SPARCS X12-837 Input Data Specifications - Table of Contents (Version 4050R and 5010R)

TABLE OF CONTENTS BY SEGMENT/ REF.DES/ LOOP ORDER

Segments Ref. Des. Loops Element Names Required for Type of Data Page
  AS ED IP OP  
ISA     INTERCHANGE CONTROL HEADER          
ISA01 Header Authorization Information Qualifier N N N N 15
ISA02 Header Authorization Information N N N N 16
ISA03 Header Security Information Qualifier N N N N 17
ISA04 Header Security Information N N N N 18
ISA05 Header Interchange Sender ID Qualifier R R R R 19
ISA06 Header Interchange Sender ID (Previously Referred to as SPARCS Collector Code) N N N N 20
ISA07 Header Interchange Receiver ID Qualifier R R R R 21
ISA08 Header Interchange Receiver ID (Previously Referred to as SPARCS Collector Code) N N N N 22
ISA09 Header Interchange Date N N N N 23
ISA10 Header Interchange Time N N N N 24
ISA11 Header Repetition Separator R R R R 25
ISA12 Header Interchange Control Version Number R R R R 26
ISA13 Header Interchange Control Number N N N N 27
ISA14 Header Acknowledgment Requested Indicator R R R R 28
ISA15 Header Test/Production Indicator R R R R 29
ISA16 Header Component Element Separator R R R R 30
 
GS     FUNCTIONAL GROUP HEADER          
GS01 Header Functional Identifier Code R R R R 31
GS02 Header Application Sender's Code (Previously Referred to as SPARCS Collector Code) N N N N 32
GS03 Header Application Receiver's Code N N N N 33
GS04 Header Functional Group Date N N N N 34
GS05 Header Functional Group Time N N N N 35
GS06 Header Group Control Number N N N N 36
GS07 Header Responsible Agency Code R R R R 37
GS08 Header Version Identifier Code R R R R 38
 
ST     TRANSACTION SET HEADER          
ST01 Header Transaction Set Identifier Code N N N N 39
ST02 Header Transaction Set Control Number N N N N 40
 
BHT     BEGINNING OF HIERARCHICAL TRANSACTION          
BHT01 Header Hierarchical Structure Code R R R R 41
BHT02 Header Transaction Set Purpose Code R R R R 42
BHT03 Header File Sequence and Serial Number N N N N 43
BHT04 Header Processing Date N N N N 44
BHT05 Header Processing Time N N N N 45
 
PER     SUBMITTER EDI CONTACT INFORMATION          
PER01 1000A Contact Function Code N N N N 51
PER02 1000A Submitter Contact Person N N N N 52
PER03 1000A Communication Number Qualifier N N N N 53
PER04 1000A Communication Number N N N N 54
 
NM1     SUBMITTER NAME          
NM101 1000A Entity Identifier Code for Submitter R R R R 46
NM102 1000A Entity Type Qualifier for Submitter R R R R 47
NM103 1000A Submitting Organization Name (Previously Submitter Name) N N N N 48
NM108 1000A Submitter Identifier R R R R 49
NM109 1000A SPARCS Collector Code R R R R 50
 
    RECEIVER NAME          
NM101 1000B Identification Code Qualifier N N N N 55
NM102 1000B Entity Type Qualifier for Receiver N N N N 56
NM103 1000B Receiver Organization Name N N N N 57
NM108 1000B Information Receiver Identification Number N N N N 58
NM109 1000B Receiver Primary Identifier N N N N 59
 
    SERVICE PROVIDER NAME          
NM101 2010AA Entity Identifier Code for Service Provider R R R R 63
NM102 2010AA Entity Type Qualifier for Service Provider R R R R 64
NM103 2010AA Service Provider Organization Name N N N N 65
NM108 2010AA Billing National Provider Identification Number (NPI) Qualifier R R R R 66
NM109 2010AA Billing National Provider Identification Number (NPI)(Previously Provider Identification Number) R R R R 67
 
    SUBSCRIBER NAME          
NM101 2010BA Entity Identifier Code for Subscriber Name S S S S 78
NM102 2010BA Entity Type Qualifier for Subscriber Name S S S S 79
NM103 2010BA Subscriber Last Name N N N N 80
NM104 2010BA Subscriber First Name N N N N 81
NM105 2010BA Subscriber Middle Name or Initial N N N N 82
NM108 2010BA Identification Code Qualifier for Subscriber S S S S 83
NM109 2010BA Insured's Policy Number (Previously Policy Number) N N R N 84
 
    PAYER NAME          
NM101 2010BB Entity Identifier Code for Payer Name R R R R 101
NM102 2010BB(Previously 2010BC Version 4050R) Entity Type Qualifier R R R R 102
NM103 2010BB(Previously 2010BC Version 4050R) Payer Name N N N N 103
NM108 2010BB(Previously 2010BC Version 4050R) Payer Identifier Code Qualifier R R R R 104
NM109 2010BB(Previously 2010BC Version 4050R) Payer Identification Number R R R R 105
 
    PATIENT NAME          
NM101 2010CA Entity Identifier Code for Patient Name S S S S 112
NM102 2010CA Entity Type Qualifier for Patient Name S S S S 113
NM103 2010CA Patient's Last Name N N N N 114
NM104 2010CA Patient's First Name N N N N 115
NM105 2010CA Patient's Middle Name or Initial N N N N 116
NM108 2010CA Identification Code Qualifier for Patient Payer N N S N 117
NM109 2010CA Insured's Policy Number for Patient (Previously Policy Number) N N R N 118
 
    ATTENDING PROVIDER NAME          
NM101 2310A Attending Provider Name Entity Identifier Code N N N N 213
NM102 2310A Attending Provider Name Entity Type Qualifier N N N N 214
NM103 2310A Attending Provider's Last Name N N N N 215
NM104 2310A Attending Provider's First Name N N N N 216
NM105 2310A Attending Provider's Middle Name or Initial N N N N 217
 
    OPERATING PHYSICIAN NAME          
NM101 2310B Operating Physician Name Entity Identifier Code N N N N 220
NM102 2310B Operating Physician Name Entity Type Qualifier N N N N 221
NM103 2310B Operating Physician's Last Name N N N N 222
NM104 2310B Operating Physician's First Name N N N N 223
NM105 2310B Operating Physician's Middle Name or Initial N N N N 224
 
    OTHER OPERATING PHYSICIAN NAME          
NM101 2310C Other Operating Physician Entity Identifier Code N O O N 227
NM102 2310C Other Operating Physician Entity Type Qualifier N O O N 228
NM103 2310C Other Operating Physician's Last Name N N N N 229
NM104 2310C Other Operating Physician's First Name N N N N 230
NM105 2310C Other Operating Physician's Middle Name or Initial N N N N 231
 
    OTHER SUBSCRIBER NAME          
NM101 2330A Other Subscriber Name Entity Code Qualifier N N O N 238
NM102 2330A Other Subscriber Name Entity Type Qualifier N N O N 239
NM103 2330A Other Subscriber Last Name N N N N 240
NM108 2330A Other Subscriber Identification Code Qualifier N N O N 241
NM109 2330A Insured's Policy Number For Other Subscriber N N O N 242
 
    OTHER PAYER NAME          
NM101 2330B Other Payer Name Entity Identifier Code N N O N 245
NM102 2330B Other Payer Name Entity Type Qualifier N N O N 246
NM103 2330B Other Payer Last Name or Organization Name N N O N 247
NM108 2330B Other Payer Name Identification Code Qualifier O O O O 248
NM109 2330B Other Payer Identification Number N N O N 249
 
REF     SERVICE PROVIDER SECONDARY IDENTIFICATION          
REF01 2010AA Reference Identification Qualifier for Service Provider Secondary ID R R R R 68
REF02 2010AA SPARCS Facility Identification Number R R R R 69
 
    SUBSCRIBER SECONDARY IDENTIFICATION          
REF01 2010BA Reference Identification Qualifier for Subscriber Secondary ID R R R R 98
REF02 2010BA Unique Personal Identifier R R R R 99-100
 
    PAYER SECONDARY IDENTIFICATION          
REF01 2010BB(Previously 2010BC Version 4050R) Secondary Payer Identification Qualifier O O O O 106
REF02 2010BB(Previously 2010BC Version 4050R) Secondary Payer Identification Number (Previously Payer Identification Number) O O O O 107
 
    PATIENT SECONDARY IDENTIFICATION          
REF01 2010CA Reference Identification Qualifier for Patient Secondary R R R R 132
REF02 2010CA Unique Personal Identifier for Patient Secondary R R R R 133-134
REF03 2010CA Insured Policy Number for Patient Name (Previously Policy Number) N N R N 135
 
    MEDICAL RECORD NUMBER          
REF01 2300 Medical Record Identification Code Qualifier R R R R 155
REF02 2300 Medical Record Number R R R R 156
REF01 2300 Mother's Medical Record Identification Qualifier N N S N 157
REF02 2300 Mother's Medical Record Number for Newborn Child N N S N 158
 
    ATTENDING PROVIDER SECONDARY IDENTIFICATION          
REF01 2310A Attending Provider Qualifier R R R R 218
REF02 2310A Attending Provider State License Number R R R R 219
 
    OPERATING PHYSICIAN SECONDARY IDENTIFICATION          
REF01 2310B Operating Physician State License Qualifier R R R N 225
REF02 2310B Operating Physician State License Number R R R N 226
 
    OTHER OPERATING PHYSICIAN SECONDARY IDENTIFICATION          
REF01 2310C Other Operating Physician State License Qualifier N O O N 232
REF02 2310C Other Operating Physician State License Number N O O N 233
 
    OTHER SUBSCRIBER SECONDARY IDENTIFICATION          
REF01 2330A Other Subscriber Identification Qualifier N N O N 243
REF02 2330A Insured's Policy Number for Other Subscriber N N O N 244
 
    OTHER PAYER SECONDARY IDENTIFIER          
REF01 2330B Other Payer Secondary Identification Qualifier N N N N 250
REF02 2330B Other Payer Secondary Identification Number N N N N 251
 
HL     SERVICE PROVIDER HIERARCHICAL LEVEL          
HL01 2000A Hierarchical ID Number R R R R 60
HL03 2000A Hierarchical Level Code R R R R 61
HL04 2000A Hierarchical Child Code R R R R 62
 
    SUBSCRIBER HIERARCHICAL LEVEL          
HL01 2000B Hierarchical ID Number for Subscriber S S S S 70
HL02 2000B Hierarchical Parent ID Number for Subscriber S S S S 71
HL03 2000B Hierarchical Level Code for Subscriber S S S S 72
HL04 2000B Hierarchical Child Code for Subscriber S S S S 73
 
    PATIENT HIERARCHICAL LEVEL          
HL01 2000C Patient Hierarchical ID Number S S S S 108
HL02 2000C Hierarchical Parent ID Number for Patient S S S S 109
HL03 2000C Patient Hierarchical Level Code S S S S 110
HL04 2000C Hierarchical Childe Code for Patient S S S S 111
 
SBR     SUBSCRIBER INFORMATION          
SBR01 2000B Payer Responsibility Sequence Number Code for Subscriber S S S S 74
SBR02 2000B Individual Relationship Code for Subscriber S S S S 75
SBR09 2000B Claim Filing Indicator Code (Previously Source of Payment) R R R R 76-77
 
    OTHER SUBSCRIBER INFORMATION          
SBR01 2320 Payer Responsibility Sequence Number Code O O O O 234
SBR02 2320 Individual Relationship Code O O O O 235
SBR09 2320 Claim Filing Indicator Code R R R R 236-237
 
N3     SUBSCRIBER ADDRESS          
N301 2010BA Subscriber Address Line 1 S S S S 85
N302 2010BA Subscriber Address Line 2 N N N N 86
 
    PATIENT ADDRESS          
N301 2010CA Patient Address Line 1 S S S S 119
N302 2010CA Patient Address Line 2 N N N N 120
 
N4     SUBSCRIBER CITY, STATE, ZIP CODE          
N401 2010BA Subscriber City Name S S S S 87
N402 2010BA Subscriber State S S S S 88
N403 2010BA Subscriber Zip Code (Previously Patient Postal Service Zip Code and Extension Code) S S S S 89
N405 2010BA Location Qualifier for County S S S S 90
N406 2010BA Subscriber County Code S S S S 91
 
    PATIENT CITY, STATE, ZIP CODE          
N401 2010CA Patient City Name S S S S 121
N402 2010CA Patient State S S S S 122
N403 2010CA Patient Zip Code (Previously Patient Postal Service Zip Code and Extension Code) S S S S 123
N405 2010CA Location Qualifier for Patient County S S S S 124
N406 2010CA Patient County Code R R R R 125
 
DMG     SUBSCRIBER DEMOGRAPHICS          
DMG01 2010BA Subscriber Birth Date Qualifier S S S S 92
DMG02 2010BA Subscriber Birth Date S S S S 93
DMG03 2010BA Subscriber Sex Code S S S S 94
DMG05-2 2010BA Race/Ethnicity Qualifier S S S S 95
DMG05-3 2010BA Subscriber Race S S S S 96
DMG05-3 2010BA Subscriber Ethnicity S S S S 97
 
    PATIENT DEMOGRAPHICS          
DMG01 2010CA Patient Birth Date Qualifier S S S S 126
DMG02 2010CA Patient Birth Date S S S S 127
DMG03 2010CA Patient Sex Code R R R R 128
DMG05-2 2010CA Patient Race/Ethnicity Qualifier S S S O 129
DMG05-3 2010CA Patient Race S S S O 130
DMG05-3 2010CA Patient Ethnicity S S S O 131
 
CLM     CLAIM INFORMATION          
CLM01 2300 Patient Control Number R R R R 136
CLM02 2300 Total Claim Charge Amount R R R R 137
CLM05-1 2300 Facility Type Code (Previously Type of Bill Digit 1 & 2 Code) R R R R 138
CLM05-2 2300 Facility Code Qualifier R R R R 139
CLM05-3 2300 Claim Transaction Type (Previously Type of Bill Digit 3 Code) R R R R 140
 
CL1     INSTITUTIONAL CLAIM CODE          
CL101 2300 Type of Admission N R N N 151
CL102 2300 Point of Origin N R R N 152-153
CL103 2300 Patient Status Code R R R N 154
 
DTP     DISCHARGE HOUR          
DTP01 2300 Discharge Hour Qualifier R R R N 141
DTP02 2300 Discharge Hour Format Qualifier R R R N 142
DTP03 2300 Discharge Hour R R R N 143
 
    STATEMENT DATES          
DTP01 2300 Statement Date Qualifier R R R R 144
DTP02 2300 Statement Date Format Qualifier R R R R 145
DTP03 2300 Statement From Date and Statement Through Date R R R R 146-147
 
    ADMISSION DATE/HOUR          
DTP01 2300 Admission Date/Hour Qualifier R R R R 148
DTP02 2300 Admission Date/Hour Format Qualifier R R R R 149
DTP03 2300 Admission Date/Start of Care and Hour (Previously separate elements: Admission Date/Start of Care and Admission Hour/Emergency Visit Hour) R R R R 150
 
    SERVICE DATE          
DTP01 2400 Service Date Qualifier O O O R 264
DTP02 2400 Service Date Format Qualifier N N N R 265
DTP03 2400 Service Date O O O R 266
 
NTE     CLAIM NOTE          
NTE01 2300 Note Reference Code R R R R 159
NTE02 2300 Note Reference Description R R R R 160
NTE02 2300 Expected Principal Reimbursement R R R N 161
NTE02 2300 Expected Reimbursement Other 1 N N R N 162
NTE02 2300 Expected Reimbursement Other 2 S S S N 163
NTE02 2300 Method of Anesthesia Used R N R N 164-165
NTE02 2300 Exempt Unit Indicator N N R N 166
NTE02 2300 Heart Rate on Arrival N S S N 167
NTE02 2300 Systolic Blood Pressure on Arrival N S S N 168
NTE02 2300 Diastolic Blood Pressure on Arrival N S S N 169
NTE02 2300 Procedure Time R N N N 170
NTE02 2300 Source of Payment Typology I R R R R 171
NTE02 2300 Source of Payment Typology II R R R R 172
NTE02 2300 Source of Payment Typology III R R R R 173
 
HI     PRINCIPAL DIAGNOSIS          
HI01-1 2300 Principal Diagnosis Code List Qualifier R R R R 174
HI01-2 2300 Principal Diagnosis Code (Previously Principal/Primary Diagnosis Code) R R R R 175-176
 
    ADMITTING DIAGNOSIS          
HI02-1 2300 Admitting Diagnosis Code List Qualifier N N R N 177
HI02-2 2300 Admitting Diagnosis Code N N R N 178
 
    PATIENT'S REASON FOR VISIT          
HI01-1 to HI03-11 2300 Patient Reason for Visit Code List Qualifier R R N N 179
HI01-2 to HI03-22 2300 Patient Reason for Visit Code R R N N 180
 
    EXTERNAL CAUSE OF INJURY          
HI01-1 to HI12-13 2300 External Cause-of-Injury(ECI)/Place-of-Injury Code List Qualifier S S S S 181
HI01-2 to HI12-24 2300 External Cause-of-Injury(ECI)/Place-of-Injury Code S S S S 182-183
 
    OTHER DIAGNOSIS INFORMATION          
HI01-1 to HI12-1 2300 Other Diagnosis Code List Qualifier 1-24 O O O O 184
HI01-2 to HI12-2 2300 Other Diagnosis Code 1-24 O O O O 185
HI01-9 to HI12-9 2300 Present on Admission Indicator 1-24 S S S S 186
 
    PRINCIPAL PROCEDURE INFORMATION          
HI01-1 2300 Principal Procedure Code List Qualifier N N R N 187
HI01-2 2300 Principal Procedure Code N N R N 188
HI01-3 2300 Principal Procedure Date Format Qualifier N N R N 189
HI01-4 2300 Principal Procedure Date N N R N 190
 
    OTHER PROCEDURE INFORMATION          
HI01-1 2300 Other Procedure Code List Qualifier 1-14 N N O N 191
HI02-2 to HI12-2 2300 Other Procedure Code 1-14 N N O N 192
HI01-3 to HI12-3 2300 Other Procedure Code Date Format Qualifier N N O N 193
HI01-4 to HI12-4 2300 Other Procedure Date 1-14 S S S S 194
 
    OCCURRENCE SPAN INFORMATION          
HI01-1 to HI12-1 2300 Occurrence Span Code List Qualifier N N S N 195
HI01-2 to HI12-2 2300 Occurrence Span Code N N S N 196
HI01-3 to HI12-3 2300 Occurrence Span Date Range Format Qualifier N N S N 197
HI01-4 to HI12-4 2300 Occurrence Span Dates for ALC and LOA N N S N 198
 
    OCCURRENCE INFORMATION          
HI01-1 2300 Occurrence Information Code List Qualifier O O O O 199
HI01-2 2300 Occurrence Information Code O O O O 200
HI01-3 2300 Occurrence Information Date Qualifier O O O O 201
HI01-4 2300 Occurrence Information Date O O O O 202
 
    VALUE INFORMATION          
HI01-1 to HI12-1 2300 Value Information Qualifier 1-12 O O O O 203
HI01-2 to HI12-25 2300 Value Codes 1-12 O O O S 204-205
HI01-5 to HI12-5 2300 Value Code Amount 1-12 S S S S 206
 
    CONDITION INFORMATION          
HI01-1 to HI12-1 2300 Condition Information Code Qualifier O O O O 207
HI02-2 to HI12-2 2300 Condition Code O O O O 208-209
 
QTY     CLAIM QUANTITY          
QTY016 2300 Day Qualifier N N R N 210
QTY027 2300 Covered/Non-Covered Days Quantity N N R N 211
QTY03-18 2300 Day Code N N R N 212
 
LX     SERVICE LINE NUMBER          
LX01 2400 Service Line Number R R R R 252
 
SV2     INSTITUTIONAL SERVICE LINE          
SV201 2400 Revenue Code (Previously: UB Accomodation Codes, Inpatient Ancillary Revenue Code, Outpatient Ancillary Revenue Code) R R R R 253-254
SV202-1 2400 HCPCS Procedure Code R R R N 255
SV202-2 2400 CPT Procedure Code R R N R 256
SV202-3 2400 Procedure Modifier 1 R R N R 257
SV202-4 2400 Procedure Modifier 2 R R N R 258
SV203 2400 Line Item Charge Amount R R R R 259
SV204 2400 Measurement Code R R R R 260
SV205 2400 Service Unit Count R R R R 261
SV206 2400 Accommodations Rate N N R N 262
SV207 2400 Non-Covered Charges Amount R R R R 263
 
GE     FUNCTIONAL GROUP TRAILER          
GE01 Trailer Number of Transaction Sets for Functional Group N N N N 269
GE02 Trailer Functional Group Control Number N N N N 270
 
SE     TRANSACTION SET TRAILER          
SE01 Trailer Transaction Segment Count N N N N 267
SE02 Trailer Transaction Set Control Numbers N N N N 268
 
IEA     INTERCHANGE CONTROL TRAILER          
IEA01 Trailer Interchange Control Trailer Functional Groups N N N N 271
IEA02 Trailer Interchange Control Number N N N N 272
 
VERSION 4050R ONLY
HI     PATIENT'S REASON FOR VISIT CODE          
HI02-19 2300 Patient Reason for Visit Code List Qualifier R R N N 179
HI02-210 2300 Patient Reason for Visit Code R R N N 180
 
    EXTERNAL CAUSE OF INJURY CODE          
HI03-1 to HI12-111 2300 External Cause-of-Injury(ECI)/Place-of-Injury Code List Qualifier S S S S 181
HI03-2 to HI12-212 2300 External Cause-of-Injury(ECI)/Place-of-Injury Code S S S S 182-183
 
QTY     CLAIM QUANTITY          
QTY0113 2300 Day Qualifier N N R N 210
QTY0214 2300 Covered/Non-Covered Days Quantity N N R N 211
QTY03-115 2300 Day Code N N R N 212


Data Edit Data Edit Name Description
R Required Data element must be submitted for the data type and must not be blank.
S Situational Required based upon values of other elements
O Optional This element is not required and may be blank, however, if submitted, it will be edited.
N Not Needed Not required, not edited, not collected. If submitted it will be ignored.

1 Previously H102-1 in Version 4050R.

2 Previously H102-2 in Version 4050R.

3 Previously H103-1 to H112-1 in Version 4050R.

4 Previously H103-2 to H112-2 in Version 4050R.

5 This segment also contains the QTY (Claim Quantity) segment from Version 4050R. The QTY segment is no longer used in Version 5010R.

6 No longer used in Version 5010R.

7 Ibid.

8 Ibid.

9 Listed as H101-1 to H103-1 in Version 5010R. See Footnote 1.

10 Listed as H101-2 to H103-2 in Version 5010R. See Footnote 2.

11 Listed as H101-1 to H112-1 in Version 5010R. See Footnote 3.

12 Listed as H101-2 to H112-2 in Version 5010R. See Footnote 4.

13 This segment now exists under Value Information (H101-2 thru H112-2) in Version 5010R.

14 Ibid.

15 Ibid.