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Facility Type Code (Type of Bill, Positions 1-3) 2300 CLM05-1

42, Utah



Name:Facility Type Code (Type of Bill, Positions 1-3) 2300 CLM05-1
Data Element ID:42
Description:Code identifying the type of facility where services were performed; the first through third positions of the Uniform Bill Type code or the Place of Service code from the Electronic Media Claims National Standard Format INDUSTRY: Facility Type Code
State:Utah
Data Type:AN
Length:1/3
Permissible Values: Facility Type Code (Type of Bill, Positions 1-3) 2300 CLM05-1 uses the following permissible values:
Code / Value Meaning
011X Hospital Inpatient (Part A)
012X Hospital Inpatient Part B
013X Hospital Outpatient
014X Hospital Other Part B
018X Hospital Swing Bed
021X SNF Inpatient
022X SNF Inpatient Part B
023X SNF Outpatient
028X SNF Swing Bed
032X Home Health
033X Home Health
034X Home Health (Part B Only)
041X Religious Nonmedical Health Care Institutions
071X Clinical Rural Health
072X Clinic ESRD
073X Federally Qualified Health Centers
074X Clinic OPT
075X Clinic CORF
076X Community Mental Health Centers
081X Nonhospital based hospice
082X Hospital based hospice
083X Hospital Outpatient (ASC) 085X Critical Access Hospital
085X Critical Access Hospital
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File Specification for Medical Claims File Submission 837I - August 12, 2009 - v1.3

Data Element ID Data Element Description Type Format Length
1 BHT01 Hierarchical Structure Code BHT06 Transaction Type Code O ID 2/2 Code specifying the type of transaction INDUSTRY: Claim or Encounter Identifier ALIAS: Claim or Encounter Indicator 1808 Use RP when the entire ST-SE envelope contains encounter transmissions. Use RP when the transmission is being sent to an entity (usually not a payer or a normal provider-payer transmission itermediary) for purposes other than adjudication of a claim. Such an entity could be a state health agency which is using the 837 for health data reporting purposes. ID 2/2
2 Functional Group Header GS08 Version / Release / Industry Identifier Code M AN 1/12 Code indicating the version, release, subrelease, and industry identifier of the EDI standard being used, including the GS and GE segments; if code in DE455 in GS segment is X, then in DE 480 positions 1-3 are the version number; positions 4-6 are the release and subrelease, level of the version; and positions 7-12 are the industry or trade association identifiers (optionally assigned by user); if code in DE455 in GS segment is T, then other formats are allowed AN 1/12
3 Functional Group Header GS01 Code identifying a group of application related transaction sets AN 2/2
4 Submitter Name 1000A NM103 Individual last name or organizational name INDUSTRY: Submitter Last or Organization Name ALIAS: Submitter Name AN 2/80
5 Submitter Identifier 1000A NM109 Code identifying a party or other code INDUSTRY: Submitter Identifier ALIAS: Submitter Primary Identification Number SYNTAX: P0809 AN 2/80
6 Submitter EDI Contact Information 1000A PER01- 05 Code identifying the major duty or responsibility of the person or group named AN 2/80
7 Receiver Name 1000B NM103 Name Last or Organization Name Individual last name or organizational name INDUSTRY: Receiver Name AN 2/80
8 Receiver Identifier 1000B NM109 Not Provided AN 2/80
9 Billing Provider Name 2010AA NM103 Individual last name or organizational name INDUSTRY: Billing Provider Last or Organizational Name ALIAS: Billing Provider Name AN 2/80
10 Billing Provider ID 2010AA NM109 Individual last name or organizational name INDUSTRY: Billing Provider Last or Organizational Name ALIAS: Billing Provider Name AN 2/80
11 Billing Provider Secondary Identification 2010AA REF02 Tax Identifiing information of the Provider that was paid AN 1/30
12 Individual Relationship Code 2000B SBR02 Code indicating the relationship between two individuals or entities ALIAS: Patients Relationship to Insured SEMANTIC: SBR02 specifies the relationship to the person insured. ID 2/2
13 Insured Group or Policy Number 2000B SBR03 Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier INDUSTRY: Insured Group or Policy Number ALIAS: Group Number SEMANTIC: SBR03 is policy or group number. AN 1/30
14 Payer Name 2010BC NM103 Individual last name or organizational name AN 1/30
15 Subscriber Lname 2010BA NM103 Individual last name or organizational name INDUSTRY: Subscriber Last Name AN 1/35
16 Subscriber Fname 2010BA NM104 Individual first name INDUSTRY: Subscriber First Name AN 1/25
17 Subscriber Middle Name 2010BA NM105 Individual middle name or initial INDUSTRY: Subscriber Middle Name ALIAS: Subscriber's Middle Initial AN 1/25
18 Subscriber Primary Identifier 2010BA NM109 Code identifying a party or other code INDUSTRY: Subscriber Primary Identifier SYNTAX: P0809 AN 2/80
19 Subscriber Address1 2010BA N301 Address information INDUSTRY: Subscriber Address Line AN 1/55
20 Subscriber Address2 2010BA N302 Address information INDUSTRY: Subscriber Address Line AN 1/55
21 Subscriber City Name 2010BA N401 Free-form text for city name INDUSTRY: Subscriber City Name COMMENT: A combination of either N401 through N404, or N405 and N406 may be adequate to specify a location. AN 2/30
22 Subscriber State 2010BA N402 Code (Standard State/Province) as defined by appropriate government agency INDUSTRY: Subscriber State Code COMMENT: N402 is required only if city name (N401) is in the U.S. or Canada. CODE SOURCE 22: States and Outlying Areas of the U.S. ID 2/2
23 Subscriber Zip Code 2010BA N403 Code defining international postal zone code excluding punctuation and blanks (zip code for United States) INDUSTRY: Subscriber Postal Zone or ZIP Code CODE SOURCE 51: ZIP Code ID 3/15
24 Subscriber Date of Birth 2010BA DMG02 Expression of a date, a time, or range of dates, times or dates and times INDUSTRY: Subscriber Birth Date ALIAS: Date of Birth - Patient SYNTAX: P0102 SEMANTIC: DMG02 is the date of birth. AN CCYYMMDD 1/35
25 Subscriber Gender 2010BA DMG03 Code indicating the sex of the individual INDUSTRY: Subscriber Gender Code ALIAS: Gender - Patient AN 1/1
26 Subscriber Secondary Identification Qualifier 2010BA REF01 Code qualifying the Reference Identification ID 2/3
27 Subscriber Secondary Identification 2010BA REF02 Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier INDUSTRY: Subscriber Supplemental Identifier SYNTAX: R0203 AN 1/30
28 Patients Relationship to Insured 2000C PAT01 Code indicating the relationship between two individuals or entities ALIAS: Patients Relationship to Insured ID 2/2
29 Patient Lname 2010CA NM103 Individual last name or organizational name INDUSTRY: Patient Last Name AN 1/35
30 Patient Fname 2010CA NM104 Name First O AN 1/25 Individual first name INDUSTRY: Patient First Name AN 1/25
31 Patient Middle Name 2010CA NM105 Individual middle name or initial INDUSTRY: Patient Middle Name AN 1/25
32 Patient Primary Identifier 2010CA NM109 Code identifying a party or other code INDUSTRY: Patient Primary Identifier SYNTAX: P0809 AN 2/80
33 Patient Address1 2010BA/2010CA N301 Address information INDUSTRY: Patient Address Line AN 1/55
34 Patient Address2 2010CA N302 Address information INDUSTRY: Patient Address Line AN 1/55
35 Patient City Name 2010CA N401 Free-form text for city name INDUSTRY: Patient City Name COMMENT: A combination of either N401 through N404, or N405 and N406 may be adequate to specify a location. AN 2/30
36 Patient State 2010CA N402 Code (Standard State/Province) as defined by appropriate government agency INDUSTRY: Patient State Code COMMENT: N402 is required only if city name (N401) is in the U.S. or Canada. CODE SOURCE 22: States and Outlying Areas of the U.S. ID 2/2
37 Patient Zip Code 2010CA N403 Code defining international postal zone code excluding punctuation and blanks (zip code for United States) INDUSTRY: Patient Postal Zone or ZIP Code CODE SOURCE 51: ZIP Code ID 3/15
38 Patient Date of Birth 2010CA DMG02 Expression of a date, a time, or range of dates, times or dates and times INDUSTRY: Patient Birth Date ALIAS: Patient's Date of Birth SYNTAX: P0102 SEMANTIC: DMG02 is the date of birth. AN 1/35
39 Patient Gender 2010CA DMG03 Code indicating the sex of the individual INDUSTRY: Patient Gender Code AN 1/1
40 Patient Secondary Identification Qualifier 2010CA REF01 Code qualifying the Reference Identification ID 2/3
41 Patient Secondary Identification 2010CA REF02 Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier INDUSTRY: Patient Secondary Identifier SYNTAX: R0203 AN 1/30
42 Facility Type Code (Type of Bill, Positions 1-3) 2300 CLM05-1 Code identifying the type of facility where services were performed; the first through third positions of the Uniform Bill Type code or the Place of Service code from the Electronic Media Claims National Standard Format INDUSTRY: Facility Type Code AN 1/3
45 Claim Frequency Type Code (Type of Bill, Position 4) 2300 CLM05-3 Code specifying the frequency of the claim; this is the third position of the Uniform Billing Claim Form Bill Type INDUSTRY: Claim Frequency Code CODE SOURCE 235: Claim Frequency Type Code ID 1/1
46 Original Reference Number 2300 REF02 When REF01=F8 Code qualifying the Reference Identification A/N 1/30
47 Admission Date/Hour 2300 DTP03 When DTP01=435 Expression of a date, a time, or range of dates, times or dates and times INDUSTRY: Discharge Hour AN 1/35
48 Institutional Claim Code 2300 CL101 Admission Type Code indicating the priority of this admission CODE SOURCE 231: Admission Type Code ID 1/1
49 Institutional Claim Code 2300 CL102 Admission Source Code indicating the source of this admission CODE SOURCE 230: Admission Source Code ID 1/1
50 Institutional Claim Code 2300 CL103 Patient Status Code Code indicating the source of this admission CODE SOURCE 230: Patient Status Code ID 1/2
51 Diagnosis Related Group (DRG) 2300 HI01-2 When HI01- 1=DR Code indicating a code from a specific industry code list AN 1/30
52 Statement Date 2300 DTP03 when DTP01=434 Expression of a date, a time, or range of dates, times or dates and times INDUSTRY: Discharge Date AN CCYYMMDD 1/35
54 Discharge Hour 2300 DTP03 When DTP01=096 Expression of a date, a time, or range of dates, times or dates and times INDUSTRY: Discharge Hour AN HHMM 1/25
55 Patient Account Number 2300 CLM01 Claim Submitter's Identifier Identifier used to track a claim from creation by the health care provider through payment INDUSTRY: Patient Account Number ALIAS: Patient Control Number AN 1/20
56 Medical Record Number 2300 REF02 When REF01=EA Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier INDUSTRY: Medical Record Number AN 1/30
57 Total Claim Charge Amount 2300 CLM02 Monetary amount INDUSTRY: Total Claim Charge Amount ALIAS: Total Claim Charges SEMANTIC: CLM02 is the total amount of all submitted charges of service segments for this claim. R 1/18
58 Patient Paid Amount 2300 AMT02 When AMT01=F5 Monetary amount INDUSTRY: Patient Amount Paid R 1/18
59 Payer Prior Payment 2320 AMT02 WHEN AMT01=C4 Monetary amount INDUSTRY: Other Payer Patient Paid Amount Prior Payments -Payers R 1/18
60 Service Facility Name 2310E NM103 Individual last name or organizational name INDUSTRY: Laboratory or Facility Name ALIAS: Laboratory/Facility Name AN 1/35
61 Service Facility ID Code 2310E NM109 Code identifying a party or other code INDUSTRY: Laboratory or Facility Primary Identifier ALIAS: Laboratory/Facility Primary Identifier SYNTAX: P0809 AN 2/80
62 Claim Adjudication Date 2330B DTP03 WHEN DTP01=573 Expression of a date, a time, or range of dates, times or dates and times INDUSTRY: Adjudication or Payment Date AN 1/35
63 Coordination of Benefits Total Allowed Amount 2320 AMT02 When AMT01=B6 Monetary amount INDUSTRY: Allowed Amount R 1/18
64 Claim Adjustment Group Code 2320 CAS01 Claim Adjustment Group Code Code identifying the general category of payment adjustment ID 1/2
65 Claim Adjustment Reason Code 2320 CAS02 Claim Adjustment reason Code Code identifying the detailed reason the adjustment was made INDUSTRY: Adjustment Reason Code ID 1/5
66 Claim Level Adjustment Amount 2320 CAS03 Monetary Amount Monetary amount INDUSTRY: Adjustment Amount SEMANTIC: CAS03 is the amount of adjustment. COMMENT: When the submitted charges are paid in full, the value for CAS03 should be zero. R 1/18
67 Laboratory or Facility Primary Identifier 2310E NM109 Code identifying a party or other code INDUSTRY: Laboratory or Facility Primary Identifier ALIAS: Laboratory/Facility Primary Identifier SYNTAX: P0809 AN 2/80
68 Principal, Admitting, E- Code and Patient Reason for Visit Diagnosis Information 2300 HI02-2 When HI02- 1=ZZ PAT Reason for Visit 1 Code indicating a code from a specific industry code list INDUSTRY: Patient's Reason for Visit AN 1/30
69 Principal, Admitting, E- Code and Patient Reason for Visit Diagnosis Information 2300 HI02-2 When HI02- 1=ZZ PAT Reason for Visit 2 Code indicating a code from a specific industry code list INDUSTRY: Patient's Reason for Visit AN 1/30
70 Principal, Admitting, E- Code and Patient Reason for Visit Diagnosis Information 2300 HI02-2 When HI02- 1=ZZ PAT Reason for Visit 3 Code indicating a code from a specific industry code list INDUSTRY: Patient's Reason for Visit AN 1/30
71 Principal, Admitting, E- Code and Patient Reason for Visit Diagnosis Information 2300 HI02-2 When HI02- 1=BJ Admitting DX Code indicating a code from a specific industry code list INDUSTRY: Admitting Diagnosis AN 1/30
72 Principal, Admitting, E- Code and Patient Reason for Visit Diagnosis Information 2300 HI01-2 When HI01- 1=BK Principal DX Code indicating a code from a specific industry code list INDUSTRY: Principal Diagnosis Code AN 99 1/30
73 Present on Admission Indicator 2300 K3 Data in fixed format agreed upon by sender and receiver AN 1/80
74 Other Diagnosis Information 2300 HI01-2 When HI01- 1=BF Code indicating a code from a specific industry code list INDUSTRY: Other Diagnosis AN 1/30
75 Other Diagnosis Information 2300 HI02-2 When HI02- 1=BF Code indicating a code from a specific industry code list INDUSTRY: Other Diagnosis AN 1/30
76 Other Diagnosis Information 2300 HI03-2 When HI03- 1=BF Code indicating a code from a specific industry code list INDUSTRY: Other Diagnosis AN 1/30
77 Other Diagnosis Information 2300 HI04-2 When HI04- 1=BF Code indicating a code from a specific industry code list INDUSTRY: Other Diagnosis AN 1/30
78 Other Diagnosis Information 2300 HI05-2 When HI05- 1=BF Code indicating a code from a specific industry code list INDUSTRY: Other Diagnosis AN 1/30
79 Other Diagnosis Information 2300 HI06-2 When HI06- 1=BF Code indicating a code from a specific industry code list INDUSTRY: Other Diagnosis AN 1/30
80 Other Diagnosis Information 2300 HI07-2 When HI07- 1=BF Code indicating a code from a specific industry code list INDUSTRY: Other Diagnosis AN 1/30
81 Other Diagnosis Information 2300 HI08-2 When HI08- 1=BF Code indicating a code from a specific industry code list INDUSTRY: Other Diagnosis AN 1/30
82 Other Diagnosis Information 2300 HI09-2 When HI09- 1=BF Code indicating a code from a specific industry code list INDUSTRY: Other Diagnosis AN 1/30
83 Other Diagnosis Information 2300 HI10-2 When HI10- 1=BF Code indicating a code from a specific industry code list INDUSTRY: Other Diagnosis AN 1/30
84 Other Diagnosis Information 2300 HI11-2 When HI11- 1=BF Code indicating a code from a specific industry code list INDUSTRY: Other Diagnosis AN 1/30
85 Other Diagnosis Information 2300 HI12-2 When HI12- 1=BF Code indicating a code from a specific industry code list INDUSTRY: Other Diagnosis AN 1/30
86 Principal, Admitting, E- Code and Patient Reason for Visit Diagnosis Information 2300 HI03-2 When HI03- 1=BN E-Code 1 Code indicating a code from a specific industry code list INDUSTRY: External Cause of Injury Code (E- code)] AN 1/30
87 Principal, Admitting, E- Code and Patient Reason for Visit Diagnosis Information 2300 HI03-2 When HI03- 1=BN E-Code 2 Code indicating a code from a specific industry code list INDUSTRY: External Cause of Injury Code (E- code)] AN 1/30
88 Principal, Admitting, E- Code and Patient Reason for Visit Diagnosis Information 2300 HI03-2 When HI03- 1=BN E-Code 3 Code indicating a code from a specific industry code list INDUSTRY: External Cause of Injury Code (E- code)] AN 1/30
89 Principal Procedure Code 2300 HI01-2 When HI01- 1=BR Principal Procedure Code indicating a code from a specific industry code list INDUSTRY: Primary Procedure AN 1/30
90 Principal Procedure Date 2300 HI01-4 When HI01- 1=BR Principal Procedure Date Date Time Period AN CCYYMMDD 1/35
91 Other Procedure Code 2300 HI01-2 When HI01- 1=BQ Code indicating a code from a specific industry code list INDUSTRY: Other Procedure AN 1/30
92 Other Procedure Date 2300 HI01-4 When HI01- 1=BQ Date Time Period AN CCYYMMDD 1/35
93 Other Procedure Code 2300 HI02-2 When HI02- 1=BQ Code indicating a code from a specific industry code list INDUSTRY: Other Procedure AN 1/30
94 Other Procedure Date 2300 HI02-4 When HI02- 1=BQ Date Time Period AN CCYYMMDD 1/35
95 Other Procedure Code 2300 HI03-2 When HI03- 1=BQ Code indicating a code from a specific industry code list INDUSTRY: Other Procedure AN 1/30
96 Other Procedure Date 2300 HI03-4 When HI03- 1=BQ Date Time Period AN CCYYMMDD 1/35
97 Other Procedure Code 2300 HI04-2 When HI04- 1=BQ Code indicating a code from a specific industry code list INDUSTRY: Other Procedure AN 1/30
98 Other Procedure Date 2300 HI04-4 When HI04- 1=BQ Date Time Period AN CCYYMMDD 1/35
99 Other Procedure Code 2300 HI05-2 When HI05- 1=BQ Code indicating a code from a specific industry code list INDUSTRY: Other Procedure AN 1/30
100 Other Procedure Date 2300 HI05-4 When HI05- 1=BQ Date Time Period AN CCYYMMDD 1/35
101 Attending Physician Specialty Information 2000A or 2310A PRV03 Reference Identification Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier INDUSTRY: Provider Taxonomy Code ALIAS: Provider Specialty Code Text 10
102 Attending Physician LName 2310A NM103 Individual last name or organizational name INDUSTRY: Attending Physician Last Name AN 1/35
103 Attending Physician FName 2310A NM104 Individual first name INDUSTRY: Attending Physician First Name AN 1/35
104 Attending Physician Name Middle 2310A NM105 Individual middle name or initial INDUSTRY: Attending Physician Middle Name AN 1/25
105 Attending Physician Name Suffix 2310A NM107 Suffix to individual name INDUSTRY: Attending Physician Name Suffix AN 1/10
106 Attending Physician Primary Identifier 2310A NM109 Code identifying a party or other code INDUSTRY: Attending Physician Primary Identifier SYNTAX: P0809 AN 2/80
107 Attending Physician Secondary Identification 2310A REF02 Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier INDUSTRY: Attending Physician Secondary Identifier SYNTAX: R0203 AN 1/30
108 Line Counter 2400 LX01 Number assigned for differentiation within a transaction set ALIAS: Line Counter This is the service line number. Begin with 1 and increment by 1 for each new LX segment within a claim. AN 1/48
109 Date(s) of Service 2400 DTP03 WHEN DTP01=472 Code specifying type of date or time, or both date and time INDUSTRY: Date Time Qualifier AN CCYYMMDD or range: CCYYMMDD-CCYYMMDD 1/35
110 Institutional Service Line Product/Service ID 2400 SV202-2 Identifying number for a product or service INDUSTRY: Procedure Code ALIAS: HCPCS Procedure Code AN 1/48
111 Institutional Service Line Procedure Modifier - 1 2400 SV202-3 This identifies special circumstances related to the performance of the service, as defined by trading partners ALIAS: HCPCS Modifier 1 AN 2/2
112 Institutional Service Line Procedure Modifier - 2 2400 SV202-4 This identifies special circumstances related to the performance of the service, as defined by trading partners ALIAS: HCPCS Modifier 2 AN 2/2
113 Institutional Service Line Procedure Modifier - 3 2400 SV202-5 This identifies special circumstances related to the performance of the service, as defined by trading partners ALIAS: HCPCS Modifier 3 AN 2/2
114 Institutional Service Line Procedure Modifier - 4 2400 SV202-6 This identifies special circumstances related to the performance of the service, as defined by trading partners ALIAS: HCPCS Modifier 4 AN 2/2
115 Institutional Service Line (Revenue Codes) 2400 SV201 Identifying number for a product or service INDUSTRY: Service Line Revenue Code SYNTAX: R0102 SEMANTIC: SV201 is the revenue code. AN 1/48
116 Service Units 2400 SV205 Numeric value of quantity INDUSTRY: Service Unit Count ALIAS: Service Line Units SYNTAX: P0405 R 1/15
117 Line Item Charge Amount 2400 SV203 Monetary amount INDUSTRY: Line Item Charge Amount ALIAS: Service Line Charge Amount SEMANTIC: SV203 is a submitted charge amount. R 1/18
119 Drug Identification 2410 LIN03 Code identifying the type/source of the descriptive number used in Product/Service ID (234) COMMENT: LIN02 through LIN31 provide for fifteen different product/service IDs for each item. For example: Case, Color, Drawing No., U.P.C. No., ISBN No., Model No., or SKU. AN 1/48
120 Prescription Number 2410 REF02 when REF01=XZ Code qualifying the Reference Identification ALIAS: Code Qualifier AN 1/30
121 Drug Units Qualifier 2410 CTP05-1 Code specifying the units in which a value is being expressed, or manner in which a measurement has been taken ALIAS: Code Qualifier R 1/15
122 Drug Number of Units 2410 CTP04 Numeric value of quantity ALIAS: National Drug Unit Count SYNTAX: P0405 R 1/15
123 Drug Cost or Unit Price 2410 CTP03 Price per unit of product, service, commodity, etc. ALIAS: Drug Unit Price SYNTAX: C1103 R 1/15
124 Line Adjustment Group Code 2430 CAS01 Claim Adjustment Group Code Code identifying the general category of payment adjustment ID 1/2
125 Line Level Adjustment Reason Code 2430 CAS02 Claim Adjustment reason Code Code identifying the detailed reason the adjustment was made INDUSTRY: Adjustment Reason Code ID 1/5
126 Line Level Adjustment Amount 2430 CAS03 Code identifying the general category of payment adjustment/Code identifying the detailed reason the adjustment was made INDUSTRY: Adjustment Reason Code CODE SOURCE 139: Claim Adjustment Reason Code/Monetary amount INDUSTRY: Adjustment Amount SEMANTIC: CAS03 is the amount of adjustment. COMMENT: When the submitted charges are paid in full, the value for CAS03 should be zero. R 1/18

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