6. Financial Management

6 . Financial Management

Chapter Chair:

Kathleen Connor VA (Edmond Scientific Company)

Chapter Chair

Beat Heggli HL7 Switzerland

Chapter Editor:

Beat Heggli HL7 Switzerland

Sponsoring TC:

Financial Management

List Server

fm@lists.hl7.org

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

MSH	Message Header	2	DB
[ { SFT } ]	Software Segment	2	DB
[ UAC ]	User Authentication Credential	2	DB
EVN	Event Type	3	DB
PID	Patient Identification	3	DB
[ PD1 ]	Additional Demographics	3	DB
[ { PRT } ]	Participation		DB
[ { ROL } ]	Kept for backwards compatibility only. PRT and ROL should not both be used.	15	DB
{	--- VISIT begin
[ PV1 ]	Patient Visit	3	DB
[ PV2 ]	Patient Visit - Additional Info	3	DB
[ { PRT } ]	Participation		DB
[ { ROL } ]	Kept for backwards compatibility only. PRT and ROL should not both be used.	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
[ { PRT } ]	Participation		DB
[ { ROL } ]	Kept for backwards compatibility only. PRT and ROL should not both be used.	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
[ { PRT } ]	Participation		DB
[ { ROL } ]	Kept for backwards compatibility only. PRT and ROL should not both be used.	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

MSH	Message Header	2	DB
[ { SFT } ]	Software Segment	2	DB
[ UAC ]	User Authentication Credential	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

MSH	Message Header	2	DB
[ { SFT } ]	Software Segment	2	DB
[ UAC ]	User Authentication Credential	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

MSH	Message Header	2	DB
[ { SFT } ]	Software Segment	2	DB
[ UAC ]	User Authentication Credential	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

MSH	Message Header	2	DB
[ { SFT } ]	Software Segment	2	DB
[ UAC ]	User Authentication Credential	2	DB
EVN	Event Type	3	DB
PID	Patient Identification	3	DB
[ PD1 ]	Additional Demographics	3	DB
[ { PRT } ]	Participation		DB
[ { ROL } ]	Kept for backwards compatibility only. PRT and ROL should not both be used.	15	DB
[ PV1 ]	Patient Visit	3	DB
[ PV2 ]	Patient Visit - Additional Info	3	DB
[ { PRT } ]	Participation		DB
[ { ROL } ]	Kept for backwards compatibility only. PRT and ROL should not both be used.	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
[ { PRT } ]	Participation		DB
[ { ROL } ]	Kept for backwards compatibility only. PRT and ROL should not both be used.		DB
[ NTE ]	Notes and Comments (on line item - FT1 - above)	2	DB
[{	--- FINANCIAL_PROCEDURE begin
PR1	Procedure	6	DB
[ { PRT } ]	Participation		DB
[ { ROL } ]	Kept for backwards compatibility only. PRT and ROL should not both be used.	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
[ { PRT } ]	Participation		DB
[ { ROL } ]	Kept for backwards compatibility only. PRT and ROL should not both be used.	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 have been withdrawn as a technical correction

ACK^P03^ACK: General Acknowledgment

MSH	Message Header	2	DB
[ { SFT } ]	Software Segment	2	DB
[ UAC ]	User Authentication Credential	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)

Retained for backwards compatibility only in version 2.4 and later; refer to Chapter 5, "Queries", section 5.4. The original mode query and the QRD/QRF segments have been replaced.

6.4.5 BAR/ACK - Update Account (Event P05)

The P05 event is sent when an existing account is being updated. From 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

MSH	Message Header	2	DB
[ { SFT } ]	Software Segment	2	DB
[ UAC ]	User Authentication Credential	2	DB
EVN	Event Type	3	DB
PID	Patient Identification	3	DB
[ PD1 ]	Additional Demographics	3	DB
[ { PRT } ]	Participation		DB
[ { ROL } ]	Kept for backwards compatibility only. PRT and ROL should not both be used.	15	DB
{	--- VISIT begin
[ PV1 ]	Patient Visit	3	DB
[ PV2 ]	Patient Visit - Additional Info	3	DB
[ { PRT } ]	Participation		DB
[ { ROL } ]	Kept for backwards compatibility only. PRT and ROL should not both be used.	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
[ { PRT } ]	Participation		DB
[ { ROL } ]	Kept for backwards compatibility only. PRT and ROL should not both be used.	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
[ { PRT } ]	Participation		DB
[ { ROL } ]	Kept for backwards compatibility only. PRT and ROL should not both be used.	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

MSH	Message Header	2	DB
[ { SFT } ]	Software Segment	2	DB
[ UAC ]	User Authentication Credential	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

MSH	Message Header	2	DB
[ { SFT } ]	Software Segment	2	DB
[ UAC ]	User Authentication Credential	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

MSH	Message Header	2	DB
[ { SFT } ]	Software Segment	2	DB
[ UAC ]	User Authentication Credential	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

MSH	Message Header	2	DB
[ { SFT } ]	Software Segment	2	DB
[ UAC ]	User Authentication Credential	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

MSH	Message Header	2	DB
[ { SFT } ]	Software Segment	2	DB
[ UAC ]	User Authentication Credential	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

MSH	Message Header	2	DB
[ { SFT } ]	Software Segment	2	DB
[ UAC ]	User Authentication Credential	2	DB
EVN	Event Type	3	DB
PID	Patient Identification	3	DB
[ PD1 ]	Additional Demographics	3	DB
[ { PRT } ]	Participation		DB
[ { ROL } ]	Kept for backwards compatibility only. PRT and ROL should not both be used.	15	DB
[ PV1 ]	Patient Visit	3	DB
[ PV2 ]	Patient Visit - Additional Info	3	DB
[ { PRT } ]	Participation		DB
[ { ROL } ]	Kept for backwards compatibility only. PRT and ROL should not both be used.	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
[ { PRT } ]	Participation		DB
[ { ROL } ]	Kept for backwards compatibility only. PRT and ROL should not both be used.	15	DB
}]	--- INSURANCE end
[ ACC ]	Accident Information	6	DB
{	--- FINANCIAL begin
FT1	Financial Transaction	6	DB
[{	--- FINANCIAL_PROCEDURE begin
PR1	Procedure	6	DB
[ { PRT } ]	Participation		DB
[ { ROL } ]	Kept for backwards compatibility only. PRT and ROL should not both be used.	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
[ { PRT } ]	Participation		DB
[ { ROL } ]	Kept for backwards compatibility only. PRT and ROL should not both be used.	15	DB
}]	--- FINANCIAL_INSURANCE end
}	--- FINANCIAL end

ACK^P11^ACK: General Acknowledgment

MSH	Message Header	2	DB
[ { SFT } ]	Software Segment	2	DB
[ UAC ]	User Authentication Credential	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

MSH	Message Header	2	DB
[ { SFT } ]	Software Segment	2	DB
[ UAC ]	User Authentication Credential	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	DB
[ { PRT } ]	Participation		DB
[ { ROL } ]	Kept for backwards compatibility only. PRT and ROL should not both be used.	15	DB
}]	--- PROCEDURE end
[ OBX ]	Observation/Result	7	DB

ACK^P12^ACK: General Acknowledgment

MSH	Message Header	2	DB
[ { SFT } ]	Software Segment	2	DB
[ UAC ]	User Authentication Credential	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	C.LEN	DT	OPT	RP/#	TBL#	ITEM#	ELEMENT NAME	DB Ref.
1	1..4		SI	O			00355	Set ID - FT1	DB
2	1..12		ST	O			00356	Transaction ID	DB
3	1..10		ST	O			00357	Transaction Batch ID	DB
4			DR	R			00358	Transaction Date	DB
5			DTM	O			00359	Transaction Posting Date	DB
6			CWE	R		0017	00360	Transaction Type	DB
7			CWE	R		0132	00361	Transaction Code	DB
8				W			00362	Transaction Description	DB
9				W			00363	Transaction Description - Alt	DB
10		6=	NM	O			00364	Transaction Quantity	DB
11			CP	O			00365	Transaction Amount - Extended	DB
12			CP	O			00366	Transaction Amount - Unit	DB
13			CWE	O		0049	00367	Department Code	DB
14			CWE	O		0072	00368	Health Plan ID	DB
15			CP	O			00369	Insurance Amount	DB
16			PL	O			00133	Assigned Patient Location	DB
17			CWE	O		0024	00370	Fee Schedule	DB
18			CWE	O		0018	00148	Patient Type	DB
19			CWE	O	Y	0051	00371	Diagnosis Code - FT1	DB
20			XCN	O	Y	0084	00372	Performed By Code	DB
21			XCN	O	Y		00373	Ordered By Code	DB
22			CP	O			00374	Unit Cost	DB
23			EI	O			00217	Filler Order Number	DB
24			XCN	O	Y		00765	Entered By Code	DB
25			CNE	O		0088	00393	Procedure Code	DB
26			CNE	O	Y	0340	01316	Procedure Code Modifier	DB
27			CWE	O		0339	01310	Advanced Beneficiary Notice Code	DB
28			CWE	O		0476	01646	Medically Necessary Duplicate Procedure Reason	DB
29			CWE	O		0549	01845	NDC Code	DB
30			CX	O			01846	Payment Reference ID	DB
31	1..4		SI	O	Y		01847	Transaction Reference Key	DB
32			XON	O	Y		02361	Performing Facility	DB
33			XON	O			02362	Ordering Facility	DB
34			CWE	O			02363	Item Number	DB
35		20=	ST	O			02364	Model Number	DB
36			CWE	O	Y		02365	Special Processing Code	DB
37			CWE	O			02366	Clinic Code	DB
38			CX	O			02367	Referral Number	DB
39			CX	O			02368	Authorization Number	DB
40			CWE	O			02369	Service Provider Taxonomy Code	DB
41			CWE	O		0456	01600	Revenue Code	DB
42			ST	O			00325	Prescription Number	DB
43			CQ	O			02370	NDC Qty and UOM	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 (DTM)> ^ <Range End Date/Time (DTM)>

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 (DTM) 00359

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 (CWE) 00360

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)> ^ <Second Alternate Identifier (ST)> ^ <Second Alternate Text (ST)> ^ <Name of Second Alternate Coding System (ID)> ^ <Second Alternate Coding System Version ID (ST)> ^ <Coding System OID (ST)> ^ <Value Set OID (ST)> ^ <Value Set Version ID (DTM)> ^ <Alternate Coding System OID (ST)> ^ <Alternate Value Set OID (ST)> ^ <Alternate Value Set Version ID (DTM)> ^ <Second Alternate Coding System OID (ST)> ^ <Second Alternate Value Set OID (ST)> ^ <Second Alternate Value Set Version ID (DTM)>

Definition: This field contains the code that identifies the type of transaction. Refer to User-defined Table 0017 - Transaction Type in Chapter 2C, Code Tables, for suggested values.

6.5.1.7 FT1-7 Transaction Code (CWE) 00361

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 in Chapter 2C, Code Tables, for suggested values. See Chapter 7 for a discussion of the universal service ID for charges.

6.5.1.8 FT1-8 Transaction Description 00362

Attention: FT1-8 was deprecated as of v 2.3 and the detail was withdrawn and removed from the standard as of v 2.6.

6.5.1.9 FT1-9 Transaction Description - Alt 00363

Attention: FT1-9 was deprecated as of v 2.3 and the detail was withdrawn and removed from the standard as of v 2.6.

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 (CWE)> ^ <Range Type (ID)>

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

Subcomponents for Range Units (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)> & <Second Alternate Identifier (ST)> & <Second Alternate Text (ST)> & <Name of Second Alternate Coding System (ID)> & <Second Alternate Coding System Version ID (ST)> & <Coding System OID (ST)> & <Value Set OID (ST)> & <Value Set Version ID (DTM)> & <Alternate Coding System OID (ST)> & <Alternate Value Set OID (ST)> & <Alternate Value Set Version ID (DTM)> & <Second Alternate Coding System OID (ST)> & <Second Alternate Value Set OID (ST)> & <Second Alternate Value Set Version ID (DTM)>

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 (CWE) 00367

Definition: This field contains the department code that controls the transaction code described above. Refer to User-defined Table 0049 - Department Code in Chapter 2C, Code Tables, for suggested values.

6.5.1.14 FT1-14 Health Plan ID (CWE) 00368

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 in Chapter 2C, Code Tables, for suggested values.

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

Subcomponents for Point of Care (HD): <Namespace ID (IS)> & <Universal ID (ST)> & <Universal ID Type (ID)>

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

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

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

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

Subcomponents for Floor (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 (CWE) 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 in chapter 2C, Code Tables, for suggested values.

6.5.1.18 FT1-18 Patient Type (CWE) 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 2C, Code Tables, 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 (CWE) 00371

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 in Chapter 2C, Code Tables, for suggested values.

6.5.1.20 FT1-20 Performed by Code (XCN) 00372

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 in Chapter 2C, Code Tables, for suggested values. As of v 2.7, if XCN.1 - ID Number is populated, then the XCN.13 - Identifier Type Code and the XCN.9 - Assigning Authority or XCN.22 - Assigning Jurisdiction or XCN.23 - Assigning Agency or Department are required. If XCN.2 - Family Name is populated, then the XCN.10 - Name Type Code is required. No assumptions can be safely made based on position or sequence. Specification of meaning based on sequence is deprecated.

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. As of v 2.7, if XCN.1 - ID Number is populated, then the XCN.13 - Identifier Type Code and the XCN.9 - Assigning Authority or XCN.22 - Assigning Jurisdiction or XCN.23 - Assigning Agency or Department are required. If XCN.2 - Family Name is populated, then the XCN.10 - Name Type Code is required. No assumptions can be safely made based on position or sequence. Specification of meaning based on sequence is deprecated. .

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 (CNE) 00393

Definition: This field contains a unique identifier assigned to the procedure, if any, associated with the charge. Refer to Externally-defined Table 0088 - Procedure Code in Chapter 2C, Code Tables, for suggested values. This field is a coded data type for compatibility with clinical and ancillary systems.

As of v 2.6, the known applicable external coding systems include those in the table below. If the code set you are using is in this table, then you must use that designation.

Procedure Code Coding Systems (from HL7 Table 0396)

Code	Description	Comment / Source
C4	CPT-4	American Medical Association, P.O. Box 10946, Chicago IL 60610.
C5	CPT-5	(under development - same contact as above)
HCPCS	CMS (formerly HCFA) Common Procedure Coding System	HCPCS: contains codes for medical equipment, injectable drugs, transportation services, and other services not found in CPT4.
HPC	CMS (formerly HCFA )Procedure Codes (HCPCS)	Health Care Financing Administration (HCFA) Common Procedure Coding System (HCPCS) including modifiers.
I10P	ICD-10 Procedure Codes	Procedure Coding System (ICD-10-PCS.) See http://www/hcfa.gov/stats/icd10.icd10.htm for more information.

6.5.1.26 FT1-26 Procedure Code Modifier (CNE) 01316

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 Externally-defined Table 0340 - Procedure Code Modifier in Chapter 2C, Code Tables, 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.

As of v 2.6, the known applicable external coding systems include those in the table below. If the code set you are using is in this table, then you must use that designation.

Procedure Code Modifier Coding Systems (From HL7 Table 0396)

Code	Description	Comment / Source
CPTM	CPT Modifier Code	Available for the AMA at the address listed for CPT above. These codes are found in Appendix A of CPT 2000 Standard Edition. (CPT 2000 Standard Edition, American Medical Association, Chicago, IL).
HPC	CMS (formerly HCFA )Procedure Codes (HCPCS)	Health Care Financing Administration (HCFA) Common Procedure Coding System (HCPCS) including modifiers.
I10P	ICD-10 Procedure Codes	Procedure Coding System (ICD-10-PCS.) See http://www/hcfa.gov/stats/icd10.icd10.htm for more information.
I9C	ICD-9CM	Commission on Professional and Hospital Activities, 1968 Green Road, Ann Arbor, MI 48105 (includes all procedures and diagnostic tests).
ICD10AM	ICD-10 Australian modification
ICD10CA	ICD-10 Canada

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

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 2C, Code Tables, 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 2C, Code Tables, for suggested values.

6.5.1.29 FT1-29 NDC Code (CWE) 01845

Definition: This field has been defined for NDC codes that are required by HIPAA for electronic claims for Pharmacy charges. Refer to Externally-defined Table 0549- NDC Codes in Chapter 2C, Code Tables, for suggested values.

If a system supports multiple NDC codes for a charge, this information will be sent in OBX segments. FT1-29 and FT1-43 can be used for single NDC codes and quantities instead of using OBX.

6.5.1.30 FT1-30 Payment Reference ID (CX) 01846

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.

6.5.1.32 FT1-32 Performing Facility (XON) 02361

Components: <Organization Name (ST)> ^ <Organization Name Type Code (CWE)> ^ <WITHDRAWN Constituent> ^ <WITHDRAWN Constituent> ^ <WITHDRAWN Constituent> ^ <Assigning Authority (HD)> ^ <Identifier Type Code (ID)> ^ <Assigning Facility (HD)> ^ <Name Representation Code (ID)> ^ <Organization Identifier (ST)>

Subcomponents for Organization Name Type Code (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)> & <Second Alternate Identifier (ST)> & <Second Alternate Text (ST)> & <Name of Second Alternate Coding System (ID)> & <Second Alternate Coding System Version ID (ST)> & <Coding System OID (ST)> & <Value Set OID (ST)> & <Value Set Version ID (DTM)> & <Alternate Coding System OID (ST)> & <Alternate Value Set OID (ST)> & <Alternate Value Set Version ID (DTM)> & <Second Alternate Coding System OID (ST)> & <Second Alternate Value Set OID (ST)> & <Second Alternate Value Set Version ID (DTM)>

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 Facility where the service is performed by the Provider Person/Group identified in FT1-20 - Performed By Code.

6.5.1.33 FT1-33 Ordering Facility (XON) 02362

Definition: This field contains the name of the Facility where the service is ordered by the Ordering Provider/Group identified in FT1-21 - Ordered By Code.

6.5.1.34 FT1-34 Item Number (CWE) 02363

Definition: This field contains the Item Number for a product. If valued, this field will override the value in the Service Catalog. Item Number (along with Model Number) can be seen as a supplemental number for specific equipment or inventory-related charges.

6.5.1.35 FT1-35 Model Number (ST) 02364

Definition: This field contains the Model Number for a product. If valued, this field will override the value in the Service Catalog. Model Number (along with Item Number) can be seen as a supplemental number for specific equipment or inventory-related charges.

6.5.1.36 FT1-36 Special Processing Code (CWE) 02365

Definition: This field contains a Special Processing Code that is available in reimbursement expressions. If valued, this field will override the value in the Service Catalog.

6.5.1.37 FT1-37 Clinic Code (CWE) 02366

Definition: This field contains the state specific or payer specific type of service or place of service.

6.5.1.38 FT1-38 Referral Number (CX) 02367

Definition: This field contains the Referral Number associated with the charge.

6.5.1.39 FT1-39 Authorization Number (CX) 02368

Definition: This field contains an authorization number assigned to the referral charge.

6.5.1.40 FT1-40 Service Provider Taxonomy Code (CWE) 02369

Definition: This field contains the Taxonomy code for the Service Provider. It allows the provider to identify their specialty category for the particular service.

6.5.1.41 FT1-41 Revenue Code (CWE) 01600

Definition: This field contains the Revenue Code for the charge. If valued, this field will override the value in the Service Catalog. Refer to User-defined Table 0456 - Revenue Code in Chapter 2C, Code Tables, for suggested values.

6.5.1.42 FT1-42 Prescription Number (ST) 00325

Definition: This field contains the prescription number as assigned by the pharmacy or treatment application. Equivalent in uniqueness to the pharmacy/treatment filler order number. At some sites, this may be the pharmacy or treatment system (internal) sequential form. At other sites, this may be an external form.

6.5.1.43 FT1-43 NDC Qty and UOM (CQ) 02370

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

Subcomponents for Units (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)> & <Second Alternate Identifier (ST)> & <Second Alternate Text (ST)> & <Name of Second Alternate Coding System (ID)> & <Second Alternate Coding System Version ID (ST)> & <Coding System OID (ST)> & <Value Set OID (ST)> & <Value Set Version ID (DTM)> & <Alternate Coding System OID (ST)> & <Alternate Value Set OID (ST)> & <Alternate Value Set Version ID (DTM)> & <Second Alternate Coding System OID (ST)> & <Second Alternate Value Set OID (ST)> & <Second Alternate Value Set Version ID (DTM)>

Definition: This field contains the Drug Code Quantity and the Units of Measurement for the corresponding NDC-Code in FT1-29 - NDC Code.

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	C_LEN	DT	OPT	RP/#	TBL#	ITEM#	ELEMENT NAME	DB Ref.
1	1..4		SI	R			00375	Set ID - DG1	DB
2				W			00376	Diagnosis Coding Method	DB
3			CWE	R		0051	00377	Diagnosis Code - DG1	DB
4				W			00378	Diagnosis Description	DB
5			DTM	O			00379	Diagnosis Date/Time	DB
6			CWE	R		0052	00380	Diagnosis Type	DB
7				W			00381	Major Diagnostic Category	DB
8				W			00382	Diagnostic Related Group	DB
9				W			00383	DRG Approval Indicator	DB
10				W			00384	DRG Grouper Review Code	DB
11				W			00385	Outlier Type	DB
12				W			00386	Outlier Days	DB
13				W			00387	Outlier Cost	DB
14				W			00388	Grouper Version And Type	DB
15		2=	NM	O		0359	00389	Diagnosis Priority	DB
16			XCN	O	Y		00390	Diagnosing Clinician	DB
17			CWE	O		0228	00766	Diagnosis Classification	DB
18	1..1		ID	O		0136	00767	Confidential Indicator	DB
19			DTM	O			00768	Attestation Date/Time	DB
20			EI	C			01850	Diagnosis Identifier	DB
21	1..1		ID	C		0206	01894	Diagnosis Action Code	DB
22			EI	C			02152	Parent Diagnosis	DB
23			CWE	O		0728	02153	DRG CCL Value Code	DB
24	1..1		ID	O		0136	02154	DRG Grouping Usage	DB
25			CWE	O		0731	02155	DRG Diagnosis Determination Status	DB
26			CWE	O		0895	02288	Present On Admission (POA) Indicator	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 00376

Attention: DG1-2 was deprecated as of v 2.3 and the detail was withdrawn and removed from the standard as of v 2.6 .

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

Definition: DG1-3 - Diagnosis Code - DG1 contains the diagnosis code assigned to this diagnosis. Refer to User-defined Table 0051 - Diagnosis Code in Chapter 2C, Code Tables, for suggested values. This field is a CWE data type for compatibility with clinical and ancillary systems. Either DG1-3.1-Identifier or DG1-3.2-Text is required. When a code is used in DG1-3.1-Identifier, a coding system is required in DG1-3.3-Name of Coding System.

Names of various diagnosis coding systems are listed in Chapter 2, Section 2.16.4, "Coding system table."

6.5.2.4 DG1-4 Diagnosis Description 00378

Attention: DG1-4 was deprecated as of v 2.3 and the detail was withdrawn and removed from the standard as of v 2.6.

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

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

6.5.2.6 DG1-6 Diagnosis Type (CWE) 00380

Definition: This field contains a code that identifies the type of diagnosis being sent. Refer to User-defined Table 0052 - Diagnosis Type in Chapter 2C, Code Tables, for suggested values. This field should no longer be used to indicate "DRG" because the DRG fields have moved to the new DRG segment.

6.5.2.7 DG1-7 Major Diagnostic Category 00381

Attention: DG1-7 was deprecated as of v 2.3 and the detail was withdrawn and removed from the standard as of v 2.6 .

6.5.2.8 DG1-8 Diagnostic Related Group 00382

Attention: DG1-8 was deprecated as of v 2.3 and the detail was withdrawn and removed from the standard as of v 2.6.

6.5.2.9 DG1-9 DRG Approval Indicator 00383

Attention: DG1-9 was deprecated as of v 2.3 and the detail was withdrawn and removed from the standard as of v 2.6

6.5.2.10 DG1-10 DRG Grouper Review Code 00384

Attention: DG1-10 was deprecated as of v 2.3 and the detail was withdrawn and removed from the standard as of v 2.6

6.5.2.11 DG1-11 Outlier Type 00385

Attention: DG1-11 was deprecated as of v 2.3 and the detail was withdrawn and removed from the standard as of v 2.6

6.5.2.12 DG1-12 Outlier Days 00386

Attention: DG1-12 was deprecated as of v 2.3 and the detail was withdrawn and removed from the standard as of v 2.6

6.5.2.13 DG1-13 Outlier Cost 00387

Attention: DG1-13 was deprecated as of v 2.3 and the detail was withdrawn and removed from the standard as of v 2.6

6.5.2.14 DG1-14 Grouper Version and Type 00388

Attention: DG1-14 was deprecated as of v 2.3 and the detail was withdrawn and removed from the standard as of v 2.6

6.5.2.15 DG1-15 Diagnosis Priority (NM) 00389

Definition: This field contains the number that identifies the significance or priority of the diagnosis code. Refer to HL7 Table 0359 - Diagnosis Priority in Chapter 2C, Code Tables, for suggested values.

Note: As of v 2.7, the data type has been changed to numeric. The meaning of the values remains the same as those in HL7 Table 0418 - Procedure Priority, The value 0 conveys that this procedure is not included in the ranking. The value 1 means that this is the primary procedure. Values 2-99 convey ranked secondary procedures.

6.5.2.16 DG1-16 Diagnosing Clinician (XCN) 00390

Definition: This field contains the individual responsible for generating the diagnosis information. As of v 2.7, if XCN.1 - ID Number is populated, then the XCN.13 - Identifier Type Code and the XCN.9 - Assigning Authority or XCN.22 - Assigning Jurisdiction or XCN.23 - Assigning Agency or Department are required. If XCN.2 - Family Name is populated, then the XCN.10 - Name Type Code is required. No assumptions can be safely made based on position or sequence. Specification of meaning based on sequence is deprecated.

6.5.2.17 DG1-17 Diagnosis Classification (CWE) 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 in Chapter 2C, Code Tables, for suggested values.

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 in Chapter 2C, "Code Tables", 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 (DTM) 00768

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

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

6.5.2.22 DG1-22 Parent Diagnosis (EI) 02152

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

Definition: This field contains the entity identifier for the parent diagnosis. This field links the "current" manifestation diagnosis ("*") to the entity identifier of the "parent" etiological diagnosis ("+").

6.5.2.23 DG1-23 DRG CCL Value Code (CWE) 02153

Definition: This field indicates the CCL value for the determined DRG for this diagnosis. Refer to Externally-defined Table 0728 - CCL Value in Chapter 2C, Code Tables, for suggested values.

6.5.2.24 DG1-24 DRG Grouping Usage (ID) 02154

Definition: This field identifies whether this particular diagnosis has been used for the DRG determination. Refer to HL7 Table 0136 - Yes/No Indicator in Chapter 2C, Code Tables, for suggested values. The values have the following meaning for this field:

Y Yes - Indicates that the diagnosis has been used for the DRG determination

N No - Indicates that the diagnosis has not been used for the DRG determination

6.5.2.25 DG1-25 DRG Diagnosis Determination Status (CWE) 02155

Definition: This field contains the status of this particular diagnosis for the DRG determination. Refer to User-defined Table 0731 - DRG Diagnosis Determination Status in Chapter 2C, Code Tables, for suggested values.

6.5.2.26 DG1-26 Present On Admission (POA) Indicator (CWE) 02288

Definition: This field contains the present on admission indicator for this particular diagnosis. US reimbursement formulas for some states and Medicare have mandated that each diagnosis code be flagged as to whether it was present on admission or not. Refer to User-defined Table 0895 - Present On Admission (POA) Indicator in Chapter 2C, Code Tables, for suggested values.

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	C.LEN	DT	OPT	TBL#	ITEM#	ELEMENT NAME	DB Ref.
1			CNE	O	0055	00382	Diagnostic Related Group	DB
2			DTM	O		00769	DRG Assigned Date/Time	DB
3	1..1		ID	O	0136	00383	DRG Approval Indicator	DB
4			CWE	O	0056	00384	DRG Grouper Review Code	DB
5			CWE	O	0083	00385	Outlier Type	DB
6		3=	NM	O		00386	Outlier Days	DB
7			CP	O		00387	Outlier Cost	DB
8			CWE	O	0229	00770	DRG Payor	DB
9			CP	O		00771	Outlier Reimbursement	DB
10	1..1		ID	O	0136	00767	Confidential Indicator	DB
11			CWE	O	0415	01500	DRG Transfer Type	DB
12			XPN	O		02156	Name of Coder	DB
13			CWE	O	0734	02157	Grouper Status	DB
14			CWE	O	0728	02158	PCCL Value Code	DB
15		5#	NM	O		02159	Effective Weight	DB
16			MO	O		02160	Monetary Amount	DB
17			CWE	O	0739	02161	Status Patient	DB
18		100#	ST	O		02162	Grouper Software Name	DB
19		100#	ST	O		02282	Grouper Software Version	DB
20			CWE	O	0742	02163	Status Financial Calculation	DB
21			MO	O		02164	Relative Discount/Surcharge	DB
22			MO	O		02165	Basic Charge	DB
23			MO	O		02166	Total Charge	DB
24			MO	O		02167	Discount/Surcharge	DB
25		5=	NM	O		02168	Calculated Days	DB
26			CWE	O	0749	02169	Status Gender	DB
27			CWE	O	0749	02170	Status Age	DB
28			CWE	O	0749	02171	Status Length of Stay	DB
29			CWE	O	0749	02172	Status Same Day Flag	DB
30			CWE	O	0749	02173	Status Separation Mode	DB
31			CWE	O	0755	02174	Status Weight at Birth	DB
32			CWE	O	0757	02175	Status Respiration Minutes	DB
33			CWE	O	0759	02176	Status Admission	DB

6.5.3.0 DRG Field Definitions

6.5.3.1 DRG-1 Diagnostic Related Group (CNE) 00382

Definition: This field contains the DRG for the transaction. Interim DRG's could be determined for an encounter. Refer to Externally-defined Table 0055 - Diagnosis Related Group in Chapter 2C, Code Tables, for suggested values.

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

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 (CWE) 00384

Definition: This code indicates that the grouper results have been reviewed and approved. Refer to User-defined Table 0056 - DRG Grouper Review Code in Chapter 2C, Code Tables, for suggested values.

6.5.3.5 DRG-5 Outlier Type (CWE) 00385

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 in Chapter 2C, code Tables, 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 (CWE) 00770

Definition: This field indicates the associated DRG Payor. Refer to User-defined Table 0229 - DRG Payor in Chapter 2C, Code Tables, for suggested values.

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 in Chapter 2C, Code Tables, 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 (CWE) 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 in Chapter 2C, code Tables, for suggested values.

6.5.3.12 DRG-12 Name of Coder (XPN) 02156

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)> ^ <WITHDRAWN Constituent> ^ <Name Type Code (ID)> ^ <Name Representation Code (ID)> ^ <Name Context (CWE)> ^ <WITHDRAWN Constituent> ^ <Name Assembly Order (ID)> ^ <Effective Date (DTM)> ^ <Expiration Date (DTM)> ^ <Professional Suffix (ST)> ^ <Called By (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 (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)> & <Second Alternate Identifier (ST)> & <Second Alternate Text (ST)> & <Name of Second Alternate Coding System (ID)> & <Second Alternate Coding System Version ID (ST)> & <Coding System OID (ST)> & <Value Set OID (ST)> & <Value Set Version ID (DTM)> & <Alternate Coding System OID (ST)> & <Alternate Value Set OID (ST)> & <Alternate Value Set Version ID (DTM)> & <Second Alternate Coding System OID (ST)> & <Second Alternate Value Set OID (ST)> & <Second Alternate Value Set Version ID (DTM)>

Definition: This field holds the name of the person ("coder") who supervised or undertook the determination of the DRG code.

6.5.3.13 DRG-13 Grouper Status (CWE) 02157

Definition: This field indicates the grouper status in general. Refer to Externally-defined Table 0734 - Grouper Status in Chapter 2C, Code Tables, for suggested values.

6.5.3.14 DRG-14 PCCL Value Code (CWE) 02158

Definition: This field indicates the PCCL (Patient Clinical Complexity Level) value for the calculated DRG as a single value. This value is calculated based on all individual CCL values calculated so far in relation to the basic DRG. Refer to Externally-defined Table 0728 - CCL Value in Chapter 2C, Code Tables, for suggested values.

6.5.3.15 DRG-15 Effective Weight (NM) 02159

Definition: This field contains the effective weight as calculated for this DRG. When exceeding the upper or lower trim point the effective weight is lower or higher.

6.5.3.16 DRG-16 Monetary Amount (MO) 02160

Components: <Quantity (NM)> ^ <Denomination (ID)>

Definition: This field contains the monetary amount as calculated for this DRG, i.e., the sum of money the insurance company will pay.

6.5.3.17 DRG-17 Status Patient (CWE) 02161

Definition: This field contains the status of the patient concerning the financial aspects. It indicates whether the length of stay is normal or respectively shorter or longer than normal. Refer to User-defined Table 0739 - DRG Status Patient in Chapter 2C, Code Tables, for suggested values.

This field is also used along with DRG-23 and DRG-24 as an indication of whether a surcharge (long length of stay) or a discount (short length of stay) has been determined.

6.5.3.18 DRG-18 Grouper Software Name (ST) 02162

Definition: This field contains the name of the software used for grouping.

6.5.3.19 DRG-19 Grouper Software Version (ST) 02282

Definition: This field contains the version information of the software used for grouping.

6.5.3.20 DRG-20 Status Financial Calculation (CWE) 02163

Definition: This field contains the status of the DRG calculation regarding the financial aspects. Refer to User-defined Table 0742 - DRG Status Financial Calculation in Chapter 2C, Code Tables, for suggested values.

6.5.3.21 DRG-21 Relative Discount/Surcharge (MO) 02164

Components: <Quantity (NM)> ^ <Denomination (ID)>

Definition: There will be a discount/surcharge for the calculated price due to a very short stay, early referral or a very long stay. This field contains the discount or surcharge that is included in the final price.

6.5.3.22 DRG-22 Basic Charge (MO) 02165

Components: <Quantity (NM)> ^ <Denomination (ID)>

Definition: The basic charge is calculated as a multiplication of the relative weight with the base rate.

6.5.3.23 DRG-23 Total Charge (MO) 02166

Components: <Quantity (NM)> ^ <Denomination (ID)>

Definition: This field contains the total charge including surcharges or discounts.

6.5.3.24 DRG-24 Discount/Surcharge (MO) 02167

Components: <Quantity (NM)> ^ <Denomination (ID)>

Definition: This field contains the discount/surcharge as determined for this DRG. The addition/reduction is indicated by DRG-17 - Status Patient.

6.5.3.25 DRG-25 Calculated Days (NM) 02168

Definition: This field contains the number of days, for which a surcharge/discount has been determined. The addition/reduction is indicated by DRG-17 - Status Patient.

6.5.3.26 DRG-26 Status Gender (CWE) 02169

Definition: This field contains the status of the use of the gender information for DRG determination. Refer to User-defined Table 0749 - DRG Grouping Status in Chapter 2C, Code Tables, for suggested values.

6.5.3.27 DRG-27 Status Age (CWE) 02170

Definition: This field contains the status of the use of the age information for DRG determination. Refer to User-defined Table 0749 - DRG Grouping Status in Chapter 2C, Code Tables, for suggested values.

6.5.3.28 DRG-28 Status Length of Stay (CWE) 02171

Definition: This field contains the status of the DRG calculation for the length of stay information. Refer to User-defined Table 0749 - DRG Grouping Status in Chapter 2C, Code Tables, for suggested values.

6.5.3.29 DRG-29 Status Same Day Flag (CWE) 02172

Definition: This field contains the status of the use of the same day information for DRG determination. Refer to User-defined Table 0749 - DRG Grouping Status in Chapter 2C, Code Tables, for suggested values.

6.5.3.30 DRG-30 Status Separation Mode (CWE) 02173

Definition: This field contains the status of the use of the separation mode information for DRG determination. Refer to User-defined Table 0749 - DRG Grouping Status in Chapter 2C, Code Tables, for suggested values.

6.5.3.31 DRG-31 Status Weight At Birth (CWE) 02174

Definition: This field contains the status of the use of the weight at birth information for DRG determination. Refer to User-defined Table 0755 - DRG Status Weight At Birth in Chapter 2C, Code Tables, for suggested values.

6.5.3.32 DRG-32 Status Respiration Minutes (CWE) 02175

Definition: This field contains the status of the use of the respiration minutes information for DRG determination. Refer to User-defined Table 0757 - DRG Status Respiration Minutes in Chapter 2C, Code Tables, for suggested values.

6.5.3.33 DRG-33 Status Admission (CWE) 02176

Definition: This field contains the admission status for the DRG determination. Refer to User-defined Table 0759 - Status Admission in Chapter 2C, Code Tables, for suggested values.

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	C.LEN	DT	OPT	RP/#	TBL#	ITEM#	ELEMENT NAME	DB Ref.
1	1..4		SI	R			00391	Set ID - PR1	DB
2				W			00392	Procedure Coding Method	DB
3			CNE	R		0088	00393	Procedure Code	DB
4				W			00394	Procedure Description	DB
5			DTM	R			00395	Procedure Date/Time	DB
6			CWE	O		0230	00396	Procedure Functional Type	DB
7		4=	NM	O			00397	Procedure Minutes	DB
8				W			00398	Anesthesiologist	DB
9			CWE	O		0019	00399	Anesthesia Code	DB
10		4=	NM	O			00400	Anesthesia Minutes	DB
11				W			00401	Surgeon	DB
12				W			00402	Procedure Practitioner	DB
13			CWE	O		0059	00403	Consent Code	DB
14	1..2		NM	O		0418	00404	Procedure Priority	DB
15			CWE	O		0051	00772	Associated Diagnosis Code	DB
16			CNE	O	Y	0340	01316	Procedure Code Modifier	DB
17			CWE	O		0416	01501	Procedure DRG Type	DB
18			CWE	O	Y	0417	01502	Tissue Type Code	DB
19			EI	C			01848	Procedure Identifier	DB
20	1..1		ID	C		0206	01849	Procedure Action Code	DB
21			CWE	O		0761	02177	DRG Procedure Determination Status	DB
22			CWE	O		0763	02178	DRG Procedure Relevance	DB
23			PL	O	Y		02371	Treating Organizational Unit	DB
24	1..1		ID	O		0136	02372	Respiratory Within Surgery	DB
25			EI	O			02373	Parent Procedure ID	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 00392

Attention: PR1-2 was deprecated as of v 2.3 and the detail was withdrawn and removed from the standard as of v 2.6.

6.5.4.3 PR1-3 Procedure Code (CNE) 00393

Definition: This field contains a unique identifier assigned to the procedure. Refer to Externally-defined Table 0088 - Procedure Code in Chapter 2C, Code Tables, for suggested values. This field is a CNE data type for compatibility with clinical and ancillary systems.

6.5.4.4 PR1-4 Procedure Description 00394

Attention: PR1-4 was deprecated as of v 2.3 and the detail was withdrawn and removed from the standard as of v 2.6.

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

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

6.5.4.6 PR1-6 Procedure Functional Type (CWE) 00396

Definition: This field contains the optional code that further defines the type of procedure. Refer to User-defined Table 0230 - Procedure Functional Type in Chapter 2C, Code Tables, for suggested values.

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. The duration starts with the point in time in PR1-5.

6.5.4.8 PR1-8 Anesthesiologist 00398

Attention: PR1-8 was deprecated as of v 2.3 and the detail was withdrawn and removed from the standard as of v 2.6.

6.5.4.9 PR1-9 Anesthesia Code (CWE) 00399

Definition: This field contains a unique identifier of the anesthesia used during the procedure. Refer to User-defined Table 0019 - Anesthesia Code in Chapter 2C, Code Tables, for suggested values.

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 00401

Attention: PR1-11 was deprecated as of v 2.3 and the detail was withdrawn and removed from the standard as of v 2.6.

6.5.4.12 PR1-12 Procedure Practitioner 00402

Attention: PR1-12 was deprecated as of v 2.3 and the detail was withdrawn and removed from the standard as of v 2.6.

6.5.4.13 PR1-13 Consent Code (CWE) 00403

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 in Chapter 2C, Code Tables, for suggested values.

6.5.4.14 PR1-14 Procedure Priority (NM) 00404

Definition: This field contains a number that identifies the significance or priority of the procedure code. Refer to HL7 Table 0418 - Procedure Priority in Chapter 2C, Code Tables, for valid values.

Note: As of v 2.7, the data type has been changed to numeric. The meaning of the values remain the same as those in HL7 Table 0418 - Procedure Priority, The value 0 conveys that this procedure is not included in the ranking. The value 1 means that this is the primary procedure. Values 2-99 convey ranked secondary procedures.

6.5.4.15 PR1-15 Associated Diagnosis Code (CWE) 00772

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 in Chapter 2C, Code Tables, for suggested values.

6.5.4.16 PR1-16 Procedure Code Modifier (CNE) 01316

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 Externally-defined Table 0340 - Procedure Code Modifier in Chapter 2C, Code Tables, for suggested values.

6.5.4.17 PR1-17 Procedure DRG Type (CWE) 01501

Definition: This field indicates a procedure's priority ranking relative to its DRG. Refer to User-defined Table 0416 - Procedure DRG Type in Chapter 2C, Code Tables, for suggested values.

6.5.4.18 PR1-18 Tissue Type Code (CWE) 01502

Definition: Code representing type of tissue removed from a patient during this procedure. Refer to User-defined Table 0417 - Tissue Type Code in Chapter 2C, Code Tables, for suggested values.

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 2C, Code Tables, for valid values. This field is required for the Update Diagnosis/Procedures (P12) message. In all other events it is optional.

6.5.4.21 PR1-21 DRG Procedure Determination Status (CWE) 02177

Definition: This field contains the status of the use of this particular procedure for the DRG determination. Refer to User-defined Table 0761 - DRG Procedure Determination Status in Chapter 2C, Code Tables, for suggested values.

6.5.4.22 PR1-22 DRG Procedure Relevance (CWE) 02178

Definition: This field contains the relevance of this particular procedure for the DRG determination. Refer to User-defined Table 0763 - DRG Procedure Relevance in Chapter 2C, code Tables, for suggested values.

6.5.4.23 PR1-23 Treating Organizational Unit (PL) 02371

Definition: This field contains information about the organizational unit that has performed the procedure.

6.5.4.24 PR1-24 Respiratory Within Surgery (ID) 02372

Definition: This field indicates whether or not a respiratory procedure has occurred during a surgery. This field is optional and only needs to be valued for respiratory procedures. Refer to HL7 Table 0136 - Yes/no Indicator in Chapter 2C, Code TableS, for valid values.

6.5.4.25 PR1-25 Parent Procedure ID (EI) 02373

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

Definitions: This field contains a procedure ID which points to the procedure group (e.g., complete surgery) in which this instance belongs.

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	C.LEN	DT	OPT	RP/#	TBL#	ITEM#	ELEMENT NAME	DB Ref.
1	1..4		SI	R			00405	Set ID - GT1	DB
2			CX	O	Y		00406	Guarantor Number	DB
3			XPN	R	Y		00407	Guarantor Name	DB
4			XPN	O	Y		00408	Guarantor Spouse Name	DB
5			XAD	O	Y		00409	Guarantor Address	DB
6			XTN	O	Y		00410	Guarantor Ph Num - Home	DB
7			XTN	O	Y		00411	Guarantor Ph Num - Business	DB
8			DTM	O			00412	Guarantor Date/Time Of Birth	DB
9			CWE	O		0001	00413	Guarantor Administrative Sex	DB
10			CWE	O		0068	00414	Guarantor Type	DB
11			CWE	O		0063	00415	Guarantor Relationship	DB
12		11=	ST	O			00416	Guarantor SSN	DB
13			DT	O			00417	Guarantor Date - Begin	DB
14			DT	O			00418	Guarantor Date - End	DB
15	1..2		NM	O			00419	Guarantor Priority	DB
16			XPN	O	Y		00420	Guarantor Employer Name	DB
17			XAD	O	Y		00421	Guarantor Employer Address	DB
18			XTN	O	Y		00422	Guarantor Employer Phone Number	DB
19			CX	O	Y		00423	Guarantor Employee ID Number	DB
20			CWE	O		0066	00424	Guarantor Employment Status	DB
21			XON	O	Y		00425	Guarantor Organization Name	DB
22	1..1		ID	O		0136	00773	Guarantor Billing Hold Flag	DB
23			CWE	O		0341	00774	Guarantor Credit Rating Code	DB
24			DTM	O			00775	Guarantor Death Date And Time	DB
25	1..1		ID	O		0136	00776	Guarantor Death Flag	DB
26			CWE	O		0218	00777	Guarantor Charge Adjustment Code	DB
27			CP	O			00778	Guarantor Household Annual Income	DB
28		3=	NM	O			00779	Guarantor Household Size	DB
29			CX	O	Y		00780	Guarantor Employer ID Number	DB
30			CWE	O		0002	00781	Guarantor Marital Status Code	DB
31			DT	O			00782	Guarantor Hire Effective Date	DB
32			DT	O			00783	Employment Stop Date	DB
33			CWE	O		0223	00755	Living Dependency	DB
34			CWE	O	Y	0009	00145	Ambulatory Status	DB
35			CWE	O	Y	0171	00129	Citizenship	DB
36			CWE	O		0296	00118	Primary Language	DB
37			CWE	O		0220	00742	Living Arrangement	DB
38			CWE	O		0215	00743	Publicity Code	DB
39	1..1		ID	O		0136	00744	Protection Indicator	DB
40			CWE	O		0231	00745	Student Indicator	DB
41			CWE	O		0006	00120	Religion	DB
42			XPN	O	Y		00109	Mother's Maiden Name	DB
43			CWE	O		0212	00739	Nationality	DB
44			CWE	O	Y	0189	00125	Ethnic Group	DB
45			XPN	O	Y		00748	Contact Person's Name	DB
46			XTN	O	Y		00749	Contact Person's Telephone Number	DB
47			CWE	O		0222	00747	Contact Reason	DB
48			CWE	O		0063	00784	Contact Relationship	DB
49		20#	ST	O			00785	Job Title	DB
50			JCC	O			00786	Job Code/Class	DB
51			XON	O	Y		01299	Guarantor Employer's Organization Name	DB
52			CWE	O		0295	00753	Handicap	DB
53			CWE	O		0311	00752	Job Status	DB
54			FC	O			01231	Guarantor Financial Class	DB
55			CWE	O	Y	0005	01291	Guarantor Race	DB
56		100#	ST	O			01851	Guarantor Birth Place	DB
57			CWE	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

Definition: This field contains the name of the guarantor. Multiple names for the same guarantor may be sent in this field. As of v 2.7, no assumptions can be made based on position or sequence. Specification of meaning based on sequence is deprecated.

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. As of v 2.7, no assumptions can be made based on position or sequence. Specification of meaning based on sequence is deprecated.

6.5.5.5 GT1-5 Guarantor Address (XAD) 00409

Definition: This field contains the guarantor's address. Multiple addresses for the same person may be sent in this field. As of v 2.7, no assumptions can be made based on position or sequence. Specification of meaning based on sequence is deprecated.

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

Definition: This field contains the guarantor's home phone number. All personal phone numbers for the guarantor may be sent in this field. As of v 2.7, no assumptions can be made based on position or sequence. Specification of meaning based on sequence is deprecated. .

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. As of v 2.7, no assumptions can be made based on position or sequence. Specification of meaning based on sequence is deprecated.

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

Definition: This field contains the guarantor's date of birth.

6.5.5.9 GT1-9 Guarantor Administrative Sex (CWE) 00413

Definition: This field contains the guarantor's gender. Refer to User-defined Table 0001 - Administrative Sex in Chapter 2C, Code Tables, for suggested values.

6.5.5.10 GT1-10 Guarantor Type (CWE) 00414

Definition: This field indicates the type of guarantor, e.g., individual, institution, etc. Refer to User-defined Table 0068 - Guarantor Type in Chapter 2C, Code Tables, for suggested values.

6.5.5.11 GT1-11 Guarantor Relationship (CWE) 00415

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 2C, Code Tables, 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. As of v 2.7, no assumptions can be made based on position or sequence. Specification of meaning based on sequence is deprecated.

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. As of v 2.7, no assumptions can be made based on position or sequence. Specification of meaning based on sequence is deprecated.

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. As of v 2.7, no assumptions can be made based on position or sequence. Specification of meaning based on sequence is deprecated. .

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 (CWE) 00424

Definition: This field contains the code that indicates the guarantor's employment status. Refer to User-Defined Table 0066 - Employment Status in Chapter 2C, Code Tables, for suggested values.

6.5.5.21 GT1-21 Guarantor Organization Name (XON) 00425

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 in Chapter 2C, Code Tables, 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 (CWE) 00774

Definition: This field contains the guarantor's credit rating. Refer to User-defined Table 0341 - Guarantor Credit Rating Code in Chapter 2C, Code Tables, for suggested values.

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

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 in Chapter 2C, Code Tables, for valid values.

Y the guarantor is deceased

N the guarantor is living

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

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 in Chapter 2C, Code Tables, for suggested values.

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

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 (CWE) 00781

Definition: This field contains the marital status of the guarantor. Refer to User-defined Table 0002 - Marital Status in Chapter 2C, Code Tables, 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 (CWE) 00755

Definition: Identifies the specific living conditions of the guarantor. Refer to User-defined Table 0223 - Living Dependency in Chapter 2C, Code Tables, for suggested values.

6.5.5.34 GT1-34 Ambulatory Status (CWE) 00145

Definition: Identifies the transient state of mobility for the guarantor. Refer to User-defined Table 0009 - Ambulatory Status in Chapter 2C, Code Tables, for suggested values.

6.5.5.35 GT1-35 Citizenship (CWE) 00129

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 in Chapter 2C, Code Tables.

6.5.5.36 GT1-36 Primary Language (CWE) 00118

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 2C, Code Tables.

6.5.5.37 GT1-37 Living Arrangement (CWE) 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 2C, Code Tables, for suggested values.

6.5.5.38 GT1-38 Publicity Code (CWE) 00743

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 2C, Code Tables, 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 (CWE) 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 in Chapter 2C, Code Tables, for suggested values.

6.5.5.41 GT1-41 Religion (CWE) 00120

Definition: This field indicates the type of religion practiced by the guarantor. Refer to User-defined Table 0006 - Religion in Chapter 2C, Code Tables, 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 (CWE) 00739

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 2C, Code Tables.

6.5.5.44 GT1-44 Ethnic Group (CWE) 00125

Definition: This field contains the guarantor's ethnic group. Refer to User-defined Table 0189 - Ethnic Group in Chapter 2C, Code Tables, 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. (E.g., 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. As of v 2.7, no assumptions can be made based on position or sequence. Specification of meaning based on sequence is deprecated.

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. As of v 2.7, no assumptions can be made based on position or sequence. Specification of meaning based on sequence is deprecated.

6.5.5.47 GT1-47 Contact Reason (CWE) 00747

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 in Chapter 2C, Code Tables, for suggested values.

6.5.5.48 GT1-48 Contact Relationship (CWE) 00784

Definition: Identifies the guarantor relationship to the contact person specified above. Refer to User-defined Table 0063 - Relationship in Chapter 2C, Code Tables, 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

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 (CWE) 00753

Definition: This field contains a code to describe the guarantor's disability. Refer to User-defined Table 0295 - Handicap in Chapter 2C, Code Tables, for suggested values.

6.5.5.53 GT1-53 Job Status (CWE) 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 2C, Code Tables, for suggested values.

6.5.5.54 GT1-54 Guarantor Financial Class (FC) 01231

Components: <Financial Class Code (CWE)> ^ <Effective Date (DTM)>

Subcomponents for Financial Class Code (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)> & <Second Alternate Identifier (ST)> & <Second Alternate Text (ST)> & <Name of Second Alternate Coding System (ID)> & <Second Alternate Coding System Version ID (ST)> & <Coding System OID (ST)> & <Value Set OID (ST)> & <Value Set Version ID (DTM)> & <Alternate Coding System OID (ST)> & <Alternate Value Set OID (ST)> & <Alternate Value Set Version ID (DTM)> & <Second Alternate Coding System OID (ST)> & <Second Alternate Value Set OID (ST)> & <Second Alternate Value Set Version ID (DTM)>

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 (CWE) 01291

Definition: This field refers to the guarantor's race. Refer to User-defined Table 0005 - Race in Chapter 2C, Code Tables, 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 (CWE) 00146

Definition: This field identifies the type of VIP for the guarantor. Refer to User-defined Table 0099 - VIP Indicator in Chapter 2C, Code Tables, 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	C.LEN	DT	OPT	RP/#	TBL#	ITEM#	ELEMENT NAME	DB Ref.
1	1..4		SI	R			00426	Set ID - IN1	DB
2			CWE	R		0072	00368	Health Plan ID	DB
3			CX	R	Y		00428	Insurance Company ID	DB
4			XON	O	Y		00429	Insurance Company Name	DB
5			XAD	O	Y		00430	Insurance Company Address	DB
6			XPN	O	Y		00431	Insurance Co Contact Person	DB
7			XTN	O	Y		00432	Insurance Co Phone Number	DB
8		12=	ST	O			00433	Group Number	DB
9			XON	O	Y		00434	Group Name	DB
10			CX	O	Y		00435	Insured's Group Emp ID	DB
11			XON	O	Y		00436	Insured's Group Emp Name	DB
12			DT	O			00437	Plan Effective Date	DB
13			DT	O			00438	Plan Expiration Date	DB
14			AUI	O			00439	Authorization Information	DB
15			CWE	O		0086	00440	Plan Type	DB
16			XPN	O	Y		00441	Name Of Insured	DB
17			CWE	O		0063	00442	Insured's Relationship To Patient	DB
18			DTM	O			00443	Insured's Date Of Birth	DB
19			XAD	O	Y		00444	Insured's Address	DB
20			CWE	O		0135	00445	Assignment Of Benefits	DB
21			CWE	O		0173	00446	Coordination Of Benefits	DB
22		2=	ST	O			00447	Coord Of Ben. Priority	DB
23	1..1		ID	O		0136	00448	Notice Of Admission Flag	DB
24			DT	O			00449	Notice Of Admission Date	DB
25	1..1		ID	O		0136	00450	Report Of Eligibility Flag	DB
26			DT	O			00451	Report Of Eligibility Date	DB
27			CWE	O		0093	00452	Release Information Code	DB
28		15=	ST	O			00453	Pre-Admit Cert (PAC)	DB
29			DTM	O			00454	Verification Date/Time	DB
30			XCN	O	Y		00455	Verification By	DB
31			CWE	O		0098	00456	Type Of Agreement Code	DB
32			CWE	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			CWE	O		0042	00460	Company Plan Code	DB
36		15=	ST	O			00461	Policy Number	DB
37			CP	O			00462	Policy Deductible	DB
38				W			00463	Policy Limit - Amount	DB
39		4=	NM	O			00464	Policy Limit - Days	DB
40				W			00465	Room Rate - Semi-Private	DB
41				W			00466	Room Rate - Private	DB
42			CWE	O		0066	00467	Insured's Employment Status	DB
43			CWE	O		0001	00468	Insured's Administrative Sex	DB
44			XAD	O	Y		00469	Insured's Employer's Address	DB
45		2=	ST	O			00470	Verification Status	DB
46			CWE	O		0072	00471	Prior Insurance Plan ID	DB
47			CWE	O		0309	01227	Coverage Type	DB
48			CWE	O		0295	00753	Handicap	DB
49			CX	O	Y		01230	Insured's ID Number	DB
50			CWE	O		0535	01854	Signature Code	DB
51			DT	O			01855	Signature Code Date	DB
52			ST	O			01899	Insured's Birth Place	DB
53			CWE	O		0099	01852	VIP Indicator	DB
54			CX	O	Y		03292	External Health Plan Identifiers	DB
55	1		ID	O		0206	03335	Insurance Action Code	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 Health Plan ID (CWE) 00368

Definition: This field contains a unique identifier for the insurance plan. Refer to User-defined Table 0072 - Insurance Plan ID in Chapter 2C, Code Tables, 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.

The assigning authority for IN1-2, Health Plan ID is assumed to be the Entity named in IN1-3, Insurance Company ID.

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. As of v 2.7, no assumptions can be made based on position or sequence. Specification of meaning based on sequence is deprecated.

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. As of v 2.7, no assumptions can be made based on position or sequence. Specification of meaning based on sequence is deprecated.

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. As of v 2.7, no assumptions can be made based on position or sequence. Specification of meaning based on sequence is deprecated.

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 (CWE) 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 in Chapter 2C, Code Tables, for suggested values.

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. As of v 2.7, no assumptions can be made based on position or sequence. Specification of meaning based on sequence is deprecated.

6.5.6.17 IN1-17 Insured's Relationship to Patient (CWE) 00442

Definition: This field indicates the insured's relationship to the patient. Refer to User-defined Table 0063 - Relationship in Chapter 2C, Code Tables, for suggested values.

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

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. As of v 2.7, no assumptions can be made based on position or sequence. Specification of meaning based on sequence is deprecated.

6.5.6.20 IN1-20 Assignment of Benefits (CWE) 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 in Chapter 2C, Code Tables, for suggested values.

6.5.6.21 IN1-21 Coordination of Benefits (CWE) 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 in Chapter 2C, Code Tables, for suggested values.

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 in Chapter 2C, Code Tables, 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 in Chapter 2C, Code Tables, 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 (CWE) 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 in Chapter 2C, Code Tables, for suggested values.

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 (DTM) 00454

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 (CWE) 00456

Definition: This field is used to further identify an insurance plan. Refer to User-defined Table 0098 - Type of Agreement in Chapter 2C, Code Tables, for suggested values.

6.5.6.32 IN1-32 Billing Status (CWE) 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 in Chapter 2C, Code Tables, for suggested values.

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 (CWE) 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 in Chapter 2C, Code Tables, for suggested values. This table contains codes used to identify an insurance company plan uniquely.

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 00463

Attention: IN1-38 was deprecated as of v 2.3 and the detail was withdrawn and removed from the standard as of v 2.6.

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 00465

Attention: IN1-40 was deprecated as of v 2.3 and the detail was withdrawn and removed from the standard as of v 2.6.

6.5.6.41 IN1-41 Room Rate - Private 00466

Attention: IN1-41 was deprecated as of v 2.3 and the detail was withdrawn and removed from the standard as of v 2.6.

6.5.6.42 IN1-42 Insured's Employment Status (CWE) 00467

Definition: This field holds the employment status of the insured. Refer to User-defined Table 0066 - Employment Status in Chapter 2C, Code Tables, 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 (CWE) 00468

Definition: This field contains the gender of the insured. Refer to User-defined Table 0001 - Administrative Sex in Chapter 2C, Code Tables, 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. As of v 2.7, no assumptions can be made based on position or sequence. Specification of meaning based on sequence is deprecated.

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 (CWE) 00471

Definition: This field uniquely identifies the prior insurance plan when the plan ID changes. Refer to User-defined Table 0072 - Insurance Plan ID in Chapter 2C, Code Tables, for suggested values.

6.5.6.47 IN1-47 Coverage Type (CWE) 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 in Chapter 2C, Code Tables, for suggested values.

6.5.6.48 IN1-48 Handicap (CWE) 00753

Definition: This field contains a code to describe the insured's disability. Refer to User-defined Table 0295 - Handicap in Chapter 2C, Code Tables, 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 (CWE) 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 in Chapter 2C, Code Tables, for suggested values.

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 (CWE) 01852

Definition: This field identifies the type of VIP for the insured. Refer to User-defined Table 0099 - VIP Indicator in Chapter 2C, Code Tables, for suggested values.

6.5.6.54 IN1-54 External Health Plan Identifiers (CX) 03292

Definition: This field contains the external Health Plan Identifiers that correspond to the internal Health Plan ID in IN1-2 - Health Plan ID. The assigning authority and identifier type code are strongly recommended for al CX data types.

6.5.6.55 IN1-55 Insurance Action Code (ID) 03335

Definition: The Insurance Action Code Defines the action to be taken for this insurance. Refer to HL7 Table 0206 - Segment Action Code in Chapter 2C, Code Tables, for valid values. When this field is valued, the IN1, IN2, and IN3 are not in "snapshot mode", rather in "action mode".

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

Definition: This field contains the required employer information data for UB82 form locator 71. Refer to User-defined Table 0139 - Employer Information Data in Chapter 2C, Code Tables, for suggested values.

6.5.7.5 IN2-5 Mail Claim Party (CWE) 00476

Definition: This field contains the party to which the claim should be mailed. Refer to User-defined Table 0137 - Mail Claim Party in Chapter 2C, Code Tables, for suggested values.

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. As of v 2.7, no assumptions can be made based on position or sequence. Specification of meaning based on sequence is deprecated.

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 (CWE) 00482

Definition: This field is defined by CMS or other regulatory agencies. Refer to User-defined Table 0342 - Military Recipient in Chapter 2C, Code Tables, for suggested values.

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 (CWE) 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 2C, Code Tables, 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 (CWE) 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 2C, Code Tables, for suggested values.

6.5.7.16 IN2-16 Military Status (CWE) 00487

Definition: This field is defined by CMS or other regulatory agencies. Refer to User-defined Table 0142 - Military Status in Chapter 2C, Code Tables, 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 in Chapter 2C, Code Tables, 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 in Chapter 2C, Code Tables, 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 in Chapter 2C, Code Tables, 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. As of v 2.7, no assumptions can be made based on position or sequence. Specification of meaning based on sequence is deprecated.

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 (CWE) 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 in Chapter 2C, Code Tables, for suggested values.

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 (CWE) 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 in Chapter 2C, Code Tables, for suggested values.

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

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

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 (CWE) 00755

Definition: This field identifies the specific living conditions for the insured. Refer to User-defined Table 0223 - Living Dependency in Chapter 2C, Code Tables, for suggested values.

6.5.7.32 IN2-32 Ambulatory Status (CWE) 00145

Definition: This field identifies the insured's state of mobility. Refer to User-defined Table 0009 - Ambulatory Status in Chapter 2C, Code Tables, for suggested values.

6.5.7.33 IN2-33 Citizenship (CWE) 00129

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 2C, Code Tables.

6.5.7.34 IN2-34 Primary Language (CWE) 00118

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 2C, Code Tables.

6.5.7.35 IN2-35 Living Arrangement (CWE) 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 2C, Code Tables, for suggested values.

6.5.7.36 IN2-36 Publicity Code (CWE) 00743

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 2C, Code Tables, 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 in Chapter 2C, Code Tables, for valid values.

Y Restrict access

N Do not restrict access

6.5.7.38 IN2-38 Student Indicator (CWE) 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 in Chapter 2C, Code Tables, for suggested values.

6.5.7.39 IN2-39 Religion (CWE) 00120

Definition: This field indicates the type of religion practiced by the insured. Refer to User-defined Table 0006 - Religion in Chapter 2C, Code Tables, 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 (CWE) 00739

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 2C, Code Tables.

6.5.7.42 IN2-42 Ethnic Group (CWE) 00125

Definition: This field indicates the insured's ethnic group. Refer to User-defined Table 0189 - Ethnic Group in Chapter 2C, Code Tables, 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 (CWE) 00119

Definition: This field contains the insured's marital status. Refer to User-defined Table 0002 - Marital Status in Chapter 2C, Code Tables, 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

Definition: This field indicates a code that identifies the insured's job code (for example, programmer, analyst, doctor, etc.).

6.5.7.48 IN2-48 Job Status (CWE) 00752

Definition: This field indicates a code that identifies the insured's current job status. Refer to User-defined Table 0311 - Job Status in Chapter 2C, Code Tables, for suggested 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. As of v 2.7, no assumptions can be made based on position or sequence. Specification of meaning based on sequence is deprecated.

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. As of v 2.7, no assumptions can be made based on position or sequence. Specification of meaning based on sequence is deprecated.

6.5.7.51 IN2-51 Employer Contact Reason (CWE) 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 in Chapter 2C, Code Tables, 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. As of v 2.7, no assumptions can be made based on position or sequence. Specification of meaning based on sequence is deprecated.

6.5.7.54 IN2-54 Insured's Contact Person Reason (CWE) 00794

Definition: This field contains the reason(s) the person should be contacted regarding the insured. Refer to User-defined Table 0222 - Contact Reason in Chapter 2C, Code Tables, 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 (CWE) 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 in Chapter 2C, Code Tables, for suggested values.

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. As of v 2.7, no assumptions can be made based on position or sequence. Specification of meaning based on sequence is deprecated.

6.5.7.59 IN2-59 Policy Scope (CWE) 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 in Chapter 2C, Code Tables, for suggested values.

6.5.7.60 IN2-60 Policy source (CWE) 00800

Definition: This user-defined field identifies how the policy information got established. Refer to User-defined Table 0313 - Policy Source in Chapter 2C, Code Tables, for suggested values.

6.5.7.61 IN2-61 Patient Member 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 (CWE) 00802

Definition: This field specifies the relationship of the guarantor to the insurance subscriber. Refer to User-defined Table 0063 - Relationship in Chapter 2C, Code Tables, 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. As of v 2.7, no assumptions can be made based on position or sequence. Specification of meaning based on sequence is deprecated.

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. As of v 2.7, no assumptions can be made based on position or sequence. Specification of meaning based on sequence is deprecated.

6.5.7.65 IN2-65 Military Handicapped Program (CWE) 00805

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 in Chapter 2C, Code Tables, for suggested values.

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 in Chapter 2C, Code Tables, 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 in Chapter 2C, Code Tables, 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 in Chapter 2C, Code Tables, 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 (CWE) 00113

Definition: Refer to User-defined Table 0005 - Race in Chapter 2C, Code Tables, 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 (CWE) 00811

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 in Chapter 2C, Code Tables, for suggested values. The UB codes listed may not represent a complete list; refer to a UB specification for additional information.

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	C.LEN	DT	OPT	RP/#	TBL#	ITEM#	ELEMENT NAME	DB Ref.
1	1..4		SI	R			00502	Set ID - IN3	DB
2			CX	O			00503	Certification Number	DB
3			XCN	O	Y		00504	Certified By	DB
4	1..1		ID	O		0136	00505	Certification Required	DB
5			MOP	O			00506	Penalty	DB
6			DTM	O			00507	Certification Date/Time	DB
7			DTM	O			00508	Certification Modify Date/Time	DB
8			XCN	O	Y		00509	Operator	DB
9			DT	O			00510	Certification Begin Date	DB
10			DT	O			00511	Certification End Date	DB
11			DTN	O			00512	Days	DB
12			CWE	O		0233	00513	Non-Concur Code/Description	DB
13			DTM	O			00514	Non-Concur Effective Date/Time	DB
14			XCN	O	Y	0010	00515	Physician Reviewer	DB
15		48#	ST	O			00516	Certification Contact	DB
16			XTN	O	Y		00517	Certification Contact Phone Number	DB
17			CWE	O		0345	00518	Appeal Reason	DB
18			CWE	O		0346	00519	Certification Agency	DB
19			XTN	O	Y		00520	Certification Agency Phone Number	DB
20			ICD	O	Y	0136	00521	Pre-Certification Requirement	DB
21		48#	ST	O			00522	Case Manager	DB
22			DT	O			00523	Second Opinion Date	DB
23			CWE	O		0151	00524	Second Opinion Status	DB
24			CWE	O	Y	0152	00525	Second Opinion Documentation Received	DB
25			XCN	O	Y	0010	00526	Second Opinion Physician	DB
26			CWE	O		0921	03336	Certification Type	DB
27			CWE	O		0922	03337	Certification Category	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 in Chapter 2C, Code Tables, 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)> ^ <Monetary 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 (DTM) 00507

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 (DTM) 00508

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 (CWE)> ^ <Number of Days (NM)>

Subcomponents for Day Type (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)> & <Second Alternate Identifier (ST)> & <Second Alternate Text (ST)> & <Name of Second Alternate Coding System (ID)> & <Second Alternate Coding System Version ID (ST)> & <Coding System OID (ST)> & <Value Set OID (ST)> & <Value Set Version ID (DTM)> & <Alternate Coding System OID (ST)> & <Alternate Value Set OID (ST)> & <Alternate Value Set Version ID (DTM)> & <Second Alternate Coding System OID (ST)> & <Second Alternate Value Set OID (ST)> & <Second Alternate Value Set Version ID (DTM)>

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 (CWE) 00513

Definition: This field contains the non-concur code and description for a denied request. Refer to User-defined Table 0233 - Non-Concur Code/Description in Chapter 2C, Code Tables, for suggested values.

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

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 2C, Code Tables, 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. As of v 2.7, no assumptions can be made based on position or sequence. Specification of meaning based on sequence is deprecated.

6.5.8.17 IN3-17 Appeal Reason (CWE) 00518

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 in Chapter 2C, Code Tables, for suggested values.

6.5.8.18 IN3-18 Certification Agency (CWE) 00519

Definition: This field contains the certification agency. Refer to User-defined Table 0346 - Certification Agency in Chapter 2C, Code Tables, for suggested values.

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 (CWE)> ^ <Certification Required (ID)> ^ <Date/Time Certification Required (DTM)>

Subcomponents for Certification Patient Type (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)> & <Second Alternate Identifier (ST)> & <Second Alternate Text (ST)> & <Name of Second Alternate Coding System (ID)> & <Second Alternate Coding System Version ID (ST)> & <Coding System OID (ST)> & <Value Set OID (ST)> & <Value Set Version ID (DTM)> & <Alternate Coding System OID (ST)> & <Alternate Value Set OID (ST)> & <Alternate Value Set Version ID (DTM)> & <Second Alternate Coding System OID (ST)> & <Second Alternate Value Set OID (ST)> & <Second Alternate Value Set Version ID (DTM)>

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 in Chapter 2C, Code Tables, 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 (CWE) 00524

Definition: This field contains the code that represents the status of the second opinion. Refer to User-defined Table 0151 - Second Opinion Status in Chapter 2C, Code Tables, for suggested values.

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

Definition: Use this field if accompanying documentation has been received by the provider. Refer to User-defined Table 0152 - Second Opinion Documentation Received in Chapter 2C, Code Tables, for suggested values.

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 2C, Code Tables, for suggested values.

6.5.8.26 IN3-26 Certification Type (CWE) 03336

Definition: This field contains the certification type code for a specific certification. Refer to User-defined Table 0921 - Certification Type Code in Chapter 2C, Code Tables, for suggested values.

6.5.8.27 IN3-27 Certification Category (CWE) 03337

Definition: This field contains the certification category code for a specific certification. Refer to User-defined Table 0922 - Certification Category Code in Chapter 2C, Code Tables, 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	C.LEN	DT	OPT	RP/#	TBL#	ITEM#	ELEMENT NAME	DB Ref.
1			DTM	O			00527	Accident Date/Time	DB
2			CWE	O		0050	00528	Accident Code	DB
3		25#	ST	O			00529	Accident Location	DB
4			CWE	B		0347	00812	Auto Accident State	DB
5	1..1		ID	O		0136	00813	Accident Job Related Indicator	DB
6	1..1		ID	O		0136	00814	Accident Death Indicator	DB
7			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..1		ID	O		0136	01505	Police Notified Indicator	DB
11			XAD	O			01853	Accident Address	DB
12		3#	NM	O			02374	Degree of patient liability	DB
13			EI	O	Y		03338	Accident Identifier	DB

6.5.9.0 ACC Field Definitions

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

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

6.5.9.2 ACC-2 Accident Code (CWE) 00528

Definition: This field contains the type of accident. Refer to User-defined Table 0050 - Accident Code in Chapter 2C, Code Tables, for suggested values. ICD accident codes are recommended.

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 (CWE) 00812

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 - State/Province in Chapter 2C, Code Tables, for suggested values.

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 in Chapter 2C, Code Tables, 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 in Chapter 2C, Code Tables, 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 in Chapter 2C, Code Tables, 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.

6.5.9.12 ACC-12 Degree of patient liability (NM) 02374

Definition: This field conveys the amount to which the patient is found to be liable for an accident. The numeric value is given as a percentage value.

If the accident is totally caused by others this value is set to "0". If it is caused by the patient, it is set to "100". Any other value in between allows for a leverage of the fault between the patient and third parties.

6.5.9.13 ACC-13 Accident Identifier (EI) 03338

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

Definition: This field contains the identifier of the accident report assigned by a jurisdiction that is required in the insurance accident claim.

6.5.10 UB1 - Uniform Billing 1 Segment

The UB1 segment contains data specific to the United States. Only billing/claims fields that do not exist in other HL7 defined segments appear in this segment. The codes listed as examples are not an exhaustive or current list.

Attention: the UB1 segment was deprecated as of v 2.3 and the detail was withdrawn and removed from the standard as of v 2.6.

HL7 Attribute Table - UB1

SEQ	DT	OPT	RP/#	ITEM#	ELEMENT NAME	DB Ref.
1	SI	W		00530	Set ID - UB1	DB
2		W		00531	Blood Deductible	DB
3		W		00532	Blood Furnished-Pints	DB
4		W		00533	Blood Replaced-Pints	DB
5		W		00534	Blood Not Replaced-Pints	DB
6		W		00535	Co-Insurance Days	DB
7		W	Y/5	00536	Condition Code	DB
8		W		00537	Covered Days	DB
9		W		00538	Non Covered Days	DB
10		W	Y/8	00539	Value Amount & Code	DB
11		W		00540	Number Of Grace Days	DB
12		W		00541	Special Program Indicator	DB
13		W		00542	PSRO/UR Approval Indicator	DB
14		W		00543	PSRO/UR Approved Stay-Fm	DB
15		W		00544	PSRO/UR Approved Stay-To	DB
16		W	Y/5	00545	Occurrence	DB
17		W		00546	Occurrence Span	DB
18		W		00547	Occur Span Start Date	DB
19		W		00548	Occur Span End Date	DB
20		W		00549	UB-82 Locator 2	DB
21		W		00550	UB-82 Locator 9	DB
22		W		00551	UB-82 Locator 27	DB
23		W		00552	UB-82 Locator 45	DB

6.5.10.0 UB1 Field Definitions

6.5.10.1 UB1-1 Set ID - UB1 00530

Attention: UB1-2 was deprecated as of v 2.3 and the detail was withdrawn and removed from the standard as of v 2.6.

6.5.10.2 UB1-2 Blood Deductible 00531

Attention: UB1-2 was deprecated as of v 2.3 and the detail was withdrawn and removed from the standard as of v 2.6.

6.5.10.3 UB1-3 Blood Furnished-Pints 00532

Attention: UB1-3 was deprecated as of v 2.3 and the detail was withdrawn and removed from the standard as of v 2.6.

6.5.10.4 UB1-4 Blood Replaced-Pints 00533

Attention: UB1-4 was deprecated as of v 2.3 and the detail was withdrawn and removed from the standard as of v 2.6.

6.5.10.5 UB1-5 Blood Not Replaced-Pints 00534

Attention: UB1-5 was deprecated as of v 2.3 and the detail was withdrawn and removed from the standard as of v 2.6.

6.5.10.6 UB1-6 Co-insurance Days 00535

Attention: UB1-6 was deprecated as of v 2.3 and the detail was withdrawn and removed from the standard as of v 2.6.

6.5.10.7 UB1-7 Condition Code 00536

Attention: UB1-7 was deprecated as of v 2.3 and the detail was withdrawn and removed from the standard as of v 2.6.

6.5.10.8 UB1-8 Covered Days 00537

Attention: UB1-8 was deprecated as of v 2.3 and the detail was withdrawn and removed from the standard as of v 2.6.

6.5.10.9 UB1-9 Non-Covered Days 00538

Attention: UB1-9 was deprecated as of v 2.3 and the detail was withdrawn and removed from the standard as of v 2.6.

6.5.10.10 UB1-10 Value Amount & Code 00539

Attention: UB1-10 was deprecated as of v 2.3 and the detail was withdrawn and removed from the standard as of v 2.6.

6.5.10.11 UB1-11 Number of Grace Days 00540

Attention: UB1-11 was deprecated as of v 2.3 and the detail was withdrawn and removed from the standard as of v 2.6.

6.5.10.12 UB1-12 Special Program Indicator 00541

Attention: UB1-12 was deprecated as of v 2.3 and the detail was withdrawn and removed from the standard as of v 2.6.

6.5.10.13 UB1-13 PSRO/UR Approval Indicator 00542

Attention: UB1-13 was deprecated as of v 2.3 and the detail was withdrawn and removed from the standard as of v 2.6.

6.5.10.14 UB1-14 PSRO/UR Approved Stay-Fm 00543

Attention: UB1-14 was deprecated as of v 2.3 and the detail was withdrawn and removed from the standard as of v 2.6.

6.5.10.15 UB1-15 PSRO/UR Approved Stay-To 00544

Attention: UB1-15 was deprecated as of v 2.3 and the detail was withdrawn and removed from the standard as of v 2.6.

6.5.10.16 UB1-16 Occurrence 00545

Attention: UB1-16 was deprecated as of v 2.3 and the detail was withdrawn and removed from the standard as of v 2.6.

6.5.10.17 UB1-17 Occurrence Span 00546

Attention: UB1-17 was deprecated as of v 2.3 and the detail was withdrawn and removed from the standard as of v 2.6.

6.5.10.18 UB1-18 Occur Span Start Date 00547

Attention: UB1-18 was deprecated as of v 2.3 and the detail was withdrawn and removed from the standard as of v 2.6.

6.5.10.19 UB1-19 Occur Span End Date 00548

Attention: UB1-19 was deprecated as of v 2.3 and the detail was withdrawn and removed from the standard as of v 2.6.

6.5.10.20 UB1-20 UB-82 Locator 2 00549

Attention: UB1-20 was deprecated as of v 2.3 and the detail was withdrawn and removed from the standard as of v 2.6.

6.5.10.21 UB1-21 UB-82 Locator 9 00550

Attention: UB1-21 was deprecated as of v 2.3 and the detail was withdrawn and removed from the standard as of v 2.6.

6.5.10.22 UB1-22 UB-82 Locator 27 00551

Attention: UB1-22 was deprecated as of v 2.3 and the detail was withdrawn and removed from the standard as of v 2.6.

6.5.10.23 UB1-23 UB-82 Locator 45 00552

Attention: UB1-23 was deprecated as of v 2.3 and the detail was withdrawn and removed from the standard as of v 2.6.

6.5.11 UB2 - UB92 Data Segment

The UB2 segment contains data necessary to complete UB92 bills specific to the United States. Realms outside the US are referred to chapter 16. Only Uniform Billing fields that do not exist in other HL7 defined segments appear in this segment. For example, Patient Name and Date of Birth are required; they are included in the PID segment and therefore do not appear here. Uniform Billing field locators are provided in parentheses ( ). The UB codes listed as examples are not an exhaustive or current list; refer to a UB specification for additional information.

HL7 Attribute Table - UB2 - Uniform Billing Data

SEQ	LEN	DT	OPT	RP/#	TBL#	ITEM#	ELEMENT NAME	DB Ref.
1	1..4	SI	O			00553	Set ID - UB2	DB
2	1..3	ST	O			00554	Co-Insurance Days (9)	DB
3		CWE	O	Y/7	0043	00555	Condition Code (24-30)	DB
4	1..3	ST	O			00556	Covered Days (7)	DB
5	1..4	ST	O			00557	Non-Covered Days (8)	DB
6		UVC	O	Y/12		00558	Value Amount & Code (39-41)	DB
7		OCD	O	Y/8		00559	Occurrence Code & Date (32-35)	DB
8		OSP	O	Y/2		00560	Occurrence Span Code/Dates (36)	DB
9	1..29	ST	O	Y/2		00561	Uniform Billing Locator 2 (state)	DB
10	1..12	ST	O	Y/2		00562	Uniform Billing Locator 11 (state)	DB
11	1..5	ST	O			00563	Uniform Billing Locator 31 (national)	DB
12	1..23	ST	O	Y/3		00564	Document Control Number	DB
13	1..4	ST	O	Y/23		00565	Uniform Billing Locator 49 (national)	DB
14	1..14	ST	O	Y/5		00566	Uniform Billing Locator 56 (state)	DB
15	1..27	ST	O			00567	Uniform Billing Locator 57 (sational)	DB
16	1..2	ST	O	Y/2		00568	Uniform Billing Locator 78 (state)	DB
17	1..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 Uniform Billing form locator 9. This field is defined by CMS or other regulatory agencies.

6.5.11.3 UB2-3 Condition Code (24-30) (CWE) 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 Uniform Billing form locators 24-30. Refer to User-defined Table 0043 - Condition Code in Chapter 2C, Code Tables, 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 Uniform Billing 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 Uniform Billing 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

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)> & <Second Alternate Identifier (ST)> & <Second Alternate Text (ST)> & <Name of Second Alternate Coding System (ID)> & <Second Alternate Coding System Version ID (ST)> & <Coding System OID (ST)> & <Value Set OID (ST)> & <Value Set Version ID (DTM)> & <Alternate Coding System OID (ST)> & <Alternate Value Set OID (ST)> & <Alternate Value Set Version ID (DTM)> & <Second Alternate Coding System OID (ST)> & <Second Alternate Value Set OID (ST)> & <Second Alternate Value Set Version ID (DTM)>

Definition: The set of values in this field can repeat up to eight times. Uniform Billing 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)> & <Second Alternate Identifier (ST)> & <Second Alternate Text (ST)> & <Name of Second Alternate Coding System (ID)> & <Second Alternate Coding System Version ID (ST)> & <Coding System OID (ST)> & <Value Set OID (ST)> & <Value Set Version ID (DTM)> & <Alternate Coding System OID (ST)> & <Alternate Value Set OID (ST)> & <Alternate Value Set Version ID (DTM)> & <Second Alternate Coding System OID (ST)> & <Second Alternate Value Set OID (ST)> & <Second Alternate Value Set Version ID (DTM)>

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

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

Definition: Medical code representing the patient's medical services when they are transferred. Refer to User-defined Table 0069 - Hospital Service in Chapter 2C, Code Tables, for suggested values.

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

Definition: Code representing the ranking of a patient's illness. Refer to User-defined Table 0421 - Severity of Illness Code in Chapter 2C, Code Tables, for suggested values.

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

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 (CWE) 01519

Definition: Code representing a patient's prioritization within the context of this abstract. Refer to User-defined Table 0422 - Triage Code in Chapter 2C, Code Tables, for suggested values.

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

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 (CWE) 01522

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 in Chapter 2C, Code Tables, for suggested values.

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 in Chapter 2C, Code Tables, 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 (CWE) 01524

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 in Chapter 2C, Code Tables, for suggested values.

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 (CWE) 01526

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 in Chapter 2C, Code Tables, for suggested values.

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 in Chapter 2C, Code Tables, 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	C.LEN	DT	OPT	RP/#	TBL#	ITEM#	ELEMENT NAME	DB Ref.
1			CWE	O		0426	01528	Blood Product Code	DB
2			CQ	O			01529	Blood Amount	DB

6.5.13.0 BLC Field Definitions

6.5.13.1 BLC-1 Blood Product Code (CWE) 01528

Definition: This field reports the blood product code. Refer to User-defined Table 0426 - Blood Product Code in Chapter 2C, Code Tables, for suggested values.

6.5.13.2 BLC-2 Blood Amount (CQ) 01529

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	DT	OPT	TBL#	ITEM#	ELEMENT NAME	DB Ref.
1	CWE	O	0427	01530	Risk Management Incident Code	DB
2	DTM	O		01531	Date/Time Incident	DB
3	CWE	O	0428	01533	Incident Type Code	DB

6.5.14.0 RMI Field Definitions

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

Definition: A code depicting the incident that occurred during a patient's stay. Refer to User-defined Table 0427 - Risk Management Incident Code in Chapter 2C, Code Tables, for suggested values.

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

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 (CWE) 01533

Definition: A code depicting a classification of the incident type. Refer to User-defined Table 0428 - Incident Type Code in Chapter 2C, Code Tables, for suggested values.

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

6.5.15.0 GP1 Field Definitions

6.5.15.1 GP1-1 Type of Bill Code (CWE) 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 in Chapter 2C, Code Tables, 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.

6.5.15.2 GP1-2 Revenue Code (CWE) 01600

Definition: This field is the same as UB92 Form Locator 42 "Revenue Code". Refer to User-defined Table 0456 - Revenue Code in Chapter 2C, Code Tables, 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.

6.5.15.3 GP1-3 Overall Claim Disposition Code (CWE) 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 in Chapter 2C, Code Tables, for suggested values. This field is defined by CMS or other regulatory agencies.

6.5.15.4 GP1-4 OCE Edits per Visit Code (CWE) 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 in Chapter 2C, Code Tables, for suggested values. This field is defined by CMS or other regulatory agencies.

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	C.LEN	DT	OPT	RP/#	TBL#	ITEM#	ELEMENT NAME	DB Ref.
1		CWE	O		0456	01600	Revenue Code	DB
2	7#	NM	O			01604	Number of Service Units	DB
3		CP	O			01605	Charge	DB
4		CWE	O		0459	01606	Reimbursement Action Code	DB
5		CWE	O		0460	01607	Denial or Rejection Code	DB
6		CWE	O	Y	0458	01608	OCE Edit Code	DB
7		CWE	O		0466	01609	Ambulatory Payment Classification Code	DB
8		CWE	O	Y	0467	01610	Modifier Edit Code	DB
9		CWE	O		0468	01611	Payment Adjustment Code	DB
10		CWE	O		0469	01617	Packaging Status Code	DB
11		CP	O			01618	Expected CMS Payment Amount	DB
12		CWE	O		0470	01619	Reimbursement Type Code	DB
13		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 (CWE) 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 in Chapter 2C, Code Tables, 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 (CWE) 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 in Chapter 2C, Code Tables, for suggested values. This field is defined by CMS or other regulatory agencies

6.5.16.5 GP2-5 Denial or Rejection Code (CWE) 01607

Definition: This field determines the OCE status of the line item. Refer to User-defined table 0460 - Denial or Rejection Code in Chapter 2C, Code Tables, for suggested values. This field is defined by CMS or other regulatory agencies.

6.5.16.6 GP2-6 OCE Edit Code (CWE) 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 in Chapter 2C, Code Tables, for suggested values.

6.5.16.7 GP2-7 Ambulatory Payment Classification Code (CWE) 01609

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 in Chapter 2C, Code Tables, for suggested values. This field is defined by CMS or other regulatory agencies.

6.5.16.8 GP2-8 Modifier Edit Code (CWE) 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 in Chapter 2C, Code Tables, for suggested values. This field is defined by CMS or other regulatory agencies

6.5.16.9 GP2-9 Payment Adjustment Code (CWE) 01611

Definition: This field contains any payment adjustment due to drugs or medical devices. Refer to User-defined Table 0468 - Payment Adjustment Code in Chapter 2C, Code Tables, for suggested values. This field is defined by CMS or other regulatory agencies

6.5.16.10 GP2-10 Packaging Status Code (CWE) 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 in Chapter 2C, Code Tables, for suggested values. This field is defined by CMS or other regulatory agencies.

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 (CWE) 01619

Definition: This field contains the fee schedule reimbursement type applied to the line item. Refer to User-defined Table 0470 - Reimbursement Type Code in Chapter 2C, Code Tables, for suggested values. This field is defined by CMS or other regulatory agencies.

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|2.8| 000000000000001|<cr>

EVN|P01|19930908135030||<cr>

PID|1||8064993^^^PATA1^MR^A~6045681^^^PATA1^BN^A~123456789ABC^^^US^NI~123456789^^^USSSA^SS||EVERYWOMAN^EVE^J^^^||19471007|F||1|22220018 HOMESTREET^^HOUSTON^TX^77030^USA|HAR||||S||6045681<cr>

GT1|001||JOHNSON^SAM^J||1111 HEALTHCARE DRIVE^^BALTIMORE^MD^

21234^USA|||||||193-22-1876<cr>

NK1|001|BETTERHALF^BORIS|F|2222 HOME STREET^^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 Eve J. Everywoman, a female Caucasian, born on October 7, 1947. Living at 1234 Homestreet, Houston, TX.

Ms. Everywoman'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. Everywoman 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|2.8| 000000000000001|<cr>

EVN|P03|19930908135030||<cr>

PID||0008064993^^^ENT^PE|0008064993^^^PAT^MR||0006045681^^^PATA^AN|EVERYWOMEN^EVE^J^^^|19471007|F||1|2222 HOMESTREET^^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. Everywoman'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 UB1 information

MSH|^~\&|UREV||PATB||19930906135030||BAR^P05^BAR_P05|MSG0018|P|2.8<cr>

EVN|P05|19930908135030

PID|||125976||EVERYMAN^ADAM^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||19930908135030||BAR^P05^BAR_P05|MSG0018|P|2.8<cr>

EVN|P05|19930908135030

PID|||125976||EVERYMAN^ADAM^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).

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

6.5.1.0 FT1 Field Definitions

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 (DTM) 00359

6.5.1.6 FT1-6 Transaction Type (CWE) 00360

6.5.1.7 FT1-7 Transaction Code (CWE) 00361

6.5.1.8 FT1-8 Transaction Description 00362

6.5.1.9 FT1-9 Transaction Description - Alt 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 (CWE) 00367

6.5.1.14 FT1-14 Health Plan ID (CWE) 00368

6.5.1.15 FT1-15 Insurance Amount (CP) 00369

6.5.1.16 FT1-16 Assigned Patient Location (PL) 00133

6.5.1.17 FT1-17 Fee Schedule (CWE) 00370

6.5.1.18 FT1-18 Patient Type (CWE) 00148

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

6.5.1.20 FT1-20 Performed by Code (XCN) 00372

6.5.1.21 FT1-21 Ordered By Code (XCN) 00373

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 (CNE) 00393

6.5.1.26 FT1-26 Procedure Code Modifier (CNE) 01316

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

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

6.5.1.29 FT1-29 NDC Code (CWE) 01845

6.5.1.30 FT1-30 Payment Reference ID (CX) 01846

6.5.1.31 FT1-31 Transaction Reference Key (SI) 01847

6.5.1.32 FT1-32 Performing Facility (XON) 02361

6.5.1.33 FT1-33 Ordering Facility (XON) 02362

6.5.1.34 FT1-34 Item Number (CWE) 02363

6.5.1.35 FT1-35 Model Number (ST) 02364

6.5.1.36 FT1-36 Special Processing Code (CWE) 02365

6.5.1.37 FT1-37 Clinic Code (CWE) 02366

6.5.1.38 FT1-38 Referral Number (CX) 02367

6.5.1.39 FT1-39 Authorization Number (CX) 02368

6.5.1.40 FT1-40 Service Provider Taxonomy Code (CWE) 02369

6.5.1.41 FT1-41 Revenue Code (CWE) 01600

6.5.1.42 FT1-42 Prescription Number (ST) 00325

6.5.1.43 FT1-43 NDC Qty and UOM (CQ) 02370

6.5.2 DG1 - Diagnosis Segment

6.5.2.0 DG1 field definitions

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

6.5.2.2 DG1-2 Diagnosis Coding Method 00376

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

6.5.2.4 DG1-4 Diagnosis Description 00378

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

6.5.2.6 DG1-6 Diagnosis Type (CWE) 00380

6.5.2.7 DG1-7 Major Diagnostic Category 00381

6.5.2.8 DG1-8 Diagnostic Related Group 00382

6.5.2.9 DG1-9 DRG Approval Indicator 00383

6.5.2.10 DG1-10 DRG Grouper Review Code 00384

6.5.2.11 DG1-11 Outlier Type 00385

6.5.2.12 DG1-12 Outlier Days 00386

6.5.2.13 DG1-13 Outlier Cost 00387

6.5.2.14 DG1-14 Grouper Version and Type 00388

6.5.2.15 DG1-15 Diagnosis Priority (NM) 00389

6.5.2.16 DG1-16 Diagnosing Clinician (XCN) 00390

6.5.2.17 DG1-17 Diagnosis Classification (CWE) 00766