Loops and Segments Table – Loop 2430 – Line Adjudication Information
Usage : Required
Element : SVD01
Value : Nil
Comment : Payer Identification Code.
Usage : Required
Element : SVD02
Value : Nil
Comment : The amount paid by the primary payer for each service line. Zero “0” is an acceptable value for this element.
Usage : Required
Element : SVD03-1
Value :
HC = Health Care Financing Administration Common Procedural Coding System (HCPCS) Codes
IV=Home Infusion EDI Coalition (HIEC) Product/Service Code
ZZ = Mutually Defined
Comment : Code to identify the type of medical procedure.
Usage : Required
Element : SVD03-2
Value : Nil
Comment : Procedure Code
Value : Required
Element : SVD03-3
Value : Nil
Comment : Procedure Code Modifier. Procedure Modifier 1
Value : Required
Element : SVD03-4
Value : Nil
Comment : Procedure Code Modifier. Procedure Modifier 2
Value : Required
Element : SVD03-5
Value : Nil
Comment : Procedure Code Modifier. Procedure Modifier 3.
Value : Required
Element : SVD03-6
Value : Nil
Comment : Procedure Code Modifier. Procedure Modifier 4.
Value : Required
Element : SVD05
Value : Nil
Comment : Paid units of service.
Value : Situational
Element : SVD06
Value : Nil
Comment : Assigned Number (used only for bundling of service lines).
Line Adjustment
Usage : Required
Element : CAS01
Value :
CO = Contractual Obligations
CR = Correction and Reversals
OA = Other Adjustments
PI = Payer Initiated Reductions
PR = Patient Responsibility
Comment : Code to identify the general category of payment adjustment.
Usage : Required
Element : CAS02
Value : Nile
Comment: Claim Adjustment Reason codes are located on the Explanation of Benefits.
Usage : Required
Element : CAS03
Value : Nil
Comment : Monetary Amount
Use this amount for the adjustment amount
Usage : Situational
Element : CAS04
Value : Nil
Comment : Quantity
Use as needed to show payer adjustment
Usage : Situational
Element : CAS05
Value : Nil
Comment : Claim Adjustment Reason Code
Use as needed to show payer adjustment
Usage : Situational
Element : CAS06 /CAS09 / CAS12 / CAS15 / CAS18
Value : Nil
Comment : Monetary Amount
Use as needed to show payer adjustment
Usage : Situational
Element : CAS07 / CAS10 / CAS13/ CAS16/ CAS19
Value : Nil
Comment : Quantity
Use as needed to show payer adjustment.
Usage : Situational
Element : CAS08 /CAS11/CAS14/CAS17
Value : Nil
Comment : Claim Adjustment Reason Code
Use as needed to show payer adjustment
Line Adjudication Date
Usage : Required
Element : DTP01
Value : 573
Comment : Date/Time Qualifier.
Usage : Required
Element : DTP02
Value : D8
Comment : Date Expressed in Format CCYYMMDD
Usage : Required
Element : DTP03
Value : Nil
Comment : Date Time Period
