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CreateClaimEdi Field Map

POST /api/SharpRcm/v1/CreateClaimEdi takes your claim as JSON and builds an X12 837P from it. This page lists every field of that request and the loop, segment and element it is written to, so you can check a field against the 837P implementation guide, or work out which JSON field produces a segment a payer asked about.

The map is checked by ClaimRev's test suite on every build. A test fills every field below with its own value, builds the 837P and confirms each value lands where this page says. The tables between the markers are generated from that test, so they cannot drift from what the API sends.

How to read it​

  • Locations are written loop segment element. 2300 CLM05-3 means loop 2300, segment CLM, element 05, component 3. REF*G1 means the REF segment whose first element is G1.
  • Lists are written []. Each entry repeats its segment or loop.
  • Qualifiers fill themselves in. Every block with a fixed qualifier, such as a date's dateQualifier or an amount's amountQualCode, gets the qualifier this page shows when you leave it out.
  • Empty fields are not sent. A segment is written only when the field this page names as its trigger is set.
  • Amounts are written in X12 form: no thousands separators and no trailing zeros, so 40.00 is sent as 40.
  • Fields under Not sent are accepted and ignored. Most belong to institutional (837I) or dental (837D) claims, which share the same model.

Building blocks​

Several shapes repeat across the request. Each table row that points to a block writes all of that block's fields.

Provider​

A person or organization: nm1Data and secondaryIdentifiers[].

FieldElement
nm1Data.entityCodeNM101. Filled in for each provider (82 rendering, DN referring, DQ supervising...).
nm1Data.entityTypeNM102: 1 person, 2 organization
nm1Data.lastNameNM103, or the organization name. The provider is written only when this is set.
nm1Data.firstNameNM104
nm1Data.middleNameNM105
nm1Data.suffixNM107
nm1Data.npiNM109, with NM108 XX. Leave it empty and NM108 is left empty too.
nm1Data.taxonomyCodePRV03, for the billing and rendering providers only
secondaryIdentifiers[].qualifierCodeREF01, such as G2 or 0B
secondaryIdentifiers[].refValueREF02
secondaryIdentifiers[].otherRefValueREF04

Address​

FieldElement
address1, address2N301, N302
city, state, zipN401, N402, N403

Contact​

FieldElement
contactNamePER02 (PER01 is always IC)
contactType1, contactInfo1PER03, PER04, such as TE and a phone number
contactType2, contactInfo2PER05, PER06
contactType3, contactInfo3PER07, PER08

Date​

FieldElement
dateQualifierDTP01, filled in
periodFormatDTP02, filled in (D8)
dateValueDTP03, CCYYMMDD. The date is written only when this is set.

Reference​

FieldElement
qualifierCodeREF01, filled in
refValueREF02. The reference is written only when this is set.
otherRefValueREF04-2, with REF04-1 2U

Adjustment​

One CAS segment per entry, for one adjustment group.

FieldElement
adjustmentGroupCodeCAS01: CO, PR, OA, PI
adjustmentGroup1.adjustmentReasonCode, .amount, .quanityCAS02, CAS03, CAS04
adjustmentGroup2 to adjustmentGroup6CAS05 to CAS19, three elements each

See Sending a secondary claim for how the adjustments must balance.

Request​

Fields on the request itself. They build the envelope and the submitter and receiver loops.

JSON field837PNotes
submitterName1000A NM1*41 NM103
submitterId1000A NM1*41 NM109Also ISA06 and GS02 when envelop.isa06 / envelop.gs02 are empty.
submitterContactName1000A PER PER02
submitterPhone1000A PER PER04PER03 is always TE.
receiverName1000B NM1*40 NM103Used only when envelop.receiverName is empty.
transactionControlNumberST ST02Also SE02.
bhtControlNumberBHT BHT03
groupControlNumberGS GS06Also GE02.
envelop.isa01ISA ISA01
envelop.isa02ISA ISA02Pad to 10.
envelop.isa03ISA ISA03
envelop.isa04ISA ISA04Pad to 10.
envelop.isa05ISA ISA05
envelop.isa06ISA ISA06Pad to 15. Falls back to submitterId.
envelop.isa07ISA ISA07
envelop.isa08ISA ISA08Pad to 15.
envelop.isa13ISA ISA13Nine digits. Also IEA02.
envelop.isa14ISA ISA14
envelop.isa15ISA ISA15P production, T test.
envelop.gs01GS GS01HC when empty.
envelop.gs02GS GS02Falls back to submitterId.
envelop.gs03GS GS03Also 1000B NM109 when envelop.receiverId is empty.
envelop.gs08GS GS08Also ST03. Send 005010X222A1.
envelop.receiverName1000B NM1*40 NM103
envelop.receiverId1000B NM1*40 NM109
envelop.bht02BHT BHT02
envelop.bht06BHT BHT06

Billing provider (2000A, 2010AA)​

Paths are relative to each entry in claims[].

JSON field837PNotes
billingProviderEditorView.nm1Data.entityCode2010AA NM1*85 NM101entityCode is filled in as 85. Filled in as 85.
billingProviderEditorView.nm1Data.entityType2010AA NM1*85 NM102
billingProviderEditorView.nm1Data.lastName2010AA NM1*85 NM103
billingProviderEditorView.nm1Data.firstName2010AA NM1*85 NM104
billingProviderEditorView.nm1Data.middleName2010AA NM1*85 NM105
billingProviderEditorView.nm1Data.suffix2010AA NM1*85 NM107
billingProviderEditorView.nm1Data.npi2010AA NM1*85 NM109
billingProviderEditorView.nm1Data.taxonomyCode2000A PRV*BI PRV03
billingProviderEditorView.address1, address2, city, state, zip2010AA N3, N4 (address)
billingProviderEditorView.secondaryIdentifiers[].qualifierCode2010AA REF*EI REF01Only EI / SY (the first one, the tax id) and 0B / 1G are written; other qualifiers are dropped. otherRefValue is not sent. Send EI.
billingProviderEditorView.secondaryIdentifiers[].refValue2010AA REF*EI REF02
billingProviderEditorView.secondaryIdentifiers[1].qualifierCode2010AA REF*0B REF01Send 0B.
billingProviderEditorView.secondaryIdentifiers[1].refValue2010AA REF*0B REF02
billingProviderEditorView.contact12010AA PER (contact)Written when contactType1 and contactInfo1 are set.
billingProviderEditorView.contact22010AA PER (contact)Written when contactType1 and contactInfo1 are set.

Pay-to address and plan (2010AB, 2010AC)​

Paths are relative to each entry in claims[].

JSON field837PNotes
payToAddressView.entityType2010AB NM1*87 NM102The loop is written when address1 is set. NM101 is always 87.
payToAddressView.address1, address2, city, state, zip2010AB N3, N4 (address)
payToPlanView.organizationName2010AC NM1*PE NM103The loop is written when organizationName is set.
payToPlanView.primaryIdentifier2010AC NM1*PE NM109
payToPlanView.address1, address2, city, state, zip2010AC N3, N4 (address)
payToPlanView.secondaryIdentifierType2010AC REF*2U REF01Send 2U.
payToPlanView.secondaryIdentifier2010AC REF02
payToPlanView.taxIdNumber2010AC REF*EI REF02

Subscriber (2000B, 2010BA)​

Paths are relative to each entry in claims[].

JSON field837PNotes
subscriberEditorView.payerResponsibility2000B SBR SBR01P, S, T...
subscriberEditorView.relationshipCode2000B SBR SBR02Written exactly as sent, no default. 18 when the subscriber is the patient; leave it empty when patientEditorView is used.
subscriberEditorView.policyNumber2000B SBR SBR03
subscriberEditorView.groupName2000B SBR SBR04
subscriberEditorView.insuranceTypeCode2000B SBR SBR05
subscriberEditorView.claimFilingIndicator2000B SBR SBR09
subscriberEditorView.dateOfDeath2000B PAT06Written when any of dateOfDeath, weight or pregnancyIndicator is set. PAT05 is D8 with a date of death; measurementCode defaults to 01 (pounds) with a weight.
subscriberEditorView.measurementCode2000B PAT07
subscriberEditorView.weight2000B PAT08
subscriberEditorView.pregnancyIndicator2000B PAT09
subscriberEditorView.entityType2010BA NM1*IL NM102NM108 is always MI.
subscriberEditorView.lastName2010BA NM1*IL NM103
subscriberEditorView.firstName2010BA NM1*IL NM104
subscriberEditorView.middleName2010BA NM1*IL NM105
subscriberEditorView.suffix2010BA NM1*IL NM107
subscriberEditorView.subscriberPrimaryIdent2010BA NM1*IL NM109
subscriberEditorView.address1, address2, city, state, zip2010BA N3, N4 (address)
subscriberEditorView.birthDay2010BA DMG02Written when either is set.
subscriberEditorView.gender2010BA DMG03
subscriberEditorView.ssn2010BA REF*SY REF02
subscriberEditorView.casualtyClaimNumber2010BA REF*Y4 REF02
subscriberEditorView.contact12010BA PER (contact)Written when contactType1 and contactInfo1 are set.

Payer (2010BB)​

Paths are relative to each entry in claims[].

JSON field837PNotes
payerEditerView.organizationName2010BB NM1*PR NM103Note the spelling: payerEditerView.
payerEditerView.payerIdentifier2010BB NM1*PR NM109Routes the claim. NM108 is always PI.
payerEditerView.address1, address2, city, state, zip2010BB N3, N4 (address)N3 needs address1; N4 needs city.
payerEditerView.taxIdNumber2010BB REF*EI REF02
payerEditerView.claimOfficeNumber2010BB REF*FY REF02
payerEditerView.naicCode2010BB REF*NF REF02
payerEditerView.locationNumber2010BB REF*LU REF02
payerEditerView.providerCommericalNumber2010BB REF*G2 REF02

Patient (2000C, 2010CA)​

Paths are relative to each entry in claims[].

JSON field837PNotes
patientEditorView.relationshipCode2000C PAT PAT01Creates the patient loop. Without it nothing in patientEditorView is written.
patientEditorView.dateOfDeath2000C PAT06PAT05 is D8 with a date of death; measurementCode defaults to 01 (pounds) with a weight.
patientEditorView.measurementCode2000C PAT07
patientEditorView.weight2000C PAT08
patientEditorView.pregnancyIndicator2000C PAT09
patientEditorView.lastName2010CA NM1*QC NM103NM102 is always 1.
patientEditorView.firstName2010CA NM1*QC NM104
patientEditorView.middleName2010CA NM1*QC NM105
patientEditorView.suffix2010CA NM1*QC NM107
patientEditorView.address1, address2, city, state, zip2010CA N3, N4 (address)
patientEditorView.birthDay2010CA DMG02
patientEditorView.gender2010CA DMG03
patientEditorView.casualtyClaimNumber2010CA REF*Y4 REF02
patientEditorView.contact2010CA PER (contact)Written when contactType1 and contactInfo1 are set.

Claim (2300)​

Paths are relative to each entry in claims[].

JSON field837PNotes
claimEditorView.patientControlNumber2300 CLM CLM01Your claim id (CLM01). It comes back on the 277CA and 835.
claimEditorView.totalClaimChargeAmt2300 CLM CLM02Must equal the sum of the line charges.
claimEditorView.placeOfService2300 CLM CLM05-1CLM05-2 is always B.
claimEditorView.claimFreqCode2300 CLM CLM05-31 original, 7 replacement, 8 void.
claimEditorView.providerSignatureOnFile2300 CLM CLM06
claimEditorView.planParticipationCode2300 CLM CLM07
claimEditorView.benefitsAssignmentCertIndicator2300 CLM CLM08
claimEditorView.releaseOfInfoCode2300 CLM CLM09
claimEditorView.patientSignatureCode2300 CLM CLM10
claimEditorView.relatedCausesCode12300 CLM11-1
claimEditorView.relatedCausesCode22300 CLM11-2
claimEditorView.accidentState2300 CLM11-4
claimEditorView.accidentCountry2300 CLM11-5
claimEditorView.specialProgramIndicator2300 CLM CLM12
claimEditorView.delayReasonCode2300 CLM CLM20
claimEditorView.dateOnSetOfCurrentIllness2300 DTP*431 (date)
claimEditorView.dateInitialTreatment2300 DTP*454 (date)
claimEditorView.dateLastSeen2300 DTP*304 (date)
claimEditorView.dateAcuteManifestation2300 DTP*453 (date)
claimEditorView.dateAccident2300 DTP*439 (date)
claimEditorView.dateLastMenstrual2300 DTP*484 (date)
claimEditorView.dateLastXRay2300 DTP*455 (date)
claimEditorView.dateHearingVisionRx2300 DTP*471 (date)
claimEditorView.dateDisability2300 DTP*314 (date)
claimEditorView.dateDisabilityStart2300 DTP*360 (date)
claimEditorView.dateDisabilityEnd2300 DTP*361 (date)
claimEditorView.dateLastWorked2300 DTP*297 (date)
claimEditorView.dateAuthorizedReturnWork2300 DTP*296 (date)
claimEditorView.dateAdmissionDate2300 DTP*435 (date)
claimEditorView.dateDischarge2300 DTP*096 (date)
claimEditorView.dateStartAssumedRelinqished2300 DTP*090 (date)
claimEditorView.dateEndAssumedRelinqished2300 DTP*091 (date)
claimEditorView.datePropertyCasualty2300 DTP*444 (date)
claimEditorView.dateRepricerReceived2300 DTP*050 (date)
claimEditorView.supplementalInfos[].reportTypeCode2300 PWK01Up to 10. PWK05 is AC when the transmission code is BM, EL, EM, FX or FT.
claimEditorView.supplementalInfos[].transmissionCode2300 PWK02
claimEditorView.supplementalInfos[].attachmentControlNumber12300 PWK06
claimEditorView.contractInfo.contractTypeCode2300 CN101Written when contractTypeCode is set.
claimEditorView.contractInfo.contractAmt2300 CN102
claimEditorView.contractInfo.contractPercent2300 CN103
claimEditorView.contractInfo.contractCode2300 CN104
claimEditorView.contractInfo.contractTermsPercent2300 CN105
claimEditorView.contractInfo.contractVersionIdent2300 CN106
claimEditorView.patientPaidAmount.qualifierCode2300 AMT*F5 AMT01Filled in as F5.
claimEditorView.patientPaidAmount.amount2300 AMT*F5 AMT02
claimEditorView.refSpecialPayment2300 REF*4N (reference)
claimEditorView.refMedicareVersionCode2300 REF*F5 (reference)
claimEditorView.refMammographyCertNumber2300 REF*EW (reference)
claimEditorView.refReferralNumber2300 REF*9F (reference)
claimEditorView.refPriorAuthorization2300 REF*G1 (reference)
claimEditorView.refOriginalReference2300 REF*F8 (reference)The payer's claim number, for a replacement or void.
claimEditorView.refClinicalLabImprovement2300 REF*X4 (reference)
claimEditorView.refRepricedClaimReference2300 REF*9A (reference)
claimEditorView.refAdjRepricedClaimRerence2300 REF*9C (reference)
claimEditorView.refQualifiedProductsList2300 REF*LX (reference)
claimEditorView.refTraceNumber2300 REF*D9 (reference)
claimEditorView.refMedicalRecordIdent2300 REF*EA (reference)
claimEditorView.refProjectCode2300 REF*P4 (reference)
claimEditorView.refFacilityIdNumber2300 REF*1J (reference)
claimEditorView.fileInformations[]2300 K3 K301Up to 10; one K3 each.
claimEditorView.note.referenceCode2300 NTE*ADD NTE01Written when noteText is set. Send ADD.
claimEditorView.note.noteText2300 NTE02
claimEditorView.ambulanceTransport.weightMeasurementCode2300 CR101Written when transportCode is set.
claimEditorView.ambulanceTransport.patientWeight2300 CR102
claimEditorView.ambulanceTransport.transportCode2300 CR104
claimEditorView.ambulanceTransport.distancetMeasurementCode2300 CR105
claimEditorView.ambulanceTransport.distance2300 CR106
claimEditorView.ambulanceTransport.roundTripReason2300 CR109
claimEditorView.ambulanceTransport.stretcherReason2300 CR110
claimEditorView.spinalManipulation.natureConditionCode2300 CR208Written when natureConditionCode is set.
claimEditorView.spinalManipulation.patientConditionDesc12300 CR210
claimEditorView.spinalManipulation.patientConditionDesc22300 CR211
claimEditorView.ambulanceCerts[].conditionIndicator2300 CRC*07 CRC02Up to 3, each written when conditionIndicator is set. CRC01 is always 07.
claimEditorView.ambulanceCerts[].conditionCode12300 CRC*07 CRC03
claimEditorView.ambulanceCerts[].conditionCode22300 CRC*07 CRC04
claimEditorView.ambulanceCerts[].conditionCode32300 CRC*07 CRC05
claimEditorView.ambulanceCerts[].conditionCode42300 CRC*07 CRC06
claimEditorView.ambulanceCerts[].conditionCode52300 CRC*07 CRC07
claimEditorView.visionCerts[].codeCategory2300 CRC*E1 CRC01Up to 3, each written when conditionIndicator is set. Send codeCategory (E1, E2, E3). Send E1.
claimEditorView.visionCerts[].conditionIndicator2300 CRC*E1 CRC02
claimEditorView.visionCerts[].conditionCode12300 CRC*E1 CRC03
claimEditorView.visionCerts[].conditionCode22300 CRC*E1 CRC04
claimEditorView.visionCerts[].conditionCode32300 CRC*E1 CRC05
claimEditorView.visionCerts[].conditionCode42300 CRC*E1 CRC06
claimEditorView.visionCerts[].conditionCode52300 CRC*E1 CRC07
claimEditorView.homeBound.codeCategory2300 CRC*75 CRC01Written when conditionIndicator is set. Send codeCategory 75. Send 75.
claimEditorView.homeBound.conditionIndicator2300 CRC*75 CRC02
claimEditorView.homeBound.conditionCode12300 CRC*75 CRC03
claimEditorView.epsdt.conditionIndicator2300 CRC*ZZ CRC02Written when conditionIndicator is set. CRC01 is always ZZ.
claimEditorView.epsdt.conditionCode12300 CRC*ZZ CRC03
claimEditorView.epsdt.conditionCode22300 CRC*ZZ CRC04
claimEditorView.epsdt.conditionCode32300 CRC*ZZ CRC05
claimEditorView.diagnosisCodes[].diagnosisType2300 HI01-1One HI composite per code, in diagnosisOrder order: ABK for the principal, ABF for the rest. Send ABK.
claimEditorView.diagnosisCodes[].diagnosisCode2300 HI01-2
claimEditorView.diagnosisCodes[1].diagnosisType2300 HI02-1Send ABF.
claimEditorView.diagnosisCodes[1].diagnosisCode2300 HI02-2
claimEditorView.anesthesaProcedureCode2300 HI*BP HI01-2Written when anesthesaProcedureCode is set.
claimEditorView.anesthesaIndustryCode2300 HI*BP HI02-2
claimEditorView.conditionCodes[]2300 HI*BGCondition codes, BG:<code> each, 12 to a segment.
claimEditorView.repricing.pricingMethodology2300 HCP01Written when pricingMethodology and repricedAllowedAmt are set.
claimEditorView.repricing.repricedAllowedAmt2300 HCP02
claimEditorView.repricing.repriceSavingsAmt2300 HCP03
claimEditorView.repricing.repricingOrgIdent2300 HCP04
claimEditorView.repricing.rate2300 HCP05
claimEditorView.repricing.groupCode2300 HCP06
claimEditorView.repricing.patientGroupAmt2300 HCP07
claimEditorView.repricing.rejectReasonCode2300 HCP13
claimEditorView.repricing.complianceCode2300 HCP14
claimEditorView.repricing.exceptionCode2300 HCP15
claimEditorView.referringProvider2310A NM1*DN, REF (provider)Written when nm1Data.lastName is set. entityCode is filled in as DN.
claimEditorView.primaryCareProvider2310A NM1*P3, REF (provider)Written when nm1Data.lastName is set. entityCode is filled in as P3.
claimEditorView.renderingProvider2310B NM1*82, PRV*PE, REF (provider)Written when nm1Data.lastName is set. entityCode is filled in as 82.
claimEditorView.serviceFacility.organizationName2310C NM1*77 NM103Written when organizationName is set. NM108 is XX when primaryIdentifier (the NPI) is set.
claimEditorView.serviceFacility.primaryIdentifier2310C NM1*77 NM109
claimEditorView.serviceFacility.address12310C N301
claimEditorView.serviceFacility.address22310C N302
claimEditorView.serviceFacility.city2310C N401
claimEditorView.serviceFacility.state2310C N402
claimEditorView.serviceFacility.zip2310C N403
claimEditorView.serviceFacility.secondaryIdentifiers[].qualifierCode2310C REF*G2 REF01Send G2.
claimEditorView.serviceFacility.secondaryIdentifiers[].refValue2310C REF02
claimEditorView.supervisingProvider2310D NM1*DQ, REF (provider)Written when nm1Data.lastName is set. entityCode is filled in as DQ.
claimEditorView.ambulancePickupLocation.entityCode2310E NM101Written when address1 or city is set. Send PW.
claimEditorView.ambulancePickupLocation.entityType2310E NM102
claimEditorView.ambulancePickupLocation.address12310E N301
claimEditorView.ambulancePickupLocation.address22310E N302
claimEditorView.ambulancePickupLocation.city2310E N401
claimEditorView.ambulancePickupLocation.state2310E N402
claimEditorView.ambulancePickupLocation.zip2310E N403
claimEditorView.ambulanceDropOffLocation.entityCode2310F NM101Written when address1 or city is set. Send 45.
claimEditorView.ambulanceDropOffLocation.entityType2310F NM102
claimEditorView.ambulanceDropOffLocation.address12310F N301
claimEditorView.ambulanceDropOffLocation.address22310F N302
claimEditorView.ambulanceDropOffLocation.city2310F N401
claimEditorView.ambulanceDropOffLocation.state2310F N402
claimEditorView.ambulanceDropOffLocation.zip2310F N403

Other payers (2320, 2330A-G)​

Paths are relative to each entry in claims[].

JSON field837PNotes
secondaryEditorView[].otherSubscriber.payerResponsibility2320 SBR01payerResponsibility and relationshipCode are both required; without them the whole entry is dropped.
secondaryEditorView[].otherSubscriber.relationshipCode2320 SBR02
secondaryEditorView[].otherSubscriber.policyNumber2320 SBR03
secondaryEditorView[].otherSubscriber.groupName2320 SBR04
secondaryEditorView[].otherSubscriber.insuranceTypeCode2320 SBR05
secondaryEditorView[].otherSubscriber.claimFilingIndicator2320 SBR09
secondaryEditorView[].lineAdjustments[]2320 CAS (adjustment)Claim-level adjustments, one entry per group code.
secondaryEditorView[].payerPaidAmt.amountQualCode2320 AMT*D AMT01Filled in as D.
secondaryEditorView[].payerPaidAmt.monetaryAmt2320 AMT*D AMT02
secondaryEditorView[].nonCoveredAmount.amountQualCode2320 AMT*A8 AMT01Filled in as A8.
secondaryEditorView[].nonCoveredAmount.monetaryAmt2320 AMT*A8 AMT02
secondaryEditorView[].amountOwed.amountQualCode2320 AMT*EAF AMT01Filled in as EAF.
secondaryEditorView[].amountOwed.monetaryAmt2320 AMT*EAF AMT02
secondaryEditorView[].benefitsAssignmentCertIndicator2320 OI03Written when benefitsAssignmentCertIndicator is set.
secondaryEditorView[].patientSignatureCode2320 OI04
secondaryEditorView[].releaseOfInfoCode2320 OI06
secondaryEditorView[].reimbursementRate2320 MOA01Medicare outpatient adjudication. Written when any is set.
secondaryEditorView[].hcpcsPayableAmt2320 MOA02
secondaryEditorView[].claimPaymentRemarkCode12320 MOA03
secondaryEditorView[].claimPaymentRemarkCode22320 MOA04
secondaryEditorView[].claimPaymentRemarkCode32320 MOA05
secondaryEditorView[].claimPaymentRemarkCode42320 MOA06
secondaryEditorView[].claimPaymentRemarkCode52320 MOA07
secondaryEditorView[].endStageRenalDiseasePmtAmt2320 MOA08
secondaryEditorView[].nonPayableProfessionalCompBilledAmt2320 MOA09
secondaryEditorView[].otherSubscriber.entityType2330A NM1*IL NM102N4 needs city, state and zip all set.
secondaryEditorView[].otherSubscriber.lastName2330A NM1*IL NM103
secondaryEditorView[].otherSubscriber.firstName2330A NM1*IL NM104
secondaryEditorView[].otherSubscriber.middleName2330A NM1*IL NM105
secondaryEditorView[].otherSubscriber.suffix2330A NM1*IL NM107
secondaryEditorView[].otherSubscriber.subscriberPrimaryIdent2330A NM1*IL NM109
secondaryEditorView[].otherSubscriber.address12330A N301
secondaryEditorView[].otherSubscriber.address22330A N302
secondaryEditorView[].otherSubscriber.city2330A N401
secondaryEditorView[].otherSubscriber.state2330A N402
secondaryEditorView[].otherSubscriber.zip2330A N403
secondaryEditorView[].otherSubscriber.ssn2330A REF*SY REF02
secondaryEditorView[].payerEditorView.organizationName2330B NM1*PR NM103payerIdentifier is what each line's adjudications[].otherPayerPrimaryIdentifier must match.
secondaryEditorView[].payerEditorView.payerIdentifier2330B NM1*PR NM109
secondaryEditorView[].payerEditorView.address12330B N301
secondaryEditorView[].payerEditorView.address22330B N302
secondaryEditorView[].payerEditorView.city2330B N401
secondaryEditorView[].payerEditorView.state2330B N402
secondaryEditorView[].payerEditorView.zip2330B N403
secondaryEditorView[].payerEditorView.adjudicationPaymentDate.dateQualifier2330B DTP*573 DTP01Filled in as 573.
secondaryEditorView[].payerEditorView.adjudicationPaymentDate.dateValue2330B DTP*573 DTP03
secondaryEditorView[].payerEditorView.additionalPayerIdentifier2330B REF*2U REF02
secondaryEditorView[].payerEditorView.taxIdNumber2330B REF*EI REF02
secondaryEditorView[].payerEditorView.claimOfficeNumber2330B REF*FY REF02
secondaryEditorView[].payerEditorView.naicCode2330B REF*NF REF02
secondaryEditorView[].payerEditorView.priorAuthNumber2330B REF*G1 REF02
secondaryEditorView[].payerEditorView.referralNumber2330B REF*9F REF02
secondaryEditorView[].payerEditorView.signalCode2330B REF*T4 REF02
secondaryEditorView[].payerEditorView.origionalRefNumber2330B REF*F8 REF02
secondaryEditorView[].referringProvider2330C NM1*DN, REF (provider)Written when nm1Data.lastName is set. entityCode is filled in as DN.
secondaryEditorView[].primaryCareProvider2330C NM1*P3, REF (provider)Written when nm1Data.lastName is set. entityCode is filled in as P3.
secondaryEditorView[].renderingProvider2330D NM1*82, REF (provider)Written when nm1Data.lastName is set. entityCode is filled in as 82. 2330D carries no taxonomy.
secondaryEditorView[].serviceFacility.organizationName2330E NM1*77 NM103Written when organizationName is set. 2330E carries no address.
secondaryEditorView[].serviceFacility.primaryIdentifier2330E NM1*77 NM109
secondaryEditorView[].serviceFacility.secondaryIdentifiers[].qualifierCode2330E REF*G2 REF01Send G2.
secondaryEditorView[].serviceFacility.secondaryIdentifiers[].refValue2330E REF02
secondaryEditorView[].supervisingProvider2330F NM1*DQ, REF (provider)Written when nm1Data.lastName is set. entityCode is filled in as DQ.
secondaryEditorView[].billingProviderEditorView2330G NM1*85, REF (provider)Written when nm1Data.lastName is set. entityCode is filled in as 85. Its address and contacts are not sent.

Service line (2400-2440)​

Paths are relative to each entry in claims[].

JSON field837PNotes
serviceLinesEditorView[].lineNumber2400 LX01
serviceLinesEditorView[].procedureCodeQualifier2400 SV101-1
serviceLinesEditorView[].procedureCode2400 SV101-2
serviceLinesEditorView[].modifier12400 SV101-3
serviceLinesEditorView[].modifier22400 SV101-4
serviceLinesEditorView[].modifier32400 SV101-5
serviceLinesEditorView[].modifier42400 SV101-6
serviceLinesEditorView[].procedureDescription2400 SV101-7
serviceLinesEditorView[].lineChargeAmount2400 SV102
serviceLinesEditorView[].serviceUnitMeasurementCode2400 SV103
serviceLinesEditorView[].serviceUnitCount2400 SV104
serviceLinesEditorView[].placeOfService2400 SV105
serviceLinesEditorView[].pointer12400 SV107-1
serviceLinesEditorView[].pointer22400 SV107-2
serviceLinesEditorView[].pointer32400 SV107-3
serviceLinesEditorView[].pointer42400 SV107-4
serviceLinesEditorView[].emergencyIndicator2400 SV109
serviceLinesEditorView[].epsdtIndicator2400 SV111
serviceLinesEditorView[].familyIndicator2400 SV112
serviceLinesEditorView[].coPayStatusCode2400 SV115
serviceLinesEditorView[].dmeService.procedureIdentifier2400 SV501-1Written when procedureCode is set.
serviceLinesEditorView[].dmeService.procedureCode2400 SV501-2
serviceLinesEditorView[].dmeService.measurementCode2400 SV502
serviceLinesEditorView[].dmeService.lengthOfMedicalNecessity2400 SV503
serviceLinesEditorView[].dmeService.dmeRentalPrice2400 SV504
serviceLinesEditorView[].dmeService.dmePurchasePrice2400 SV505
serviceLinesEditorView[].dmeService.rentalUnitPriceIndicator2400 SV506
serviceLinesEditorView[].supplementalInfos[].reportTypeCode2400 PWK01Up to 10. PWK05 is AC when the transmission code is BM, EL, EM, FX or FT.
serviceLinesEditorView[].supplementalInfos[].transmissionCode2400 PWK02
serviceLinesEditorView[].supplementalInfos[].attachmentControlNumber12400 PWK06
serviceLinesEditorView[].dmeCertOfMedicalNecessityIndicator.reportTypeCode2400 PWK*CT PWK01DME certificate of medical necessity. Written when transmissionCode is set. Filled in as CT.
serviceLinesEditorView[].dmeCertOfMedicalNecessityIndicator.transmissionCode2400 PWK*CT PWK02
serviceLinesEditorView[].ambulanceTransport.weightMeasurementCode2400 CR101Written when transportCode is set.
serviceLinesEditorView[].ambulanceTransport.patientWeight2400 CR102
serviceLinesEditorView[].ambulanceTransport.transportCode2400 CR104
serviceLinesEditorView[].ambulanceTransport.distancetMeasurementCode2400 CR105
serviceLinesEditorView[].ambulanceTransport.distance2400 CR106
serviceLinesEditorView[].ambulanceTransport.roundTripReason2400 CR109
serviceLinesEditorView[].ambulanceTransport.stretcherReason2400 CR110
serviceLinesEditorView[].durableMedicalEquipmentCert.certificationTypeCode2400 CR301Written when certificationTypeCode and dmeMedicalEquipmentDurationUnit are set.
serviceLinesEditorView[].durableMedicalEquipmentCert.dmeMedicalEquipmentDurationUnitCode2400 CR302
serviceLinesEditorView[].durableMedicalEquipmentCert.dmeMedicalEquipmentDurationUnit2400 CR303
serviceLinesEditorView[].ambulanceCerts[].conditionIndicator2400 CRC*07 CRC02Up to 3, each written when conditionIndicator is set. CRC01 is always 07.
serviceLinesEditorView[].ambulanceCerts[].conditionCode12400 CRC*07 CRC03
serviceLinesEditorView[].ambulanceCerts[].conditionCode22400 CRC*07 CRC04
serviceLinesEditorView[].ambulanceCerts[].conditionCode32400 CRC*07 CRC05
serviceLinesEditorView[].ambulanceCerts[].conditionCode42400 CRC*07 CRC06
serviceLinesEditorView[].ambulanceCerts[].conditionCode52400 CRC*07 CRC07
serviceLinesEditorView[].hospiceIndicator.hospiceEmployedProviderIndicator2400 CRC*70 CRC02Written when both are set.
serviceLinesEditorView[].hospiceIndicator.conditionIndicator2400 CRC*70 CRC03
serviceLinesEditorView[].dmeCondition.certificationConditionIndicatorCode2400 CRC*09 CRC02Written when certificationConditionIndicatorCode and certificationConditionIndicator1 are set.
serviceLinesEditorView[].dmeCondition.certificationConditionIndicator12400 CRC*09 CRC03
serviceLinesEditorView[].dmeCondition.certificationConditionIndicator22400 CRC*09 CRC04
serviceLinesEditorView[].dateService2400 DTP*472 (date)A dateValue with a hyphen (20260801-20260805) is sent as a range, RD8.
serviceLinesEditorView[].datePrescription2400 DTP*471 (date)
serviceLinesEditorView[].dateCertificationRevisionRecert2400 DTP*607 (date)
serviceLinesEditorView[].dateBeginTherapy2400 DTP*463 (date)
serviceLinesEditorView[].dateLastCertification2400 DTP*461 (date)
serviceLinesEditorView[].dateLastSeen2400 DTP*304 (date)
serviceLinesEditorView[].dateRecentHemoglobin2400 DTP*738 (date)
serviceLinesEditorView[].dateRecentSerumCreatine2400 DTP*739 (date)
serviceLinesEditorView[].dateShipped2400 DTP*011 (date)
serviceLinesEditorView[].dateLastXRay2400 DTP*455 (date)
serviceLinesEditorView[].dateInitialTreatment2400 DTP*454 (date)
serviceLinesEditorView[].refRepricedLineItemRefNumber2400 REF*9B (reference)
serviceLinesEditorView[].refAdjRepricedLineItemRefNumber2400 REF*9D (reference)
serviceLinesEditorView[].refPriorAuthorization2400 REF*G1 (reference)
serviceLinesEditorView[].refLineItemControlNumber2400 REF*6R (reference)Your line id; it comes back on the 835.
serviceLinesEditorView[].refMammographyCertNumber2400 REF*EW (reference)
serviceLinesEditorView[].refCliaNumber2400 REF*X4 (reference)
serviceLinesEditorView[].refCliaNumberFacilityIdent2400 REF*F4 (reference)
serviceLinesEditorView[].refImmunizationBatchNumber2400 REF*BT (reference)
serviceLinesEditorView[].refReferralNumber2400 REF*9F (reference)
serviceLinesEditorView[].ambulancePatientCount.quanityQualifier2400 QTY*PT QTY01Filled in as PT.
serviceLinesEditorView[].ambulancePatientCount.quanity2400 QTY*PT QTY02
serviceLinesEditorView[].obstretricAnesthesiaAddUnits.quanityQualifier2400 QTY*FL QTY01Filled in as FL.
serviceLinesEditorView[].obstretricAnesthesiaAddUnits.quanity2400 QTY*FL QTY02
serviceLinesEditorView[].testResults[].measurementRefIdCode2400 MEA01Up to 5.
serviceLinesEditorView[].testResults[].measurementQualifier2400 MEA02
serviceLinesEditorView[].testResults[].testResults2400 MEA03
serviceLinesEditorView[].contractInfo.contractTypeCode2400 CN101Written when contractTypeCode is set.
serviceLinesEditorView[].contractInfo.contractAmt2400 CN102
serviceLinesEditorView[].contractInfo.contractPercent2400 CN103
serviceLinesEditorView[].contractInfo.contractCode2400 CN104
serviceLinesEditorView[].contractInfo.contractTermsPercent2400 CN105
serviceLinesEditorView[].contractInfo.contractVersionIdent2400 CN106
serviceLinesEditorView[].salesTaxAmount.amountQualCode2400 AMT*T AMT01Filled in as T.
serviceLinesEditorView[].salesTaxAmount.monetaryAmt2400 AMT*T AMT02
serviceLinesEditorView[].postageClaimedAmt.amountQualCode2400 AMT*F4 AMT01Filled in as F4.
serviceLinesEditorView[].postageClaimedAmt.monetaryAmt2400 AMT*F4 AMT02
serviceLinesEditorView[].fileInformations[]2400 K3 K301Up to 10.
serviceLinesEditorView[].lineNote.referenceCode2400 NTE*ADD NTE01Each written when both referenceCode and noteText are set. Send ADD.
serviceLinesEditorView[].lineNote.noteText2400 NTE02
serviceLinesEditorView[].thirdPartyNote.referenceCode2400 NTE*TPO NTE01Send TPO.
serviceLinesEditorView[].thirdPartyNote.noteText2400 NTE02
serviceLinesEditorView[].purchasedServiceInfo.referenceIdent2400 PS101Written when monetaryAmount is set.
serviceLinesEditorView[].purchasedServiceInfo.monetaryAmount2400 PS102
serviceLinesEditorView[].repricing.pricingMethodology2400 HCP01Written when pricingMethodology and repricedAllowedAmt are set.
serviceLinesEditorView[].repricing.repricedAllowedAmt2400 HCP02
serviceLinesEditorView[].repricing.repriceSavingsAmt2400 HCP03
serviceLinesEditorView[].repricing.repricingOrgIdent2400 HCP04
serviceLinesEditorView[].repricing.rate2400 HCP05
serviceLinesEditorView[].repricing.groupCode2400 HCP06
serviceLinesEditorView[].repricing.patientGroupAmt2400 HCP07
serviceLinesEditorView[].repricing.productIdQualifier2400 HCP09
serviceLinesEditorView[].repricing.repricedApprHcpcsCode2400 HCP10
serviceLinesEditorView[].repricing.measurementCode2400 HCP11
serviceLinesEditorView[].repricing.serviceUnitCount2400 HCP12
serviceLinesEditorView[].repricing.rejectReasonCode2400 HCP13
serviceLinesEditorView[].repricing.complianceCode2400 HCP14
serviceLinesEditorView[].repricing.exceptionCode2400 HCP15
serviceLinesEditorView[].drugIdentification.productServiceIdQualifier2410 LIN02Written when productServiceIdQualifier and nationalDrugCode are set.
serviceLinesEditorView[].drugIdentification.nationalDrugCode2410 LIN03
serviceLinesEditorView[].drugIdentification.drugQuanity2410 CTP04
serviceLinesEditorView[].drugIdentification.drugQtyUnitOfMeasure2410 CTP05
serviceLinesEditorView[].drugIdentification.prescriptionCompoundDrugNumber.qualifierCode2410 REF*XZ REF01Send XZ.
serviceLinesEditorView[].drugIdentification.prescriptionCompoundDrugNumber.refValue2410 REF02
serviceLinesEditorView[].renderingProvider2420A NM1*82, PRV*PE, REF (provider)Written when nm1Data.lastName is set. entityCode is filled in as 82.
serviceLinesEditorView[].purchasedServiceProvider2420B NM1*QB, REF (provider)Written when nm1Data.lastName is set. entityCode is filled in as QB.
serviceLinesEditorView[].serviceFacility.organizationName2420C NM1*77 NM103Written when organizationName is set.
serviceLinesEditorView[].serviceFacility.primaryIdentifier2420C NM1*77 NM109
serviceLinesEditorView[].serviceFacility.address12420C N301
serviceLinesEditorView[].serviceFacility.address22420C N302
serviceLinesEditorView[].serviceFacility.city2420C N401
serviceLinesEditorView[].serviceFacility.state2420C N402
serviceLinesEditorView[].serviceFacility.zip2420C N403
serviceLinesEditorView[].serviceFacility.secondaryIdentifiers[].qualifierCode2420C REF*G2 REF01Send G2.
serviceLinesEditorView[].serviceFacility.secondaryIdentifiers[].refValue2420C REF02
serviceLinesEditorView[].supervisingProvider2420D NM1*DQ, REF (provider)Written when nm1Data.lastName is set. entityCode is filled in as DQ.
serviceLinesEditorView[].orderingProvider2420E NM1*DK, REF (provider)Written when nm1Data.lastName is set. entityCode is filled in as DK. Also takes an address (N3/N4) and a contact (PER).
serviceLinesEditorView[].orderingProvider.address1, address2, city, state, zip2420E N3, N4 (address)
serviceLinesEditorView[].orderingProvider.contact2420E PER (contact)Written when contactType1 and contactInfo1 are set.
serviceLinesEditorView[].referringProvider2420F NM1*DN, REF (provider)Written when nm1Data.lastName is set. entityCode is filled in as DN.
serviceLinesEditorView[].primaryCareProvider2420F NM1*P3, REF (provider)Written when nm1Data.lastName is set. entityCode is filled in as P3.
serviceLinesEditorView[].ambulancePickupLocation.entityCode2420G NM101Written when address1 or city is set. Send PW.
serviceLinesEditorView[].ambulancePickupLocation.entityType2420G NM102
serviceLinesEditorView[].ambulancePickupLocation.address12420G N301
serviceLinesEditorView[].ambulancePickupLocation.address22420G N302
serviceLinesEditorView[].ambulancePickupLocation.city2420G N401
serviceLinesEditorView[].ambulancePickupLocation.state2420G N402
serviceLinesEditorView[].ambulancePickupLocation.zip2420G N403
serviceLinesEditorView[].ambulanceDropOffLocation.entityCode2420H NM101Written when address1 or city is set. Send 45.
serviceLinesEditorView[].ambulanceDropOffLocation.entityType2420H NM102
serviceLinesEditorView[].ambulanceDropOffLocation.address12420H N301
serviceLinesEditorView[].ambulanceDropOffLocation.address22420H N302
serviceLinesEditorView[].ambulanceDropOffLocation.city2420H N401
serviceLinesEditorView[].ambulanceDropOffLocation.state2420H N402
serviceLinesEditorView[].ambulanceDropOffLocation.zip2420H N403
serviceLinesEditorView[].adjudications[].otherPayerPrimaryIdentifier2430 SVD01One per payer that adjudicated the line. Written only when otherPayerPrimaryIdentifier is set, and it must match that payer's secondaryEditorView[].payerEditorView.payerIdentifier.
serviceLinesEditorView[].adjudications[].serviceLinePaidAmt2430 SVD02
serviceLinesEditorView[].adjudications[].productServiceIdQualifier2430 SVD03-1
serviceLinesEditorView[].adjudications[].procedureCode2430 SVD03-2
serviceLinesEditorView[].adjudications[].modifier12430 SVD03-3
serviceLinesEditorView[].adjudications[].modifier22430 SVD03-4
serviceLinesEditorView[].adjudications[].modifier32430 SVD03-5
serviceLinesEditorView[].adjudications[].modifier42430 SVD03-6
serviceLinesEditorView[].adjudications[].procedureDescription2430 SVD03-7
serviceLinesEditorView[].adjudications[].serviceLineRevenueCode2430 SVD04
serviceLinesEditorView[].adjudications[].paidServiceUnitCount2430 SVD05
serviceLinesEditorView[].adjudications[].bundledLineNumber2430 SVD06
serviceLinesEditorView[].adjudications[].lineAdjustments[]2430 CAS (adjustment)One entry per group code. Entries without a group code or a first reason code are skipped.
serviceLinesEditorView[].adjudications[].dateClaimPaid2430 DTP*573 (date)
serviceLinesEditorView[].adjudications[].amountOwed.amountQualCode2430 AMT*EAF AMT01Filled in as EAF.
serviceLinesEditorView[].adjudications[].amountOwed.monetaryAmt2430 AMT*EAF AMT02
serviceLinesEditorView[].formIdent[].codeListQualifier2440 LQ01Written when codeListQualifier, industryCode and the first questionNumber are set.
serviceLinesEditorView[].formIdent[].industryCode2440 LQ02
serviceLinesEditorView[].formIdent[].supportingDocuments[].questionNumber2440 FRM01
serviceLinesEditorView[].formIdent[].supportingDocuments[].questionResponseYN2440 FRM02
serviceLinesEditorView[].formIdent[].supportingDocuments[].questionResponse2440 FRM03
serviceLinesEditorView[].formIdent[].supportingDocuments[].questionResponseDate2440 FRM04
serviceLinesEditorView[].formIdent[].supportingDocuments[].questionResponseDecimal2440 FRM05

Not sent​

These fields are accepted but do not appear in the 837P. Most belong to institutional or dental claims, which share the same model.

JSON fieldWhy
accountNumberReplaced by the account your credentials resolve to.
envelop.isa09ISA09/ISA10 are the time ClaimRev builds the file.
envelop.isa10ISA09/ISA10 are the time ClaimRev builds the file.
envelop.isa11Taken from envelop.separators.
envelop.isa12Always 00501.
envelop.isa16Taken from envelop.separators.
envelop.separatorsSets the delimiters ClaimRev writes with; *, ~, : and ^ when omitted.
claimIdYours to use; not part of the 837.
sharpRcmClaimIdInternal.
claimStatusIdInternal.
claimTextInternal.
claimErrorsOutput only.
receiverViewModelThe receiver (1000B) comes from envelop.receiverName / receiverName.
submitterEditViewModelRequired, but the submitter (1000A) comes from submitterName, submitterId, submitterContactName and submitterPhone.
*.qualifierCodeHintEditor hints.
*.refValueHintEditor hints.
*.otherRefValueHintEditor hints.
*.nm1Data.taxonomyCodeWritten only for the billing (2000A PRV) and rendering providers (2310B, 2420A PRV).
billingProviderEditorView.secondaryIdentifiers[].otherRefValueNot sent for the billing provider.
payToAddressView.entityCodeAlways 87.
payerEditerView.priorAuthNumberUse claimEditorView.refPriorAuthorization. These payer fields are only sent for other payers (2330B).
payerEditerView.referralNumberUse claimEditorView.refReferralNumber.
payerEditerView.signalCodeOther payers (2330B) only.
payerEditerView.origionalRefNumberUse claimEditorView.refOriginalReference.
payerEditerView.additionalPayerIdentifierOther payers (2330B) only.
payerEditerView.adjudicationPaymentDateOther payers (2330B) only.
payerEditerView.predeterminationOfBenefitsNot used in 837P.
secondaryEditorView[].payerEditorView.providerCommericalNumberA billing-provider id (2010BB); not valid for another payer (2330B).
secondaryEditorView[].payerEditorView.locationNumberA billing-provider id (2010BB); not valid for another payer (2330B).
secondaryEditorView[].serviceFacility.address12330E carries the name and ids only.
secondaryEditorView[].serviceFacility.address22330E carries the name and ids only.
secondaryEditorView[].serviceFacility.city2330E carries the name and ids only.
secondaryEditorView[].serviceFacility.state2330E carries the name and ids only.
secondaryEditorView[].serviceFacility.zip2330E carries the name and ids only.
secondaryEditorView[].payerEditorView.predeterminationOfBenefitsNot used in 837P.
secondaryEditorView[].payerEditorView.adjudicationPaymentDate.periodFormatAlways D8.
claimEditorView.claimSubmissionReasonCodeNot used; the frequency code is claimFreqCode.
claimEditorView.notesUse note; 837P carries one claim NTE.
claimEditorView.serviceDates of service are per line (serviceLinesEditorView[].dateService).
claimEditorView.dateStatementDateInstitutional (837I) only.
claimEditorView.appliancePlacementDental (837D) only.
claimEditorView.refPredeterminationOfBenefitsIdentNot used in 837P.
claimEditorView.refLocationNumberNot used in 837P.
claimEditorView.refProApprovalNumberNot used in 837P.
claimEditorView.ambulanceCerts[].codeCategoryAlways 07.
claimEditorView.epsdt.codeCategoryAlways ZZ.
claimEditorView.diagnosisCodes[].diagnosisOrderSets the order of the HI composites; not itself sent.
claimEditorView.diagnosisCodes[].presentOnAdmissionInstitutional (837I) only.
claimEditorView.diagnosisCodes[].procedureDateInstitutional (837I) only.
claimEditorView.diagnosisCodes[].monitaryAmountInstitutional (837I) only.
claimEditorView.admittingDiagnosisCodeInstitutional (837I) only.
claimEditorView.reasonForVisitDiagnosisCodesInstitutional (837I) only.
claimEditorView.externalCauseInjDiagnosisCodesInstitutional (837I) only.
claimEditorView.principalProcedureCodeInstitutional (837I) only.
claimEditorView.otherPrincipalProcedureCodesInstitutional (837I) only.
claimEditorView.occurrenceSpanCodesInstitutional (837I) only.
claimEditorView.occurrenceCodesInstitutional (837I) only.
claimEditorView.valueInformationInstitutional (837I) only.
claimEditorView.drgCodeInstitutional (837I) only.
claimEditorView.treatmentCodesInstitutional (837I) only.
claimEditorView.claimCodeInstitutional (837I) only.
claimEditorView.attendingProviderInstitutional (837I) only.
claimEditorView.operatingProviderInstitutional (837I) only.
claimEditorView.otherOperatingProviderInstitutional (837I) only.
claimEditorView.assistantSurgeonDental (837D) only.
claimEditorView.orthoTotalMonthsTreatmentDental (837D) only.
claimEditorView.toothStatusesDental (837D) only.
claimEditorView.repricing.productIdQualifierLine-level only (HCP09).
claimEditorView.repricing.repricedApprHcpcsCodeLine-level only (HCP10).
claimEditorView.repricing.measurementCodeLine-level only (HCP11).
claimEditorView.repricing.serviceUnitCountLine-level only (HCP12).
claimEditorView.serviceFacility.secondaryIdentifiers[].otherRefValueWritten as REF04.
secondaryEditorView[].otherSubscriber.dateOfDeathNot part of 2330A.
secondaryEditorView[].otherSubscriber.measurementCodeNot part of 2330A.
secondaryEditorView[].otherSubscriber.weightNot part of 2330A.
secondaryEditorView[].otherSubscriber.pregnancyIndicatorNot part of 2330A.
secondaryEditorView[].otherSubscriber.birthDayNot part of 2330A.
secondaryEditorView[].otherSubscriber.genderNot part of 2330A.
secondaryEditorView[].otherSubscriber.casualtyClaimNumberNot part of 2330A.
secondaryEditorView[].otherSubscriber.contact1Not part of 2330A.
secondaryEditorView[].inpatientAdjudicationInstitutional (837I) only.
secondaryEditorView[].attendingProviderInstitutional (837I) only.
secondaryEditorView[].operatingProviderInstitutional (837I) only.
secondaryEditorView[].otherOperatingProviderInstitutional (837I) only.
secondaryEditorView[].assistantSurgeonDental (837D) only.
secondaryEditorView[].billingProviderEditorView.address12330G carries the name and ids only.
secondaryEditorView[].billingProviderEditorView.address22330G carries the name and ids only.
secondaryEditorView[].billingProviderEditorView.city2330G carries the name and ids only.
secondaryEditorView[].billingProviderEditorView.state2330G carries the name and ids only.
secondaryEditorView[].billingProviderEditorView.zip2330G carries the name and ids only.
secondaryEditorView[].billingProviderEditorView.contact12330G carries the name and ids only.
secondaryEditorView[].billingProviderEditorView.contact22330G carries the name and ids only.
secondaryEditorView[].serviceFacility.secondaryIdentifiers[].otherRefValueWritten as REF04.
serviceLinesEditorView[].revenueCodeInstitutional (837I) only.
serviceLinesEditorView[].nonCoveredChargeAmountInstitutional (837I) only.
serviceLinesEditorView[].oralCavityDesignationCode1Dental (837D) only.
serviceLinesEditorView[].oralCavityDesignationCode2Dental (837D) only.
serviceLinesEditorView[].oralCavityDesignationCode3Dental (837D) only.
serviceLinesEditorView[].oralCavityDesignationCode4Dental (837D) only.
serviceLinesEditorView[].oralCavityDesignationCode5Dental (837D) only.
serviceLinesEditorView[].prosthesisCrownInlayCodeDental (837D) only.
serviceLinesEditorView[].procedureCountDental (837D) only.
serviceLinesEditorView[].teethInformationDental (837D) only.
serviceLinesEditorView[].dateEstimatedPriorPlacementDental (837D) only.
serviceLinesEditorView[].datePriorPlacementDental (837D) only.
serviceLinesEditorView[].dateAppliancePlacementDental (837D) only.
serviceLinesEditorView[].dateApplianceReplacementDental (837D) only.
serviceLinesEditorView[].dateTreatmentStartDental (837D) only.
serviceLinesEditorView[].dateTreatmentEndDental (837D) only.
serviceLinesEditorView[].assistantSurgeonDental (837D) only.
serviceLinesEditorView[].operatingProviderInstitutional (837I) only.
serviceLinesEditorView[].otherOperatingProviderInstitutional (837I) only.
serviceLinesEditorView[].ambulanceCerts[].codeCategoryAlways 07.
serviceLinesEditorView[].refPredeterminationOfBenefitsIdentNot used in 837P.
serviceLinesEditorView[].refRepricedClaimRefNumberNot used at line level in 837P.
serviceLinesEditorView[].refAdjRepricedClaimRefNumberNot used at line level in 837P.
serviceLinesEditorView[].serviceTaxAmountNot used in 837P.
serviceLinesEditorView[].miscTaxesNot used in 837P.
serviceLinesEditorView[].hospiceIndicator.codeCategoryAlways 70.
serviceLinesEditorView[].dmeCondition.codeCategoryAlways 09.
serviceLinesEditorView[].dmeCertOfMedicalNecessityIndicator.attachmentControlNumber1PWK*CT carries no control number.
serviceLinesEditorView[].drugIdentification.prescriptionCompoundDrugNumber.otherRefValueNot sent.
serviceLinesEditorView[].serviceFacility.secondaryIdentifiers[].otherRefValueWritten as REF04.
serviceLinesEditorView[].adjudications[].modifier5SVD03 carries four modifiers.
serviceLinesEditorView[].adjudications[].dateClaimPaid.periodFormatAlways D8.