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Apex EDI API V3 Documentation

Medical Enumerations

This document contains the definitions of the enumerations used in uploaded claims and in payer responses.

AcuteManifestationCodes

  • AcuteCondition
  • AcuteManifestationOfAChronicCondition

AdjustmentGroupCode

  • ContractualObligations
  • OtherAdjustments
  • PayorInitiatedReductions
  • PatientResponsibility

AmbulanceTransportReasonCode

  • NearestFacility
  • PreferredPhysician
  • NearFamily
  • Specialist
  • Rehabilitation

AssignmentOrPlanParticipationCode

  • Assigned
  • AcceptClinicalLabService (not used)
  • NotAssigned

ClaimCoverageType

  • Medicaid
  • Medicare
  • Tricare
  • Champva
  • Feca
  • Group
  • Other

ClaimFrequencyType

  • Unknown
  • NonPaymentZeroClaims
  • AdmitThroughDischarge
  • InterimFirst
  • InterimContinuing
  • InterimLastClaim
  • LateChargesOnly
  • AdjustmentOfPriorClaim
  • ReplacementOfPriorClaim
  • VoidCancelPriorClaim
  • FinalClaim
  • AdmissionElectionNotice
  • HospiceMedicareTermination
  • HospiceChangeOfProvider
  • HospiceMedicareVoidCancel
  • HospiceChangeOfOwnership
  • BeneficiaryInitiatedAdjustment
  • CwfGeneratedAdjustment
  • CmsGeneratedAdjustment
  • MiscAdjustment
  • OtherAdjustment
  • OigAdjustment
  • MspAdjustment
  • QioAdjustment
  • QaAdjustment
  • HospitalEncounterAlternateSubmission

ClaimStatusCategory

  • Unknown
  • AckForwarded
  • AckReceipt
  • AckAccept
  • AckReturned
  • AckNotFound
  • AckSplitClaim
  • AckRejectMissingInformation
  • AckRejectInvalidInformation
  • AckRejectRelationalField
  • ErrorSubmittedData
  • ErrorSystemStatus
  • ErrorNoResponse
  • ErrorRelationalCorrectionRequired
  • ErrorDataCorrectionRequired
  • Finalized
  • FinalizedPayment
  • FinalizedDenial
  • FinalizedRevised
  • FinalizedForwarded
  • FinalizedNotForwarded
  • FinalizedAdjudicationComplete
  • Pending
  • PendingInProcess
  • PendingPayerReview
  • PendingProviderRequestedInformation
  • PendingPatientRequestedInformation
  • PendingPayerAdministrative

DelayReasonCode

  • ProofOfEligibilityUnknown
  • Litigation
  • AuthorizationDelays
  • DelayCertifyingProvider
  • DelaySupplyingBillingForms
  • DelayDeliveryCustomAppliances
  • DelayThirdParyProcessing
  • DelayEligibilityDetermination
  • OriginalClaimRejectedOrDenied
  • AdministrationDelayPriorApproval
  • Other
  • NaturalDisaster

DeliveryMethod

  • Unknown
  • ByMail
  • Email
  • FileTransfer
  • Online

DocumentType (claims)

  • Unknown
  • MedicalClaim
  • DentalClaim
  • Statement

DocumentType (payer responses)

  • Unknown
  • Claim
  • ClaimStatus
  • InterchangeStatus
  • RemittanceAdvice

EntityType

  • Unknown
  • Individual
  • Organization

FinancialTransactionType

  • Unknown
  • Credit
  • Debit

InsuredAuthorization

  • Y
  • N
  • NA

MeasurementReferenceIdCode

  • Original
  • TestResults

MeasurementQualifier

  • Height
  • Hemoglobin
  • Hematocrit
  • EpoetinStartingDosage
  • Creatinine

PatientAuthorization

  • Yes
  • InformedConsent

PayerClaimType

  • Unknown
  • PreferredProviderOrganization
  • PointOfService
  • ExclusiveProviderOrganization
  • IndemnityInsurance
  • HmoMedicare
  • DentalMaintenanceOrganization
  • AutomobileMedical
  • Champus
  • Disability
  • Hmo
  • LiabilityMedical
  • MedicarePartA
  • MedicarePartB
  • Medicaid
  • OtherFederalProgram
  • TitleV
  • VeteransAffairsPlan
  • WorkersCompensationHealthClaim
  • MutuallyDefined

PayerResponseType

  • Unknown
  • ClaimStatus
  • RemittanceAdvice
  • EmdeonClaimStatus
  • InterchangeStatus
  • BenefitResponse

PaymentFormatCode

  • Unknown
  • CashDisbursement
  • CorporateTradeExchange

PaymentsPaymentMethodCode

  • Unknown
  • Ach
  • FinancialInstitution
  • Check
  • FedWire
  • None

PlaceOfServiceCode

  • Unknown
  • Pharmacy
  • School
  • HomelessShelter
  • IhsFreestandingFacility
  • IhsProviderFacility
  • Tribal638FreestandingFacility
  • Tribal638ProviderFacility
  • CorrectionalFacility
  • Office
  • Home
  • AssistedLivingFacility
  • GroupHome
  • MobileUnit
  • TemporaryLodging
  • WalkinRetailHealthClinic
  • PlaceOfEmploymentWorksite
  • UrgentCareFacility
  • InpatientHospital
  • OutpatientHospital
  • EmergencyRoomHospital
  • AmbulatorySurgicalCenter
  • BirthingCenter
  • MilitaryTreatmentFacility
  • SkilledNursingFacility
  • NursingFacility
  • CustodialCareFacility
  • Hospice
  • AmbulanceLand
  • AmbulanceAirOrWater
  • IndependentClinic
  • FederallyQualifiedHealthCenter
  • InpatientPsychiatricFacility
  • PsychiatricFacilityPartialHospitalization
  • CommunityMentalHealthCenter
  • IntermediateCareMentalFacility
  • ResidentialSubstanceAbuseTreatmentFacility
  • PsychiatricResidentialTreatmentCenter
  • NonresidentialSubstanceAbuseTreatmentFacility
  • MassImmunizationCenter
  • ComprehensiveInpatientRehabilitationFacility
  • ComprehensiveOutpatientRehabilitationFacility
  • EndstageRenalDiseaseTreatmentFacility
  • PublicHealthClinic
  • RuralHealthClinic
  • IndependentLaboratory
  • OtherPlaceOfService

ProcedureCodeSource

  • Unknown
  • JurisdictionSpecific
  • Hcpcs
  • Hiec
  • Abc
  • Ada

Relationship

  • Invalid
  • Spouse
  • Self
  • Child
  • Employee
  • Unknown
  • OrganDonor
  • CadaverDonor
  • LifePartner
  • Other

SenderType

  • Unknown
  • Clearninghouse
  • Payer

Sex

  • M
  • F
  • Unknown

StatusAction

  • Unknown
  • Reject
  • Accept
  • Pending

StatusEntity

  • Unknown
  • None
  • Dependent
  • Provider
  • HomeHealthCare
  • Receiver
  • SubmitterName
  • AttendingPhysician
  • OperatingPhysician
  • OtherPhysician
  • ServiceLocation
  • RenderingProvider
  • BillingProvider
  • PayToProvider
  • Clearinghouse
  • OrderingProvider
  • ReferringProvider
  • SupervisingProvider
  • Facility
  • OtherInsured
  • Subscriber
  • Insured
  • IndependentLab
  • Payer
  • PurchaseServiceProvider
  • Patient
  • ResponsibleParty
  • TestingLaboratory
  • ThirdPartyRepricingOrganization
  • MammographyScreeningCenter
  • PrimaryPayer
  • SecondaryPayer
  • TertiaryPayer

StatusLevel

  • Unknown
  • Transaction
  • Provider
  • Claim

StatusOfClaim

  • Unknown
  • ProcessedAsPrimary
  • ProcessedAsSecondary
  • ProcessedAsTertiary
  • Denied
  • ProcessedAsPrimaryForwarded
  • ProcessedAsSecondaryForwarded
  • ProcessedAsTertiaryForwarded
  • PaymentReversal
  • ForwardedNotOurs
  • PredeterminationOnly

UnitOrBaseOfMeasurement

  • InternationalUnit
  • Gram
  • Milligram
  • Milliliter
  • Unit

Dental Enumerations

TreatmentResultingFrom

  • EM = 0 (Occupational illness/injury)
  • AA = 1 (Auto Accident)
  • OA = 2 (Other Accident)

TypeOfTransaction

  • NotSet = 0
  • ActualServices = 1
  • RequestForPreauth = 2
  • EpsdtTitleXix = 3

OtherPatientRelationship

  • Spouse = 0
  • Self = 1
  • Child = 2
  • Employee = 3
  • Unknown = 4
  • OrganDonor = 5
  • CadaverDonor = 6
  • LifePartner = 7
  • OtherRelationship = 8

ReferenceIdQualifier

  • SY = 0 (SSN)
  • EI = 1 (TIN)

AttachmentReportType

  • B4 = 0 (Referral Form)
  • DA = 1 (Dental Models)
  • DG = 2 (Diagnostic Report)
  • EB = 3 (Explanation of Benefits Coordination of Benefits or Medicare Secondary Payor))
  • OZ = 4 (Support Data for Claim)
  • P6 = 5 (Periodontal Chart)
  • RB = 6 (Radiology Files)
  • RR = 7 (Radiology Reports)

AttachmentTransmissionCodeType

  • AA = 0 (Available on Request)
  • BM = 1 (By Mail)
  • EL = 2 (Electronically only)
  • EM = 3 (E-Mail)
  • FT = 4 (File Transfer)
  • FX = 5 (By Fax)