Medical Claim Field Reference

This table documents the fields that may be used when submitting Medical claims. The Required column indicates whether the field is required on all claims. Optional fields may be required in certain situations. The Level column indicates whether the field appears at the claim level or the service line level of the claim.

For more definitions of the various enumerations, see Enumerations.

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Level	CMS 1500 Claim Form Locator		837P			General Notes	Name of JSON Field	Data Type	Min Value or Length	Max Value or Length	Required?
Level	Item Number	Title	Loop ID	Segment/Data Element	Notes	General Notes	Name of JSON Field	Data Type	Min Value or Length	Max Value or Length	Required?
Claim	Apex	Apex Payer ID					Apex_PayerId	string			Y
Claim	Apex	Vendor Claim ID					Apex_VendorClaimId	string	1	50	Y
Claim	header	Payer Name	2010BB	NM103	Carrier Block		F00_PayerName	string	1	60	Y
Claim	header	Payer Address 1	2010BB	N301	Carrier Block		F00_PayerAddress1	string	1	55	N
Claim	header	Payer Address 2	2010BB	N302	Carrier Block		F00_PayerAddress2	string	1	55	N
Claim	header	Payer City	2010BB	N401	Carrier Block		F00_PayerCity	string	2	30	N
Claim	header	Payer State	2010BB	N402	Carrier Block		F00_PayerState	string	2	2	N
Claim	header	Payer Zip	2010BB	N403	Carrier Block		F00_PayerZip	string	3	15	N
Claim	1	Medicare, Medicaid, TRICARE, CHAMPVA, Group Health Plan, FECA, Black Lung, Other	2000B	SBR09	Claim Filing Indicator Code in the 837P.		F01_ClaimType	ClaimCoverageType enumeration			N
Claim	1a	Insured's ID Number	2010BA	NM109	Subscriber Primary Identifier in the 837P.		F01A_InsuredId	string	2	80	Y
Claim	2	Patient's Last Name	2010CA or 2010BA	NM103			F02_PatientNameLast	string	1	60	Y
Claim	2	Patient's First Name	2010CA or 2010BA	NM104			F02_PatientNameFirst	string	1	35	Y
Claim	2	Patient's Middle Name	2010CA or 2010BA	NM105			F02_PatientNameMiddle	string	1	25	N
Claim	2	Patient's Suffix	2010CA or 2010BA	NM107			F02_PatientSuffix	string	1	10	N
Claim	3	Patient's Birth Date	2010CA or 2010BA	DMG02			F03_PatientDob	date YYYY-MM-DD	10	10	Y
Claim	3	Patient's Sex	2010CA or 2010BA	DMG03	Sex is Gender in the 837P.	M, F, Unknown	F03_PatientSex	Sex enumeration			Y
Claim	4	Insured's Name	2010BA	NM103	Subscriber in the 837P.		F04_InsuredNameLast	string	1	60	y
Claim	4	Insured's Name	2010BA	NM104	Subscriber in the 837P.		F04_InsuredNameFirst	string	1	35	N
Claim	4	Insured's Name	2010BA	NM105	Subscriber in the 837P.		F04_InsuredNameMiddle	string	1	25	N
Claim	4	Insured's Name	2010BA	NM107	Subscriber in the 837P.		F04_InsuredSuffix	string	1	10	N
Claim	5	Patient's Address	2010CA	N301			F05_PatientAddress1	string		55	N
Claim	5	Patient's Address	2010CA	N302			F05_PatientAddress2	string		55	N
Claim	5	Patient's Address	2010CA	N401			F05_PatientCity	string	2	30	Y
Claim	5	Patient's Address	2010CA	N402			F05_PatientState	string	2	2	Y
Claim	5	Patient's Address	2010CA	N403			F05_PatientZip	string	3	15	Y
Claim	6	Patient Relationship to Insured	2000B 2000C	SBR02 PAT01	Individual Relationship Code in the 837P.	Of the relationships in the enumeration, only Child, Other, Self, and Spouse are accepted in this context.	F06_PatientRelationshipToInsured	Relationship enumeration			Y
Claim	7	Insured's Address	2010BA	N301	Subscriber Address in the 837P.		F07_InsuredAddress1	string		55	Y
Claim	7	Insured's Address	2010BA	N302	Subscriber Address in the 837P.		F07_InsuredAddress2	string		55	N
Claim	7	Insured's Address	2010BA	N401	Subscriber Address in the 837P.		F07_InsuredCity	string	2	30	Y
Claim	7	Insured's Address	2010BA	N402	Subscriber Address in the 837P.		F07_InsuredState	string	2	2	Y
Claim	7	Insured's Address	2010BA	N403	Subscriber Address in the 837P.		F07_InsuredZip	string	3	15	Y
Claim	9	Other Insured's Name	2330A	NM103	Other Subscriber Name in the 837P.		F09_OtherInsuredNameLast	string	1	60	N
Claim	9	Other Insured's Name	2330A	NM104	Other Subscriber Name in the 837P.		F09_OtherInsuredNameFirst	string		35	N
Claim	9	Other Insured's Name	2330A	NM105	Other Subscriber Name in the 837P.		F09_OtherInsuredNameMiddle	string		25	N
Claim	9	Other Insured's Name	2330A	NM107	Other Subscriber Name in the 837P.		F09_OtherInsuredSuffix	string		10	N
Claim	9	Other Insured's relation to patient					F09_PatientRelationshipToInsured	Relationship enumeration			N
Claim	9a	Other Insured's Policy or Group Number	2320	SBR03	Insured Group or Policy Number in the 837P.		F09A_OtherInsuredGroupNum	string		50	N
Claim	9d	Insurance Plan Name or Program Name	2320	SBR04	Other Insured Group Name in the 837P.		F09D_OtherPlanName	string		60	N
Claim	10a	Is Patient's Condition Related to: Employment	2300	CLM11-1, CLM11-2, CLM11-3	Related Causes Code in the 837P.	Boolean - true/false	F10A_PatientCondEmployment	boolean			N
Claim	10b	Is Patient's Condition Related to: Auto Accident	2300	CLM11-1, CLM11-2, CLM11-3	Related Causes Code in the 837P.		F10B_PatientCondAutoAccident - Boolean true/false	boolean			N
Claim	10b	Is Patient's Condition Related to: Auto Accident	2300	CLM11-4	Related Causes Code in the 837P.	If F10B_PatientCondAutoAccident is set, then set F10B_PatientCondAutoAccidentState.	F10B_PatientCondAutoAccidentState	string	2	2	N
Claim	10c	Is Patient's Condition Related to: Other Accident	2300	CLM11-1, CLM11-2, CLM11-3	Related Causes Code in the 837P.		F10C_PatientCondOtherAccident - Boolean true/false	boolean			N
Claim	11	Insured's Policy, Group, or FECA Number	2000B	SBR03	Subscriber Group or Policy Number in the 837P.		F11_InsuredsPolicyGroupOrFecaNumber	string	1	50	N
Claim	11a	Insured's Date of Birth	2010BA	DMG02	Subscriber Birth Date in the 837P.		F11A_InsuredDob	date YYYY-MM-DD	10	10	Y
Claim	11a	Insured's Date of Birth, Sex	2010BA	DMG03	Subscriber Gender Code in the 837P.	M, F, Unknown	F11A_InsuredSex	Sex enumeration			Y
Claim	11c	Insurance Plan Name or Program Name	2000B	SBR04	Subscriber Group Name in the 837P.		F11C_PlanName	string		29	N
Claim	12	Patient's or Authorized Person's Signature	2300	CLM09	Release of Information Code in the 837P.		F12_PatientAuthorization Yes, InformedConsent	PatientAuthorization enumeration			Y
Claim	12	Patient's or Authorized Person's Signature Date	2300	CLM09	Release of Information Code in the 837P.		F12_PatientAuthorizationDate	date YYYY-MM-DD	10	10	N
Claim	13	Insured's or Authorized Persons Signature	2300	CLM08	Benefits Assignment Certification Indicator in the 837P.		F13_InsuredAuthorization	InsuredAuthorization enumeration			Y
Claim	14	Date of Current Illness, Injury, Pregnancy	2300	DTP01 DTP03	In the 837P: Date - Onset of Current Illness or Symptom Qualifier 431		F14_DateOfCurrentIllnessOrSymptom	date YYYY-MM-DD	10	10	N
Claim	14	Date of Current Illness, Injury, Pregnancy	2300	DTP01 DTP03	In the 837P: Date - Last Menstrual Period Qualifier 484		F14_LastMenstrualPeriodDate	date YYYY-MM-DD	10	10	N
Claim	15	Other Date (previously If Patient Has Had Same or Similar Illness)	2300	DTP03	Titled in the 837P: Date - Initial Treatment Date. Qualifier 454		F15_InitialTreatmentDate	date YYYY-MM-DD	10	10	N
Claim	15	Other Date (previously If Patient Has Had Same or Similar Illness)	2300	DTP03	Titled in the 837P: Date - Last Seen Date. Qualifier 304		F15_LastSeenDate	date YYYY-MM-DD	10	10	N
Claim	15	Other Date (previously If Patient Has Had Same or Similar Illness)	2300	DTP03	Titled in the 837P: Date - Acute Manifestation. Qualifier 453 F15_AcuteManifestionDate Required when Loop ID-2300 CR208 = "A" or "M", the claim involves spinal manipulation, and the payer is Medicare. If not required by this implementation guide, do not send.	This field is required when X12_AcuteManifestationCode is set to "AcuteCondition" or "AcuteManifestationOfAChronicCondition".	F15_AcuteManifestionDate	date YYYY-MM-DD	10	10	N
Claim	15	Other Date (previously If Patient Has Had Same or Similar Illness)	2300	DTP03	Titled in the 837P: Date - Accident. Qualifier 439		F15_AccidentDate	date YYYY-MM-DD	10	10	N
Claim	15	Other Date (previously If Patient Has Had Same or Similar Illness)	2300	DTP03	Titled in the 837P: Date - Last X-ray Date. Qualifier 455		F15_LastXRayDate	date YYYY-MM-DD	10	10	N
Claim	15	Other Date (previously If Patient Has Had Same or Similar Illness)	2300	DTP03	Titled in the 837P: Date - Hearing and Vision Prescription Date. Qualifier 471		F15_HearingAndVisionPrescriptionDate	date YYYY-MM-DD	10	10	N
Claim	15	Other Date (previously If Patient Has Had Same or Similar Illness)	2300	DTP03	Titled in the 837P: Date - Assumed and Relinquished Care Dates. Qualifier 090		F15_AssumedCareStartDate	date YYYY-MM-DD	10	10	N
Claim	15	Other Date (previously If Patient Has Had Same or Similar Illness)	2300	DTP03	Titled in the 837P: Date - Assumed and Relinquished Care Dates. Qualifier 091		F15_AssumedCareEndDate	date YYYY-MM-DD	10	10	N
Claim	15	Other Date (previously If Patient Has Had Same or Similar Illness)	2300	DTP03	Titled in the 837P: Date - Property and Casualty Date of First Contact. Qualifier 444		F15_PropertyCasualtyFirstContactDate	date YYYY-MM-DD	10	10	N
Claim	X12	Dates Patient Unable to Work in Current Occupation	2300	DTP03 qualifier 360	Crosswalk: Disability From Date and Work Return Date in the 837P. Apex: DTP - DATE - DISABILITY DATES, Implementation Name for DTP03 is Disability From Date Qualifier 360 Either neither or both of F15_DisabilityDateFrom and F15_DisabilityDateTo must be set, in order to match the behavior of our electronic claim form. If both are set, they go in a single DTP segment with a qualifier of 314 and a syntax of RD8.	If X12_DisabilityDateTo is set, then this field must also be set.	X12_DisabilityDateFrom	date YYYY-MM-DD	10	10	N
Claim	X12	Dates Patient Unable to Work in Current Occupation	2300	DTP03 qualifier 361	Crosswalk: Disability From Date and Work Return Date in the 837P. If both are set, they go in a single DTP segment with a qualifier of 314 and a syntax of RD8. Apex: DTP - DATE - DISABILITY DATES, Implementation Name for DTP03 is Disability From Date Qualifier 361 (DTP02 data element)	Either neither or both of F15_DisabilityDateFrom and F15_DisabilityDateTo must be set, in order to match the behavior of our electronic claim form. If X12_DisabilityDateFrom is set, then this field must also be set.	X12_DisabilityDateTo	date YYYY-MM-DD	10	10	N
Claim	16	Dates Patient Unable to Work in Current Occupation	2300	DTP03 qualifier 297	Apex: Use this for F16 instead of Disability Date From. DTP - DATE - LAST WORKED, Implementation Name for DTP03 is Work Return Date. Qualifier 297		F16_LastWorkedDate	date YYYY-MM-DD	10	10	N
Claim	16	Dates Patient Unable to Work in Current Occupation	2300	DTP03 qualifier 296	Crosswalk: Work Return Date in the 837P. DTP - DATE - AUTHORIZED RETURN TO WORK, Implementation Name for DTP03 is Work Return Date. Qualifier 296		F16_AuthorizedReturnedToWorkDate	date YYYY-MM-DD	10	10	N
Claim	17	Name of Referring Provider or Other Source	2310A	NM103	Qualifier DN	Last Name	F17_ReferringProviderNameLast			60	N
Claim	17	Name of Referring Provider or Other Source	2310A	NM104		First Name	F17_ReferringProviderNameFirst			35	N
Claim	17	Name of Referring Provider or Other Source	2310A	NM105		Middle Name	F17_ReferringProviderNameMiddle			25	N
Claim	17	Name of Referring Provider or Other Source	2310A	NM107		Suffix	F17_ReferringProviderSuffix			10	N
Claim	17a	Other ID#	2310A	REF02	Referring Provider Secondary Identifier in the 837P.		F17A_ReferringProviderIdNumber		1	50	N
Claim	17b	NPI #	2310A	NM109	Referring Provider Identifier in the 837P.		F17B_ReferringProviderNpi		10	10	N
Claim	17	Name of Referring Provider or Other Source	2310D	NM103	Qualifier DQ	Last Name	F17_SupervisingProviderNameLast			60	N
Claim	17	Name of Referring Provider or Other Source	2310D	NM104		First Name	F17_SupervisingProviderNameFirst			35	N
Claim	17	Name of Referring Provider or Other Source	2310D	NM105		Middle Name	F17_SupervisingProviderNameMiddle			25	N
Claim	17	Name of Referring Provider or Other Source	2310D	NM107		Suffix	F17_SupervisingProviderSuffix			10	N
Claim	17a	Other ID#	2310D	REF02	Supervising Provider Secondary Identifier in the 837P.		F17A_SupervisingProviderIdNumber		1	50	N
Claim	17b	NPI #	2310D	NM109	Supervising Provider Identifier in the 837P.		F17B_SupervisingProviderNpi		10	10	N
Claim	17	Name of Referring Provider or Other Source	2420E	NM103	Qualifier DK	Last Name	F17_OrderingProviderNameLast			60	N
Claim	17	Name of Referring Provider or Other Source	2420E	NM104		First Name	F17_OrderingProviderNameFirst			35	N
Claim	17	Name of Referring Provider or Other Source	2420E	NM105		Middle Name	F17_OrderingProviderNameMiddle			25	N
Claim	17	Name of Referring Provider or Other Source	2420E	NM107		Suffix	F17_OrderingProviderSuffix			10	N
Claim	17a	Other ID#	2420E	REF02	Ordering Provider Secondary Identifier in the 837P.		F17A_OrderingProviderIdNumber		1	50	N
Claim	17b	NPI #	2420E	NM109	Ordering Provider Identifier in the 837P.		F17B_OrderingProviderNpi		10	10	N
Claim	18	Hospitalization Dates Related to Current Services	2300	DTP03	Related Hospitalization Admission Date in the 837P.	YYYY-MM-DD	F18_HospitalizationDateFrom	date YYYY-MM-DD	10	10	N
Claim	18	Hospitalization Dates Related to Current Services	2300	DTP03	Related Hospitalization Discharge Date in the 837P.	YYYY-MM-DD	F18_HospitalizationDateTo	date YYYY-MM-DD	10	10	N
Claim	19	Additional Claim Information (previously Reserved for Local Use)	2300	NTE NTE01=ADD	NTE - CLAIM NOTE PWK - CLAIM SUPPLEMENTAL INFORMATION Only the NTE segment with the ADD qualifier is supported at this time. The PWK - CLAIM SUPPLEMENTAL INFORMATION segment is not supported at this time		F19_ClaimSupplementalInfoNoteText	string	1	80	N
Claim	21	Diagnosis or Nature of Illness or Injury	2300	HI01-2, HI02-2, HI03-2, HI04-2, HI05-2, HI06-2, HI07-2, HI08-2, HI09-2, HI10-2, HI11-2, HI12-2	Outside Lab is on form - yes/no boxes - not in PS1, so don't know where it goes.	2300 HI0X-1 Diagnosis Type = 9 or 10. Date of service after 10/1/2015 requires 10.	F21_IcdIndicator	string	1	3	N
Claim	21	Diagnosis or Nature of Illness or Injury	2300	HI01-2, HI02-2, HI03-2, HI04-2, HI05-2, HI06-2, HI07-2, HI08-2, HI09-2, HI10-2, HI11-2, HI12-2	2300 HI0X-2 Diagnosis Code - X is 1 through 12, at least one required.	Array of strings - Up to 12 The first one is considered the primary diagnosis for the claim	F21_DiagnosisCodes	array of strings, each string 1 to 30 characters	1	12	Y
Claim	22	Medicaid Resubmission and/or Original Reference Number	2300	CLM05-3	Claim Frequency Code in the 837P.		F22_MedicaidResubmissionCode	string		11	N
Claim	22	Medicaid Resubmission and/or Original Reference Number	2300	REF02	Payer Claim Control Number in the 837P.		F22_OriginalReferenceNumber	string		50	N
Claim	23	Prior Authorization Number	2300	REF02	Prior Authorization Number in the 837P.		F23_PriorAuthorizationNumber	string		50	N
Claim	23	Prior Authorization Number	2300	REF02	Referral Number in the 837P.		F23_ReferralNumber	string		50	N
Claim	23	Prior Authorization Number	2300	REF02	Clinical Laboratory Improvement Amendment Number in the 837P.		F23_ClinicalLaboratoryImprovementAmendmentNumber	string		50	N
Claim	23	Prior Authorization Number	2300	REF02	Mammography Certification Number in the 837P.		F23_MammographyCertificationNumber	string		50	N
Claim						This JSON field contains an array of claim line objects. The line-level fields identified below are the fields of the claim line object.	F24_ClaimLines	claim line	1		Y
Line	24 A-H Shaded Line	Note	2400	NTE NTE01=ADD	NTE - LINE NOTE PWK - LINE SUPPLEMENTAL INFORMATION Only the NTE segment with the ADD qualifier is supported at this time. The PWK - LINE SUPPLEMENTAL INFORMATION segment is not supported at this time.		F24_Shaded_LineNoteText	string	1	80	N
Line	24A	Date(s) of Service	2400	DTP03	Service Date in the 837P.		F24A_DateOfServiceFrom	date YYYY-MM-DD	10	10	Y
Line	24A	Date(s) of Service	2400	DTP03	Service Date in the 837P.		F24A_DateOfServiceTo	date YYYY-MM-DD	10	10	N
Line	24B	Place of Service	2400	SV105	Place of Service Code in the 837P.	X12_PlaceOfServiceCode is not present on the printed form, but it is required by Apex. F24B_PlaceOfServiceCode may be used to override the place of service for a particular claim line.	F24B_PlaceOfServiceCode		1	2	Y
Line	24C	EMG	2400	SV109	Emergency Indicator in the 837P.	Boolean - true / false	F24C_Emg	boolean			N
Line	24D	Procedures, Services, or Supplies	2400	SV101-1, SV101-2	There are 4 qualifiers for SV101-1 in the spec, but only "HC" is supported at this time. F24D_HcpcsProcedureCode will be used for both Medicare and other claims. Product/Service ID in the 837P. The value placed in this field goes into SV101-2. Setting a value in this field implies a value of "HC" in SV101-1.		F24D_HcpcsProcedureCode		1	48	Y
Line	24D	Procedures, Services, or Supplies	2400	SV101-3 to SV101-6	Product/Service ID and Procedure Modifier in the 837P.	If present, must contain 1 to 4 strings, each exactly two characters in length.	F24D_Modifiers	array of strings	1	4	N
Line	24D	Procedures, Services, or Supplies	2400	SV101-7			X12_Description	string	1	80	N
Line	24E	Diagnosis Pointer	2400	SV107 (1-4)	Diagnosis Code Pointer in the 837P. Alpha pointers on the 1500 claim form MUST be converted to numeric pointers in the 837P.	Valid values are the single characters A through L. Each entry refers to a diagnosis code in F21_DiagnosisCodes, where A refers to the first diagnosis code in F21_DiagnosisCodes, B refers to the second, etc.	F24E_DiagnosisPointers	array of strings maximum number of strings is 4, each string can only contain 1 character, A-L	1 string, 1 char	4 strings, 1 char each	Y
Line	24F	$ Charges	2400	SV102	Line Item Charge Amount in the 837P.	Can't be less than 0, but 0 is acceptable	F24F_Charges	decimal			Y
Line	24G	Days or Units	2400	SV104	Service Unit Count in the 837P.	A numeric value with optional decimal point. Up to 8 digits are allowed, not including the decimal point. At most three digits may appear after the decimal point.	F24G_DaysOrUnits	decimal	1	9	N
Line	24H	EPSDT/Family Plan	2400	SV111	EPSDT Indicator in the 837P.	Boolean - true / false	F24H_EarlyPeriodicScreeningDiagnosisAndTreatment	boolean			N
Line	24H	EPSDT/Family Plan	2400	SV112	Family Planning Indicator in the 837P.		F24H_FamilyPlanning - Boolean true/false	boolean			N
Line	24J Shaded Line	Rendering Provider ID #	2420A	PRV01 - PRV03	Provider Taxonomy Code in the 837P. Qualifier: PXC. The use of this field implicitly determines the qualifier in PRV02.	For claim level information, see X12_RendProviderTaxonomyCode, etc.	F24J_Shaded_RendProviderTaxonomyCode	string	1	50	N
Line	24J Shaded Line	Rendering Provider ID #	2420A	REF01, REF02	Rendering Provider Secondary Identifier in the 837P. The use of these fields implicitly determines the qualifier in REF01.		F24J_Shaded_RendProviderStateLicenseNumber F24J_Shaded_RendProviderUpinNumber F24J_Shaded_RendProviderCommercialNumber F24J_Shaded_RendProviderLocationNumber	string	1	50	N
Line	24J	Rendering Provider ID #	2420A	NM109	Rendering Provider Identifier in the 837P.	For claim level rendering provider NPI, see X12_RenderingNPI.	F24J_RenderingNpi	string		10	N
Claim	25	Federal Tax ID Number	2010AA	REF02 REF01=EI	Reference Identification Qualifier and Billing Provider Tax Identification Number in the 837P REF - BILLING PROVIDER TAX IDENTIFICATION. EI=Employer Identification Number	Employer Identification Number used as the Billing Provider Tax Id. The value should contain no hyphens. At most one of F25_FederalTaxIdEin and F25_FederalTaxIdSsn should be set.	F25_FederalTaxIdEin	string		15	N
Claim	25	Federal Tax ID Number	2010AA	REF02 REF01=SY	Reference Identification Qualifier and Billing Provider Tax Identification Number in the 837P. REF - BILLING PROVIDER TAX IDENTIFICATION SY=Social Security Number.	Social Security Number used as the Billing Provider Tax Id. The value should contain no hyphens. At most one of F25_FederalTaxIdEin and F25_FederalTaxIdSsn should be set.	F25_FederalTaxIdSsn	string	9	9	N
Claim	26	Patient's Account No.	2300	CLM01	Patient Control Number in the 837P.		F26_PatientAccountNumber	string		38	N
Claim	27	Accept Assignment?	2300	CLM07	Assignment or Plan Participation Code in the 837P. Qualifiers are A (Assigned) B (Accept on Clinical Lab Services) C (Not Assigned)		F27_AcceptAssignment	AssignmentOrPlanParticipationCode enumeration			N
Claim	28	Total Charge	2300	CLM02	Total Claim Charge Amount in the 837P.		F28_TotalCharge	decimal			Y
Claim	29	Amount Paid	2300	AMT02	Patient Amount Paid in the 837P.		F29_PatientAmountPaid	decimal			N
Claim	29	Amount Paid	2320	AMT02	Payer Paid Amount in the 837P.		F29_PayerAmountPaid	decimal			N
Claim	31	Signature of Physician or Supplier Including Degrees or Credentials	2300	CLM06	Provider or Supplier Signature Indicator in the 837P.	Boolean- true / false	F31_PhysicianOrSupplierSignatureIsOnFile	boolean			Y
Claim	32	Service Facility Location Information	2310C	NM103			F32_FacilityName	string		60	N
Claim	32	Service Facility Location Information	2310C	N301			F32_FacilityAddress1	string		55	N
Claim	32	Service Facility Location Information	2310C	N302			F32_FacilityAddress2	string		55	N
Claim	32	Service Facility Location Information	2310C	N401			F32_FacilityCity	string	2	30	N
Claim	32	Service Facility Location Information	2310C	N402			F32_FacilityState	string	2	2	N
Claim	32	Service Facility Location Information	2310C	N403			F32_FacilityZip	string	3	15	N
Claim	32a	NPI #	2310C	NM109	Laboratory or Facility Primary Identifier in the 837P.		F32A_FacilityNpi	string	10	10	N
Claim	32b	Other ID #	2310C	REF01 REF02	Reference Identification Qualifier and Laboratory or Facility Secondary Identifier in the 837P.		F32B_FacilityIdStateLicenseNumber	string	1	50	N
Claim	32b	Other ID #	2310C	REF01 REF02	Reference Identification Qualifier and Laboratory or Facility Secondary Identifier in the 837P.		F32B_FacilityIdProviderCommercialLicenseNumber	string	1	50	N
Claim	32b	Other ID #	2310C	REF01 REF02	Reference Identification Qualifier and Laboratory or Facility Secondary Identifier in the 837P.		F32B_FacilityIdLocationNumber	string	1	50	N
Claim	33	Billing Provider Info & Ph #	2010AA	NM103			F33_BillingProviderNameLast	string	1	60	Y
Claim	33	Billing Provider Info & Ph #	2010AA	NM104			F33_BillingProviderNameFirst	string	1	35	N
Claim	33	Billing Provider Info & Ph #	2010AA	NM105			F33_BillingProviderNameMiddle	string	1	25	N
Claim	33	Billing Provider Info & Ph #	2010AA	NM107			F33_BillingProviderSuffix	string	1	10	N
Claim	33	Billing Provider Info & Ph #	2010AA	N301			F33_BillingProviderAddress1	string	1	55	Y
Claim	33	Billing Provider Info & Ph #	2010AA	N302			F33_BillingProviderAddress2	string	1	55	N
Claim	33	Billing Provider Info & Ph #	2010AA	N401			F33_BillingProviderCity	string	2	30	Y
Claim	33	Billing Provider Info & Ph #	2010AA	N402			F33_BillingProviderState	string	2	2	Y
Claim	33	Billing Provider Info & Ph #	2010AA	N403			F33_BillingProviderZip	string	3	15	N
Claim	33	Billing Provider Info & Ph #	2010AA	PER04			F33_BillingProviderPhoneNumber	string	1	256	N
Claim	33a	NPI #	2010AA	NM109	Billing Provider Identifier in the 837P.		F33A_BillingProviderNpi	string	10	10	Y
Claim	33b	Other ID #	2000A	PRV1-PRV03	Provider Taxonomy Code in the 837P.		F33B_BillingProviderTaxonomyCode	string	1	50	N
Claim	33b	Other ID #	2010AA	REF01, REF02	Titled Reference Identification Qualifier and Billing Provider Additional Identifier in the 837P.		F33B_BillingProviderSsn	string	1	50	Y*
Line	X12	Anesthesia	2400	SV104 - Quantity Other fields filled in because it is Anesthesia	SV1 - PROFESSIONAL SERVICE -Looks like this is information in to make a specific Service Line (2400 SV1) -SV101-1 (HC) Health Care Financing Administration Common Procedural Coding System (HCPCS) Codes -SV101-2 Procedure Code - Anesthesia CPT code - ex 00142 lens surgery (see spec ex) - SV101-3 - SV101-6 Procedure Modifier - SV102 Monetary Amount - SV103 Unit Or Base Measurement - For Anesthesia (MJ) Minutes - SV104 Quantity (Service Unit Count) - Max length 8 digits - For Anesthesia this is where the minutes go How to correlate with F24A - F24J Service Line Entry	Defaults to false (non-anesthesia). If true, then F24G_DaysOrUnits must be set to the number of minutes.	X12_Anesthesia	boolean			N
Claim	X12	Claim Level Payer Amount	2320	AMT02	Loop 2320 AMT AMT - COORDINATION OF BENEFITS (COB)	PAYER PAID AMOUNT. Looks like this is claim level primary payer amount or the sum of all the line item primary payer paid amounts	X12_ClaimPrimaryPayerPaidAmount	nullable decimal			N
Line	X12	F24_LineAdjudicationDate	2430	DTP01-03	Loop 2420 DTP Line Check Or Remittance Date DTP01 - 573, DTP02 - D8, DTP03 -Adjudication or Payment Date		X12_AdjudicationOrPaymentDate	date YYYY-MM-DD	10	10	N
Line	X12	F24_LineAdjustments	2430	CAS01-19	Should be an array of adjustments where the members have the info. Loop 2340 CAS - Group Code is in CAS01, and then up to 6 adjustments Reason Code, Amount, Quantity in 2-4, 5-7, 8-10, 11-13, 14-16 and 17-9 associated with that code.	Each of these fields consists of an array of objects of type ServiceLineAdjustment, which is defined to consist of: ReasonCode (string) MonetaryAmount (monetary amount, decimal number) Quantity (optional, decimal number)	X12_LineContractualObligationAdjustments X12_LineCorrectionAndReversalAdjustments X12_LineOtherAdjustments X12_LinePayorInitiatedReductions X12_LinePatientResponsibilityAdjustments See X12_ClaimContractualObligationAdjustments, etc., for claim level adjustments.	array of objects			N
Line	X12	X12_LineTestResults	2400	MEA	Loop 2400 MEA	An array of objects with the fields MeasurementId (of type MeasurementReferenceIdCode enumeration, MEA01), MeasurementQualifier (of type MeasurementQualifier enumeration, MEA02), and MeasurementValue (decimal, MEA03). Example: X12_LineTestResults: [ { "MeasurementId": "TestResults", "MeasurementQualifier": "Hemoglobin", "MeasurementValue": 113.4 }, { "MeasurementId": "TestResults", "MeasurementQualifier": "Hematocrit", "MeasurementValue": 14.2 } ]	X12_LineTestResults	array of objects			N
Line	X12	F24_NDC - In Mapping Spread Sheet	2410	LIN02-LIN03		Must be in 5-4-2 format. Omit hyphens. If this field is set, then exactly one of X12_DrugQuantityInternationalUnits, X12_DrugQuantityGrams, X12_DrugQuantityMilligrams, X12_DrugQuantityMilliliters, or X12_DrugQuantityUnits must be set.	X12_NdcCode	string	11	11	N
Line	X12	F24_NDC - In Mapping Spread Sheet	2410	CTP04-CTP05		If X12_NdcCode is used, then exactly one of these fields must be set. Otherwise, do not use.	X12_DrugQuantityInternationalUnits X12_DrugQuantityGrams X12_DrugQuantityMilligrams X12_DrugQuantityMilliliters X12_DrugQuantityUnits	nullable decimal			N
Line	X12	REF - PRESCRIPTION OR COMPOUND DRUG ASSOCIATION NUMBER	2410	REF01-REF02	Loop 2410 REF01 - XZ (Pharmacy Prescription #) Loop 2410 REF02 - Prescription Number Loop 2410 REF01 - VY (Link #) Loop 2410 REF02 - Link Number F24_NDC - In Mapping Spread Sheet	At most one of these fields may be set.	X12_NdcPharmacyPrescriptionNumber X12_NdcLinkSequenceNumber	string	1	50	N
Line	X12	F24_PrimaryPayerPaidAmount	2430	SVD02	Loop 2430 Line Adjudication Information SVD02 Service Line Paid Amount??		X12_PrimaryPayerPaidAmount	nullable decimal			N
Line	X12	F24_ProviderControlNumber	2400	REF01-02	Loop 2400 REF - Line Item Control Number REF01 - 6R Provider Control Number / REF02 Line Item Control Number		X12_ProviderControlNumber	string	1	50	N
Claim	X12		2300	CLM05-1	Facility Code Value in the 837P.	The place of service for the entire claim. May be overridden if necessary for a particular claim line by placing a value in F24B_PlaceOfServiceCode for that claim line.	X12_PlaceOfServiceCode	string	1	2	N
Claim	X12	Rendering Provider Last Name	2310B	NM103	Provider Last or Organization Name	Claim level. Not on form	X12_RendProviderNameLast	string	1	60	N
Claim	X12	Rendering Provider First Name	2310B	NM104	Provider First Name	Claim level. Not on form	X12_RendProviderNameFirst	string	1	35	N
Claim	X12	Rendering Provider Middle Name	2310B	NM105	Provider Middle Name	Claim level. Not on form	X12_RendProviderNameMiddle	string	1	25	N
Claim	X12	Rendering Provider Suffix	2310B	NM106	Provider Suffix	Claim level. Not on form	X12_RendProviderSuffix	string	1	10	N
Claim	X12	Rendering Provider Taxonomy Code	2310B	PRV02, PRV03	Provider Taxonomy Code in the 837P.	Claim level rendering provider taxonomy code. Optional. This identifier may be overridden at the claim line level by F24J_Shaded_RendProviderTaxonomyCode.	X12_RendProviderTaxonomyCode	string		10	N
Claim	X12	Rendering Provider Secondary Identifier	2310B	REF01, REF02	Provider Secondary Identifier in the 837P.	Claim level rendering provider identifier. Optional. At most one of these may be set. This identifier may be overridden at the claim line level by one of the 24J_... Identifiers.	X12_RendProviderStateLicenseNumber X12_RendProviderUpinNumber X12_RendProviderCommercialNumber X12_RendProviderLocationNumber	string		10	N
Claim	X12	Rendering Provider NPI	2310B	NM109	Rendering Provider Identifier in the 837P.	This is the NPI of the rendering provider for the entire claim. This can be optionally overridden for a particular claim line by use of F24J_RenderingNpi.	X12_RenderingNpi	string		10	N
Claim	X12	x12_AcuteManifestationConditionCode	2300	CR208	CR2 - SPINAL MANIPULATION SERVICE INFORMATION CR208 - Nature of Condition Code A - Acute Condition M - Acute Manifestation of a Chronic Condition	See also F15_AcuteManifestionDate.	X12_AcuteManifestationCode	enumeration AcuteManifestationCodes	1	1	N
Claim	X12	x12_AmountPaidByPrimary	2320	AMT02	2320 AMT - COB PayerPaid Amount	Required for secondary claims. Must reconcile with line item amounts.	X12_ClaimPrimaryPaidAmount	nullable decimal			N
Claim	X12	x12_AssumedCareDate	2300	DTP03 DTP01=090	Qualifier - 090		use F15_AssumedCareStartDate
Claim	X12	x12_ClaimAdjudicationDate	2330B	DTP01-DTP03	DTP - CLAIM CHECK OR REMITTANCE DATE. The Claim Adjudication Date (DTP) segment has been renamed to Claim Check or Remittance Date.		X12_ClaimAdjudicationDate	string			N
Claim	X12		2320	CAS01-19	See line level equivalents.	See comments for line level adjustments, X12_LineContractualObligationAdjustments, etc	X12_ClaimContractualObligationAdjustments X12_ClaimCorrectionAndReversalAdjustments X12_ClaimOtherAdjustments X12_ClaimPayorInitiatedReductions X12_ClaimPatientResponsibilityAdjustments .	Each is and Array of Claims adjustments			N
Claim	X12	x12_MedicalRecordNumber	2300	REF02	REF - MEDICAL RECORD NUMBER		X12_MedicalRecordNumber	string	1	50	N
Claim	X12		2300	CRC	CRC - PATIENT CONDITION INFORMATION: VISION The field names imply which code category: E1, E2, or E3 (CRC01). The boolean gives the value of CRC02. The array of ConditionCodes provide the values for CRC03-CRC07: L1 General Standard of 20 Degree or .5 Diopter Sphere or Cylinder Change Met L2 Replacement Due to Loss or Theft L3 Replacement Due to Breakage or Damage L4 Replacement Due to Patient Preference L5 Replacement Due to Medical Reason	Each field consists of an object with two fields: CertificationConditionIndicator (boolean), and ConditionCodes (array of one to five strings, "L1", "L2", etc.). Example: "X12_SpectacleLenses": { "CertificationConditionIndicator": true, "ConditionCodes": [ "L1", "L4" ] }	X12_SpectacleLenses X12_ContactLenses X12_SpectacleFrames				N
Claim	X12	X12_DelayReasonCode	2300	CN1	CN1 - CONTRACT INFORMATION		X12_DelayReasonCode	DelayReasonCode enumeration			N
Claim	X12	X12_OtherPayerName	2330B	NM103	Loop 2330B NM101 = PR (Payer) NM102 = 2 (Non-Person Entity) NM103 = Other Organization Name		X12_OtherPayerName	string	1	60	N
Claim	X12	X12_AmbulanceCertifications	2300	CRC	CRC - AMBULANCE CERTIFICATION The CRC02 value is a boolean condition for Yes/No Condition or Response code. The array of ConditionCodes provide the values for CRC03-CRC07: 01 Patient was admitted to a hospital 04 Patient was moved by stretcher 05 Patient was unconscious or in shock 06 Patient was transported in an emergency situation 07 Patient had to be physically restrained 08 Patient had visible hemorrhaging 09 Ambulance service was medically necessary 12 Patient is confined to a bed or chair (Use code 12 to indicate patient was bedridden during transport)	Each field consists of an object with two fields: CertificationConditionIndicator (boolean), and ConditionCodes (array of one to five strings, "01", "04", "06", "09", etc.). Example: "X12_AmbulanceCertification": { "CertificationConditionIndicator": true, "ConditionCodes":["01","04","06","09"] }	X12_AmbulanceCertification				N
Claim	X12	X12_AmbulancePatientWeight	2300	CR102	CR1 - AMBULANCE TRANSPORT INFORMATION	Weight of the patient at time of transport. Required when it is necessary to justify the medical necessity of the level of ambulance services.	X12_AmbulancePatientWeight	string	1	10	N
Claim	X12	X12_AmbulanceTransportReasonCode	2300	CR104	CR1 - AMBULANCE TRANSPORT INFORMATION Ambulance Transport Reason Code: NearestFacility PreferredPhysician NearFamily Specialist Rehabilitation	This field is required only if PlaceOfService code is 41 (Ambulance by Land) or 42 (Ambulance by Air or Water). The possible codes indicating the reason for ambulance transport. are aliases for the single letter codes of A-E indicated by the 837 spec. A = NearestFacility, B=PreferredPhysician, etc. Example: "X12_AmbulanceTransportReasonCode":"NearestFacility"	X12_AmbulanceTransportReasonCode	string	1	1	N
Claim	X12	X12_AmbulanceTransportDistance	2300	CR106	CR1 - AMBULANCE TRANSPORT INFORMATION Ambulance Transport Distance	This field is required only if PlaceOfService code is 41 (Ambulance by Land) or 42 (Ambulance by Air or Water). The value is in terms of Miles Example: "X12_AmbulanceTransportDistance":"5"	X12_AmbulanceTransportDistance	string	1	15	N
Claim	X12	X12_AmbulanceRoundTripPurposeDescription	2300	CR109	CR1 - AMBULANCE TRANSPORT INFORMATION Round Trip Purpose Description	This field is required only if PlaceOfService code is 41 (Ambulance by Land) or 42 (Ambulance by Air or Water) and when the ambulance service is for a round trip The value is in terms of Miles Example: "X12_AmbulanceRoundTripPurposeDescription":"Required round trip for surgery"	X12_AmbulanceRoundTripPurposeDescription	string	1	80	N
Claim	X12	X12_AmbulanceStretcherPurposeDescription	2300	CR110	CR1 - AMBULANCE TRANSPORT INFORMATION Stretcher Purpose Description	This field is required only if PlaceOfService code is 41 (Ambulance by Land) or 42 (Ambulance by Air or Water) and when needed to justify usage of stretcher The value is in terms of Miles Example: "X12_AmbulanceStretcherPurposeDescription":"Patient immobile"	X12_AmbulanceStretcherPurposeDescription	string	1	80	N
Claim	X12	X12_AmbulancePickupAddress1	2310E	N301	N3 - AMBULANCE PICKUP LOCATION Address	This field is required only if PlaceOfService code is 41 (Ambulance by Land) or 42 (Ambulance by Air or Water) This is Address line 1 Example: "X12_AmbulancePickupAddress1":"123 MAIN STREET"	X12_AmbulancePickupAddress1	string	1	55	N
Claim	X12	X12_AmbulancePickupAddress2	2310E	N302	N3 - AMBULANCE PICKUP LOCATION Second Address Line (If Needed)	This field is required only if PlaceOfService code is 41 (Ambulance by Land) or 42 (Ambulance by Air or Water) and a second address line is needed Example: "X12_AmbulancePickupAddress2":"SUITE #200"	X12_AmbulancePickupAddress2	string	1	55	N
Claim	X12	X12_AmbulancePickupCity	2310E	N401	N3 - AMBULANCE PICKUP LOCATION City	This field is required only if PlaceOfService code is 41 (Ambulance by Land) or 42 (Ambulance by Air or Water) This is the Ambulance Pickup Location city Example: "X12_AmbulancePickupCity":"MY TOWN"	X12_AmbulancePickupCity	string	2	30	N
Claim	X12	X12_AmbulancePickupState	2310E	N402	N3 - AMBULANCE PICKUP LOCATION State or Province Code	This field is required only if PlaceOfService code is 41 (Ambulance by Land) or 42 (Ambulance by Air or Water) This is the Ambulance Pickup Location State or Province Code Example: "X12_AmbulancePickupState":"NY"	X12_AmbulancePickupState	string	2	2	N
Claim	X12	X12_AmbulancePickupZip	2310E	N403	N3 - AMBULANCE PICKUP LOCATION Postal Code	This field is required only if PlaceOfService code is 41 (Ambulance by Land) or 42 (Ambulance by Air or Water) This is the Postal Code Example: "X12_AmbulancePickupState":"10022"	X12_AmbulancePickupZip	string	3	15	N
Claim	X12	X12_AmbulancePickupCountry	2310E	N404	N3 - AMBULANCE PICKUP LOCATION Country	This field is required only if PlaceOfService code is 41 (Ambulance by Land) or 42 (Ambulance by Air or Water) This is the Country Code, required when the address is outside of the United States of America Example: "X12_AmbulancePickupState":"CAN"	X12_AmbulancePickupZip	string	2	3	N
Claim	X12	X12_AmbulanceDropOffAddress1	2310E	N301	N3 - AMBULANCE DROP-OFF LOCATION Address	This field is required only if PlaceOfService code is 41 (Ambulance by Land) or 42 (Ambulance by Air or Water) This is Address line 1 Example: "X12_AmbulanceDropOffAddress1":"123 MAIN STREET"	X12_AmbulanceDropOffAddress1	string	1	55	N
Claim	X12	X12_AmbulanceDropOffAddress2	2310F	N302	N3 - AMBULANCE DROP-OFF LOCATION Second Address Line (If Needed)	This field is required only if PlaceOfService code is 41 (Ambulance by Land) or 42 (Ambulance by Air or Water) and a second address line is needed Example: "X12_AmbulanceDropOffAddress2":"SUITE #200"	X12_AmbulanceDropOffAddress2	string	1	55	N
Claim	X12	X12_AmbulanceDropOffCity	2310F	N401	N3 - AMBULANCE DROP-OFF LOCATION City	This field is required only if PlaceOfService code is 41 (Ambulance by Land) or 42 (Ambulance by Air or Water) This is the Ambulance Pickup Location city Example: "X12_AmbulanceDropOffCity":"MY TOWN"	X12_AmbulanceDropOffCity	string	2	30	N
Claim	X12	X12_AmbulanceDropOffState	2310F	N402	N3 - AMBULANCE DROP-OFF LOCATION State or Province Code	This field is required only if PlaceOfService code is 41 (Ambulance by Land) or 42 (Ambulance by Air or Water) This is the Ambulance Pickup Location State or Province Code Example: "X12_AmbulanceDropOffState":"NY"	X12_AmbulanceDropOffState	string	2	2	N
Claim	X12	X12_AmbulanceDropOffZip	2310F	N403	N3 - AMBULANCE DROP-OFF LOCATION Postal Code	This field is required only if PlaceOfService code is 41 (Ambulance by Land) or 42 (Ambulance by Air or Water) This is the Postal Code Example: "X12_AmbulanceDropOffState":"10022"	X12_AmbulanceDropOffZip	string	3	15	N
Claim	X12	X12_AmbulanceDropOffCountry	2310F	N404	N3 - AMBULANCE DROP-OFF LOCATION Country	This field is required only if PlaceOfService code is 41 (Ambulance by Land) or 42 (Ambulance by Air or Water) This is the Country Code, required when the address is outside of the United States of America Example: "X12_AmbulanceDropOffState":"CAN"	X12_AmbulanceDropOffZip	string	2	3	N
Line	X12	X12_AmbulanceCertifications	2400	CRC	CRC - AMBULANCE CERTIFICATION The CRC02 value is a boolean condition for Yes/No Condition or Response code. The array of ConditionCodes provide the values for CRC03-CRC07: 01 Patient was admitted to a hospital 04 Patient was moved by stretcher 05 Patient was unconscious or in shock 06 Patient was transported in an emergency situation 07 Patient had to be physically restrained 08 Patient had visible hemorrhaging 09 Ambulance service was medically necessary 12 Patient is confined to a bed or chair (Use code 12 to indicate patient was bedridden during transport)	Each field consists of an object with two fields: CertificationConditionIndicator (boolean), and ConditionCodes (array of one to five strings, "01", "04", "06", "09", etc.). Example: "X12_AmbulanceCertification": { "CertificationConditionIndicator": true, "ConditionCodes":["01","04","06","09"] }	X12_AmbulanceCertification				N
Line	X12	X12_AmbulancePatientWeight	2400	CR102	CR1 - AMBULANCE TRANSPORT INFORMATION	Weight of the patient at time of transport. Required when it is necessary to justify the medical necessity of the level of ambulance services.	X12_AmbulancePatientWeight	string	1	10	N
Line	X12	X12_AmbulanceTransportReasonCode	2400	CR104	CR1 - AMBULANCE TRANSPORT INFORMATION Ambulance Transport Reason Code: NearestFacility PreferredPhysician NearFamily Specialist Rehabilitation	This field is required only if PlaceOfService code is 41 (Ambulance by Land) or 42 (Ambulance by Air or Water). The possible codes indicating the reason for ambulance transport. are aliases for the single letter codes of A-E indicated by the 837 spec. A = NearestFacility, B=PreferredPhysician, etc. Example: "X12_AmbulanceTransportReasonCode":"NearestFacility"	X12_AmbulanceTransportReasonCode	string	1	1	N
Line	X12	X12_AmbulanceTransportDistance	2400	CR106	CR1 - AMBULANCE TRANSPORT INFORMATION Ambulance Transport Distance	This field is required only if PlaceOfService code is 41 (Ambulance by Land) or 42 (Ambulance by Air or Water). The value is in terms of Miles Example: "X12_AmbulanceTransportDistance":"5"	X12_AmbulanceTransportDistance	string	1	15	N
Line	X12	X12_AmbulanceRoundTripPurposeDescription	2400	CR109	CR1 - AMBULANCE TRANSPORT INFORMATION Round Trip Purpose Description	This field is required only if PlaceOfService code is 41 (Ambulance by Land) or 42 (Ambulance by Air or Water) and when the ambulance service is for a round trip The value is in terms of Miles Example: "X12_AmbulanceRoundTripPurposeDescription":"Required round trip for surgery"	X12_AmbulanceRoundTripPurposeDescription	string	1	80	N
Line	X12	X12_AmbulanceStretcherPurposeDescription	2400	CR110	CR1 - AMBULANCE TRANSPORT INFORMATION Stretcher Purpose Description	This field is required only if PlaceOfService code is 41 (Ambulance by Land) or 42 (Ambulance by Air or Water) and when needed to justify usage of stretcher The value is in terms of Miles Example: "X12_AmbulanceStretcherPurposeDescription":"Patient immobile"	X12_AmbulanceStretcherPurposeDescription	string	1	80	N
Line	X12	X12_AmbulancePickupAddress1	2420G	N301	N3 - AMBULANCE PICKUP LOCATION Address	This field is required only if PlaceOfService code is 41 (Ambulance by Land) or 42 (Ambulance by Air or Water) This is Address line 1 Example: "X12_AmbulancePickupAddress1":"123 MAIN STREET"	X12_AmbulancePickupAddress1	string	1	55	N
Line	X12	X12_AmbulancePickupAddress2	2420G	N302	N3 - AMBULANCE PICKUP LOCATION Second Address Line (If Needed)	This field is required only if PlaceOfService code is 41 (Ambulance by Land) or 42 (Ambulance by Air or Water) and a second address line is needed Example: "X12_AmbulancePickupAddress2":"SUITE #200"	X12_AmbulancePickupAddress2	string	1	55	N
Line	X12	X12_AmbulancePickupCity	2420G	N401	N3 - AMBULANCE PICKUP LOCATION City	This field is required only if PlaceOfService code is 41 (Ambulance by Land) or 42 (Ambulance by Air or Water) This is the Ambulance Pickup Location city Example: "X12_AmbulancePickupCity":"MY TOWN"	X12_AmbulancePickupCity	string	2	30	N
Line	X12	X12_AmbulancePickupState	2420G	N402	N3 - AMBULANCE PICKUP LOCATION State or Province Code	This field is required only if PlaceOfService code is 41 (Ambulance by Land) or 42 (Ambulance by Air or Water) This is the Ambulance Pickup Location State or Province Code Example: "X12_AmbulancePickupState":"NY"	X12_AmbulancePickupState	string	2	2	N
Line	X12	X12_AmbulancePickupZip	2420G	N403	N3 - AMBULANCE PICKUP LOCATION Postal Code	This field is required only if PlaceOfService code is 41 (Ambulance by Land) or 42 (Ambulance by Air or Water) This is the Postal Code Example: "X12_AmbulancePickupState":"10022"	X12_AmbulancePickupZip	string	3	15	N
Line	X12	X12_AmbulancePickupCountry	2420G	N404	N3 - AMBULANCE PICKUP LOCATION Country	This field is required only if PlaceOfService code is 41 (Ambulance by Land) or 42 (Ambulance by Air or Water) This is the Country Code, required when the address is outside of the United States of America Example: "X12_AmbulancePickupState":"CAN"	X12_AmbulancePickupZip	string	2	3	N
Line	X12	X12_AmbulanceDropOffAddress1	2420H	N301	N3 - AMBULANCE DROP-OFF LOCATION Address	This field is required only if PlaceOfService code is 41 (Ambulance by Land) or 42 (Ambulance by Air or Water) This is Address line 1 Example: "X12_AmbulanceDropOffAddress1":"124 MAIN STREET"	X12_AmbulanceDropOffAddress1	string	1	55	N
Line	X12	X12_AmbulanceDropOffAddress2	2420H	N302	N3 - AMBULANCE DROP-OFF LOCATION Second Address Line (If Needed)	This field is required only if PlaceOfService code is 41 (Ambulance by Land) or 42 (Ambulance by Air or Water) and a second address line is needed Example: "X12_AmbulanceDropOffAddress2":"SUITE #200"	X12_AmbulanceDropOffAddress2	string	1	55	N
Line	X12	X12_AmbulanceDropOffCity	2420H	N401	N3 - AMBULANCE DROP-OFF LOCATION City	This field is required only if PlaceOfService code is 41 (Ambulance by Land) or 42 (Ambulance by Air or Water) This is the Ambulance Pickup Location city Example: "X12_AmbulanceDropOffCity":"MY TOWN"	X12_AmbulanceDropOffCity	string	2	30	N
Line	X12	X12_AmbulanceDropOffState	2420H	N402	N3 - AMBULANCE DROP-OFF LOCATION State or Province Code	This field is required only if PlaceOfService code is 41 (Ambulance by Land) or 42 (Ambulance by Air or Water) This is the Ambulance Pickup Location State or Province Code Example: "X12_AmbulanceDropOffState":"NY"	X12_AmbulanceDropOffState	string	2	2	N
Line	X12	X12_AmbulanceDropOffZip	2420H	N403	N3 - AMBULANCE DROP-OFF LOCATION Postal Code	This field is required only if PlaceOfService code is 41 (Ambulance by Land) or 42 (Ambulance by Air or Water) This is the Postal Code Example: "X12_AmbulanceDropOffState":"10022"	X12_AmbulanceDropOffZip	string	3	15	N
Line	X12	X12_AmbulanceDropOffCountry	2420H	N404	N3 - AMBULANCE DROP-OFF LOCATION Country	This field is required only if PlaceOfService code is 41 (Ambulance by Land) or 42 (Ambulance by Air or Water) This is the Country Code, required when the address is outside of the United States of America Example: "X12_AmbulanceDropOffState":"CAN"	X12_AmbulanceDropOffZip	string	2	3	N
Line	X12	X12_AmbulancePatientCount	2400	QT02	QTY - AMBULANCE PATIENT COUNT	This field is required only if PlaceOfService code is 41 (Ambulance by Land) or 42 (Ambulance by Air or Water) and when more than one patient is transported in the same vehicle for Ambulance or non-emergency transportation services. Example: "X12_AmbulancePatientCount":"2"	X12_AmbulanceDropOffZip	string	1	15	N

Dental Claim Field Reference

This table documents the fields that may be used when submitting Dental claims. The Required column indicates whether the field is required on all claims. Optional fields may be required in certain situations. The Level column indicates whether the field appears at the claim level or the service line level of the claim.

For more definitions of the various enumerations, see Enumerations.

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Level	ADA 1900 Claim Form Locator		837D			General Notes	Name of JSON Field	Data Type	Min Value or Length	Max Value or Length	Required?
Level	Item Number	Title	Loop ID	Segment/Data Element	Notes	General Notes	Name of JSON Field	Data Type	Min Value or Length	Max Value or Length	Required?
Claim	Apex	Vendor Claim ID					Apex_VendorClaimId		1	50	Y
Claim	Apex	Apex Payer ID			Apex payer ID		Apex_PayerId	string			Y
Claim	1	Type of Transaction	2300	CLM19/CLM12		ActualServices, RequestForPreauth, EpsdtTitleXix	F01_TypeOfTransaction	enum TypeOfTransaction			Y
Claim	2	Preauthorization Number	2300	REF02 (G1)			F02_PriorAuthNum	string		50	N
Claim	3	Payer Name	2010BB	NM103	Insurance Company Block		F03_PayerName	string	1	60	Y
Claim	3	Payer Address 1	2010BB	N301	Insurance Company Block	One of payer address or payer ID must be present or claim will fail Apex validations. Both may also be present.	F03_PayerAddress1	string		55	N
Claim	3	Payer Address 2	2010BB	N302	Insurance Company Block	One of payer address or payer ID must be present or claim will fail Apex validations. Both may also be present.	F03_PayerAddress2	string		55	N
Claim	3	Payer City	2010BB	N401	Insurance Company Block	One of payer address or payer ID must be present or claim will fail Apex validations. Both may also be present.	F03_PayerCity	string		30	N
Claim	3	Payer State	2010BB	N402	Insurance Company Block	One of payer address or payer ID must be present or claim will fail Apex validations. Both may also be present. Standard postal abbreviations	F03_PayerState	string	2	2	N
Claim	3	Payer Zip	2010BB	N403	Insurance Company Block	One of payer address or payer ID must be present or claim will fail Apex validations. Both may also be present.	F03_PayerZip	string	5	15	N
Claim	4	Other Coverage	2320	SBR	Loop/segment are present if true; not present if false		F04_OtherCoverage	boolean			Y
Claim	5	Other Insured's Last Name	2330A	NM103			F05_OtherInsuredLastName	string		60	N
Claim	5	Other Insured's First Name	2330A	NM104			F05_OtherInsuredFirstName	string		35	N
Claim	5	Other Insured's Middle Initial	2330A	NM105			F05_OtherInsuredMI	string		25	N
Claim	5	Other Insured's Suffix	2330A	NM107			F05_OtherInsuredSuffix	string		10	N
Claim	8	Other Insured ID	2330A	NM109			F08_OtherInsuredPolicy	string	2	80	N
Claim	9	Other Insured's Plan/Group Number	2320	SBR03			F09_OtherInsuredGrpNumber	string	1	50	N
Claim	10	Patient Relationship to Other Insured	2320	SBR02		https://developers.apexedi.com/v3/ClaimApiEnumerationsV3.asp	F10_OtherPatientRelationship	enum OtherPatientRelationship			N
Claim	11	Other Payer Name	2330B	NM103	Other Insurance Carrier Block		F11_OtherPayerName	string		60	N
Claim	11	Other Payer Address	2330B	N301	Other Insurance Carrier Block		F11_OtherPayerAddress	string		55	N
Claim	11	Other Payer City	2330B	N401	Other Insurance Carrier Block		F11_OtherPayerCity	string		30	N
Claim	11	Other Payer State	2330B	N402	Other Insurance Carrier Block	Standard postal abbreviations	F11_OtherPayerST	string		2	N
Claim	11	Other Payer Zip	2330B	N403	Other Insurance Carrier Block		F11_OtherPayerZip	string	5	15	N
Claim	12	Insured's Last Name	2010BA	NM103			F12_InsuredLastName	string	1	60	Y
Claim	12	Insured's First Name	2010BA	NM104			F12_InsuredFirstName	string	1	35	Y
Claim	12	Insured's Middle Initial	2010BA	NM105			F12_InsuredMI	string		25	N
Claim	12	Insured's Suffix	2010BA	NM107			F12_InsuredSuffix	string		10	N
Claim	12	Insured's Address	2010BA	N301		*If subscriber is patient then required.	F12_InsuredAddress	string		55	N*
Claim	12	Insured's City	2010BA	N401		*If subscriber is patient then required.	F12_InsuredCity	string		30	N*
Claim	12	Insured's State	2010BA	N402		*If subscriber is patient then required. Standard postal abbreviations	F12_InsuredST	string	2	2	N*
Claim	12	Insured's Zip Code	2010BA	N403		*If subscriber is patient then required.	F12_InsuredZip	string	5	15	N*
Claim	13	Insured's Date of Birth	2010BA	DMG02		*If subscriber is patient then required.	F13_InsuredDOB	date YYYY-MM-DD			N*
Claim	14	Insured's Gender	2010BA	DMG03		*If subscriber is patient then required. M, F, Unknown	F14_InsuredSex	enum Sex			N*
Claim	15	Insured's ID	2010BA	NM109			F15_InsuredID	string	2	80	Y
Claim	16	Insured's Plan/Group Number	2010BA	SBR03			F16_InsuredGroupNumber	string		50	N
Claim	18	Patient Relationship to Insured	2010CA/2010BA	PAT01/SBR02		https://developers.apexedi.com/v3/ClaimApiEnumerationsV3.asp	F18_PatientRelationship	enum Relationship			Y
Claim	20	Patient Last Name	2010CA	NM103		*If subscriber is patient then this information is given in subscriber loop - 2010BA - if patient is not subscriber then these fields are required.	F20_PatientLastName	string	1	60	N*
Claim	20	Patient First Name	2010CA	NM104		*If subscriber is patient then this information is given in subscriber loop - 2010BA - if patient is not subscriber then these fields are required.	F20_PatientFirstName	string	1	35	N*
Claim	20	Patient Middle Name	2010CA	NM105			F20_PatientMI	string		25	N
Claim	20	Patient Suffix	2010CA	NM107			F20_PatientSuffix	string		10	N
Claim	20	Patient Address	2010CA	N301		*If subscriber is patient then this information is given in subscriber loop - 2010BA - if patient is not subscriber then these fields are required.	F20_PatientAddress	string		55	N*
Claim	20	Patient City	2010CA	N401		*If subscriber is patient then this information is given in subscriber loop - 2010BA - if patient is not subscriber then these fields are required.	F20_PatientCity	string	1	30	N*
Claim	20	Patient State	2010CA	N402		*If subscriber is patient then this information is given in subscriber loop - 2010BA - if patient is not subscriber then these fields are required. Standard postal abbreviation.	F20_PatientST	string	2	2	N*
Claim	20	Patient Zip Code	2010CA	N403		*If subscriber is patient then this information is given in subscriber loop - 2010BA - if patient is not subscriber then these fields are required.	F20_PatientZip	string	5	15	N*
Claim	21	Patient Date of Birth	2010CA	DMG02		*If subscriber is patient then this information is given in subscriber loop - 2010BA - if patient is not subscriber then these fields are required.	F20_PatientDOB	date YYYY-MM-DD			N*
Claim	22	Patient Gender	2010CA	DMG03		*If subscriber is patient then this information is given in subscriber loop - 2010BA - if patient is not subscriber then these fields are required.	F22_PatientSex	enum Sex	1		N*
Claim	32	Total Fee	2300	CLM02		e.g. use "55000" for 550.00	F32_TotalFee	string	1	18	Y
Claim	33	Missing Teeth	2300	DN201		Missing teeth values are 1-32 and A-T	F33_MissingTeeth	array of strings			N
Claim	34	Diagnosis Code Qualifier	2300	HI01-1,HI02-1�	Not supported at this time by Apex (not needed for dental claims)	When implemented, "10" will be assumed.	F34_DiagnosiseCodeQualifier	string			N
Claim	34a	Diagnosis Code(s)	2300	HI01-2,HI02-2�	Not supported at this time by Apex (not needed for dental claims)		F34a_DiagnosisCode	string			N
Claim	35	Remarks	2300	NTE02	Up to 5 string remarks can be added to simulate multiple NTE segments		F35_Remarks	array of strings, limit of 80 characters per remark		5	N
Claim	36	Patient Signature	2300	CLM09			F36_PatientSignature	string	1	20	Y
Claim	37	Subscriber Signature	2300	CLM08		If field is empty or null, then "No" is sent, meaning provider does not accept assignment for claim payment.	F37_InsuredSignature	string		20	N
Claim	38	Place of Treatment	2300	CLM05-1			F38_PlaceOfTreatment	string	1	2	N
Claim	40	Treatment for Orthodontics	2300	DN1			F40_OrthoTreatment	boolean			Y
Claim	41	Date Appliance Placed	2300	DTP03 (452)			F41_DateAppliancePlaced	date YYYY-MM-DD			N
Claim	42	Months of Treatment Remaining	2300	DN102			F42_MonthsTreatment	integer			N
Claim	43	Replacement of Prosthesis	2400	SV305			F43_Prosthesis	boolean			Y
Claim	44	Date of Prior Placement	2400	DTP03			F44_ProsthesisDateOfPriorPlacement	date YYYY-MM-DD			N
Claim	45	Treatment Resulting from	2300	CLM11-1/CLM11-2	Both elements populated with "EM", "AA", or "OA" depending on accident type	Options: Occupational Injury, Auto Accident, Other Accident	F45_TreatmentResultingFrom	enum TreatmentResultingFrom			N
Claim	46	Date of Accident	2300	DTP03 (439)			F46_AccidentDate	date YYYY-MM-DD			N
Claim	47	Auto Accident State	2300	CLM11-4			F47_AutoAccidentState	string	2	2	N
Claim	48	Billing Dentist Last Name	2010AA	NM103	Last name of billing dentist or organization name of billing entity.	Apex typically uses billing provider name on file, this will primarily be used to identify provider on the claim	F48_BillingDentistLastName	string	1	60	Y
Claim	48	Billing Dentist First Name	2010AA	NM104			F48_BillingDentistFirstName	string		35	N
Claim	48	Billing Dentist Middle Name	2010AA	NM105			F48_BillingDentistMI	string		25	N
Claim	48	Billing Dentist Suffix	2010AA	NM107			F48_BillingDentistSuffix	string		50	N
Claim	48	Billing Dentist Address	2010AA	N301			F48_BillingDentistAddress	string	1	55	Y
Claim	48	Billing Dentist City	2010AA	N401			F48_BillingDentistCity	string	1	30	Y
Claim	48	Billing Dentist State	2010AA	N402			F48_BillingDentistST	string	2	2	Y
Claim	48	Billing Dentist Zip Code	2010AA	N403			F48_BillingDentistZip	string	5	15	Y
Claim	49	Billing Dentist NPI	2010AA	NM109			F48_BillingDentistNPI	string	10	10	Y
Claim	50	Billing Dentist License Number	2010AA	REF02 (0B)			F50_BillingDentistLicense	string		50	N
Claim	51	Billing Dentist SSN or TIN	2010AA	REF02			F51_BillingDentistTaxID	string	1	50	Y
Claim	X12	Billing Dentist SSN or TIN qualifier	2010AA	REF01	Qualifier "SY" for SSN or "EI" for TIN	SY, EI	X12_TINorSSNQualifier	enum ReferenceIdQualifier			Y
Claim	52	Billing Dentist Phone Number	2010AA	PER(04,06, or 08)		Apex uses provider phone number on file typically	F52_BillingDentistPhone	string		256	N
Claim	52a	Billing Dentist Additional Provider ID	2010AA	REF02			F52a_BillingDentistID	string		50	N
Claim	53	Treating Dentist Signature	2300	CLM06			F53_TreatingDentistSignature	string	1	30	Y
Claim	X12	Treating Dentist Last Name	2310B	NM103	2310B is rendering provider loop	Apex typically uses rendering provider name on file, this will primarily be used to identify provider on the claim. Required when billing entity is an organization.	X12_RenderingProvLastName	string		60	N
Claim	X12	Treating Dentist First Name	2310B	NM104	2310B is rendering provider loop	Required when billing entity is an organization.	X12_RenderingProvFirstName	string		35	N
Claim	X12	Treating Dentist Middle Name	2310B	NM105	2310B is rendering provider loop		X12_RenderingProvMI	string		25	N
Claim	X12	Treating Dentist Suffix	2310B	NM107	2310B is rendering provider loop		X12_RenderingProvSuffix	string		50	N
Claim	54	Treating Dentist NPI	2310B	NM109	2310B is rendering provider loop	Required when billing entity is an organization.	F53_TreatingDentistNPI	string	10	10	N
Claim	55	Treating Dentist License Number	2310B	REF02 (0B)	2310B is rendering provider loop		F55_TreatingDentistLicense	string		50	N
Claim	X12	Treatment Facility Name	2310C	NM103	2310C is service facility location loop		X12_TreatmantLocationName	string		60	N
Claim	56	Treatment Facility Address	2310C	N301	2310C is service facility location loop		F56_TreatmentAddress	string		55	N
Claim	56	Treatment Facility City	2310C	N401	2310C is service facility location loop		F56_TreatmentCity	string		30	N
Claim	56	Treatment Facility State	2310C	N402	2310C is service facility location loop		F56_TreatmentST	string	2	2	N
Claim	56	Treatment Facility Zip	2310C	N403	2310C is service facility location loop		F56_TreatmentZip	string	5	15	N
Claim	X12	Treatment Facility NPI	2310C	NM109	2310C is service facility location loop		X12_TreatmantLocationNPI	string		80	N
Claim	56a	Treating Dentist Specialty Code	2310B	PRV03	2310B is rendering provider loop	Apex uses specialty code on file typically	F56a_DentistSpecialtyCode	string		50	N
Claim	58	Treating Dentist Additional Provider ID	2310B	REF02			F58_TreatingDentistAddlID	string		50	N
Claim	X12	Pay to address	2010AB	N3		Currently only the "pay to" address on file at Apex is used. Address on claim is not used. This if for future implementation.	X12_Paytoaddress	string		55	N
Claim	X12	Pay to City	2010AB	N401		Currently only the "pay to" address on file at Apex is used. Address on claim is not used. This if for future implementation.	X12_PaytoCity	string		30	N
Claim	X12	Pay to ST	2010AB	N402		Currently only the "pay to" address on file at Apex is used. Address on claim is not used. This if for future implementation.	X12_PaytoST	string	2	2	N
Claim	X12	Pay to Zip	2010AB	N403		Currently only the "pay to" address on file at Apex is used. Address on claim is not used. This if for future implementation.	X12_PaytoZip	string	5	15	N
Claim	X12	Attachment Report Type Code	2300	PWK01	Several options - see spec	https://developers.apexedi.com/v3/ClaimApiEnumerationsV3.asp	X12_AttachmentReportType	enum AttachmentReportType			N
Claim	X12	Attachment Control Number	2300	PWK06			X12_AttachmentControlNumber	string		80	N
Claim	X12	Attachment Transmission Code	2300	PWK02		By fax (FX), email (EM), electronically (EL), file transfer (FT), mail (BM), or available upon request (AA)	X12_AttachmentTransmissionCode	enum AttachmentTransmissionCodeType			N
Claim	X12	Patient Amount Paid	2300	AMT02	F5 qualifier		X12_PatientAmountPaid	string		18	N
Claim	X12	Prior Authorization Number	2300	REF02 (G3)	Required when sending the Predetermination of Benefits Identification Number for services that have been previously predetermined and are now being submitted for payment		X12_PredeterminationID	string		50	N
Claim	X12	Claim Frequency Code	2300	CLM05-3			X12_ClaimFrequencyCode	string	1	1	N
Claim	X12	Payer Claim Control Number	2300	REF02 (F8)	Required when CLM05-3 (Claim Frequency Code) indicates this claim is a replacement or void to a previously adjudicated claim.	If not given, default value will be 1.	X12_PayerControlNumber	string		50	N
Claim	X12	Subscriber Identification Code Qualifier	2010BA	NM108 (IL)		II, MI	X12_SubscriberIdentificationCodeQualifier	string	1	2	N
Claim	X12	Subscriber Entity Type Qualifier	2010BA	NM102 (IL)		1 = Person, 2 = Non-Person Entity	X12_SubscriberEntityTypeQualifier	string	1	1	Y
Claim	X12	Service Date				Used in claim level information		date YYYY-MM-DD			Y
Line	24	Procedure Date	2300/2400	DTP03 (472)			F24_DateOfServiceFrom	date YYYY-MM-DD			Y
Line	24	Procedure Date	2300/2400	DTP03 (472)			F24_DateOfServiceTo	date YYYY-MM-DD			N
Line	25	Area of Oral Cavity	2400	SV304-1	Options: 00, 01, 02, 10, 20, 30, 40	CODE SOURCE 135: American Dental Association	F25_AreaOfOralCavity	array of strings			N
Line	26	Tooth Sytem	2400	TOO01	"JP" is only option, will be hard coded when TOO segment is used		F26_ToothSystem	string	2	2	N
Line	29	Procedure Code	2400	SV301-2			F29_ProcedureCode	string	1	48	Y
Line	29a	Diagnosis Pointer(s)	2400	SV311	Not supported at this time by Apex (not needed for dental claims)		F29a_DiagnosisPointer	string			N
Line	29b	Quantity	2400	SV306			F29b_Quantity	integer			N
Line	30	Description	2400	SV301-7			F30_Description	string		80	N
Line	31	Fee	2400	SV302			F31_LineFee	string	1	18	Y
Line	31a	Other Fee	2400	AMT02 (T)	This segment is for line item sales tax. "Other Fee" otherwise not used.	Sales Tax Amount	F31a_OtherFee	string		18	N
Line	X12	Line Item Control Number	2400	REF02 (6R)	Must be unique		X12_LineControlNumber	string		50	N
Line	X12	Treating Dentist Last Name	2420A	NM103	2420A is the line level rendering provider loop		X12_LineTreatingDentistLastname	string		60	N
Line	X12	Treating Dentist First Name	2420A	NM104	2420A is the line level rendering provider loop		X12_LineTreatingDentistFirstname	string		35	N
Line	X12	Treating Dentist Middle Name	2420A	NM105	2420A is the line level rendering provider loop		X12_LineTreatingDentistMI	string		25	N
Line	X12	Treating Dentist Suffix	2420A	NM107	2420A is the line level rendering provider loop		X12_LineTreatingDentistSuffix	string		10	N
Line	X12	Treating Dentist NPI	2420A	NM109	2420A is the line level rendering provider loop		X12_LineTreatingDentistNPI	string	10	10	N
Line	X12	Treating Dentist Specialty Code	2420A	PRV03	2420A is the line level rendering provider loop		X12_LineTreatingDentistSpecialtyCode	string		50	N
Line	X12	Secondary Claim - Primary Paid Amount	2430	SVD02			X12_PrimaryPaidAmount	string		18	N
Line	X12	Secondary claim units	2430	SVD05	Paid units from primary EOB		X12_UnitsPaid	string		15	N
Line	X12	Secondary Claim - Adjudication Date	2430	DTP03 (573)			X12_AdjudicationDate	date YYYY-MM-DD			N
Line	X12	Place of service code					X12_PlaceOfServiceCode	string		2	N
Tooth	27	Tooth Number(s) or Letter(s)	2400	TOO02			F27_Tooth	string			N
Tooth	28	Tooth Surface(s)	2400	TOO03	03-1,03-2�03-5		F28_ToothSurface	array of strings			N
Adjustment	X12	Secondary Claims -Adjustment Group Code(s)	2430	CAS01	Each AGC will be matched to corresponding list item in that ARC and $ amount elements	Limit of 5	X12_AdjustmentGroupCode	string		2	N
Adjustment	X12	Secondary Claims -Adjustment Reason Code(s)	2430	CAS02	Each ARC will be matched to corresponding list item in that AGC and $ amount elements	Limit of 5	X12_AdjustmentReasonCode	string		5	N
Adjustment	X12	Secondary Claims -Adjustment Amount(s)	2430	CAS03	Each $ amount will be matched to corresponding list item in that ARC and AGC elements	Limit of 5	X12_AdjustmentAmount	string		18	N