| Exported Name | 837 Loop | Segment | Data Element-Sub Data |
|---|---|---|---|
| Billing Provider Loop 2000A | |||
| Billing Provider Name | 2010AA | NM1 | 03,04 |
| Subscriber Loop 2000B | |||
| Subscriber Name | 2010BA | NM1 | 03,04 |
| Subscriber ID, Member Identification Number | 2010BA | NM1 | 09 |
| Patient Loop 2000C | |||
| Patient Name, First and Last Name | 2010CA | NM1 | 03,04 |
| Relationship Code, related to Insured person | 2010C | PAT | 01 |
| Claims, Loop 2300 | |||
| Control Number, Patient Control Number or Claim Number | 2300 | CLM | 01 |
| Total Charge, Total Claim Charged Amount | 2300 | CLM | 02 |
| ICD 1 .. ICD 8, Diagnostic Codes, ICD-9 or ICD-10 | 2300 | HI | 01-2 .. 08-2 |
| Service Lines, Loop 2400 | |||
| Line Number | 2400 | LX | 01 |
| Proc Code Q, Procedure Code Qualifier for HCPCS or others | 2400 | SV1 | 01-1 |
| Proc Code, Procedure Code, HCPCS or others | 2400 | SV1 | 01-2 |
| M1 .. M4, Procedure Modifier 1 .. 4 | 2400 | SV1 | 01-3 .. 01-6 |
| Charged, Line Item Charge Amount | 2400 | SV1 | 02 |
| Service Date, Qualifier=472 | 2400 | DTP | 03 |
| Line Adjudication Information, Loop 2430 | |||
| Adjudication other payer ID, Other Payer Primary Identification | 2430 | SVD | 01 |
| Amount Paid, Service Line Paid Amount | 2430 | SVD | 02 |
| Proc Code, Procedure Code used to pay the service line | 2430 | SVD | 03-2 |
| Paid Unit, Paid Service Unit Count | 2430 | SVD | 05 |
| Patient Liability, Qualifier=EAF, Remaining Patient Liability | 2430 | AMT | 02 |
| Adjustment Group 1 .. 4, Claim Adjustment Group Code, repeated in same segment | 2430 | CAS | 01 |
| Reason 1 .. 4, Claim Adjustment Reason Code 1 .. 4 | 2430 | CAS | 02,05,08,11 |
| Amount 1 .. 4, Claim Adjustment Amount 1 .. 4 | 2430 | CAS | 03,06,09,12 |
To be defined
To be defined