CLM Health Claim
Opt
AtMax 1
To specify basic data about the claim
Elements
| Position | Element | Name | Type | Min/Max | Repeat | ||
|---|---|---|---|---|---|---|---|
| 1 | 1028 | Claim Submitter's Identifier | Mandatory | Alphanumeric | 1/38 | AtMax 1 | |
| 2 | 782 | Monetary Amount | Opt | Decimal | 1/18 | AtMax 1 | |
| 3 | 1032 | Claim Filing Indicator Code | Opt | ID | 1/2 | AtMax 1 | |
| 4 | 1343 | Non-Institutional Claim Type Code | Opt | ID | 1/2 | AtMax 1 | |
AtMax 1 | |||||||
| 6 | 1073 | Yes/No Condition or Response Code | Opt | ID | 1/1 | AtMax 1 | |
| 7 | 1359 | Provider Accept Assignment Code | Opt | ID | 1/1 | AtMax 1 | |
| 8 | 1073 | Yes/No Condition or Response Code | Opt | ID | 1/1 | AtMax 1 | |
| 9 | 1363 | Release of Information Code | Opt | ID | 1/1 | AtMax 1 | |
| 10 | 1351 | Patient Signature Source Code | Opt | ID | 1/1 | AtMax 1 | |
AtMax 1 | |||||||
| 12 | 1366 | Special Program Code | Opt | ID | 2/3 | AtMax 1 | |
| 13 | 1073 | Yes/No Condition or Response Code | Opt | ID | 1/1 | AtMax 1 | |
| 14 | 1338 | Level of Service Code | Opt | ID | 1/3 | AtMax 1 | |
| 15 | 1073 | Yes/No Condition or Response Code | Opt | ID | 1/1 | AtMax 1 | |
| 16 | 1360 | Provider Agreement Code | Opt | ID | 1/1 | AtMax 1 | |
| 17 | 1029 | Claim Status Code | Opt | ID | 1/2 | AtMax 1 | |
| 18 | 1073 | Yes/No Condition or Response Code | Opt | ID | 1/1 | AtMax 1 | |
| 19 | 1383 | Claim Submission Reason Code | Opt | ID | 2/2 | AtMax 1 | |
| 20 | 1514 | Delay Reason Code | Opt | ID | 1/2 | AtMax 1 | |
Element Details
ID1028
NameClaim Submitter's Identifier
LengthMin 1 / Max 38
Position1
RequirementMandatory