provider Primary Identifier 2310D NM109 XX endering Provider NPI 2310D EF01 List eference Number Qualifier 2310D EF02 endering Provider Secondary Identifier 2310D EF02 0B endering Provider State License Number Page 28 of 47

32 Loop Segment Qualifier Description Change Comment New Del elocate T3 Use Code Qualifier X12 Use X12 Size 2310D EF02 1G endering Provider UPIN 2310D EF02 G2 endering Provider Commercial Number 2310D EF02 LU endering Provider Number 2310E NM Name Qualifier Qualifier FA changed to E NM103 Laboratory or Facility Name Min/Max changed from 1/35 to 1/60. X12 Attribute changed from Optional (O) to Conditional (X). 2310E NM108 Identification Code Qualifier Qualifiers 24 and 34 were deleted. Due to NPI mandate, NPI (XX) is the only valid qualifier. 2310E NM Service Facility Employer Identification Number 2310E NM Service Facility Social Security Number 2310E N402 Service Facility Location State/Province Code Changed from equired to Situational. equired when US or it's territories or Canada. X12 Attribute changed from Optional (O) to Conditional (X). Only one of N402 or N407 may be present. 2310E N403 Service Facility Location Postal Zone or Zip Code Changed from equired to Situational. equired when US or it's territories or Canada. When reporting zip codes for US addresses the full nine digit zip code must be provided. 2310E N404 Service Facility Location Country Code Clarification was added that ISO 1366 Part 1 Alpha list should be used. X12 Attribute changed from O to X. If N407 is present then N404 is required. 2310E N407 Service Facility Country Subdivision Code Only one of N402 or N407 may be present. If N407 is present then N404 is required. 2310E EF02 Service Facility Location Secondary Identifier Min/Max changed from 1/30 to 1/ E EF02 0B Service Facility Location State License Number Min/Max changed from 1/30 to 1/ E EF02 1A Service Facility Blue Cross Provider Number 2310E EF02 1B Service Facility Blue Shield Number 2310E EF02 1C Service Facility Medicare Number 2310E EF02 1D Service Facility Medicaid Number 2310E EF02 1G Service Facility Provider UPIN Page 29 of 47

33 Loop Segment Qualifier Description Change Comment New Del elocate T3 Use Code Qualifier X12 Use X12 Size 2310E EF02 1H Service Facility CHAMPUS Number 2310E EF02 1J Service Facility Identification Number 2310E EF02 EI Service Facility Employer Identification Number 2310E EF02 FH Service Facility Clinic Number 2310E EF02 G2 Service Facility Location Commercial Number Min/Max changed from 1/30 to 1/ E EF02 G5 Service Facility Provider Site Number 2310E EF02 LU Service Facility Location Number Min/Max changed from 1/30 to 1/ E EF02 N5 Service Facility Network Identification Number 2310E EF02 X5 Service Facility State Industrial Accident Number 2310F NM101 DN Name Qualifier 2310F NM102 1 Entity Type Qualifier 2310F NM103 eferring Provider Last Name 2310F NM104 eferring Provider Physician First Name equired when NM102 equals 1 and the person has a first name. 2310F NM105 eferring Provider Middle Name or Initial 2310F NM107 eferring Provider Name Suffix 2310F NM108 XX Identification Code Qualifier 2310F NM109 eferring Provider Primary Identifier 2310F NM109 eferring Provider NPI 2310F EF01 List eference Number Qualifier 2310F EF02 eferring Provider Secondary Identifier 2310F EF02 0B eferring Provider State License Number 2310F EF02 1G eferring Provider UPIN Number 2310F EF02 G2 eferring Provider Commercial Number 2320 SB01 Payer esponsibility Code Code Values A H and U were added to support payers Provider Products should not allow U as a valid value since this is for Payer to Payer COB only. Page 30 of 47