C001 Composite Unit of Measure To identify a composite unit of measure

003070 COMPOSITE UIT OF MEASURE C001 C001 Composite Unit of Measure To identify a composite unit of measure (See Figures Appendix for examples of use) SEGMETS USED I ATR ATV BCS CBS CFT CRT CSF CSS CST CSU CTP EA FAA GDP III IC J K3 OC TR MEA MII MIR 12 CA OPS PAM PAY PD PDE PEX P POC PRC PSC PSD PTF QTY RAT RCD REA REC RT RPA SII SI S SPS STA TBA TIA TRF UCS UIT USD TRASACTIO SETS USED I 124 130 131 135 139 140 141 142 143 148 149 150 151 152 153 154 155 159 160 175 176 180 185 186 188 189 194 195 196 197 198 199 200 201 203 205 206 215 242 249 251 252 255 256 260 261 262 263 264 265 266 268 270 271 272 273 280 285 288 290 300 301 304 310 312 325 355 362 404 410 417 422 426 432 436 470 500 501 503 511 517 521 527 536 540 561 568 650 805 806 810 811 813 816 819 820 821 822 823 824 826 829 830 831 832 833 834 835 836 837 838 839 840 841 842 843 844 845 846 847 848 849 850 851 852 853 855 856 857 858 859 860 861 862 863 865 866 867 868 869 870 871 872 880 881 883 884 886 887 888 889 940 945 996 COMMETS 1 If C001-02 is not used, its value is to be interpreted as 1. 2 If C001-03 is not used, its value is to be interpreted as 1. 3 If C001-05 is not used, its value is to be interpreted as 1. 4 If C001-06 is not used, its value is to be interpreted as 1. 5 If C001-08 is not used, its value is to be interpreted as 1. 6 If C001-09 is not used, its value is to be interpreted as 1. 7 If C001-11 is not used, its value is to be interpreted as 1. 8 If C001-12 is not used, its value is to be interpreted as 1. 9 If C001-14 is not used, its value is to be interpreted as 1. 10 If C001-15 is not used, its value is to be interpreted as 1. C00101 355 C00102 1018 C00103 649 C00104 355 C00105 1018 C00106 649 C001 UnitBasis Meas Exponent Multiplier UnitBasis Meas Exponent Multiplier M 22 O R 115 O R 110 O 22 O R 115 O R 110 C00107 355 C00108 1018 C00109 649 C00110 355 C00111 1018 C00112 649 UnitBasis Meas Exponent Multiplier UnitBasis Meas Exponent Multiplier O 22 O R 115 O R 110 O 22 O R 115 O R 110 C00113 355 C00114 1018 C00115 649 UnitBasis Meas Exponent Multiplier O 22 O R 115 O R 110 C002 Actions Indicated Actions to be performed on the piece of paperwork identified SEGMETS USED I PWK TRASACTIO SETS USED I 143 147 161 186 194 195 198 206 252 255 261 262 265 272 277 278 280 304 310 500 511 536 810 830 833 836 837 840 841 842 843 850 855 856 860 865 867 870 872 C002 C00201 704 C00202 704 C00203 704 C00204 704 C00205 704 Paperwork Action Paperwork Action Paperwork Action Paperwork Action Paperwork Action M 12 O 12 O 12 O 12 O 12 DECEMBER 1996 COMPOSITE DATA EEMET DIRECTORY 1

003070 COMPOSITE MEDICA PROCEDURE ETIFIER C003 C003 Composite Medical Procedure Identifier To identify a medical procedure by its standardized codes and applicable modifiers SEGMETS USED I EB EQ SV1 SV2 SV3 SV4 SV5 SV6 SVC SVD TRASACTIO SETS USED I 270 271 276 277 835 837 SEMATIC OTES 1 C003-03 modifies the value in C003-02. 2 C003-04 modifies the value in C003-02. 3 C003-05 modifies the value in C003-02. 4 C003-06 modifies the value in C003-02. 5 C003-07 is the description of the procedure identified in C003-02. C003 C00301 235 C00302 234 C00303 1339 C00304 1339 C00305 1339 C00306 1339 ProdServ Qual Product Service Procedure Modifier Procedure Modifier Procedure Modifier Procedure Modifier M 22 M A 148 O A 22 O A 22 O A 22 O A 22 C00307 352 Description O A 180 C004 Composite Diagnosis Pointer To identify one or more diagnosis code pointers SEGMETS USED I SV1 SV3 SV6 TRASACTIO SETS USED I 837 SEMATIC OTES 1 C004-01 identifies the primary diagnosis code for this service line. 2 C004-02 identifies the second diagnosis code for this service line. 3 C004-03 identifies the third diagnosis code for this service line. 4 C004-04 identifies the fourth diagnosis code for this service line. C004 C00401 1328 C00402 1328 C00403 1328 C00404 1328 Diagnosis Pointr Diagnosis Pointr Diagnosis Pointr Diagnosis Pointr M 0 12 O 0 12 O 0 12 O 0 12 C005 Tooth Surface To identify one or more tooth surface codes SEGMETS USED I TOO TRASACTIO SETS USED I 837 C005 C00501 1369 C00502 1369 C00503 1369 C00504 1369 C00505 1369 Tooth Surf Tooth Surf Tooth Surf Tooth Surf Tooth Surf M 12 O 12 O 12 O 12 O 12 C006 Oral Cavity Designation To identify one or more areas of the oral cavity DECEMBER 1996 COMPOSITE DATA EEMET DIRECTORY 2

003070 AMOUT QUAIFYIG DESCRIPTIO C007 SEGMETS USED I SV3 TRASACTIO SETS USED I 837 C006 C00601 1361 C00602 1361 C00603 1361 C00604 1361 C00605 1361 Oral Cavity Desig. Oral Cavity Desig. Oral Cavity Desig. Oral Cavity Desig. Oral Cavity Desig. M 13 O 13 O 13 O 13 O 13 C007 Amount Qualifying Description To qualify an amount SEGMETS USED I ASO AWD TRASACTIO SETS USED I 155 SEMATIC OTES 1 C007-01 is the primary Amount. 2 C007-02 is used when a compound Amount is required. 3 C007-03 qualifies the Amount referenced in C007-01 and C007-02. 4 C007-04 qualifies the Amount referenced in C007-01 and C007-02. 5 C007-05 defines the time period of the Amount referenced in C007-01 and C007-02. 6 C007-06 specifies whether the Amount referenced in C007-01 and C007-02 is net or gross. 7 C007-07 qualifies the amount when an exact amount is not available. 8 C007-08 is used for free-form description of an amount. COMMETS 1 This composite data element can be used to break apart the Amount into its individual components. See Appendix (Composite Data Structure Figures) for usage examples of C007. 2 C007-08 is only used when C007-01 is "FK" (other). C00701 522 C00702 522 C00703 1638 C00704 935 C00705 344 C00706 1637 C007 Amount Qual Amount Qual Value Detail Cd Measurement Sig Unit Time Interval etgross M 12 O 12 O 11 O 22 O 22 O 11 C00707 935 C00708 352 Measurement Sig Description O 22 O A 180 C022 Health Care Information To send health care codes and their associated dates, amounts and quantities SEGMETS USED I HI TRASACTIO SETS USED I 278 834 837 SYTAX OTES 1 P0304 - If either C02203 or C02204 is present, the - If either C02203, C02204, C022 -, C022 I, C022f, C022ei, C022th, C022er, C022 C, C02202, C02220, C0223, C022or, C022 C, C02202, C02220, C0224, C022is, C022 p, C022re, C022se, C022nt, C022, or C022th are present, then the others are required. SEMATIC OTES 1 C022-01 qualifies C022-02, C022-04, C022-05 and C022-06. 2 C022-03 is the date format that will appear in C022-04. DECEMBER 1996 COMPOSITE DATA EEMET DIRECTORY 3

003070 HEATH CARE SERVICE OCATIO IFORMATIO C023 3 C022-07 qualifies C022-01. C022 C02201 1270 C02202 1271 C02203 1250 C02204 1251 C02205 782 C02206 380 ist Qual Industry Date Time Format Qual Date Time Period Monetary Amount Quantity M 13 M A 130 C 23 C A 135 O R 115 O R 115 C02207 799 O A 130 C023 Health Care Service ocation Information To provide information that identifies the place of service or the type of bill related to the location at which a health care service was rendered SEGMETS USED I CM UM TRASACTIO SETS USED I 278 837 SEMATIC OTES 1 C023-02 qualifies C023-01 and C023-03. C023 C02301 1331 C02302 1332 C02303 1325 Facility Facility Qual Claim Freq Type M A 12 O 12 O 11 C024 Related Causes Information To identify one or more related causes and associated state or country information SEGMETS USED I CM UM TRASACTIO SETS USED I 278 837 COMMETS 1 C024-04 and C024-05 apply only to auto accidents when C024-01, C024-02, or C024-03 is equal to "AA". C024 C02401 1362 C02402 1362 C02403 1362 C02404 156 C02405 26 Related Causes Related Causes Related Causes State or Prov Country M 23 O 23 O 23 O 22 O 23 C028 Assurance Token Parameters Parameters needed to calculate the Assurance Token SEGMETS USED I S1A S2A SYTAX OTES 1 C0403 - If C02804 is present, then C02803 is requi - If C02804 is present, then C02803, C028 -, C028 I, C028f, C028C0, C02828, C02804, C028 i, C028s, C028pr, C028es, C028en, C028t,, C028 t, C028he, C028n, C028C0, C02828, C02803, C028 i, C028s, C028re and C028qu are required. 2 C0605 - If C02806 is present, then C02805 is requi - If C02806 is present, then C02805, C028 -, C028 I, C028f, C028C0, C02828, C02806, C028 i, C028s, C028pr, C028es, C028en, C028t,, C028 t, C028he, C028n, C028C0, C02828, C02805, C028 i, C028s, C028re and C028qu are required. 3 C0807 - If C02808 is present, then C02807 is requi - If C02808 is present, then C02807, C028 -, C028 I, C028f, C028C0, C02828, C02808, C028 i, C028s, C028pr, C028es, C028en, C028t,, C028 t, C028he, C028n, C028C0, C02828, C02807, C028 i, C028s, C028re and C028qu are required. DECEMBER 1996 COMPOSITE DATA EEMET DIRECTORY 4

003070 POSITIO I SEGMET C030 4 C1009 - If C02810 is present, then C02809 is requi - If C02810 is present, then C02809, C028 -, C028 I, C028f, C028C0, C02828, C02810, C028 i, C028s, C028pr, C028es, C028en, C028t,, C028 t, C028he, C028n, C028C0, C02828, C02809, C028 i, C028s, C028re and C028qu are required. 5 C1211 - If C02812 is present, then C02811 is requi - If C02812 is present, then C02811, C028 -, C028 I, C028f, C028C0, C02828, C02812, C028 i, C028s, C028pr, C028es, C028en, C028t,, C028 t, C028he, C028n, C028C0, C02828, C02811, C028 i, C028s, C028re and C028qu are required. 6 C1413 - If C02814 is present, then C02813 is requi - If C02814 is present, then C02813, C028 -, C028 I, C028f, C028C0, C02828, C02814, C028 i, C028s, C028pr, C028es, C028en, C028t,, C028 t, C028he, C028n, C028C0, C02828, C02813, C028 i, C028s, C028re and C028qu are required. 7 C1615 - If C02816 is present, then C02815 is requi - If C02816 is present, then C02815, C028 -, C028 I, C028f, C028C0, C02828, C02816, C028 i, C028s, C028pr, C028es, C028en, C028t,, C028 t, C028he, C028n, C028C0, C02828, C02815, C028 i, C028s, C028re and C028qu are required. 8 C1817 - If C02818 is present, then C02817 is requi - If C02818 is present, then C02817, C028 -, C028 I, C028f, C028C0, C02828, C02818, C028 i, C028s, C028pr, C028es, C028en, C028t,, C028 t, C028he, C028n, C028C0, C02828, C02817, C028 i, C028s, C028re and C028qu are required. 9 C2019 - If C02820 is present, then C02819 is requi - If C02820 is present, then C02819, C028 -, C028 I, C028f, C028C0, C02828, C02820, C028 i, C028s, C028pr, C028es, C028en, C028t,, C028 t, C028he, C028n, C028C0, C02828, C02819, C028 i, C028s, C028re and C028qu are required. C02801 1439 C02802 1442 C02803 1439 C02804 1442 C02805 1439 C02806 1442 C028 M 22 M A 164 C 22 O A 164 C 22 O A 164 C02807 1439 C02808 1442 C02809 1439 C02810 1442 C02811 1439 C02812 1442 C 22 O A 164 C 22 O A 164 C 22 O A 164 C02813 1439 C02814 1442 C02815 1439 C02816 1442 C02817 1439 C02818 1442 C 22 O A 164 C 22 O A 164 C 22 O A 164 C02819 1439 C02820 1442 C 22 O A 164 C030 Position in Segment indicating the relative position of a simple data element, or the relative position of a composite data structure combined with the relative position of the component data element within the composite data structure, in error; the count starts with 1 for the simple data element or composite data structure immediately following the segment SEGMETS USED I AK4 TRASACTIO SETS USED I 997 C030 C03001 722 C03002 1528 Element Pos in Segment DE Pos in Composite M 0 12 O 0 12 C031 Encryption Key Information Information needed to identify or obtain the encryption key DECEMBER 1996 COMPOSITE DATA EEMET DIRECTORY 5

003070 ECRYPTIO SERVICE IFORMATIO C032 SEGMETS USED I S1S S2S C031 C03101 993 C03102 1564 C03103 1565 C03104 1566 C03105 1567 Encryption Key ame Protocol ook-up Value Keying Material One-time Encrypt Key M A 164 O 33 O A 14096 O A 1512 O A 1512 C032 Encryption Service Information Information required by the encryption operation SEGMETS USED I S1S S2S SYTAX OTES 1 P0405 - If either C03204 or C03205 is present, the - If either C03204, C03205, C032 -, C032 I, C032f, C032ei, C032th, C032er, C032 C, C03203, C03220, C0324, C032or, C032 C, C03203, C03220, C0325, C032is, C032 p, C032re, C032se, C032nt, C032, or C032th are present, then the others are required. 2 P0607 - If either C03206 or C03207 is present, the - If either C03206, C03207, C032 -, C032 I, C032f, C032ei, C032th, C032er, C032 C, C03203, C03220, C0326, C032or, C032 C, C03203, C03220, C0327, C032is, C032 p, C032re, C032se, C032nt, C032, or C032th are present, then the others are required. C03201 994 C03202 1568 C03203 1569 C03204 1570 C03205 799 C03206 1571 C032 Encryption Serv Algorithm Algorithm Mode of Op Filter Compression M 13 O 33 O 33 C 33 C A 130 C 33 C03207 799 C A 130 C033 Security Value Value of the Security Token SEGMETS USED I CSC SVA TRASACTIO SETS USED I 815 C033 C03301 1572 C03302 1573 Security Val Qual M 33 Encoded Secur Val M A 1 1E+16 C034 Computation Methods Algorithms used to calculate an assurance SEGMETS USED I S1A S2A C034 C03401 1574 C03402 1575 Assurance Algorithm Hashing Algorithm M 33 M 33 C035 Provider Specialty Information To provide provider specialty information DECEMBER 1996 COMPOSITE DATA EEMET DIRECTORY 6

003070 EX ETIFICATIO C036 SEGMETS USED I PRV TRASACTIO SETS USED I 270 271 275 278 834 837 SEMATIC OTES 1 C035-02 qualifies C035-01. 2 C035-03 is the provider specialty certification indicator. A "Y" value indicates the provider is certified in the specialty indicated. An "" value indicates the provider is not certified in the specialty indicated. A "U" value indicates that it is unknown whether the provider is certified in the specialty indicated. C035 C03501 1222 C03502 559 C03503 1073 Provider Specy Agency Qual Yeso Cond Resp M A 13 O 22 O 11 C036 Index Identification To identify an index SEGMETS USED I IX TRASACTIO SETS USED I 194 SYTAX OTES 1 P0203 - If either C03602 or C03603 is present, the - If either C03602, C03603, C036 -, C036 I, C036f, C036ei, C036th, C036er, C036 C, C03603, C03660, C0362, C036or, C036 C, C03603, C03660, C0363, C036is, C036 p, C036re, C036se, C036nt, C036, or C036th are present, then the others are required. 2 R0204 - At least one of C03602 or C03604 is requir - At least one of C03602, C03604, C036 -, C036 A, C036t, C036le, C036as, C036t, C036on, C036e, C036of, C036 C, C03603, C03660, C0362, C036or, C036 C, C03603, C03660, C0364, C036is, C036 r, C036eq or C036ui is required. 3 P0405 - If either C03604 or C03605 is present, the - If either C03604, C03605, C036 -, C036 I, C036f, C036ei, C036th, C036er, C036 C, C03603, C03660, C0364, C036or, C036 C, C03603, C03660, C0365, C036is, C036 p, C036re, C036se, C036nt, C036, or C036th are present, then the others are required. SEMATIC OTES 1 C036-02 is the beginning range sequence number. It is the first cell included in either an absolute or relative load pattern. 2 C036-03 is the ending range sequence number. It is the last cell in an array identified by an absolute load pattern. In a relative load pattern, it is the count of the number of cells included in the array range inclusive of the beginning range sequence number. COMMETS 1 Use C036-01 to identify the array loading sequence or pattern. 2 Use C036-02 and C036-03 to express a range of array cell identifiers for which data is to be loaded to the array in an absolute reference or the beginning and total number of cells, inclusive, in a relative load pattern. 3 Use C036-04 and C036-05 to express the cell coordinates for an individual array cell value to be loaded to the array. C036 C03601 1395 C03602 127 C03603 127 C03604 863 C03605 864 Config Type X-Peg Y-Peg O 11 C A 130 C A 130 C R 16 C R 16 C037 Tax Field Identification To identify a data field and to indicate the field status SEGMETS USED I TIA DECEMBER 1996 COMPOSITE DATA EEMET DIRECTORY 7

003070 REFERECE ETIFIER C040 TRASACTIO SETS USED I 149 151 813 826 C037 C03701 817 C03702 647 Tax Info umber Appl Error Cond M A 130 O 13 C040 Identifier To identify one or more reference numbers or identification numbers as specified by the SEGMETS USED I CSC 2 9 PDS RDM REF TRASACTIO SETS USED I 101 104 110 120 121 124 130 131 135 140 141 142 143 144 146 147 148 149 151 152 153 154 155 159 160 161 163 170 175 176 180 185 186 188 189 191 194 195 196 197 198 199 200 201 203 204 205 206 210 213 217 218 242 248 249 250 251 252 255 256 260 261 262 263 264 265 266 268 270 271 272 273 275 276 277 278 280 285 288 300 301 304 309 310 311 312 313 315 317 322 324 325 326 350 355 362 404 410 414 417 418 421 422 426 432 435 452 455 456 470 500 501 503 504 511 517 521 527 536 540 561 567 568 601 602 650 715 805 806 810 811 812 813 814 815 816 818 819 820 821 823 824 826 827 828 829 830 831 832 833 834 835 836 837 838 839 840 841 842 843 844 845 846 847 848 849 850 851 852 853 854 855 856 857 858 859 860 861 862 863 864 865 866 867 869 870 871 872 875 876 879 880 881 882 884 885 887 888 889 891 894 896 920 940 943 944 945 947 990 SYTAX OTES 1 P0304 - If either C04003 or C04004 is present, the - If either C04003, C04004, C040 -, C040 I, C040f, C040ei, C040th, C040er, C040 C, C04004, C04000, C0403, C040or, C040 C, C04004, C04000, C0404, C040is, C040 p, C040re, C040se, C040nt, C040, or C040th are present, then the others are required. 2 P0506 - If either C04005 or C04006 is present, the - If either C04005, C04006, C040 -, C040 I, C040f, C040ei, C040th, C040er, C040 C, C04004, C04000, C0405, C040or, C040 C, C04004, C04000, C0406, C040is, C040 p, C040re, C040se, C040nt, C040, or C040th are present, then the others are required. C040 C04001 128 C04002 127 C04003 128 C04004 127 C04005 128 C04006 127 Qual Qual Qual M 23 M A 130 C 23 C A 130 C 23 C A 130 C041 Composite Date To identify the complete date, including century, year, month and day SEGMETS USED I BAK BCA BCH BEG TRASACTIO SETS USED I 850 855 860 865 C04101 373 C04102 624 C041 Date Century M DT 66 O 0 22 C042 Adjustment Identifier To provide the category and identifying reference information for an adjustment SEGMETS USED I PB DECEMBER 1996 COMPOSITE DATA EEMET DIRECTORY 8

003070 HEATH CARE CAIM STATUS C043 TRASACTIO SETS USED I 835 C042 C04201 426 C04202 127 Adjustment Reason M 22 O A 130 C043 Health Care Claim Status Used to convey status of the entire claim or a specific service line SEGMETS USED I STC TRASACTIO SETS USED I 248 277 SEMATIC OTES 1 C043-01 is used to specify the logical groupings of Health Care Claim Status s (See Source 507). 2 C043-02 is used to identify the status of an entire claim or a serviceline (See Source 508). 3 C043-03 identifies the entity associated with the Health Care Claim Status. C043 C04301 1271 C04302 1271 C04303 98 Industry Industry Entity M A 130 M A 130 O 23 C045 Conditions Indicated To identify one or more conditions qualifying an option or event SEGMETS USED I CDI TRASACTIO SETS USED I 205 C045 C04501 1321 C04502 1321 C04503 1321 C04504 1321 C04505 1321 Certificate Cond Certificate Cond Certificate Cond Certificate Cond Certificate Cond M 22 O 22 O 22 O 22 O 22 C046 Composite Identifier To identify one or more qualifiers describing a rate or value SEGMETS USED I VDI TRASACTIO SETS USED I 205 C046 C04601 122 C04602 122 C04603 122 C04604 122 C04605 122 RateValue RateValue RateValue RateValue RateValue M 22 O 22 O 22 O 22 O 22 C050 Certificate ook-up Information Conveys the information related to or used for certificate identification SEGMETS USED I CSC DECEMBER 1996 COMPOSITE DATA EEMET DIRECTORY 9

003070 CERTIFICATE OOK-UP IFORMATIO C050 TRASACTIO SETS USED I 815 SYTAX OTES 1 P05060708 - If either C05005, C05006, C05007 or C0 - If either C05005, C05006, C05007, C05008, C050 -, C050 I, C050f, C050ei, C050th, C050er, C050 C, C05005, C05000, C0505,, C050 C, C05005, C05000, C0506,, C050 C, C05005, C05000, C0507, C050or or C050 C are present, then the others are required. 2 P09101112 - If either C05009, C05010, C05011 or C0 - If either C05009, C05010, C05011, C05012, C050 -, C050 I, C050f, C050ei, C050th, C050er, C050 C, C05005, C05000, C0509,, C050 C, C05005, C05001, C0500,, C050 C, C05005, C05001, C0501, C050or or C050 C are present, then the others are required. C05001 1675 C05002 1570 C05003 799 C05004 1565 C05005 1675 C05006 1570 C050 ookup Val Protocol Cd Filter ook-up Value ookup Val Protocol Cd Filter M 22 M 33 M A 130 M A 14096 C 22 C 33 C05007 799 C05008 1565 C05009 1675 C05010 1570 C05011 799 C05012 1565 ook-up Value ookup Val Protocol Cd Filter ook-up Value C A 130 C A 14096 C 22 C 33 C A 130 C A 14096 DECEMBER 1996 COMPOSITE DATA EEMET DIRECTORY 10