Segment
X12 EDI Release 00403
To specify information associated with other health insurance coverage
Elements
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 identifying reason for claim submission
Codes (18)- 15Resubmission
- 16Proposed
- 17Cancel to be Reissued
- 18Reissue
- 20Final Transmission
- 22Information Copy
- 27Verify
- 28Late Charges
- 29Adjustment
- 00Original
- 01Cancellation
- 02Corrected and Verified Original Claim
- 03Corrected and Verified Final Claim
- 05Replace
- 07Duplicate
- 08Pre-Determination
- 09Encounter
- PBPredetermination of Dental Benefits
Code indicating how the patient or subscriber authorization signatures were obtained and how they are being retained by the provider
Codes (5)- BSigned signature authorization form or forms for both HCFA-1500 Claim Form block 12 and block 13 are on file
- CSigned HCFA-1500 Claim Form on file
- MSigned signature authorization form for HCFA-1500 Claim Form block 13 on file
- PSignature generated by provider because the patient was not physically present for services
- SSigned signature authorization form for HCFA-1500 Claim Form block 12 on file
Code indicating the type of agreement under which the provider is submitting this claim
Codes (7)- DManaged Dental Care Program
- ECivilian Health and Medical Program of the Uniformed Services (CHAMPUS) "External" Partnership Agreement
- HHealth Maintenance Organization (HMO) Agreement
- ICivilian Health and Medical Program of the Uniformed Services (CHAMPUS) "Internal" Partnership Agreement
- NNo Agreement
- PParticipation Agreement
- YPreferred Provider Organization (PPO) Agreement
Code indicating whether the provider has on file a signed statement by the patient authorizing the release of medical data to other organizations
Codes (6)- AAppropriate Release of Information on File at Health Care Service Provider or at Utilization Review Organization
- IInformed Consent to Release Medical Information for Conditions or Diagnoses Regulated by Federal Statutes
- MThe Provider has Limited or Restricted Ability to Release Data Related to a Claim
- NNo, Provider is Not Allowed to Release Data
- OOn file at Payor or at Plan Sponsor
- YYes, Provider has a Signed Statement Permitting Release of Medical Billing Data Related to a Claim
