Qualifier Codes

Healthcare EDI transactions use qualifier codes to provide context and meaning to data elements. These standardized codes tell you what type of information a field contains — without them, raw EDI data would be nearly impossible to interpret.

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What Are Qualifier Codes?

A qualifier code is a short code that identifies the type or category of the data that follows. They appear throughout EDI segments, typically as the first element.

Example

In this NM1 segment:

NM1*IL*1*SMITH*JOHN****MI*123456789~

• IL is the entity identifier code — it tells you this is the Insured or Subscriber
• 1 is the entity type qualifier — it indicates this is a Person (not an organization)
• MI is the identification code qualifier — it tells you the ID that follows is a Member Identification Number

Without these qualifiers, you'd just have random data. With them, you know exactly what you're looking at.

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Entity Identifier Codes

The NM1 segment (name segment) uses entity identifier codes to specify who is being identified. These are some of the most common codes you'll encounter:

Common Entity Identifiers

Code	Description	Where You'll See It
40	Receiver	1000B loop — the entity receiving the transaction
41	Submitter	1000A loop — the entity submitting the transaction
85	Billing Provider	2010AA loop — who's billing for services
87	Pay-to Provider	2010AB loop — where payment should be sent
IL	Insured/Subscriber	2010BA loop — the insurance policy holder
PR	Payer	2010BB loop — the insurance company
QC	Patient	2010CA loop — the person receiving services
DN	Referring Provider	2310A loop — the referring physician
82	Rendering Provider	2310B loop — who performed the service
77	Service Location	2310C loop — where service was rendered
PE	Payee	835 — who receives the payment

Less Common Entity Identifiers

Code	Description
1P	Provider
36	Employer
71	Attending Physician
72	Operating Physician
73	Other Physician
74	Corrected Insured
DK	Ordering Provider
DQ	Supervising Provider
FA	Facility
GB	Other Insured
P3	Primary Care Provider
PW	Pickup Address
45	Drop-off Location

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Entity Type Qualifiers

The entity type qualifier (usually the second element in NM1) indicates whether the entity is a person or an organization:

Code	Description
1	Person (individual)
2	Non-Person Entity (organization, business)

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Identification Code Qualifiers

These codes appear in reference segments and NM1 segments to specify what type of ID number follows:

Common ID Qualifiers

Code	Description	Example Context
24	Employer's Identification Number (EIN)	Provider tax ID
34	Social Security Number	Individual identification
46	Electronic Transmitter ID Number	Submitter ID
FI	Federal Taxpayer's ID	Tax identification
MI	Member Identification Number	Insurance member ID
PI	Payor Identification	Payer ID number
SV	Service Provider Number	State license number
XX	NPI (National Provider Identifier)	Provider NPI

Reference Identification Qualifiers (REF Segment)

Code	Description
0B	State License Number
1C	Medicare Provider Number
1D	Medicaid Provider Number
1G	Provider UPIN Number
1J	Facility ID Number
4A	Personal ID Number
6R	Provider Control Number
9A	Repriced Claim Number
9C	Adjusted Repriced Claim Number
BB	Authorization Number
CE	Class of Contract Code
D9	Claim Number
EA	Medical Record ID
EI	Employer's ID Number
EJ	Patient Account Number
EO	Submitter ID
F8	Original Reference Number
G1	Prior Authorization Number
HPI	NPI
LU	Location Number
SY	Social Security Number
TJ	Federal Taxpayer's ID

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Service Type Codes

Service Type Codes appear in eligibility transactions (270/271) to specify what type of benefit is being inquired about or reported:

Common Service Type Codes

Code	Description
1	Medical Care
2	Surgical
3	Consultation
4	Diagnostic X-Ray
5	Diagnostic Lab
6	Radiation Therapy
7	Anesthesia
8	Surgical Assistance
12	Durable Medical Equipment Purchase
14	Renal Supplies in the Home
18	Durable Medical Equipment Rental
23	Diagnostic Dental
24	Periodontics
25	Restorative
26	Endodontics
27	Maxillofacial Prosthetics
28	Adjunctive Dental Services
30	Health Benefit Plan Coverage
33	Chiropractic
35	Dental Care
36	Dental Crowns
37	Dental Accident
38	Orthodontics
39	Prosthodontics
40	Oral Surgery
41	Routine Preventive Dental
42	Home Health Care
45	Hospice
46	Respite Care
47	Hospital
48	Hospital - Inpatient
50	Hospital - Outpatient
51	Hospital - Emergency Accident
52	Hospital - Emergency Medical
53	Hospital - Ambulatory Surgical
54	Long Term Care
55	Major Medical
56	Medically Related Transportation
57	Air Transportation
58	Cabulance
59	Licensed Ambulance
60	General Benefits
61	In-vitro Fertilization
62	MRI/CAT Scan
63	Donor Procedures
64	Acupuncture
65	Newborn Care
66	Pathology
67	Smoking Cessation
68	Well Baby Care
69	Maternity
70	Transplants
71	Audiology Exam
72	Inhalation Therapy
73	Diagnostic Medical
74	Private Duty Nursing
75	Prosthetic Device
76	Dialysis
77	Otological Exam
78	Chemotherapy
79	Allergy Testing
80	Immunizations
81	Routine Physical
82	Family Planning
83	Infertility
84	Abortion
85	AIDS
86	Emergency Services
87	Cancer
88	Pharmacy
89	Free Standing Prescription Drug
90	Mail Order Prescription Drug
91	Brand Name Prescription Drug
92	Generic Prescription Drug
93	Podiatry
94	Podiatry - Office Visits
95	Podiatry - Nursing Home Visits
96	Professional (Physician)
98	Professional (Physician) Visit - Office
99	Professional (Physician) Visit - Inpatient
A0	Professional (Physician) Visit - Outpatient
A1	Professional (Physician) Visit - Nursing Home
A2	Professional (Physician) Visit - Skilled Nursing
A3	Professional (Physician) Visit - Home
A4	Psychiatric
A5	Psychiatric - Room & Board
A6	Psychotherapy
A7	Psychiatric - Inpatient
A8	Psychiatric - Outpatient
A9	Rehabilitation
AA	Rehabilitation - Room & Board
AB	Rehabilitation - Inpatient
AC	Rehabilitation - Outpatient
AD	Occupational Therapy
AE	Physical Therapy
AF	Speech Therapy
AG	Skilled Nursing Care
AH	Skilled Nursing Care - Room & Board
AI	Substance Abuse
AJ	Alcoholism
AK	Drug Addiction
AL	Vision (Optometry)
AM	Frames
AN	Routine Eye Exam
AO	Lenses
AQ	Nonmedically Necessary Physical
AR	Experimental Drug Therapy
BA	Independent Medical Evaluation
BB	Partial Hospitalization (Psychiatric)
BC	Day Care (Psychiatric)
BD	Cognitive Therapy
BE	Massage Therapy
BF	Pulmonary Rehabilitation
BG	Cardiac Rehabilitation
BH	Pediatric
BI	Nursery
BJ	Skin
BK	Orthopedic
BL	Cardiac
BM	Lymphatic
BN	Gastrointestinal
BP	Endocrine
BQ	Neurology
BR	Eye
BS	Invasive Procedures
BT	Gynecological
BU	Obstetrical
BV	Obstetrical/Gynecological
BW	Mail Order Prescription Drug: Brand Name
BX	Mail Order Prescription Drug: Generic
BY	Physician Visit - Office: Sick
BZ	Physician Visit - Office: Well
CK	Screening X-ray
CL	Screening laboratory
MH	Mental Health

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Claim Adjustment Reason Codes (CARCs)

Claim Adjustment Reason Codes explain why a payment differs from the billed amount. These appear in 835 remittance advice transactions:

Contractual Obligation (Group Code CO)

Code	Description
1	Deductible amount
2	Coinsurance amount
3	Co-payment amount
4	The procedure code is inconsistent with the modifier used
5	The procedure code/bill type is inconsistent with the place of service
6	The procedure/revenue code is inconsistent with the patient's age
7	The procedure/revenue code is inconsistent with the patient's gender
9	The diagnosis is inconsistent with the patient's age
10	The diagnosis is inconsistent with the patient's gender
11	The diagnosis is inconsistent with the procedure
16	Claim/service lacks information or has submission/billing error
18	Exact duplicate claim/service
19	This is a work-related injury/illness (Worker's Comp)
22	This care may be covered by another payer
23	The impact of prior payer(s) adjudication
24	Charges are covered under a capitation agreement
26	Expenses incurred prior to coverage
27	Expenses incurred after coverage terminated
29	The time limit for filing has expired
31	Patient cannot be identified as our insured
32	Our records indicate that this dependent is not an eligible dependent
33	Insured has no dependent coverage
34	Insured has no coverage for newborns
35	Lifetime benefit maximum has been reached
39	Services denied at the time authorization/pre-certification was requested
40	Charges do not meet qualifications for emergent/urgent care
45	Charge exceeds fee schedule/maximum allowable
49	This is a non-covered service (not a contract exclusion)
50	These are non-covered services (contract exclusion)
51	These are non-covered services (pre-existing condition)
53	Services by an immediate relative or member of the same household
54	Multiple physicians/ambulatory facility
55	Procedure/treatment/drug is deemed experimental/investigational
56	Procedure/treatment has not been deemed 'proven to be effective'
58	Treatment was deemed by the payer to have been rendered in an inappropriate setting
59	Processed based on multiple/other coverage rules
60	Charges for outpatient services not adjudicated within 3 days of discharge
89	Not covered by patient's primary or secondary policy
90	Ingredient cost adjustment (pharmacy)
91	Dispensing fee adjustment (pharmacy)
94	Processed in excess of charges
96	Non-covered charges
97	The benefit for this service is included in the allowance for another service
100	Payment made to patient/insured/responsible party
107	The related or qualifying claim/service was not identified
109	Claim/service not covered by this payer/contractor
119	Benefit maximum for this time period or occurrence has been reached
125	Submission/billing error(s). Corrected claim resubmission required
127	Coinsurance
131	Claim specific negotiated discount
140	Patient/insured health ID card not on file
142	Monthly bundling adjustment
146	Diagnosis was invalid for dates of service
197	Precertification/authorization/notification absent
198	Precertification/authorization exceeded
199	Revenue code and procedure code do not match
204	Service not covered under patient lock-in program
226	Information requested from patient not received
227	Information requested from provider not received
234	This procedure is not paid separately
235	Sales tax
237	Legislative/regulatory fee
253	Sequestration - Loss of federal funding

Patient Responsibility (Group Code PR)

Code	Description
1	Deductible
2	Coinsurance
3	Co-payment
100	Patient responsible due to coordination of benefits
109	Not covered by plan
119	Benefit maximum reached

Other Adjustments (Group Code OA)

Code	Description
23	Prior payer impact
94	Processed in excess of charges
109	Claim not covered by payer

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Claim Adjustment Group Codes

These codes categorize the type of adjustment:

Code	Description	Financial Responsibility
CO	Contractual Obligations	Provider write-off (cannot bill patient)
CR	Correction and Reversal	Correction to prior claim
OA	Other Adjustment	General adjustment
PI	Payer Initiated Reductions	Payer adjustment
PR	Patient Responsibility	May be billed to patient

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Remittance Advice Remark Codes (RARCs)

RARCs provide additional explanation beyond adjustment reason codes. They're informational and appear alongside CARCs:

Common RARCs

Code	Description
M1	X-ray not taken within the past 12 months or near enough to time of treatment
M2	Not paid separately when the patient is inpatient
M15	Separately billed services/tests have been bundled
M20	Missing/incomplete/invalid HCPCS
M27	Missing/incomplete/invalid entitlement
M32	Alert: This is a conditional payment made pending a decision
M39	The patient is not liable for payment for this service
M49	Missing/incomplete/invalid value code(s) or amount(s)
M50	Missing/incomplete/invalid revenue code(s)
M51	Missing/incomplete/invalid procedure code(s)
M76	Missing/incomplete/invalid attending physician info
M77	Missing/incomplete/invalid operating physician info
N1	Alert: You may appeal this decision
N4	Missing/invalid/insufficient billing provider information
N5	Alert: Payment based on an alternate fee schedule
N6	Alert: This discount only applies to different payer
N20	Service not consistent with test results
N30	Patient ineligible for this service
N56	Procedure code billed is not correct; please resubmit
N130	Ongoing care not provided in this setting
N362	Service not covered
N381	Alert: This payment is being adjusted
N432	Alert: Adjustment based on diagnosis code
N519	Invalid or incorrect provider identifier
N522	Duplicate claim; previously processed

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Benefit Information Codes (EB Segment)

The EB segment in 271 eligibility responses uses these codes to describe benefit information:

Information Type (EB01)

Code	Description
1	Active Coverage
2	Active - Full Risk Capitation
3	Active - Services Capitated
4	Active - Services Capitated to Primary Care Physician
5	Active - Pending Investigation
6	Inactive
7	Inactive - Pending Eligibility Update
8	Inactive - Pending Investigation
A	Co-Insurance
B	Co-Payment
C	Deductible
CB	Coverage Basis
D	Benefit Description
E	Exclusions
F	Limitations
G	Out of Pocket (Stop Loss)
H	Unlimited
I	Non-Covered
J	Cost Containment
K	Reserve
L	Primary Care Provider
M	Pre-existing Condition
MC	Managed Care Coordinator
N	Services Restricted to Following Provider
O	Not Deemed a Medical Necessity
P	Benefit Disclaimer
Q	Second Surgical Opinion Required
R	Other or Additional Payor
S	Prior Year(s) History
T	Card(s) Reported Lost/Stolen
U	Contact Following Entity for Eligibility
V	Cannot Process
W	Other Source of Data
X	Health Care Facility
Y	Spend Down

Coverage Level (EB02)

Code	Description
CHD	Child/Children Only
DEP	Dependents Only
E1D	Employee and One Dependent
E2D	Employee and Two Dependents
E3D	Employee and Three or More Dependents
ECH	Employee and Child/Children
EMP	Employee Only
ESP	Employee and Spouse
FAM	Family
IND	Individual
SPC	Spouse and Child/Children
SPO	Spouse Only

Time Period Qualifier (EB06)

Code	Description
6	Hour
7	Day
21	Years
22	Service Year
23	Calendar Year
24	Year to Date
25	Contract
26	Episode
27	Visit
28	Outlier
29	Remaining
30	Exceeded
31	Not Exceeded
32	Lifetime
33	Lifetime Remaining
34	Month
35	Week
36	Admission

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Claim Status Category Codes

Used in 277 claim status response transactions:

Code	Description
A0	Acknowledgement/Receipt - The claim/encounter has been received
A1	Acknowledgement/Receipt - The claim/encounter is accepted for processing
A2	Acknowledgement/Receipt - Rejected with errors
A3	Acknowledgement/Forwarded - The claim has been forwarded
A4	Acknowledgement/Returned as unprocessable
A5	Acknowledgement/Split claim
E0	Response not possible - Error on submitted request
F0	Finalized - The claim has been adjudicated
F1	Finalized - Payment (full or partial)
F2	Finalized - Denial
F3	Finalized - Revised
F4	Finalized - Forwarded
P0	Pending - in process
P1	Pending - Waiting for additional information
P2	Pending - Waiting for additional information from subscriber
P3	Pending - Waiting for additional information from provider
P4	Pending - In review
R0	Requests for additional information
R3	Requests for additional information - Claim must be resubmitted
R4	Requests for additional information - Documentation

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Where to Find Official Code Lists

For complete, authoritative code lists, consult these resources:

X12 External Code Lists

• X12.org External Code Lists — Official source for X12-maintained codes
• Washington Publishing Company — Free access to code lists

Claim Adjustment Reason Codes

• X12 CARC List — Official CARC source
• CMS.gov — Medicare-specific guidance

Remittance Advice Remark Codes

• X12 RARC List — Complete RARC list
• Updated quarterly

Service Type Codes

• ASC X12 Service Type Codes — Full list with descriptions

Condition/Diagnosis Codes

• ICD-10-CM — Diagnosis codes (CMS ICD-10)
• ICD-10-PCS — Procedure codes (inpatient)
• CPT/HCPCS — Procedure codes (AMA CPT)

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Tips for Working with Qualifier Codes

In EDI Paisan

When viewing files in EDI Paisan:

1. Hover over codes — Many elements show code descriptions on hover
2. Use the segment detail view — Click any segment to see element-by-element breakdown
3. Search by code — Use search (Ctrl/Cmd + K) to find specific codes within a file
4. Check the element position — The meaning of a code depends on which element position it's in

Common Mistakes

Watch Out

• Don't confuse entity identifier codes (NM101) with identification code qualifiers (NM108)
• CARC codes are not the same as RARC codes — CARCs explain why, RARCs provide additional info
• Service type codes vary by payer — always verify with the specific payer's companion guide

Quick Reference Pattern

When you see a code you don't recognize:

1. Note the segment (NM1, REF, EB, CAS, etc.)
2. Note the element position (01, 02, 03, etc.)
3. Look up in the appropriate table based on segment + position
4. Check payer-specific guides if the standard meaning doesn't fit

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Related Documentation

• Loop Hierarchy — Understanding transaction structure
• Segment Reference — Common segments explained
• File Types — Transaction-specific documentation

Need More?

This reference covers the most common codes. For edge cases or payer-specific codes, consult the official X12 implementation guides or your payer's companion guide.