Claim Required Data Elements

837 Claim Required Data Elements

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

Data Element NameLoopSegment/Data Element ID
Billing Provider Entity ID Code2010AANM101
Billing Provider Entity Type Qualifier2010AANM102
Billing Provider Last/Org Name2010AANM103
Billing Provider ID Code Qualifier2010AANM108
Billing Provider ID Code2010AANM109
Subscriber Entity ID Code2010BANM101
Subscriber Entity Type Qualifier2010BANM102
Subscriber (i.e., Insurance) Org Name2010BANM103
Subscriber First Name2010BANM104
Subscriber ID Code Qualifier2010BANM108
Subscriber ID Code2010BANM109
Payer Entity ID Code2010BBNM101
Payer Entity Type Qualifier2010BBNM102
Payer Org Name2010BBNM103
Payer ID Code Qualifier2010BBNM108
Payer ID Code2010BBNM109
Patient Relationship Code2000B orSBR02 or PAT01
Patient Date of Birth2010BA orDMG01 and DMG02
Patient Gender2010BA orDMG03
Patient Last Name2010BA orNM103
Patient First Name2010BA orNM104
Claim ID2300CLM01
Total Claim Charge Amount2300CLM02
Service From Date2300DTP01, DTP02 and DTP03

X12 ISA/GS Required Data Elements

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

FieldRequired ValueFormatMinMax
ISA01 Author Info Qualifier“00”22
ISA02 Author Information< blank >1010
ISA03 Security Info Qualifier“00”22
ISA04 Security Information< blank >1010
ISA05 Interchange ID Qualifier“ZZ”22
ISA06 Interchange Sender ID< InstaMed assigned EMC ID > 1515
ISA07 Interchange ID Qualifier“ZZ”22
ISA08 Interchange Receiver ID“INSTAMED”Pad right spaces1515
ISA12 Interchange Control Version Number“00501” or “00401”55
ISA13 Interchange Control Number< Unique Number >Pad left with zeros99
ISA14 Acknowledgement Requested“0”11
ISA15 Usage Indicator“P” for production data
“T” for test data
ISA16 Component Element Separator“:” or agreed upon11
GS02 Application Sender’s Code< Assigned by InstaMed or agreed upon >215
GS03 Application Receiver’s Code“INSTAMED”215