This article dives into the specifics of Loop 2300 and assumes that you know how to read an EDI (837) file. If you are looking for a general outline of an EDI and how to read the basic structure, please see: How to read an EDI (837) File - Overview.

We will be using the following sample EDI file to break down this loop.

Loops 2300 - Claim Information

Segment CLM - Claim

Example: CLM*18434718T0*150.00***11:B:1*Y*A*Y*Y~

• Element 01 = Claim Identifier (18434718T0) Box 26 (On EDI claims only)
  • Unique number used for ERA matching
• Element 02 = Claim Amount ($150) Box 28
• Element 05-1 = Place of Service (11) Box 24b
  • 02 = Telehealth
  • 03 = School
  • 04 = Homeless Shelter
  • 09 = Prison/Correctional Facility
  • 11 = Office
  • 12 = Home
  • 13 = Assisted Living Facility
  • 14 = Group Home
  • 15 = Mobile Unit
  • 16 = Temporary Lodging
  • 21 = Hopital
  • 22 = Outpatient Hospital
  • 26 = Military Treatment Facility
  • 31 = Skilled Nursing Facility
  • 32 = Nursing Facility
  • 34 = Hospice
  • 49 = Independent Clinic
  • 53 = Community Mental Health Center
  • 62 = Outpatient Rehab
  • 99 = Other Setting
• Element 05-2 = Hardcoded to B for Professional Claim
• Element 05-3 = Claim Frequency Type Code (1) Box 22 Resubmission Code
• Element 06 = Provider Signature Indicator (Y) Box 31
• Element 07 = Provider Accept Assignment (A) Box 27
  
  • A = Assigned
  • C = Not Assigned
• Element 08 = Provider Benefits Assignment Certification (Y) Box 13
  • Y = Valid Signature on File
  • N = No Valid Signature on File
• Element 09 = Release of Information Code (Y) Box 12
  • Y = Valid Signature on File
  • I = Signature Not Required
• Element 10 = Client Signature Source Code
• Element 11-(1-3) = Related Cause Code Box 10abc
  • EM = Employment
  • AA = Auto Accident
  • OA = Other Accident
• Element 11-4 = Auto Accident State Code Box 10b
• Element 12 = Special Program Code
• Element 20 = Delay Reason Code

Segment DTP - Date

Example: DTP*431*D8*20170720~

• Element 01 = Date Qualifier (431)
  • 096 = Discharge/Hospitalized To Box 18 To (Element 03)
  • 296 = Disability/Unable to Work To Box 16 To (Element 03)
  • 297 = Disability/Unable to Work From Box 16 From (Element 03)
  • 304 = Last Seen Box 15 Qual (Element 03)
  • 431 = Onset of Current Illness/First Symptoms Box 14 Qual (Element 03)
  • 435 = Admission/Hospitalized From Box 18 From (Element 03)
  • 439 = Accident Box 15 Qual (Element 03)
  • 454 = Initial Treatment Box 15 Qual (Element 03)
• Element 02 = Format - Hardcoded to D8
• Element 03 = Date YYYYMMDD (2017/07/20)

Segment PWK (Workers Comp and Auto)

Example: PWK*07*EL***AC*TBCLAIMID68~

• Element 01 = Supplemental Information Code (07)
  • 04 = Drugs Administered
  • 05 = Treatment Diagnosis
  • 06 = Initial Assessment
  • 07 = Functional Goals
  • 08 = Plan of Treatment
  • 09 = Progress Report
  • 10 = Continued Treatment
  • 11 = Chemical Analysis
  • 13 = Certified Test Report
  • 15 = Justification For Admission
• Element 02 = Transmission Code (EL)
  • AA = Available On Request
  • BM = By Mail
  • EL = Electronic
  • EM = Email
  • FX = By Fax
  • FT = File Transfer
• Element 05 = Hardcoded to AC (if 02 is BM, EL, EM, FX, or FT)
  • AC = Attachment Control Number Identifier
• Element 06 = Attachment Control Number (TBCLAIMID68)
  • This populates the Submission ID from the CMS-1500 Filing

Segment REF - Identifier

Example: REF*G1*12345~

• Element 01 = Identifier Code Qualifier (G1)
  • G1 = Authorization Number Box 23 (Element 02)
  • F8 = Control Number Box 22 Original Ref. No. (Element 02) 
  • 9F = Referral Number/Medicaid Montana Passport Box 17a (Element 02)
• Element 02 = Identifier Code (12345)

Segment AMT - Amount

Example: AMT*F5*15.00~

• Element 01 = Qualifier Code - Hardcoded to F5 for Patient Amount Paid
• Element 02 = Monetary Amount ($15) Box 29

Segment NTE - Note

Example: NTE*ADD*N5455845~

• Element 01 = Reference Code (Add)
• Element 02 = Note Text (N5455845) Box 19

Segment HI - Diagnosis Codes

Example: HI*ABK:M24532*ABF:M21332~

• Element (01-12) = Diagnosis Code
  • Sub-Element 1 = Diagnosis Code Qualifier (ABK or ABF)
    • ABK = Principal Diagnosis
    • ABF = Other Diagnosis
  • Sub-Element 2 = Diagnosis Code (M24532 and M21332) Box 21

Loop 2310A - Referring Provider

Segment NM1 - Name

Example: NM1*DN*1*HENSON*JIM****XX*9999999995~

• Element 01 = Hardcoded to DN for Referring Provider Box 17
• Element 02 = Hardcoded to 1 for Individual
• Element 03 = Last Name (Henson) Box 17
• Element 04 = First Name (Jim) Box 17
• Element 05 = Middle Name/Initial Box 17
• Element 07 = Suffix Box 17
• Element 08 = Identifier Code Qualifier - Hardcoded to XX for NPI
• Element 09 = Identifier Code (9999999995) Box 17b

Segment REF - Reference (Not always present)

Example: REF*0B*A485422~

• Element 01 = Identifier Code Qualifier (0B) Box 17a
  • 0B = State License Number
  • G2 = Commercial Number
• Element 02 = Identifier Code (A485422) Box 17a

Loop 2310B - Rendering Provider

Segment NM1 - Name

Example: NM1*82*1*SMITH*TERESA****XX*5595436374~

• Element 01 = Hardcoded to 82 for Rendering Provider 
• Element 02 = Hardcoded to 1 for Individual
• Element 03 = Last Name (Smith)
• Element 04 = First Name (Teresa)
• Element 05 = Middle Name/Initial
• Element 07 = Suffix
• Element 08 = Identifier Code Qualifier - Hardcoded to XX for NPI
• Element 09 = Identifier Code (5595436374) Box 24j

Segment PRV - Provider

Example: PRV*PE*PXC*225100000X~

• Element 01 = Hardcoded to PE for Performing
• Element 02 = Hardcoded to PXC for Provider Taxonomy Code
• Element 03 = Identifier Code/Taxonomy (225100000X)

Segment REF - Reference

Example: REF*G2*998855~

• Element 01 = Secondary Indentification Reference ID Qualifier (G2) Box 24i
  • G2 = Commercial Number
  • 0B = State License Number
  • 1G = Provider UPIN Number
• Element 02 = Secondary Indentification Reference ID (998855) Box 24j Shaded

Loops 2310C - Service Facility Location

Segment NM1 - Name

Example: NM1*77*2*MY HOME CLINIC*****XX*9999999995~

• Element 01 = Hardcoded to 77 for Service Location
• Element 02 = Hardcoded to 2 for Non-Person Entity
• Element 03 = Service Facility Name (My Home Clinic) Box 32
• Element 08 = Identifier Code Qualifier - Hardcoded to XX for NPI
• Element 09 = Identifier Code (999999995) Box 32a

Segment N3 - Street Address

Example: N3*Box 123~

• Element 01 = Street Address (Box 123) Box 32

Segment N4 - City, State, and ZIP

Example: N*PHOENIX*AZ*850030000~

• Element 01 = City (Phoenix) Box 32
• Element 02 = State (Arizona) Box 32
• Element 03 = ZIP Code (850030000) Box 32