Loop ID Reference Name Codes Notes/Comments Category claim adjudication. . 2300 PWK02 Attachment Transmission Code BM, FX The only values which may be used in adjudication are “BM” and “FX”. 6 2300 CN1 CONTRACT INFORMATION Must not be present. Submission of this segment will cause your claim to reject. 4 2300 REF – Segment Rule MANDATORY MEDICARE (SECTION 4081) CROSSOVER INDICATOR Must not be present. Submission of this segment will cause your claim to reject. 4 2300 REF – Segment Rule PAYER CLAIM CONTROL NUMBER Must not be present. Submission of this segment will cause your claim to reject. 4 2300 CR102 Patient Weight The maximum number of characters to be submitted in the patient weight field is four characters to the left of the decimal and two characters to the right. Patient weight in excess of 9,999.99 pounds will be rejected. 2 2300 CR106 Transport Distance The maximum number of characters to be submitted in the transport distance is four characters. Transport distance in excess of 9,999 miles will be rejected. 2 2300 HI – Segment Rule Health Care Diagnosis Code All diagnosis codes submitted on a claim must be valid codes per the qualified code source. Claims that contain invalid diagnosis codes (pointed to or not) will be rejected. 1 2310A REF – Segment Rule REFERRING PROVIDER SECONDARY IDENTIFICATION Must not be present (non- VA contractors). Submission of this segment will cause your claim to reject. 4 2310C REF – Segment Rule SERVICE FACILITY LOCATION SECONDARY IDENTIFICATION Must not be present (non- VA contractors). Submission of this segment 4
Loop ID Reference Name Codes Notes/Comments Category 2400 CR106 Patient Weight The maximum number of characters to be submitted in the patient weight field is four characters to the left of the decimal and two characters to the right. Patient weight in excess of 9,999.99 pounds will be rejected. 2 2400 CR3 – Segment Rule Transport Distance The maximum number of characters to be submitted in the transport distance is four characters. Transport distance in excess of 9,999 miles will be rejected. 2 2400 CRC – Segment Rule DURABLE MEDICAL EQUIPMENT CERTIFICATION Must not be present. Submission of this segment for Part B will cause your claim to reject. 4 2400 DTP03 CONDITION INDICATOR/ DURABLE MEDICAL EQUIPMENT Must not be a future date. 4 2400 DTP03 DATE - SERVICE DATE Must not be a future date. 6 2400 DTP – Segment Rule DATE - PRESCRIPTION DATE Must not be present. Submission of this segment for Part B will cause your claim to reject. 6 2400 DTP03 DATE - CERTIFICATION REVISION/RECERTIFICATION DATE Must not be a future date. 4 2400 DTP – Segment Rule Certification Revision Recertification Date Must not be present. Submission of this segment for Part B will cause your claim to reject. 6 2400 DTP03 DATE – BEGIN THERAPY DATE Must not be a future date. 4
Loop ID Reference Name Codes Notes/Comments Category 2400 DTP – Segment Rule Begin Therapy Date Must not be present. Submission of this segment for Part B will cause your claim to reject. 6 2400 DTP03 DATE - LAST CERTIFICATION DATE Must not be a future date. 4 2400 DTP03 Last Certification Date Must not be a future date. 6 2400 DTP03 Last Seen Date Must not be a future date. 6 2400 DTP03 Test Performed Date Must not be a future date. 6 2400 DTP03 X-ray date Must not be a future date. 6 2400 QTY02 Initial Treatment Date Must be between 1 and 99. Submission of a value less than 1 or greater than 99 will cause your claim to reject. 6 2400 QTY02 Ambulance Patient Count Must be between 1 and 99. Submission of a value less than 1 or greater than 99 will cause your claim to reject. 2 2400 MEA03 Obstetric Additional Units Must be one to two positions and can contain one decimal place. Submission of a value greater than 99.9 will cause your claim to reject. 2 2400 CN1 – Segment Rule Test Result Must not be present. Submission of this segment for Part B will cause your claim to reject. 2
Loop ID Reference Name Codes Notes/Comments Category 2420B REF – Segment Rule PURCHASED SERVICE PROVIDER SECONDARY IDENTIFICATION Must not be present (non- VA contractors). Submission of this segment will cause your claim to reject. 4 2420C REF – Segment Rule SERVICE FACILITY LOCATION SECONDARY IDENTIFICATION Must not be present (non- VA contractors). Submission of this segment will cause your claim to reject. 4 2420D REF – Segment Rule SUPERVISING PROVIDER SECONDARY IDENTIFICATION Must not be present (non- VA contractors). Submission of this segment will cause your claim to reject. 4 2420E REF – Segment Rule ORDERING PROVIDER SECONDARY IDENTIFICATION Must not be present (non- VA contractors). Submission of this segment will cause your claim to reject. 4 2420F LQ – Segment Rule REFERRING PROVIDER SECONDARY IDENTIFICATION Must not be present. Submission of this segment for Part B will cause your claim to reject. 4 2440 LQ – Segment Rule FORM IDENTIFICATION CODE If 2400 PWK01 = CT and PWK02= AD, the LQ segment must be submitted. 4 2440 LQ01 FORM IDENTIFICATION CODE UT Must be “UT”. Submission of any other value will cause your claim to reject. 1 2440 FRM – Segment Rule SUPPORTING DOCUMENTATION Must not be present. Submission of this segment for Part B will cause your claim to reject. 6
Loop ID Reference Name Codes Notes/Comments Category 2440 FRM – Segment Rule SUPPORTING DOCUMENTATION When LQ02 = "484.03", occurrences of FRM with FRM01 = ("1A" or "1B") and FRM01 = "1C" and FRM01 = "05" are required. 4 2440 FRM – Segment Rule SUPPORTING DOCUMENTATION When LQ02 = "484.03" and FRM01 = "1A" and FRM03 >= 55.5 and <= 59.4, one occurrence of FRM with FRM01 = "07", "08" or "09" is required. 1 2440 FRM – Segment Rule SUPPORTING DOCUMENTATION When LQ02 = "484.03" and FRM01 = "1B" and FRM03 >= 88.5 and <=89.4, one occurrence of FRM with FRM01 = "07", "08" or "09" is required. 1 2440 FRM01 SUPPORTING DOCUMENTATION When LQ02='484.03' and FRM01='05' is present and the value in FRM03 is > '4', an occurrence of FRM01 with the value of '6A' or '6B' is required. 1 2440 FRM01 Question Number/Letter When LQ02='484.03' and FRM01='6A' or '6B', an occurrence of FRM01 with the value of '6C' is required. 1 2440 FRM01 Question Number/Letter When LQ02='484.03' and FRM01='6C', an occurrence of FRM01 with the value of '6A' or '6B' is required. 1 2440 FRM02 Question Number/Letter When LQ02 = '484.03" and FRM with FRM01 = "04", "07", "08" or "09" is present, then FRM02 must 1