Claim Required Data Elements - InstaMed Developer Portal

837 Claim Required Data Elements

InstaMed requires the following data elements to be present in all 837 claim submissions:

Data Element Name	Loop	Segment/Data Element ID
Billing Provider Entity ID Code	2010AA	NM101
Billing Provider Entity Type Qualifier	2010AA	NM102
Billing Provider Last/Org Name	2010AA	NM103
Billing Provider ID Code Qualifier	2010AA	NM108
Billing Provider ID Code	2010AA	NM109
Subscriber Entity ID Code	2010BA	NM101
Subscriber Entity Type Qualifier	2010BA	NM102
Subscriber (i.e., Insurance) Org Name	2010BA	NM103
Subscriber First Name	2010BA	NM104
Subscriber ID Code Qualifier	2010BA	NM108
Subscriber ID Code	2010BA	NM109
Payer Entity ID Code	2010BB	NM101
Payer Entity Type Qualifier	2010BB	NM102
Payer Org Name	2010BB	NM103
Payer ID Code Qualifier	2010BB	NM108
Payer ID Code	2010BB	NM109
Patient Relationship Code	2000B or	SBR02 or PAT01
Patient Relationship Code	2000C	SBR02 or PAT01
Patient Date of Birth	2010BA or	DMG01 and DMG02
Patient Date of Birth	2010CA	DMG01 and DMG02
Patient Gender	2010BA or	DMG03
Patient Gender	2010CA	DMG03
Patient Last Name	2010BA or	NM103
Patient Last Name	2010CA	NM103
Patient First Name	2010BA or	NM104
Patient First Name	2010CA	NM104
Claim ID	2300	CLM01
Total Claim Charge Amount	2300	CLM02
Service From Date	2300	DTP01, DTP02 and DTP03

When sending X12 Transactions to InstaMed please use the below segment requirements.

Field	Required Value	Format	Min	Max
ISA01 Author Info Qualifier	“00”		2	2
ISA02 Author Information	< blank >		10	10
ISA03 Security Info Qualifier	“00”		2	2
ISA04 Security Information	< blank >		10	10
ISA05 Interchange ID Qualifier	“ZZ”		2	2
ISA06 Interchange Sender ID	< InstaMed assigned EMC ID >		15	15
ISA07 Interchange ID Qualifier	“ZZ”		2	2
ISA08 Interchange Receiver ID	“INSTAMED”	Pad right spaces	15	15
ISA12 Interchange Control Version Number	“00501” or “00401”		5	5
ISA13 Interchange Control Number	< Unique Number >	Pad left with zeros	9	9
ISA14 Acknowledgement Requested	“0”		1	1
ISA15 Usage Indicator	“P” for production data “T” for test data		1	1
ISA16 Component Element Separator	“:” or agreed upon		1	1

GS02 Application Sender’s Code	< Assigned by InstaMed or agreed upon >		2	15
GS03 Application Receiver’s Code	“INSTAMED”		2	15