Common use of SEQ Clause in Contracts

SEQ. 011600 011700 TX-HEADER ZERO ZERO ZERO ZERO ZERO ZERO 00 ZERO 011800 PROVIDER PPPPP ZERO ZERO ZERO ZERO ZERO 01 ZERO 011900 SUBSCRIBER PPPPP SSSSS ZERO ZERO ZERO ZERO 02 ZERO 012000 PATIENT PPPPP SSSSS TTTTT ZERO ZERO ZERO 03 ZERO 012100 CLAIM PPPPP SSSSS TTTTT CCCCC ZERO ZERO 04 ZERO 012200 OTHER-SUBS-INFO PPPPP SSSSS TTTTT CCCCC ZERO HHHHH 05 ZERO 012300 CLAIM-LVL-ADJ PPPPP SSSSS TTTTT CCCCC ZERO HHHHH 06 1-999 012400 SVC-LINE PPPPP SSSSS TTTTT CCCCC LLLLL ZERO 07 ZERO 012500 LINE-DRUG-ID PPPPP SSSSS TTTTT CCCCC LLLLL ZERO 09 1-25 012600 LINE-LVL-ADJ PPPPP SSSSS TTTTT CCCCC LLLLL ZERO 08 1-999 012700 TX-TRAILER 99999 SSSSS TTTTT CCCCC ZERO ZERO 99 99999 012800 012900 013000 013100 013200 837I – TRANSACTION HEADER RECORD 013300 013400 013500 01 X837I-TX-HEADER. 013600 013700 05 X837I-RECORD-CODE 013800 PIC X(02). 013900 014000 05 X837I-SORT-KEY. 014100 014200 10 X837I-PROV-SEQ-NUM 014300 VALUE ZEROES 014400 PIC 9(11). 014500 014600 10 X837I-SUBSCRIBER-SEQ-NUM 014700 VALUE ZEROES 014800 PIC 9(11). 014900 015000 10 X837I-PATIENT-SEQ 015100 VALUE ZEROES 015200 PIC 9(11). 015300 015400 10 X837I-CLAIM-SEQ 015500 VALUE ZEROES 015600 PIC 9(11). 015700 015800 10 X837I-SVC-LINE-SEQ 015900 VALUE ZEROES 016000 PIC 9(11). 016100 016200 016300 SUB-SEQ IS THE ‘OTHER-SUBSCRIBER-SEQ’ WHEN USED ON A 016400 ‘OTHER-SUBSCRIBER-INFO’ RECORD OR A ‘CLAIM-LVL-ADJ’RECORD. 016500 016600 016700 10 X837I-SUB-SEQ 016800 VALUE ZEROES 016900 PIC 9(11). 017000 017100 10 X837I-TX-CODE 017200 VALUE ‘00’ 017300 PIC X(02). 017400 017500 10 X837I-TX-CODE-SEQ-NUM 017600 VALUE ZEROES 017700 PIC 9(07). 017800 017900 END OF HDR SORT-KEY. 018000 018100 018200 018300 05 X837I-TX-HEADER-SEG. 018400

SEQ. 011600 011700 001250 001260 TX-HEADER ZERO ZERO ZERO ZERO ZERO ZERO 00 ZERO 011800 001270 PROVIDER PPPPP ZERO ZERO ZERO ZERO ZERO 01 ZERO 011900 001280 SUBSCRIBER PPPPP SSSSS ZERO ZERO ZERO ZERO 02 ZERO 012000 001290 PATIENT PPPPP SSSSS TTTTT ZERO ZERO ZERO 03 ZERO 012100 001300 CLAIM PPPPP SSSSS TTTTT CCCCC ZERO ZERO 04 ZERO 012200 001310 OTHER-SUBS-INFO PPPPP SSSSS TTTTT CCCCC ZERO HHHHH 05 ZERO 012300 001320 CLAIM-LVL-ADJ PPPPP SSSSS TTTTT CCCCC ZERO HHHHH 06 1-999 012400 001330 SVC-LINE PPPPP SSSSS TTTTT CCCCC LLLLL ZERO 07 ZERO 012500 001340 LINE-DRUG-ID PPPPP SSSSS TTTTT CCCCC LLLLL ZERO 09 1-25 012600 001350 LINE-LVL-ADJ PPPPP SSSSS TTTTT CCCCC LLLLL ZERO 08 1-999 012700 001360 FORM-IDENT-CODE PPPPP SSSSS TTTTT CCCCC LLLLL FFFFF 10 ZERO 001370 TX-TRAILER 99999 SSSSS TTTTT CCCCC ZERO ZERO 99 99999 012800 012900 013000 013100 013200 837I – 001380 001390 001400 001410 001420 837P - TRANSACTION HEADER RECORD 013300 013400 013500 001430 001440 001450 01 X837IX837P-TX-HEADER. 013600 013700 001460 001470 05 X837IX837P-RECORD-CODE 013800 001480 PIC X(02). 013900 014000 001490 001500 05 X837IX837P-SORT-KEY. 014100 014200 001510 001520 10 X837IX837P-PROV-SEQ-NUM 014300 001530 VALUE ZEROES 014400 001540 PIC 9(11). 014500 014600 001550 001560 10 X837IX837P-SUBSCRIBER-SEQ-NUM 014700 001570 VALUE ZEROES 014800 001580 PIC 9(11). 014900 015000 001590 001600 10 X837IX837P-PATIENT-SEQ 015100 001610 VALUE ZEROES 015200 001620 PIC 9(11). 015300 015400 001630 001640 10 X837IX837P-CLAIM-SEQ 015500 001650 VALUE ZEROES 015600 001660 PIC 9(11). 015700 015800 001670 001680 10 X837IX837P-SVC-LINE-SEQ 015900 001690 VALUE ZEROES 016000 001700 PIC 9(11). 016100 016200 016300 001710 001720 001730 SUB-SEQ IS THE ‘OTHER-SUBSCRIBER-SEQ’ WHEN USED ON A 016400 001740 ‘OTHER-SUBSCRIBER-INFO’ RECORD OR A ‘CLAIM-LVL-ADJ’ RECORD. 001750 001760 SUB-SEQ IS THE ‘FORM-IDENT-SEQ’ WHEN USED ON A 001770 ‘FORM-IDENT-CODE’ RECORD. 001780 001790 10 X837P-SUB-SEQ 001800 VALUE ZEROES 001810 PIC 9(11). 001820 001830 10 X837P-TX-CODE 001840 VALUE ‘00’ 001850 PIC X(02). 001860 001870 10 X837P-TX-CODE-SEQ-NUM 001880 VALUE ZEROES 001890 PIC 9(07). 001900 001910 END OF HDR SORT-KEY 001920 001930 001940 001950 05 X837P-TX-HEADER-SEG. 001960 001970 10 X837P-TX-ID 001980 VALUE ‘837’ 001990 PIC X(03). 002000 10 X837P-TX-CTL-NUM 002010 PIC X(09). 002020 10 FILLER 002030 PIC X(10). 002040 002050 05 X837P-BEG-SEGMENT. 002060 002070 10 X837P-TX-HIERACH-STRUCT-CODE 002080 PIC X(04). 002090 10 X837P-TX-PURPOSE-CODE 002100 PIC X(02). 002110 10 X837P-TX-ID-CODE 002120 PIC X(30). 002130 10 X837P-TX-CREATION-DATE 002140 PIC X(08). 002150 10 X837P-TX-CREATION-TIME 002160 PIC X(08). 002170 10 X837P-TX-TYPE-CODE 002180 PIC X(02). 002190 10 FILLER 002200 PIC X(10). 002210 002220 05 X837P-XMIT-TYPE-ID-SEG. 002230 10 X837P-XMIT-REF-ID-CODE 002240 PIC X(02). 002250 10 X837P-XMIT-REF-ID 002260 PIC X(30). 002270 10 FILLER 002280 PIC X(10). 002290 002300 05 X837P-SUBMITTER-NAME-SEG. 002310 002320 10 X837P-SUBMITTER-ENTITY-CODE 002330 PIC X(02). 002340 10 X837P-SUBMITTER-NAME-LAST 002350 PIC X(35). 002360 10 X837P-SUBMITTER-NAME-FIRST 002370 PIC X(25). 002380 10 X837P-SUBMITTER-NAME-MIDDLE 002390 PIC X(25). 002400 10 X837P-SUBMITTER-ID-CODE 002410 PIC X(80). 002420 10 FILLER 002430 PIC X(10). 002440 002450 05 X837P-SUBMITTER-CONTACT-SEG 002460 OCCURS 2 TIMES 002470 INDEXED BY X837P-SUBMITTER-CONTACT-NDX. 002480 002490 10 X837P-CONTACT-NAME 002500 PIC X(60). 002510 10 X837P-COMMUNICATION-TYPE-CODE 002520 PIC X(02). 002530 10 X837P-COMMUNICATION-NUMBER 002540 PIC X(80). 002550 10 FILLER 002560 PIC X(10). 002570 002580 05 X837P-RECEIVER-NAME-SEG. 002590 002600 10 X837P-RECEIVER-NAME-LAST 002610 PIC X(35). 002620 10 X837P-RECEIVER-ID-CODE 002630 PIC X(80). 002640 10 FILLER 002650 PIC X(10). 002660 002670 002680 002690 002700 837P - DETAIL, BILLING/PAY-TO PROVIDER 002710 002720 002730 837P LOOP 2000A DETAIL, BILLING/PAY-TO PROVIDER 002740 002750 01 X837P-PROVIDER. 002760 002770 05 X837P-RECORD-CODE 002780 PIC X(02). 002790 002800 05 X837P-SORT-KEY. 002810 002820 10 X837P-PROV-SEQ-NUM 002830 VALUE ZEROES 002840 PIC 9(11). 002850 002860 10 X837P-SUBSCRIBER-SEQ-NUM 002870 VALUE ZEROES 002880 PIC 9(11). 002890 002900 10 X837P-PATIENT-SEQ 002910 VALUE ZEROES 002920 PIC 9(11). 002930 002940 10 X837P-CLAIM-SEQ 002950 VALUE ZEROES 002960 PIC 9(11). 002970 002980 10 X837P-SVC-LINE-SEQ 002990 VALUE ZEROES 003000 PIC 9(11). 003010 003020 003030 SUB-SEQ IS THE ‘OTHER-SUBSCRIBER-SEQ’ WHEN USED ON A 003040 ‘OTHER-SUBSCRIBER-INFO’ RECORD OR A ‘CLAIM-LVL-ADJ’ RECORD. 003050 003060 SUB-SEQ IS THE ‘FORM-IDENT-SEQ’ WHEN USED ON A 003070 ‘FORM-IDENT-CODE’ RECORD. 003080 003090 10 X837P-SUB-SEQ 003100 VALUE ZEROES 003110 PIC 9(11). 003120 003130 10 X837P-TX-CODE 003140 VALUE ‘01’ 003150 PIC X(02). 003160 003170 10 X837P-TX-CODE-SEQ-NUM 003180 VALUE ZEROES 003190 PIC 9(07). 003200 003210 END OF HDR SORT-KEY 003220 003230 003240 003250 LOOP-ID-2000A 003260 003270 05 X837P-PROV-HIERACHICAL-LVL-SEG. 003280 003290 10 X837P-PROV-HIER-NBR 003300 PIC X(12). 003310 10 X837P-PROV-HIER-LVL-CODE 003320 PIC X(02). 003330 10 X837P-PROV-HIER-CHILD-CODE 003340 PIC X(01). 003350 10 FILLER 003360 PIC X(10). 003370 003380 003390 05 X837P-PROV-SPECIALTY-INFO-SEG. 003400 003410 10 X837P-PROV-TYPE-CODE 003420 PIC X(03). 003430 10 X837P-PROV-SPECIALTY-CODE 003440 PIC X(30). 003450 10 FILLER 003460 PIC X(10). 003470 003480 05 X837P-CURRENCY-INFO-SEG. 003490 003500 10 X837P-CURRENCY-CODE 003510 PIC X(03). 003520 10 FILLER 003530 PIC X(10). 003540 003550 LOOP-ID-2010AA 003560 003570 05 X837P-BILLING-PROV-NAME-SEG. 003580 003590 10 X837P-▇▇▇▇-PROV-ENTITY-CODE 003600 PIC X(01). 003610 10 X837P-▇▇▇▇-PROV-NAME-LAST 003620 PIC X(35). 003630 10 X837P-▇▇▇▇-PROV-NAME-FIRST 003640 PIC X(25). 003650 10 X837P-▇▇▇▇-PROV-NAME-MIDDLE 003660 PIC X(25). 003670 10 X837P-▇▇▇▇-PROV-NAME-SFX 003680 PIC X(10). 003690 10 X837P-▇▇▇▇-PROV-ID-CODE 003700 PIC X(02). 003710 10 X837P-▇▇▇▇-PROV-ID-NBR 003720 PIC X(80). 003730 10 FILLER 003740 PIC X(10). 003750 003760 05 X837P-▇▇▇▇-PROV-ADDR-SEG. 003770 003780 10 X837P-▇▇▇▇-PROV-ADDR1 003790 PIC X(55). 003800 10 X837P-▇▇▇▇-PROV-ADDR2 003810 PIC X(55). 003820 10 FILLER 003830 PIC X(10). 003840 003850 05 X837P-▇▇▇▇-PROV-LOC-SEG. 003860 003870 10 X837P-▇▇▇▇-PROV-CITY 003880 PIC X(30). 003890 10 X837P-▇▇▇▇-PROV-STATE 003900 PIC X(02). 003910 10 X837P-▇▇▇▇-PROV-ZIP 003920 PIC X(15). 003930 10 X837P-▇▇▇▇-PROV-COUNTRY 003940 PIC X(03). 003950 10 FILLER 003960 PIC X(10). 003970 003980 05 X837P-▇▇▇▇-PROV-2ND-IDENT-SEG. 003990 OCCURS 8 TIMES 004000 INDEXED BY X837P-▇▇▇▇-PROV-2ND-IDENT-NDX. 004010 004020 10 X837P-▇▇▇▇-PROV-2ND-ID-CODE 004030 PIC X(03). 004040 10 X837P-▇▇▇▇-PROV-2ND-ID 004050 PIC X(30). 004060 10 FILLER 004070 PIC X(10). 004080 004090 05 X837P-▇▇▇▇-PROV-BANK-CARD-SEG 004100 OCCURS 8 TIMES 004110 INDEXED BY X837P-▇▇▇▇-PROV-BANK-CARD-NDX. 004120 004130 10 X837P-▇▇▇▇-PROV-CRDT-CRD-ID-TP 004140 PIC X(03). 004150 10 X837P-▇▇▇▇-PROV-CRDT-CRD-ID 004160 PIC X(30). 004170 10 FILLER 004180 PIC X(10). 004190 004200 05 X837P-▇▇▇▇-PROV-CONTACT-SEG 004210 OCCURS 2 TIMES 004220 INDEXED BY X837P-▇▇▇▇-PROV-CONTACT-NDX. 004230 004240 10 X837P-▇▇▇▇-PRV-CONTACT-NAME 004250 PIC X(60). 004260 10 X837P-▇▇▇▇-PRV-CONTACT-NB-TP-1 004270 PIC X(02). 004280 10 X837P-▇▇▇▇-PRV-CONTACT-NB-1 004290 PIC X(80). 004300 10 X837P-▇▇▇▇-PRV-CONTACT-NB-TP-2 004310 PIC X(02). 004320 10 X837P-▇▇▇▇-PRV-CONTACT-NB-2 004330 PIC X(80). 004340 10 X837P-▇▇▇▇-PRV-CONTACT-NB-TP-3 004350 PIC X(02). 004360 10 X837P-▇▇▇▇-PRV-CONTACT-NB-3 004370 PIC X(80). 004380 10 FILLER 004390 PIC X(10). 004400 004410 LOOP-ID-2010AB 004420 004430 05 X837P-PAY-TO-PROV-NAME-SEG. 004440 004450 10 X837P-PAYTO-PROV-ENTITY-CODE 004460 PIC X(01). 004470 10 X837P-PAYTO-PROV-NAME-LAST 004480 PIC X(35). 004490 10 X837P-PAYTO-PROV-NAME-FIRST 004500 PIC X(25). 004510 10 X837P-PAYTO-PROV-NAME-MIDDLE 004520 PIC X(25). 004530 10 X837P-PAYTO-PROV-NAME-SFX 004540 PIC X(10). 004550 10 X837P-PAYTO-PROV-ID-CODE 004560 PIC X(02). 004570 10 X837P-PAYTO-PROV-ID-NBR 004580 PIC X(80). 004590 10 FILLER 004600 PIC X(10). 004610 004620 05 X837P-PAY-TO-PROV-ADDR-SEG. 004630 004640 10 X837P-PAYTO-PROV-ADDR1 004650 PIC X(55). 004660 10 X837P-PAYTO-PROV-ADDR2 004670 PIC X(55). 004680 10 FILLER 004690 PIC X(10). 004700 004710 05 X837P-PAYTO-PROV-LOC-SEG. 004720 004730 10 X837P-PAYTO-PROV-CITY 004740 PIC X(30). 004750 10 X837P-PAYTO-PROV-STATE 004760 PIC X(02). 004770 10 X837P-PAYTO-PROV-ZIP 004780 PIC X(15). 004790 10 X837P-PAYTO-PROV-COUNTRY 004800 PIC X(03). 004810 004820 05 X837P-PAYTO-PROV-2ND-ID-SEG. 004830 OCCURS 5 TIMES 004840 INDEXED BY X837P-PAYTO-PROV-2ND-ID-NDX. 004850 004860 10 X837P-PAYTO-PROV-2ND-ID-CODE 004870 PIC X(03). 004880 10 X837P-PAYTO-PROV-2ND-ID 004890 PIC X(30). 004900 10 FILLER 004910 PIC X(10). 004920 004930 004940 004950 837P - SUBSCRIBER 004960 004970 004980 004990 837P DETAIL, SUBSCRIBER HIERARCHAL LEVEL 005000 005010 01 X837P-SUBSCRIBER. 005020 005030 05 X837P-RECORD-CODE 005040 PIC X(02). 005050 005060 05 X837P-SORT-KEY. 005070 005080 10 X837P-PROV-SEQ-NUM 005090 VALUE ZEROES 005100 PIC 9(11). 005110 005120 10 X837P-SUBSCRIBER-SEQ-NUM 005130 VALUE ZEROES 005140 PIC 9(11). 005150 005160 10 X837P-PATIENT-SEQ 005170 VALUE ZEROES 005180 PIC 9(11). 005190 005200 10 X837P-CLAIM-SEQ 005210 VALUE ZEROES 005220 PIC 9(11). 005230 005240 10 X837P-SVC-LINE-SEQ 005250 VALUE ZEROES 005260 PIC 9(11). 005270 005280 005290 SUB-SEQ IS THE ‘OTHER-SUBSCRIBER-SEQ’ WHEN USED ON A 005300 ‘OTHER-SUBSCRIBER-INFO’ RECORD OR A ‘CLAIM-LVL-ADJ’RECORD. 016500 016600 016700 005310 005320 SUB-SEQ IS THE ‘FORM-IDENT-SEQ’ WHEN USED ON A 005330 ‘FORM-IDENT-CODE’ RECORD. 005340 005350 10 X837IX837P-SUB-SEQ 016800 005360 VALUE ZEROES 016900 005370 PIC 9(11). 017000 017100 005380 005390 10 X837IX837P-TX-CODE 017200 005400 VALUE ‘0002’ 017300 005410 PIC X(02). 017400 017500 005420 005430 10 X837IX837P-TX-CODE-SEQ-NUM 017600 005440 VALUE ZEROES 017700 005450 PIC 9(07). 017800 017900 005460 005470 END OF HDR SORT-KEY 005480 005500 005510 LOOP-ID-2000B 005520 005530 05 X837P-SUBS-HIERACHICAL-LVL-SEG. 005540 005550 10 X837P-SUBS-HIER-NBR 005560 PIC X(12). 005570 10 X837P-SUBS-HIER-PARENT-NBR 005580 PIC X(12). 005590 10 X837F-SUBS-HIER-LVL-CODE 005600 PIC X(02). 005610 10 X837P-SUBS-HIER-CHILD-CODE 005620 PIC X(01). 005630 10 FILLER 005640 PIC X(10). 005650 005660 05 X837P-SUBSCRIBER-INFO-SEG. 005670 005680 10 X837P-SUBS-PYR-RESPONS-SEQ-CD 005690 PIC X(01). 005700 10 X837P-SUBS-RELATIONSHIP-CODE 005710 PIC X(02). 005720 10 X837P-SUBS-POLICY-NBR 005730 PIC X(30). 005740 10 X837P-SUBS-PLAN-NAME 005750 PIC X(60). 005760 10 X837P-SUBS-INSURANCE-TYPE-CODE 005770 PIC X(03). 005780 10 X837P-SUBS-CLAIM-FILING-IND-CD 005790 PIC X(02). 005800 10 FILLER 005810 PIC X(10). 005820 005830 05 X837P-SUBS-PATIENT-INFO-SEG. 005840 005850 10 X837P-SUBS-DATE-OF-DEATH 005860 PIC X(08). 005870 10 X837P-SUBS-WEIGHT-CODE 005880 PIC X(02). 005890 10 X837P-SUBS-WEIGHT 005900 PIC 9(5). 005910 10 X837P-SUBS-PREGNANCY-INDICATOR 005920 PIC X(01). 005930 10 FILLER 005940 PIC X(10). 005950 005960 LOOP-ID-2010BA 005970 005980 05 X837P-SUBS-NAME-SEG. 005990 006000 10 X837P-SUBS-TYPE-CODE 006010 PIC X(01). 006020 10 X837P-SUBS-NAME-LAST 006030 PIC X(35). 006040 10 X837P-SUBS-NAME-FIRST 006050 PIC X(25). 006060 10 X837P-SUBS-NAME-MIDDLE 006070 PIC X(25). 006080 10 X837P-SUBS-NAME-SFX 006090 PIC X(10). 006100 10 X837P-SUBS-ID-CODE-TYPE 006110 PIC X(02). 006120 10 X837P-SUBS-ID-CODE 006130 PIC X(80). 006140 10 FILLER 006150 PIC X(10). 006160 006170 05 X837P-SUBS-ADDR-SEG. 006180 006190 10 X837P-SUBS-ADDR1 006200 PIC X(55). 006210 10 X837P-SUBS-ADDR2 006220 PIC X(55). 006230 10 FILLER 006240 PIC X(10). 006250 006260 05 X837P-SUBS-CITY-STATE-SEG. 006270 006280 10 X837P-SUBS-CITY 006290 PIC X(30). 006300 10 X837P-SUBS-STATE-CODE 006310 PIC X(02). 006320 10 X837P-SUBS-ZIP-CODE 006330 PIC X(15). 006340 10 X837P-SUBS-COUNTRY-CODE 006350 PIC X(03). 006360 10 FILLER 006370 PIC X(10). 006380 006390 05 X837P-SUBS-DEMOGRAPHIC-SEG. 006400 006410 10 X837P-OTHR-INSURED-DOB 006420 PIC X(08). 006430 10 X837P-OTHR-GENDER-CODE 006440 PIC X(01). 006450 10 FILLER 006460 PIC X(10). 006470 006480 05 X837P-SUBS-2ND-ID-SEG. 006490 OCCURS 4 TIMES 006500 INDEXED BY X837P-SUBS-2ND-ID-NDX. 006510 006520 10 X837P-SUBS-2ND-ID-TYPE 006530 PIC X(03). 006540 10 X837P-SUBS-2ND-ID 006550 PIC X(30). 006560 10 FILLER 006570 PIC X(10). 006580 006590 05 X837P-SUBS-PROP-CLAIM-NBR-SEG. 006600 006610 10 X837P-SUBS-PROP-CLAIM-NBR 006620 PIC X(30). 006630 10 FILLER 006640 PIC X(10). 006650 006660 LOOP-ID-2010BB 006670 006680 05 X837P-PAYER-NAME-SEG. 006690 006700 10 X837P-PAYER-NAME 006710 PIC X(35). 006720 10 X837P-PAYER-ID-CODE-TYPE 006730 PIC X(02). 006740 10 X837P-PAYER-ID-CODE 006750 PIC X(80). 006760 10 FILLER 006770 PIC X(10). 006780 006790 05 X837P-PAYER-ADDR-SEG. 006800 006810 10 X837P-PAYER-ADDR1 006820 PIC X(55). 006830 10 X837P-PAYER-ADDR2 006840 PIC X(55). 006850 10 FILLER 006860 PIC X(10). 006870 006880 05 X837P-PAYER-CITY-STATE-SEG. 006890 006900 10 X837P-PAYER-CITY 006910 PIC X(30). 006920 10 X837P-PAYER-STATE-CODE 006930 PIC X(02). 006940 10 X837P-PAYER-ZIP-CODE 006950 PIC X(15). 006960 10 X837P-PAYER-COUNTRY-CODE 006970 PIC X(03). 006980 10 FILLER 006990 PIC X(10). 007000 007010 05 X837P-PAYER-2ND-ID-SEG 007020 OCCURS 3 TIMES 007030 INDEXED BY X837P-PAYER-2ND-ID-NDX. 007040 007050 10 X837P-PAYER-2ND-ID-TYPE 007060 PIC X(03). 007070 10 X837P-PAYER-2ND-ID 007080 PIC X(30). 007090 10 FILLER 007100 PIC X(10). 007110 007120 05 X837P-PAYER-PROP-CLAIM-NBR-SEG. 007130 007140 10 X837P-PAYER-PROP-CLAIM-NBR 007150 PIC X(30). 007160 10 FILLER 007170 PIC X(10). 007180 007190 LOOP-ID-2010BC 007200 007210 05 X837P-RESPON-PARTY-NAME-SEG. 007220 007230 10 X837P-RESP-PARTY-ENTITY-CODE 007240 PIC X(01). 007250 10 X837P-RESP-PARTY-NAME-LAST 007260 PIC X(35). 007270 10 X837P-RESP-PARTY-NAME-FIRST 007280 PIC X(25). 007290 10 X837P-RESP-PARTY-NAME-MIDDLE 007300 PIC X(25). 007310 10 X837P-RESP-PARTY-NAME-SFX 007320 PIC X(10). 007330 10 FILLER 007340 PIC X(10). 007350 007360 05 X837P-RESPON-PARTY-ADDR-SEG. 007370 007380 10 X837P-RESP-PARTY-ADDR1 007390 PIC X(55). 007400 10 X837P-RESP-PARTY-ADDR2 007410 PIC X(55). 007420 10 FILLER 007430 PIC X(10). 007440 007450 05 X837P-RESPON-PARTY-LOC-SEG. 007460 007470 10 X837P-RESP-PARTY-CITY 007480 PIC X(30). 007490 10 X837P-RESP-PARTY-STATE 007500 PIC X(02). 007510 10 X837P-RESP-PARTY-ZIP 007520 PIC X(15). 007530 10 X837P-RESP-PARTY-COUNTRY 007540 PIC X(03). 007550 10 FILLER 007560 PIC X(10). 007570 007580 LOOP-ID-2010BD 007590 007600 05 X837P-CARD-HOLDER-NAME-SEG. 007610 007620 10 X837P-CARD-HLDR-TYPE-CODE 007630 PIC X(01). 007640 10 X837P-CARD-HLDR-NAME-LAST 007650 PIC X(35). 007660 10 X837P-CARD-HLDR-NAME-FIRST 007670 PIC X(25). 007680 10 X837P-CARD-HLDR-NAME-MIDDLE 007690 PIC X(25). 007700 10 X837P-CARD-HLDR-NAME-SFX 007710 PIC X(10). 007720 10 X837P-CARD-HLDR-ID-CODE-TYPE 007730 PIC X(02). 007740 10 X837P-CARD-HLDR-ID-CODE 007750 PIC X(80). 007760 10 FILLER 007770 PIC X(10). 007780 007790 05 X837P-CRDT-DBT-CARD-INFO-SEG. 007800 OCCURS 2 TIMES 007810 INDEXED BY X837P-CRDT-DBT-CARD-INFO-NDX. 007820 007830 10 X837P-CRDT-DBT-CARD-AUTH-NBR 007840 PIC X(30). 007850 10 FILLER 007860 PIC X(10). 007870 007880 007890 007900 837P - PATIENT 007910 007920 007930 007940 837P DETAIL, PATIENT HIERARCHAL LEVEL 007950 007960 01 X837P-PATIENT. 007970 007980 05 X837P-RECORD-CODE 007990 PIC X(02). 008000 008010 05 X837P-SORT-KEY. 018000 018100 018200 018300 05 X837I008020 008030 10 X837P-PROV-SEQ-NUM 008040 VALUE ZEROES 008050 PIC 9(11). 008060 008070 10 X837P-SUBSCRIBER-SEQ-NUM 008080 VALUE ZEROES 008090 PIC 9(11). 008100 008110 10 X837P-PATIENT-SEQ 008120 VALUE ZEROES 008130 PIC 9(11). 008140 008150 10 X837P-CLAIM-SEQ 008160 VALUE ZEROES 008170 PIC 9(11). 008180 008190 10 X837P-SVC-LINE-SEQ 008200 VALUE ZEROES 008210 PIC 9(11). 008220 008230 008240 SUB-SEQ IS THE ‘OTHER-SUBSCRIBER-SEQ’ WHEN USED ON A 008250 ‘OTHER-SUBSCRIBER-INFO’ RECORD OR A ‘CLAIM-LVL-ADJ’ RECORD. 008260 008270 SUB-SEQ IS THE ‘FORM-IDENT-SEQ’ WHEN USED ON A 008280 ‘FORM-IDENT-CODE’ RECORD. 008290 008300 10 X837P-SUB-SEQ 008310 VALUE ZEROES 008320 PIC 9(11). 008330 008340 10 X837P-TX-HEADERCODE 008350 VALUE ‘03’ 008360 PIC X(02). 008370 008380 10 X837P-TX-CODE-SEQ-NUM 008390 VALUE ZEROES 008400 PIC 9(07). 008410 008420 END OF HDR SORT-KEY 008430 008440 008450 008460 LOOP-ID-2000C 008470 008480 05 X837P-▇▇▇-HIERACHICAL-LVL-SEG. 018400008490 008500 10 X837P-▇▇▇-HIER-NBR 008510 PIC X(12). 008520 10 X837P-▇▇▇-HIER-PARENT-NBR 008530 PIC X(12). 008540 10 X837P-▇▇▇-HIER-LVL-CODE 008550 PIC X(02). 008560 10 X837P-▇▇▇-HIER-CHILD-CODE 008570 PIC X(01). 008580 10 FILLER 008590 PIC X(10). 008600 008610 05 X837P-PATIENT-INFO-SEG. 008620 008630 10 X837P-▇▇▇-RELATIONSHIP-CODE 008640 PIC X(02). 008650 10 X837P-▇▇▇-DATE-OF-DEATH 008660 PIC X(08). 008670 10 X837P-▇▇▇-WEIGHT-CODE 008680 PIC X(02). 008690 10 X837P-▇▇▇-WEIGHT 008700 PIC 9(5). 0

SEQ. 011600 011700 001110 001120 TX-HEADER ZERO ZERO ZERO ZERO ZERO ZERO 00 ZERO 011800 001130 PROVIDER PPPPP ZERO ZERO ZERO ZERO ZERO 01 ZERO 011900 001140 SUBSCRIBER PPPPP SSSSS ZERO ZERO ZERO ZERO 02 ZERO 012000 001150 PATIENT PPPPP SSSSS TTTTT ZERO ZERO ZERO 03 ZERO 012100 001160 CLAIM PPPPP SSSSS TTTTT CCCCC ZERO ZERO 04 ZERO 012200 001170 OTHER-SUBS-INFO PPPPP SSSSS TTTTT CCCCC ZERO HHHHH 05 ZERO 012300 001180 CLAIM-LVL-ADJ PPPPP SSSSS TTTTT CCCCC ZERO HHHHH 06 1-999 012400 001190 SVC-LINE PPPPP SSSSS TTTTT CCCCC LLLLL ZERO 07 ZERO 012500 LINE-DRUG-ID PPPPP SSSSS TTTTT CCCCC LLLLL ZERO 09 1-25 012600 001200 LINE-LVL-ADJ PPPPP SSSSS TTTTT CCCCC LLLLL ZERO 08 1-999 012700 001210 TX-TRAILER 99999 SSSSS TTTTT CCCCC ZERO ZERO 99 99999 012800 012900 013000 013100 013200 837I – 001220 001230 001240 001250 001260 83ZD - TRANSACTION HEADER RECORD 013300 013400 013500 001270 001280 001290 01 X837IX837D-TX-HEADER. 013600 013700 001300 001310 05 X837IX837D-RECORD-CODE 013800 001320 PIC X(02). 013900 014000 001330 001340 05 X837IX837D-SORT-KEY. 014100 014200 001350 001360 10 X837IX837D-PROV-SEQ-NUM 014300 001370 VALUE ZEROES 014400 001380 PIC 9(11). 014500 014600 001390 001400 10 X837IX837D-SUBSCRIBER-SEQ-NUM 014700 001410 VALUE ZEROES 014800 001420 PIC 9(11). 014900 015000 001430 001440 10 X837IX837D-PATIENT-SEQ 015100 001450 VALUE ZEROES 015200 001460 PIC 9(11). 015300 015400 001470 001480 10 X837IX837D-CLAIM-SEQ 015500 001490 VALUE ZEROES 015600 001500 PIC 9(11). 015700 015800 001510 001520 10 X837IX837D-SVC-LINE-SEQ 015900 SEC 001530 VALUE ZEROES 016000 001540 PIC 9(11). 016100 016200 016300 001550 001560 001570 SUB-SEQ IS THE ‘OTHER-SUBSCRIBER-SEQ’ WHEN USED ON A 016400 001580 ‘OTHER-SUBSCRIBER-INFO’ RECORD OR A ‘CLAIM-LVL-ADJ’RECORDADJ’ RECORD. 016500 016600 016700 001590 001600 001610 10 X837IX837D-SUB-SEQ 016800 001620 VALUE ZEROES 016900 001630 PIC 9(11). 017000 017100 001640 001650 10 X837IX837D-TX-CODE 017200 001660 VALUE ‘00’ 017300 001670 PIC X(02)) . 017400 017500 001680 001690 10 X837IX837D-TX-CODE-SEQ-NUM 017600 001700 VALUE ZEROES 017700 001710 PIC 9(07). 017800 017900 001720 001730 END OF HDR SORT-KEY. 018000 018100 018200 018300 KEY 001740 001750 001760 001770 05 X837IX837D-TX-HEADER-SEG. 018400001780 001790 10 X837D-TX-ID 001800 VALUE ‘837’ 001810 PIC X(03). 001820 10 X837D-TX-CTL-NUM 001830 PIC X(09). 001840 10 FILLER 001850 PIC X(10). 001860 001870 05 X837D-BEG-SEGMENT. 001880 001890 10 X837D-TX-HIERACH-STRUCT-CODE 001900 PIC X(04). 001910 10 X837D-TX-PURPOSE-CODE 001920 PIC X(02). 001930 10 X837D-TX-ID-CODE 001940 PIC X(30). 001950 10 X837D-TX-CREATION-DATE 001960 PIC X(08). 001970 10 X837D-TX-CREATION-TIME 001980 PIC X(08). 001990 10 X837D-TX-TYPE-CODE 002000 PIC X(02). 002010 10 FILLER 002020 PIC X(10). 002030 002040 05 X837D-XMIT-TYPE-ID-SEG. 002050 10 X837D-XMIT-REF-ID-CODE 002060 PIC X(03). 002070 10 X837D-XMIT-REF-ID 002080 PIC X(30). 002090 10 FILLER 002100 PIC X(10). 002110 002120 05 X837D-SUBMITTER-NAME-SEG. 002130 002140 10 X837D-SUBMITTER-ENTITY-QUAL 002150 PIC X(01). 002160 10 X837D-SUBMITTER-NAME-LAST 002170 PIC X(35). 002180 10 X837D-SUBMITTER-NAME-FIRST 002190 PIC X(25). 002200 10 X837D-SUBMITTER-NAME-MIDDLE 002210 PIC X(25). 002220 10 X837D-SUBMITTER-ID-CODE 002230 PIC X(80). 002240 10 FILLER 002250 PIC X(10). 002260 002270 05 X837D-SUBMITTER-CONTACT-SEG 002280 OCCURS 2 TIMES 002290 INDEXED BY X837D-SUBMITTER-CONTACT-NDX. 002300 002310 10 X837D-CONTACT-NAME 002320 PIC X(60). 002330 10 X837D-COMMUNICATION-INFO 002340 OCCURS 4 TIMES 002350 INDEXED BY X837D-COMMUNICATION-INFO-NDX. 002360 15 X837D-COMMUNICATION-QUAL 002370 PIC X(02). 002380 15 X837D-COMMUNICATION-NUMBER 002390 PIC X(80). 002400 10 FILLER 002410 PIC X(10). 002420 002430 05 X837D-RECEIVER-NAME-SEG. 002440 002450 10 X837D-RECEIVER-NAME-LAST 002460 PIC X(35). 002470 10 X837D-RECEIVER-ID-CODE 002480 PIC X(80). 002490 10 FILLER 002500 PIC X(10). 002510 002520 002530 002540 002550 837D - DETAIL, BILLING/PAY-TO PROVIDER 002560 002570 002580 837D LOOP 2000A DETAIL, BILLING/PAY-TO PROVIDER 002590 002600 01 X837D-PROVIDER. 002610 002620 05 X837D-RECORD-CODE 002630 PIC X(02). 002640 002650 05 X837D-SORT-KEY. 002660 002670 10 X837D-PROV-SEQ-NUM 002680 VALUE ZEROES 002690 PIC 9(11). 002700 002710 10 X837D-SUBSCRIBER-SEQ-NUM 002720 VALUE ZEROES 002730 PIC 9(11). 002740 002750 10 X837D-PATIENT-SEQ 002760 VALUE ZEROES 002770 PIC 9(11). 002780 002790 10 X837D-CLAIM-SEQ 002800 VALUE ZEROES 002810 PIC 9(11). 002820 002830 10 X837D-SVC-LINE-SEQ 002840 VALUE ZEROES 002850 PIC 9(11). 002860 002870 002880 SUB-SEQ IS THE ‘OTHER-SUBSCRIBER-SEQ’ WHEN USED ON A 002890 ‘OTHER-SUBSCRIBER-INFO’ RECORD OR A ‘CLAIM-LVL-ADJ’ RECORD. 002900 002910 002920 10 X837D-SUB-SEQ 002930 VALUE ZEROES 002940 PIC 9(11). 002950 002960 10 X837D-TX-CODE 002970 VALUE ‘01’ 002980 PIC X(02). 002990 003000 10 X837D-TX-CODE-SEQ-NUM 003010 VALUE ZEROES 003020 PIC 9(07). 003030 003040 END OF HDR SORT-KEY 003050 003060 003070 003080 LOOP-ID-2000A 003090 003100 05 X837D-PROV-HIERACHICAL-LVL-SEG. 003110 003120 10 X837D-PROV-HIER-NBR 003130 PIC X(12). 003140 10 X837D-PROV-HIER-LVL-CODE 003150 PIC X(02). 003160 10 X837D-PROV-HIER-CHILD-CODE 003170 PIC X(01). 003180 10 FILLER 003190 PIC X(10). 003200 003210 05 X837D-PROV-SPECIALTY-INFO-SEG. 003220 003230 10 X837D-PROV-TYPE-CODE 003240 PIC X(03). 003250 10 X837D-PROV-SPECIALTY-CODE 003260 PIC X(30). 003270 10 FILLER 003280 PIC X(10). 003290 003300 05 X837D-CURRENCY-INFO-SEG. 003310 003320 10 X837D-CURRENCY-CODE 003330 PIC X(03). 003340 10 FILLER 003350 PIC X(10). 003360 003370 LOOP-ID-2010AA 003380 003390 05 X837D-BILLING-PROV-NAME-SEG. 003400 003410 10 X83ZD-▇▇▇▇-PROV-TYPE-CODE 003420 PIC X(01). 003430 10 X83ZD-▇▇▇▇-PROV-NAME-LAST 003440 PIC X(35). 003450 10 X83ZD-▇▇▇▇-PROV-NAME-FIRST 003460 PIC X(25). 003470 10 X83ZD-▇▇▇▇-PROV-NAME-MIDDLE 003480 PIC X(25). 003490 10 X83ZD-▇▇▇▇-PROV-NAME-SFX 003500 PIC X(10). 003510 10 X83ZD-▇▇▇▇-PROV-ID-CODE-TYPE 003520 PIC X(02). 003530 10 X83ZD-▇▇▇▇-PROV-ID-CODE 003540 PIC X(80). 003550 10 FILLER 003560 PIC X(10). 003570 003580 05 X837D-▇▇▇▇-PROV- ADDR-SEG. 003590 003600 10 X837D-▇▇▇▇-PROV-ADDR1 003610 PIC X(55). 003620 10 X837D-▇▇▇▇-PROV-ADDR2 003630 PIC X(55). 003640 10 FILLER 003650 PIC X(10). 003660 003670 05 X837D-▇▇▇▇-PROV- LOC-SEG. 003680 003690 10 X837D-▇▇▇▇-PROV- CITY 003700 PIC X(30). 003710 10 X837D-▇▇▇▇-PROV-STATE 003720 PIC X(02). 003730 10 X837D-▇▇▇▇-PROV-ZIP 003740 PIC X(15). 003750 10 X837D-▇▇▇▇-PROV-COUNTRY 003760 PIC X(03). 003770 10 FILLER 003780 PIC X(10). 003790 003800 05 X837D-▇▇▇▇-PROV-2ND-IDENT-SEG 003810 OCCURS 5 TIMES 003820 INDEXED BY X837D-▇▇▇▇-PROV-2ND-IDENT-NDX. 003830 003840 10 X837D-▇▇▇▇-PROV-2ND-ID-CODE 003850 PIC X(03). 003860 10 X837D-▇▇▇▇-PROV-2ND-ID 003870 PIC X(30). 003880 10 FILLER 003890 PIC X(10). 003900 003910 05 X837D-SUBMITTER-BANK-CARD-SEG 003920 OCCURS 8 TIMES 003930 INDEXED BY X837D-SUBMITTER-BANK-CARD-NDX. 003940 003950 10 X837D-SUBMITTER-CRDT-CRD-ID-TP 003960 PIC X(03). 003970 10 X837D-SUBMITTER-CRDT-CRD-ID 003980 PIC X(30). 003990 10 FILLER 004000 PIC X(10). 004010 004020 LOOP-ID-2010AB 004030 004040 05 X8 3ZD-PAYTO-PROV-NAME-SEG. 004050 004060 10 X8 3ZD-PAYTO-PROV-TYPE-CODE 004070 PIC X(01). 004080 10 X83ZD-PAYTO-PROV-NAME-LAST 004090 PIC X(35). 004100 10 X83ZD-PAYTO-PROV-NAME-FIRST 004110 PIC X(25). 004120 10 X83ZD-PAYTO-PROV-NAME-MIDDLE 004130 PIC X(25). 004140 10 X83ZD-PAYTO-PROV-NAME-SFX 004150 PIC X(10). 004160 10 X83ZD-PAYTO-PROV-ID-CODE-TYPE 004170 PIC X(02). 004180 10 X83ZD-PAYTO-PROV-ID-CODE 004190 PIC X(80). 004200 10 FILLER 004210 PIC X(10). 004220 004230 05 X837D-PAYTO-PROV-ADDR-SEG. 004240 004250 10 X837D-PAYTO-PROV-ADDR1 004260 PIC X(55). 004270 10 X837D-PAYTO-PROV-ADDR2 004280 PIC X(55). 004290 10 FILLER 004300 PIC X(10). 004310 004320 05 X837D-PAYTO-PROV-LOC-SEG. 004330 004340 10 X837D-PAYTO-PROV-CITY 004350 PIC X(30). 004360 10 X837D-PAYTO-PROV-STATE 004370 PIC X(02). 004380 10 X837D-PAYTO-PROV-ZIP 004390 PIC X(15). 004400 10 X837D-PAYTO-PROV-COUNTRY 004410 PIC X(03). 004420 10 FILLER 004430 PIC X(10). 004440 004450 05 X837D-PAYTO-PROV-2ND-ID-SEG. 004460 OCCURS 5 TIMES 004470 INDEXED BY X837D-PAYTO-PROV-2ND-ID-NDX. 004480 004490 10 X837D-PAYTO-PROV-2ND-ID-CODE 004500 PIC X(03). 004510 10 X837D-PAYTO-PROV-2ND-ID 004520 PIC X(30). 004530 10 FILLER 004540 PIC X(10). 004550 004560 004570 004580 837D - SUBSCRIBER 004590 004600 004610 004620 837D DETAIL, SUBSCRIBER HIERARCHAL LEVEL 004630 004640 01 X837D-SUBSCRIBER. 004650 004660 05 X837D-RECORD-CODE 004670 PIC X(02). 004680 004690 05 X837D-SORT-KEY.