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)