6. Financial Management

6 . Financial Management

Chapter Chair:

Freida B. Hall CAP Gemini Ernst & Young U.S. LLC

Chapter Chair:

Michael van Campen TNT Global Systems

Chapter Chair

Chuck Meyer McKesson Information Solutions

Chapter Editor:

Gaby Jewell Cerner Corporation

6.1 CHAPTER 6 CONTENTS

6.2 PURPOSE

The Finance chapter describes patient accounting transactions. Other financial transactions may be added in the future. Financial transactions can be sent between applications either in batches or online. As defined in Chapter 2 on batch segments, multiple transactions may be grouped and sent through all file transfer media or programs when using the HL7 Encoding Rules.

This chapter defines the transactions that take place at the seventh level, that is, the abstract messages. The examples included in this chapter were constructed using the HL7 Encoding Rules.

6.3 PATIENT ACCOUNTING MESSAGE SET

The patient accounting message set provides for the entry and manipulation of information on billing accounts, charges, payments, adjustments, insurance, and other related patient billing and accounts receivable information.

This Standard includes all of the data defined in the National Uniform Billing Field Specifications. We have excluded state-specific coding and suggest that, where required, it be implemented in site-specific _Z_ segments. State-specific fields may be included in the Standard at a later time. In addition, no attempt has been made to define data that have traditionally been required for the financial responsibility (_proration_) of charges. This requirement is unique to a billing system and not a part of an interface.

We recognize that a wide variety of billing and accounts receivable systems exist today. Therefore, in an effort to accommodate the needs of the most comprehensive systems, we have defined an extensive set of transaction segments.

6.4 TRIGGER EVENTS AND MESSAGE DEFINITIONS

The triggering events that follow are served by Detail Financial Transaction (DFT), Add/Change Billing Account (BAR), and General Acknowledgment (ACK) messages.

Each trigger event is documented below, along with the applicable form of the message exchange. The notation used to describe the sequence, optionality, and repetition of segments is described in Chapter 2, _Format for Defining Abstract Messages._

6.4.1 BAR/ACK - Add Patient Account (Event P01)

Data are sent from some application (usually a Registration or an ADT system) for example, to the patient accounting or financial system to establish an account for a patient_s billing/accounts receivable record. Many of the segments associated with this event are optional. This optionality allows those systems needing these fields to set up transactions that fulfill their requirements and yet satisfy the HL7 requirements.

When an account_s start and end dates span a period greater than any particular visit, the P01 (add account) event should be used to transmit the opening of an account. The A01 (admit/visit notification) event can notify systems of the creation of an account as well as notify them of a patient_s arrival in the healthcare facility. In order to create a new account without notifying systems of a patient_s arrival, use the P01 trigger event.

From Standard Version 2.3 onward, the P01 event should only be used to add a new account that did not exist before, not to update an existing account. The new P05 (update account) event should be used to update an existing account. The new P06 (end account) event should be used to close an account. With the P01 event, EVN-2 - Recorded Date/Time should contain the account start date.

BAR^P01^BAR_P01	Add Billing Account	Chapter	DB Ref.
MSH	Message Header	2	DB
[ { SFT } ]	Software Segment	2	DB
EVN	Event Type	3	DB
PID	Patient Identification	3	DB
[ PD1 ]	Additional Demographics	3	DB
[ { ROL } ]	Role	15	DB
{	--- VISIT begin
[ PV1 ]	Patient Visit	3	DB
[ PV2 ]	Patient Visit - Additional Info	3	DB
[ { ROL } ]	Role	15	DB
[ { DB1 } ]	Disability Information	3	DB
[ { OBX } ]	Observation/Result	7	DB
[ { AL1 } ]	Allergy Information	3	DB
[ { DG1 } ]	Diagnosis	6	DB
[ DRG ]	Diagnosis Related Group	6	DB
[{	--- PROCEDURE begin
PR1	Procedures	6	DB
[ { ROL } ]	Role	15	DB
}]	--- PROCEDURE end
[ { GT1 } ]	Guarantor	6	DB
[ { NK1 } ]	Next of Kin/Associated Parties	3	DB
[{	--- INSURANCE begin
IN1	Insurance	6	DB
[ IN2 ]	Insurance - Additional Info.	6	DB
[ { IN3 } ]	Insurance - Add'l Info. - Cert.	6	DB
[ { ROL } ]	Role	15	DB
}]	--- INSURANCE end
[ ACC ]	Accident Information	6	DB
[ UB1 ]	Universal Bill Information	6	DB
[ UB2 ]	Universal Bill 92 Information	6	DB
}	--- VISIT end

ACK^P01^ACK General Acknowledgment Status Chapter DB Ref.

MSH Message Header
2 DB

[ { SFT } ] Software Segment
2 DB

MSA Message Acknowledgment
2 DB

[ { ERR } ] Error
2 DB

The error segment will indicate the fields that caused a transaction to be rejected.

6.4.2 BAR/ACK - Purge Patient Accounts (Event P02)

Generally, the elimination of all billing/accounts receivable records will be an internal function controlled, for example, by the patient accounting or financial system. However, on occasion, there will be a need to correct an account, or a series of accounts, that may require that a notice of account deletion be sent from another sub-system and processed, for example, by the patient accounting or financial system. Although a series of accounts may be purged within this one event, we recommend that only one PID segment be sent per event.

BAR^P02^BAR_P02	Purge Billing Account	Chapter	DB Ref.
MSH	Message Header	2	DB
[ { SFT } ]	Software Segment	2	DB
EVN	Event Type	3	DB
{	--- PATIENT begin
PID	Patient Identification	3	DB
[ PD1 ]	Additional Demographics	3	DB
[ PV1 ]	Patient Visit	3	DB
[ { DB1 } ]	Disability Information	3	DB
}	--- PATIENT end

ACK^P02^ACK General Acknowledgment Status Chapter DB Ref.

MSH Message Header
2 DB

[ { SFT } ] Software Segment
2 DB

MSA Message Acknowledgment
2 DB

[ { ERR } ] Error
2 DB

The error segment indicates the fields that caused a transaction to be rejected.

6.4.3 DFT/ACK - Post Detail Financial Transactions (Event P03)

The Detail Financial Transaction (DFT) message is used to describe a financial transaction transmitted between systems, that is, to the billing system for ancillary charges, ADT to billing system for patient deposits, etc.

Use case for Post Detail Financial Transaction with related Order:

This information can originate in many ways. For instance, a detailed financial transaction for an ancillary charge is sent to a billing system that also tracks the transaction(s) in relation to their order via placer order number or wishes to post these transactions with the additional order information. Therefore a service reaches a state where a detailed financial transaction is created and interfaced to other systems along with optional associated order information. If the message contains multiple transactions for the same order such as a test service and venipuncture charge on the same order the ordering information is entered in the Order segment construct that precedes the FT1 segments. If a message contains multiple transactions for disparate orders for the same account each FT1 segment construct may contain the order related information specific to that transaction within the message.

If the common order information is sent, the Order Control Code should reflect the current state of the common order and is not intended to initiate any order related triggers on the receiving application. For example if observations are included along with common order information the order control code would indicate _RE_ as observations to follow.
If common order information is sent related to the entire message or a specific financial transaction, the required Order Control Code should reflect the current state of the common order and is not intended to initiate any order related triggers on the receiving application. For example if observations are included along with common order information the order control code would indicate _RE_ as observations to follow.
If order detail information is sent related to the entire message or a specific financial transaction, the required fields for that detail segment must accompany that information.

DFT^P03^DFT_P03	Detail Financial Transaction	Chapter	DB Ref.
MSH	Message Header	2	DB
[ { SFT } ]	Software Segment	2	DB
EVN	Event Type	3	DB
PID	Patient Identification	3	DB
[ PD1 ]	Additional Demographics	3	DB
[ { ROL } ]	Role	15	DB
[ PV1 ]	Patient Visit	3	DB
[ PV2 ]	Patient Visit - Additional Info	3	DB
[ { ROL } ]	Role	15	DB
[ { DB1 } ]	Disability Information	3	DB
[{	--- COMMON_ORDER begin
[ ORC ]	Common Order (across all FT1s)	4	DB
[{	--- TIMING_QUANTITY begin
TQ1	Timing/Quantity	4	DB
[ { TQ2 } ]	Timing/Quantity Order Sequence	4	DB
}]	--- TIMING_QUANTITY end
[	--- ORDER begin
OBR	Order Detail Segment	4	DB
[ { NTE } ] ]	Notes and Comments (on Order Detail)	2	DB
]	--- ORDER end
[{	--- OBSERVATION begin
OBX	Observations / Result	7	DB
[ { NTE } ]	Notes and Comments (on Result)	2	DB
}]	--- OBSERVATION end
}]	--- COMMON_ORDER end
{	--- FINANCIAL begin
FT1	Financial Transaction	6	DB
[ NTE ]	Notes and Comments (on line item - FT1 - above)	2	DB
[{	--- FINANCIAL_PROCEDURE begin
PR1	Procedure	6	DB
[ { ROL } ]	Role	15	DB
}]	--- FINANCIAL_PROCEDURE end
[{	--- FINANCIAL_COMMON ORDER begin
[ ORC ]	Common Order (specific to above FT1)	4	DB
[{	--- FINANCIAL_TIMING QUANTITY begin
TQ1	Timing/Quantity	4	DB
[ { TQ2 } ]	Timing/Quantity Order Sequence	4	DB
}]	--- FINANCIAL_TIMING_QUANTITY end
[	--- FINANCIAL_ORDER begin
OBR	Order Detail Segment	4	DB
[ { NTE } ]	Notes and Comments (on Order Detail)	2	DB
]	--- FINANCIAL_ORDER end
[{	--- FINANCIAL_OBSERVATION begin
OBX	Observations / Result	7	DB
[ { NTE } ]	Notes and Comments (on Result)	2	DB
}]	--- FINANCIAL_OBSERVATION end
}]	--- FINANCIAL_COMMON ORDER end
}	--- FINANCIAL end
[ { DG1 } ]	Diagnosis (global across all FT1s)	6	DB
[ DRG ]	Diagnosis Related Group	6	DB
[ { GT1 } ]	Guarantor (global across all FT1s)	6	DB
[{	--- INSURANCE begin
IN1	Insurance (global across all FT1s)	6	DB
[ IN2 ]	Insurance - Additional Info.	6	DB
[ { IN3 } ]	Insurance - Add_l Info. - Cert.	6	DB
[ { ROL } ]	Role	15	DB
}]	--- INSURANCE end
[ ACC ]	Accident Information	6	DB

Note: The ROL segment is optionally included after the PD1 to transmit information for patient level primary care providers, after the PV2 for additional information on the physicians whose information is sent there (i.e. Attending Doctor, Referring Doctor, Consulting Doctor), and within the insurance construct to transmit information for insurance level primary care providers.

Note: There is an information overlap between the FT1, DG1 and PR1 segments. If diagnosis information is sent in an FT1 segment, it should be consistent with the information contained in any DG1 segments present within its hierarchy. Since the procedure code field within the FT1 does not repeat, if procedure information is sent on an FT1 it is recommended that the single occurrence of the code in FT1 equates to the primary procedure (PR1-14 - Procedure Priority code value 1).

Note: The extra set of DG1/DRG/GT1/IN1/IN2/IN3/ROL segments added in V2.4 has been withdrawn as a technical correction

ACK^P03^ACK	General Acknowledgment	Chapter	DB Ref.
MSH	Message Header	2	DB
[ { SFT } ]	Software Segment	2	DB
MSA	Message Acknowledgment	2	DB
[ { ERR } ]	Error	2	DB

The error segment indicates the fields that caused a transaction to be rejected.

6.4.4 QRY/DSR - Generate Bills And Accounts Receivable Statements (Event P04)

For patient accounting systems that support demand billing, the QRY/DSR transaction, as defined in Chapter 2, will provide the mechanism with which to request a copy of the bill for printing or viewing by the requesting system.

Note: This is a display-oriented response. The associated messages are defined in Chapter 5.

6.4.5 BAR/ACK - Update Account (Event P05)

The P05 event is sent when an existing account is being updated. From Standard Version 2.3 onward, the P01 (add account) event should no longer be used for updating an existing account, but only for creating a new account. With the addition of P10 (transmit ambulatory payment classification [APC] groups) in Version 2.4, it is expected that the P05 (update account) will be used to send inpatient coding information and the P10 (transmit ambulatory payment classification [APC] groups) will be used to send outpatient coding information.

BAR^P05^BAR_P05	Update Billing Account	Chapter	DB Ref.
MSH	Message Header	2	DB
[ { SFT } ]	Software Segment	2	DB
EVN	Event Type	3	DB
PID	Patient Identification	3	DB
[ PD1 ]	Additional Demographics	3	DB
[ { ROL } ]	Role	15	DB
{	--- VISIT begin
[ PV1 ]	Patient Visit	3	DB
[ PV2 ]	Patient Visit - Additional Info	3	DB
[ { ROL } ]	Role	15	DB
[ { DB1 } ]	Disability Information	3	DB
[ { OBX } ]	Observation/Result	7	DB
[ { AL1 } ]	Allergy Information	3	DB
[ { DG1 } ]	Diagnosis	6	DB
[ DRG ]	Diagnosis Related Group	6	DB
[{	--- PROCEDURE begin
PR1	Procedures	6	DB
[ { ROL } ]	Role	15	DB
}]	--- PROCEDURE end
[ { GT1 } ]	Guarantor	6	DB
[ { NK1 } ]	Next of Kin/Associated Parties	3	DB
[{	--- INSURANCE begin
IN1	Insurance	6	DB
[ IN2 ]	Insurance - Additional Info.	6	DB
[ { IN3 } ]	Insurance - Add'l Info. - Cert.	6	DB
[ { ROL } ]	Role	15	DB
}]	--- INSURANCE end
[ ACC ]	Accident Information	6	DB
[ UB1 ]	Universal Bill Information	6	DB
[ UB2 ]	Universal Bill 92 Information	6	DB
[ ABS ]	Abstract	6	DB
[ { BLC } ]	Blood Code	6	DB
[ RMI ]	Risk Management Incident	6	DB
}	--- VISIT end

ACK^P05^ACK General Acknowledgment Status Chapter DB Ref.

MSH Message Header
2 DB

[ { SFT } ] Software Segment
2 DB

MSA Message Acknowledgment
2 DB

[ { ERR } ] Error
2 DB

The error segment indicates the fields that caused a transaction to be rejected.

6.4.6 BAR/ACK - End Account (event P06)

The P06 event is a notification that the account is no longer open, that is, no new charges can accrue to this account. This notification is not related to whether or not the account is paid in full. EVN-2 - Recorded Date/Time must contain the account end date.

BAR^P06^BAR_P06	End Billing Account	Chapter	DB Ref.
MSH	Message Header	2	DB
[ { SFT } ]	Software Segment	2	DB
EVN	Event Type	3	DB
{	--- PATIENT begin
PID	Patient Identification	3	DB
[ PV1 ]	Patient Visit	3	DB
}	--- PATIENT end

ACK^P06^ACK General Acknowledgment Status Chapter DB Ref.

MSH Message Header
2 DB

[ { SFT } ] Software Segment
2 DB

MSA Message Acknowledgment
2 DB

[ { ERR } ] Error
2 DB

The error segment indicates the fields that caused a transaction to be rejected.

Note: P07-P09 have been defined by the Orders/Observations Technical Committee as product experience messages. Refer to Chapter 7.

6.4.7 BAR/ACK - Transmit Ambulatory Payment Classification (APC) Groups (Event P10)

The P10 event is used to communicate Ambulatory Payment Classification (APC) grouping. The grouping can be estimated or actual, based on the APC status indictor in GP1-1. This information is mandated in the USA by the Centers for Medicare and Medicaid Services (CMS) for reimbursement of outpatient services. The PID and PV1 segments are included for identification purposes only. When other patient or visit related fields change, use the A08 (update patient information) event.

BAR^P10^BAR_P10	Transmit Ambulatory Payment Classification (APC) groups	Chapter	DB Ref.
MSH	Message Header	2	DB
[ { SFT } ]	Software Segment	2	DB
EVN	Event Type	3	DB
PID	Patient Identification	3	DB
PV1	Patient Visit	3	DB
[ { DG1 } ]	Diagnosis	6	DB
GP1	Grouping/Reimbursement - Visit	6	DB
[{	--- PROCEDURE begin
PR1	Procedures	6	DB
[ GP2 ]	Grouping/reimbursement - Procedure	6	DB
}]	--- PROCEDURE end

ACK^P10^ACK General Acknowledgment Status Chapter DB Ref.

MSH Message Header
2 DB

[ { SFT } ] Software Segment
2 DB

MSA Message Acknowledgment
2 DB

[ { ERR } ] Error
2 DB

The error segment indicates the fields that caused a transaction to be rejected.

6.4.8 DFT/ACK - Post Detail Financial Transactions - Expanded (Event P11)

The Detail Financial Transaction (DFT) - Expanded message is used to describe a financial transaction transmitted between systems, that is, to the billing system for ancillary charges, ADT to billing system for patient deposits, etc. It serves the same function as the Post Detail Financial Transactions (event P03) message, but also supports the use cases described below.

Use case for adding the INx and GT1 segments inside the FT1 repetition:

If the insurance and/or the guarantor information is specific to a certain financial transaction of a patient and differs from the patient's regular insurance and/or guarantor, you may use the INx and GT1 segments related to the FT1 segment. If being used, the information supersedes the information on the patient level.

Example: Before being employed by a company, a pre-employment physical is required. The cost of the examinations is paid by the company, and not by the person_s private health insurance. One of the physicians examining the person is an eye doctor. For efficiency reasons, the person made an appointment for these examinations on the same day as he already had an appointment with his eye doctor in the same hospital. The costs for this eye doctor appointment are being paid by the patient's private health insurance. Both financial transactions for the same patient/person could be sent in the same message. To bill the examination for the future-employer to that organization, you need to use the GT1 segment that is related to the FT1.

DFT^P11^DFT_P11	Detail Financial Transaction - Expanded	Chapter	DB Ref.
MSH	Message Header	2	DB
[ { SFT } ]	Software Segment	2	DB
EVN	Event Type	3	DB
PID	Patient Identification	3	DB
[ PD1 ]	Additional Demographics	3	DB
[ { ROL } ]	Role	15	DB
[ PV1 ]	Patient Visit	3	DB
[ PV2 ]	Patient Visit - Additional Info	3	DB
[ { ROL } ]	Role	15	DB
[ { DB1 } ]	Disability Information	3	DB
[{	--- COMMON_ORDER begin
[ ORC ]	Common Order (global across all FT1s)	4	DB
[{	--- TIMING_QUANTITY begin
TQ1	Timing/Quantity	4	DB
[ { TQ2 } ]	Timing/Quantity Order Sequence	4	DB
}]	--- TIMING_QUANTITY end
[	--- ORDER begin
OBR	Order Detail Segment	4	DB
[ { NTE } ]	Notes and Comments (on Order Detail)	2	DB
]	--- ORDER end
[{	--- OBSERVATION begin
OBX	Observations / Result	7	DB
[ { NTE } ]	Notes and Comments (on Result)	2	DB
}]	--- OBSERVATION end
}]	--- COMMON_ORDER end
[ { DG1 } ]	Diagnosis (global across all FT1s)	6	DB
[ DRG ]	Diagnosis Related Group (global across all FT1s)	6	DB
[ { GT1 } ]	Guarantor (global across all FT1s)	6	DB
[{	--- INSURANCE begin
IN1	Insurance (global across all FT1s)	6	DB
[ IN2 ]	Insurance - Additional Info.	6	DB
[ { IN3 } ]	Insurance - Add_l Info. - Cert.	6	DB
[ { ROL } ]	Role	15	DB
}]	--- INSURANCE end
[ ACC ]	Accident Information	6	DB
{	--- FINANCIAL begin
FT1	Financial Transaction	6	DB
[{	--- FINANCIAL_PROCEDURE begin
PR1	Procedure	6	DB
[ { ROL } ]	Role	15	DB
}]	--- FINANCIAL_PROCEDURE end
[{	--- FINANCIAL_COMMON ORDER begin
[ ORC ]	Common Order (specific to above FT1)	4	DB
[{	--- FINANCIAL_TIMING QUANTITY begin
TQ1	Timing/Quantity	4	DB
[ { TQ2 } ]	Timing/Quantity Order Sequence	4	DB
}]	--- FINANCIAL_TIMING QUANTITY end
[	--- FINANCIAL_ORDER begin
OBR	Order Detail Segment	4	DB
[ { NTE } ]	Notes and Comments (on Order Detail)	2	DB
]	--- FINANCIAL_ORDER end
[{	--- FINANCIAL_OBSERVATION begin
OBX	Observations / Result	7	DB
[ { NTE } ]	Notes and Comments (on Result)	2	DB
}]	--- FINANCIAL_OBSERVATION end
}]	--- FINANCIAL_COMMON ORDER end
[ { DG1 } ]	Diagnosis (specific to above FT1)	6	DB
[ DRG ]	Diagnosis Related Group (specific to above FT1)	6	DB
[ { GT1 } ]	Guarantor (specific to above FT1)	6	DB
[{	--- FINANCIAL_INSURANCE begin
IN1	Insurance (specific to above FT1)	6	DB
[ IN2 ]	Insurance - Additional Info.	6	DB
[ { IN3 } ]	Insurance - Add_l Info. - Cert.	6	DB
[ { ROL } ]	Role	15	DB
}]	--- FINANCIAL_INSURANCE end
}	--- FINANCIAL end

ACK^P11^ACK	General Acknowledgment	Chapter	DB Ref.
MSH	Message Header	2	DB
[ { SFT } ]	Software Segment	2	DB
MSA	Message Acknowledgment	2	DB
[ { ERR } ]	Error	2	DB

The error segment indicates the fields that caused a transaction to be rejected.

6.4.9 BAR/ACK - Update Diagnosis/Procedure (Event P12)

The P12 event is used to communicate diagnosis and/or procedures in update mode. The newly created fields in DG1 and PR1, i.e. identifiers and action codes, must be populated to indicate which change should be applied. When other patient or visit related fields change, use the A08 (update patient information) event.

BAR^P12^BAR_P12	Update Diagnosis/Procedures	Chapter	DB Ref.
MSH	Message Header	2	DB
[ { SFT } ]	Software Segment	2	DB
EVN	Event Type	3	DB
PID	Patient Identification	3	DB
PV1	Patient Visit	3	DB
[ { DG1 } ]	Diagnosis	6	DB
[ DRG ]	Diagnosis Related Group	6	DB
[{	--- PROCEDURE begin

PR1

Procedures		6
[ { ROL } ]	Role		15	DB
}]	--- PROCEDURE end

ACK^P12^ACK General Acknowledgment Status Chapter DB Ref.

MSH Message Header
2 DB

[ { SFT } ] Software Segment
2 DB

MSA Message Acknowledgment
2 DB

[ { ERR } ] Error
2 DB

The error segment indicates the fields that caused a transaction to be rejected.

6.5 MESSAGE SEGMENTS

6.5.1 FT1 - Financial Transaction Segment

The FT1 segment contains the detail data necessary to post charges, payments, adjustments, etc. to patient accounting records.

HL7 Attribute Table - FT1 - Financial Transaction

SEQ	LEN	DT	OPT	RP/#	TBL#	ITEM#	ELEMENT NAME	DB Ref.
1	4	SI	O			00355	Set ID - FT1	DB
2	12	ST	O			00356	Transaction ID	DB
3	10	ST	O			00357	Transaction Batch ID	DB
4	53	DR	R			00358	Transaction Date	DB
5	26	TS	O			00359	Transaction Posting Date	DB
6	8	IS	R		0017	00360	Transaction Type	DB
7	250	CE	R		0132	00361	Transaction Code	DB
8	40	ST	B			00362	Transaction Description	DB
9	40	ST	B			00363	Transaction Description - Alt	DB
10	6	NM	O			00364	Transaction Quantity	DB
11	12	CP	O			00365	Transaction Amount - Extended	DB
12	12	CP	O			00366	Transaction Amount - Unit	DB
13	250	CE	O		0049	00367	Department Code	DB
14	250	CE	O		0072	00368	Insurance Plan ID	DB
15	12	CP	O			00369	Insurance Amount	DB
16	80	PL	O			00133	Assigned Patient Location	DB
17	1	IS	O		0024	00370	Fee Schedule	DB
18	2	IS	O		0018	00148	Patient Type	DB
19	250	CE	O	Y	0051	00371	Diagnosis Code - FT1	DB
20	250	XCN	O	Y	0084	00372	Performed By Code	DB
21	250	XCN	O	Y		00373	Ordered By Code	DB
22	12	CP	O			00374	Unit Cost	DB
23	427	EI	O			00217	Filler Order Number	DB
24	250	XCN	O	Y		00765	Entered By Code	DB
25	250	CE	O		0088	00393	Procedure Code	DB
26	250	CE	O	Y	0340	01316	Procedure Code Modifier	DB
27	250	CE	O		0339	01310	Advanced Beneficiary Notice Code	DB
28	250	CWE	O		0476	01646	Medically Necessary Duplicate Procedure Reason.	DB
29	250	CNE	O		0549	01845	NDC Code	DB
30	250	CX	O			01846	Payment Reference ID	DB
31	4	SI	O	Y		01847	Transaction Reference Key	DB

6.5.1.0 FT1 Field Definitions

6.5.1.1 FT1-1 Set ID - FT1 (SI) 00355

Definition: This field contains the number that identifies this transaction. For the first occurrence of the segment the sequence number shall be 1, for the second occurrence it shall be 2, etc.

6.5.1.2 FT1-2 Transaction ID (ST) 00356

Definition: This field contains a number assigned by the sending system for control purposes. The number can be returned by the receiving system to identify errors.

6.5.1.3 FT1-3 Transaction Batch ID (ST) 00357

Definition: This field uniquely identifies the batch in which this transaction belongs.

6.5.1.4 FT1-4 Transaction Date (DR) 00358

Components: <Range Start Date/Time (TS)> ^ <Range End Date/Time (TS)>

Subcomponents for Range Start Date/Time (TS): <Time (DTM)> & <DEPRECATED-Degree of Precision (ID)>

Subcomponents for Range End Date/Time (TS): <Time (DTM)> & <DEPRECATED-Degree of Precision (ID)>

Definition: This field contains the date/time or date/time range of the transaction. For example, this field would be used to identify the date a procedure, item, or test was conducted or used. It may be defaulted to today_s date. To specify a single point in time, only the first component is valued. When the second component is valued, the field specifies a time interval during which the transaction took place.

6.5.1.5 FT1-5 Transaction Posting Date (TS) 00359

Components: <Time (DTM)> ^ <DEPRECATED-Degree of Precision (ID)>

Definition: This field contains the date of the transaction that was sent to the financial system for posting.

6.5.1.6 FT1-6 Transaction Type (IS) 00360

Definition: This field contains the code that identifies the type of transaction. Refer to User-defined Table 0017 - Transaction Type for suggested values.

User-defined Table 0017 - Transaction Type

Values	Description	Comment
CG	Charge
CD	Credit
PY	Payment
AJ	Adjustment
CO	Co-payment

6.5.1.7 FT1-7 Transaction Code (CE) 00361

Components: <Identifier (ST)> ^ <Text (ST)> ^ <Name of Coding System (ID)> ^ <Alternate Identifier (ST)> ^ <Alternate Text (ST)> ^ <Name of Alternate Coding System (ID)>

Definition: This field contains the code assigned by the institution for the purpose of uniquely identifying the transaction based on the Transaction Type (FT1-6). For example, this field would be used to uniquely identify a procedure, supply item, or test for charges; or to identify the payment medium for payments. Refer to User-defined Table 0132 - Transaction Code for suggested values. See Chapter 7 for a discussion of the universal service ID for charges.

User-defined Table 0132 - Transaction Code

Value	Description	Comment
	No suggested values defined

6.5.1.8 FT1-8 Transaction Description (ST) 00362

Definition: This field has been retained for backward compatibility only. As of Version 2.3, FT1-7 - Transaction Code contains a component for the transaction description. When used for backward compatibility, FT1-8 - Transaction Description contains a description of the transaction associated with the code entered in FT1-7 - Transaction Code.

6.5.1.9 FT1-9 Transaction Description - Alt (ST) 00363

Definition: This field has been retained for backward compatibility only. As of Version 2.3, FT1-7 - Transaction Code contains a component for the alternate transaction description. When used for backward compatibility, FT1-9 - Transaction Description - Alt contains an alternate description of the transaction associated with the code entered in FT1-7 - Transaction Code.

6.5.1.10 FT1-10 Transaction Quantity (NM) 00364

Definition: This field contains the quantity of items associated with this transaction.

6.5.1.11 FT1-11 Transaction Amount - Extended (CP) 00365

Components: <Price (MO)> ^ <Price Type (ID)> ^ <From Value (NM)> ^ <To Value (NM)> ^ <Range Units (CE)> ^ <Range Type (ID)>

Subcomponents for Price (MO): <Quantity (NM)> & <Denomination (ID)>

Subcomponents for Range Units (CE): <Identifier (ST)> & <Text (ST)> & <Name of Coding System (ID)> & <Alternate Identifier (ST)> & <Alternate Text (ST)> & <Name of Alternate Coding System (ID)>

Definition: This field contains the amount of a transaction. It may be left blank if the transaction is automatically priced. Total price for multiple items.

6.5.1.12 FT1-12 Transaction Amount - Unit (CP) 00366

Definition: This field contains the unit price of a transaction. Price of a single item.

6.5.1.13 FT1-13 Department Code (CE) 00367

Components: <Identifier (ST)> ^ <Text (ST)> ^ <Name of Coding System (ID)> ^ <Alternate Identifier (ST)> ^ <Alternate Text (ST)> ^ <Name of Alternate Coding System (ID)>

Definition: This field contains the department code that controls the transaction code described above. Refer to User-defined Table 0049 - Department Code for suggested values.

User-defined Table 0049 - Department Code

Value	Description	Comment
	No suggested values defined

6.5.1.14 FT1-14 Insurance Plan ID (CE) 00368

Components: <Identifier (ST)> ^ <Text (ST)> ^ <Name of Coding System (ID)> ^ <Alternate Identifier (ST)> ^ <Alternate Text (ST)> ^ <Name of Alternate Coding System (ID)>

Definition: This field contains the identifier of the primary insurance plan with which this transaction should be associated. Refer to User-defined Table 0072 - Insurance Plan ID for suggested values.

User-defined Table 0072 - Insurance Plan ID

Value	Description	Comment
	No suggested values defined

6.5.1.15 FT1-15 Insurance Amount (CP) 00369

Definition: This field contains the amount to be posted to the insurance plan referenced above.

6.5.1.16 FT1-16 Assigned Patient Location (PL) 00133

Components: <Point of Care (IS)> ^ <Room (IS)> ^ <Bed (IS)> ^ <Facility (HD)> ^ <Location Status (IS)> ^ <Person Location Type (IS)> ^ <Building (IS)> ^ <Floor (IS)> ^ <Location Description (ST)> ^ <Comprehensive Location Identifier (EI)> ^ <Assigning Authority for Location (HD)>

Subcomponents for Facility (HD): <Namespace ID (IS)> & <Universal ID (ST)> & <Universal ID Type (ID)>

Subcomponents for Comprehensive Location Identifier (EI): <Entity Identifier (ST)> & <Namespace ID (IS)> & <Universal ID (ST)> & <Universal ID Type (ID)>

Subcomponents for Assigning Authority for Location (HD): <Namespace ID (IS)> & <Universal ID (ST)> & <Universal ID Type (ID)>

Definition: This field contains the current patient location. This can be the location of the patient when the charge item was ordered or when the charged service was rendered. For the current assigned patient location, use PV1-3 - Assigned Patient Location.

6.5.1.17 FT1-17 Fee Schedule (IS) 00370

Definition: This field contains the code used to select the appropriate fee schedule to be used for this transaction posting. Refer to User-defined Table 0024 - Fee Schedule for suggested values.

User-defined Table 0024 - Fee Schedule

Value	Description	Comment
	No suggested values defined

6.5.1.18 FT1-18 Patient Type (IS) 00148

Definition: This field contains the type code assigned to the patient for this episode of care (visit or stay). Refer to User-defined Table 0018 - Patient Type in Chapter 3 for suggested values. This is for use when the patient type for billing purposes is different than the visit patient type in PV1-18 - Patient Type.

6.5.1.19 FT1-19 Diagnosis Code - FT1 (CE) 00371

Components: <Identifier (ST)> ^ <Text (ST)> ^ <Name of Coding System (ID)> ^ <Alternate Identifier (ST)> ^ <Alternate Text (ST)> ^ <Name of Alternate Coding System (ID)>

Definition: This field contains the primary diagnosis code for billing purposes. ICD9-CM is assumed for all diagnosis codes. This is the most current diagnosis code that has been assigned to the patient. ICD10 can also be used. The name of coding system (third component) indicates which coding system is used. Refer to User-defined Table 0051 - Diagnosis Code for suggested values.

User-defined Table 0051 - Diagnosis Code

Value	Description	Comment
	No suggested values defined

6.5.1.20 FT1-20 Performed by Code (XCN) 00372

Components: <ID Number (ST)> ^ <Family Name (FN)> ^ <Given Name (ST)> ^ <Second and Further Given Names or Initials Thereof (ST)> ^ <Suffix (e.g., JR or III) (ST)> ^ <Prefix (e.g., DR) (ST)> ^ <DEPRECATED-Degree (e.g., MD) (IS)> ^ <Source Table (IS)> ^ <Assigning Authority (HD)> ^ <Name Type Code (ID)> ^ <Identifier Check Digit (ST)> ^ <Check Digit Scheme (ID)> ^ <Identifier Type Code (ID)> ^ <Assigning Facility (HD)> ^ <Name Representation Code (ID)> ^ <Name Context (CE)> ^ <DEPRECATED-Name Validity Range (DR)> ^ <Name Assembly Order (ID)> ^ <Effective Date (TS)> ^ <Expiration Date (TS)> ^ <Professional Suffix (ST)> ^ <Assigning Jurisdiction (CWE)> ^ <Assigning Agency or Department (CWE)>

Subcomponents for Family Name (FN): <Surname (ST)> & <Own Surname Prefix (ST)> & <Own Surname (ST)> & <Surname Prefix From Partner/Spouse (ST)> & <Surname From Partner/Spouse (ST)>

Subcomponents for Assigning Authority (HD): <Namespace ID (IS)> & <Universal ID (ST)> & <Universal ID Type (ID)>

Subcomponents for Assigning Facility (HD): <Namespace ID (IS)> & <Universal ID (ST)> & <Universal ID Type (ID)>

Subcomponents for Name Context (CE): <Identifier (ST)> & <Text (ST)> & <Name of Coding System (ID)> & <Alternate Identifier (ST)> & <Alternate Text (ST)> & <Name of Alternate Coding System (ID)>

Subcomponents for DEPRECATED-Name Validity Range (DR): <Range Start Date/Time (TS)> & <Range End Date/Time (TS)>

Note subcomponent contains sub-subcomponents

Subcomponents for Effective Date (TS): <Time (DTM)> & <DEPRECATED-Degree of Precision (ID)>

Subcomponents for Expiration Date (TS): <Time (DTM)> & <DEPRECATED-Degree of Precision (ID)>

Subcomponents for Assigning Jurisdiction (CWE): <Identifier (ST)> & <Text (ST)> & <Name of Coding System (ID)> & <Alternate Identifier (ST)> & <Alternate Text (ST)> & <Name of Alternate Coding System (ID)> & <Coding System Version ID (ST)> & <Alternate Coding System Version ID (ST)> & <Original Text (ST)>

Subcomponents for Assigning Agency or Department (CWE): <Identifier (ST)> & <Text (ST)> & <Name of Coding System (ID)> & <Alternate Identifier (ST)> & <Alternate Text (ST)> & <Name of Alternate Coding System (ID)> & <Coding System Version ID (ST)> & <Alternate Coding System Version ID (ST)> & <Original Text (ST)>

Definition: This field contains the composite number/name of the person/group that performed the test/procedure/transaction, etc. This is the service provider. Refer to User-defined Table 0084 - Performed by for suggested values. Multiple names and identifiers for the same practitioner may be sent in this field, not multiple practitioners. The legal name is assumed to be in the first repetition. When the legal name is not sent, a repeat delimiter must be sent first for the first repetition.

User-defined Table 0084 - Performed by

Value	Description	Comment
	No suggested values defined

6.5.1.21 FT1-21 Ordered by Code (XCN) 00373

Definition: This field contains the composite number/name of the person/group that ordered the test/ procedure/transaction, etc. Multiple names and identifiers for the same practitioner may be sent in this field, not multiple practitioners. The legal name is assumed to be in the first repetition. When the legal name is not sent, a repeat delimiter must be sent first for the first repetition.

6.5.1.22 FT1-22 Unit Cost (CP) 00374

Definition: This field contains the unit cost of transaction. The cost of a single item.

6.5.1.23 FT1-23 Filler Order Number (EI) 00217

Components: <Entity Identifier (ST)> ^ <Namespace ID (IS)> ^ <Universal ID (ST)> ^ <Universal ID Type (ID)>

Definition: This field is used when the billing system is requesting observational reporting justification for a charge. This is the number used by a filler to uniquely identify a result. See Chapter 4 for a complete description.

6.5.1.24 FT1-24 Entered by Code (XCN) 00765

Definition: This field identifies the composite number/name of the person who entered the insurance information.

6.5.1.25 FT1-25 Procedure Code (CE) 00393

Components: <Identifier (ST)> ^ <Text (ST)> ^ <Name of Coding System (ID)> ^ <Alternate Identifier (ST)> ^ <Alternate Text (ST)> ^ <Name of Alternate Coding System (ID)>

Definition: This field contains a unique identifier assigned to the procedure, if any, associated with the charge. Refer to User-defined Table 0088 - Procedure Code for suggested values. This field is a CE data type for compatibility with clinical and ancillary systems.

User-defined Table 0088 - Procedure Code

Value	Description	Comment
	No suggested values defined

6.5.1.26 FT1-26 Procedure Code Modifier (CE) 01316

Components: <Identifier (ST)> ^ <Text (ST)> ^ <Name of Coding System (ID)> ^ <Alternate Identifier (ST)> ^ <Alternate Text (ST)> ^ <Name of Alternate Coding System (ID)>

Definition: This field contains the procedure code modifier to the procedure code reported in FT1-25 - Procedure Code, when applicable. Procedure code modifiers are defined by regulatory agencies such as CMS and the AMA. Multiple modifiers may be reported. The modifiers are sequenced in priority according to user entry. This is a requirement of the UB and the 1500 claim forms. Multiple modifiers are allowed and the order placed on the form affects reimbursement. Refer to User-defined Table 0340 - Procedure Code Modifier for suggested values.

Usage Rule: This field can only be used if FT1-25 - Procedure Code contains certain procedure codes that require a modifier in order to be billed or performed. For example HCPCS codes that require a modifier to be precise.

User-defined Table 0340 - Procedure Code Modifier

Value	Description	Comment
	No suggested values defined

6.5.1.27 FT1-27 Advanced Beneficiary Notice Code (CE) 01310

Components: <Identifier (ST)> ^ <Text (ST)> ^ <Name of Coding System (ID)> ^ <Alternate Identifier (ST)> ^ <Alternate Text (ST)> ^ <Name of Alternate Coding System (ID)>

Definition: This field indicates the status of the patient_s or the patient_s representative_s consent for responsibility to pay for potentially uninsured services. This element is introduced to satisfy CMS Medical Necessity requirements for outpatient services. This element indicates (a) whether the associated diagnosis codes for the service are subject to medical necessity procedures, (b) whether, for this type of service, the patient has been informed that they may be responsible for payment for the service, and (c) whether the patient agrees to be billed for this service. Refer to User-defined Table 0339 -Advanced Beneficiary Notice Code in Chapter 4 for suggested values.

6.5.1.28 FT1-28 Medically Necessary Duplicate Procedure Reason (CWE) 01646

Definition: This field is used to document why the procedure found in FT1-25 - Procedure Code is a duplicate of one ordered/charged previously for the same patient within the same date of service and has been determined to be medically necessary. The reason may be coded or it may be a free text entry. This field is intended to provide financial systems information on who to bill for duplicate procedures. Refer to User-Defined Table 0476 _ Medically Necessary Duplicate Procedure Reason in Chapter 4 for suggested values.

6.5.1.29 FT1-29 NDC Code (CNE) 01845

Components: <Identifier (ST)> ^ <Text (ST)> ^ <Name of Coding System (ID)> ^ <Alternate Identifier (ST)> ^ <Alternate Text (ST)> ^ <Name of Alternate Coding System (ID)> ^ <Coding System Version ID (ST)> ^ <Alternate Coding System Version ID (ST)> ^ <Original Text (ST)>

Definition: This field has been defined for NDC codes that are required by HIPAA for electronic claims for Pharmacy charges. Refer to User-defined Table 0549- NDC Codes for suggested values.

User-defined Table 0549 _ NDC Codes

Value	Description	Comment
	No suggested values defined

6.5.1.30 FT1-30 Payment Reference ID (CX) 01846

Components: <ID Number (ST)> ^ <Check Digit (ST)> ^ <Check Digit Scheme (ID)> ^ <Assigning Authority (HD)> ^ <Identifier Type Code (ID)> ^ <Assigning Facility (HD)> ^ <Effective Date (DT)> ^ <Expiration Date (DT)> ^ <Assigning Jurisdiction (CWE)> ^ <Assigning Agency or Department (CWE)>

Subcomponents for Assigning Authority (HD): <Namespace ID (IS)> & <Universal ID (ST)> & <Universal ID Type (ID)>

Subcomponents for Assigning Facility (HD): <Namespace ID (IS)> & <Universal ID (ST)> & <Universal ID Type (ID)>

Subcomponents for Assigning Jurisdiction (CWE): <Identifier (ST)> & <Text (ST)> & <Name of Coding System (ID)> & <Alternate Identifier (ST)> & <Alternate Text (ST)> & <Name of Alternate Coding System (ID)> & <Coding System Version ID (ST)> & <Alternate Coding System Version ID (ST)> & <Original Text (ST)>

Subcomponents for Assigning Agency or Department (CWE): <Identifier (ST)> & <Text (ST)> & <Name of Coding System (ID)> & <Alternate Identifier (ST)> & <Alternate Text (ST)> & <Name of Alternate Coding System (ID)> & <Coding System Version ID (ST)> & <Alternate Coding System Version ID (ST)> & <Original Text (ST)>

Definition: The payment reference number of the payment medium reported in FT1-7 - Transaction Code.

6.5.1.31 FT1-31 Transaction Reference Key (SI) 01847

Definition: The reference key linking the payment to the corresponding charge in an e-claim. This field should contain the FT1-1 - Set ID FT1 that identifies the charge corresponding to the payment. This field is repeating to allow a payment to be posted against multiple charges.

6.5.2 DG1 - Diagnosis Segment

The DG1 segment contains patient diagnosis information of various types, for example, admitting, primary, etc. The DG1 segment is used to send multiple diagnoses (for example, for medical records encoding). It is also used when the FT1-19 - Diagnosis Code - FT1 does not provide sufficient information for a billing system. This diagnosis coding should be distinguished from the clinical problem segment used by caregivers to manage the patient (see Chapter 12, Patient Care). Coding methodologies are also defined.

HL7 Attribute Table - DG1 - Diagnosis

SEQ	LEN	DT	OPT	RP/#	TBL#	ITEM#	ELEMENT NAME	DB Ref.
1	4	SI	R			00375	Set ID - DG1	DB
2	2	ID	(B) R		0053	00376	Diagnosis Coding Method	DB
3	250	CE	O		0051	00377	Diagnosis Code - DG1	DB
4	40	ST	B			00378	Diagnosis Description	DB
5	26	TS	O			00379	Diagnosis Date/Time	DB
6	2	IS	R		0052	00380	Diagnosis Type	DB
7	250	CE	B		0118	00381	Major Diagnostic Category	DB
8	250	CE	B		0055	00382	Diagnostic Related Group	DB
9	1	ID	B		0136	00383	DRG Approval Indicator	DB
10	2	IS	B		0056	00384	DRG Grouper Review Code	DB
11	250	CE	B		0083	00385	Outlier Type	DB
12	3	NM	B			00386	Outlier Days	DB
13	12	CP	B			00387	Outlier Cost	DB
14	4	ST	B			00388	Grouper Version And Type	DB
15	2	ID	O		0359	00389	Diagnosis Priority	DB
16	250	XCN	O	Y		00390	Diagnosing Clinician	DB
17	3	IS	O		0228	00766	Diagnosis Classification	DB
18	1	ID	O		0136	00767	Confidential Indicator	DB
19	26	TS	O			00768	Attestation Date/Time	DB
20	427	EI	C			01850	Diagnosis Identifier	DB
21	1	ID	C		0206	01894	Diagnosis Action Code	DB

6.5.2.0 DG1 field definitions

6.5.2.1 DG1-1 Set ID - DG1 (SI) 00375

Definition: This field contains the number that identifies this transaction. For the first occurrence of the segment the sequence number shall be 1, for the second occurrence it shall be 2, etc.

6.5.2.2 DG1-2 Diagnosis Coding Method (ID) 00376

Definition: As of Version 2.3, this field has been retained for backward compatibility only. Use the components of DG1-3 - Diagnosis Code - DG1 instead of this field. When used for backward compatibility, ICD9 is the recommended coding methodology. Refer to User-defined Table 0053 - Diagnosis Coding Method for suggested values.

User-defined Table 0053 - Diagnosis Coding Method

Value	Description	Comment
	No suggested values defined

6.5.2.3 DG1-3 Diagnosis Code - DG1 (CE) 00377

Components: <Identifier (ST)> ^ <Text (ST)> ^ <Name of Coding System (ID)> ^ <Alternate Identifier (ST)> ^ <Alternate Text (ST)> ^ <Name of Alternate Coding System (ID)>

Definition: Use this field instead of DG1-2 - Diagnosis Coding Method and DG1-4 - Diagnosis Description, which have been retained, as of Version 2.3, for backward compatibility only. DG1-3 - Diagnosis Code - DG1 contains the diagnosis code assigned to this diagnosis. Refer to User-defined Table 0051 - Diagnosis Code for suggested values. This field is a CE data type for compatibility with clinical and ancillary systems.

Names of various diagnosis coding systems are listed in Chapter 2, Section 2.17.5, _Coding system table._

6.5.2.4 DG1-4 Diagnosis Description (ST) 00378

Definition: As of Version 2.3, this field has been retained for backward compatibility only. Use the components of DG1-3 - Diagnosis Code - DG1 field instead of this field. When used for backward compatibility, DG1-4 - Diagnosis Description contains a description that best describes the diagnosis.

6.5.2.5 DG1-5 Diagnosis Date/Time (TS) 00379

Components: <Time (DTM)> ^ <DEPRECATED-Degree of Precision (ID)>

Definition: This field contains the date/time that the diagnosis was determined.

6.5.2.6 DG1-6 Diagnosis Type (IS) 00380

Definition: This field contains a code that identifies the type of diagnosis being sent. Refer to User-defined Table 0052 - Diagnosis Type for suggested values. This field should no longer be used to indicate _DRG_ because the DRG fields have moved to the new DRG segment.

User-defined Table 0052 - Diagnosis Type

Values	Description	Comment
A	Admitting
W	Working
F	Final

6.5.2.7 DG1-7 Major Diagnostic Category (CE) 00381

Components: <Identifier (ST)> ^ <Text (ST)> ^ <Name of Coding System (ID)> ^ <Alternate Identifier (ST)> ^ <Alternate Text (ST)> ^ <Name of Alternate Coding System (ID)>

Definition: As of Version 2.3, this field has been retained for backward compatibility only. This field should only be used in a master file transaction. Refer to User-defined Table 0118 - Major Diagnostic Category for suggested values.

User-defined Table 0118 _ Major Diagnostic Category

Value	Description	Comment
	No suggested values defined

6.5.2.8 DG1-8 Diagnostic Related Group (CE) 00382

Components: <Identifier (ST)> ^ <Text (ST)> ^ <Name of Coding System (ID)> ^ <Alternate Identifier (ST)> ^ <Alternate Text (ST)> ^ <Name of Alternate Coding System (ID)>

Definition: As of Version 2.3, this field has been retained for backward compatibility only. This field has moved to the new DRG segment. It contains the DRG for the transaction. Interim DRGs could be determined for an encounter. Refer to User-defined Table 0055 - Diagnosis Related Group for suggested values.

User-defined Table 0055 - Diagnosis related group

Value	Description	Comment
	No suggested values defined

6.5.2.9 DG1-9 DRG Approval Indicator (ID) 00383

Definition: As of Version 2.3, this field has been retained for backward compatibility only. This field has moved to the new DRG segment. This field indicates if the DRG has been approved by a reviewing entity. Refer to HL7 Table 0136 - Yes/no Indicator for valid values.

Y the DRG has been approved by a reviewing entity

N the DRG has not been approved

6.5.2.10 DG1-10 DRG Grouper Review Code (IS) 00384

Definition: As of Version 2.3, this field has been retained for backward compatibility only. This field has moved to the new DRG segment. Refer to User-defined Table 0056 - DRG Grouper Review Code for suggested values. This code indicates that the grouper results have been reviewed and approved.

User-defined Table 0056 - DRG grouper review code

Value	Description	Comment
	No suggested values defined

6.5.2.11 DG1-11 Outlier Type (CE) 00385

Components: <Identifier (ST)> ^ <Text (ST)> ^ <Name of Coding System (ID)> ^ <Alternate Identifier (ST)> ^ <Alternate Text (ST)> ^ <Name of Alternate Coding System (ID)>

Definition: As of Version 2.3, this field has been retained for backward compatibility only. This field has moved to the new DRG segment. When used for backward compatibility, this field contains the type of outlier (i.e. period of care beyond DRG-standard stay in facility) that has been paid. Refer to User-defined Table 0083 - Outlier Type for suggested values.

User-defined Table 0083 - Outlier Type

Values	Description	Comment
D	Outlier days
C	Outlier cost

6.5.2.12 DG1-12 Outlier Days (NM) 00386

Definition: As of Version 2.3, this field has been retained for backward compatibility only. This field has moved to the new DRG segment. When used for backward compatibility, this field contains the number of days that have been approved for an outlier payment.

6.5.2.13 DG1-13 Outlier Cost (CP) 00387

Definition: As of Version 2.3, this field has been retained for backward compatibility only. This field has moved to the new DRG segment. When used for backward compatibility, this field contains the amount of money that has been approved for an outlier payment.

6.5.2.14 DG1-14 Grouper Version and Type (ST) 00388

Definition: As of Version 2.3, this field has been retained for backward compatibility only. This field has moved to the new DRG segment; refer to the field definition in Section 6.5.3.1. When used for backward compatibility, this field contains the grouper version and type.

6.5.2.15 DG1-15 Diagnosis Priority (ID) 00389

Definition: This field contains the number that identifies the significance or priority of the diagnosis code. Refer to HL7 Table 0359 - Diagnosis Priority for suggested values.

HL7 Table 0359 - Diagnosis Priority

Value	Description	Comment
0	Not included in diagnosis ranking
1	The primary diagnosis
2 _	For ranked secondary diagnoses

6.5.2.16 DG1-16 Diagnosing Clinician (XCN) 00390

Definition: This field contains the individual responsible for generating the diagnosis information. Multiple names and identifiers for the same person may be sent in this field, not multiple diagnosing clinicians. The legal name is assumed to be in the first repetition. When the legal name is not sent, a repeat delimiter must be sent first for the first repetition.

6.5.2.17 DG1-17 Diagnosis Classification (IS) 00766

Definition: This field indicates if the patient information is for a diagnosis or a non-diagnosis code. Refer to User-defined Table 0228 - Diagnosis Classification for suggested values.

User-defined Table 0228 - Diagnosis Classification

Value	Description	Comment
C	Consultation
D	Diagnosis
M	Medication (antibiotic)
O	Other
R	Radiological scheduling (not using ICDA codes)
S	Sign and symptom
T	Tissue diagnosis
I	Invasive procedure not classified elsewhere (I.V., catheter, etc.)

6.5.2.18 DG1-18 Confidential Indicator (ID) 00767

Definition: This field indicates whether the diagnosis is confidential. Refer to HL7 table 0136 - Yes/no Indicator for valid values.

Y the diagnosis is a confidential diagnosis

N the diagnosis does not contain a confidential diagnosis

6.5.2.19 DG1-19 Attestation Date/Time (TS) 00768

Components: <Time (DTM)> ^ <DEPRECATED-Degree of Precision (ID)>

Definition: This field contains the time stamp that indicates the date and time that the attestation was signed.

6.5.2.20 DG1-20 Diagnosis Identifier (EI) 01850

Components: <Entity Identifier (ST)> ^ <Namespace ID (IS)> ^ <Universal ID (ST)> ^ <Universal ID Type (ID)>

Definition: This field contains a value that uniquely identifies a single diagnosis for an encounter. It is unique across all segments and messages for an encounter. This field is required in all implementations employing Update Diagnosis/Procedures (P12) messages.

6.5.2.21 DG1-21 Diagnosis Action Code (ID) 01894

This field defines the action to be taken for this diagnosis. Refer to HL7 Table 0206 - Segment Action Code in Chapter 2 for valid values. This field is required for the update diagnosis/procedures (P12) message. In all other events it is optional.

6.5.3 DRG - Diagnosis Related Group Segment

The DRG segment contains diagnoses-related grouping information of various types. The DRG segment is used to send the DRG information, for example, for billing and medical records encoding.

HL7 Attribute Table - DRG - Diagnosis Related Group

SEQ	LEN	DT	OPT	TBL#	ITEM#	ELEMENT NAME	DB Ref.
1	250	CE	O	0055	00382	Diagnostic Related Group	DB
2	26	TS	O		00769	DRG Assigned Date/Time	DB
3	1	ID	O	0136	00383	DRG Approval Indicator	DB
4	2	IS	O	0056	00384	DRG Grouper Review Code	DB
5	250	CE	O	0083	00385	Outlier Type	DB
6	3	NM	O		00386	Outlier Days	DB
7	12	CP	O		00387	Outlier Cost	DB
8	1	IS	O	0229	00770	DRG Payor	DB
9	9	CP	O		00771	Outlier Reimbursement	DB
10	1	ID	O	0136	00767	Confidential Indicator	DB
11	21	IS	O	0415	01500	DRG Transfer Type	DB

6.5.3.0 DRG Field Definitions

6.5.3.1 DRG-1 Diagnostic Related Group (CE) 00382

Components: <Identifier (ST)> ^ <Text (ST)> ^ <Name of Coding System (ID)> ^ <Alternate Identifier (ST)> ^ <Alternate Text (ST)> ^ <Name of Alternate Coding System (ID)>

Definition: This field contains the DRG for the transaction. Interim DRG_s could be determined for an encounter. Refer to User-defined Table 0055 _ Diagnosis Related Group for suggested values. For the name of coding system component, send the grouper version and type.

6.5.3.2 DRG-2 DRG Assigned Date/Time (TS) 00769

Components: <Time (DTM)> ^ <DEPRECATED-Degree of Precision (ID)>

Definition: This field contains the time stamp to indicate the date and time that the DRG was assigned.

6.5.3.3 DRG-3 DRG Approval Indicator (ID) 00383

Definition: This field indicates if the DRG has been approved by a reviewing entity. Refer to HL7 table 0136 - Yes/no Indicator for valid values.

Y the DRG has been approved by a reviewing entity

N the DRG has not been approved

6.5.3.4 DRG-4 DRG Grouper Review Code (IS) 00384

Definition: This code indicates that the grouper results have been reviewed and approved. Refer to User-defined Table 0056 - DRG Grouper Review Code for suggested values.

6.5.3.5 DRG-5 Outlier Type (CE) 00385

Components: <Identifier (ST)> ^ <Text (ST)> ^ <Name of Coding System (ID)> ^ <Alternate Identifier (ST)> ^ <Alternate Text (ST)> ^ <Name of Alternate Coding System (ID)>

Definition: Refers to the type of outlier (i.e. period of care beyond DRG-standard stay in facility) that has been paid. Refer to User-defined Table 0083 - Outlier Type for suggested values.

6.5.3.6 DRG-6 Outlier Days (NM) 00386

Definition: This field contains the number of days that have been approved as an outlier payment.

6.5.3.7 DRG-7 Outlier Cost (CP) 00387

Definition: This field contains the amount of money that has been approved for an outlier payment.

6.5.3.8 DRG-8 DRG Payor (IS) 00770

Definition: This field indicates the associated DRG Payor. Refer to User-defined Table 0229 - DRG Payor for suggested values.

User-defined Table 0229 - DRG Payor

Value	Description	Comment
M	Medicare
C	Champus
G	Managed Care Organization

6.5.3.9 DRG-9 Outlier Reimbursement (CP) 00771

Definition: Where applicable, the outlier reimbursement amount indicates the part of the total reimbursement designated for reimbursement of outlier conditions (day or cost).

6.5.3.10 DRG-10 Confidential Indicator (ID) 00767

Definition: This field indicates if the DRG contains a confidential diagnosis. Refer to HL7 table 0136 - Yes/no Indicator for valid values.

Y the DRG contains a confidential diagnosis

N the DRG does not contain a confidential diagnosis

6.5.3.11 DRG-11 DRG Transfer Type (IS) 01500

Definition: This field indicates the type of hospital receiving a transfer patient, which affects how a facility is reimbursed under diagnosis related group (DRG_s), for example, exempt or non-exempt. Refer to User-defined Table 0415 - DRG Transfer Type for suggested values.

User-defined Table 0415 - DRG Transfer Type

Value	Description	Comment
N	DRG Non Exempt
E	DRG Exempt

6.5.4 PR1 - Procedures Segment

The PR1 segment contains information relative to various types of procedures that can be performed on a patient. The PR1 segment can be used to send procedure information, for example: Surgical, Nuclear Medicine, X-ray with contrast, etc. The PR1 segment is used to send multiple procedures, for example, for medical records encoding or for billing systems.

HL7 Attribute Table - PR1 - Procedures

SEQ	LEN	DT	OPT	RP/#	TBL#	ITEM#	ELEMENT NAME	DB Ref.
1	4	SI	R			00391	Set ID - PR1	DB
2	3	IS	(B) R		0089	00392	Procedure Coding Method	DB
3	250	CE	R		0088	00393	Procedure Code	DB
4	40	ST	B			00394	Procedure Description	DB
5	26	TS	R			00395	Procedure Date/Time	DB
6	2	IS	O		0230	00396	Procedure Functional Type	DB
7	4	NM	O			00397	Procedure Minutes	DB
8	250	XCN	B	Y	0010	00398	Anesthesiologist	DB
9	2	IS	O		0019	00399	Anesthesia Code	DB
10	4	NM	O			00400	Anesthesia Minutes	DB
11	250	XCN	B	Y	0010	00401	Surgeon	DB
12	250	XCN	B	Y	0010	00402	Procedure Practitioner	DB
13	250	CE	O		0059	00403	Consent Code	DB
14	2	ID	O		0418	00404	Procedure Priority	DB
15	250	CE	O		0051	00772	Associated Diagnosis Code	DB
16	250	CE	O	Y	0340	01316	Procedure Code Modifier	DB
17	20	IS	O		0416	01501	Procedure DRG Type	DB
18	250	CE	O	Y	0417	01502	Tissue Type Code	DB
19	427	EI	C			01848	Procedure Identifier	DB
20	1	ID	C		0206	01849	Procedure Action Code	DB

6.5.4.0 PR1 Field Definitions

6.5.4.1 PR1-1 Set ID - PR1 (SI) 00391

Definition: This field contains the number that identifies this transaction. For the first occurrence of the segment the sequence number shall be 1, for the second occurrence it shall be 2, etc.

6.5.4.2 PR1-2 Procedure Coding Method (IS) 00392

Definition: As of Version 2.3, this field has been retained for backward compatibility only. Use the components of PR1-3 - Procedure Code instead of this field.

When used for backward compatibility, PR1-2 - Procedure Coding Method contains the methodology used to assign a code to the procedure (CPT4, for example). If more than one coding method is needed for a single procedure, this field and the associated values in PR1-3 - Procedure Code and PR1-4 - Procedure Description may repeat. In this instance, the three fields (PR1-2 through PR1-4) are directly associated with one another. Refer to User-defined Table 0089 - Procedure Coding Method for suggested values.

User-defined Table 0089 - Procedure Coding Method

Value	Description	Comment
	No suggested values defined

6.5.4.3 PR1-3 Procedure Code (CE) 00393

Components: <Identifier (ST)> ^ <Text (ST)> ^ <Name of Coding System (ID)> ^ <Alternate Identifier (ST)> ^ <Alternate Text (ST)> ^ <Name of Alternate Coding System (ID)>

Definition: Use this field instead of PR1-2 - Procedure Coding Method and PR1-4 - Procedure Description. Those two fields have been retained for backward compatibility only. This field contains a unique identifier assigned to the procedure. Refer to User-defined Table 0088 - Procedure Code for suggested values. This field is a CE data type for compatibility with clinical and ancillary systems.

6.5.4.4 PR1-4 Procedure Description (ST) 00394

Definition: As of Version 2.3, this field has been retained for backward compatibility only. Use the components of PR1-3 - Procedure Code instead of this field. The field contains a text description that describes the procedure.

6.5.4.5 PR1-5 Procedure Date/Time (TS) 00395

Components: <Time (DTM)> ^ <DEPRECATED-Degree of Precision (ID)>

Definition: This field contains the date/time that the procedure was performed.

6.5.4.6 PR1-6 Procedure Functional Type (IS) 00396

Definition: This field contains the optional code that further defines the type of procedure. Refer to User-defined Table 0230 - Procedure Functional Type for suggested values.

User-defined Table 0230 - Procedure Functional Type

Value	Description	Comment
A	Anesthesia
P	Procedure for treatment (therapeutic, including operations)
I	Invasive procedure not classified elsewhere (e.g., IV, catheter, etc.)
D	Diagnostic procedure

6.5.4.7 PR1-7 Procedure Minutes (NM) 00397

Definition: This field indicates the length of time in whole minutes that the procedure took to complete.

6.5.4.8 PR1-8 Anesthesiologist (XCN) 00398

Components: <ID Number (ST)> ^ <Family Name (FN)> ^ <Given Name (ST)> ^ <Second and Further Given Names or Initials Thereof (ST)> ^ <Suffix (e.g., JR or III) (ST)> ^ <Prefix (e.g., DR) (ST)> ^ <DEPRECATED-Degree (e.g., MD) (IS)> ^ <Source Table (IS)> ^ <Assigning Authority (HD)> ^ <Name Type Code (ID)> ^ <Identifier Check Digit (ST)> ^ <Check Digit Scheme (ID)> ^ <Identifier Type Code (ID)> ^ <Assigning Facility (HD)> ^ <Name Representation Code (ID)> ^ <Name Context (CE)> ^ <DEPRECATED-Name Validity Range (DR)> ^ <Name Assembly Order (ID)> ^ <Effective Date (TS)> ^ <Expiration Date (TS)> ^ <Professional Suffix (ST)> ^ <Assigning Jurisdiction (CWE)> ^ <Assigning Agency or Department (CWE)>

Subcomponents for Family Name (FN): <Surname (ST)> & <Own Surname Prefix (ST)> & <Own Surname (ST)> & <Surname Prefix From Partner/Spouse (ST)> & <Surname From Partner/Spouse (ST)>

Subcomponents for Assigning Authority (HD): <Namespace ID (IS)> & <Universal ID (ST)> & <Universal ID Type (ID)>

Subcomponents for Assigning Facility (HD): <Namespace ID (IS)> & <Universal ID (ST)> & <Universal ID Type (ID)>

Subcomponents for Name Context (CE): <Identifier (ST)> & <Text (ST)> & <Name of Coding System (ID)> & <Alternate Identifier (ST)> & <Alternate Text (ST)> & <Name of Alternate Coding System (ID)>

Subcomponents for DEPRECATED-Name Validity Range (DR): <Range Start Date/Time (TS)> & <Range End Date/Time (TS)>

Note subcomponent contains sub-subcomponents

Subcomponents for Effective Date (TS) : <Time (DTM)> & <DEPRECATED-Degree of Precision (ID)>

Subcomponents for Expiration Date (TS): <Time (DTM)> & <DEPRECATED-Degree of Precision (ID)>

Subcomponents for Assigning Jurisdiction (CWE): <Identifier (ST)> & <Text (ST)> & <Name of Coding System (ID)> & <Alternate Identifier (ST)> & <Alternate Text (ST)> & <Name of Alternate Coding System (ID)> & <Coding System Version ID (ST)> & <Alternate Coding System Version ID (ST)> & <Original Text (ST)>

Subcomponents for Assigning Agency or Department (CWE): <Identifier (ST)> & <Text (ST)> & <Name of Coding System (ID)> & <Alternate Identifier (ST)> & <Alternate Text (ST)> & <Name of Alternate Coding System (ID)> & <Coding System Version ID (ST)> & <Alternate Coding System Version ID (ST)> & <Original Text (ST)>

Definition: HL7 has introduced the ROL segment to report a wide range of practitioner roles related to a single procedure. This segment is described in Chapter 12. When using trigger events introduced in HL7 Version 2.3, it is recommended that the ROL segment be used to report all practitioner roles related to the procedure.

However, in order to maintain backward compatibility, the practitioner roles existing in HL7 Version 2.2 (PR1-8 - Anesthesiologist, PR1-11 - Surgeon and PR1-12 - Procedure Practitioner) should also be populated in the PR1 segment as per the HL7 2.2 specifications. You may additionally report the practitioner information in the ROL segment (See Chapter 12, Section 12.3.3, _ROL - Role Segment_).

When this field is used for backward compatibility, the XCN data type applies. It contains the anesthesiologist who administered the anesthesia. Refer to User-defined Table 0010 - Physician ID in Chapter 3 for suggested values for first component. Multiple names and identifiers for the same person should be sent in this field, not multiple anesthesiologists. The legal name is assumed to be in the first repetition. When the legal name is not sent, a repeat delimiter must be sent first for the first repetition.

6.5.4.9 PR1-9 Anesthesia Code (IS) 00399

Definition: This field contains a unique identifier of the anesthesia used during the procedure. Refer to User-defined Table 0019 - Anesthesia Code for suggested values.

User-defined Table 0019 - Anesthesia Code

Value	Description	Comment
	No suggested values defined

6.5.4.10 PR1-10 Anesthesia Minutes (NM) 00400

Definition: This field contains the length of time in minutes that the anesthesia was administered.

6.5.4.11 PR1-11 Surgeon (XCN) 00401

When this field is being used for backward compatibility, the XCN data type applies. It contains the surgeon who performed the procedure. Refer to User-defined Table 0010 - Physician ID in Chapter 3 for suggested values for the first component. Multiple names and identifiers for the same person should be sent in this field, not multiple surgeons. The legal name is assumed to be in the first repetition. When the legal name is not sent, a repeat delimiter must be sent first for the first repetition.

6.5.4.12 PR1-12 Procedure Practitioner (XCN) 00402

This field contains the different types of practitioners associated with this procedure. The ID and name components follow the standard rules defined for a composite name (XCN) field. The last component, identifier type code, indicates which type of procedure practitioner is shown. When the identifier type component is unvalued, it is assumed that the practitioner identified is a resident. Refer to User-defined Table 0010 - Physician ID in Chapter 3 for suggested values for the first component. Refer to User-defined Table 0133 - Procedure Practitioner Identifier Code Type for suggested values for the identifier type code component.

User-defined Table 0133 - Procedure Practitioner Identifier Code Type

Value	Description	Comment
AN	Anesthesiologist/Anesthetist
PR	Procedure MD/ Surgeon
RD	Radiologist
RS	Resident
NP	Nurse Practitioner
CM	Certified Nurse Midwife
SN	Scrub Nurse
PS	Primary Surgeon
AS	Assistant Surgeon

6.5.4.13 PR1-13 Consent Code (CE) 00403

Components: <Identifier (ST)> ^ <Text (ST)> ^ <Name of Coding System (ID)> ^ <Alternate Identifier (ST)> ^ <Alternate Text (ST)> ^ <Name of Alternate Coding System (ID)>

Definition: This field contains the type of consent that was obtained for permission to treat the patient. Refer to User-defined Table 0059 - Consent Code for suggested values.

User-defined Table 0059 - Consent Code

Value	Description	Comment
	No suggested values defined

6.5.4.14 PR1-14 Procedure Priority (ID) 00404

Definition: This field contains a number that identifies the significance or priority of the procedure code. Refer to HL7 Table 0418 - Procedure Priority for valid values.

HL7 Table 0418 - Procedure Priority

Value	Description	Comment
0	the admitting procedure
1	the primary procedure
2 _	for ranked secondary procedures

6.5.4.15 PR1-15 Associated Diagnosis Code (CE) 00772

Components: <Identifier (ST)> ^ <Text (ST)> ^ <Name of Coding System (ID)> ^ <Alternate Identifier (ST)> ^ <Alternate Text (ST)> ^ <Name of Alternate Coding System (ID)>

Definition: This field contains the diagnosis that is the primary reason this procedure was performed, e.g. in the US, Medicare wants to know for which diagnosis this procedure is submitted for inclusion on CMS 1500 form. Refer to User-defined Table 0051 - Diagnosis Code for suggested values.

6.5.4.16 PR1-16 Procedure Code Modifier (CE) 01316

Components: <Identifier (ST)> ^ <Text (ST)> ^ <Name of Coding System (ID)> ^ <Alternate Identifier (ST)> ^ <Alternate Text (ST)> ^ <Name of Alternate Coding System (ID)>

Definition: This field contains the procedure code modifier to the procedure code reported in field 3, when applicable. Procedure code modifiers are defined by regulatory agencies such as CMS and the AMA. Multiple modifiers may be reported. Refer to User-defined Table 0340 - Procedure Code Modifier for suggested values.

6.5.4.17 PR1-17 Procedure DRG Type (IS) 01501

Definition: This field indicates a procedure_s priority ranking relative to its DRG. Refer to User-defined Table 0416 - Procedure DRG Type for suggested values.

User-defined Table 0416 - Procedure DRG Type

Value	Description	Comment
1	1st non-Operative
2	2nd non-Operative
3	Major Operative
4	2nd Operative
5	3rd Operative

6.5.4.18 PR1-18 Tissue Type Code (CE) 01502

Components: <Identifier (ST)> ^ <Text (ST)> ^ <Name of Coding System (ID)> ^ <Alternate Identifier (ST)> ^ <Alternate Text (ST)> ^ <Name of Alternate Coding System (ID)>

Definition: Code representing type of tissue removed from a patient during this procedure. Refer to User-defined Table 0417 - Tissue Type Code for suggested values.

User-defined Table 0417 - Tissue Type Code

Value	Description	Comment
1	Insufficient Tissue
2	Not abnormal
3	Abnormal-not categorized
4	Mechanical abnormal
5	Growth alteration
6	Degeneration & necrosis
7	Non-acute inflammation
8	Non-malignant neoplasm
9	Malignant neoplasm
0	No tissue expected
B	Basal cell carcinoma
C	Carcinoma-unspecified type
G	Additional tissue required

6.5.4.19 PR1-19 Procedure Identifier (EI) 01848

Components: <Entity Identifier (ST)> ^ <Namespace ID (IS)> ^ <Universal ID (ST)> ^ <Universal ID Type (ID)>

This field contains a value that uniquely identifies a single procedure for an encounter. It is unique across all segments and messages for an encounter. This field is required in all implementations employing Update Diagnosis/Procedures (P12) messages.

6.5.4.20 PR1-20 Procedure Action Code (ID) 01849

This field defines the action to be taken for this procedure. Refer to HL7 Table 0206 - Segment Action Code in Chapter 2 for valid values. This field is required for the Update Diagnosis/Procedures (P12) message. In all other events it is optional.

6.5.5 GT1 - Guarantor Segment

The GT1 segment contains guarantor (e.g., the person or the organization with financial responsibility for payment of a patient account) data for patient and insurance billing applications.

HL7 Attribute Table - GT1 - Guarantor

SEQ	LEN	DT	OPT	RP/#	TBL#	ITEM#	ELEMENT NAME	DB Ref.
1	4	SI	R			00405	Set ID - GT1	DB
2	250	CX	O	Y		00406	Guarantor Number	DB
3	250	XPN	R	Y		00407	Guarantor Name	DB
4	250	XPN	O	Y		00408	Guarantor Spouse Name	DB
5	250	XAD	O	Y		00409	Guarantor Address	DB
6	250	XTN	O	Y		00410	Guarantor Ph Num - Home	DB
7	250	XTN	O	Y		00411	Guarantor Ph Num - Business	DB
8	26	TS	O			00412	Guarantor Date/Time Of Birth	DB
9	1	IS	O		0001	00413	Guarantor Administrative Sex	DB
10	2	IS	O		0068	00414	Guarantor Type	DB
11	250	CE	O		0063	00415	Guarantor Relationship	DB
12	11	ST	O			00416	Guarantor SSN	DB
13	8	DT	O			00417	Guarantor Date - Begin	DB
14	8	DT	O			00418	Guarantor Date - End	DB
15	2	NM	O			00419	Guarantor Priority	DB
16	250	XPN	O	Y		00420	Guarantor Employer Name	DB
17	250	XAD	O	Y		00421	Guarantor Employer Address	DB
18	250	XTN	O	Y		00422	Guarantor Employer Phone Number	DB
19	250	CX	O	Y		00423	Guarantor Employee ID Number	DB
20	2	IS	O		0066	00424	Guarantor Employment Status	DB
21	250	XON	O	Y		00425	Guarantor Organization Name	DB
22	1	ID	O		0136	00773	Guarantor Billing Hold Flag	DB
23	250	CE	O		0341	00774	Guarantor Credit Rating Code	DB
24	26	TS	O			00775	Guarantor Death Date And Time	DB
25	1	ID	O		0136	00776	Guarantor Death Flag	DB
26	250	CE	O		0218	00777	Guarantor Charge Adjustment Code	DB
27	10	CP	O			00778	Guarantor Household Annual Income	DB
28	3	NM	O			00779	Guarantor Household Size	DB
29	250	CX	O	Y		00780	Guarantor Employer ID Number	DB
30	250	CE	O		0002	00781	Guarantor Marital Status Code	DB
31	8	DT	O			00782	Guarantor Hire Effective Date	DB
32	8	DT	O			00783	Employment Stop Date	DB
33	2	IS	O		0223	00755	Living Dependency	DB
34	2	IS	O	Y	0009	00145	Ambulatory Status	DB
35	250	CE	O	Y	0171	00129	Citizenship	DB
36	250	CE	O		0296	00118	Primary Language	DB
37	2	IS	O		0220	00742	Living Arrangement	DB
38	250	CE	O		0215	00743	Publicity Code	DB
39	1	ID	O		0136	00744	Protection Indicator	DB
40	2	IS	O		0231	00745	Student Indicator	DB
41	250	CE	O		0006	00120	Religion	DB
42	250	XPN	O	Y		00109	Mother_s Maiden Name	DB
43	250	CE	O		0212	00739	Nationality	DB
44	250	CE	O	Y	0189	00125	Ethnic Group	DB
45	250	XPN	O	Y		00748	Contact Person_s Name	DB
46	250	XTN	O	Y		00749	Contact Person_s Telephone Number	DB
47	250	CE	O		0222	00747	Contact Reason	DB
48	3	IS	O		0063	00784	Contact Relationship	DB
49	20	ST	O			00785	Job Title	DB
50	20	JCC	O			00786	Job Code/Class	DB
51	250	XON	O	Y		01299	Guarantor Employer_s Organization Name	DB
52	2	IS	O		0295	00753	Handicap	DB
53	2	IS	O		0311	00752	Job Status	DB
54	50	FC	O			01231	Guarantor Financial Class	DB
55	250	CE	O	Y	0005	01291	Guarantor Race	DB
56	250	ST	O			01851	Guarantor Birth Place	DB
57	2	IS	O		0099	00146	VIP Indicator	DB

6.5.5.0 GT1 Field Definitions

6.5.5.1 GT1-1 Set ID - GT1 (SI) 00405

Definition: GT1-1 - Set ID contains a number that identifies this transaction. For the first occurrence of the segment the sequence shall be 1, for the second occurrence it shall be 2, etc.

6.5.5.2 GT1-2 Guarantor Number (CX) 00406

Definition: This field contains the primary identifier, or other identifiers, assigned to the guarantor. The assigning authority and identifier type code are strongly recommended for all CX data types.

6.5.5.3 GT1-3 Guarantor Name (XPN) 00407

Components: <Family Name (FN)> ^ <Given Name (ST)> ^ <Second and Further Given Names or Initials Thereof (ST)> ^ <Suffix (e.g., JR or III) (ST)> ^ <Prefix (e.g., DR) (ST)> ^ <DEPRECATED-Degree (e.g., MD) (IS)> ^ <Name Type Code (ID)> ^ <Name Representation Code (ID)> ^ <Name Context (CE)> ^ <DEPRECATED-Name Validity Range (DR)> ^ <Name Assembly Order (ID)> ^ <Effective Date (TS)> ^ <Expiration Date (TS)> ^ <Professional Suffix (ST)>

Subcomponents for Family Name (FN): <Surname (ST)> & <Own Surname Prefix (ST)> & <Own Surname (ST)> & <Surname Prefix From Partner/Spouse (ST)> & <Surname From Partner/Spouse (ST)>

Subcomponents for Name Context (CE): <Identifier (ST)> & <Text (ST)> & <Name of Coding System (ID)> & <Alternate Identifier (ST)> & <Alternate Text (ST)> & <Name of Alternate Coding System (ID)>

Subcomponents for DEPRECATED-Name Validity Range (DR): <Range Start Date/Time (TS)> & <Range End Date/Time (TS)>

Note subcomponent contains sub-subcomponents

Subcomponents for Effective Date (TS): <Time (DTM)> & <DEPRECATED-Degree of Precision (ID)>

Subcomponents for Expiration Date (TS): <Time (DTM)> & <DEPRECATED-Degree of Precision (ID)>

Definition: This field contains the name of the guarantor. Multiple names for the same guarantor may be sent in this field. The legal name is assumed to be in the first repetition. When the legal name is not sent, a repeat delimiter must be sent first for the first repetition.

Beginning with Version 2.3, if the guarantor is an organization, send a null value ("") in GT1-3 - Guarantor Name and put the organization name in GT1-21 - Guarantor Organization Name. Either guarantor name or guarantor organization name is required.

6.5.5.4 GT1-4 Guarantor Spouse Name (XPN) 00408

Definition: This field contains the name of the guarantor_s spouse. Multiple names for the same guarantor spouse may be sent in this field. The legal name is assumed to be in the first repetition. When the legal name is not sent, a repeat delimiter must be sent first for the first repetition.

6.5.5.5 GT1-5 Guarantor Address (XAD) 00409

Components: <Street Address (SAD)> ^ <Other Designation (ST)> ^ <City (ST)> ^ <State or Province (ST)> ^ <Zip or Postal Code (ST)> ^ <Country (ID)> ^ <Address Type (ID)> ^ <Other Geographic Designation (ST)> ^ <County/Parish Code (IS)> ^ <Census Tract (IS)> ^ <Address Representation Code (ID)> ^ <DEPRECATED-Address Validity Range (DR)> ^ <Effective Date (TS)> ^ <Expiration Date (TS)>

Subcomponents for Street Address (SAD): <Street or Mailing Address (ST)> & <Street Name (ST)> & <Dwelling Number (ST)>

Subcomponents for DEPRECATED-Address Validity Range (DR): <Range Start Date/Time (TS)> & <Range End Date/Time (TS)>

Note subcomponent contains sub-subcomponents

Subcomponents for Effective Date (TS): <Time (DTM)> & <DEPRECATED-Degree of Precision (ID)>

Subcomponents for Expiration Date (TS): <Time (DTM)> & <DEPRECATED-Degree of Precision (ID)>

Definition: This field contains the guarantor_s address. Multiple addresses for the same person may be sent in this field. The mailing address is assumed to be in the first repetition. When the mailing address is not sent, a repeat delimiter must be sent first for the first repetition.

6.5.5.6 GT1-6 Guarantor Ph Num - Home (XTN) 00410

Components: <DEPRECATED-Telephone Number (ST)> ^ <Telecommunication Use Code (ID)> ^ <Telecommunication Equipment Type (ID)> ^ <Email Address (ST)> ^ <Country Code (NM)> ^ <Area/City Code (NM)> ^ <Local Number (NM)> ^ <Extension (NM)> ^ <Any Text (ST)> ^ <Extension Prefix (ST)> ^ <Speed Dial Code (ST)> ^ <Unformatted Telephone number (ST)>

Definition: This field contains the guarantor_s home phone number. All personal phone numbers for the guarantor may be sent in this field. The primary telephone number is assumed to be in the first repetition. When the primary telephone number is not sent, a repeat delimiter must be sent first for the first repetition.

6.5.5.7 GT1-7 Guarantor Ph Num - Business (XTN) 00411

Definition: This field contains the guarantor_s business phone number. All business phone numbers for the guarantor may be sent in this field. The primary telephone number is assumed to be in the first repetition. When the primary telephone number is not sent, a repeat delimiter must be sent first for the first repetition.

6.5.5.8 GT1-8 Guarantor Date/Time of Birth (TS) 00412

Components: <Time (DTM)> ^ <DEPRECATED-Degree of Precision (ID)>

Definition: This field contains the guarantor_s date of birth.

6.5.5.9 GT1-9 Guarantor Administrative Sex (IS) 00413

Definition: This field contains the guarantor_s gender. Refer to User-defined Table 0001 - Administrative Sex in Chapter 3 for suggested values.

6.5.5.10 GT1-10 Guarantor Type (IS) 00414

Definition: This field indicates the type of guarantor, e.g., individual, institution, etc. Refer to User-defined Table 0068 - Guarantor Type for suggested values.

User-defined Table 0068 - Guarantor Type

Value	Description	Comment
	No suggested values defined

6.5.5.11 GT1-11 Guarantor Relationship (CE) 00415

Components: <Identifier (ST)> ^ <Text (ST)> ^ <Name of Coding System (ID)> ^ <Alternate Identifier (ST)> ^ <Alternate Text (ST)> ^ <Name of Alternate Coding System (ID)>

Definition: This field indicates the relationship of the guarantor with the patient, e.g., parent, child, etc. Refer to User-defined Table 0063 - Relationship in Chapter 3 for suggested values.

6.5.5.12 GT1-12 Guarantor SSN (ST) 00416

Definition: This field contains the guarantor_s social security number.

6.5.5.13 GT1-13 Guarantor Date - Begin (DT) 00417

Definition: This field contains the date that the guarantor becomes responsible for the patient_s account.

6.5.5.14 GT1-14 Guarantor Date - End (DT) 00418

Definition: This field contains the date that the guarantor stops being responsible for the patient_s account.

6.5.5.15 GT1-15 Guarantor Priority (NM) 00419

Definition: This field is used to determine the order in which the guarantors are responsible for the patient_s account.

_1_ = primary guarantor

_2_ = secondary guarantor, etc.

6.5.5.16 GT1-16 Guarantor Employer Name (XPN) 00420

Definition: This field contains the name of the guarantor_s employer, if the employer is a person. When the guarantor_s employer is an organization, use GT1-51 - Guarantor Employer_s Organization Name. Multiple names for the same person may be sent in this field, not multiple employers. The legal name must be sent first in the repetition. When the legal name is not sent, a repeat delimiter must be sent first for the first repetition.

6.5.5.17 GT1-17 Guarantor Employer Address (XAD) 00421

Definition: This field contains the guarantor_s employer_s address. Multiple addresses for the same employer may be sent in this field. The mailing address must be sent first in the repetition. When the mailing address is not sent, a repeat delimiter must be sent first for the first repetition.

6.5.5.18 GT1-18 Guarantor Employer Phone Number (XTN) 00422

Definition: This field contains the guarantor_s employer_s phone number. Multiple phone numbers for the same employer may be sent in this field. The primary telephone number must be sent first in the sequence. When the primary telephone number is not sent, a repeat delimiter must be sent first for the first repetition.

6.5.5.19 GT1-19 Guarantor Employee ID Number (CX) 00423

Definition: This field contains the guarantor_s employee number. The assigning authority and identifier type code are strongly recommended for all CX data types.

6.5.5.20 GT1-20 Guarantor Employment Status (IS) 00424

Definition: This field contains the code that indicates the guarantor_s employment status. Refer to User-Defined Table 0066 - Employment Status for suggested values.

User-defined Table 0066 - Employment Status

Value	Description	Comment
1	Full time employed
2	Part time employed
4	Self-employed,
C	Contract, per diem
L	Leave of absence (e.g. Family leave, sabbatical, etc.)
T	Temporarily unemployed
3	Unemployed
5	Retired
6	On active military duty
O	Other
9	Unknown

6.5.5.21 GT1-21 Guarantor Organization Name (XON) 00425

Components: <Organization Name (ST)> ^ <Organization Name Type Code (IS)> ^ <DEPRECATED-ID Number (NM)> ^ <Check Digit (NM)> ^ <Check Digit Scheme (ID)> ^ <Assigning Authority (HD)> ^ <Identifier Type Code (ID)> ^ <Assigning Facility (HD)> ^ <Name Representation Code (ID)> ^ <Organization Identifier (ST)>

Subcomponents for Assigning Authority (HD): <Namespace ID (IS)> & <Universal ID (ST)> & <Universal ID Type (ID)>

Subcomponents for Assigning Facility (HD): <Namespace ID (IS)> & <Universal ID (ST)> & <Universal ID Type (ID)>

Definition: This field contains the name of the guarantor when the guarantor is an organization. Multiple names for the same guarantor may be sent in this field, not multiple guarantors. The legal name is assumed to be in the first repetition. When the legal name is not sent, a repeat delimiter must be sent first for the first repetition.

Beginning with Version 2.3, if the guarantor is a person, send a null value ("") in GT1-21 - Guarantor Organization Name and put the person name in GT1-3 - Guarantor Name. Either guarantor person name or guarantor organization name is required.

6.5.5.22 GT1-22 Guarantor Billing Hold Flag (ID) 00773

Definition: Refer to HL7 table 0136 - Yes/no Indicator for valid values. This field indicates whether or not a system should suppress printing of the guarantor_s bills.

Y a system should suppress printing of guarantor_s bills

N a system should not suppress printing of guarantor_s bills

6.5.5.23 GT1-23 Guarantor Credit Rating Code (CE) 00774

Components: <Identifier (ST)> ^ <Text (ST)> ^ <Name of Coding System (ID)> ^ <Alternate Identifier (ST)> ^ <Alternate Text (ST)> ^ <Name of Alternate Coding System (ID)>

Definition: This field contains the guarantor_s credit rating. Refer to User-defined Table 0341 - Guarantor Credit Rating Code for suggested values.

User-defined Table 0341 - Guarantor Credit Rating Code

Value	Description	Comment
	No suggested values defined

6.5.5.24 GT1-24 Guarantor Death Date and Time (TS) 00775

Components: <Time (DTM)> ^ <DEPRECATED-Degree of Precision (ID)>

Definition: This field is used to indicate the date and time at which the guarantor_s death occurred.

6.5.5.25 GT1-25 Guarantor Death Flag (ID) 00776

Definition: This field indicates whether or not the guarantor is deceased. Refer to HL7 table 0136 - Yes/no Indicator for valid values.

Y the guarantor is deceased

N the guarantor is living

6.5.5.26 GT1-26 Guarantor Charge Adjustment Code (CE) 00777

Components: <Identifier (ST)> ^ <Text (ST)> ^ <Name of Coding System (ID)> ^ <Alternate Identifier (ST)> ^ <Alternate Text (ST)> ^ <Name of Alternate Coding System (ID)>

Definition: This field contains user-defined codes that indicate which adjustments should be made to this guarantor_s charges. For example, when the hospital agrees to adjust this guarantor_s charges to a sliding scale. Refer to User-defined Table 0218 - Patient Charge Adjustment for suggested values.

Example: This field would contain the value used for sliding-fee scale processing.

User-defined Table 0218 - Patient Charge Adjustment

Value	Description	Comment
	No suggested values defined

6.5.5.27 GT1-27 Guarantor Household Annual Income (CP) 00778

Definition: This field contains the combined annual income of all members of the guarantor_s household.

6.5.5.28 GT1-28 Guarantor Household Size (NM) 00779

Definition: This field specifies the number of people living at the guarantor_s primary residence.

6.5.5.29 GT1-29 Guarantor Employer ID Number (CX) 00780

Definition: This is a code that uniquely identifies the guarantor_s employer when the employer is a person. It may be a user-defined code or a code defined by a government agency (Federal Tax ID#).

When further breakdowns of employer information are needed, such as a division or plant, it is recommended that the coding scheme incorporate the relationships (e.g., define separate codes for each division). The assigning authority and identifier type code are strongly recommended for all CX data types.

6.5.5.30 GT1-30 Guarantor Marital Status Code (CE) 00781

Components: <Identifier (ST)> ^ <Text (ST)> ^ <Name of Coding System (ID)> ^ <Alternate Identifier (ST)> ^ <Alternate Text (ST)> ^ <Name of Alternate Coding System (ID)>

Definition: This field contains the marital status of the guarantor. Refer to User-defined Table 0002 - Marital Status in Chapter 3 for suggested values.

6.5.5.31 GT1-31 Guarantor Hire Effective Date (DT) 00782

Definition: This field contains the date that the guarantor_s employment began.

6.5.5.32 GT1-32 Employment Stop Date (DT) 00783

Definition: This field indicates the date on which the guarantor_s employment with a particular employer ended.

6.5.5.33 GT1-33 Living Dependency (IS) 00755

Definition: Identifies the specific living conditions of the guarantor. Refer to User-defined Table 0223 - Living Dependency in Chapter 3 for suggested values.

6.5.5.34 GT1-34 Ambulatory Status (IS) 00145

Definition: Identifies the transient state of mobility for the guarantor. Refer to User-defined Table 0009 - Ambulatory Status in Chapter 3 for suggested values.

6.5.5.35 GT1-35 Citizenship (CE) 00129

Components: <Identifier (ST)> ^ <Text (ST)> ^ <Name of Coding System (ID)> ^ <Alternate Identifier (ST)> ^ <Alternate Text (ST)> ^ <Name of Alternate Coding System (ID)>

Definition: This field contains the code to identify the guarantor_s citizenship. HL7 recommends using ISO table 3166 as the suggested values in User-defined Table 0171 - Citizenship defined in Chapter 3.

6.5.5.36 GT1-36 Primary Language (CE) 00118

Components: <Identifier (ST)> ^ <Text (ST)> ^ <Name of Coding System (ID)> ^ <Alternate Identifier (ST)> ^ <Alternate Text (ST)> ^ <Name of Alternate Coding System (ID)>

Definition: This field identifies the guarantor_s primary speaking language. HL7 recommends using ISO table 639 as the suggested values in User-defined Table 0296 - Primary Language defined in Chapter 3.

6.5.5.37 GT1-37 Living Arrangement (IS) 00742

Definition: This field identifies the situation in which the person lives at his residential address. Refer to User-defined Table 0220 - Living Arrangement in Chapter 3 for suggested values.

6.5.5.38 GT1-38 Publicity Code (CE) 00743

Components: <Identifier (ST)> ^ <Text (ST)> ^ <Name of Coding System (ID)> ^ <Alternate Identifier (ST)> ^ <Alternate Text (ST)> ^ <Name of Alternate Coding System (ID)>

Definition: This field contains a user-defined code indicating what level of publicity is allowed (e.g., No Publicity, Family Only) for a guarantor. Refer to User-defined Table 0215 - Publicity Code in Chapter 3 for suggested values.

6.5.5.39 GT1-39 Protection Indicator (ID) 00744

Definition: This field identifies the guarantor_s protection, which determines whether or not access to information about this enrollee should be restricted from users who do not have adequate authority. Refer to HL7 table 0136 - Yes/no Indicator for valid values.

Y restrict access

N do not restrict access

6.5.5.40 GT1-40 Student Indicator (IS) 00745

Definition: This field indicates whether the guarantor is currently a student, and whether the guarantor is a full-time or part-time student. This field does not indicate the degree level (high school, college) of the student, or his/her field of study (accounting, engineering, etc.). Refer to User-defined Table 0231- Student Status for suggested values.

User-defined Table 0231 - Student Status

Values	Description	Comment
F	Full-time student
P	Part-time student
N	Not a student

6.5.5.41 GT1-41 Religion (CE) 00120

Components: <Identifier (ST)> ^ <Text (ST)> ^ <Name of Coding System (ID)> ^ <Alternate Identifier (ST)> ^ <Alternate Text (ST)> ^ <Name of Alternate Coding System (ID)>

Definition: This field indicates the type of religion practiced by the guarantor. Refer to User-defined Table 0006 - Religion in Chapter 3 for suggested values.

6.5.5.42 GT1-42 Mother_s Maiden Name (XPN) 00109

Definition: This field indicates the guarantor_s mother_s maiden name.

6.5.5.43 GT1-43 Nationality (CE) 00739

Components: <Identifier (ST)> ^ <Text (ST)> ^ <Name of Coding System (ID)> ^ <Alternate Identifier (ST)> ^ <Alternate Text (ST)> ^ <Name of Alternate Coding System (ID)>

Definition: This field contains a code that identifies the nation or national grouping to which the person belongs. This may be different from a person_s citizenship in countries in which multiple nationalities are recognized (for example, Spain: Basque, Catalan, etc.). HL7 recommends using ISO table 3166 as suggested values in User-defined Table 0212 - Nationality in Chapter 3.

6.5.5.44 GT1-44 Ethnic Group (CE) 00125

Components: <Identifier (ST)> ^ <Text (ST)> ^ <Name of Coding System (ID)> ^ <Alternate Identifier (ST)> ^ <Alternate Text (ST)> ^ <Name of Alternate Coding System (ID)>

Definition: This field contains the guarantor_s ethnic group. Refer to User-defined Table 0189 - Ethnic Group in Chapter 3 for suggested values. The second triplet of the CE data type for ethnic group (alternate identifier, alternate text, and name of alternate coding system) is reserved for governmentally assigned codes. In the US, a current use is to report ethnicity in line with US federal standards for Hispanic origin.

6.5.5.45 GT1-45 Contact Person_s Name (XPN) 00748

Definition: This field contains the name of the person who should be contacted regarding the guarantor bills, etc. This may be someone other than the guarantor. (Contact guarantor_s wife regarding all bills - guarantor lives out of country).

This is a repeating field that allows for multiple names for the same person. The legal name is assumed to be in the first repetition. When the legal name is not sent, a repeat delimiter must be sent first for the first repetition.

6.5.5.46 GT1-46 Contact Person_s Telephone Number (XTN) 00749

Definition: This field contains the telephone number of the guarantor (person) to contact regarding guarantor bills, etc. Multiple phone numbers for that person may be sent in this sequence. The primary telephone number is assumed to be in the first repetition. When the primary telephone number is not sent, a repeat delimiter must be sent first for the first repetition.

6.5.5.47 GT1-47 Contact Reason (CE) 00747

Components: <Identifier (ST)> ^ <Text (ST)> ^ <Name of Coding System (ID)> ^ <Alternate Identifier (ST)> ^ <Alternate Text (ST)> ^ <Name of Alternate Coding System (ID)>

Definition: This field contains a user-defined code that identifies the reason for contacting the guarantor, for example, to phone the guarantor if payments are late. Refer to User-defined Table 0222 - Contact reason for suggested values.

User-defined Table 0222 - Contact Reason

Value	Description	Comment
	No suggested values defined

6.5.5.48 GT1-48 Contact Relationship (IS) 00784

Definition: Identifies the guarantor relationship to the contact person specified above. Refer to User-defined Table 0063 - Relationship in Chapter 3 for suggested values. Examples include wife, attorney, power of attorney, self, and organization.

6.5.5.49 GT1-49 Job Title (ST) 00785

Definition: This field contains a descriptive name of the guarantor_s occupation (e.g., Sr. Systems Analyst, Sr. Accountant).

6.5.5.50 GT1-50 Job Code/Class (JCC) 00786

Components: <Job Code (IS)> ^ <Job Class (IS)> ^ <Job Description Text (TX)>

Definition: This field contains the guarantor_s job code and employee classification.

6.5.5.51 GT1-51 Guarantor Employer_s Organization Name (XON) 01299

Definition: This field contains the name of the guarantor_s employer when the guarantor_s employer is an organization. When the guarantor_s employer is a person, use GT1-16 - Guarantor Employer Name. Multiple names for the same guarantor may be sent in this field. The legal name is assumed to be in the first repetition. When the legal name is not sent, a repeat delimiter must be sent first for the first repetition.

6.5.5.52 GT1-52 Handicap (IS) 00753

Definition: This field contains a code to describe the guarantor_s disability. Refer to User-defined Table 0295 - Handicap in Chapter 3 for suggested values.

6.5.5.53 GT1-53 Job Status (IS) 00752

Definition: This field contains a code that identifies the guarantor_s current job status. Refer to User-defined Table 0311 - Job Status in Chapter 3 for suggested values.

6.5.5.54 GT1-54 Guarantor Financial Class (FC) 01231

Components: <Financial Class Code (IS)> ^ <Effective Date (TS)>

Subcomponents for Effective Date (TS): <Time (DTM)> & <DEPRECATED-Degree of Precision (ID)>

Definition: This field contains the financial class (FC) assigned to the guarantor for the purpose of identifying sources of reimbursement. It can be different than that of the patient. When the FC of the guarantor is different than the FC of the patient, and the guarantor_s coverage for that patient has been exhausted, the source of reimbursement falls back onto the FC of the patient.

6.5.5.55 GT1-55 Guarantor Race (CE) 01291

Components: <Identifier (ST)> ^ <Text (ST)> ^ <Name of Coding System (ID)> ^ <Alternate Identifier (ST)> ^ <Alternate Text (ST)> ^ <Name of Alternate Coding System (ID)>

Definition: This field refers to the guarantor_s race. Refer to User-defined Table 0005 - Race in Chapter 3 for suggested values. The second triplet of the CE data type for race (alternate identifier, alternate text, and name of alternate coding system) is reserved for governmentally assigned codes.

6.5.5.56 GT1-56 Guarantor Birth Place (ST) 01851

Definition: This field contains the description of the guarantor_s birth place, for example _St. Francis Community Hospital of Lower South Side._ The actual address is reported in GT1-5 _ Guarantor Address with an identifier of _N_.

6.5.5.57 GT1-57 VIP Indicator (IS) 00146

Definition: This field identifies the type of VIP for the guarantor. Refer to User-defined Table 0099 _ VIP indicator in Chapter 3 for suggested values.

6.5.6 IN1 - Insurance Segment

The IN1 segment contains insurance policy coverage information necessary to produce properly pro-rated and patient and insurance bills.

HL7 Attribute Table - IN1 - Insurance

SEQ	LEN	DT	OPT	RP/#	TBL#	ITEM#	ELEMENT NAME	DB Ref.
1	4	SI	R			00426	Set ID - IN1	DB
2	250	CE	R		0072	00368	Insurance Plan ID	DB
3	250	CX	R	Y		00428	Insurance Company ID	DB
4	250	XON	O	Y		00429	Insurance Company Name	DB
5	250	XAD	O	Y		00430	Insurance Company Address	DB
6	250	XPN	O	Y		00431	Insurance Co Contact Person	DB
7	250	XTN	O	Y		00432	Insurance Co Phone Number	DB
8	12	ST	O			00433	Group Number	DB
9	250	XON	O	Y		00434	Group Name	DB
10	250	CX	O	Y		00435	Insured_s Group Emp ID	DB
11	250	XON	O	Y		00436	Insured_s Group Emp Name	DB
12	8	DT	O			00437	Plan Effective Date	DB
13	8	DT	O			00438	Plan Expiration Date	DB
14	239	AUI	O			00439	Authorization Information	DB
15	3	IS	O		0086	00440	Plan Type	DB
16	250	XPN	O	Y		00441	Name Of Insured	DB
17	250	CE	O		0063	00442	Insured_s Relationship To Patient	DB
18	26	TS	O			00443	Insured_s Date Of Birth	DB
19	250	XAD	O	Y		00444	Insured_s Address	DB
20	2	IS	O		0135	00445	Assignment Of Benefits	DB
21	2	IS	O		0173	00446	Coordination Of Benefits	DB
22	2	ST	O			00447	Coord Of Ben. Priority	DB
23	1	ID	O		0136	00448	Notice Of Admission Flag	DB
24	8	DT	O			00449	Notice Of Admission Date	DB
25	1	ID	O		0136	00450	Report Of Eligibility Flag	DB
26	8	DT	O			00451	Report Of Eligibility Date	DB
27	2	IS	O		0093	00452	Release Information Code	DB
28	15	ST	O			00453	Pre-Admit Cert (PAC)	DB
29	26	TS	O			00454	Verification Date/Time	DB
30	250	XCN	O	Y		00455	Verification By	DB
31	2	IS	O		0098	00456	Type Of Agreement Code	DB
32	2	IS	O		0022	00457	Billing Status	DB
33	4	NM	O			00458	Lifetime Reserve Days	DB
34	4	NM	O			00459	Delay Before L.R. Day	DB
35	8	IS	O		0042	00460	Company Plan Code	DB
36	15	ST	O			00461	Policy Number	DB
37	12	CP	O			00462	Policy Deductible	DB
38	12	CP	B			00463	Policy Limit - Amount	DB
39	4	NM	O			00464	Policy Limit - Days	DB
40	12	CP	B			00465	Room Rate - Semi-Private	DB
41	12	CP	B			00466	Room Rate - Private	DB
42	250	CE	O		0066	00467	Insured_s Employment Status	DB
43	1	IS	O		0001	00468	Insured_s Administrative Sex	DB
44	250	XAD	O	Y		00469	Insured_s Employer_s Address	DB
45	2	ST	O			00470	Verification Status	DB
46	8	IS	O		0072	00471	Prior Insurance Plan ID	DB
47	3	IS	O		0309	01227	Coverage Type	DB
48	2	IS	O		0295	00753	Handicap	DB
49	250	CX	O	Y		01230	Insured_s ID Number	DB
50	1	IS	O		0535	01854	Signature Code	DB
51	8	DT	O			01855	Signature Code Date	DB
52	250	ST	O			01899	Insured_s Birth Place	DB
53	2	IS	O		0099	01852	VIP Indicator	DB

6.5.6.0 IN1 Field Definitions

6.5.6.1 IN1-1 Set ID - IN1 (SI) 00426

Definition: IN1-1 - set ID - IN1 contains the number that identifies this transaction. For the first occurrence the sequence number shall be 1, for the second occurrence it shall be 2, etc. The Set ID in the IN1 segment is used to aggregate the grouping of insurance segments. For example, a patient with two insurance plans would have two groupings of insurance segments. IN1, IN2, and IN3 segments for Insurance Plan A with set ID 1, followed by IN1, IN2, and IN3 segments for Insurance Plan B, with set ID 2. There is no set ID in the IN2 segment because it is contained in the IN1, IN2, IN3 grouping, and is therefore not needed. The set ID in the IN3 segment is provided because there can be multiple repetitions of the IN3 segment if there are multiple certifications for the same insurance plan, e.g., IN1 (Set ID 1), IN2, IN3 (Set ID 1), IN3 (Set ID 2), IN3 (Set ID 3)

6.5.6.2 IN1-2 Insurance Plan ID (CE) 00368

Components: <Identifier (ST)> ^ <Text (ST)> ^ <Name of Coding System (ID)> ^ <Alternate Identifier (ST)> ^ <Alternate Text (ST)> ^ <Name of Alternate Coding System (ID)>

Definition: This field contains a unique identifier for the insurance plan. Refer to User-defined Table 0072 - Insurance Plan ID for suggested values. To eliminate a plan, the plan could be sent with null values in each subsequent element. If the respective systems can support it, a null value can be sent in the plan field.

6.5.6.3 IN1-3 Insurance Company ID (CX) 00428

Definition: This field contains unique identifiers for the insurance company. The assigning authority and identifier type code are strongly recommended for all CX data types.

6.5.6.4 IN1-4 Insurance Company Name (XON) 00429

Definition: This field contains the name of the insurance company. Multiple names for the same insurance company may be sent in this field. The legal name is assumed to be in the first repetition. When the legal name is not sent, a repeat delimiter must be sent first for the first repetition.

6.5.6.5 IN1-5 Insurance Company Address (XAD) 00430

Definition: This field contains the address of the insurance company. Multiple addresses for the same insurance company may be sent in this field. The mailing address is assumed to be in the first repetition. When the mailing address is not sent, a repeat delimiter must be sent first for the first repetition.

6.5.6.6 IN1-6 Insurance Co Contact Person (XPN) 00431

Definition: This field contains the name of the person who should be contacted at the insurance company. Multiple names for the same contact person may be sent in this field. The legal name is assumed to be in the first repetition. When the legal name is not sent, a repeat delimiter must be sent first for the first repetition.

6.5.6.7 IN1-7 Insurance Co Phone Number (XTN) 00432

Definition: This field contains the phone number of the insurance company. Multiple phone numbers for the same insurance company may be sent in this field. The primary phone number is assumed to be in the first repetition. When the primary phone number is not sent, a repeat delimiter must be sent first for the first repetition.

6.5.6.8 IN1-8 Group Number (ST) 00433

Definition: This field contains the group number of the insured_s insurance.

6.5.6.9 IN1-9 Group Name (XON) 00434

Definition: This field contains the group name of the insured_s insurance.

6.5.6.10 IN1-10 Insured_s Group Emp. ID (CX) 00435

Definition: This field holds the group employer ID for the insured_s insurance. The assigning authority and identifier type code are strongly recommended for all CX data types.

6.5.6.11 IN1-11 Insured's Group Emp Name (XON) 00436

Definition: This field contains the name of the employer that provides the employee_s insurance. Multiple names for the same employer may be sent in this sequence. The legal name must be sent first. When the legal name is not sent, a repeat delimiter must be sent first for the first repetition.

6.5.6.12 IN1-12 Plan Effective Date (DT) 00437

Definition: This field contains the date that the insurance goes into effect.

6.5.6.13 IN1-13 Plan Expiration Date (DT) 00438

Definition: This field indicates the last date of service that the insurance will cover or be responsible for.

6.5.6.14 IN1-14 Authorization Information (AUI) 00439

Components: <Authorization Number (ST)> ^ <Date (DT)> ^ <Source (ST)>

Definition: Based on the type of insurance, some coverage plans require that an authorization number or code be obtained prior to all non-emergency admissions, and within 48 hours of an emergency admission. Insurance billing would not be permitted without this number. The date and source of authorization are the components of this field.

6.5.6.15 IN1-15 Plan Type (IS) 00440

Definition: This field contains the coding structure that identifies the various plan types, for example, Medicare, Medicaid, Blue Cross, HMO, etc. Refer to User-defined Table 0086 - Plan ID for suggested values.

User-defined Table 0086 - Plan ID

Value	Description	Comment
	No suggested values defined

6.5.6.16 IN1-16 Name of Insured (XPN) 00441

Definition: This field contains the name of the insured person. The insured is the person who has an agreement with the insurance company to provide healthcare services to persons covered by the insurance policy. Multiple names for the same insured person may be sent in this field. The legal name is assumed to be in the first repetition. When the legal name is not sent, a repeat delimiter must be sent first for the first repetition.

6.5.6.17 IN1-17 Insured_s Relationship to Patient (CE) 00442

Components: <Identifier (ST)> ^ <Text (ST)> ^ <Name of Coding System (ID)> ^ <Alternate Identifier (ST)> ^ <Alternate Text (ST)> ^ <Name of Alternate Coding System (ID)>

Definition: This field indicates the insured_s relationship to the patient. Refer to User-defined Table 0063 - Relationship in Chapter 3 for suggested values.

6.5.6.18 IN1-18 Insured's Date of Birth (TS) 00443

Components: <Time (DTM)> ^ <DEPRECATED-Degree of Precision (ID)>

Definition: This field contains the date of birth of the insured.

6.5.6.19 IN1-19 Insured's Address (XAD) 00444

Definition: This field contains the address of the insured person. The insured is the person who has an agreement with the insurance company to provide healthcare services to persons covered by an insurance policy. Multiple addresses for the same insured person may be in this field. The mailing address must be sent in the first repetition. When the legal name is not sent, a repeat delimiter must be sent first for the first repetition.

6.5.6.20 IN1-20 Assignment of Benefits (IS) 00445

Definition: This field indicates whether the insured agreed to assign the insurance benefits to the healthcare provider. If so, the insurance will pay the provider directly. Refer to User-defined Table 0135 - Assignment of Benefits for suggested values.

User-defined Table 0135 - Assignment of Benefits

Value	Description	Comment
Y	Yes
N	No
M	Modified assignment

6.5.6.21 IN1-21 Coordination of Benefits (IS) 00446

Definition: This field indicates whether this insurance works in conjunction with other insurance plans, or if it provides independent coverage and payment of benefits regardless of other insurance that might be available to the patient. Refer to User-defined Table 0173 - Coordination of Benefits for suggested values.

User-defined Table 0173 - Coordination of Benefits

Value	Description	Comment
CO	Coordination
IN	Independent

6.5.6.22 IN1-22 Coord of Ben. Priority (ST) 00447

Definition: If the insurance works in conjunction with other insurance plans, this field contains priority sequence. Values are: 1, 2, 3, etc.

6.5.6.23 IN1-23 Notice of Admission Flag (ID) 00448

Definition: This field indicates whether the insurance company requires a written notice of admission from the healthcare provider. Refer to HL7 table 0136 - Yes/no Indicator for valid values.

Y written notice of admission required

N no notice required

6.5.6.24 IN1-24 Notice of Admission Date (DT) 00449

Definition: If a notice is required, this field indicates the date that it was sent.

6.5.6.25 IN1-25 Report of Eligibility Flag (ID) 00450

Definition: This field indicates whether this insurance carrier sends a report that indicates that the patient is eligible for benefits and whether it identifies those benefits. Refer to HL7 table 0136 - Yes/no Indicator for valid values.

Y eligibility report is sent

N no eligibility report is sent

6.5.6.26 IN1-26 Report of Eligibility Date (DT) 00451

Definition: This field indicates whether a report of eligibility (ROE) was received, and also indicates the date that it was received.

6.5.6.27 IN1-27 Release Information Code (IS) 00452

Definition: This field indicates whether the healthcare provider can release information about the patient, and what information can be released. Refer to User-defined Table 0093 - Release Information for suggested values.

User-defined Table 0093 - Release Information

Value	Description	Comment
Y	Yes
N	No
_	user-defined codes

6.5.6.28 IN1-28 Pre-admit Cert (PAC) (ST) 00453

Definition: This field contains the pre-admission certification code. If the admission must be certified before the admission, this is the code associated with the admission.

6.5.6.29 IN1-29 Verification Date/Time (TS) 00454

Components: <Time (DTM)> ^ <DEPRECATED-Degree of Precision (ID)>

Definition: This field contains the date/time that the healthcare provider verified that the patient has the indicated benefits.

6.5.6.30 IN1-30 Verification by (XCN) 00455

Definition: Refers to the person who verified the benefits. Multiple names for the same insured person may be sent in this field. The legal name is assumed to be in the first repetition. When the legal name is not sent, a repeat delimiter must be sent first for the first repetition.

6.5.6.31 IN1-31 Type of Agreement Code (IS) 00456

Definition: This field is used to further identify an insurance plan. Refer to User-defined Table 0098 - Type of Agreement for suggested values.

User-defined Table 0098 - Type of Agreement

Value	Description	Comment
S	Standard
U	Unified
M	Maternity

6.5.6.32 IN1-32 Billing Status (IS) 00457

Definition: This field indicates whether the particular insurance has been billed and, if so, the type of bill. Refer to User-defined Table 0022 - Billing Status for suggested values.

User-defined Table 0022 - Billing Status

Value	Description	Comment
	No suggested values defined

6.5.6.33 IN1-33 Lifetime Reserve Days (NM) 00458

Definition: This field contains the number of days left for a certain service to be provided or covered under an insurance policy.

6.5.6.34 IN1-34 Delay Before L.R. Day (NM) 00459

Definition: This field indicates the delay before lifetime reserve days.

6.5.6.35 IN1-35 Company Plan Code (IS) 00460

Definition: This field contains optional information to further define the data in IN1-3 - Insurance Company ID. Refer to User-defined Table 0042 - Company Plan Code for suggested values. This table contains codes used to identify an insurance company plan uniquely.

User-defined Table 0042 - Company Plan Code

Value	Description	Comment
	No suggested values defined

6.5.6.36 IN1-36 Policy Number (ST) 00461

Definition: This field contains the individual policy number of the insured to uniquely identify this patient_s plan. For special types of insurance numbers, there are also special fields in the IN2 segment for Medicaid, Medicare, Champus (i.e., IN2-6 - Medicare Health Ins Card Number, IN2-8 - Medicaid Case Number, IN2-10 - Military ID Number). But we recommend that this field (IN1-36 - Policy Number) be filled even when the patient_s insurance number is also passed in one of these other fields.

6.5.6.37 IN1-37 Policy Deductible (CP) 00462

Definition: This field contains the amount specified by the insurance plan that is the responsibility of the guarantor (i.e. deductible, excess, etc.).

6.5.6.38 IN1-38 Policy Limit - Amount (CP) 00463

Definition: As of Version 2.3, this field has been retained for backward compatibility only. Use IN2-29 - Policy Type/Amount instead of this field. This field contains the maximum amount that the insurance policy will pay. In some cases, the limit may be for a single encounter.

6.5.6.39 IN1-39 Policy Limit - Days (NM) 00464

Definition: This field contains the maximum number of days that the insurance policy will cover.

6.5.6.40 IN1-40 Room Rate - Semi-Private (CP) 00465

Definition: As of Version 2.3, this field has been retained for backward compatibility only. Use IN2-28 - Room Coverage Type/Amount instead of this field. When used for backward compatibility, IN1-40 - Room Rate Semi-Private contains the average room rate that the policy covers.

6.5.6.41 IN1-41 Room Rate - Private (CP) 00466

Definition: As of Version 2.3, this field has been retained for backward compatibility only. Use IN2-28 - Room Coverage Type/Amount instead of this field. When used for backward compatibility IN1-41 - Room Rate - Private contains the maximum private room rate that the policy covers.

6.5.6.42 IN1-42 Insured_s Employment Status (CE) 00467

Components: <Identifier (ST)> ^ <Text (ST)> ^ <Name of Coding System (ID)> ^ <Alternate Identifier (ST)> ^ <Alternate Text (ST)> ^ <Name of Alternate Coding System (ID)>

Definition: This field holds the employment status of the insured. Refer to User-defined Table 0066 - Employment Status for suggested values. This field contains UB92 field 64. For this field element, values from the US CMS UB92 and others are used.

6.5.6.43 IN1-43 Insured_s Administrative Sex (IS) 00468

Definition: This field contains the gender of the insured. Refer to User-defined Table 0001 - Administrative Sex in Chapter 3 for suggested values.

6.5.6.44 IN1-44 Insured's Employer_s Address (XAD) 00469

Definition: This field contains the address of the insured employee_s employer. Multiple addresses for the same employer may be sent in this field. The mailing address must be sent first. When the mailing address is not sent, a repeat delimiter must be sent first for the first repetition.

6.5.6.45 IN1-45 Verification Status (ST) 00470

Definition: This field contains the status of this patient_s relationship with this insurance carrier.

6.5.6.46 IN1-46 Prior Insurance Plan ID (IS) 00471

Definition: This field uniquely identifies the prior insurance plan when the plan ID changes. Refer to User-defined Table 0072 - Insurance Plan ID for suggested values.

6.5.6.47 IN1-47 Coverage Type (IS) 01227

Definition: This field contains the coding structure that identifies the type of insurance coverage, or what types of services are covered for the purposes of a billing system. For example, a physician billing system will only want to receive insurance information for plans that cover physician/professional charges. Refer to User-defined Table 0309 - Coverage Type for suggested values.

User-defined Table 0309 - Coverage Type

Value	Description	Comment
H	Hospital/institutional
P	Physician/professional
B	Both hospital and physician

6.5.6.48 IN1-48 Handicap (IS) 00753

Definition: This field contains a code to describe the insured_s disability. Refer to User-defined Table 0295 - Handicap in Chapter 3 for suggested values.

6.5.6.49 IN1-49 Insured_s ID Number (CX) 01230

Definition: This data element contains a healthcare institution_s identifiers for the insured. The assigning authority and identifier type code are strongly recommended for all CX data types.

6.5.6.50 IN1-50 Signature Code (IS) 01854

Definition: This field contains the code to indicate how the patient/subscriber authorization signature was obtained and how it is being retained by the provider. Refer to User-defined Table 0535 - Signature Code for suggested values.

User-defined Table 0535 - Signature Code

Value	Description	Comment
C	Signed CMS-1500 claim form on file, e.g. authorization for release of any medical or other information necessary to process this claim and assignment of benefits.
S	Signed authorization for release of any medical or other information necessary to process this claim on file.
M	Signed authorization for assignment of benefits on file.
P	Signature generated by provider because the patient was not physically present for services.

6.5.6.51 IN1-51 Signature Code Date (DT) 01855

Definition: The date the patient/subscriber authorization signature was obtained.

6.5.6.52 IN1-52 Insured_s Birth Place (ST) 01899

Definition: This field contains the description of the insured_s birth place, for example _St. Francis Community Hospital of Lower South Side._ The actual address is reported in IN1-19 _ Insured_s Address with an identifier of _N_.

6.5.6.53 IN1-53 VIP Indicator (IS) 01852

Definition: This field identifies the type of VIP for the insured. Refer to User-defined Table 0099 _ VIP indicator in Chapter 3 for suggested values.

6.5.7 IN2 - Insurance Additional Information Segment

The IN2 segment contains additional insurance policy coverage and benefit information necessary for proper billing and reimbursement. Fields used by this segment are defined by CMS or other regulatory agencies.

HL7 Attribute Table - IN2 - Insurance Additional Information

SEQ	LEN	DT	OPT	RP/#	TBL#	ITEM#	ELEMENT NAME	DB Ref.
1	250	CX	O	Y		00472	Insured_s Employee ID	DB
2	11	ST	O			00473	Insured_s Social Security Number	DB
3	250	XCN	O	Y		00474	Insured_s Employer_s Name and ID	DB
4	1	IS	O		0139	00475	Employer Information Data	DB
5	1	IS	O	Y	0137	00476	Mail Claim Party	DB
6	15	ST	O			00477	Medicare Health Ins Card Number	DB
7	250	XPN	O	Y		00478	Medicaid Case Name	DB
8	15	ST	O			00479	Medicaid Case Number	DB
9	250	XPN	O	Y		00480	Military Sponsor Name	DB
10	20	ST	O			00481	Military ID Number	DB
11	250	CE	O		0342	00482	Dependent Of Military Recipient	DB
12	25	ST	O			00483	Military Organization	DB
13	25	ST	O			00484	Military Station	DB
14	14	IS	O		0140	00485	Military Service	DB
15	2	IS	O		0141	00486	Military Rank/Grade	DB
16	3	IS	O		0142	00487	Military Status	DB
17	8	DT	O			00488	Military Retire Date	DB
18	1	ID	O		0136	00489	Military Non-Avail Cert On File	DB
19	1	ID	O		0136	00490	Baby Coverage	DB
20	1	ID	O		0136	00491	Combine Baby Bill	DB
21	1	ST	O			00492	Blood Deductible	DB
22	250	XPN	O	Y		00493	Special Coverage Approval Name	DB
23	30	ST	O			00494	Special Coverage Approval Title	DB
24	8	IS	O	Y	0143	00495	Non-Covered Insurance Code	DB
25	250	CX	O	Y		00496	Payor ID	DB
26	250	CX	O	Y		00497	Payor Subscriber ID	DB
27	1	IS	O		0144	00498	Eligibility Source	DB
28	82	RMC	O	Y		00499	Room Coverage Type/Amount	DB
29	56	PTA	O	Y		00500	Policy Type/Amount	DB
30	25	DDI	O			00501	Daily Deductible	DB
31	2	IS	O		0223	00755	Living Dependency	DB
32	2	IS	O	Y	0009	00145	Ambulatory Status	DB
33	250	CE	O	Y	0171	00129	Citizenship	DB
34	250	CE	O		0296	00118	Primary Language	DB
35	2	IS	O		0220	00742	Living Arrangement	DB
36	250	CE	O		0215	00743	Publicity Code	DB
37	1	ID	O		0136	00744	Protection Indicator	DB
38	2	IS	O		0231	00745	Student Indicator	DB
39	250	CE	O		0006	00120	Religion	DB
40	250	XPN	O	Y		00109	Mother_s Maiden Name	DB
41	250	CE	O		0212	00739	Nationality	DB
42	250	CE	O	Y	0189	00125	Ethnic Group	DB
43	250	CE	O	Y	0002	00119	Marital Status	DB
44	8	DT	O			00787	Insured_s Employment Start Date	DB
45	8	DT	O			00783	Employment Stop Date	DB
46	20	ST	O			00785	Job Title	DB
47	20	JCC	O			00786	Job Code/Class	DB
48	2	IS	O		0311	00752	Job Status	DB
49	250	XPN	O	Y		00789	Employer Contact Person Name	DB
50	250	XTN	O	Y		00790	Employer Contact Person Phone Number	DB
51	2	IS	O		0222	00791	Employer Contact Reason	DB
52	250	XPN	O	Y		00792	Insured_s Contact Person_s Name	DB
53	250	XTN	O	Y		00793	Insured_s Contact Person Phone Number	DB
54	2	IS	O	Y	0222	00794	Insured_s Contact Person Reason	DB
55	8	DT	O			00795	Relationship to the Patient Start Date	DB
56	8	DT	O	Y		00796	Relationship to the Patient Stop Date	DB
57	2	IS	O		0232	00797	Insurance Co. Contact Reason	DB
58	250	XTN	O			00798	Insurance Co Contact Phone Number	DB
59	2	IS	O		0312	00799	Policy Scope	DB
60	2	IS	O		0313	00800	Policy Source	DB
61	250	CX	O			00801	Patient Member Number	DB
62	250	CE	O		0063	00802	Guarantor_s Relationship to Insured	DB
63	250	XTN	O	Y		00803	Insured_s Phone Number - Home	DB
64	250	XTN	O	Y		00804	Insured_s Employer Phone Number	DB
65	250	CE	O		0343	00805	Military Handicapped Program	DB
66	1	ID	O		0136	00806	Suspend Flag	DB
67	1	ID	O		0136	00807	Copay Limit Flag	DB
68	1	ID	O		0136	00808	Stoploss Limit Flag	DB
69	250	XON	O	Y		00809	Insured Organization Name and ID	DB
70	250	XON	O	Y		00810	Insured Employer Organization Name and ID	DB
71	250	CE	O	Y	0005	00113	Race	DB
72	250	CE	O		0344	00811	CMS Patient_s Relationship to Insured	DB

6.5.7.0 IN2 Field Definitions

6.5.7.1 IN2-1 Insured's Employee ID (CX) 00472

Definition: This field contains the employee ID of the insured. The assigning authority and identifier type code are strongly recommended for all CX data types.

6.5.7.2 IN2-2 Insured_s Social Security Number (ST) 00473

Definition: This field contains the social security number of the insured.

6.5.7.3 IN2-3 Insured's Employer_s Name and ID (XCN) 00474

Definition: This field contains the name and ID of the insured_s employer or the person who purchased the insurance for the insured, if the employer is a person. Multiple names and identifiers for the same person may be sent in this field, not multiple persons. The legal name is assumed to be in the first repetition. When the legal name is not sent, a repeat delimiter must be sent first for the first repetition. When the employer is an organization use IN2-70 - Insured Employer Organization Name and ID.

6.5.7.4 IN2-4 Employer Information Data (IS) 00475

Definition: This field contains the required employer information data for UB82 form locator 71. Refer to User-defined Table 0139 - Employer Information Data for suggested values.

User-defined Table 0139 - Employer Information Data

Value	Description	Comment
	No suggested values defined

6.5.7.5 IN2-5 Mail Claim Party (IS) 00476

Definition: This field contains the party to which the claim should be mailed. Refer to User-defined Table 0137 - Mail claim party for suggested values.

User-defined Table 0137 - Mail Claim Party

Value	Description	Comment
E	Employer
G	Guarantor
I	Insurance company
O	Other
P	Patient

6.5.7.6 IN2-6 Medicare Health Ins Card Number (ST) 00477

Definition: This field contains the Medicare Health Insurance Number (HIN), defined by CMS or other regulatory agencies.

6.5.7.7 IN2-7 Medicaid Case Name (XPN) 00478

Definition: This field contains the Medicaid case name, defined by CMS or other regulatory agencies. Multiple names for the same person may be sent in this field. The legal name is assumed to be in the first repetition. When the legal name is not sent, a repeat delimiter must be sent first for the first repetition.

6.5.7.8 IN2-8 Medicaid Case Number (ST) 00479

Definition: This field contains the Medicaid case number, defined by CMS or other regulatory agencies, which uniquely identifies a patient_s Medicaid policy.

6.5.7.9 IN2-9 Military Sponsor Name (XPN) 00480

Definition: This field is defined by CMS or other regulatory agencies. Multiple names for the same person may be sent in this field. The legal name is assumed to be in the first repetition. When the legal name is not sent, a repeat delimiter must be sent first for the first repetition.

6.5.7.10 IN2-10 Military ID Number (ST) 00481

Definition: This field contains the military ID number, defined by CMS or other regulatory agencies, which uniquely identifies a patient_s military policy.

6.5.7.11 IN2-11 Dependent of Military Recipient (CE) 00482

Components: <Identifier (ST)> ^ <Text (ST)> ^ <Name of Coding System (ID)> ^ <Alternate Identifier (ST)> ^ <Alternate Text (ST)> ^ <Name of Alternate Coding System (ID)>

Definition: This field is defined by CMS or other regulatory agencies. Refer to User-defined Table 0342 - Military Recipient for suggested values.

User-defined Table 0342 - Military Recipient

Value	Description	Comment
	No suggested values defined

6.5.7.12 IN2-12 Military Organization (ST) 00483

Definition: This field is defined by CMS or other regulatory agencies.

6.5.7.13 IN2-13 Military Station (ST) 00484

Definition: This field is defined by CMS or other regulatory agencies.

6.5.7.14 IN2-14 Military Service (IS) 00485

Definition: This field is defined by CMS or other regulatory agencies and refers to the military branch of service. Refer to User-defined Table 0140 - Military Service in Chapter 3 for suggested values. The UB codes listed may not represent a complete list; refer to a UB specification for additional information.

6.5.7.15 IN2-15 Military Rank/Grade (IS) 00486

Definition: This user-defined field identifies the military rank/grade of the insured. Refer to User-defined Table 0141 - Military Rank/Grade in Chapter 3 for suggested values.

6.5.7.16 IN2-16 Military Status (IS) 00487

Definition: This field is defined by CMS or other regulatory agencies. Refer to User-defined Table 0142 - Military Status in Chapter 3 for suggested values. The UB codes listed may not represent a complete list; refer to a UB specification for additional information

6.5.7.17 IN2-17 Military Retire Date (DT) 00488

Definition: This field is defined by CMS or other regulatory agencies.

6.5.7.18 IN2-18 Military Non-Avail Cert on File (ID) 00489

Definition: Refer to HL7 table 0136 - Yes/no Indicator for valid values.

Y Certification on file

N Certification not on file

6.5.7.19 IN2-19 Baby Coverage (ID) 00490

Definition: Refer to HL7 table 0136 - Yes/no Indicator for valid values.

Y Baby coverage

N no baby coverage

6.5.7.20 IN2-20 Combine Baby Bill (ID) 00491

Definition: Refer to HL7 table 0136 - Yes/no Indicator for valid values.

Y combine bill

N normal billing

6.5.7.21 IN2-21 Blood Deductible (ST) 00492

Definition: Use this field instead of UB1-2 - Blood Deductible, as the blood deductible can be associated with the specific insurance plan via this field.

6.5.7.22 IN2-22 Special Coverage Approval Name (XPN) 00493

Definition: This field contains the name of the individual who approves any special coverage. Multiple names for the same person may be sent in this field. The legal name is assumed to be in the first repetition. When the legal name is not sent, a repeat delimiter must be sent first for the first repetition.

6.5.7.23 IN2-23 Special Coverage Approval Title (ST) 00494

Definition: This field contains the title of the person who approves special coverage.

6.5.7.24 IN2-24 Non-Covered Insurance Code (IS) 00495

Definition: This field contains the code that describes why a service is not covered. Refer to User-defined Table 0143 - Non-covered Insurance Code for suggested values.

User-defined Table 0143 - Non-covered Insurance Code

Value	Description	Comment
	No suggested values defined

6.5.7.25 IN2-25 Payor ID (CX) 00496

Definition: In the US this field is required for ENVOY Corporation (a US claims clearing house) processing, and it identifies the organization from which reimbursement is expected. This field can also be used to report the National Health Plan ID. The assigning authority and identifier type code are strongly recommended for all CX data types.

6.5.7.26 IN2-26 Payor Subscriber ID (CX) 00497

Definition: In the US this field is required for ENVOY Corporation processing, and it identifies the specific office within the insurance carrier that is designated as responsible for the claim. The assigning authority and identifier type code are strongly recommended for all CX data types.

6.5.7.27 IN2-27 Eligibility Source (IS) 00498

Definition: In the US this field is required for ENVOY Corporation processing, and it identifies the source of information about the insured_s eligibility for benefits. Refer to User-defined Table 0144 - Eligibility Source for suggested values.

User-defined Table 0144 - Eligibility Source

Value	Description	Comment
1	Insurance company
2	Employer
3	Insured presented policy
4	Insured presented card
5	Signed statement on file
6	Verbal information
7	None

6.5.7.28 IN2-28 Room Coverage Type/Amount (RMC) 00499

Components: <Room Type (IS)> ^ <Amount Type (IS)> ^ <DEPRECATED-Coverage Amount (NM)> ^ <Money or Percentage (MOP)>

Subcomponents for Money or Percentage (MOP): <Money or Percentage Indicator (ID)> & <Money or Percentage Quantity (NM)> & <Currency Denomination (ID)>

Definition: Use this field instead of IN1-40 - Room Rate - Semi-Private and IN1-41 - Room Rate - Private. This field contains room type (e.g., private, semi-private), amount type (e.g., limit, percentage) and amount covered by the insurance.

6.5.7.29 IN2-29 Policy Type/Amount (PTA) 00500

Components: <Policy Type (IS)> ^ <Amount Class (IS)> ^ <DEPRECATED-Money or Percentage Quantity (NM)> ^ <Money or Percentage (MOP)>

Subcomponents for Money or Percentage (MOP): <Money or Percentage Indicator (ID)> & <Money or Percentage Quantity (NM)> & <Currency Denomination (ID)>

Definition: This field contains the policy type (e.g., ancillary, major medical) and amount (e.g., amount, percentage, limit) covered by the insurance. Use this field instead of IN1-38 - Policy Limit - Amount.

6.5.7.30 IN2-30 Daily Deductible (DDI) 00501

Components: <Delay Days (NM)> ^ <Monetary Amount (MO)> ^ <Number of Days (NM)>

Subcomponents for Monetary Amount (MO): <Quantity (NM)> & <Denomination (ID)>

Definition: This field contains the number of days after which the daily deductible begins, the amount of the deductible, and the number of days to apply the deductible.

If "number of days" is not valued, the deductible is ongoing.

6.5.7.31 IN2-31 Living Dependency (IS) 00755

Definition: This field identifies the specific living conditions for the insured. Refer to User-defined Table 0223 - Living Dependency in Chapter 3 for suggested values.

6.5.7.32 IN2-32 Ambulatory Status (IS) 00145

Definition: This field identifies the insured_s state of mobility. Refer to User-defined Table 0009 - Ambulatory Status in Chapter 3 for suggested values.

6.5.7.33 IN2-33 Citizenship (CE) 00129

Components: <Identifier (ST)> ^ <Text (ST)> ^ <Name of Coding System (ID)> ^ <Alternate Identifier (ST)> ^ <Alternate Text (ST)> ^ <Name of Alternate Coding System (ID)>

Definition: This field contains the code that identifies the insured_s citizenship. HL7 recommends using ISO table 3166 as the suggested values in User-defined Table 0171 - Citizenship defined in Chapter 3.

6.5.7.34 IN2-34 Primary Language (CE) 00118

Components: <Identifier (ST)> ^ <Text (ST)> ^ <Name of Coding System (ID)> ^ <Alternate Identifier (ST)> ^ <Alternate Text (ST)> ^ <Name of Alternate Coding System (ID)>

Definition: This field identifies the insured_s primary speaking language. HL7 recommends using ISO table 639 as the suggested values in User-defined Table 0296 - Primary Language defined in Chapter 3.

6.5.7.35 IN2-35 Living Arrangement (IS) 00742

Definition: This field indicates the situation in which the insured person lives at his primary residence. Refer to User-defined Table 0220 - Living Arrangement in Chapter 3 for suggested values.

6.5.7.36 IN2-36 Publicity Code (CE) 00743

Components: <Identifier (ST)> ^ <Text (ST)> ^ <Name of Coding System (ID)> ^ <Alternate Identifier (ST)> ^ <Alternate Text (ST)> ^ <Name of Alternate Coding System (ID)>

Definition: This field contains a user-defined code indicating what level of publicity is allowed (e.g., No Publicity, Family Only) for the insured. Refer to User-defined Table 0215 - Publicity Code in Chapter 3 for suggested values.

6.5.7.37 IN2-37 Protection Indicator (ID) 00744

Definition: This field identifies the insured_s protection, which determines whether or not access to information about this enrollee should be restricted from users who do not have adequate authority. Refer to HL7 table 0136 - Yes/no Indicator for valid values.

Y restrict access

N do not restrict access

6.5.7.38 IN2-38 Student Indicator (IS) 00745

Definition: This field identifies whether the insured is currently a student or not, and whether the insured is a full-time or a part-time student. This field does not indicate the degree level (high school, college) of student, or his/her field of study (accounting, engineering, etc.). Refer to User-defined Table 0231 - Student Status for suggested values.

6.5.7.39 IN2-39 Religion (CE) 00120

Components: <Identifier (ST)> ^ <Text (ST)> ^ <Name of Coding System (ID)> ^ <Alternate Identifier (ST)> ^ <Alternate Text (ST)> ^ <Name of Alternate Coding System (ID)>

Definition: This field indicates the type of religion practiced by the insured. Refer to User-defined Table 0006 - Religion in Chapter 3 for suggested values.

6.5.7.40 IN2-40 Mother_s Maiden Name (XPN) 00109

Definition: This field indicates the insured_s mother_s maiden name.

6.5.7.41 IN2-41 Nationality (CE) 00739

Components: <Identifier (ST)> ^ <Text (ST)> ^ <Name of Coding System (ID)> ^ <Alternate Identifier (ST)> ^ <Alternate Text (ST)> ^ <Name of Alternate Coding System (ID)>

Definition: This field contains a code that identifies the nation or national grouping to which the insured person belongs. This information may be different from a person_s citizenship in countries in which multiple nationalities are recognized (for example, Spain: Basque, Catalan, etc.). HL7 recommends using ISO table 3166 as the suggested values in User-defined Table 0212 - Nationality in Chapter 3.

6.5.7.42 IN2-42 Ethnic Group (CE) 00125

Components: <Identifier (ST)> ^ <Text (ST)> ^ <Name of Coding System (ID)> ^ <Alternate Identifier (ST)> ^ <Alternate Text (ST)> ^ <Name of Alternate Coding System (ID)>

Definition: This field indicates the insured_s ethnic group. Refer to User-defined Table 0189 - Ethnic Group in Chapter 3 for suggested values. The second triplet of the CE data type for ethnic group (alternate identifier, alternate text, and name of alternate coding system) is reserved for governmentally assigned codes. In the US, a current use is to report ethnicity in line with US federal standards for Hispanic origin.

6.5.7.43 IN2-43 Marital Status (CE) 00119

Components: <Identifier (ST)> ^ <Text (ST)> ^ <Name of Coding System (ID)> ^ <Alternate Identifier (ST)> ^ <Alternate Text (ST)> ^ <Name of Alternate Coding System (ID)>

Definition: This field contains the insured_s marital status. Refer to User-defined Table 0002 - Marital Status in Chapter 3 for suggested values.

6.5.7.44 IN2-44 Insured_s Employment Start Date (DT) 00787

Definition: This field indicates the date on which the insured_s employment with a particular employer began.

6.5.7.45 IN2-45 Employment Stop Date (DT) 00783

Definition: This field indicates the date on which the person_s employment with a particular employer ended.

6.5.7.46 IN2-46 Job Title (ST) 00785

Definition: This field contains a descriptive name for the insured_s occupation (for example, Sr. Systems Analyst, Sr. Accountant).

6.5.7.47 IN2-47 Job Code/Class (JCC) 00786

Components: <Job Code (IS)> ^ <Job Class (IS)> ^ <Job Description Text (TX)>

6.5.7.48 Definition: This field indicates a code that identifies the insured_s job code (for example, programmer, analyst, doctor, etc.). IN2-48 Job Status (IS) 00752

Definition: This field indicates a code that identifies the insured_s current job status. Refer to User-defined Table 0311 - Job Status for values.

6.5.7.49 IN2-49 Employer Contact Person Name (XPN) 00789

Definition: This field contains the name of the contact person that should be contacted at the insured_s place of employment. (Joe Smith is the insured. He works at GTE. Contact Sue Jones at GTE regarding Joe Smith_s policy). Multiple names for the same person may be sent in this sequence. The legal name is assumed to be in the first repetition. When the legal name is not sent, a repeat delimiter must be sent first for the first repetition.

6.5.7.50 IN2-50 Employer Contact Person Phone Number (XTN) 00790

Definition: This field contains the telephone number for Sue Jones who is the contact person at GTE (Joe Smith_s place of employment). Joe Smith is the insured. Multiple phone numbers for the same contact person may be sent in this sequence, not multiple contacts. The primary telephone number is assumed to be in the first repetition. When no primary telephone number is sent, a repeat delimiter must be present for the first repetition.

6.5.7.51 IN2-51 Employer Contact Reason (IS) 00791

Definition: This field contains the reason(s) that Sue Jones should be contacted on behalf of Joe Smith, a GTE employer. Refer to User-defined Table 0222 - Contact Reason for suggested values.

6.5.7.52 IN2-52 Insured_s Contact Person_s Name (XPN) 00792

Definition: This field contains the contact person for the insured.

6.5.7.53 IN2-53 Insured_s Contact Person Phone Number (XTN) 00793

Definition: This field contains the telephone number for the contact person for the insured. Multiple phone numbers for the same person may be sent in this contact, not multiple contacts. The primary telephone number is assumed to be in the first repetition. When the primary telephone number is not sent, a repeat delimiter must be sent first for the first repetition.

6.5.7.54 IN2-54 Insured_s Contact Person Reason (IS) 00794

Definition: This field contains the reason(s) the person should be contacted regarding the insured. Refer to User-defined Table 0222 - Contact Reason for suggested values

6.5.7.55 IN2-55 Relationship to the Patient Start Date (DT) 00795

Definition: This field indicates the date on which the insured_s patient relationship (defined in IN1-17 - Insured_s Relationship to Patient) became effective (began).

6.5.7.56 IN2-56 Relationship to the Patient Stop Date (DT) 00796

Definition: This field indicates the date after which the relationship (defined in IN1-17 - Insured_s Relationship to Patient) is no longer effective.

6.5.7.57 IN2-57 Insurance Co Contact Reason (IS) 00797

Definition: This field contains a user-defined code that specifies how the contact should be used. Refer to User-defined Table 0232 - Insurance Company Contact Reason for suggested values.

User-defined Table 0232 - Insurance Company Contact Reason

Value	Description	Comment
01	Medicare claim status
02	Medicaid claim status
03	Name/address change

6.5.7.58 IN2-58 Insurance Co Contact Phone Number (XTN) 00798

Definition: This field contains the telephone number of the person who should be contacted at the insurance company for questions regarding an insurance policy/claim, etc. Multiple phone numbers for the insurance company may be sent in this sequence. The primary telephone number is assumed to be in the first repetition. When the primary telephone number is not sent, a repeat delimiter must be sent first for the first repetition.

6.5.7.59 IN2-59 Policy Scope (IS) 00799

Definition: This field contains a user-defined code designating the extent of the coverage for a participating member (e.g., _single,_ _family,_ etc. Refer to User-defined Table 0312 - Policy Scope for suggested values.

User-defined Table 0312 - Policy Scope

Value	Description	Comment
	No suggested values defined

6.5.7.60 IN2-60 Policy source (IS) 00800

Definition: This user-defined field identifies how the policy information got established. Refer to User-defined Table 0313 - Policy source for suggested values.

User-defined Table 0313 - Policy Source

Value	Description	Comment
	No suggested values defined

6.5.7.61 IN2-61 Patient f Number (CX) 00801

Definition: This field contains an identifying number assigned by the payor for each individual covered by the insurance policy issued to the insured. For example, each individual family member may have a different member number from the insurance policy number issued to the head of household. The assigning authority and identifier type code are strongly recommended for all CX data types.

6.5.7.62 IN2-62 Guarantor_s Relationship to Insured (CE) 00802

Components: <Identifier (ST)> ^ <Text (ST)> ^ <Name of Coding System (ID)> ^ <Alternate Identifier (ST)> ^ <Alternate Text (ST)> ^ <Name of Alternate Coding System (ID)>

Definition: This field specifies the relationship of the guarantor to the insurance subscriber. Refer to User-defined Table 0063 - Relationship in Chapter 3 for suggested values.

6.5.7.63 IN2-63 Insured_s Phone Number - Home (XTN) 00803

Definition: The value of this field represents the insured_s telephone number. Multiple phone numbers may be sent in this sequence. The primary telephone number is assumed to be in the first repetition (PRN - Primary, PH - Telephone). When the primary telephone number is not sent, a repeat delimiter must be sent first for the first repetition.

6.5.7.64 IN2-64 Insured_s Employer Phone Number (XTN) 00804

Definition: The value of this field represents the insured_s employer_s telephone number. Multiple phone numbers may be sent in this sequence. The primary telephone number is assumed to be in the first repetition. When the primary telephone number is not sent, a repeat delimiter must be sent first for the first repetition.

6.5.7.65 IN2-65 Military Handicapped Program (CE) 00805

Components: <Identifier (ST)> ^ <Text (ST)> ^ <Name of Coding System (ID)> ^ <Alternate Identifier (ST)> ^ <Alternate Text (ST)> ^ <Name of Alternate Coding System (ID)>

Definition: This field indicates the military program for the handicapped in which the patient is enrolled. Refer to User-defined Table 0343 - Military Handicapped Program Code for suggested values.

User-defined Table 0343 - Military Handicapped Program Code

Value	Description	Comment
	No suggested values defined

6.5.7.66 IN2-66 Suspend Flag (ID) 00806

Definition: This field indicates whether charges should be suspended for a patient. Refer to HL7 table 0136 - Yes/no Indicator for valid values.

Y charges should be suspended

N charges should NOT be suspended

6.5.7.67 IN2-67 Copay Limit Flag (ID) 00807

Definition: This field indicates if the patient has reached the co-pay limit so that no more co-pay charges should be calculated for the patient. Refer to HL7 table 0136 - Yes/no Indicator for valid values.

Y the patient is at or exceeds the co-pay limit

N the patient is under the co-pay limit

6.5.7.68 IN2-68 Stoploss Limit Flag (ID) 00808

Definition: This field indicates if the patient has reached the stoploss limit established in the Contract Master. Refer to HL7 table 0136 - Yes/no Indicator for valid values.

Y the patient has reached the stoploss limit

N the patient has not reached the stoploss limit

6.5.7.69 IN2-69 Insured Organization Name and ID (XON) 00809

Definition: This field indicates the name of the insured if the insured/subscriber is an organization. Multiple names for the insured may be sent in this sequence, not multiple insured people. The legal name is assumed to be in the first repetition. When the legal name is not sent, a repeat delimiter must be sent first for the first repetition.

6.5.7.70 IN2-70 Insured Employer Organization Name and ID (XON) 00810

Definition: This field indicates the name of the insured_s employer, or the organization that purchased the insurance for the insured, if the employer is an organization. Multiple names and identifiers for the same organization may be sent in this field, not multiple organizations. The legal name is assumed to be in the first repetition. When the legal name is not sent, a repeat delimiter must be sent first for the first repetition.

6.5.7.71 IN2-71 Race (CE) 00113

Components: <Identifier (ST)> ^ <Text (ST)> ^ <Name of Coding System (ID)> ^ <Alternate Identifier (ST)> ^ <Alternate Text (ST)> ^ <Name of Alternate Coding System (ID)>

Definition: Refer to User-defined Table 0005 - Race in Chapter 3 for suggested values. The second triplet of the CE data type for race (alternate identifier, alternate text, and name of alternate coding system) is reserved for governmentally assigned codes.

6.5.7.72 IN2-72 Patient_s Relationship to Insured (CE) 00811

Components: <Identifier (ST)> ^ <Text (ST)> ^ <Name of Coding System (ID)> ^ <Alternate Identifier (ST)> ^ <Alternate Text (ST)> ^ <Name of Alternate Coding System (ID)>

Definition: This field indicates the relationship of the patient to the insured, as defined by CMS or other regulatory agencies. Refer to User-defined Table 0344 - Patient_s Relationship to Insured for suggested values. The UB codes listed may not represent a complete list; refer to a UB specification for additional information.

User-defined Table 0344 - Patient_s Relationship to Insured

Value	Description	Comment
01	Patient is insured
02	Spouse
03	Natural child/insured financial responsibility
04	Natural child/Insured does not have financial responsibility
05	Step child
06	Foster child
07	Ward of the court
08	Employee
09	Unknown
10	Handicapped dependent
11	Organ donor
12	Cadaver donor
13	Grandchild
14	Niece/nephew
15	Injured plaintiff
16	Sponsored dependent
17	Minor dependent of a minor dependent
18	Parent
19	Grandparent

6.5.8 IN3 - Insurance Additional Information, Certification Segment

The IN3 segment contains additional insurance information for certifying the need for patient care. Fields used by this segment are defined by CMS, or other regulatory agencies.

HL7 Attribute Table - IN3 - Insurance Additional Information, Certification

SEQ	LEN	DT	OPT	RP/#	TBL#	ITEM#	ELEMENT NAME	DB Ref.
1	4	SI	R			00502	Set ID - IN3	DB
2	250	CX	O			00503	Certification Number	DB
3	250	XCN	O	Y		00504	Certified By	DB
4	1	ID	O		0136	00505	Certification Required	DB
5	23	MOP	O			00506	Penalty	DB
6	26	TS	O			00507	Certification Date/Time	DB
7	26	TS	O			00508	Certification Modify Date/Time	DB
8	250	XCN	O	Y		00509	Operator	DB
9	8	DT	O			00510	Certification Begin Date	DB
10	8	DT	O			00511	Certification End Date	DB
11	6	DTN	O			00512	Days	DB
12	250	CE	O		0233	00513	Non-Concur Code/Description	DB
13	26	TS	O			00514	Non-Concur Effective Date/Time	DB
14	250	XCN	O	Y	0010	00515	Physician Reviewer	DB
15	48	ST	O			00516	Certification Contact	DB
16	250	XTN	O	Y		00517	Certification Contact Phone Number	DB
17	250	CE	O		0345	00518	Appeal Reason	DB
18	250	CE	O		0346	00519	Certification Agency	DB
19	250	XTN	O	Y		00520	Certification Agency Phone Number	DB
20	40	ICD	O	Y		00521	Pre-Certification Requirement	DB
21	48	ST	O			00522	Case Manager	DB
22	8	DT	O			00523	Second Opinion Date	DB
23	1	IS	O		0151	00524	Second Opinion Status	DB
24	1	IS	O	Y	0152	00525	Second Opinion Documentation Received	DB
25	250	XCN	O	Y	0010	00526	Second Opinion Physician	DB

6.5.8.0 IN3 Field Definitions

6.5.8.1 IN3-1 Set ID - IN3 (SI) 00502

Definition: IN3-1 - Set ID - IN3 contains the number that identifies this transaction. For the first occurrence of the segment the sequence number shall be 1, for the second occurrence it shall be 2, etc. The set ID in the IN3 segment is used when there are multiple certifications for the insurance plan identified in IN1-2.

6.5.8.2 IN3-2 Certification Number (CX) 00503

Definition: This field contains the number assigned by the certification agency. The assigning authority and identifier type code are strongly recommended for all CX data types.

6.5.8.3 IN3-3 Certified By (XCN) 00504

Definition: This field contains the party that approved the certification. Multiple names and identifiers for the same person may be sent in this sequence. The legal name is assumed to be in the first repetition. When the legal name is not sent, a repeat delimiter must be sent first for the first repetition.

6.5.8.4 IN3-4 Certification Required (ID) 00505

Definition: This field indicates whether certification is required. Refer to HL7 table 0136 - Yes/no Indicator for valid values.

Y certification required

N certification not required

6.5.8.5 IN3-5 Penalty (MOP) 00506

Components: <Money or Percentage Indicator (ID)> ^ <Money or Percentage Quantity (NM)> ^ <Currency Denomination (ID)>

Definition: This field contains the penalty, in dollars or a percentage that will be assessed if the pre-certification is not performed.

6.5.8.6 IN3-6 Certification Date/Time (TS) 00507

Components: <Time (DTM)> ^ <DEPRECATED-Degree of Precision (ID)>

Definition: This field contains the date and time stamp that indicates when insurance was certified to exist for the patient.

6.5.8.7 IN3-7 Certification Modify Date/Time (TS) 00508

Components: <Time (DTM)> ^ <DEPRECATED-Degree of Precision (ID)>

Definition: This field contains the date/time that the certification was modified.

6.5.8.8 IN3-8 Operator (XCN) 00509

Definition: This field contains the name party who is responsible for sending this certification information. Multiple names for the same person may be sent in this sequence. The legal name is assumed to be in the first repetition. When the legal name is not sent, a repeat delimiter must be sent first for the first repetition.

6.5.8.9 IN3-9 Certification Begin Date (DT) 00510

Definition: This field contains the date that this certification begins.

6.5.8.10 IN3-10 Certification End Date (DT) 00511

Definition: This field contains date that this certification ends.

6.5.8.11 IN3-11 Days (DTN) 00512

Components: <Day Type (IS)> ^ <Number of Days (NM)>

Definition: This field contains the number of days for which this certification is valid. This field applies to denied, pending, or approved days.

6.5.8.12 IN3-12 Non-Concur Code/Description (CE) 00513

Components: <Identifier (ST)> ^ <Text (ST)> ^ <Name of Coding System (ID)> ^ <Alternate Identifier (ST)> ^ <Alternate Text (ST)> ^ <Name of Alternate Coding System (ID)>

Definition: This field contains the non-concur code and description for a denied request. Refer to User-defined Table 0233 - Non-Concur Code/Description for suggested values.

User-defined Table 0233 - Non-Concur Code/Description

Value	Description	Comment
	No suggested values defined

6.5.8.13 IN3-13 Non-Concur Effective Date/Time (TS) 00514

Components: <Time (DTM)> ^ <DEPRECATED-Degree of Precision (ID)>

Definition: This field contains the effective date of the non-concurrence classification.

6.5.8.14 IN3-14 Physician Reviewer (XCN) 00515

Definition: This field contains the physician who works with and reviews cases that are pending physician review for the certification agency. Multiple names for the same person may be sent in this sequence. The legal name is assumed to be in the first repetition. When the legal name is not sent, a repeat delimiter must be sent first for the first repetition. Refer to User-defined Table 0010 - Physician ID in Chapter 3 for suggested values.

6.5.8.15 IN3-15 Certification Contact (ST) 00516

Definition: This field contains the name of the party contacted at the certification agency who granted the certification and communicated the certification number.

6.5.8.16 IN3-16 Certification Contact Phone Number (XTN) 00517

Definition: This field contains the phone number of the certification contact. Multiple phone numbers for the same certification contact may be sent in this sequence. The primary phone number is assumed to be in the first repetition. When the primary telephone number is not sent, a repeat delimiter must be sent first for the first repetition.

6.5.8.17 IN3-17 Appeal Reason (CE) 00518

Components: <Identifier (ST)> ^ <Text (ST)> ^ <Name of Coding System (ID)> ^ <Alternate Identifier (ST)> ^ <Alternate Text (ST)> ^ <Name of Alternate Coding System (ID)>

Definition: This field contains the reason that an appeal was made on a non-concur for certification. Refer to User-defined Table 0345 - Appeal Reason for suggested values.

User-defined Table 0345 - Appeal Reason

Value	Description	Comment
	No suggested values defined

6.5.8.18 IN3-18 Certification Agency (CE) 00519

Components: <Identifier (ST)> ^ <Text (ST)> ^ <Name of Coding System (ID)> ^ <Alternate Identifier (ST)> ^ <Alternate Text (ST)> ^ <Name of Alternate Coding System (ID)>

Definition: This field contains the certification agency. Refer to User-defined Table 0346 - Certification Agency for suggested values.

User-defined Table 0346 - Certification Agency

Value	Description	Comment
	No suggested values defined

6.5.8.19 IN3-19 Certification Agency Phone Number (XTN) 00520

Definition: This field contains the phone number of the certification agency.

6.5.8.20 IN3-20 Pre-Certification Requirement (ICD) 00521

Components: <Certification Patient Type (IS)> ^ <Certification Required (ID)> ^ <Date/Time Certification Required (TS)>

Subcomponents for Date/Time Certification Required (TS): <Time (DTM)> & <DEPRECATED-Degree of Precision (ID)>

Definition: This field indicates whether pre-certification is required for particular patient types, and the time window for obtaining the certification. The following components of this field are defined as follows:

pre-certification required refers to HL7 table 0136 - Yes/no Indicator for valid values

Y pre-certification required

N no pre-certification required

pre-certification window is the date/time by which the pre-certification must be obtained.

6.5.8.21 IN3-21 Case Manager (ST) 00522

Definition: This field contains the name of the entity, which is handling this particular patient_s case (e.g., UR nurse, or a specific healthcare facility location).

6.5.8.22 IN3-22 Second Opinion Date (DT) 00523

Definition: This field contains the date that the second opinion was obtained.

6.5.8.23 IN3-23 Second Opinion Status (IS) 00524

Definition: This field contains the code that represents the status of the second opinion. Refer to User-defined Table 0151 - Second Opinion Status for suggested values.

User-defined Table 0151 - Second Opinion Status

Value	Description	Comment
	No suggested values defined

6.5.8.24 IN3-24 Second Opinion Documentation Received (IS) 00525

Definition: Use this field if accompanying documentation has been received by the provider. Refer to User-defined Table 0152 - Second Opinion Documentation Received for suggested values.

User-defined Table 0152 - Second Opinion Documentation Received

Value	Description	Comment
	No suggested values defined

6.5.8.25 IN3-25 Second Opinion Physician (XCN) 00526

Definition: This field contains an identifier and name of the physician who provided the second opinion. Multiple names and identifiers for the same person may be sent in this sequence. The legal name is assumed to be in the first repetition. When the legal name is not sent, a repeat delimiter must be sent first for the first repetition. Refer to User-defined Table 0010 - Physician ID in Chapter 3 for suggested values.

6.5.9 ACC - Accident Segment

The ACC segment contains patient information relative to an accident in which the patient has been involved.

HL7 Attribute Table - ACC - Accident

SEQ	LEN	DT	OPT	TBL#	ITEM#	ELEMENT NAME	DB Ref.
1	26	TS	O		00527	Accident Date/Time	DB
2	250	CE	O	0050	00528	Accident Code	DB
3	25	ST	O		00529	Accident Location	DB
4	250	CE	B	0347	00812	Auto Accident State	DB
5	1	ID	O	0136	00813	Accident Job Related Indicator	DB
6	12	ID	O	0136	00814	Accident Death Indicator	DB
7	250	XCN	O		00224	Entered By	DB
8	25	ST	O		01503	Accident Description	DB
9	80	ST	O		01504	Brought In By	DB
10	1	ID	O	0136	01505	Police Notified Indicator	DB
11	250	XAD	O		01853	Accident Address	DB

6.5.9.0 ACC Field Definitions

6.5.9.1 ACC-1 Accident Date/Time (TS) 00527

Components: <Time (DTM)> ^ <DEPRECATED-Degree of Precision (ID)>

Definition: This field contains the date/time of the accident.

6.5.9.2 ACC-2 Accident Code (CE) 00528

Components: <Identifier (ST)> ^ <Text (ST)> ^ <Name of Coding System (ID)> ^ <Alternate Identifier (ST)> ^ <Alternate Text (ST)> ^ <Name of Alternate Coding System (ID)>

Definition: This field contains the type of accident. Refer to User-defined Table 0050 - Accident Code for suggested values. ICD accident codes are recommended.

User-defined Table 0050 - Accident Code

Value	Description	Comment
	No suggested values defined

6.5.9.3 ACC-3 Accident Location (ST) 00529

Definition: This field contains the location of the accident.

6.5.9.4 ACC-4 Auto Accident State (CE) 00812

Components: <Identifier (ST)> ^ <Text (ST)> ^ <Name of Coding System (ID)> ^ <Alternate Identifier (ST)> ^ <Alternate Text (ST)> ^ <Name of Alternate Coding System (ID)>

Definition: As of Version 2.5, this field has been retained for backward compatibility only. Use ACC-11 - Accident Address instead of this field, as the state in which the accident occurred is part of the address. This field specifies the state in which the auto accident occurred. (CMS 1500 requirement in the US.) Refer to User-defined Table 0347 - Auto Accident State for suggested values.

User-defined Table 0347 - Auto Accident State

Value	Description	Comment
	No suggested values defined

6.5.9.5 ACC-5 Accident Job Related Indicator (ID) 00813

Definition: This field indicates if the accident was related to a job. Refer to HL7 Table 0136 - Yes/no Indicator for valid values.

Y the accident was job related

N the accident was not job related

6.5.9.6 ACC-6 Accident Death Indicator (ID) 00814

Definition: This field indicates whether or not a patient has died as a result of an accident. Refer to HL7 Table 0136 - Yes/no Indicator for valid values.

Y the patient has died as a result of an accident

N the patient has not died as a result of an accident

6.5.9.7 ACC-7 Entered By (XCN) 00224

Definition: This field identifies the person entering the accident information.

6.5.9.8 ACC-8 Accident Description (ST) 01503

Definition: Description of the accident.

6.5.9.9 ACC-9 Brought in By (ST) 01504

Definition: This field identifies the person or organization that brought in the patient.

6.5.9.10 ACC-10 Police Notified Indicator (ID) 01505

Definition: This field indicates if the police were notified. Refer to HL7 Table 0136 - Yes/No Indicator for valid values.

Y the police were notified

N the police were not notified.

6.5.9.11 ACC-11 Accident Address (XAD) 01853

Definition: This field contains the address where the accident occurred.

6.5.10 UB1 - UB82 Data Segment

The UB1 segment contains the data necessary to complete UB82 bills specific to the United States; other realms may choose to implement using regional code sets. Only UB82 fields that do not exist in other HL7 defined segments appear in this segment. Patient Name and Date of Birth are required for UB82 billing; however, they are included in the PID segment and therefore do not appear here. The UB codes listed as examples are not an exhaustive or current list. Refer to a UB specification for additional information.

The Uniform Billing segments are specific to the US and may not be implemented in non-US systems.

HL7 Attribute Table - UB1 - UB82

SEQ	LEN	DT	OPT	RP/#	TBL#	ITEM#	ELEMENT NAME	DB Ref.
1	4	SI	O			00530	Set ID - UB1	DB
2	1	NM	B			00531	Blood Deductible (43)	DB
3	2	NM	O			00532	Blood Furnished-Pints Of (40)	DB
4	2	NM	O			00533	Blood Replaced-Pints (41)	DB
5	2	NM	O			00534	Blood Not Replaced-Pints(42)	DB
6	2	NM	O			00535	Co-Insurance Days (25)	DB
7	14	IS	O	Y/5	0043	00536	Condition Code (35-39)	DB
8	3	NM	O			00537	Covered Days - (23)	DB
9	3	NM	O			00538	Non Covered Days - (24)	DB
10	41	UVC	O	Y/8		00539	Value Amount & Code (46-49)	DB
11	2	NM	O			00540	Number Of Grace Days (90)	DB
12	250	CE	O		0348	00541	Special Program Indicator (44)	DB
13	250	CE	O		0349	00542	PSRO/UR Approval Indicator (87)	DB
14	8	DT	O			00543	PSRO/UR Approved Stay-Fm (88)	DB
15	8	DT	O			00544	PSRO/UR Approved Stay-To (89)	DB
16	259	OCD	O	Y/5		00545	Occurrence (28-32)	DB
17	250	CE	O		0351	00546	Occurrence Span (33)	DB
18	8	DT	O			00547	Occur Span Start Date(33)	DB
19	8	DT	O			00548	Occur Span End Date (33)	DB
20	30	ST	B			00549	UB-82 Locator 2	DB
21	7	ST	B			00550	UB-82 Locator 9	DB
22	8	ST	B			00551	UB-82 Locator 27	DB
23	17	ST	B			00552	UB-82 Locator 45	DB

6.5.10.0 UB1 Field Definitions

6.5.10.1 UB1-1 Set ID - UB1 (SI) 00530

Definition: This field contains the number that identifies this transaction. For the first occurrence of the segment the sequence number shall be 1, for the second occurrence it shall be 2, etc.

6.5.10.2 UB1-2 Blood Deductible (43) (NM) 00531

Definition: As of Version 2.3, this field has been retained for backward compatibility only. Use IN2-21 - Blood Deductible instead of this field, as the blood deductible can be associated with the specific insurance plan via that segment. This field is defined by CMS or other regulatory agencies.

UB1-3 Blood Furnished-Pints of (40) (NM) 00532

Definition: This field identifies the amount of blood furnished to the patient for this visit. The (40) indicates the corresponding UB82 field number. This field is defined by CMS or other regulatory agencies.

6.5.10.3 UB1-4 Blood Replaced-Pints (41) (NM) 00533

Definition: This field contains UB82 Field 41. This field is defined by CMS or other regulatory agencies.

6.5.10.4 UB1-5 Blood Not Replaced- Pints (42) (NM) 00534

Definition: This field contains the blood not replaced, as measured in pints. UB82 Field 42. This field is defined by CMS or other regulatory agencies.

6.5.10.5 UB1-6 Co-insurance Days (25) (NM) 00535

Definition: This field contains UB82 Field 25. This field is defined by CMS or other regulatory agencies.

6.5.10.6 UB1-7 Condition Code (35-39) (IS) 00536

Definition: The code in this field repeats five times. UB82 Fields (35), (36), (37), (38), and (39). Refer to User-defined Table 0043 - Condition Code for suggested values. Refer to a UB specification for additional information. This field is defined by CMS or other regulatory agencies.

User-defined Table 0043 - Condition Code

Value	Description	Comment
	No suggested values

6.5.10.7 UB1-8 Covered Days - (23) (NM) 00537

Definition: This field contains UB82 Field 23. This field is defined by CMS or other regulatory agencies.

6.5.10.8 UB1-9 Non-Covered Days - (24) (NM) 00538

Definition: This field contains UB82 Field 24. This field is defined by CMS or other regulatory agencies.

6.5.10.9 UB1-10 Value Amount & Code (46-49) (UVC) 00539

Components: <Value Code (CNE)> ^ <Value Amount (MO)>

Subcomponents for Value Code (CNE): <Identifier (ST)> & <Text (ST)> & <Name of Coding System (ID)> & <Alternate Identifier (ST)> & <Alternate Text (ST)> & <Name of Alternate Coding System (ID)> & <Coding System Version ID (ST)> & <Alternate Coding System Version ID (ST)> & <Original Text (ST)>

Subcomponents for Value Amount (MO): <Quantity (NM)> & <Denomination (ID)>

Definition: This field contains a monetary amount and an associated billing code. The pair in this field can repeat up to eight times to represent/contain UB82 form locators 46A, 47A, 48A, 49A, 46B, 47B, 48B, and 49B. This field is defined by CMS or other regulatory agencies.

6.5.10.10 UB1-11 Number of Grace Days (90) (NM) 00540

Definition: This field contains UB82 Field 90. This field is defined by CMS or other regulatory agencies.

6.5.10.11 UB1-12 Special Program Indicator (44) (CE) 00541

Components: <Identifier (ST)> ^ <Text (ST)> ^ <Name of Coding System (ID)> ^ <Alternate Identifier (ST)> ^ <Alternate Text (ST)> ^ <Name of Alternate Coding System (ID)>

Definition: This field contains the special program indicator. UB82 Field 44. This field is defined by CMS or other regulatory agencies. Refer to User-defined Table 0348 - Special Program Indicator for suggested values. Refer to a UB specification for additional information

User-defined Table 0348 - Special Program Indicator

Value	Description	Comment
	No suggested values defined

6.5.10.12 UB1-13 PSRO/UR Approval Indicator (87) (CE) 00542

Components: <Identifier (ST)> ^ <Text (ST)> ^ <Name of Coding System (ID)> ^ <Alternate Identifier (ST)> ^ <Alternate Text (ST)> ^ <Name of Alternate Coding System (ID)>

Definition: This field contains the PSRO/UR approval indicator. UB82 field 87. This field is defined by CMS or other regulatory agencies. Refer to User-defined Table 0349 - PSRO/UR Approval Indicator for suggested values. Refer to a UB specification for additional information.

User-defined Table 0349 - PSRO/UR Approval Indicator

Value	Description	Comment
	No suggested values

6.5.10.13 UB1-14 PSRO/UR Approved Stay-Fm (88) (DT) 00543

Definition: This field contains the PSRO/UR approved stay date (from). UB82 Field 88. This field is defined by CMS or other regulatory agencies.

6.5.10.14 UB1-15 PSRO/UR Approved Stay-To (89) (DT) 00544

Definition: This field contains the PSRO/UR approved stay date (to). UB82 Field 89. This field is defined by CMS or other regulatory agencies.

6.5.10.15 UB1-16 Occurrence (28-32) (OCD) 00545

Components: <Occurrence Code (CNE)> ^ <Occurrence Date (DT)>

Subcomponents for Occurrence Code (CNE): <Identifier (ST)> & <Text (ST)> & <Name of Coding System (ID)> & <Alternate Identifier (ST)> & <Alternate Text (ST)> & <Name of Alternate Coding System (ID)> & <Coding System Version ID (ST)> & <Alternate Coding System Version ID (ST)> & <Original Text (ST)>

Definition: The set of values in this field can repeat up to five times. UB82 Fields 28-32. This field is defined by CMS or other regulatory agencies. Refer to a UB specification for additional information.

6.5.10.16 UB1-17 Occurrence Span (33) (CE) 00546

Components: <Identifier (ST)> ^ <Text (ST)> ^ <Name of Coding System (ID)> ^ <Alternate Identifier (ST)> ^ <Alternate Text (ST)> ^ <Name of Alternate Coding System (ID)>

Definition: UB82 Field 33. This field is defined by CMS or other regulatory agencies. Refer to User-defined Table 0351 - Occurrence Span in Chapter 2 for suggested values.

6.5.10.17 UB1-18 Occur Span Start Date (33) (DT) 00547

Definition: This field contains the occurrence span start date. UB82 Field 33. This field is defined by CMS or other regulatory agencies.

6.5.10.18 UB1-19 Occur Span End Date (33) (DT) 00548

Definition: This field contains the occurrence span end date. UB82 Field 33. This field is defined by CMS or other regulatory agencies.

6.5.10.19 UB1-20 UB-82 Locator 2 (ST) 00549

Definition: Defined by UB-82 CMS specification and maintained for backward compatibility.

6.5.10.20 UB1-21 UB-82 Locator 9 (ST) 00550

Definition: Defined by UB-82 CMS specification and maintained for backward compatibility.

6.5.10.21 UB1-22 UB-82 Locator 27 (ST) 00551

Definition: Defined by UB-82 CMS specification and maintained for backward compatibility.

6.5.10.22 UB1-23 UB-82 Locator 45 (ST) 00552

Definition: Defined by UB-82 CMS specification and maintained for backward compatibility.

6.5.11 UB2 - UB92 Data Segment

The UB2 segment contains data necessary to complete UB92 bills specific to the United States; other realms may choose to implement using regional code sets. Only UB82 and UB92 fields that do not exist in other HL7 defined segments appear in this segment. Just as with the UB82 billing, Patient Name and Date of Birth are required; they are included in the PID segment and therefore do not appear here. When the field locators are different on the UB92, as compared to the UB82, the element is listed with its new location in parentheses ( ). The UB codes listed as examples are not an exhaustive or current list; refer to a UB specification for additional information.

The Uniform Billing segments are specific to the US and may not be implemented in non-US systems.

HL7 Attribute Table - UB2 - UB92 Data

SEQ	LEN	DT	OPT	RP/#	TBL#	ITEM#	ELEMENT NAME	DB Ref.
1	4	SI	O			00553	Set ID - UB2	DB
2	3	ST	O			00554	Co-Insurance Days (9)	DB
3	2	IS	O	Y/7	0043	00555	Condition Code (24-30)	DB
4	3	ST	O			00556	Covered Days (7)	DB
5	4	ST	O			00557	Non-Covered Days (8)	DB
6	41	UVC	O	Y/12		00558	Value Amount & Code	DB
7	259	OCD	O	Y/8		00559	Occurrence Code & Date (32-35)	DB
8	268	OSP	O	Y/2		00560	Occurrence Span Code/Dates (36)	DB
9	29	ST	O	Y/2		00561	UB92 Locator 2 (State)	DB
10	12	ST	O	Y/2		00562	UB92 Locator 11 (State)	DB
11	5	ST	O			00563	UB92 Locator 31 (National)	DB
12	23	ST	O	Y/3		00564	Document Control Number	DB
13	4	ST	O	Y/23		00565	UB92 Locator 49 (National)	DB
14	14	ST	O	Y/5		00566	UB92 Locator 56 (State)	DB
15	27	ST	O			00567	UB92 Locator 57 (National)	DB
16	2	ST	O	Y/2		00568	UB92 Locator 78 (State)	DB
17	3	NM	O			00815	Special Visit Count	DB

6.5.11.0 UB2 Field Definitions

6.5.11.1 UB2-1 Set ID - UB2 (SI) 00553

Definition: This field contains the number that identifies this transaction. For the first occurrence of the segment the sequence number shall be 1, for the second occurrence it shall be 2, etc.

6.5.11.2 UB2-2 Co-Insurance Days (9) (ST) 00554

Definition: This field contains the number of inpatient days exceeding defined benefit coverage. In the US, this corresponds to UB92 form locator 9. This field is defined by CMS or other regulatory agencies.

6.5.11.3 UB2-3 Condition Code (24-30) (IS) 00555

Definition: This field contains a code reporting conditions that may affect payer processing; for example, the condition is related to employment (Patient covered by insurance not reflected here, treatment of non-terminal condition for hospice patient). The code in this field can repeat up to seven times to correspond to UB92 form locators 24-30. Refer to User-defined Table 0043 - Condition Code for suggested values. Refer to a UB specification for additional information. This field is defined by CMS or other regulatory agencies.

6.5.11.4 UB2-4 Covered Days (7) (ST) 00556

Definition: This field contains UB92 field 7. This field is defined by CMS or other regulatory agencies.

6.5.11.5 UB2-5 Non-Covered Days (8) (ST) 00557

Definition: This field contains UB92 field 8. This field is defined by CMS or other regulatory agencies.

6.5.11.6 UB2-6 Value Amount & Code (39-41) (UVC) 00558

Definition: This field contains a monetary amount and an associated billing code. The pair in this field can repeat up to twelve times to represent/contain UB92 form locators 39a, 39b, 39c, 39d, 40a, 40b, 40c, 40d, 41a, 41b, 41c, and 41d. This field is defined by CMS or other regulatory agencies.

6.5.11.7 UB2-7 Occurrence Code & Date (32-35) (OCD) 00559

Definition: The set of values in this field can repeat up to eight times. UB92 fields 32a, 32b, 33a, 33b, 34a, 34b, 35a, and 35b. This field is defined by CMS or other regulatory agencies.

6.5.11.8 UB2-8 Occurrence Span Code/Dates (36) (OSP) 00560

Components: <Occurrence Span Code (CNE)> ^ <Occurrence Span Start Date (DT)> ^ <Occurrence Span Stop Date (DT)>

Subcomponents for Occurrence Span Code (CNE): <Identifier (ST)> & <Text (ST)> & <Name of Coding System (ID)> & <Alternate Identifier (ST)> & <Alternate Text (ST)> & <Name of Alternate Coding System (ID)> & <Coding System Version ID (ST)> & <Alternate Coding System Version ID (ST)> & <Original Text (ST)>

6.5.11.9 UB2-9 UB92 Locator 2 (state) (ST) 00561

Definition: This field contains an occurrence span code and an associated date. This field can repeat up to two times to represent/contain UB92 form locators 36a and 36b. This field is defined by CMS or other regulatory agencies.

Definition: The value in this field may repeat up to two times.

6.5.11.10 UB2-10 UB92 Locator 11 (state) (ST) 00562

Definition: The value in this field may repeat up to two times.

6.5.11.11 UB2-11 UB92 Locator 31 (national) (ST) 00563

Definition: Defined by CMS or other regulatory agencies.

6.5.11.12 UB2-12 Document Control Number (ST) 00564

Definition: This field contains the number assigned by payor that is used for rebilling/adjustment purposes. It may repeat up to three times. Refer UB92 field 37

6.5.11.13 UB2-13 UB92 Locator 49 (national) (ST) 00565

Definition: This field is defined by CMS or other regulatory agencies. This field may repeat up to twenty-three times.

6.5.11.14 UB2-14 UB92 Locator 56 (state) (ST) 00566

Definition: This field may repeat up to five times.

6.5.11.15 UB2-15 UB92 Locator 57 (national) (ST) 00567

Definition: Defined by UB-92 CMS specification.

6.5.11.16 UB2-16 UB92 Locator 78 (state) (ST) 00568

Definition: This field may repeat up to two times.

6.5.11.17 UB2-17 Special Visit Count (NM) 00815

Definition: This field contains the total number of special therapy visits.

6.5.12 ABS - Abstract Segment

This segment was created to communicate patient abstract information used for billing and reimbursement purposes. _Abstract_ is a condensed form of medical history created for analysis, care planning, etc.

HL7 Attribute Table - ABS - Abstract

SEQ	LEN	DT	OPT	TBL#	ITEM#	ELEMENT NAME	DB Ref.
1	250	XCN	O	0010	01514	Discharge Care Provider	DB
2	250	CE	O	0069	01515	Transfer Medical Service Code	DB
3	250	CE	O	0421	01516	Severity of Illness Code	DB
4	26	TS	O		01517	Date/Time of Attestation	DB
5	250	XCN	O		01518	Attested By	DB
6	250	CE	O	0422	01519	Triage Code	DB
7	26	TS	O		01520	Abstract Completion Date/Time	DB
8	250	XCN	O		01521	Abstracted By	DB
9	250	CE	O	0423	01522	Case Category Code	DB
10	1	ID	O	0136	01523	Caesarian Section Indicator	DB
11	250	CE	O	0424	01524	Gestation Category Code	DB
12	3	NM	O		01525	Gestation Period - Weeks	DB
13	250	CE	O	0425	01526	Newborn Code	DB
14	1	ID	O	0136	01527	Stillborn Indicator	DB

6.5.12.0 ABS Field Definitions

6.5.12.1 ABS-1 Discharge Care Provider (XCN) 01514

Definition: Identification number of the provider responsible for the discharge of the patient from his/her care. Refer to User-defined Table 0010 - Physician ID in Chapter 3 for suggested values.

6.5.12.2 ABS-2 Transfer Medical Service Code (CE) 01515

Components: <Identifier (ST)> ^ <Text (ST)> ^ <Name of Coding System (ID)> ^ <Alternate Identifier (ST)> ^ <Alternate Text (ST)> ^ <Name of Alternate Coding System (ID)>

Definition: Medical code representing the patient_s medical services when they are transferred. Refer to User-defined Table 0069 - Hospital Service in Chapter 3 for suggested values

6.5.12.3 ABS-3 Severity of Illness Code (CE) 01516

Components: <Identifier (ST)> ^ <Text (ST)> ^ <Name of Coding System (ID)> ^ <Alternate Identifier (ST)> ^ <Alternate Text (ST)> ^ <Name of Alternate Coding System (ID)>

Definition: Code representing the ranking of a patient_s illness. Refer to User-defined Table 0421 - Severity of Illness Code for suggested values.

User-defined Table 0421 - Severity of Illness Code

Values	Description	Comment
MI	Mild
MO	Moderate
SE	Severe

6.5.12.4 ABS-4 Date/time of Attestation (TS) 01517

Components: <Time (DTM)> ^ <DEPRECATED-Degree of Precision (ID)>

Definition: Date/time that the medical record was reviewed and accepted.

6.5.12.5 ABS-5 Attested by (XCN) 01518

Definition: Identification number of the person (usually a provider) who reviewed and accepted the abstract of the medical record.

6.5.12.6 ABS-6 Triage Code (CE) 01519

Components: <Identifier (ST)> ^ <Text (ST)> ^ <Name of Coding System (ID)> ^ <Alternate Identifier (ST)> ^ <Alternate Text (ST)> ^ <Name of Alternate Coding System (ID)>

Definition: Code representing a patient_s prioritization within the context of this abstract. Refer to User-defined Table 0422 - Triage Code for suggested values.

User-defined Table 0422 - Triage Code

Values	Description	Comment
1	Non-acute
2	Acute
3	Urgent
4	Severe
5	Dead on Arrival (DOA)
99	Other

6.5.12.7 ABS-7 Abstract Completion Date/Time (TS) 01520

Components: <Time (DTM)> ^ <DEPRECATED-Degree of Precision (ID)>

Definition: Date/time the abstraction was completed.

6.5.12.8 ABS-8 Abstracted by (XCN) 01521

Definition: Identification number of the person completing the Abstract.

6.5.12.9 ABS-9 Case Category Code (CE) 01522

Components: <Identifier (ST)> ^ <Text (ST)> ^ <Name of Coding System (ID)> ^ <Alternate Identifier (ST)> ^ <Alternate Text (ST)> ^ <Name of Alternate Coding System (ID)>

Definition: Code indicating the reason a non- urgent patient presents to the Emergency Room for treatment instead of a clinic or physician office. Refer to User-defined Table 0423 - Case Category Code for suggested values.

User-defined Table 0423 - Case Category Code

Values	Description	Comment
D	Doctor_s Office Closed

6.5.12.10 ABS-10 Caesarian Section Indicator (ID) 01523

Definition: Indicates if the delivery was by Caesarian Section. Refer to HL7 table 0136 - Yes/no Indicator for valid values.

Y Delivery was by Caesarian Section.

N Delivery was not by Caesarian Section.

6.5.12.11 ABS-11 Gestation Category Code (CE) 01524

Components: <Identifier (ST)> ^ <Text (ST)> ^ <Name of Coding System (ID)> ^ <Alternate Identifier (ST)> ^ <Alternate Text (ST)> ^ <Name of Alternate Coding System (ID)>

Definition: The gestation category code is used to indicate the status of the birth in relation to the gestation. Refer to User-defined Table 0424 - Gestation Category Code for suggested values.

User-defined Table 0424 - Gestation Category Code

Values	Description	Comment
1	Premature / Pre-term
2	Full Term
3	Overdue / Post-term

6.5.12.12 ABS-12 Gestation Period - Weeks (NM) 01525

Definition: Newborn_s gestation period expressed as a number of weeks.

6.5.12.13 ABS-13 Newborn Code (CE) 01526

Components: <Identifier (ST)> ^ <Text (ST)> ^ <Name of Coding System (ID)> ^ <Alternate Identifier (ST)> ^ <Alternate Text (ST)> ^ <Name of Alternate Coding System (ID)>

Definition: The newborn code is used to indicate whether the baby was born in or out of the facility. Refer to User-defined Table 0425 - Newborn Code for suggested values.

User-defined Table 0425 - Newborn Code

Values	Description	Comment
5	Born at home
3	Born en route
1	Born in facility
4	Other
2	Transfer in

6.5.12.14 ABS-14 Stillborn Indicator (ID) 01527

Definition: Indicates whether or not a newborn was stillborn. Refer to HL7 table 0136 - Yes/no Indicator for valid values.

Y Stillborn.

N Not stillborn.

6.5.13 BLC - Blood Code Segment

The BLC segment contains data necessary to communicate patient abstract blood information used for billing and reimbursement purposes. This segment is repeating to report blood product codes and the associated blood units.

HL7 Attribute Table - BLC - Blood Code

SEQ	LEN	DT	OPT	RP/#	TBL#	ITEM#	ELEMENT NAME	DB Ref.
1	250	CE	O		0426	01528	Blood Product Code	DB
2	267	CQ	O			01529	Blood Amount	DB

6.5.13.0 BLC Field Definitions

6.5.13.1 BLC-1 Blood Product Code (CE) 01528

Components: <Identifier (ST)> ^ <Text (ST)> ^ <Name of Coding System (ID)> ^ <Alternate Identifier (ST)> ^ <Alternate Text (ST)> ^ <Name of Alternate Coding System (ID)>

Definition: This field reports the blood product code. Refer to User-defined Table 0426 - Blood Product Code for suggested values.

User-defined Table 0426 - Blood Product Code

Value	Description	Comment
CRYO	Cryoprecipitated AHF
CRYOP	Pooled Cryoprecipitate
FFP	Fresh Frozen Plasma
FFPTH	Fresh Frozen Plasma - Thawed
PC	Packed Cells
PCA	Autologous Packed Cells
PCNEO	Packed Cells - Neonatal
PCW	Washed Packed Cells
PLT	Platelet Concentrate
PLTNEO	Reduced Volume Platelets
PLTP	Pooled Platelets
PLTPH	Platelet Pheresis
PLTPHLR	Leukoreduced Platelet Pheresis
RWB	Reconstituted Whole Blood
WBA	Autologous Whole Blood

6.5.13.2 BLC-2 Blood Amount (CQ) 01529

Components: <Quantity (NM)> ^ <Units (CE)>

Subcomponents for Units (CE): <Identifier (ST)> & <Text (ST)> & <Name of Coding System (ID)> & <Alternate Identifier (ST)> & <Alternate Text (ST)> & <Name of Alternate Coding System (ID)>

Definition: This field indicates the quantity and units administered for the blood code identified in field 1, for example, 2^pt. Standard ISO or ANSI units, as defined in Chapter 7 are recommended.

6.5.14 RMI - Risk Management Incident Segment

The RMI segment is used to report an occurrence of an incident event pertaining or attaching to a patient encounter.

HL7 Attribute Table - RMI - Risk Management Incident

SEQ	LEN	DT	OPT	TBL#	ITEM#	ELEMENT NAME	DB Ref.
1	250	CE	O	0427	01530	Risk Management Incident Code	DB
2	26	TS	O		01531	Date/Time Incident	DB
3	250	CE	O	0428	01533	Incident Type Code	DB

6.5.14.0 RMI Field Definitions

6.5.14.1 RMI-1 Risk Management Incident Code (CE) 01530

Components: <Identifier (ST)> ^ <Text (ST)> ^ <Name of Coding System (ID)> ^ <Alternate Identifier (ST)> ^ <Alternate Text (ST)> ^ <Name of Alternate Coding System (ID)>

Definition: A code depicting the incident that occurred during a patient_s stay. Refer to User-defined Table 0427 - Risk Management Incident Code for suggested values.

User-defined Table 0427 - Risk Management Incident Code

Values	Description	Comment
B	Body fluid exposure
C	Contaminated Substance
D	Diet Errors
E	Equipment problem
F	Patient fell (not from bed)
H	Patient fell from bed
I	Infusion error
J	Foreign object left during surgery
K	Sterile precaution violated
P	Procedure error
R	Pharmaceutical error
S	Suicide Attempt
T	Transfusion error
O	Other

6.5.14.2 RMI-2 Date/Time Incident (TS) 01531

Components: <Time (DTM)> ^ <DEPRECATED-Degree of Precision (ID)>

Definition: This field contains the date and time the Risk Management Incident identified in RMI-1 - Risk Management Incident Code occurred.

6.5.14.3 RMI-3 Incident Type Code (CE) 01533

Components: <Identifier (ST)> ^ <Text (ST)> ^ <Name of Coding System (ID)> ^ <Alternate Identifier (ST)> ^ <Alternate Text (ST)> ^ <Name of Alternate Coding System (ID)>

Definition: A code depicting a classification of the incident type. Refer to User-defined Table 0428 - Incident Type Code for suggested values.

User-defined Table 0428 - Incident Type Code

Values	Description	Comment
P	Preventable
U	User Error
O	Other

6.5.15 GP1 Grouping/Reimbursement - Visit Segment

These fields are used in grouping and reimbursement for CMS APCs. Please refer to the "Outpatient Prospective Payment System Final Rule" ("OPPS Final Rule") issued by CMS.

The GP1 segment is specific to the US and may not be implemented in non-US systems.

HL7 Attribute Table - GP1 - Grouping/Reimbursement - Visit

SEQ	LEN	DT	OPT	RP/#	TBL#	ITEM#	ELEMENT NAME	DB Ref.
1	3	IS	R		0455	01599	Type of Bill Code	DB
2	3	IS	O	Y	0456	01600	Revenue Code	DB
3	1	IS	O		0457	01601	Overall Claim Disposition Code	DB
4	2	IS	O	Y	0458	01602	OCE Edits per Visit Code	DB
5	12	CP	O			00387	Outlier Cost	DB

6.5.15.0 GP1 Field Definitions

6.5.15.1 GP1-1 Type of Bill Code (IS) 01599

Definition: This field is the same as UB92 Form Locator 4 "Type of Bill". Refer to User-defined Table 0455 - Type of Bill Code for suggested values. Refer to a UB specification for additional information. This field is defined by CMS or other regulatory agencies. It is a code indicating the specific type of bill with digit 1 showing type of facility, digit 2 showing bill classification, and digit 3 showing frequency.

User-defined Table 0455 - Type of Bill Code

Values	Description	Comment


...	No suggested values

6.5.15.2 GP1-2 Revenue Code (IS) 01600

Definition: This field is the same as UB92 Form Locator 42 "Revenue Code". Refer to User-defined Table 0456 - Revenue Code for suggested values. This field identifies revenue codes that are not linked to a HCPCS/CPT code. It is used for claiming for non-medical services such as telephone, TV or cafeteria charges, etc. There can be many per visit or claim. This field is defined by CMS or other regulatory agencies.

There can also be a revenue code linked to a HCPCS/CPT code. These are found in GP2-1 - Revenue Code. Refer to UB92 specifications.

User-defined Table 0456 - Revenue code

Values	Description	Comment






...	No suggested values

6.5.15.3 GP1-3 Overall Claim Disposition Code (IS) 01601

Definition: This field identifies the final status of the claim. The codes listed as examples are not an exhaustive or current list, refer to OPPS Final Rule. Refer to User-defined Table 0457 - Overall Claim Disposition Code for suggested values. This field is defined by CMS or other regulatory agencies.

User-defined Table 0457 - Overall Claim Disposition Code

Values	Description	Comment
0	No edits present on claim
1	Only edits present are for line item denial or rejection
2	Multiple-day claim with one or more days denied or rejected
3	Claim denied, rejected, suspended or returned to provider with only post payment edits
4	Claim denied, rejected, suspended or returned to provider with only pre payment edits

6.5.15.4 GP1-4 OCE Edits per Visit Code (IS) 01602

Definition: This field contains the edits that result from processing the HCPCS/CPT procedures for a record after evaluating all the codes, revenue codes, and modifiers. The codes listed as examples are not an exhaustive or current list, refer to OPPS Final Rule. OCE (Outpatient Code Editor) edits also exist at the pre-procedure level. Refer to User-defined Table 0458 - OCE Edit Code for suggested values. This field is defined by CMS or other regulatory agencies.

User-defined Table 0458 - OCE Edit Code

Values	Description	Comment
1	Invalid diagnosis code
2	Diagnosis and age conflict
3	Diagnosis and sex conflict
4	Medicare secondary payer alert
5	E-code as reason for visit
6	Invalid procedure code
7	Procedure and age conflict
8	Procedure and sex conflict
9	Nov-covered service
10	Non-covered service submitted for verification of denial (condition code 21 from header information on claim)
11	Non-covered service submitted for FI review (condition code 20 from header information on claim)
12	Questionable covered service
13	Additional payment for service not provided by Medicare
14	Code indicates a site of service not included in OPPS
15	Service unit out of range for procedure
16	Multiple bilateral procedures without modifier 50 (see Appendix A)
17	Multiple bilateral procedures with modifier 50 (see Appendix A)
18	Inpatient procedure
19	Mutually exclusive procedure that is not allowed even if appropriate modifier present
20	Component of a comprehensive procedure that is not allowed even if appropriate modifier present
21	Medical visit on same day as a type "T" or "S" procedure without modifier 25 (see Appendix B)
22	Invalid modifier
23	Invalid date
24	Date out of OCE range
25	Invalid age
26	Invalid sex
27	Only incidental services reported
28	Code not recognized by Medicare; alternate code for same service available
29	Partial hospitalization service for non-mental health diagnosis
30	Insufficient services on day of partial hospitalization
31	Partial hospitalization on same day as ECT or type "T" procedure
32	Partial hospitalization claim spans 3 or less days with in-sufficient services, or ECT or significant procedure on at least one of the days
33	Partial hospitalization claim spans more than 3 days with insufficient number of days having mental health services
34	Partial hospitalization claim spans more than 3 days with insufficient number of days meeting partial hospitalization criteria
35.	Only activity therapy and/or occupational therapy services provided
36.	Extensive mental health services provided on day of ECT or significant procedure
37	Terminated bilateral procedure or terminated procedure with units greater than one
38.	Inconsistency between implanted device and implantation procedure
39.	Mutually exclusive procedure that would be allowed if appropriate modifier were present
40.	Component of a comprehensive procedure that would be allowed if appropriate modifier were present
41.	Invalid revenue code
42.	Multiple medical visits on same day with same revenue code without condition code G0 (see Appendix B)
_

6.5.15.5 GP1-5 Outlier Cost (CP) 00387

Definition: This field contains the amount that exceeds the outlier limitation as defined by APC regulations. This field is analogous to DRG-7 - Outlier Cost however the definition in this field note supersedes the DRG-7 definition.

6.5.16 GP2 Grouping/Reimbursement - Procedure Line Item Segment

This segment is used for items that pertain to each HCPC/CPT line item.

The GP2 segment is specific to the US and may not be implemented in non-US systems.

HL7 Attribute Table - GP2 - Grouping/Reimbursement - Procedure Line Item

SEQ	LEN	DT	OPT	RP/#	TBL#	ITEM#	ELEMENT NAME	DB Ref.
1	3	IS	O		0456	01600	Revenue Code	DB
2	7	NM	O			01604	Number of Service Units	DB
3	12	CP	O			01605	Charge	DB
4	1	IS	O		0459	01606	Reimbursement Action Code	DB
5	1	IS	O		0460	01607	Denial or Rejection Code	DB
6	3	IS	O	Y	0458	01608	OCE Edit Code	DB
7	250	CE	O		0466	01609	Ambulatory Payment Classification Code	DB
8	1	IS	O	Y	0467	01610	Modifier Edit Code	DB
9	1	IS	O		0468	01611	Payment Adjustment Code	DB
10	1	IS	O		0469	01617	Packaging Status Code	DB
11	12	CP	O			01618	Expected CMS Payment Amount	DB
12	2	IS	O		0470	01619	Reimbursement Type Code	DB
13	12	CP	O			01620	Co-Pay Amount	DB
14	4	NM	O			01621	Pay Rate per Service Unit	DB

6.5.16.0 GP2 Field Definitions

6.5.16.1 GP2-1 Revenue Code (IS) 01600

Definition: This field identifies a specific ancillary service for each HCPC/CPT This field is the same as UB92 Form Locator 42 "Revenue Code". Refer to User-defined Table 0456 - Revenue Code for suggested values. This field is defined by CMS or other regulatory agencies.

6.5.16.2 GP2-2 Number of Service Units (NM) 01604

Definition: This field contains the quantitative count of units for each HCPC/CPT. This field is the same as UB92 Form Locator 46 "Units of Service". This field is defined by CMS or other regulatory agencies.

6.5.16.3 GP2-3 Charge (CP) 01605

Definition: This field contains the amount charged for the specific individual line item (HCPC/CPT). This field is the same as UB92 Form Locator 56. This field is defined by CMS or other regulatory agencies.

6.5.16.4 GP2-4 Reimbursement Action Code (IS) 01606

Definition: This field identifies the action to be taken during reimbursement calculations. If valued, this code overrides the value in GP2-6 - OCE Edit Code. Refer to User-defined Table 0459 - Reimbursement Action Code for suggested values. This field is defined by CMS or other regulatory agencies

User-defined Table 0459 - Reimbursement Action Code

Value	Description	Comment
0	OCE line item denial or rejection is not ignored
1	OCE line item denial or rejection is ignored
2	External line item denial. Line item is denied even if no OCE edits
3	External line item rejection. Line item is rejected even if no OCE edits

6.5.16.5 GP2-5 Denial or Rejection Code (IS) 01607

Definition: This field determines the OCE status of the line item. Refer to User-defined table 0460 - Denial or Rejection Code for suggested values. This field is defined by CMS or other regulatory agencies

User-defined Table 0460 - Denial or Rejection Code

Value	Description	Comment
0	Line item not denied or rejected
1	Line item denied or rejected
2	Line item is on a multiple-day claim. The line item is not denied or rejected, but occurs on a day that has been denied or rejected.

6.5.16.6 GP2-6 OCE Edit Code (IS) 01608

Definition: This field contains the edit that results from the processing of HCPCS/CPT procedures for a line item HCPCS/CPT, after evaluating all the codes, revenue codes, and modifiers. Refer to User-defined table 0458 - OCE Edit Code for suggested values.

6.5.16.7 GP2-7 Ambulatory Payment Classification Code (CE) 01609

Components: <Identifier (ST)> ^ <Text (ST)> ^ <Name of Coding System (ID)> ^ <Alternate Identifier (ST)> ^ <Alternate Text (ST)> ^ <Name of Alternate Coding System (ID)>

Definition: This field contains the derived APC code. This is the APC code used for payment, which is the same as the assigned APC, for all situations except partial hospitalization. If partial hospitalization is billed in this visit, the assigned APC will differ from the APC used for payment. Partial hospitalization is the only time an assigned APC differs from the APC used for payment. The payment APC is used for billing and should be displayed in this field. The first component contains the APC identifier. The second component reports the text description for the APC group. Refer to User-defined table 0466 - Ambulatory Payment Classification Code for suggested values. This field is defined by CMS or other regulatory agencies

User-defined Table 0466 - Ambulatory Payment Classification Code

Value	Description	Comment
031	Dental procedures
163	Excision/biopsy
181	Level 1 skin repair.
...

6.5.16.8 GP2-8 Modifier Edit Code (IS) 01610

Definition: This field contains calculated edits of the modifiers for each line or HCPCS/CPT. This field can be repeated up to five times, one edit for each of the modifiers present. This field relates to the values in PR1-16 - Procedure Code Modifier. Each repetition corresponds positionally to the order of the PR1-16 modifier codes. If no modifier code exists, use the code _U_ (modifier edit code unknown) as a placeholder. The repetitions of Modifier Edit Codes must match the repetitions of Procedure Code Modifiers. For example, if PR1-16 - Procedure Code Modifier reports _|01~02~03~04|_ as modifier codes, and modifier code 03 modifier status code is unknown, GP2-8 - Modifier Edit Code would report _|1~1~U~1|... Refer to User-defined table 0467 - Modifier Edit Code for suggested values. This field is defined by CMS or other regulatory agencies

User-defined Table 0467 - Modifier Edit Code

Value	Description	Comment
0	Modifier does NOT exist
1	Modifier present, no errors
2	Modifier invalid
3	Modifier NOT approved for ASC/HOPD use
4	Modifier approved for ASC/HOPD use, inappropriate for code
U	Modifier edit code unknown

6.5.16.9 GP2-9 Payment Adjustment Code (IS) 01611

Definition: This field contains any payment adjustment due to drugs or medical devices. Refer to User-defined Table 0468 - Payment Adjustment Code for suggested values. This field is defined by CMS or other regulatory agencies

User-defined Table 0468 - Payment Adjustment Code

Value	Description	Comment
1	No payment adjustment
2	Designated current drug or biological payment adjustment applies to APC (status indicator G)
3	Designated new device payment adjustment applies to APC (status indicator H)
4	Designated new drug or new biological payment adjustment applies to APC (status indicator J)
5	Deductible not applicable (specific list of HCPCS codes)

6.5.16.10 GP2-10 Packaging Status Code (IS) 01617

Definition: This field contains the packaging status of the service. A status indicator of N may accompany this, unless it is part of a partial hospitalization. Refer to User defined (CMS) Table 0469 - Packaging Status Code for suggested values. This field is defined by CMS or other regulatory agencies

User-defined Table 0469 - Packaging Status Code

Value	Description	Comment
0	Not packaged
1	Packaged service (status indicator N, or no HCPCS code and certain revenue codes)
2	Packaged as part of partial hospitalization per diem or daily mental health service per diem

6.5.16.11 GP2-11 Expected CMS Payment Amount (CP) 01618

Definition: This field contains the calculated dollar amount that CMS is expected to pay for the line item.

6.5.16.12 GP2-12 Reimbursement Type Code (IS) 01619

Definition: This field contains the fee schedule reimbursement type applied to the line item. Refer to User-defined Table 0470 - Reimbursement Type Code for suggested values. This field is defined by CMS or other regulatory agencies.

User-defined Table 0470 - Reimbursement Type Code

Value	Description	Comment
OPPS	Outpatient Prospective Payment System
Pckg	Packaged APC
Lab	Clinical Laboratory APC
Thrpy	Therapy APC
DME	Durable Medical Equipment
EPO	Epotein
Mamm	Screening Mammography APC
PartH	Partial Hospitalization APC
Crnl	Corneal Tissue APC
NoPay	This APC is not paid

6.5.16.13 GP2-13 Co-Pay Amount (CP) 01620

Definition: This field contains the patient's Co-pay amount for the line item.

6.5.16.14 GP2-14 Pay Rate per Service Unit (NM) 01621

Definition: This field contains the calculated rate, or multiplying factor, for each service unit for the line item.

6.6 EXAMPLE TRANSACTIONS

6.6.1 Create a patient billing/accounts receivable record

MSH|^~\&|PATA|01|PATB|01|19930908135031||BAR^P01^BAR_P01|641|P|2.5| 000000000000001|<cr>

EVN|P01|1993090813503||<cr>

PID|1||8064993^^^PATA1^MR^A~6045681^^^PATA1^BN^A~123456789ABC^^^US^NI~123456789^^^USSSA^SS||SMITH^PAT^J^^^||19471007|F||1|1234 FANNIN^^HOUSTON^TX^77030^USA|HAR||||S||6045681<cr>

GT1|001||JOHNSON^SAM^J||8339 MORVEN RD^^BALTIMORE^MD^

21234^US|||||||193-22-1876<cr>

NK1|001|SMITH^WILLIAM|F|522 MAIN ST^^CUMBERLAND^MD

^28765^US|(301)555-2134<cr>

IN1|001|A357|1234|BCMD||||| 132987<cr>

A patient has been registered by the ADT system (PATA) and notification is sent to the Patient Billing system (PATB). The patient_s name is Pat J. Smith, a female Caucasian, born on October 7, 1947. Living at 1234 Fannin, Houston, TX.

Ms. Smith_s medical record number is 8064993 and her billing number is 6045681. Her national identifier is 123456789ABC. Her social security number, assigned by the U.S. Social Security Administration, is 123456789. Ms. Smith has provided her father_s name and address for next of kin. Ms. Smith is insured under plan ID A357 with an insurance company known to both systems as BCMD, with a company ID of 1234.

6.6.2 Post a charge to a patient_s account

MSH|^~\&|PATA|01|PATB|01|19930908135031||DFT^P03^DFT_P03|641|P|2.5| 000000000000001|<cr>

EVN|P03|1993090813503||<cr>

PID||0008064993^^^ENT^PE|0008064993^^^PAT^MR||0006045681^^^PATA^AN|SMITH^PAT^J^^^|19471007|F||1|1234 FANNIN^^HOUSTON^TX^77030^USA|HAR||||S||6045681^^^PATA^AN<cr>

FT1|1|||19950715|19950716|CG|B1238^BIOPSY-SKIN^SYSTEMA|||1|||ONC|A357||||||P8765^KILDARE^BEN<cr>

Ms. Smith_s patient number is 8064993 and her billing number is 6045681. This transaction is posting a charge for a skin biopsy to her account.

6.6.3 Update patient accounts - update UB82 information

MSH|^~\&|UREV||PATB||||BAR^P05^BAR_P05|MSG0018|P|2.5<cr>

EVN|P05|1993090813503

PID|||125976||JOHNSON^SAM^J|||||||||||||125976011<cr>

UB1|1|1|5|3|1||39|||01^500.00|||1|19880501|19880507|10^19880501<cr>

Utilization review sends data for Patient Billing to the Patient Accounting system. The patient_s insurance program has a 1-pint deductible for blood; the patient received five pints of blood, and three pints were replaced, with one pint not yet replaced.

The patient has been assigned to a medically necessary private room (UB condition code 39). The hospital_s most common semi-private rate is $500.00 (UB value code 01.)

The services provided for the period 05/01/88 through 05/07/88 are fully approved (PSRO/UR Approval Code 1). The patient_s hospitalization is the result of an auto accident (UB occurrence code 01.)

6.6.4 Update patient accounts - update diagnosis and DRG information

MSH|^~\&|UREV||PATB||||BAR^P05^BAR_P05|MSG0018|P|2.5<cr>

EVN|P05|1993090813503

PID|||125976||JOHNSON^SAM^J|||||||||||||125976011<cr>

DG1|001|I9|1550|MAL NEO LIVER, PRIMARY|19880501103005|F<cr>

DRG|203|19880501103010|Y||D|5<cr>

The DG1 segment contains the information that the patient was diagnosed on May 1 as having a malignancy of the hepatobiliary system or pancreas (ICD9 code 1550). In the DRG segment, the patient has been assigned a Diagnostic Related Group (DRG) of 203 (corresponding to the ICD9 code of 1550). Also, the patient has been approved for an additional five days (five-day outlier).

6.7 IMPLEMENTATION CONSIDERATIONS

The Set-ID used to be needed to identify whether or not a record was to be used for deletion, update, or cancellation. This information was redundant since the event type indicates this fact. Consequently, the Set-ID is now only used to identify a segment.

Contents

6 . Financial Management

6.1 CHAPTER 6 CONTENTS

6.2 PURPOSE

6.3 PATIENT ACCOUNTING MESSAGE SET

6.4 TRIGGER EVENTS AND MESSAGE DEFINITIONS

6.4.1 BAR/ACK - Add Patient Account (Event P01)

6.4.2 BAR/ACK - Purge Patient Accounts (Event P02)

6.4.3 DFT/ACK - Post Detail Financial Transactions (Event P03)

6.4.4 QRY/DSR - Generate Bills And Accounts Receivable Statements (Event P04)

6.4.5 BAR/ACK - Update Account (Event P05)

6.4.6 BAR/ACK - End Account (event P06)

6.4.7 BAR/ACK - Transmit Ambulatory Payment Classification (APC) Groups (Event P10)

6.4.8 DFT/ACK - Post Detail Financial Transactions - Expanded (Event P11)

6.4.9 BAR/ACK - Update Diagnosis/Procedure (Event P12)

6.5 MESSAGE SEGMENTS

6.5.1 FT1 - Financial Transaction Segment

6.5.1.1 FT1-1 Set ID - FT1 (SI) 00355

6.5.1.2 FT1-2 Transaction ID (ST) 00356

6.5.1.3 FT1-3 Transaction Batch ID (ST) 00357

6.5.1.4 FT1-4 Transaction Date (DR) 00358

6.5.1.5 FT1-5 Transaction Posting Date (TS) 00359

6.5.1.6 FT1-6 Transaction Type (IS) 00360

6.5.1.9 FT1-9 Transaction Description - Alt (ST) 00363

6.5.1.10 FT1-10 Transaction Quantity (NM) 00364

6.5.1.11 FT1-11 Transaction Amount - Extended (CP) 00365

6.5.1.12 FT1-12 Transaction Amount - Unit (CP) 00366

6.5.1.13 FT1-13 Department Code (CE) 00367

6.5.1.16 FT1-16 Assigned Patient Location (PL) 00133

6.5.1.17 FT1-17 Fee Schedule (IS) 00370

6.5.1.19 FT1-19 Diagnosis Code - FT1 (CE) 00371

6.5.1.22 FT1-22 Unit Cost (CP) 00374

6.5.1.23 FT1-23 Filler Order Number (EI) 00217

6.5.1.24 FT1-24 Entered by Code (XCN) 00765

6.5.1.25 FT1-25 Procedure Code (CE) 00393

6.5.1.27 FT1-27 Advanced Beneficiary Notice Code (CE) 01310

6.5.1.28 FT1-28 Medically Necessary Duplicate Procedure Reason (CWE) 01646

6.5.1.29 FT1-29 NDC Code (CNE) 01845

6.5.1.31 FT1-31 Transaction Reference Key (SI) 01847

6.5.2 DG1 - Diagnosis Segment

6.5.2.1 DG1-1 Set ID - DG1 (SI) 00375

6.5.2.2 DG1-2 Diagnosis Coding Method (ID) 00376

6.5.2.4 DG1-4 Diagnosis Description (ST) 00378

6.5.2.5 DG1-5 Diagnosis Date/Time (TS) 00379

6.5.2.6 DG1-6 Diagnosis Type (IS) 00380

6.5.2.10 DG1-10 DRG Grouper Review Code (IS) 00384

6.5.2.13 DG1-13 Outlier Cost (CP) 00387

6.5.2.14 DG1-14 Grouper Version and Type (ST) 00388

6.5.2.15 DG1-15 Diagnosis Priority (ID) 00389

6.5.2.17 DG1-17 Diagnosis Classification (IS) 00766

6.5.2.19 DG1-19 Attestation Date/Time (TS) 00768

6.5.2.20 DG1-20 Diagnosis Identifier (EI) 01850

6.5.2.21 DG1-21 Diagnosis Action Code (ID) 01894

6.5.3 DRG - Diagnosis Related Group Segment

6.5.3.1 DRG-1 Diagnostic Related Group (CE) 00382

6.5.3.2 DRG-2 DRG Assigned Date/Time (TS) 00769

6.5.3.3 DRG-3 DRG Approval Indicator (ID) 00383

6.5.3.4 DRG-4 DRG Grouper Review Code (IS) 00384

6.5.3.5 DRG-5 Outlier Type (CE) 00385

6.5.3.6 DRG-6 Outlier Days (NM) 00386

6.5.3.7 DRG-7 Outlier Cost (CP) 00387

6.5.3.8 DRG-8 DRG Payor (IS) 00770

6.5.3.10 DRG-10 Confidential Indicator (ID) 00767

6.5.3.11 DRG-11 DRG Transfer Type (IS) 01500

6.5.4.1 PR1-1 Set ID - PR1 (SI) 00391

6.5.4.2 PR1-2 Procedure Coding Method (IS) 00392

6.5.4.4 PR1-4 Procedure Description (ST) 00394

6.5.4.5 PR1-5 Procedure Date/Time (TS) 00395

6.5.4.6 PR1-6 Procedure Functional Type (IS) 00396

6.5.4.8 PR1-8 Anesthesiologist (XCN) 00398

6.5.4.9 PR1-9 Anesthesia Code (IS) 00399

6.5.4.11 PR1-11 Surgeon (XCN) 00401

6.5.4.12 PR1-12 Procedure Practitioner (XCN) 00402

6.5.4.16 PR1-16 Procedure Code Modifier (CE) 01316

6.5.4.17 PR1-17 Procedure DRG Type (IS) 01501

6.5.4.20 PR1-20 Procedure Action Code (ID) 01849

6.5.5 GT1 - Guarantor Segment

6.5.5.1 GT1-1 Set ID - GT1 (SI) 00405

6.5.5.2 GT1-2 Guarantor Number (CX) 00406

6.5.5.3 GT1-3 Guarantor Name (XPN) 00407