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Appendix NN -Programmers Guide for SPARCS Requirements

Data Element Name Segment ID Data Type Min./Max. Length Syntax/Value Notes
ISA Interchange Control Header (Header) Fixed Length required
  ISA01 ID 2/2 May equal "00"  
  ISA02 AN 10/10 May equal Authorization Information  
  ISA03 ID 2/2 May equal "0"  
  ISA04 AN 10/10 May equal Security Information  
  ISA05 ID 2/2 Must equal "ZZ"  
  ISA06 AN 15/15 May equal Interchange Sender ID or SPARCS Collector Code  
  ISA07 ID 2/2 Must equal "ZZ"  
  ISA08 AN 15/15 May equal Interchange Receiver ID or SPARCS Collector Code  
  ISA09 DT 6/6 May equal Interchange Date - YYMMDD format  
  ISA10 TM 4/46 May equal Interchange Time - HHMM format  
  ISA11 ID 1/1 Must equal Repetition Separator, "^"  
  ISA12 ID 5/5 Must equal "00405"

Must Equal "00501"
4050 Only

5010 Only
  ISA13 AN 9/9 May equal Interchange Control Number (same value as Interchange Control Trailer, IEA02)  
  ISA14 ID 1/1 Must equal "0" or "1"  
  ISA15 ID 1/1 Must equal "P" or "T"  
  ISA16 AN 1/1 Must equal Component Element Separator, ":"  
GS Functional Group Header Required
  GS01 ID 2/2 Must equal "HC"  
  GS02 AN 2/15 May equal Application Sender's Code or SPARCS Collector Code  
  GS03 AN 2/15 May equal Application Reviewer's Code or "SPARCS"  
  GS04 DT 8/8 May equal Functional Group Date (Creation Date - CCYYMMDD format)  
  GS05 TM 4/8 May equal Functional Group Time (Creation Time - HHMM format)  
  GS06 AN 1/9 May equal Group Control Number (same value as Functional Group Trailer, GE02)  
  GS07 ID 1/2 Must equal "X"  
  GS08 AN 1/12 Must equal "004050X156"

Must Equal "005010X225A1" or "005010X225A2" or "005010X225E1"
4050 Only

5010 Only
ST Transaction Set Header (Header) Required
  ST01 ID 3/3 May equal "837"  
  ST02 AN 4/9 May equal Transaction Set Control Number (same value as SE02)  
BHT Beginning of Hierarchical Transaction (Header) Required
  BHT01 ID 4/4 Must equal "0019"  
  BHT02 ID 2/2 Must equal "00" or "18"  
  BHT03 AN 1/7* May equal File Sequence and Serial Number  
  BHT04 DT 8/8 May equal Processing Date - CCYYMMDD format  
  BHT05 TM 4/8 May equal Processing Time - HHMM format  
NM1 Submitter Name (1000A) Required
  NM101 ID 2/3 Must equal "41"  
  NM102 ID 1/1 Must equal "2"  
  NM103 AN 1/21* May equal Submitting Organization Name  
  NM108 ID 1/2 Must equal "46"  
  NM109 AN 2/3 Must equal SPARCS Collector Code  
REF Submitter Secondary Identifcation (1000A) Not Used by SPARCS
PER Submitter EDI Contact Information(1000A) Not Used by SPARCS
  PER01 ID 2/2 May equal "IC"  
  PER02 AN 1/21* May equal Submitter Contact Person (Name)  
  PER03 ID 2/2 May equal "ED", "EM", "FX", or "TE"

Must equal "EM", "FX", or "TE"
4050 Only

5010 Only
  PER04 AN 1/256 May equal Communication Number  
NM1 Receiver Name (1000B) Not Used by SPARCS
  NM101 ID 2/3 May equal "40"  
  NM102 ID 1/1 May equal "2"  
  NM103 AN 1/60 May equal Receiver Organization Name  
  NM108 ID 1/2 May equal "46"  
  NM109 AN 2/80 May equal Receiver Primary Identification  
HL Service Provider Hierarchical Level (2000A) Required
  HL01 N 1/12 Must begin with 1 for the first HL01 in the transaction and be incremented by 1 each time an HL is used within the transaction. Only numeric values are allowed in HL01. The same value should also be reported in every subordinate Subscriber Hierarchical Level HL02.  
  HL03 ID 1/2 Must equal "20"  
  HL04 ID 1/1 Must equal "1"  
NM1 Service Provider Name (2010AA) Required
  NM101 ID 2/3 Must equal "SJ"  
  NM102 ID 1/1 Must equal "2"  
  NM103 AN 1/60 May equal Service Provider Organization Name  
  NM108 ID 1/2 Must equal "XX"  
  NM109 AN 2/13 Must equal Billing National Provider Identification (when available)  
REF Service Provider Secondary Identification (2010AA) Required
  REPEAT 1  
  REF01 ID 2/3 Must equal "1J"  
  REF02 N 5/5* Must equal appropriate SPARCS Facility Identification Number  
HL Subscriber Hierarchial Level (2000B)
Note: If the subscriber is not the same as the patient, Loop 2000C must be used for the patient information. If the subscriber is the same as the patient, Loop 2000C is not sent.

 
  HL01 AN 1/12 Must begin with 1 for the first HL01 in the transaction and be incremented by 1 each time an HL is used within the transaction. Only numeric values are allowed in HL01. The same value should also be reported in every subordinate Patient Hierarchical Level HL02.  
  HL02 AN 1/12 Must contain the same value as the parent Service Provider Hierarchical Level HL01.  
  HL03 ID 1/2 Must equal "22"  
  HL04 ID 1/1 Must equal "0" or "1"  
SBR Subscriber Information (2000B)
Note: SPARCS only processes and stores the subscriber information when the subscriber IS the patient
Required
  SBR01 ID 1/1 Must equal "P"  
  SBR02 ID 2/2 Must equal "18" if the subscriber IS the patient, otherwise not required.  
  SBR09 ID 1/2 Must equal Claim Filing Indicator Code  
PAT Patient Information (2000B) Not Used by SPARCS
NM1 Subscriber Name (2010BA) -
The following are SPARCS data values for this segment if the subscriber IS the patient.
The subscriber's name will not be stored on the SPARCS master files.
Required if the subscriber IS the patient
  NM101 ID 2/3 Must equal "IL"  
  NM102 ID 1/1 Must equal "1"  
  NM103 AN 1/60 May equal Subscriber's Last name or masked  
  NM104 AN 1/35 May equal subscriber's First Name or masked  
  NM105 AN 1/25 May equal Subscriber's Middle Name or masked  
  NM108 ID 1/2 Must equal "MI"

Must Equal "MI" or "II" (when HIPAA Individual Patient Identifier is mandated)
4050 Only

5010 Only
  NM109 AN 2/19* Must equal Insurance Policy Number IP Only
N3 Subscriber Address (2010BA) Required if subscriber IS the patient
  N301 AN 1/18* Must equal Subscriber's Street Address  
  N302 AN 1/18* Must equal Subscriber's Street Address Line 2, if applicable  
N4 Subscriber City/State/Zip Code (2010BA) Required if subscriber IS the patient
  N401 AN 2/15* Must equal Subscriber's City  
  N402 ID 2/2 Must equal Subscriber's State  
  N403 ID 3/9* Must equal Subscriber's Postal Code  
  N405 ID 1/2 Must equal "CO"  
  N406 N 1/2* Must equal County Code  
DMG Subscriber Demographic Information (2010BA) Required if subscriber IS the patient
  DMG01 ID 2/3 Must equal "D8"  
  DMG02 AN 1/8* Must equal Birthdate in CCYYMMDD format  
  DMG03 ID 1/1 Must equal Patient Sex ("F", "M", or "U")  
  DMG05-2 ID 1/3 Must equal "RET" IP, AS, ED, only
  DMG05-3 ID 1/2* Race must equal: "R1", "R2", "R3", "R4", "R5", "R9"

Ethnicity must equal: "E1" or "E2"

See example on page in Data Specifications.
IP, AS, ED, only

Optional for OP
REF Subscriber Secondary Identification(2010BA) Required if subscriber IS the patient
  REF01 ID 2/3 Must equal "ABB"  
  REF02 AN 1/10* Must equal Unique Personal Identification Number  
NM1 Payer Name(2010BC) 4050 Only moved to 2010BB in 5010
  NM101 ID 2/3 Must equal "PR" 4050 only
  NM102 ID 1/1 Must equal "2" 4050 only
  NM103 AN 1/60 Must equal Payer Name 4050 only
  NM108 ID 1/2 Must equal "PI" or "XV" 4050 only
  NM109 AN 2/80 Must equal Payer Identification Number 4050 only
NM1 Payer Name(2010BB) 5010 ONLY
  NM101 ID 2/3 Must equal "PR" 5010 only
  NM102 ID 1/1 Must equal "2" 5010 only
  NM103 AN 1/60 Must equal Payer Name 5010 only
  NM108 ID 1/2 Must equal "PI" or "XV" 5010 only
  NM109 AN 2/8* Must equal Payer Identification Number 5010 only
REF Payer Secondary Identification (2010BC)1  
  REF01 ID 2/3 May equal "2U", "NF"  
  REF02 AN 1/8* May equal Payer Identification Number  
HL Patient Hierarchical Level (2000C)
Note: If the subscriber is not the same as the patient, Loop 2000C must be used for the patient information. If the subscriber is the same as the patient, Loop 2000C is not sent.
Required if the patient is NOT the subscriber
  HL01 AN 1/12 Must begin with 1 for the first HL01 in the transaction and be incremented by 1 each time an HL is used within the transaction. Only numeric values are allowed in HL01.  
  HL02 AN 1/12 Must contain the same value as the parent Subscriber Hierarchical Level HL01  
  HL03 ID 1/2 Must equal "PT"

Must equal "23"
4050 Only

5010 Only
  HL04 ID 1/1 Must equal "0"  
PAT Patient Information (2000C) Not required for SPARCS
NM1 Patient Name(2010CA)
The following are SPARCS data values for this segment if the subscriber IS NOT the patient. The patient's name will not be stored on the SPARCS master files.
Required if subscriber IS NOT the patient
  NM101 ID 2/3 Must equal "QC" 4050 Only. Not needed in 5010
  NM102 ID 1/1 Must equal "1" 4050 Only. Not needed in 5010
  NM103 AN 1/60 May equal Patient's Last Name or masked 4050 Only. Not needed in 5010
  NM104 AN 1/35 May equal Patient's First Name or masked 4050 Only. Not needed in 5010
  NM105 AN 1/25 May equal Patient's Middle Name or masked 4050 Only. Not needed in 5010
  NM108 ID 1/2 Must equal "MI"
Removed 34,ZZ
4050 Only
  NM109 AN 2/19* Must equal Insurance Policy Number 4050 Only
N3 Patient Address (2010CA) Required if subscriber IS NOT the patient
  N301 AN 1/18* Must equal Patient's Street Address  
  N302 AN 1/18* Must equal Patient's Street Address Line 2, if applicable  
N4 Patient City/State/Zip Code (2010CA) Required if subscriber IS NOT the patient
  N401 AN 2/15* Must equal Patient's City  
  N402 ID 2/2 Must equal Patient's State  
  N403 ID 3/9* Must equal Patient's Postal Code  
  N405 ID 1/2 Must equal "CO"  
  N406 N 1/2* Must equal County Code  
DMG Patient Demographic Information(2010CA) Required if subscriber IS NOT the patient
  DMG01 ID 2/3 Must equal "D8"  
  DMG02 N 1/8* Must equal Birth Date in CCYYMMDD format  
  DMG03 AN 1/1 Must equal Patient Sex ("F", "M", or "U")  
        DMG05 is a composite data element. The Component Element Separator (ISA16) must be used before and after the composite data element DMG05-2, "RET". In addition, the Repetition Separator (ISA11) must be used between race and ethnicity.  
  DMG05-2 ID 1/3 Must equal "RET" IP, AS, ED only
  DMG05-3 ID 1/2* Race must equal: "R1", "R2", "R3", "R4", "R5", "R9"

Ethnicity must equal: "E1" or "E2"

See example on page in Data Specifications.
IP, AS, ED only

Optional for OP
REF Patient Secondary Identification(2010CA) Required if subscriber IS NOT the patient
In 5010R, REF section is used to report two data elements. REF01 ID 2/3 "ABB" - Use this qualifier for Unique Personal Identifier


"IG" - Use this qualifier for Insured's Policy Number
4050R and 5010R

5010R only
REF02 AN 1/10* (Unique Personal ID)

1/19* (Insured's Policy #)
Must equal Unique Personal Identification Number when qualifier is "ABB"


In 5010R only, when qualifier is "IG", REF02 must equal Insurance Policy Number
 
CLM Claim Information (2300) Required
  CLM01 AN 1/20* Must equal Patient Control Number  
  CLM02 N 1/12* Must equal Total Claim Charges  
        CLM05 is a composite data element. The Component Element Separator(ISA16) must be used before and after the composite data element CLM05-2, "A"  
  CLM05-1 AN 1/2 Must equal Bill Type Facility Code Value  
  CLM05-2 ID 1/2 Must equal "A"  
  CLM05-3 ID 1/1 Must equal Bill Type Frequency Code  
DTP Discharge Hour(2300) - Required Required
  DTP01 ID 3/3 Must equal "096"  
  DTP02 ID 2/3 Must equal "TM"  
  DTP03 AN 1/2* Must equal Discharge Hour (HHMM format used. SPARCS currently edits the first two characters)  
DTP Statement Dates(2300) Required
  DTP01 ID 3/3 Must equal "434"  
  DTP02 ID 2/3 Must equal "RD8"  
  DTP03 N 16/16 where:

8/8 for Statement From and 8/8 for Statement Through
Must equal Statement Period From and Through Dates(CCYYMMDD-CCYYMMDD format)  
DTP Admission Date/Hour(2300) Required
  DTP01 ID 3/3 Must equal "435"  
  DTP02 ID 2/3 Must equal "DT"  
  DTP03 DT 1/12* where:

8/8 for Admission Date and 2/4 for Admission Hour
Must equal Admission Date/Hour (CCYYMMDDHHMM format)  
CL1 Institutional Claim Code(2300) Required
  CL101 AN 1/1 Must equal Type of Admission Code IP Only
  CL102 AN 1/1 Must equal Point of Origin IP Only
  CL103 AN 1/2 Must equal Patient Status Code  
PWK Claim Supplemental Information(2300) Not Required by SPARCS
AMT Payer Estimated Amount Due(2300) Not Required by SPARCS
AMT Patient Estimated Amount Due(2300) Not Required by SPARCS
REF Medical Record Number(2300) Required
  REF01 ID 2/3 Must equal "EA"  
  REF02 AN 1/17* Must equal Medical Record Number  
REF Mother's Medical Record Number for Newborns(2300) Required
  REF01 ID 2/3 Must equal "MRN" IP Only
  REF02 AN 1/17* Must equal Mother's Medical Record Number IP Only
K3 File Information(2300) Not Required by SPARCS
NTE Claim Note - Required(2300) Required
  NTE01 ID 3/3 Must equal "UPI"  
  NTE02 AN 1/80 See below for SPARCS NTE requirements  
SPARCS 2300 NTE SEGMENT LAYOUT  
Description Inpatient
Position
Outpatient
Position
Length/Format  
Expected Principal Reimbursement 1-2 1-2    2            A/N IP, AS, ED only
Expected Principal Reimbursement Other 1 3-4 Not Required    2            A/N IP only
Expected Reimbursement Other 2 5-6 Not Required    2            A/N IP only
Method of Anesthesia 7-8 3-4    2            A/N IP, AS only
Exempt Unit Indicator 9-11 Not Required    3            A/N IP only
Filler 12-14 5-7    -            --- Removed Patient Race and Ethnicity to DMG.
Heart Rate 15-17 8-10    3            AN Removed Patient Race and Ethnicity to DMG.
Blood Pressure - Systolic 18-20 11-13    2            AN IP, ED only.
Blood Pressure - Diastolic 21-23 14-16    3            AN IP, ED only.
Procedure Time IP not required 17-19    3            AN AS only.
Source of Payment Typology I 24-28 20-24    5            AN  
Source of Payment Typology II 29-33 25-29    5            AN  
Source of Payment Typology III 34-38 30-34    5            AN  
End of Segment Indicator~ 39 35    1            AN  
      Note:Spaces equaling the data element length must be used if a data element cannot be supplied.
HI Principal, Admitting, and External Cause of Injury Codes (2300)
HI101-HI12 is required composite data elements. HI05-HI12 is used for claims that have a third through tenth E-code, respectively. Component Element Separator (ISA16) must be used between segment data elements. This section is repeated to clarify the difference between the 4050 and the 5010.
Required
This HI Section applies to the 4050 ONLY:
Data Element Name Segment ID Data Type Min./Max. Length Syntax/Value Notes
  HI01-1 ID 1/3 Must equal "BK"  
  HI01-1 ID 1/3 Must equal "BK"  
  HI01-2 AN 1/30 Must equal Principal Diagnosis Code  
  HI02-1 ID 1/3 Must equal "BJ" IP Only
  HI02-2 AN 1/30 Must equal Admitting Diagnosis Code
  HI02-1 ID 1/3 Must equal "PR" AS, ED Only
  HI02-2 AN 1/30 Must equal Patient Reason for Visit
  HI03-1 ID 1/3 Must equal "BN" External Cause-of-Injury Code in the range of E850.0-E869.9 or E880.0-E928.9 is reported, then a "Place of Occurrence" code must also be reported.
  HI03-2 AN 1/30 Must equal External Cause of Injury Code
  HI04-1 ID 1/3 Must equal "BN"  
  HI04-2 AN 1/30 Must equal Place of Injury Code  
  HI05-1 thru HI12-1 ID 1/3 Must equal "BN" External Cause-of-Injury Code in the range of E850.0-E869.9 or E880.0-E928.9 is reported, then a "Place of Occurrence" code must also be reported.
  HI05-2 thru HI12-2 AN 1/30 Must equal External Cause of Injury Code
This HI Section applies to the 5010 ONLY:  
  HI01-1 ID 1/3 Must equal "BK" (for ICD-9-CM)
Must equal "ABK" (for ICD-10-CM reporting)
 
  HI01-2 AN 1/30 Must equal Principal Diagnosis Code
  HI01-1 ID 1/3 Must equal "BJ" (for ICD-9-CM)
Must equal "ABJ" (for ICD-10-CM reporting)
IP Only
  HI01-2 AN 1/30 Must equal Admitting Diagnosis Code
  HI01-1 ID 1/3 Must equal "PR" (for ICD-9-CM)
Must equal "APR" (for ICD-10-CM reporting)
AS, ED Only

Up to three reasons for visit can be reported. First reason in HI01.
  HI01-2 AN 1/30 Must equal Patient's Reason for Visit Code
  HI02-1 ID 1/3 Must equal "PR" (for ICD-9-CM)
Must equal "APR" (for ICD-10-CM reporting)
AS, ED Only

Up to three reasons for visit can be reported. Second reason in HI02.
  HI02-2 AN 1/30 Must equal Patient's Reason for Visit Code
  HI03-1 ID 1/3 Must equal "PR" (for ICD-9-CM)
Must equal "APR" (for ICD-10-CM reporting)
AS, ED Only

Up to three reasons for visit can be reported. Third reason in HI03.
  HI03-2 AN 1/30 Must equal Patient's Reason for Visit Code
  HI01-1 thru HI12-1 ID 1/3 Must equal "BN"(for ICD-9-CM)
Must equal "ABN"(for ICD-10-CM reporting)
Up to twelve external causes of injury can be reported. External Cause-of-Injury Code in the range of E850.0-E869.9 or E880.0-E928.9 is reported, then a "Place of Occurrence" code must also be reported.
  HI01-2 thru HI12-2 AN 1/30 Must equal External Cause of Injury Code
HI Diagnosis Related Group (DRG) Information(2300) Not Required by SPARCS
HI Other Diagnosis Information (2300)
HI01-HI12 are required composite data elements. HI02-HI12 are used for claims that have a second through twelfth Other Diagnosis Code, repspectively. Component Element Separator (ISA16) must be used between segment data elements.

Note: A second repeat of these segments may be used to report Other Diagnosis Codes 13 through 24.
Situational
  HI01-1 thru HI12-1 ID 1/3 Must equal "BF" (for ICD-9-CM)
Must equal "ABF" (for ICD-10-CM reporting)
 
  HI01-2 thru HI12-2 AN 1/6* Must equal Other Diagnosis Code  
  HI01-9 thru HI12-9 ID 1/1 Must equal Present on Admission Indicator("N", "U", "Y", or "W") IP Only
HI Principal Procedure Information (2300)
HI01 is a required composite data element. Component Element Separator (ISA16) must be used between segment data elements.
Situational
  HI01-1 ID 1/3 Must equal "BR"(for ICD-9-CM)
Must equal "BBR" (for ICD-10-CM reporting)
IP Only
  HI01-2 AN 1/7* Must equal Principal Procedure Code IP Only
  HI01-3 ID 2/3 Must equal "D8" IP Only
  HI01-4 N 8/8* Must equal Principal Procedure Date (CCYYMMDD format) IP Only
HI Other Procedure Information (2300)
HI01-HI12 are required composite data elements. HI02-HI12 are used for claims that have a second through twelfth Other Procedure Code, repspectively. Component Element Separator (ISA16) must be used between segment data elements.
Situational
  HI01-1 thru HI12-1 ID 1/3 Must equal "BQ"(for ICD-9-CM)
Must equal "BBQ" (for ICD-10-CM reporting)
IP Only
  HI01-2 thru HI12-2 AN 1/7* Must equal Other Procedure Code IP Only
  HI01-3 thru HI12-3 ID 2/3 Must equal "D8" IP Only
  HI01-4 thru HI12-4 N 8/8* Must equal Other Procedure Date (CCYYMMDD format) IP Only
        Note: A second repeat of these segments may be used to report Other Procedure Codes 12 through 24. Although all other procedure codes for a claim may be entered on two iterations of this composite segment, SPARCS currently only processes the first fourteen (14) Other Procedure Codes.  
HI Occurence Span Information (2300)
HI01-HI12 are required composite data elements. HI02-HI12 are used for claims that have additional reportable Occurrence Span Code conditions. Component Element Separator (ISA16) must be used between segment data elements. SPARCS allows a maximum of 30 Occurrence Spans.
Situational
  HI01-1 thru HI12-1 ID 1/3 Must equal "BI" IP Only
  HI01-2 thru HI12-2 AN 1/2* Must equal "74" or "75" (Removed "81" and "82") IP Only
  HI01-3 thru HI12-3 ID 2/3 Must equal "RD8" IP Only
  HI01-4 thru HI12-4 AN 1/35 Must equal Occurrence Span Date range (CCYYMMDD-CCYYMMDD format) IP Only
        Note: Reportable Occurrence Span Code conditions may be coded in any order, and may be reported multiple times. This HI segment may be reported 2 times as indicated in the 837 Implementation Guides.  
HI Occurence Information (2300)
HI01-HI12 are required composite data elements. HI02-HI12 are used for claims that have additional reportable Occurrence Code conditions. Component Element Separator (ISA16) must be used between segment data elements.
Situational
  HI01-1 thru HI12-1 ID 1/3 Must equal "BH"  
  HI01-2 thru HI12-2 AN 1/30 Must equal "01", "02", "03", "04", "05", or "06"  
  HI01-3 thru HI12-3 ID 2/3 Must equal "D8"  
  HI01-4 thru HI12-4 AN 1/35 Must equal Occurrence Associated Date(CCYYMMDD format) IP Only
        Note: Reportable Occurrence Code conditions may be reported multiple times. This HI segment may be reported 2 times as indicated in the 837 Implementation Guides.  
HI Value Information (2300)
HI01-HI12 are required composite data elements. HI02-HI12 are used for claims that have additional reportable Value Code conditions. Component Element Separator (ISA16) must be used between segment data elements.
Situational
  HI01-1 thru HI12-1 ID 1/3 Must equal "BE"  
  HI01-2 thru HI12-2 AN 1/2* Must equal:

Inpatient (IP) Only:
"14"- No Fault, Incl. Auto/other
"15"- Worker's Comp.
"21"- Catastrophic
"22"- Surplus
"23"- Recurring Monthly Income
"37"- Units of Blood

"54"- Newborn Weight in Grams

"80"- Covered Days
"81"- Non-covered Days


Ambulatory Surgery(AS) and Emergency Dept (ED) only:
"45"- Accident Hour


Outpatient (OP) Only:
"24"- Medicaid Rate Code
Use of codes for specific type of data:
example - Code 45 is AS, ED Only

5010 Only
5010 Only
  HI01-5 thru HI12-5 R 1/19* Must equal Value Information  
        Note: Reportable Value Code conditions may be reported multiple times. This HI segment may be reported 2 times as indicated in the 837 Implementation Guides.  
HI Condition Information (2300)
HI01-HI12 are required composite data elements. HI02-HI12 are used for claims that have additional reportable Condition Codes. Component Element Separator (ISA16) must be used between segment data elements.
Situational
  HI01-1 thru HI12-1 ID 1/3 Must equal "BG"  
  HI01-2 thru HI12-2 AN 1/2* Must equal "17", "25", "A2", "A3", "A4", "A5" or "P7"


Note: P7 new for state reporting
Use of codes for specific type of data: i.e., Code 17 is all data types, all others codes for IP only.
        Note:Condition Codes may be reported multiple times. This HI segment may be reported 2 times as indicated in the 837 Implementation Guides.  
QTY Claim Quantity Required
  Loop 1       IP ONLY
  QTY01 ID 2/2 Must equal "CA" 4050 only
  QTY02 R 1/15 Must equal Covered Days 4050 only
  QTY03-1 ID 2/2 Must equal "DA" 4050 only
  Loop 2       IP ONLY
  QTY01 ID 2/2 Must equal "NA" 4050 only
  QTY02 R 1/15 Must equal Non-Covered Days 4050 only
  QTY03-1 ID 2/2 Must equal "DA" 4050 only
        Note: Loop 2 of the QTY segment is NOT required for claims with no reportable non-covered days.  
NM1 Attending Physician Name (2310A) Not Required by SPARCS
  NM101 ID 2/3 May equal "71"  
  NM102 ID 1/1 May equal "1"  
        The following data elements in this segment are required for X12 syntax, but are not required for the SPARCS data collection system. The Attending Physician's name will not be stored on the SPARCS master files.  
  NM103 AN 1/60 May equal Attending Physician Last Name  
  NM104 AN 1/35 May equal Attending Physician First Name  
  NM105 AN 1/25 May equal Attending Physician Middle Name  
REF Attending Physician Secondary Identification (2310A)
SPARCS is collecting the State License Number.
Required
  REF01 ID 2/3 Must equal "OB" ED, IP, OP only
  REF02 AN 1/50 Must equal Attending Physician
State License Number
ED, IP, OP only
NM1 Operating Physician Name (2310B) Not Required by SPARCS
  NM101 ID 2/3 May equal "72"  
  NM102 ID 1/1 May equal "1"  
        The following data elements in this segment are required for X12 syntax, but are not required for the SPARCS data collection system. The Operating Physician's name will not be stored on the SPARCS master files.  
  NM103 AN 1/60 May equal Operating Physician Last Name  
  NM104 AN 1/35 May equal Operating Physician First Name  
  NM105 AN 1/25 May equal Operating Physician Middle Name  
REF Operating Physician Secondary IDentification (2310B)
SPARCS is collecting the State License Number.
Required
  REF01 ID 2/3 Must equal "0B" AS, ED, IP only
  REF02 AN 1/50 Must equal Operating Physician State License Number AS, ED, IP only
NM1 Other Operating Physician Name (2310C) Not Required By SPARCS
  NM101 ID 2/3 May equal "73" in 4050R

May equal "ZZ" in 5010R
4050R

5010R
  NM102 ID 1/1 May equal "1"  
        The following data elements in this segment are required for X12 syntax, but are not required for the SPARCS data collection system. The Operating Provider's name will not be stored on the SPARCS master files.  
  NM103 AN 1/60 May equal Other Provider Last Name  
  NM104 AN 1/35 May equal Other Provider First Name  
  NM105 AN 1/25 May equal Other Provider Middle Name  
REF Other Provider Secondary Identification (2310C)
SPARCS is collecting the State License Number.
Required
  REF01 ID 2/3 May equal "OB" ED, IP only
  REF02 AN 1/50 May equal Other Provider State License Number ED, IP only
NM1 Referring Provider Name (2310D) Not Required for SPARCS
REF Referring Provider Secondary Identification (2310D) Not Required for SPARCS
SBR Other Subscriber Information (2320) Situational
  SBR01 ID 1/1 May equal "S", or "T" IP only
  SBR02 ID 1/2 May equal Individual Relationship Code "01", "18", "19", "20", "21", "39", "40", "53", "G8" IP only
  SBR09 ID 1/2 Claim Filing Indicator Code  
AMT Payer Prior Payment (2320) Not Required by SPARCS
NM1 Other Subscriber Name (2330A)
The following are SPARCS data values for this segement if other subscriber information is reportable. The Other Subscriber name will not be stored on the SPARCS master files.
Situational
  NM101 ID 2/3 May equal "1L" IP only
  NM102 ID 1/1 May equal "1" IP only
  NM103 AN 1/60 May equal Other Subscriber Last Name or "XXXXX" IP only
  NM108 ID 1/2 May equal "MI" (removed "ZZ")
May equal "MI" or "II" (when HIPPA Individual Patient Identifier is mandated)
4050 Only
5010 Only
  NM109 AN 1/19* May equal Other Subscriber Policy Number IP Only
REF Other Subscriber Secondary Information (2330A)
The following are SPARCS data values for this segment if other subscriber information is reportable.
Situational
  REF01 ID 2/3 May equal "1W" or "1G" 4050R only
IP only
  REF02 AN 1/19* May equal Other Subscriber Policy Number 4050R only
IP only
NM1 Other Payer Name (2330B)
The following are SPARCS data values for this segment if other payer information is reportable.
The Other Payer name will not be stored on the SPARCS master files
Situational
  NM101 ID 2/3 Must equal "PR" IP only
  NM102 ID 1/1 Must equal "2" IP only
  NM103 AN 1/60 Must equal Other Payer Name IP only
  NM108 AN 2/8* Must equal "PI" or "XV" IP only
  NM109 AN 1/2 Must equal "PI" or "XV" IP only
REF Other Payer Secondary Information (2330B)
The following SPARCS data values for this segment if other subscriber information is reportable.
Situational
  REF01 ID 2/3 Must equal "2U" or "NF" IP only
  REF02 AN 1/50 Must equal Other Payer Identification Number IP only
NM1 Other Payer Patient Information (2330C) Not Required by SPARCS
REF Other Payer Identification Number (2330C) Not Required by SPARCS
LX Service Line Number (2400) Not Required by SPARCS
  LX01 N 1/6 This is the service line number. Begin with 1 and increment by 1 for each new LX segment within a claim.  
SV2 Institutional Service Line (2400)
Note: SPARCS allows for a maximum of 999 service lines to be reported.
Required
  SV201 AN 1/4* Must equal Revenue Code  
  SV202-1 AN 2/2 Must equal HCPCS Procedure Code Qualifier  
  SV202-2 AN 1/5* Must equal HCPCS Procedure Code  
  SV203 AN 2/2 Must equal Procedure Modifier 1  
  SV202-4 AN 2/2 Must equal Procedure Modifier 2  
  SV202-3 R 1/18* Must equal Line Item Charge Amount  
  SV204 ID 2/2 Must equal "DA" = Days

"UN" = Units
"UN" for 5010 reporting.
  SV205 N 1/4* Must equal quantity of days or units. Number of Units added for 5010. IP and OP only.
  SV206 N 1/9* Must equal rate 4050 only. Removed in 5010
  SV207 R 1/10* Must equal Non-Covered Charge Amount  
DTP Service Line Date (2400) Required
  DTP01 ID 3/3 Must equal "472" OP only
  DTP02 ID 2/3 Must equal "D8" OP only
  DTP03 AN 1/35 Service Date (or Range of dates) OP only
SE Transaction Set Trailer (Trailer)  
  SE01 N 1/10 May equal Total number of segments included in a transaction set including ST and SE segments  
  SE02 AN 4/9 May equal Transaction Set Control Number (same value as ST02)  
GE Functional Group Trailer (Trailer)  
  GE01 AN 1/6 May equal Number of Transaction Sets  
  GE02 AN 1/9 May equal Group Control Number (same value as Functional Group Header, GS06)  
IEA Interchange Control Trailer (Trailer)  
  IEA01 N 1/5 May equal Number of Included Functional Groups  
  IEA02 N 9/9 May equal Interchange Control Number (same value as Interchange Control Header, ISA13)  

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