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Admission Date/Hour 2300 DTP03 When DTP01=435

47, Utah



Name:Admission Date/Hour 2300 DTP03 When DTP01=435
Data Element ID:47
Description:Expression of a date, a time, or range of dates, times or dates and times INDUSTRY: Discharge Hour
State:Utah
Data Type:AN
Length:1/35
Notes:Required for inpatient claims only
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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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