Segment
X12 EDI Release 00403
To specify information about the claim being reported
Elements
Code identifying the specific type of item maintenance
Codes (121)- 100Sale of Mortgage Change
- 101Servicer Change
- 102Mortgagor Change
- 104Prepayment Termination
- 105Non-conveyance Termination
- 106Voluntary Action Termination
- 107Loan Refinanced Termination
- 108Transfer Due to Interest and Servicing Sold
- 109Retain Servicing
- 110Transfer Servicing
- 111Assign Servicing
- 112Servicer Loan Number Change
- 113Merger
- 114Acquisition
- 115Receivership
- 116Loan Maturity Maintenance
- 117Binder
- 118New Policy
- 119Renewal Policy
- 123Canceled by Administrator
- 124Canceled by Insured
- 125Re-Write
- 126Non-renewal
- 127Termination of All Endorsements
- 128Termination of Lessor Interest
- 129Termination of Additional Insured Interest
- 130Termination of Lienholder or Loss Payee
- 131Addition of Lessor Endorsement
- 132Addition of Lienholder Endorsement
- 133Addition of Additional Insured Endorsement
- 134Change of Lessor Endorsement
- 135Change of Lienholder Endorsement
- 136Change of Additional Insured Endorsement
- 137Acquired Unallocated
- 138Acquired Payment
- 139Investigation Pending
- 140Concurrent Benefit
- 141Abbreviated First Report on an Acquired Claim
- 142Employer Paid
- 143Employer Reinstatement
- 144Suspension Directed by Agency
- 145Occupational Safety and Health Administration Injury and Illness Log (OSHA-300)
- 146Occupational Injury Survey
- 147Bureau of Labor and Statistics Survey
- 148First Payment on an Acquired Claim
- 149First Report on an Acquired Claim
- 150Impairment Report
- 151Return to Work Report
- 152Office of Workers Compensation Program Injury Claim Report (OWCP CA-1)
- 153Office of Workers Compensation Program Illness Claim Report (OWCP CA-2)
- 154Occupational Safety and Health Administration Injury and Illness Record (OSHA-301)
- 155First Aid Injury Only
- 001Change
- 002Delete
- 003Add Full Item Detail
- 004Withdraw Item (Temporary)
- 005Restore Item
- 006Membership Type
- 007Purchase Eligibility
- 008Verified
- 009Not Verified
- 010Periodic Report
- 011All Items Refresh
- 012Medical Noncompliance
- 013Administrative Noncompliance
- 014Suspended Pending Settlement Approval
- 015Suspended Pending Appeal or Judicial Review
- 016Injury Report Creation
- 017Illness Report Creation
- 018Transfer of Beneficial Rights
- 019Record Security Instrument
- 020Assignment
- 021Addition
- 022Change in Status
- 023Change in Rate Factors
- 024Cancellation or Termination
- 025Reinstatement
- 026Correction
- 028Policy Adjustment
- 029Inquiry
- 030Audit or Compare
- 031Medical Examination Authorization
- 032Employee Information Not Applicable
- 033Release of Interim Funding Interest
- 050Original
- 051Denial
- 052Initial Payment
- 053Change in Benefit Amount
- 054Change in Benefit Type
- 055Reinstatement of Benefit
- 056Reduced Earnings
- 057Final
- 059Suspension Medically Determined or Qualified to Return to Work
- 060Non-compliance of Medical Requirements
- 061Non-compliance of Administrative Requirements
- 062Compensable Death
- 063Incarceration
- 064Claimant's Whereabouts Unknown
- 065Volunteer
- 066Status Request
- 067Benefits Exhausted
- 068Jurisdictional Change
- 069Payment Notification
- 070Status Request Response
- 071Re-issue Identification Card(s)
- 072Suspension Due to Claimant Death
- 073Partial Denial
- 074Partial Suspension, Returned to Work, or Medically Determined or Qualified to Return to Work
- 075Partial Suspension, Medical Non-compliance
- 076Partial Suspension, Administrative Non-compliance
- 077Partial Suspension, Claimant Death
- 078Partial Suspension, Incarceration
- 079Partial Suspension, Claimant's whereabouts Unknown
- 080Partial Suspension, Benefits Exhausted
- 081Partial Suspension, Jurisdiction Change
- 082Partially Suspended, Benefits Pending Settlement Approval
- 083Partially Suspended, Pending Appeal or Judicial Review
- CEPChange Excluding Price
- PRIPrice Change Only
- TBVTo Be Verified
- ZZZMutually Defined
Code identifying the status of an entire claim as assigned by the payor, claim review organization or repricing organization
Codes (41)- 1Processed as Primary
- 2Processed as Secondary
- 3Processed as Tertiary
- 4Denied
- 5Pended
- 6Approved as amended
- 7Approved as submitted
- 8Cancelled due to inactivity
- 9Pending - under investigation
- 10Received, but not in process
- 11Rejected, duplicate claim
- 12Rejected, please resubmit with corrections
- 13Suspended
- 14Suspended - incomplete claim
- 15Suspended - investigation with field
- 16Suspended - return with material
- 17Suspended - review pending
- 18Suspended Product Registration
- 19Processed as Primary, Forwarded to Additional Payer(s)
- 20Processed as Secondary, Forwarded to Additional Payer(s)
- 21Processed as Tertiary, Forwarded to Additional Payer(s)
- 22Reversal of Previous Payment
- 23Not Our Claim, Forwarded to Additional Payer(s)
- 24Transferred to Proper Carrier
- 25Predetermination Pricing Only - No Payment
- 26Documentation Claim - No Payment Associated
- 27Reviewed
- 28Repriced
- 29Audited
- 30Processed as Conditional
- IInitial
- ADAdditional
- APAppealed
- CCWeekly Certification
- CLClosed
- CPOpen
- RAReaudited
- RBReissue
- RCReopened and Closed
- RDRedetermination
- ROReopened
Code identifying the reason for the maintenance change
Codes (111)- 10Consolidation Omnibus Budget Reconciliation Act (COBRA) Premium Paid
- 11Surviving Spouse
- 12Lay Off
- 13Leave of Absence
- 14Voluntary Withdrawal
- 15Primary Care Provider (PCP) Change
- 16Quit
- 17Fired
- 18Suspended
- 19Sabbatical
- 20Active
- 21Disability
- 22Plan Change
- 23Furloughed
- 24Resigned
- 25Change in Identifying Data Elements
- 26Declined Coverage
- 27Pre-Enrollment
- 28Initial Enrollment
- 29Benefit Selection
- 30Discrimination Test
- 31Legal Separation
- 32Marriage
- 33Personnel Data
- 34Investment Elections and Contribution Rates
- 35Loan Repayment
- 36Contribution or Plan Allocation
- 37Leave of Absence with Benefits
- 38Leave of Absence without Benefits
- 39Lay Off with Benefits
- 40Lay Off without Benefits
- 41Re-enrollment
- 42New Entity
- 43Change of Location
- 44Change of Telephone Number
- 45Went Out of Business
- 46Current Customer Information File in Error
- 47Account Balance Reporting
- 48Fees Processing
- 49Interfund Transfer
- 50Loan Request
- 51Enrollment in Subsequent Benefit Plan
- 52Health Care Facility Change
- 53Name Synonym Add
- 54Sub Location Add
- 55Sub Location Change
- 56Sub Location Expire
- 57Buyout
- 58Merger
- 59Non Payment
- 60Coverage Placed Elsewhere
- 61Duplicate Coverage
- 62Change in Ownership
- 63Business Sold
- 64Underwriting Reason
- 65No Employees, Exposure or Operations
- 66Revocation of Voluntary Market Acceptance
- 67Include Primary Business Management
- 68Exclude Primary Business Management
- 69Failure to Pay Deductible
- 70Misrepresented Information
- 71Rewritten
- 72Adding a Jurisdiction
- 73Deleting a Jurisdiction
- 75Occupational Illness
- 76Change Insured Federal Employer Identification Number (FEIN)
- 77Change Employer Federal Employer Identification Number (FEIN)
- 78Change Employer Unemployment Insurance (UI) Code
- 79Change Policy Number
- 80Modification without a Specific Operating Unit Location in Jurisdiction
- 81Change Policy Effective Date
- 82Change Policy Expiration Date
- 83Change Insurer Federal Employer Identification Number (FEIN)
- 84No Eligible Employees
- 85Reinstatement - Canceled in Error
- 86Change in Insured Information
- 87Change in Employer Information
- 88Parent Identification Change
- 89Change to Expiration Date
- 90Phone Verify Only
- 91Name Synonym Delete
- 92Duplicate Entry on Customer Identification File
- 01Divorce
- 02Birth
- 03Death
- 04Retirement
- 05Adoption
- 06Strike
- 07Termination of Benefits
- 08Termination of Employment
- 09Consolidation Omnibus Budget Reconciliation Act (COBRA)
- 4ABusiness Name Change
- 4BBusiness Name Correction
- 4CPhysical or Mailing Address Correction
- AADissatisfaction with Office Staff
- ABDissatisfaction with Medical Care/Services Rendered
- ACInconvenient Office Location
- ADDissatisfaction with Office Hours
- AEUnable to Schedule Appointments in a Timely Manner
- AFDissatisfaction with Physician's Referral Policy
- AGLess Respect and Attention Time Given than to Other Patients
- AHPatient Moved to a New Location
- AINo Reason Given
- AJAppointment Times not Met in a Timely Manner
- XBBecame Medical Only
- XIIndemnity
- XLBecame Lost Time
- XMMedical Only
- XNNotification Only
- XTTransfer
- ZZMutually Defined
Code indicating frequency or type of activities or actions being reported
Codes (22)- 1Weekly
- 2Biweekly
- 3Semimonthly
- 4Monthly
- 5Other
- 6Daily
- 7Annual
- 8Two Calendar Months
- 9Lump-Sum Separation Allowance
- AQuarter-to-Date
- BYear-to-Date
- CSingle
- DPolicy Period
- EClaim Period
- FUnit Report Identifier
- GMonth-to-Date
- HHourly
- JCurrent Period
- QQuarterly
- SSemiannual
- UUnknown
- ZMutually Defined
Code identifying type of claim
Codes (45)- 10Central Certification
- 11Other Non-Federal Programs
- 12Preferred Provider Organization (PPO)
- 13Point of Service (POS)
- 14Exclusive Provider Organization (EPO)
- 15Indemnity Insurance
- 16Health Maintenance Organization (HMO) Medicare Risk
- 17Dental Maintenance Organization
- 18Deed-in-Lieu Property Sold
- 19Deed-in-Lieu Property Not Sold
- 20Foreclosure Complete Property Sold
- 21Foreclosure Complete Property Not Sold
- 22Liability Insurance
- 01Property Conveyance
- 02Mortgage Assignment
- 03Automatic Mortgage Assignment
- 04Mortgage Coinsurance
- 05Supplemental Claim
- 06Property Nonconveyance (Claim without Conveyance of Title)
- 07Property Preforeclosure Sale
- 08Initial Claim
- 09Self-pay
- AMAutomobile Medical
- BLBlue Cross/Blue Shield
- CHChampus
- CICommercial Insurance Co.
- CNContractual
- DSDisability
- FIFederal Employees Program
- HMHealth Maintenance Organization
- LILiability
- LMLiability Medical
- MAMedicare Part A
- MBMedicare Part B
- MCMedicaid
- MHManaged Care Non-HMO
- OFOther Federal Program
- SASelf-administered Group
- TVTitle V
- VAVeterans Affairs Plan
- WBWorkers' Compensation First Report of Injury
- WCWorkers' Compensation Health Claim
- WDWorkers' Compensation Subsequent Report of Injury
- WEWorkers' Compensation Combined First and Subsequent Report
- ZZMutually Defined
Code indicating the date format, time format, or date and time format
Codes (41)- CCFirst Two Digits of Year Expressed in Format CCYY
- CDMonth and Year Expressed in Format MMMYYYY
- CMDate in Format CCYYMM
- CQDate in Format CCYYQ
- CYYear Expressed in Format CCYY
- D6Date Expressed in Format YYMMDD
- D8Date Expression in Format CCYYMMDD
- DARange of Dates within a Single Month Expressed in Format DD-DD
- DBDate Expressed in Format MMDDCCYY
- DDDay of Month in Numeric Format
- DTDate and Time Expressed in Format CCYYMMDDHHMM
- EHLast Digit of Year and Julian Date Expressed in Format YDDD
- KADate Expressed in Format YYMMMDD
- MDMonth of Year and Day of Month Expressed in Format MMDD
- MMMonth of Year in Numeric Format
- RDRange of Dates Expressed in Format MMDDCCYY-MMDDCCYY
- TCJulian Date Expressed in Format DDD
- TMTime Expressed in Format HHMM
- TQDate Expressed in Format MMYY
- TRDate and Time Expressed in Format DDMMYYHHMM
- TSTime Expressed in Format HHMMSS
- TTDate Expressed in Format MMDDYY
- TUDate Expressed in Format YYDDD
- UNUnstructured
- YMYear and Month Expressed in Format YYMM
- YYLast Two Digits of Year Expressed in Format CCYY
- DDTRange of Dates and Time, Expressed in CCYYMMDD-CCYYMMDDHHMM
- DTDRange of Dates and Time, Expressed in CCYYMMDDHHMM-CCYYMMDD
- DTSRange of Date and Time Expressed in Format CCYYMMDDHHMMSS-CCYYMMDDHHMMSS
- RD2Range of Years Expressed in Format YY-YY
- RD4Range of Years Expressed in Format CCYY-CCYY
- RD5Range of Years and Months Expressed in Format CCYYMM-CCYYMM
- RD6Range of Dates Expressed in Format YYMMDD-YYMMDD
- RD8Range of Dates Expressed in Format CCYYMMDD-CCYYMMDD
- RDMRange of Dates Expressed in Format YYMMDD-MMDD
- RDTRange of Date and Time, Expressed in Format CCYYMMDDHHMM-CCYYMMDDHHMM
- RMDRange of Months and Days Expressed in Format MMDD-MMDD
- RMYRange of Years and Months Expressed in Format YYMM-YYMM
- RTMRange of Time Expressed in Format HHMM-HHMM
- RTSDate and Time Expressed in Format CCYYMMDDHHMMSS
- YMMRange of Year and Months, Expressed in CCYYMMM-MMM Format
Specifies an additional characteristic of the adjustment reason
Codes (156)- 1Primary Disability - Frozen
- 2Primary Disability - Non-frozen
- 3Dependent Disability - Frozen
- 4Dependent Disability - Non-frozen
- 5Retirement - Frozen
- 6Retirement - Non-frozen
- 7Permanent
- 8Temporary
- 9Canadian
- 10Joint
- 11Deferred
- 12Eligible
- 13Applied
- 14Receiving
- 15Defense Medical Evaluation
- 16Delayed Reporting Penalty (Insured)
- 17Engineering Services
- 18Expert Test (Trial)
- 19Expert Fees and Expenses (excluding tests and testimony)
- 22Fee Schedule Savings
- 23Fatal
- 24Permanent Total
- 25Permanent Total Supplemental
- 26Permanent Partial Scheduled
- 27Permanent Partial Unscheduled
- 28Temporary Total
- 29Temporary Partial
- 30Employer Liability
- 31Permanent Partial Disfigurement
- 32Unspecified Employer Payments
- 34Funeral Expenses
- 35Penalties
- 36Interest
- 37Employer's Legal Expenses
- 38Claimant's Legal Expenses
- 39Payments to Physicians
- 40Hospital Costs
- 41Other Medical
- 42Vocational Rehabilitation Evaluation
- 43Vocational Rehabilitation Education
- 44Other Vocational Rehabilitation
- 45Total Temporary Catastrophic
- 46Unknown Payment Type
- 57Vocational Rehabilitation Maintenance
- 58Claim Value Recovery
- 60Deductible Recovery
- 61Additional Living Expense
- 62Alternative Dispute Resolution Services
- 63Anesthesiologist
- 64Annuity
- 65Attorney Expenses
- 66Attorney Fees
- 67Auto Liability Subrogation
- 69Not Eligible
- 71Catastrophic Benefits
- 72Central Index Bureau Filing Fees
- 73Chiropractor
- 74Indemnity Reserves
- 75Medical Reserves
- 76Expense Reserves
- 77Vocational Rehabilitation Reserves
- 78Indemnity Payments
- 79Medical Payments
- 80Expense Payments
- 81Vocational Rehabilitation Payments
- 82Claim Payment
- 83Claim Reserve
- 84Bodily Injury Payment
- 85Bodily Injury Reserve
- 86Property Damage Payment
- 87Property Damage Reserve
- 88Comprehensive Payment
- 89Comprehensive Reserve
- 90Collision Payment
- 91Collision Reserve
- 92Salvage
- 93Expert Witness Fees
- 94Claimant Legal Expense
- 95Claimant Medical Evaluation
- 96Commercial Photographers
- 97Mandated Medical Exam
- 98Death Benefits
- 99Defense Attorney Fees and Expenses
- A1Funeral Benefits
- A2Hearing Attendance or Representation Fees
- A3Hospital - Inpatient Charges
- A4Hospital - Outpatient Charges
- A5Hospital Bill Audit
- A6Impairment Income Benefits
- A7Independent Adjustor Expense
- A8Independent Medical Exam
- A9Legal Expenses - Miscellaneous
- AAChiropractic Expenses
- ABDental Expenses
- ACPhysical Therapy Costs
- ADPharmaceutical Costs
- AEDurable Medical Costs
- AFMedical Travel Costs
- AGEmployee Medical-Legal Costs
- AHEmployer-Claim Administrator Medical-Legal Costs
- AIAgreed upon or Directed Medical-Legal Costs
- AJUnallocated Funds
- AKFuture Credit Recovery
- B1Liability Settlement
- B2Life Pension
- B3Lump Sum Remarriage Payment
- B4Lump Sum Settlement Amount
- B5Major Case of Individual Case Reporting
- B6Medical Equipment
- B7Peer Review Board Expenses
- B8Medical Management Services
- B9Medical Records or Reports
- C1Medical Rehabilitation
- C2Medical Test (Trial)
- C3No-fault benefit or expense (Non-Workers Compensation)
- C4Nursing Care
- C5Extended Care Facility
- C6State Fund - Other
- C7Penalties Paid on Medical Benefits
- C8Penalties Paid on Indemnity Benefits
- C9Pension Indemnity Benefit
- D1
- D2Personal Property or Contents
- D3Pharmacy
- D4Photographs other than Commercial
- D5Physiotherapy
- D6PPO (Preferred Provider Organization) Fees or Expenses
- D7Product Liability Subrogation
- D8Property Adjustment
- D9Provider Bill Audit Expense
- E1Radiology
- E2Time and Expense Fees
- E3Scheduled Award
- E4Social Security
- E5State Second Injury Fund
- E6State Supplemental Fund
- E7Supplemental Permanent Total Benefits
- F1Testing Lab
- F2Third Party Contribution
- F3Transportation - Other
- F4Transportation - Medical Treatment
- F5Treating or Panel Physician
- F6Utilization Review - Hospital
- F7Utilization Review - Physician
- F8Unallocated Indemnity
- F9Unallocated Medical
- G2Witness Fees and Expenses - Other than Expert Witness
- G3Vocational Rehabilitation Training
- G4Appraisal Fees
- G5Autopsy Fees
- G6Surveillance Special Investigation Fees and Expenses
- G7Temporary Income Benefits
- G8
- G9Federal Second Injury Fund
- H2Federal Supplemental Fund
- H3Flat Rate
Identifies the reason for tardiness
Codes (23)- C1Coverage Lack of Information
- D1Dispute Concerning Coverage
- D2Dispute Concerning Compensability in Whole
- D3Dispute Concerning Compensability in Part
- D4Dispute Concerning Disability in Whole
- D5Dispute Concerning Disability in Part
- D6Dispute Concerning Impairment
- E1Wrongful Determination of No Coverage
- E2Error(s) from Employer
- E3Error(s) from Employee
- E4Error(s) from State
- E5Error(s) from Health Care Provider
- E6Error(s) from Other Claim Administrator, Independent Adjuster or Third Party Administrator
- L1Late No Excuse
- L2Late Notification, Employer
- L3Late Notification, Employee
- L4Late Notification, State
- L5Late Notification, Health Care Provider
- L6Late Notification, Assigned Risk
- L7Late Investigation
- L8Technical Processing Delay or Computer Failure
- L9Manual Processing Delay
- LAIntermittent Lost Time Prior to First Payment
