*Payers May Request Different Loops*

Electronic Location:
Loop 2300 and Loop 2400
"Claim Information"

Segments not Specified: Extra Narative Data

*Payers May Request Different Loops*

Electronic Location:
Loop 2300
"Claim Information"

Segments

*Payers May Request Different Loops*

Electronic Location:
Loop 2310C
"Service Facility Location"

Segments

*Payers May Request Different Loops*

Electronic Location:
Loop 2310D
"Service Facility Location"

Segments

*Payers May Request Different Loops*

Electronic Location:
Loop 2400
"Claim Information"

Segments

*Payers May Request Different Loops*

Electronic Location:
Loop 2420B
"Purchesed Service Provider Name"

Segments

*Payers May Request Different Loops*

Electronic Location:
Loop 2420D
"Supervising Provider Name"

Segments

Medisoft Location for Paper Claims

Box 19

Additional Claim Information (designated by NUCC) If there is a Taxonomy Code in the Provider ID grid for the provider in Box 24j, pull that information first for box 19. Print the qualifier ZZ, no space, and the taxonomy value. For example, ZZ12345AAAA88. If there is a value in the Legacy Identifier 2 field for that provider, print the Legacy Identifier 2 qualifier and value. For example, 0B98765466. If there is a value for both Taxonomy Code and Legacy Identifier 2, print the Taxonomy value, three blank spaces, and then the Legacy Identifier 2 value. If the Payer type is Worker's Comp, print three blank spaces and the Transaction Entry EDI notes for PWK in addition to the IDs listed above. If none of the other required information is printed in this box, information from Local Use B on the Case, Miscellaneous tab will appear.